Interrelation of ST-segment depression during bicycle ergometry and extent of myocardial ischaemia by myocardial perfusion SPECT.

PURPOSE: The aim of this study was to compare ST-segment depression (STD) during bicycle ergometry and extent of myocardial ischaemia assessed by myocardial perfusion SPECT (MPS) in a large patient cohort. METHODS: Consecutive patients (n = 955) referred for MPS with bicycle ergometry and interpretable stress ECG were evaluated with respect to ECG and MPS findings of ischaemia. The maximal STD was recorded and exercise ECG was considered ischaemic if STD was horizontal or downsloping (>or=1 mm). MPS was interpreted using a 20-segment model with a scale of 0 to 4. A summed stress (SSS), summed rest (SRS) and summed difference score (SDS = SSS-SRS, e.g. extent of ischaemia) were derived. Ischaemia was defined as an SDS >or= 2. RESULTS: An exercise-induced STD was present in 215 patients (22%) and myocardial ischaemia on MPS was present in 366 patients (38%). The extent of ST-segment depression and the number of ECG leads with significant STD were each strongly and significantly associated with increasing severity of ischaemia and the number of coronary territories involved (p < 0.01 for all correlations). CONCLUSION: These data demonstrate a strong correlation between the extent of STD, number of ischaemic leads and severity of myocardial ischaemia as assessed by MPS during bicycle ergometry.

Detection of intake of nonsteroidal anti-inflammatory drugs in elderly patients with heart failure. How to ask the patient?

PRINCIPLES: Heart failure hospitalisations may be related to non-steroidal anti-inflammatory drug (NSAID) use. Since NSAIDs are usually prescribed by general practitioners or taken without prescription, their use may be largely underestimated. Therefore, we assessed the impact of a focussed analgesic medication history as compared to a usual medication history on detection of NSAID intake in elderly heart failure patients and the potential effect of medical advice on discontinuation of this therapy in a non-controlled study design. METHODS: A structured and stepwise history of analgesic intake (firstly open questioning about medication intake, secondly with a focus on analgesic intake, finally focussing on behaviour in case of pain) was done in 197 elderly heart failure patients taking part in the TIME-CHF study at baseline and up to 3 follow-up visits. All participants were informed about the potential hazardous effects of NSAIDs and alternative analgesic therapy was proposed in case of NSAID intake. Patients were aged 60 years or older with clinical signs of heart failure NYHA > or =II, elevated NT-BNP, and had been hospitalised due to heart failure within the last year. Details of this study have been described previously. RESULTS: At baseline, 43 patients (22%) were taking NSAID. Almost half (n = 19) taking NSAID reported the use only after specific questioning. Therefore, a focussed analgesic medication history was superior as compared to a usual medication history to detect patients taking NSAIDs (22% vs 12%; p <0.001). After instruction and proposal of alternative analgesic therapy, NSAID intake dropped from 22% to 7% (p <0.001). No risk factor for continuous use was identified. CONCLUSIONS: NSAID use in heart failure patients is relatively common. Specific questioning may help to increase detection of NSAID intake and information on its hazardous effects to decrease NSAID use.

Frequency and predictors of hyperkalemia in patients ≥60 years of age with heart failure undergoing intense medical therapy.

Hyperkalemia is a concern in heart failure (HF), especially in older patients with co-morbidities. Previous studies addressing this issue have focused mainly on younger patients. This study was aimed at determining the frequency and predictors of hyperkalemia in older patients with HF undergoing intense medical therapy. Frequency and predictors of hyperkalemia were defined in patients (n = 566) participating in the Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure, in which patients ≥60 years of age were randomized to a standard versus an intensified N-terminal brain natriuretic peptide-guided HF therapy. During an 18-month follow-up 76 patients (13.4%) had hyperkalemia (≥5.5 mmol/L) and 28 (4.9%) had severe hyperkalemia (≥6.0 mmol/L). Higher baseline serum potassium (odds ratio [OR] 2.92 per mmol/L), baseline creatinine (OR 1.11 per 10 µmol/L), gout (OR 2.56), New York Heart Association (NYHA) class (compared to NYHA class II, IV OR 3.08), higher dosage of spironolactone at baseline (OR 1.20 per 12.5 mg/day), and higher dose changes of spironolactone (compared to no dose change: 12.5 mg, OR 1.45; 25 mg, OR 2.52; >25 mg, OR 3.24) were independent predictors for development of hyperkalemia (p <0.05 for all comparisons). In conclusion, hyperkalemia is common in patients ≥60 years of age with HF undergoing intense medical therapy. Risk is increased in patients treated with spironolactone, in addition to patient-specific risk factors such as chronic kidney disease, higher serum potassium, advanced NYHA class, and gout. Careful surveillance of serum potassium and cautious use of spironolactone in patients at risk may help to decrease the incidence of potentially hazardous complications caused by hyperkalemia.

Gate-keeper to coronary angiography: comparison of exercise testing, myocardial perfusion SPECT and individually tailored approach for risk stratification.

We aimed to evaluate the differences between exercise testing (ET), myocardial perfusion SPECT (MPS) and a combination of ET and MPS based risk assessment as outlined by the guidelines with respect to their "gate-keeper" role to coronary angiography (cath) and the associated diagnostic procedural costs if prognostic considerations, as those proposed by the current guidelines and the recent literature, were taken into account. The Duke-score and the summed difference score (SDS; extent of ischemia) were assessed in 955 consecutive patients referred for MPS combined with ET. According to the guidelines and the available literature, three different algorithms for risk stratification were retrospectively applied: (1) ET based risk stratification and cath if intermediate or high risk Duke-score; (2) MPS based risk stratification and cath if SDS ≥ 8; (3) combined approach with ET as first step and MPS in case of intermediate risk Duke-score. A cath would have been suggested in every patient with either high risk Duke-score or SDS ≥ 8 in patients with intermediate risk Duke-score. The referral rate to cath was 27% according to the ET alone, 13% using MPS, and finally 12% applying the combined risk stratification. The cost of the diagnostic work-up including cath were: 615€, 1,299€, and 598€ per patient, respectively. The coronary angiography referral rate widely depends on the diagnostic modality used for risk stratification and according to the referral criteria provided by the guidelines. In the present study, the use of a stress imaging modality (MPS) and published prognostic data was associated with a lower referral rate to cath as compared to exercise testing alone and thus underlines the advantage of a risk based approach applying stress imaging in patients with intermediate risk Duke-score.