The value of treadmill exercise test parameters together in patients with known or suspected peripheral arterial disease.

BACKGROUND: Exercise test parameters (exercise ankle brachial index (ABI), walking distance and blood pressure response) separately are associated with long-term outcome in patients with known or suspected peripheral arterial disease (PAD). However, the clinical value of the combination of these parameters together is unknown. METHODS: 2165 patients performed a treadmill exercise test to diagnose or to evaluate their PAD. Resting ABI, exercise ABI, abnormal blood pressure response (hypotensive and hypertensive) and walking distance (impairment <150 m) were measured. The study population was divided into patients with a resting ABI ≥ 0.90 and patients with PAD (resting ABI < 0.90). RESULTS: The mean follow-up period was 5 years (0.5-14 years). Long-term mortality rate and risks increases when more exercise parameters became abnormal (p-value = 0.001). Patients with a normal resting ABI but with an abnormal exercise test had a higher mortality risk--HR 1.90 (1.32-2.73)--than patients with a normal exercise test. The highest mortality risk and cardiac death was observed in PAD patients with a walking impairment together with an abnormal blood pressure response--HR 3.48 (2.22-5.46). CONCLUSION: Exercise tests give multiple parameters, which together provide important prognostic information on long-term outcome in both patients with normal resting ABI and PAD.

Prognostic significance of baseline ST-T-wave abnormalities in diagnostic stress echocardiography.

OBJECTIVE: The aim of this study was to determine whether resting ST-T wave abnormalities (ST-Ta) provide incremental prognostic information in patients with no history of coronary artery disease undergoing dobutamine stress echocardiography (DSE). METHODS: We evaluated 1308 consecutive patients without previous myocardial infarction (MI) or revascularization who underwent DSE. Ischemia was defined as new or worsening wall motion abnormalities. End points during follow-up were all-cause death and cardiac death/nonfatal MI. RESULTS: ST-Ta were detected in 162 (12%) patients. The incidence of ischemia was higher in patients with baseline ST-Ta than patients without [74 (46%) vs. 327 (28%), P=0.00001]. During a follow-up of 4.6 ± 3 years, cardiac death/nonfatal MI occurred in 42 (26%) patients with resting ST-Ta and in 157 (14%) patients without resting ST-Ta (P<0.001). Patients with ST-Ta had a higher annual cardiac death/nonfatal MI rate compared with patients without, both in the presence of normal DSE (3.2 vs. 1.4%, P=0.01) as well as abnormal DSE (5.3 vs. 3%, P<0.001). In a Cox proportional modeling, resting ST-Ta added incremental value over clinical and stress echocardiographic data for the prediction of death (global χ 125, 140, 150, respectively; P<0.05) and cardiac death/nonfatal MI (global χ 79, 100, 111, respectively; P<0.05). CONCLUSION: Baseline ST-Ta are associated with an increased risk of cardiac death/nonfatal MI and all-cause mortality, incremental to clinical data and DSE results. The associated risk is persistent among patients with normal DSE.

Preoperative cardiac risk management.

Approximately 100 million people undergo noncardiac surgery annually worldwide. It is estimated that around 3% of patients undergoing noncardiac surgery experience a major adverse cardiac event. Although cardiac events, like myocardial infarction, are major cause of perioperative morbidity or mortality, its true incidence is difficult to assess. The risk of perioperative cardiac complications depends mainly on two conditions: (1) identified risk factors, and (2) the type of the surgical procedure. On that basis, different scoring systems have been developed in order to accurately assess the perioperative cardiac risk and to improve the patient management. Importantly, patients with estimated high risk should be tested preoperatively by non-invasive cardiac imaging modalities. According to test results, they can proceed directly to planed surgery with the use of cardioprotective drugs (beta-blockers, statins, aspirin), or to myocardial revascularization prior to non-cardiac surgery. In this review, we discuss the role of clinical cardiac risk factors, laboratory measurements, additional non-invasive cardiac testing, and consequent strategies in perioperative management of patients undergoing noncardiac surgery.

Quality assurance in perioperative care.

Nowadays more and more clinical guidelines are developed. Clinical guidelines aim to assist practitioner and patient decision making about appropriate care for specific clinical conditions. Furthermore, guidelines can play a crucial role in the quality cycle form guidelines to clinical practice. However, this does not necessarily mean that these guidelines are actually implemented and the ultimately goal, improved patient outcome, is achieved. Care gaps exist between guidelines and daily clinical practice in perioperative care. Research should be focused on identification of barriers to adherence and subsequent effect implementation strategies to achieve higher standards of quality of care. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment of patients with peripheral arterial disease.

Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have increased postoperative morbidity and mortality. Epidural analgesia (EDA) improves postoperative outcome but may worsen postoperative lung function. It is unknown whether patients with COPD benefit from EDA. The objective of this study was to determine whether patients with COPD undergoing major abdominal surgery benefit from EDA in addition to general anesthesia. METHODS: This cohort study included 541 consecutive patients with COPD who underwent major abdominal surgery between 1995 and 2007 at a university medical center. Propensity scores estimating the probability of receiving EDA were used in multivariate correction. The primary outcome was postoperative pneumonia and 30-day mortality. RESULTS: There were 324 patients (60%) who received EDA in addition to general anesthesia. The incidence of postoperative pneumonia (16% vs. 11%; P = 0.08) and 30-day mortality (9% vs. 5%; P = 0.03) was lower in patients who received EDA. After correction EDA was associated with improved outcome for postoperative pneumonia (OR 0.5; 95% CI: 0.3-0.9; P = 0.03). The strongest preventive effect was seen in patients with the most severe type of COPD. CONCLUSION: This study provides evidence that in patients with COPD who are scheduled for major abdominal surgery, epidural analgesia decreases postoperative pulmonary complications.

Perioperative cardiac evaluation, monitoring, and risk reduction strategies in noncardiac surgery patients.

PURPOSE OF REVIEW: Cardiac complications after noncardiac surgery cause significant morbidity and mortality. This review will discuss recent developments in risk stratification, monitoring, and risk reduction strategies. RECENT FINDINGS: The addition of biomarkers for ischemia, left ventricular function, and atherosclerosis to classic cardiac risk factors improves the prediction of both short-term and long-term outcome after noncardiac surgery. Intraoperative monitoring, using continuous 12-lead ECG assessment and transesophageal echocardiography, may timely identify treatable myocardial ischemia and arrhythmias. A prudent perioperative beta-blocker and statin regimen can reduce cardiac complications and mortality without increasing the risk of stroke in intermediate to high-risk patients. The use of circulatory assist devices might improve outcomes after major surgery in patients with severely reduced left ventricular function. SUMMARY: Systematic preoperative assessment can identify patients at high risk of cardiac complications and guide the application of appropriate risk reduction strategies.

Radial force measurements in carotid stents: influence of stent design and length of the lesion.

PURPOSE: To assess the differences in radial force of carotid stents and whether the length of the lesion influences the measurements. MATERIALS AND METHODS: Different models of tapered stents of similar size (length, 30 mm) were used. The tapered nitinol Acculink, Protégé, and Cristallo Ideale carotid artery stents and the straight, braided Elgiloy carotid Wallstent were compared. A measurement device consisting of three film loops along the stent body connected to aluminium rods with copper strain gauges was developed. Five stents of each type were deployed within 3-mm stenoses in simulated long (26 mm) and short (8 mm) stenoses. RESULTS: In the short stenosis simulation, the greatest radial force was seen in the Protégé stent, at 3.14 N ± 0.45, followed by the Cristallo Ideale stent (1.73 N ± 0.51), Acculink (1.16 N ± 0.21), and Wallstent (0.84 N ± 0.10; P < .001). In the long stenosis simulation, peak radial force again was highest in the Protégé stent (1.67 N ± 0.37), but the Acculink stent was second (0.95 N ± 0.12) and the Wallstent third (0.80 N ± 0.06). The Cristallo Ideale stent, in contrast to the short stenosis simulation, produced the least radial force (0.44 N ± 0.13) in the long stenosis simulation (P = .001). CONCLUSIONS: Radial forces exerted by carotid stents vary significantly among stent designs. Differences between stent types are dependent on the length of the stenosis. An understanding of radial force is necessary for a well-considered choice of stent type in each individual patient.

Influence of noninvasive cardiovascular imaging in primary prevention: systematic review and meta-analysis of randomized trials.

BACKGROUND: Despite extensive use in practice, the impact of noninvasive cardiovascular imaging in primary prevention remains unclear. METHODS: We searched for randomized trials that compared imaging with usual care and reported any of the following outcomes in a primary prevention setting: medication prescribing, lifestyle modification (including diet, exercise, or smoking cessation), angiography, or revascularization. RESULTS: Seven trials were included. Trials screened patients for inducible myocardial ischemia (2 trials), coronary calcification (3 trials), carotid atherosclerosis (1 trial), or left ventricular hypertrophy (1 trial). Imaging had no effect on medication prescribing overall (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.76-1.33) or on provision of lipid-modifying agents (OR, 1.08; 95% CI, 0.58-2.01), antihypertensive drugs (OR, 1.05; 95% CI, 0.75-1.47), or antiplatelet agents (OR, 1.05; 95% CI, 0.84-1.32). Similarly, no effect was seen on dietary improvement (OR, 0.78; 95% CI, 0.22-2.85), physical activity (0.02 vs -0.08 point change for imaging vs control on a 5-point scale; P = .23), or smoking cessation (OR, 2.24; 95% CI, 0.97-5.19). Imaging was not associated with invasive angiography (OR, 1.26; 95% CI, 0.89-1.79). CONCLUSIONS: We found limited evidence suggesting that noninvasive cardiovascular imaging alters primary prevention efforts. However, given the imprecision of these results, further high-quality studies are needed.

Exercise ankle brachial index adds important prognostic information on long-term out-come only in patients with a normal resting ankle brachial index.

BACKGROUND: The clinical value of exercise ankle brachial index (ABI) is still unclear, especially in patients with normal resting ABI. METHOD: 2164 patients performed a single-stage treadmill exercise test to diagnose or evaluate PAD. The population was divided into two groups: a normal resting ABI (resting ABI≥0.90) and PAD (resting ABI<0.90). Patients with a normal resting ABI were divided into 4 exercise ABI groups: exercise ABI<0.90, 0.90-0.99, 1.00-1.09 and 1.10-1.29 (reference). RESULTS: Mean follow-up was 5 years. Exercise ABI added significant prognostic information on all cause long-term mortality only in patients with normal resting ABI (p-value 0.014, HR 0.99 95% CI (0.98-0.99)), not in patients with PAD. Fifty years or older (OR 2.93 95% CI (1.65-5.20)) and resting systolic blood pressure>140 mmHg (OR 2.18 95% CI (1.35-3.55)) were associated with an abnormal exercise ABI in patients with a normal resting ABI. Mortality rate increased when the exercise ABI became worse (p trend 0.0001) with a 2.5-fold increase mortality risk in patients with a normal resting ABI but exercise ABI <0.90 (HR 2.56, 95% CI (1.11-5.91)). CONCLUSION: In patients with a normal resting ABI, treadmill exercise ABI added important prognostic information on long-term mortality. Based on our results we recommend that at least all patients suspected for PAD, with a resting ABI≥0.90, who are 50 years or older and having hypertension should undergo treadmill exercise testing.

Exercise blood pressure response and perioperative complications after major vascular surgery.

OBJECTIVE: Earlier studies have shown that hypertensive or hypotensive blood pressure (BP) response during a preoperative treadmill exercise test in patients with peripheral arterial disease is associated with a two-fold increased risk of cardiovascular events and mortality. However, it is unknown if these patients also experience an increased perioperative complication risk at major vascular surgery. METHODS: In total 665 consecutive patients with peripheral arterial disease underwent elective major vascular surgery (carotid endarterectomy, abdominal aorta repair, or lower extremity revascularization). Perioperative complications (infection, myocardial infarction, angina pectoris, cardiac arrhythmia, heart failure, cerebrovascular accident or spinal cord ischemia, dialyses, amputation, thrombectomy, reoperation or death) were defined as occurring within 30 days after surgery and were collected using medical records. Hypertensive BP response was defined as a difference between exercise systolic BP and resting systolic BP of more than 55 mmHg. Hypotensive BP response was defined as a drop in exercise systolic BP below resting systolic BP. RESULTS: Patients with a hypertensive BP response during a preoperative exercise test (n = 66) showed a higher risk of early perioperative thrombectomy [hazard ratio (HR) 2.80 95% CI (1.24-6.33)] compared with patients with a normal BP response (n = 582). Patients with a hypotensive BP response (n = 18) showed an increased risk of perioperative myocardial infarction [HR 3.69 95% CI (1.08-12.64)] and cardiac complications [HR 2.90 95% CI (1.02-8.19)] compared with patients with a normal BP response. CONCLUSION: Patients with an abnormal BP response have more cardiovascular complications at elective major vascular surgery.

Clinical and echocardiographic predictors of nonresponse to cardiac resynchronization therapy.

BACKGROUND: Lack of response to cardiac resynchronization therapy (CRT) ranges between 30% to 40% of heart failure (HF) patients. The present study aimed to evaluate the clinical and echocardiographic determinants of nonresponse to CRT. METHODS: A total of 581 patients (66.4 ± 10.0 years, 77.9% male) with advanced HF scheduled for CRT implantation were included. Clinical and echocardiographic evaluations were performed at baseline and 6 months of follow-up. Nonresponse was defined as no improvement in the New York Heart Association functional class, death from worsening HF or heart transplantation, and <15% reduction in left ventricular (LV) end-systolic volume. RESULTS: At 6 months of follow-up, 254 patients (44%) did not respond to CRT. The nonresponders were more frequently male (81.9% vs 74.3%, P = .030) and had ischemic cardiomyopathy (69.7% vs 53.2%, P < .001), shorter QRS duration (150.6 ± 29.9 milliseconds vs 156.0 ± 32.5 milliseconds, P = .041), worse New York Heart Association functional class (2.8 ± 0.6 vs 2.7 ± 0.6, P = .008) and shorter 6-minute walk distance (297.9 ± 110.7 m vs 331.8 ± 112.6 m, P = .001), larger left atrial volumes (44.9 ± 16.9 mL/m(2) vs 40.9 ± 17.6 mL/m(2), P = .006), less baseline LV dyssynchrony (56.2 ± 41.3 milliseconds vs 69.1 ± 39.9 milliseconds, P < .001), and, more frequently, anterior LV lead position (12.4% vs 4.0%, P = .007). At multivariate analysis, only the ischemic etiology of HF (odds ratio [OR] 2.264, P = .005), shorter 6-minute walk distance at baseline (OR 0.998, P = .030), less baseline LV dyssynchrony (OR 0.989, P < .001), and anterior LV lead position (OR 3.713, P < .010) remained independent predictors of nonresponse to CRT. CONCLUSIONS: Ischemic etiology of HF, shorter baseline 6-minute walk distance, less baseline LV dyssynchrony, and anterior LV lead position are independent determinants of nonresponse to CRT.

Effects of adherence to guidelines for the control of major cardiovascular risk factors on outcomes in the REduction of Atherothrombosis for Continued Health (REACH) Registry Europe.

OBJECTIVES: To examine the impact of cardiovascular risk factor control on 3-year cardiovascular event rates in patients with stable symptomatic atherothrombotic disease in Europe. METHODS: The REduction of Atherothrombosis for Continued Health (REACH) Registry recruited patients aged ≥45 years with established atherothrombotic disease or three or more risk factors, of whom 20 588 symptomatic patients from 18 European countries were analysed in this study at baseline and 12, 24 and 36 months. 'Good control' of cardiovascular risk factors was defined as three to five risk factors at target values of international guideline recommendations (systolic blood pressure <140 mm Hg, diastolic blood pressure <90 mm Hg, fasting glycaemia <110 mg/dl, total cholesterol <200 mg/dl, non-smoking). Independent predictors of 'good control' of major risk factors were assessed by multivariate analysis. RESULTS: Among symptomatic patients in the REACH Registry Europe (mean age 67 years, 70.6% male), 59.4% had good control of risk factors at baseline. Good risk factor control was associated with lower cardiovascular death/non-fatal stroke/non-fatal myocardial infarction (OR 0.76; 95% CI 0.69 to 0.83) and mortality (OR 0.89; 95% CI 0.79 to 0.99) at 36 months, compared with poor control. Independent predictors of good control of risk factors included residence in western versus eastern Europe (OR 1.29), high level of education (OR 1.16), established coronary artery disease (OR 1.18), treatment with one or more antithrombotic (OR 1.59) and one or more lipid-lowering agent (OR 1.16). CONCLUSIONS: In REACH, less than 60% of patients with stable atherothrombotic disease had good control of the five major cardiovascular risk factors. Improved risk factor control is associated with a positive impact on 3-year cardiovascular event rates and mortality.

Preoperative left ventricular dysfunction predisposes to postoperative acute kidney injury and long-term mortality.

BACKGROUND: Both preoperative left ventricular dysfunction (LVD) and acute kidney injury (AKI) in the postoperative period are independently associated with mortality. We evaluated the prevalence and prognostic implications of AKI in a cohort of vascular surgery patients. METHODS: Before vascular surgery, 1,158 patients were screened for LVD. Development of AKI, defined by RIFLE classification, was detected by serial serum creatinine measurements at days 1 to 3 after surgery. Primary end point was cardiovascular mortality during a median follow-up of 2.2 years (interquartile range [IQR] 1.0-4.0). RESULTS: LVD was present in 558 patients (48%), and 120 patients (10%) developed postoperative AKI. Subjects with LVD developed postoperative AKI more often than patients without LVD (8% vs. 13%, p=0.01). Patients were categorized as (i) no LVD, without AKI (n=551, 48%), (ii) LVD without AKI (n=487, 42%), (iii) no LVD, with AKI (n=49, 4%) and (iv) LVD with AKI (n=71/6%). Patients with LVD prior to surgery who developed postoperative AKI had the highest cardiovascular mortality risk (hazard ratio = 4.9; 95% confidence interval, 2.9-8.2). CONCLUSION: Patients with preoperatively LVD have an increased risk of developing AKI after vascular surgery. The occurrence of AKI in patients with LVD has an incremental predictive value toward cardiovascular mortality risk during long-term follow-up.

Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis.

AIMS: To identify changes in multidirectional strain and strain rate (SR) in patients with aortic stenosis (AS). METHODS AND RESULTS: A total of 420 patients (age 66.1 ± 14.5 years, 60.7% men) with aortic sclerosis, mild, moderate, and severe AS with preserved left ventricular (LV) ejection fraction [(EF), ≥50%] were included. Multidirectional strain and SR imaging were performed by two-dimensional speckle tracking. Patients were more likely to be older (P < 0.001) and at a worse New York Heart Association functional class (P < 0.001) with increasing AS severity. There was a progressive stepwise impairment in longitudinal, circumferential, and radial strain and SR with increasing AS severity (all P < 0.001). The myocardial dysfunction appeared to start in the subendocardium with mild AS, to mid-wall dysfunction with moderate AS, and eventually transmural dysfunction with severe AS. Aortic valve area, as a measure of AS severity, was an independent determinant of multidirectional strain and SR on multiple linear regressions. CONCLUSIONS: Patients with AS have evidence of subclinical myocardial dysfunction early in the disease process despite normal LVEF. The myocardial dysfunction appeared to start in the subendocardium and progressed to transmural dysfunction with increasing AS severity. Symptomatic moderate and severe AS patients had more impaired multidirectional myocardial functions compared with asymptomatic patients.