Prognostic value of myocardial perfusion scintigraphy in elderly patients with hypertension: a 10-year follow-up analysis.

PURPOSE: The aim of the study was to assess the role of myocardial perfusion scintigraphy (MPS) in the prediction of future cardiac events in elderly hypertensive patients and to investigate if its prognostic value is maintained during a 10-year follow-up period. METHODS: A total of 229 consecutive patients ≥ 65 years old (range 65-88 years) with arterial hypertension, who were referred to our institution for stress/rest (99m)Tc-sestamibi MPS between January 2000 and November 2001, were followed up for 10-12 years. Cardiac death, myocardial infarction and a coronary revascularization procedure were considered as events. Survival curves were computed by the Kaplan-Meier method. A stepwise Cox proportional hazards analysis was used to identify predictors of events. RESULTS: Follow-up was completed in 221 (96.5 %) patients; 26 patients experienced cardiac death, 29 myocardial infarction and 51 coronary revascularization. Annual event rates for cardiac death, cardiac death/myocardial infarction and cardiac death/myocardial infarction/coronary revascularization were, respectively, 0, 0.2 and 0.4 % for patients with a normal scan and 1.5, 3.0 and 5.3 % after an abnormal MPS. Event-free survival was significantly different according to extent and severity of perfusion defects (all p < 0.01). An increase in global chi-square in predicting cardiac events occurred when MPS data were added to pre-scan information (from 47.28 to 88.87; p < 0.001). CONCLUSION: MPS provides incremental prognostic information for the prediction of cardiac events in elderly patients with hypertension. Subjects with a normal scan have an excellent 10-year outcome, and the risk of experiencing a cardiac event increases with extension and severity of stress perfusion defect.

Acceptable reperfusion delay to prefer primary angioplasty over fibrin-specific thrombolytic therapy is affected (mainly) by the patient's mortality risk: 1 h does not fit all.

AIMS: The mortality benefit of primary percutaneous coronary angioplasty (PPCI) is time-dependent. We explored the relationship between risk and PPCI delay, adjusted for the delay at presentation, which leads to equivalent 30-day mortality between PPCI and fibrin-specific thrombolytic therapy (TT). METHODS AND RESULTS: Sixteen randomized trials were analysed. The mortality rate in the TT arm was interpreted as a proxy for mortality risk. We calculated the PPCI-related delay as the difference between 'door-to-balloon minus door-to-needle' time and PPCI survival benefit as 30-day mortality after TT minus 30-day mortality after PPCI. Baseline mortality risk (P = 0.004), PPCI delay (P = 0.006), and presentation delay (P = 0.03) were correlated with 30-day survival benefit of PPCI. By the regression analysis, the following equation: Z = 0.59X - 0.033Y - 0.0003W - 1.3 (where Z is the absolute reduction in mortality of PPCI over TT, X the mortality risk, Y the PPCI-delay, and W the presentation delay), can be calculated. According to this equation, acceptable angioplasty-related delay shows a wide range based mainly on the different risk profiles. CONCLUSION: Baseline mortality risk of ST elevation myocardial infarction patients is a major determinant of the acceptable time delay to choose the most appropriate therapy. Although a longer delay lowers the survival advantage of PPCI, a longer PPCI-related delay could be acceptable in high-risk STEMI patients.

Understanding and recognition of the right ventricular function and dysfunction via a numerical study.

The role played by the right ventricular (RV) dysfunction has long been underestimated in clinical practice. Recent findings are progressively confirming that when the RV efficiency deteriorates both the right and the left circulation is (significantly) affected, but studies dedicated to a detailed description of RV hemodynamic role still lack. In response to such a gap in knowledge, this work proposes a numerical model that for the first time evaluates the effect of isolated RV dysfunction on the whole circulation. Lumped parameter modelling was applied to represent the physio-pathological hemodynamics. Different grades of impairment were simulated for three dysfunctions i.e., systolic, diastolic, and combined systolic and diastolic. Hemodynamic alterations (i.e., of blood pressure, flow, global hemodynamic parameters), arising from the dysfunctions, are calculated and analysed. Results well accord with clinical observations, showing that RV dysfunction significantly affects both the pulmonary and systemic hemodynamics. Successful verification against in vivo data proved the clinical potentiality of the model i.e., the capability of identifying the degree of RV impairment for given hemodynamic conditions. This study aims at contributing to the improvement of RV dysfunction recognition and treatment, and to the development of tools for the clinical management of pathologies involving the right heart.

Predictors and time-related impact of distal embolization during primary angioplasty.

AIMS: We sought to identify predictors of distal embolization (DE) occurring during primary percutaneous coronary intervention (p-PCI) as well as to assess its impact on both myocardial reperfusion and necrosis, according to time-to-treatment. METHODS AND RESULTS: Clinical and angiographic characteristics were prospectively assessed in 400 consecutive patients who underwent p-PCI, in order to identify predictors of DE. The impact of DE on Thrombolysis in Myocardial Infarction (TIMI) flow, myocardial blush, and troponin I (TnI) was assessed according to symptom onset-to-balloon time. DE occurred in 64 (16%) patients and did not change with time-to-treatment (P = 0.87). The occlusion pattern of infarct-related artery (IRA), treatment of right coronary artery, higher TIMI thrombus score, longer lesion, and large IRA diameter were predictors of DE. The rate of TIMI 0/1 and myocardial blush 0/1 was higher in patients exhibiting DE when time-to-treatment was < or =6 h (P < 0.0001), while TnI was higher in patients with DE when time-to-treatment was <3 h. CONCLUSION: DE during p-PCI occurs more often in the presence of high thrombus burden lesion. It reduces the effectiveness of myocardial reperfusion within 6 h and enhances myocardial damage within 3 h after symptom onset. Afterwards, it does not affect myocardial reperfusion or the extent of myocardial damage.

Non-cardiovascular mortality, low-density lipoprotein cholesterol and statins: a meta-regression analysis.

BACKGROUND: As of today, the effect of statins on non-cardiovascular mortality is still being debated. Single studies have not been able to provide definite answers. We performed a meta-regression analysis on randomized statin trials in order to provide evidence that non-cardiovascular mortality is related to statin treatment and low-density lipoprotein (LDL) cholesterol plasma level. METHODS: We selected 29 randomized controlled trials of statins versus placebo, a total of 90,480 patients, with a follow-up of >12 months. Baseline and follow-up LDL levels and all-cause, cardiovascular and non-cardiovascular mortality were recorded. Weighted linear regression analysis was carried out separately for placebo and treatment groups. RESULTS: LDL level was inversely related to overall mortality (p = 0.0105) and non-cardiovascular mortality (p = 0.0171) in the treatment group. By contrast, in the placebo group only non-cardiovascular mortality was inversely correlated to LDL (p = 0.0032). The regression lines have similar slopes and run almost parallel to each other, with the treatment line lying below the placebo line. To identify the threshold of risk for starting statin therapy, we analysed the relationship between baseline cardiovascular risk and overall mortality in the two groups. Both correlations are highly significant and regression lines intersect at a risk of 0.29% per year. This implies that the effects of statins are favourable when the baseline cardiovascular risk exceeds approximately 3% in 10 years. CONCLUSIONS: A trend of increased non-cardiovascular mortality with decreased LDL exists both in placebo and treatment groups. However, at each given LDL cholesterol level, non-cardiovascular mortality is lower in treated patients. Therefore, statin therapy may improve the biological impact of LDL on non-cardiovascular mortality.

Periprocedural abciximab administration in ST elevation myocardial infarction patients. Effect on severe microvascular obstruction beyond the restoration of epicardial coronary flow by primary angioplasty.

OBJECTIVES: The impact of periprocedural (before primary percutaneous coronary angioplasty, PCI) abciximab administration on microvascular obstruction in patients with occluded infarct-related artery (IRA) is unknown. METHODS: We studied 36 consecutive patients with first ST elevation myocardial infarction (STEMI) and occluded IRA treated with successful primary PCI within 12 h from symptom onset, who received intravenous abciximab immediately before PCI and 49 matched patients who did not receive abciximab as controls. All patients underwent delayed-enhanced magnetic resonance (DE-MR) 6 +/- 2 days after PCI. Necrosis was judged as transmural when DE was extended to > or =75% of left ventricular (LV) segment thickness. Severe microvascular obstruction was identified as areas of late hypoenhancement surrounded by DE. RESULTS: Time to treatment was comparable in the two groups (182 +/- 60 vs. 188 +/- 110 min, respectively). Transmurality and severe microvascular obstruction were present in 3.03 +/- 2.8 versus 3.09 +/- 2.9 (p = 0.9) and 1.05 +/- 1.5 versus 1.06 +/- 1.8 (p = 0.6) of LV segments, respectively, in the abciximab group versus controls. At multivariate analysis, severe microvascular obstruction was independently associated only with transmural necrosis (OR 1.5, p < 0.001) and age (OR 1.1, p = 0.02) but not with the use of abciximab. CONCLUSIONS: Severe microvascular obstruction after primary PCI of STEMI patients with occluded IRA is related to transmural necrosis but not to the use of abciximab.

Discrepancies between catheter and Doppler estimates of aortic stenosis: the role of pressure recovery evaluated 'in vivo'.

BACKGROUND AND AIM OF THE STUDY: Wide discrepancies are often observed between catheter- and Doppler-derived gradients and valve areas. The study aim was to verify if these measurements could be attenuated in a clinical setting by taking into account pressure recovery. METHODS: Between 1st January 2000 and 31st March 2005, a total of 259 patients with an aortic valve area (AVA) < or =2 cm(2) was prospectively collected. During a standard diagnostic catheterization, the aortic valve gradient was taken as: [peak left ventricular pressure-- peak aortic pressure]. The AVA was calculated using the Gorlin formula (AG). Echocardiography was performed within 30 days of this procedure. Transvalvular gradients were measured using the Doppler technique, and the AVA was computed using the continuity equation (ACE). The diameter of the ascending aorta was monitored in the parasternal long-axis view, and the values averaged. The ascending aorta sectional area (AA) was then computed according to geometric formulae. In order to correct for pressure recovery, an energy loss coefficient (ELCO) equation was used [ELCO = (AA x ACE)/(AA -ACE)]. Correlations between AG, ACE and ELCO were evaluated by linear regression analysis. As cardiac output affects the estimates of valve areas, the correlation was calculated separately for patients with a median cardiac index (CI) above and below 2.7 1/min/m(2). RESULTS: A good linear correlation was found between AG and ACE with regression coefficient 0.88, independent of cardiac output. A similar correlation was present between AG and ELCO, with correlation coefficient 0.99 in patients with CI >2.7 1/min/m(2), and

Aortic stenosis severity assessment: how to match non-invasive to invasive metrics.

This article underscores the importance of the haemodynamic principles of the methods of measurement, as well as inherited limitations of each method, to adequately manage differing data between invasive and non-invasive tests.

Relation of patient age to outcome of percutaneous mitral valvuloplasty.

The aim of this study was to evaluate the impact of age on immediate- and long-term outcomes of percutaneous mitral balloon valvuloplasty (PMV). PMV is the first-line treatment for patients with symptomatic mitral stenosis. However, long-term results in large series of patients from Europe and the United States have been found less favorable than those from Asia and South America involving younger patients. Six hundred ten patients who underwent 626 PMV procedures were prospectively followed for 6.1 +/- 4.10 years using clinical and echocardiographic evaluation. Patients were divided in quartiles according to age: < or =41 years (n = 163), 42 to 53 years (n = 163), 54 to 63 years (n = 142), and >63 years (n = 158). The success of PMV was defined as valve area > or =1.5 cm(2) without severe regurgitation; restenosis was defined as a loss > or =50% of initial gain, with a valve area of <1.5 cm(2). PMV success was significantly more prevalent in younger patients: 95.7% in group 1, 91.4% in group 2, 86.4% in group 3, and 83.4% in group 4 (p = 0.002). No significant differences in complications were found among all age groups, including death, cardiac tamponade, emergency mitral replacement, and any embolic events (p = NS). Event-free survival was greater in younger patients (p <0.0001), but on multivariate analysis, age was not an independent predictor of events (p = NS). Restenosis occurred in 27.9% of patients, throughout all groups (p = NS). In conclusion, PMV may be safely and effectively performed in younger and older patients. Although event-free survival was greater in younger groups, multivariate analysis did not find that age was an independent predictor of events.

Influence of transmurality, infarct size, and severe microvascular obstruction on left ventricular remodeling and function after primary coronary angioplasty.

Infarct size has been considered an established marker of left ventricular (LV) remodeling. We assessed the predictive value of myocardial/microvascular injury assessed by delayed enhanced magnetic resonance imaging (MRI) on LV remodeling and LV ejection fraction after primary coronary intervention (PCI) compared with peak troponin levels, an established index of myocardial infarct size. We performed MRI in 76 patients with first acute myocardial infarction 6 +/- 2 days after successful PCI. Necrosis was judged as transmural when delayed enhancement was extended to >or=75% of LV segment thickness. Severe microvascular obstruction was identified as areas of late hypoenhancement surrounded by delayed enhancement. Infarct size was expressed as an index by dividing the total percentage of delayed enhancement involvement by the number of LV segments. LV end-diastolic volume index and function were quantified by 2-dimensional echocardiography at 6 +/- 1 months after acute myocardial infarction. Remodeling was evaluated as a change in LV end-diastolic volume index at follow-up compared with baseline. At univariate analyses, transmural necrosis, severe microvascular obstruction, infarct size, and troponin level were correlated directly with remodeling and inversely with LV function at follow-up (p <0.001). At multiple regression, only transmural necrosis and troponin level remained independent predictors of LV remodeling and function. With respect to troponin, transmural necrosis improved the predictive power of LV remodeling (R2 for change = 0.19) and function (R2 for change = 0.16). In conclusion, in patients with acute myocardial infarction undergoing PCI, the amount of transmural necrosis as assessed by MRI is a major determinant of LV remodeling and function, with significant additional predictive value to infarct size and severe microvascular obstruction.

Moderate-to-severe ischemic mitral regurgitation and multivessel coronary artery disease: Impact of different treatment on survival and rehospitalization.

BACKGROUND: The outcome of moderate-to-severe ischemic mitral regurgitation with multivessel coronary artery disease is still debated. We analysed the effect of different treatments, i.e. medical therapy (MT), coronary artery by-pass grafting (CABG) alone and CABG with mitral valve surgery (MVS), on the survival and rehospitalization of these patients. METHODS: Between 1990 and 2002, we identified 111 consecutive patients, aged 73+/-8 years, with chronic moderate-to-severe mitral regurgitation and multivessel coronary artery disease at cardiac catheterization, in absence of primary valve disease. Twenty-two patients were treated by MT, 50 by CABG and 39 by CABG+MVS. Overall, the median clinical and echocardiographic follow-ups were 34.9 and 14.6 months, respectively. RESULTS: Groups differed significantly (p < 0.03) for left ventricular end-diastolic volume index (MT 153+/-54, CABG 125+/-35, CABG + MVS 129+/-38, ml/m2), ejection fraction (MT 35+/-14, CABG 38+/-13, CABG + MVS 50+/-14, %) and mammary artery graft use (CABG 60, CABG + MVS 74, %). While in-hospital mortality was higher in surgical patients (MT 13.6, CABG 18, CABG + MVS 17.9, %, p=0.09), 7-years mortality showed a trend in favour of CABG + MVS compared to other groups (MT 100, CABG 57, CABG + MVS 29, %, p = 0.1). After adjusting for baseline differences, CABG alone or with MVS had a 57% (HR 0.43, p = 0.005) and 53% (HR 0.47, p = 0.02) risk reduction of combined cardiac death and rehospitalization rate compared to MT. However, only CABG + MVS independently predicted mortality (risk reduction 65%, HR 0.35, p = 0.027). CONCLUSIONS: In moderate-to-severe ischemic mitral regurgitation and multivessel coronary artery disease, surgery reduced total cardiac events but only a concomitant MVS significantly improved survival.

Explanation for the survival benefit of primary angioplasty over thrombolytic therapy in patients with ST-elevation acute myocardial infarction.

Our study evaluated the interaction across mortality risk, time delay related to percutaneous coronary intervention (PCI), and survival benefit of PCI over thrombolytic therapy (risk-time benefit analysis). Mortality risk and angioplasty-related time delay were independently correlated to 30-day survival benefit of primary angioplasty over lytic therapy. A PCI-related delay>60 minutes could be justified for high-risk patients.

Correlations between clinical presentation, brain natriuretic peptide, big endothelin-1, tumor necrosis factor-alpha and cardiac troponins in heart failure patients.

BACKGROUND: The term "biochemical marker" of heart failure is used to define a biochemical substance whose plasma levels correlate with the clinical and hemodynamic status and predict the prognosis of patients with heart failure. The aim of this study was to prospectively evaluate, in a single population of patients with heart failure, the correlations between the plasma levels of brain natriuretic peptide (BNP), big endothelin-1 (BET-1), tumor necrosis factor-alpha (TNF-alpha), cardiac troponin I (cTnI) and T (cTnT), the clinical presentation, and the left ventricular function. METHODS: The study population included a series of 120 patients (97 males, 81%, mean age 56+/-12 years) in NYHA functional class I (49%), II (20%), III (26%), IV (5%) who were admitted to our institution or followed up as outpatients. All patients underwent cardiologic evaluation, standard electrocardiography, two-dimensional echocardiography, and venous blood sampling on the same day. RESULTS: At univariate analysis the following correlations were found to be significant: all the laboratory parameters correlated with the NYHA class (BNP r = 0.63, BET-1 r = 0.56, cTnI r = 0.25, cTnT r = 0.24, TNF-alpha r = 0.23); BNP (r = -0.39) and BET-1 (r = -0.27) with left ventricular ejection fraction; BNP (r = 0.37) and BET-1 (r = 0.21) with the degree of mitral insufficiency; BNP (r = -0.39), BET-1 (r = 0.25) and TNF-alpha (r = -0.19) with systolic blood pressure; cTnT (r = 0.34), cTnI (r = 0.33), BNP (r = 0.22) and BET-1 (r = 0.19) with heart rate; BNP with age (r = 0.33) and body mass index (r = -0.28). The plasma levels of BNP, BET-1, cTnT and cTnI were significantly higher in case of systemic or pulmonary congestion. At multiple regression analysis the following correlations were still present: BNP with the NYHA functional class (p < 0.005) and with pulmonary venous congestion (p < 0.05); BET-1 with the presence of pulmonary venous congestion (p < 0.005); TNF-alpha with the NYHA class (p < 0.05) and systolic blood pressure (p < 0.001); cardiac troponins with heart rate (p < 0.05). CONCLUSIONS: The plasma concentrations of BNP and BET-1 showed the best and comparable correlations with parameters describing the clinical status of patients with heart failure, in particular with the presence of pulmonary venous congestion. The value of the plasma concentration of TNF-alpha and those of cardiac troponins were found to be limited in patients with relatively stable heart failure.

Myocardial perfusion grade and survival after percutaneous transluminal coronary angioplasty in patients with cardiogenic shock.

We sought to evaluate myocardial reperfusion and its prognostic value after percutaneous transluminal coronary angioplasty (PTCA) in patients admitted for cardiogenic shock. Lack of myocardial reperfusion despite restored coronary flow affects the survival of patients with acute myocardial infarction (AMI). Myocardial blush grade (MBG) is an angiographic measure of myocardial perfusion. We assessed MBG in 41 consecutive patients admitted to our department within 12 hours from the onset of AMI and in cardiogenic shock. PTCA was successful in 83% of patients. Thrombolysis In Mycardial Infarction (TIMI) grade 3 flow was demonstrated in 22 patients (53%). MBG 2/3 was found in 14 patients (34%); among them, 12 had TIMI 3 flow. Compared with patients with MBG 2/3, those with MBG 0/1 were older (71 +/- 11 vs 57 +/- 13 years, p = 0.001), had a higher prevalence of diabetes (48% vs 14%, p = 0.04) and hypertension (63% vs 29%, p = 0.04), showed a trend toward longer ischemic time (6.1 +/- 2.4 vs 4.9 +/- 1.1), and had larger enzymatic infarct size (peak creatine kinase 7,690 +/- 3,516 vs 5,500 +/- 2,977 IU/L). Mortality was higher in patients with MBG 0/1 both in the hospital (81% vs 14%, p <0.001) and at follow-up (81% vs 29%, p = 0.001). After adjustment by multivariate analysis, MBG 0/1 (odds ratio 16, p = 0.01) and age (odds ratio 3.8/10 years, p = 0.04) were correlated with in-hospital mortality. MBG 2/3 was achieved in a few patients in cardiogenic shock after AMI who were treated with PTCA; this was a strong predictor of in-hospital survival. Also, risk stratification after mechanical revascularization should include assessment of restoration of myocardial reperfusion.