Impact of high altitude on echocardiographically determined cardiac morphology and function in patients with coronary artery disease and healthy controls.

AIMS: To evaluate the impact of high altitude on cardiac morphology and function in patients with coronary artery disease (CAD) and healthy controls. METHODS AND RESULTS: Eight patients with a history of acute myocardial infarction [53 +/- 8 years, left ventricular (LV) ejection fraction 54 +/- 6%] and a low risk score were compared with seven healthy controls (41 +/- 16 years) during the Dutch Heart Expedition 2007 at the Aconcagua (6960 m) in Argentina. An exercise test and echocardiography were performed at sea level and at base camp (4200 m). In the apical four-chamber view, right ventricular (RV) diameter, tricuspid annular plane systolic excursion (TAPSE), early transmitral inflow peak velocity (E), atrial transmitral inflow peak velocity (A), and peak tissue velocity during early diastole (E') were obtained. Changes in global LV function and wall motion score index (WMSI) were used as markers of ischaemia. There were no significant differences in individual global LV function and WMSI at high altitude compared with sea level in both groups. A significant increase in RV diameter was observed in the patient group at 4200 m compared with sea level and a trend towards the same result in the control group. A decrease in TAPSE was observed. Measurements of the E' showed a significant decrease in the LV septum and lateral wall at high altitude compared with sea level in both groups. CONCLUSION: Symptoms and echocardiographic signs of myocardial ischaemia were absent in low-risk patients with a history of CAD during and after exercise up to an altitude of 4200 m. Patients and healthy controls showed comparable changes at high altitude compared with sea level with an increase in RV diameter, a decrease in TAPSE, and decreased E' as early signs of pulmonary hypertension and LV diastolic dysfunction. As these alterations are most likely physiological adaptation to high altitude, the results seem to affirm current guidelines. The safety of expanding previous recommendations to patients with low-risk CAD to an altitude ascent of 4200 m requires confirmation in a larger study with appropriately defined clinical endpoints.

Long-term clinical outcome of patients with diabetes proposed for coronary revascularisation.

BACKGROUND: The optimal method of revascularisation in diabetic patients with coronary artery disease (CAD) remains controversial. It was our aim to evaluate long-term outcome in diabetic patients with CAD in daily practice, in whom an invasive approach was considered. METHODS: A prospective follow-up study of patients with CAD in whom a coronary revascularisation procedure was considered. Follow-up data were obtained on the vital status up to ten years after inclusion. RESULTS: Of the 872 included patients, a total of 107 patients (12%) had diabetes. Patients with diabetes were older and more frequently female. Long-term mortality was higher in diabetics than nondiabetics (36 vs 25%, p = 0.01). This association was observed in both medically treated patients (65 vs 31%, p = 0.01) and in those treated by percutaneous coronary intervention (41 vs 24%, p = 0.02). There was, however, no difference in mortality in diabetes vs nondiabetes patients after coronary artery bypass grafting (24 vs 24%, p = 0.89). Multivariate analysis did not change these findings. CONCLUSION: Diabetic patients with significant CAD had a higher long-term mortality compared with patients without diabetes. In patients with diabetes, survival was highest after coronary artery bypass grafting and appeared to be comparable between diabetic and nondiabetic patients. Complete revascularisation may decrease the influence of diabetes on survival.

Improvement of diagnosis in the non-invasive assessment of coronary artery disease: enhanced evaluation of quantitative exercise 201thallium imaging by multivariate analysis.

STUDY OBJECTIVE: The aim was to evaluate discriminant analysis, performed in patients without prior myocardial infarction, in enhancing the diagnostic value of quantitative exercise 201thallium scintigraphy. DESIGN: All clinical, electrocardiographic, and scintigraphic variables were first subjected to a univariate analysis. Afterwards a discriminant analysis was done. PATIENTS: 135 patients (104 male) were studied. Age was 24-70 years, mean 55 years. MEASUREMENTS AND MAIN RESULTS: Two discriminant analyses were done. In the first analysis, the ability to detect the presence of coronary artery disease was tested. Significant variables were: (1) history of angina, (2) sex, (3) quantitative analysis of 201thallium scintigraphy, (4) age, (5) ischaemic ST response, (6) angina during the test, and (7) the pressure-rate product. The sensitivity, specificity, and accuracy of classification using the discriminant function were 91%, 87%, and 90%, respectively. The sensitivity was higher than when using only visual interpretation (sensitivity 70%; p less than 0.0002) or quantitative interpretation (sensitivity = 66%; p less than 0.0001) of thallium scans, without significant loss of specificity (p less than 0.5488; p less than 0.6875). In the second analysis, a discriminant function was calculated to detect multivessel disease. Five input variables were selected: (1) number of vessels with stenosis predicted by quantitative analysis, (2) number of vessels with stenosis predicted by visual analysis, (3) ischaemic ST response, (4) sex, (5) angina during the test. Multivariate analysis showed an increase in sensitivity when compared with visual interpretation (78% v 55%; p less than 0.0043) and quantitative analysis (66%; p less than 0.0156). Using the classification, the discriminant function was more accurate than visual analysis (81% v 69%) or quantitative analysis (77%). CONCLUSIONS: The results show that multivariate analysis of non-invasive test results in quantitative thallium exercise testing allows convenient use for clinical purposes with improved results.

Evaluation of the incremental diagnostic value and impact on patient treatment of thallium scintigraphy.

The incremental diagnostic yield of exercise 201Tl scintigraphy with visual and quantitative analysis was determined in 191 patients with known or suspected coronary artery disease (CAD). The coronary arteriogram was used as the gold standard. After pre-test clinical and exercise electrocardiographic data were taken into consideration, scintigraphy was found to have additional diagnostic value both in the diagnosis of CAD and of multivessel disease, with quantitative analysis being superior to visual analysis. The impact of 201Tl scintigraphy on the patient's treatment--conservative treatment versus revascularization--was also evaluated. The impact was relatively low, as the decision for revascularization was based primarily on the angiographic result and the severity of the anginal pain. This result reflects only the decision making process used in our clinic and permits no conclusion to be made concerning the possible value of 201Tl scintigraphy in this type of medical decision making process.

The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands.

OBJECTIVE: To determine the appropriateness of intention to treat decisions concerning coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for patients with coronary artery disease in The Netherlands. DESIGN: Prospective study of intention to treat decisions using a computerised expert system. SETTING: "Presentation" sessions in 10 tertiary referral heart centres in 1992. PATIENTS: 3207 consecutive patients: 1618 CABG and 1589 PTCA candidates. MAIN OUTCOME MEASURE: Percentage of invasive treatment decisions rated appropriate, uncertain, or inappropriate by the expert system. RESULTS: PTCA decisions were common for patients with one-vessel disease and CABG decisions for patients with three-vessel and left main disease. PTCA decisions outnumbered CABG decisions in acute myocardial infarction. Of CABG decisions, 84% were rated appropriate, 12% uncertain, and 4% inappropriate. The proportions for PTCA decisions were 39% appropriate, 31% uncertain, and 29% inappropriate. Type C lesion was the main determinant of inappropriateness of PTCA decisions. If type C lesions were downgraded to type A/B lesions the rate of inappropriate PTCA decisions dropped to 6%. CONCLUSIONS: Clinicians in tertiary referral centres in The Netherlands favoured CABG if vessel disease was extensive or involved the left main artery, and PTCA for patients with less extensive disease and with acute myocardial infarction. Few CABG decisions were inappropriate. The main determinant of inappropriateness of PTCA decisions was its intended use in patients with type C lesions.

Exercise 201Tl scintigraphy: evaluation of the additional diagnostic value.

The additional diagnostic yield of exercise 201Tl scintigraphy using both visual and quantitative analysis was determined in 221 patients with known or suspected coronary artery disease (CAD). The coronary arteriogram was adopted as the gold standard. After pretest clinical and exercise electrocardiographic data were taken into consideration, scintigraphy added diagnostic accuracy both in the diagnosis of CAD and of multivessel disease. The diagnostic yield of the scintigraphy in terms of sensitivity and specificity was, however, not significant. In 79% (121/153) of the patients, the diagnosis of the presence, or exclusion, of CAD was highly probable (P > 0.80 or P < 0.20) when considering clinical and exercise data. The diagnosis was, however, not significantly improved by the scintigraphic result. Twenty-seven per cent (20/73) returned a negative scintigraphic results with a high (P > 0.80) prescintigraphic probability for CAD and a positive arteriogram. It was concluded that 201Tl scintigraphy has additional diagnostic value after clinical and exercise parameters were taken into consideration in the diagnosis of coronary artery and multiple vessel disease. It is not recommended to refer patients with either a low or high probability of CAD for screening and diagnosis as in a high proportion of patients the diagnosis of CAD could have been made using clinical or exercise data alone.

[Quality of life following coronary surgery and balloon angioplasty; more chest pain and social inhibition following angioplasty]. / Kwaliteit van leven na coronariachirurgie en na ballonangioplastiek; meer pijn op de borst en sociale geremdheid na angioplastiek.

OBJECTIVE: To determine the differences in quality of life between patients who had a coronary artery bypass graft (CABG) and patients who had a percutaneous transluminal coronary angioplasty (PTCA). DESIGN: Comparative and prospective study. SETTING: Rotterdam, the Netherlands. METHOD: 91 patients with multi-vessel coronary disease who had been randomised to CABG (n = 37) or PTCA (n = 54), as participants in the CABRI study (Coronary angioplasty or bypass revascularisation investigation) completed several psychological questionnaires. Besides, the severity of angina pectoris after the procedure was estimated using the Canadian Cardiovascular Society score. In a subpopulation of 36 patients (CABG:14; PTCA:22) the quality of life just before the intervention was measured, also using psychological questionnaires. RESULTS: A significant difference in angina pectoris was found between the two groups. The PTCA group experienced more chest pain (p < 0.01), at an average of 2.6 years after the intervention. The quality of life aspects did not differ between the two groups, except for 'social inhibition' (p < 0.05): the PTCA group experienced more problems and had less energy (p < 0.01). No significant differences between the PTCA and CABG groups were found regarding to the change in quality of life caused by the intervention. CONCLUSION: The persistent angina pectoris and social inhibition among patients who have had a PTCA need further study.

[Complications shortly after transluminal angioplasty or following coronary surgery in 183 comparable patients with multi-vessel coronary disease]. / Complicaties kort na percutane transluminale angioplastiek of na coronariachirurgie bij 183 vergelijkbare patiënten met een meervatscoronaria-aandoening.

OBJECTIVE: Description of the differences in complications within 30 days after percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery (CABG) in patients suffering from multiple vessel coronary disease. DESIGN: Prospective, randomised. SETTING: 3 hospitals in the Netherlands. METHOD: Between 1988 and 1992, 183 Dutch patients took part in the European Coronary angioplasty versus bypass revascularisation investigation (CABRI) and were randomly treated with PTCA or CABG. Apart from the clinical result, all complications and cardiac events from time of randomisation until 30 days after the intervention were registered. RESULTS: The CABG group consisted of 88 patients with a total of 255 vascular obstructions, the PTCA group of 95 patients with 294 vascular lesions. In this short period of observation the clinical results of the two treatments were the same. The death rates were 1.1% and 2.1%, for CABG and PTCA respectively. The proportion of transmural, non-fatal myocardial infarctions was 2.3% in the CABG group versus 3.1% in the PTCA group. The proportion of reinterventions was higher in the PTCA group, 11.4% versus 1.1%. CONCLUSION: The differences in death rate and myocardial infarctions are not significant, in contrast to the difference in the numbers of reinterventions. These results appear to be in accordance with those of other randomised studies. Although long-term evaluation is needed, treatment of multiple vessel coronary disease by means of PTCA seems a reasonable alternative to coronary surgery.

Completeness of revascularisation by percutaneous coronary intervention.

OBJECTIVE: To evaluate the relationship between the completeness of revascularisation by percutaneous coronary intervention and the one-year occurrence of adverse cardiac events in patients with multivessel disease. PATIENTS: Patients with stable or unstable angina pectoris, or with exercise-induced ischaemia, were enrolled in the Coronary Angioplasty versus Bypass Revascularisation Investigation (CABRI). METHODS: In CABRI, patients were randomised to coronary bypass grafting (CABG; n=513) or angioplasty (PTCA; n=541). Revascularisation in patients randomised to PTCA was defined as complete if no lesions with a diameter stenosis <50% remained post-procedure. Patients with complete revascularisation were distinguished from those with one, two, and three or more remaining lesions, respectively. Differences in baseline characteristics and in the one-year occurrence of death, myocardial infarction, (re)CABG, and (re)PTCA between these subgroups were evaluated. Comparisons were made with patients randomised to CABG. RESULTS: Complete revascularisation was obtained in 148 patients randomised to PTCA (27%). In 147 (27%) cases one lesion remained, while there were 122 (23%) and 119 (22%) patients with two and three or more remaining lesions, respectively. Five (1%) patients could not be classified. The one-year rates of either death or MI were 9.5%, 5.4%, 8.2%, and 12.6% in the respective PTCA subgroups (p=0.225), and 6.2% in patients randomised to CABG (comparison with three or more remaining lesions after PTCA: p=0.017). The percentages of repeat interventions during one-year follow-up were 29.7%, 29.3%, 39.3%, and 51.3% (p<0.001), much higher than after CABG (3.5%; p<0.001). CONCLUSION: Complete revascularisation by PTCA in multivessel coronary disease did not result in a lower death or MI rate compared with incomplete revascularisation. Overall the patient's prognosis after PTCA is similar to CABG, but patients with three or more remaining lesions after PTCA had a worse prognosis than CABG patients.

The relation between myocardial blush grade and myocardial contrast echocardiography: which one is a better predictor of myocardial damage?

Background. Myocardial blush grade (MBG) and myocardial contrast echocardiography (MCE) are both indices for myocardial perfusion in patients with ST-elevation acute myocardial infarction (STEMI). We aimed to compare MBG with MCE in the infarct-related artery segment for assessing infarct size in patients with STEMI treated with primary percutaneous coronary intervention (PCI).Methods. 43 patients underwent successful (postprocedural TIMI flow 3) primary PCI for STEMI. MBG was assessed at the end of the PCI procedure and MCE was assessed 1.7+/-1.8 days after PCI. Enzymatic infarct size was estimated by measurementof enzyme activities by using lactate dehydrogenase (LDH) as the referenceenzyme. Cumulative enzyme release (LDHQ(48)) from at least five serial measurements up to 48 hours after symptom onset was calculated. Also peak creatine kinase, CK-MB and peak LDH were measured.Results. MBG 0/1, 2 and 3 were observed in 14, 12 and 17 patients, respectively, and was compared with tertiles of MCE. We found a parallel correlation between both MBG and MCE and LDHQ(48). However, there was no correlation between MCE and MBG. Patients with both normal MCE and a normal MBG had least myocardial damage and those with both impaired MCE and an impaired MBG had most myocardial damage.Conclusion. Both MBG and MCE are good predictors of infarct size in STEMI patients treated with PCI. However, these markers are not mutually related, possibly due to time-related changes in myocardial perfusion. Combining these two markers may yield a more accurate prediction of final myocardial damage. (Neth Heart J 2010;18:25-30.).

Effects of altitude on exercise level and heart rate in patients with coronary artery disease and healthy controls.

Background. To evaluate the safety and effects of high altitude on exercise level and heart rate in patients with coronary artery disease compared with healthy controls.Methods. Eight patients with a history of an acute myocardial infarction (ejection fraction >5%) with a low-risk score were compared with seven healthy subjects during the Dutch Heart Expedition at the Aconcagua in Argentina in March 2007. All subjects underwent a maximum exercise test with a cycle ergometer at sea level and base camp, after ten days of acclimatisation, at an altitude of 4200 m. Exercise capacity and maximum heart rate were compared between groups and within subjects.Results. There was a significant decrease in maximum heart rate at high altitude compared with sea level in both the patient and the control group (166 vs. 139 beats/min, p<0.001 and 181 vs. 150 beats/min, p<0.001). There was no significant difference in the decrease of the exercise level and maximum heart rate between patients and healthy controls (-31 vs. -30%, p=0.673).Conclusion. Both patients and healthy controls showed a similar decrease in exercise capacity and maximum heart rate at 4200 m compared with sea level, suggesting that patients with a history of coronary artery disease may tolerate stay and exercise at high altitude similarly to healthy controls. (Neth Heart J 2010;18:118-21.).

Reversible cardiac valvular disease in catastrophic antiphospholipid syndrome.

Catastrophic antiphospholipid syndrome (CAPS) is a severe form of antiphospholipid syndrome (APS). It frequently leads to multiorgan failure with an approximate mortality rate of 50%. The heart is involved in about 50% of the patients with CAPS. We report two cases with CAPS and severe heart manifestations, documented by echocardiography. Both women show regression of the valvular regurgitation under treatment. Valve replacement therapy was no longer necessary. In earlier studies and case reports, cardiac valve involvement had been characterised by valve thickening and vegetations. We suppose that (sometimes reversible) microvascular disturbances lead to valvular regurgitation via papillary muscle dysfunction and myocardial stunning.

Indications for routine heart-catheterization after CABG and PTCA.

Routine heart-catheterization after Coronary Artery Bypass Graft surgery (CABG) or Percutaneous Transluminal Coronary Angioplasty (PTCA) has been advocated to determine the change in bypass graft or dilated coronary artery and native coronary artery status, the effective disease remaining after CABG or PTCA and the relation between progression of disease, left ventricular function and symptomatology. Results of angiographic follow-up data after CABG and PTCA are presented and the practical implications are discussed. The reliability of symptoms, invasive and non-invasive test for the detection of ischemia are considered. Finally, recommendations are made for the indication of routine heart-catheterization after CABG and PTCA.

Coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. Twenty-year clinical outcome.

AIMS: The purpose of this study is to compare the long-term outcome (up to 20 years) of coronary artery bypass surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in a consecutive patient series at a single centre. Survival is similar after CABG and PTCA up to 8 years follow-up in patients with multivessel disease, with a reduced need for repeat revascularization after CABG. As coronary artery disease is a lifetime disease, longer-term follow-up of these revascularization therapies is necessary to help clinical decision-making. METHODS AND RESULTS: The CABG study population consisted of the first 1041 consecutive patients who underwent a first elective coronary bypass surgery between 1970 and 1980. The PTCA study population consisted of 702 consecutive patients who underwent a first elective coronary angioplasty procedure between 1980 and 1985. Mortality and subsequent revascularization up to 20 years were captured. Survival rates were adjusted using proportional hazards methods to account for baseline differences. RESULTS: The unadjusted survival rates were 92%, 77%, 57% and 49% after CABG at respectively, 5-, 10-, 15- and 17 years and 91%, 80%, 64% and 59% after PTCA. In the multivessel disease subgroup, survival was similar with a benefit apparent after CABG in the first 8 years of follow-up. The therapy chosen, CABG or PTCA, was a univariate predictor of mortality in favour of PTCA (RR: 1.28; 95% CI: 1.10-1.49), but after correction for baseline characteristics, the relative risk of mortality for CABG vs PTCA was comparable (RR: 1.03; 95% CI: 0.87-1.24). The adjusted survival curves in the subgroup of diabetic elderly patients with multivessel disease were similar after the tenth year with only a slightly better survival in the CABG population in the first 10 years. Repeat intervention was more frequently required after PTCA during the first 8 years, but after this time more frequently in the CABG group. CONCLUSION: When comparing CABG and PTCA it can be concluded that both strategies are equally effective in terms of 20-year survival. In particular, after more than 10 years all differences tend to disappear. While repeat intervention was significantly higher in the first year after PTCA, after 7-8 years, reintervention was greater in patients who had initial CABG.

Patients with a normal exercise thallium-201 myocardial scintigram: always a good prognosis?

The prognostic value of a normal exercise thallium-201 scintigram was determined in 211 patients with a normal exercise and resting scintigram. Endpoints were sudden cardiac death, non-fatal acute myocardial infarction and coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Forty patients (19%) had a history of a previous myocardial infarction and 40 (19%) were known to have had a previous percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Sixty-four patients (31%) were on treatment with beta-blocking agents. After a mean follow-up period of 23.5 months, 22 patients had had a cardiac event (1 cardiac death, 6 myocardial infarction, 15 revascularization). For the total group, the 1-year event rate for cardiac death, myocardial infarction, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting was 7.0%. For cardiac death or myocardial infarction alone the event rate was 2.8%. The only parameter independently predictive for cardiac events was the regular use of beta-blocking agents. The high event rate in patients on beta-blocking treatment is partly due to the fact that these patients were more symptomatic for coronary artery disease. The sustained beta-adrenergic blockade in this patient group, even in patients advised to stop medication, was suspected to interfere with the results of 201Tl scintigraphy. Therefore, more attention should be paid to patient instruction regarding the discontinuation of medication before the test.

The ARTS study (Arterial Revascularization Therapies Study).

The rising costs of health care have forced policy makers to make choices, and new treatments are increasingly assessed in terms of the balance between additional costs and additional effects. The recent recognition that stenting has a major and long-lasting effect enhancing balloon PTCA procedure has made it imperative to compare in patients with multivessel disease the standard surgical procedure with multiple stenting in a large scale multinational and multicentre approach (19 countries, 68 sites). Selection and inclusion of patients is based on a consensus of the cardiac surgeon and interventional cardiologist on equal 'treatability' of patients by both techniques with analysis of clinical follow-up (event-free survival) on the short (30 day), medium (1 year), and long-term (3 and 5 year) with analysis of cost-effectiveness and quality of life (EuroQol and SF-36). Of the entire trial, the primary null hypothesis which needs to be rejected is that there will be no difference in event-free survival or effectiveness (E), at 1 year and also that the direct and indirect costs (C) per event-free year are not different between surgery or stenting. For this to become significant with a power of 90% one needs 1200 patients. Between April 97 and June 98, 1205 patients have been randomized with a monthly recruitment of 83 patients. Expected costs, effects and cost-effectiveness ratio (CE ratio) are: Stent high costs 2 VDStent high costs 3 VDStent low costs 2 VDStent low costs 3 VDCABG costs (C)$19.297$24.566$16.638$20.456$21.350 effects (E)81%81%81%81%88% CE ratio$23.876$30.397$20.586$25.322$24.348 Clinically, stenting is not expected to be more effective than CABG, but should be cost effective in both the 2- and 3-VD group when using the lower cost estimate and in the 2 VD group when using the higher cost assumptions.