Role of BMIPP imaging for risk stratification in patients with coronary artery disease.
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Current and future status on cardiac computed tomography imaging for diagnosis and risk stratification.
Computed tomography (CT) permits cross-sectional imaging with high spatial resolution and has, during the past years, undergone tremendous development mainly concerning the temporal resolution. By use of multidetector spiral technology, as well as electrocardiography-gated image acquisition and reconstruction techniques, 16- and 64-slice CT permits visualization of cardiac morphology and function. In this context, however, CT imaging does not play a major clinical role because other imaging methods (mainly echocardiography) usually provide all necessary information. Under certain conditions, multidetector CT also permits visualization of the coronary arteries. Detection of coronary calcification, as well as coronary CT angiography, can provide clinically useful information if applied to suitable patient groups. It is foreseeable that CT angiography will become part of the routine workup in some subsets of patients with suspected coronary artery disease, either alone or in combination with other imaging techniques. Among the limitations of cardiac CT are the requirement of a regular (and preferably low) heart rate, the associated x-ray exposure, and the need for an iodinated contrast agent for most applications. It is important to note that reliable and accurate results will require use of the most advanced CT scanner technology, optimal image quality, and sufficient experience in the acquisition and interpretation of cardiac CT data sets.
Angiography↗
Role of invasive and noninvasive testing in risk stratification of sudden cardiac death in children and young adults: an electrophysiologic perspective.
Sudden cardiac death is a rare, but devastating, event in the young population. Arrhythmia is the mechanism of death in many cases. In addition to clinical history, noninvasive and invasive tests can be used to identify patients who are at risk. Although these tools are not perfect, they can prove valuable if used in proper clinical circumstances. An overview of these tests is presented.
Adolescent↗
The stratification of social capital and its consequences for self-rated health in Taganrog, Russia.
Russian public health and its social determinants have been the theme of several recent studies. In one of these, Rose [(2000). How much does social capital add to individual health? A survey study of Russians. Social Science & Medicine, 51(9), 1421-1435] puts forward a composite model as a way of getting away from two traditions: one that postulates that social capital influences health independently of human capital attributes (education, social class, income, etc.) and one that postulates that human capital is the main determinant of health, while social capital is more or less irrelevant. In this study, we investigate the composite model, conceptualising social capital as a type of capital, on the basis of Bourdieu. By doing this, not only do the relations between social capital and other types of capital become relevant, but also whether the effect of social capital on health differs depending on the possession of other types of capital. We used the Taganrog survey of 1998 which used structured interviews with the family members of 1,009 households and the response rate was 81%. We found that social capital is stratified by education, and also that its effect on health varies depending on the volume of educational capital possessed. It also seems to be extremely important to specify different types of social capital, in order to get a better overview of possible mechanisms by means of which different types of capital might affect health.
Data Collection↗
The stratification of platelet reactivity and activation in patients with stable coronary artery disease on aspirin therapy.
UNLABELLED: Heightened platelet reactivity may affect the occurrence of ischemic events in patients with coronary artery disease on aspirin therapy. However, a definition to stratify platelet reactivity in this group of patients has not been previously reported. We studied platelet reactivity and activation by measuring platelet aggregation and the expression of p-selectin, total GP IIb/IIIa and active GP IIb/IIIa (n=96). Patients were divided into quartiles by each of the markers; correlations were made between the markers; and a definition of heightened platelet reactivity was proposed. Marked variability in activation and reactivity were observed despite aspirin therapy. BACKGROUND: Heightened platelet reactivity and activation may affect the occurrence of ischemic events in patients with coronary artery disease on aspirin therapy. However, a definition to stratify platelet reactivity has not been previously reported. METHODS AND RESULTS: Platelet aggregation (5 and 20 micromol/l ADP), total GP IIb/IIIa, active GP IIb/IIIa and the expression of maximally stimulated p-selectin were measured in patients about to undergo elective coronary stenting (n=96). All patients had received aspirin (325 mg). There was marked variability in platelet reactivity and activation as measured by all markers. The highest quartile was defined by 77+/-1% and 98+/-1% aggregation by 5 and 20 micromol/l ADP, respectively; 65+/-2% p-selectin positivity; 508+/-15 MFI for total GP IIb/IIIa; and 23.0+/-1.8 MFI for active GP IIb/IIIa. CONCLUSIONS: There is a wide range in platelet reactivity and activation as measured by multiple markers in stable coronary disease patients on aspirin therapy. From these indices, we can define those patients at the extremes of reactivity and activation and thus, the greatest potential risk of thrombosis and bleeding. These indices will serve as a guide to future studies investigating the relationships of platelet reactivity, activation, drug-induced inhibition and clinical outcomes.
Aspirin↗
Risk stratification in patients with unstable angina and/or non-ST-elevation myocardial infarction by Troponin T and plasminogen-activator-inhibitor-1 (PAI-1).
BACKGROUND: Increased Troponin T (TnT) and PAI-1 levels are markers of poor outcome in acute coronary syndromes (ACS). In order to stratify the risk for 30-day combined endpoint of mortality and/or reinfarction in unstable angina and/or non-ST-elevation myocardial infarction (UA/NSTEMI), TnT and PAI-1 levels were simultaneously assessed. METHODS: The TnT and PAI-1 levels of 113 patients with UA/NSTEM were estimated within the first 48 h. Initial therapy was medical. Percutaneous coronary interventions were performed in case of recurrent ischemia and/or hemodynamic and/or rhythmic instability. RESULTS: Statistically significant differences in mean admission PAI-1 (4.2+/-3.4 vs. 2.8+/-2.4 U/ml, p<0.05), mean peak PAI-1 levels within the first 48 h (4.98 +/- 3.1 vs. 3.4 +/- 2.5 U/ml, p < 0.05), and no significant difference in any TnT level were observed between patients with and without 30-day mortality and/or reinfarction. The risk for 30-day mortality and/or reinfarction significantly increased in patients with admission PAI-1 levels > 4.0 U/ml (OR=4.44, 95%CI=1.47-13.4), peak PAI-1 levels > 4.0 U/ml (OR=5.78, 95%CI=1.838-18.20) and with simultaneously increased peak PAI-1 > 3.5 U/ml and TnT > 0.1 microg/l within the first 48 h (OR=4.9, 95%CI=1.569-15.385). CONCLUSIONS: Simultaneous assessment of TnT and PAI-1 would provide complementary prognostic information and enable clinicians to stratify risk more effectively among patients with UA/NSTEMI.
Aged↗
Usefulness of pulmonary hypertension reversibility test with sodium nitroprusside in stratification of early death risk after orthotopic heart transplantation.
AIM: To assess the prognostic value of a PH reversibility test with NPS to predict early death risk after orthotopic heart transplantation (OHT). MATERIALS AND METHODS: We analyzed the results of 94 consecutive OHT procedures performed from 2002 to 2003. Pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) were assessed as part of the routine pre-OHT evaluation. PH was excluded in 57 patients (61%, group A); TPG > or = 12 mmHg and/or PVR > 2.5 Wood units were observed in 37 patients (39%). Sixteen patients underwent a PH reversibility test with NPS: 9 patients (group B) achieved normal TPG and PVR without a drop in systolic arterial pressure (BP(s) > 85 mmHg), while a marked decrease of BP(s) (< 85 mmHg) during NPS infusion was observed in 7 patients (group C). Then, 21 patients were selected for OHT despite PH without any reversibility test. We compared the number of early deaths after OHT among groups (chi-square test). RESULTS: The 30-day death rate was 7% in group A, 11% in group B, 71% in group C, and 29% in group D. (A vs C, P = .0001 and A vs D, P = .03). Right ventricle or biventricular failure was the cause of death in 1 patient in group A, 1 patient in group B, 5 patients in group C, and 6 patients in group D (A vs C, P < .0001 and A vs D, P = .0012). CONCLUSION: PH reversibility revealed with NPS does not increase the risk of early death after OHT unless there is an absence of marked fall in systemic pressure.
Adult↗
Tumor-size breakpoint for prognostic stratification of localized renal cell carcinoma.
OBJECTIVES: To identify an optimal tumor-size breakpoint to distinguish between two groups with different prognoses in a large cohort of patients with localized renal cell carcinoma (RCC). METHODS: We reviewed the clinical records of 813 patients who had undergone surgical treatment for localized RCC from 1976 to 2000. The optimal breakpoint for the pathologic size was calculated by receiver operating characteristic curve analysis. RESULTS: The receiver operating characteristic curve analysis identified 5.5 cm as the optimal breakpoint to predict cancer-specific survival rates. The pathologic size was 5.5 cm or less in 565 neoplasms (69.5%) and more than 5.5 cm in 248 (30.5%). In the multivariate analysis, the more predictive model included the 5.5-cm-or-less pathologic size breakpoint. The pathologic size of 7 cm or less was not an independent variable in this cohort of patients. CONCLUSIONS: In a large cohort of patients with localized RCC, 5.5 cm was the optimal breakpoint to classify patients with localized RCC into two subgroups with different prognoses; the 7-cm-or-less cutoff value was not an independent variable. The data obtained by analyzing a large cohort of consecutive patients should be validated by other large series with the prospective of redefining the TNM staging system.
Adolescent↗
Isolated seminal vesicle invasion imparts better outcomes after radical retropubic prostatectomy for clinically localized prostate cancer: prognostic stratification of pt3b disease by nodal and margin status.
OBJECTIVES: To examine the survival differences in men with seminal vesicle invasion (SVI) according to surgical margin (SM) and nodal (N) status to characterize the influence of isolated SVI on disease progression after radical retropubic prostatectomy for clinically localized prostate cancer. METHODS: We reviewed the records of 941 men who underwent radical retropubic prostatectomy for clinically localized prostate cancer between 1984 and 2002. Three groups with evidence of SVI (SM-/N-, SM+/N-, and N+) were analyzed to identify differences in age, preoperative prostate-specific antigen (PSA) level, biopsy Gleason score, surgical Gleason score, time to PSA progression, follow-up time, and cancer-specific and overall survival. Kaplan-Meier estimates and univariate and multivariate calculations were generated to examine differences in biochemical-free survival. RESULTS: Of 941 patients, 87 were identified with SVI; of these, 28 (32.2%) were SM-/N-, 35 (40.2%) were SM+/N-, and 24 (27.6%) were N+. The median follow-up for all patients was 70 months. The 5-year biochemical progression-free rate for SM-/N-, SM+/N-, and N+ patients was 71.9%, 36.6%, and 25.9%, respectively. The median time to PSA progression for SM-/N-, SM+/N-, and N+ patients was 26, 16, and 6 months, respectively. The clinical stage, pretreatment PSA level, and margin and node status were statistically predictive (P < 0.05) on univariate analyses; however, only positive margin status approached statistical significance on multivariate analysis (P = 0.06). The overall and cancer-specific 5-year survival rates for SM-/N-, SM+/N-, and N+ patients were 89% and 100%, 79% and 97%, and 78% and 86%, respectively. CONCLUSIONS: Isolated SVI is associated with lower rates of, and longer intervals to, biochemical failure compared with SVI with positive margins and/or regional lymph node involvement.
Aged↗
Impact of the percentage of positive biopsy cores on the further stratification of primary grade 3 and grade 4 Gleason score 7 tumors in radical prostatectomy patients.
OBJECTIVES: To examine whether the percentage of core biopsies positive can further stratify Gleason score 7 patients with primary Gleason grade into precise prognostic groups. METHODS: Between 1991 and 1999, 379 radical prostatectomy patients were found to have pathologic Gleason 7 tumors. The patients were divided into primary grade 3 or 4. Percentage positive was calculated by dividing the number of positive core biopsies by the total number of cores. RESULTS: In the cohort, 290 tumors were primary grade 3, and 89 were primary grade 4. On univariate analysis patients with primary grade 3 tumors had a significant prostate-specific antigen (PSA) progression-free survival advantage over grade 4 patients. When separated according to percentage of core biopsies positive, statistical analysis revealed significantly better 60-month actuarial PSA progression-free survival for patients with grade 3 and grade 4 and less than 50% core biopsies positive as compared with grade 3 and grade 4 and 50% or more core biopsies positive (85%, 85%, 61%, and 33%, respectively). Furthermore, multivariate analysis demonstrated that primary grade did not have an independent impact on biochemical progression-free survival. However, on subset analysis, among patients with 50% or more biopsy cores positive, primary Gleason grade was indeed found to have a significant, independent impact. CONCLUSIONS: In the present study Gleason 7 patients with primary grade 4 tumors and less than 50% of biopsy cores positive had an excellent prognosis after radical prostatectomy. Our data suggest that among Gleason 7 patients, the percentage of positive biopsies is a stronger predictor of biochemical progression-free survival than primary Gleason grade.
Adult↗
Combination of B-type natriuretic peptide and peak oxygen consumption improves risk stratification in outpatients with chronic heart failure.
BACKGROUND: Peak oxygen consumption is a cornerstone for prognostic determination in patients with congestive heart failure. The purpose of this study was to assess whether plasma B-type natriuretic peptide (BNP) provided any additional prognostic information. METHODS: Plasma concentrations of atrial natriuretic peptide, N terminal pro-atrial natriuretic peptide, BNP, endothelin-1, norepinephrine, and peak VO2 were measured in 250 consecutive outpatients with mild to moderate heart failure (96% in New York Heart Association [NYHA] class II or III) and left ventricular ejection fraction (LVEF) <45%. RESULTS: During a median follow-up of 584 days, 42 patients died (19 from sudden death) and 5 underwent urgent heart transplantation. Multivariate stepwise regression analysis showed that, among 13 variables including NYHA and LVEF, plasma BNP (chi2 = 11.9, P =.0001) was the strongest independent predictor of death or urgent transplantation, followed by serum sodium (chi2 = 8, P =.0046), resting heart rate (chi2 = 7.5, P =.0062), plasma endothelin-1 (chi2 = 7.2, P =.007), and peak VO2 (chi2 = 6.2, P =.012). Patients with plasma BNP above the upper quartile value (260 pg/mL) had a 1-year rate of death or urgent transplantation of 31%. The 1- and 2-year survival rates without urgent transplantation in patients with a peak VO2 < or =14 mL x kg(-1) x min(-1) were 71% and 59%, respectively, when plasma BNP was >137 pg/mL (median value), compared with 100% and 89%, respectively, when plasma BNP was < or =137 pg/mL (P =.008). Furthermore, plasma BNP was the only independent predictor of sudden death (chi2 = 19.9, P =.00001). CONCLUSIONS: Plasma BNP provides additive independent prognostic information compared to peak VO2 alone in outpatients with mild to moderate heart failure.
Aged↗
Optimizing glycoprotein IIb/IIIa receptor antagonist use for the non-ST-segment elevation acute coronary syndromes: risk stratification and therapeutic intervention.
Despite extensive data supporting their use for non-ST-segment elevation acute coronary syndromes, glycoprotein (GP) IIb/IIIa antagonists are underutilized. This is likely the consequence of confusion as to which patients should receive these agents, as well as to the most appropriate timing and venue for their initiation. We will review the advances in the understanding of GP IIb/IIIa antagonist therapy, emphasizing methods of identifying those most likely to benefit from the use of GP IIb/IIIa receptor blockade. In addition, we will consider appropriate methods/venues for use of GP IIb/IIIa receptor antagonism, including its role in an "early invasive" catheterization strategy.
Abciximab↗
Is dipyridamole-thallium imaging preferable to submaximal exercise thallium testing for risk stratification after thrombolysis?
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Aged↗
Noninvasive risk stratification after myocardial infarction: which test is best?
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Decision Trees↗
Risk stratification with pre-hospital discharge exercise technetium-99m sestamibi myocardial tomography in men after acute myocardial infarction.
BACKGROUND: Exercise thallium-201 imaging early after acute myocardial infarction (MI) may provide information concerning risk of future cardiac events. The prognostic value of exercise technetium-99m sestamibi (MIBI) single-photon emission computed tomography in such patients has not been established. METHODS AND RESULTS: Submaximal exercise stress testing with MIBI tomography was done before hospital discharge in 134 consecutive men after acute MI. Patients were monitored for occurrence of late cardiac events (nonfatal MI or cardiac death). Coronary revascularization was done in 31 patients (23%) < or = 3 months after testing. Nonfatal MI or cardiac death occurred in 30 (23%) of the overall group of 133 patients monitored (mean 35+/-19 months) and in 25 (25%) of the 102 patients treated medically. A history of congestive heart failure, failure to reach 85% of age-predicted maximal heart rate, and an isolated fixed MIBI defect were associated with significantly increased risk (p < 0.05) of a late cardiac event in both groups of patients. A reversible MIBI defect was not associated with increased risk. In a multivariable Cox proportional hazards model, only a history of congestive heart failure (relative risk 4.2, 95% confidence interval [CI] 1.7 to 10.4, p < 0.002) and an isolated fixed MIBI defect (relative risk 2.1, 95% CI 1.1 to 4.3, p < 0.05) were independent predictors of increased risk in the total group of 133 patients. In the 102 patients treated medically, only a history of congestive heart failure (relative risk 4.9, 95% CI 1.9 to 13.1) and achievement of 85% of age-predicted maximal heart rate (relative risk 0.13, 95% CI 0.02 to 0.9) were independent predictors of risk. CONCLUSIONS: Early post-MI submaximal exercise testing with MIBI tomography provides limited prognostic information for late cardiac events. An isolated fixed MIBI defect is associated with increased risk but not as strongly as other variables, particularly a history of congestive heart failure.
Adult↗
Admission standard electrocardiogram for early risk stratification in patients with unstable coronary artery disease not eligible for acute revascularization therapy: a TRIM substudy. ThRombin Inhibition in Myocardial Infarction.
OBJECTIVES: The purpose of this study was to determine the prognostic capacity of a single electrocardiogram (ECG) obtained early after admission to the hospital in patients suspected of non-Q-wave myocardial infarction and unstable angina pectoris. METHODS: Six hundred twenty-nine patients from the TRIM study were included. The patients were divided into subgroups on the basis of ST-segment changes in the inclusion ECG. Death, acute myocardial infarction, or refractory angina (despite treatment) were registered during a follow-up period of 30 days. RESULTS: Patients with ST depression had a significantly higher event rate compared with patients with other ECG changes or with normal ECG results. The difference in event rates between patients with ST depression and patients without ST depression regarding the composite of death and acute myocardial infarction was highly significant (P =.0008). A significant association between the magnitude of the ST-segment depression (in millimeters) and the risk of cardiac events was also demonstrated. Multivariate analysis proved ST depression early after admission to be an independent predictor of high risk. CONCLUSION: In patients with unstable coronary artery disease, ST-segment depression at admission is a strong predictor of early (30 days) cardiac events and the extent of ST depression carries important prognostic information as well.
Aged↗
Noninvasive risk stratification in women with uncomplicated acute myocardial infarction.
The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.
Aged↗
Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery.
Transthoracic echocardiography (TTE) is frequently ordered before noncardiac surgery, although its ability to predict perioperative cardiac complications is uncertain. To evaluate the incremental information provided by TTE after consideration of clinical data for prediction of cardiac complications after noncardiac surgery, 570 patients who underwent TTE before major noncardiac surgery at a university hospital were studied. Preoperative clinical data and clinical outcomes were collected prospectively according to a structured protocol. TTE data included left ventricular (LV) function, hypertrophy indexes, and Doppler-derived measurements. In univariate analyses, preoperative systolic dysfunction was associated with postoperative myocardial infarction (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.1 to 7.0), cardiogenic pulmonary edema (OR 3.2, 95% CI 1.4 to 7.0), and major cardiac complications (OR 2.4, 95% Cl 1.3 to 4.5). Moderate to severe LV hypertrophy, moderate to severe mitral regurgitation, and increased aortic valve gradient were also associated with major cardiac events (OR 2.3, 95% CI 1.2 to 4.6; OR 2.2, 95% CI 1.1 to 4.3; OR 2.1, 95% CI 1.0 to 4.5, respectively). In logistic regression analysis, models with echocardiographic variables predicted major cardiac complications significantly better than those that included only clinical variables (c statistic 0.73 vs 0.68; p <0.05). Echocardiographic data added significant information for patients at increased risk for cardiac complications by clinical criteria, but not in otherwise low-risk patients. In conclusion, preoperative TTE before noncardiac surgery can provide independent information about the risk of postoperative cardiac complications in selected patients.
Aged↗