Assessing mortality risk in Type 2 Diabetes patients with prolonged ASCVD risk factors: the inclusive Poh-Ai predictive scoring system with CAC Score integration.

PURPOSE: To enhance the predictive risk model for all-cause mortality in individuals with Type 2 Diabetes (T2DM) and prolonged Atherosclerotic Cardiovascular Disease (ASCVD) risk factors. Despite the utility of the Coronary Artery Calcium (CAC) score in assessing cardiovascular risk, its capacity to predict all-cause mortality remains limited. METHODS: A retrospective cohort study included 1929 asymptomatic T2DM patients with ASCVD risk factors, aged 40-80. Variables encompassed demographic attributes, clinical parameters, CAC scores, comorbidities, and medication usage. Factors predicting all-cause mortality were selected to create a predictive scoring system. By using stepwise selection in a multivariate Cox proportional hazards model, we divided the patients into three risk groups. RESULTS: In our analysis of all-cause mortality in T2DM patients with extended ASCVD risk factors over 5 years, we identified significant risk factors, their adjusted hazard ratios (aHR), and scores: e.g., CAC score > 1000 (aHR: 1.57, score: 2), CAC score 401-1000 (aHR: 2.05, score: 2), and more. These factors strongly predict all-cause mortality, with varying risk groups (e.g., very low-risk: 2.0%, very high-risk: 24.0%). Significant differences in 5-year overall survival rates were observed among these groups (log-rank test < 0.001). CONCLUSION: The Poh-Ai Predictive Scoring System excels in forecasting mortality and cardiovascular events in individuals with Type 2 Diabetes Mellitus and extended ASCVD risk factors.

Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED.

BACKGROUND: There are several causes of ST-segment elevation (STE) besides acute myocardial infarction (MI). OBJECTIVES: We design this study to determine the prevalence, etiology, clinical manifestation, electrocardiographic characteristics, and outcome in patients with false-positive STEMI. METHODS: This is a retrospective case-control study design. At our emergency department, 297 patients who underwent emergent coronary angiography for suspected STEMI were enrolled from January 2004 to December 2010. RESULTS: Of the 297 patients who underwent coronary angiography, 31 patients (10.4%) did not have a clear culprit coronary lesion and were classified as false-positive STEMI. False-positive STEMI patients had a lower incidence of typical chest pain or chest tightness (58.1% vs 87.6%, P < .001). Inferior STE occurred significantly more often in the patients with true-positive STEMI (49.6% vs 25.8%, P = .012), and diffuse STE, more often in the patients with false-positive STEMI (19.4% vs 0.38%, P = .001). Total height of STE was lower in false-positive STEMI patients (7.5 ± 4.9 vs 10.9 ± 7.9 mm, P = .002) if excluding 5 patients of marked STE just after cardiopulmonary resuscitation. Concave STE and no reciprocal ST-segment depression occurred more often in false-positive STEMI patients (51.6% vs 24.1%, P = .001; 64.5% vs 19.2%, P < .001). There was no significant difference of in-hospital major adverse events in the patients with false-positive and true-positive STEMI. CONCLUSIONS: The diagnosis of false-positive STEMI is not uncommon. Detailed clinical evaluation and electrocardiogram interpretation may avoid partly unnecessary catheterization laboratory activation.

Coronary Artery Calcium Score Predicts Long-Term Cardiovascular Outcomes in Asymptomatic Patients with Type 2 Diabetes.

AIMS: Type 2 diabetes mellitus (T2DM) is no longer regarded as a coronary risk equivalent, and heterogeneity of cardiovascular risk exists, suggesting that further risk stratification should be mandatory. This study aimed to determine the prevalence and clinical predictors of coronary artery calcium (CAC) score, and evaluate the CAC score as a predictor of cardiovascular outcome in a large asymptomatic T2DM cohort. METHODS: A total of 2,162 T2DM patients were recruited from a Diabetes Shared Care Network and the CAC score was measured. Cardiovascular outcomes were obtained for 1,928 patients after a follow-up of 8.4 years. Multiple regression analysis and Cox proportional hazard regression were applied to identify clinical predictors of CAC and calculate the incidence and hazard ratios (HRs) for all-cause mortality and cardiovascular events by CAC category. RESULTS: Of the recruited patients, 96.8% had one or more risk factors. The distribution of CAC scores was as follows: CAC=0 in 24.2% of the patients, 0 ＜CAC ≤ 100 in 41.5%, 100 ＜CAC ≤ 400 in 20.3%, CAC ＞400 in 14.7%. The multivariable predictor of increased CAC included age (years) (odds ratio, 1.07; 95% confidence interval, 1.06-1.08), male sex (1.82; 1.54-2.17), duration (years) of T2DM (1.07; 1.05-1.09), and multiple risk factors (1.94; 1.28-2.95). Increasing severity of CAC was associated with higher all-cause or cardiac mortality and higher incident cardiovascular events. The HRs for cardiac death or major cardiac events in CAC ＞400 vs CAC=0 were 8.67 and 10.52, respectively ( p＜0.001) Conclusion: CAC scoring provides better prognostication of cardiovascular outcome than traditional risk factors in asymptomatic T2DM patients, and may allow identifying a high-risk subset for enhancing primary prevention.

Assessing myocardial bridging and left ventricular configuration by 64-slice computed tomography in patients with apical hypertrophic cardiomyopathy presenting with chest pain.

OBJECTIVE: We aimed to assess the usefulness of multislice computed tomographic (CT) angiography to detect coronary artery disease (CAD), including myocardial bridging (MB) and left ventricular morphology (LVG), in patients with apical hypertrophic cardiomyopathy (AHCM) who presented with angina and apical asynergy. MATERIALS AND METHODS: Sixty-four-slice CT angiography was performed in 14 patients with echocardiographically diagnosed AHCM who presented with typical or atypical chest pain. Coronary angiography was performed in 7 patients because of either suspected CAD or echocardiographic apical hypokinesia. We assessed the correlations between coronary anatomy, apical thickness, and LV configuration that were determined by echocardiography, LVG, and 64-slice CT angiography. RESULTS: The multislice CT confirmed the diagnosis of AHCM in 14 patients. The LVGs were all compatible between the 64-slice CT angiography and the LVG in the 7 patients who had "ace-of-spades" configurations, apical sequestrations, and an apical aneurysm. Furthermore, 2 significant CADs and 7 MBs were detected by 64-slice CT angiography. CONCLUSIONS: Multislice CT can offer high accuracy for the noninvasive detection of apical wall thickness and left ventricular configuration in patients with AHCM. It also provides additional information about significant coronary stenosis and MB in patients with chest pain. This promising technology has a potential to complement invasive cardiac catheterization in clinical practice.

5A/6A polymorphism of the stromelysin-1 gene and angiographic restenosis after coronary artery stenting.

BACKGROUND: Coronary stent deployment is a major advance in interventional treatment, but 20-40% of patients still develop in-stent restenosis (ISR) due to neointimal hyperplasia. Genetic factors play a role in restenosis. This study investigated the frequency of 5A/6A polymorphism in the promoter of the stromelysin-1 gene, and the issue of whether it contributes to restenosis among patients receiving coronary stent in the Chinese population in Taiwan. METHODS: We investigated 344 symptomatic patients after successful coronary stent placement. All patients received repeated angiography after 6 months, or earlier if clinically indicated. Angiographic restenosis was defined as > or = 50% diameter stenosis at follow-up. Genotyping for stromelysin-1 promoter was based on a polymerase chain reaction technique. RESULTS: The stromelysin-1 gene promoter genotypes 5A5A, 5A6A, and 6A6A were distributed in 3.5%, 22.7%, and 73.8% of patients, respectively. The frequency of the 6A allele was 0.85. There was no significant difference in angiographic ISR between the non-6A6A and 6A6A groups (28.9% and 37.0%, respectively, p = 0.165). However, subgroup analysis revealed a significant difference in patients according to angina status. Among the 5A5A and 5A6A genotype groups, patients with unstable angina had significantly higher ISR rates than those with stable angina (48% vs 21.5%, p = 0.013). On the other hand, among patients with stable angina, those with a 6A6A genotype had a higher ISR rate than those with a non-6A6A genotype (p = 0.029), making the 6A6A genotype an independent predictor of ISR (odds ratio, 2.57; 95% confidence interval, 1.22-5.41; p = 0.013). CONCLUSION: There is a low frequency of the stromelysin-1 promoter 5A allele in the Chinese population in Taiwan. How stromelysin-1 5A/6A polymorphism affects ISR appears to be linked to angina status. These results merit further study to identify patients carrying genotypes which put them at increased risk of ISR, and which matrix metalloproteinase inhibitors or drug-eluting stents are more effective for those at risk.

Coronary Artery Calcium Score Compared with Cardio-Ankle Vascular Index in the Prediction of Cardiovascular Events in Asymptomatic Patients with Type 2 Diabetes.

AIM: Coronary artery calcium (CAC) score has a role in stratifying cardiovascular risk in patients with diabetes. Cardio-ankle vascular index (CAVI) is also a useful method to detect coronary artery calcification. This study compares CAC score with CAVI in the prediction of cardiovascular events in patients with diabetes. METHODS: From August 2006 to June 2008, a total of 626 patients with diabetes who received CAC score assessment with concomitant tests of ankle-brachial index and CAVI were included in this study. RESULTS: During 4 years of follow-up, 98 participants developed cardiovascular events. There is an increased incidence of coronary revascularization and total cardiovascular events with higher categories of CAC score (P ＜ 0.05 when CAC score ≥ 100). The logistic regression analyses revealed pooled odd ratios for coronary revascularization, and total cardiovascular events were 1.25 [95% confidence interval (CI) 1.03- 1.51, P =0.021] and 1.23 (95% CI 1.07-1.42, P = 0.005), respectively, for high versus low CAVI (CAVI ≥ 9.0 vs CAVI ＜ 9.0). The logistic regression model revealed that a CACscore of ≥ 1000 rather than a CAVI of ≥ 9.0 had a higher predictive value for total cardiovascular events. CONCLUSIONS: A CAC score of ≥ 100 or a CAVI of ≥ 9.0 predicts future total cardiovascular events in asymptomatic patients with type 2 diabetes. Considering the advantages of CAVI, it can be used as one of the screening tools to reflect coronary atherosclerosis in these patients.

Apical hypertrophic cardiomyopathy: correlations between echocardiographic parameters, angiographic left ventricular morphology, and clinical outcomes.

BACKGROUND: Echocardiographic parameters could be implicated in the development of apical asynergy (characterized by apical sequestration or apical aneurysm) and worse cardiovascular outcome in patients with apical hypertrophic cardiomyopathy (ApHCM). HYPOTHESIS: Echocardiographic parameters and morphological patterns of left ventriculograms are associated with cardiovascular morbidity and mortality in patients with ApHCM. METHODS: We followed 47 cases with echocardiographically documented ApHCM. Echocardiographic findings of the extent and degree of hypertrophy, sustained cavity obliteration, and paradoxical diastolic jet flow were measured. All patients underwent a cardiac catheterization except for the cases whose informed consent was not acquired. The clinical manifestations were assessed and recorded by the attending physicians during 35.4 ± 23.7 months follow-up. RESULTS: Among the 47 patients with ApHCM, 30 patients presented as the "pure" form and 17 patients present as the "mixed" form. Seventeen of 28 patients with sustained cavity obliteration showed paradoxical flow by echocardiography. Thirty-one underwent left ventriculograms and showed morphological abnormalities, including "ace-of-spades" configuration (15/31), apical sequestration (12/31), and apical aneurysm (4/31). The results demonstrated that cardiovascular morbidities occurred in 21 of 47 patients and were closely related to the presence of mixed form ApHCM, cavity obliteration, and paradoxical flow by univariate and multivariate Cox analysis. During the period of follow-up, 4 patients (9.5%) died, and among them 3 had concomitant apical aneurysm. CONCLUSIONS: We concluded that detection of cavity obliteration and paradoxical flow and discrimination of pure form from mixed form by echocardiography, as well apical sequestration from apical aneurysm in ApHCM patients, is warranted.

677TT polymorphism of methylenetetrahydrofolate reductase in combination with low serum vitamin B12 is associated with coronary in-stent restenosis.

BACKGROUND: Recent studies have shown that a common mutation (nucleotide 677 C-->T) in the methylenetetrahydrofolate reductase (MTHFR) gene may contribute to a mild rise in plasma homocysteine levels and increase the incidence of coronary artery disease. Therefore, this study was designed to further investigate whether the effects of MTHFR 677 C to T mutation, plasma homocysteine, serum vitamin B12, and folate can influence restenosis after successful coronary stenting. METHODS AND RESULTS: We investigated 260 patients each with a lesion after successful coronary stent placement. All patients received a repeated angiography after 6 months, or earlier if clinically indicated. Angiographic in-stent restenosis (ISR) was defined as >or=50% diameter stenosis at follow-up. Genotyping for MTHFR was based on a polymerase chain reaction technique. Also fasting plasma homocysteine, vitamin B12, and folate levels were measured at the same time. The ISR rate was higher among the patients with the TT genotype than in those with the non-TT genotypes (64.0% versus 32.9%, P=0.002). There was no significant difference in plasma homocysteine levels among patients with the TT genotype and patients with the non-TT genotypes (15.9+/-7.6 versus 15.5+/-6.6 micromol/L, P=0.75). However, among the patients with the TT genotype, those with higher plasma homocysteine levels (>or=12 micromol/L) demonstrated a significantly higher ISR rate (75.0% versus 33.5%, P=0.001). Logistic regression analysis revealed that the combined presence of the MTHFR TT genotype and lower than average serum vitamin B12 (>or=550 pg/mL) resulted in the most significant difference in the risk of ISR (OR=3.57, CI=1.51-8.46, P=0.004; OR=2.36, CI=1.35-4.15, P=0.003). CONCLUSIONS: MTHFR 677TT polymorphism and low serum vitamin B12 each individually increased the risk of coronary ISR. Furthermore, the combination of these parameters resulted in a greater increase in risk.

Development of atrial fibrillation in patients with atrioventricular block after atrioventricular synchronized pacing.

Many studies have evidenced an increased incidence of AF in patients receiving single chamber ventricular pacing (VVI) when compared with those undergoing an atrial-based system (AAI or DDD). However, the difference in incidence of AF between two atrial-based systems (VDD, DDD) in patients with AV block was still controversial. This study was conducted to compare the development of AF between different modes of pacemakers (VDD and DDD) in patients with symptomatic AV block. A retrospective review was conducted of the detailed records of all consecutive patients who received permanent pacemakers due to symptomatic bradycardia from March 1995 to March 2000. The occurrence of AF was documented when there was presence of AF in the free-run or 12-lead ECG, any ECG strips, or persistent AF on 24-hour Holter ECG during the follow-up. The study included 152 patients (44 women, 108 men; mean age 73). The patients were divided into two groups: VDD (n = 100) and DDD (n = 52). The mean follow-up was 48.9 +/- 22.9 months. The incidence of AF was 7.9%. A higher incidence of AF was noted in the DDD group (15.4%) when compared with the VDD group (4.0%, P = 0.023). The incidence of development of AF in patients with AV block was higher in those receiving DDD cardiac pacing when compared with those who received the VDD system. The authors suggest that VDD pacing may be a better choice than the DDD system for patients with AV block, but without clinical evidence of sinus node dysfunction, and if an atrial lead is required, it should be placed close to the Bachmann's bundle.