Quality of life as predictor for the development of cardiac ischemia in high-risk asymptomatic diabetic patients.

BACKGROUND: Ischemia induced by psychological stress and depression is a common phenomenon in stable coronary artery disease (CAD). We evaluated the quality of life (QoL) of diabetic patients screened for CAD and assessed the prognostic value of mental and physical QoL scores to predict the development of new cardiac ischemia. METHODS: Prospective multicentre outcome study. The study comprised 400 asymptomatic diabetic patients without history or symptoms of CAD. They underwent myocardial perfusion single-photon emission computed tomography (MPS) and assessment of QoL by two questionnaires: Hospital Depression and Anxiety Scale (HADS-D and HADS-A) and Medical Outcomes Study Short Form 36 (SF-36) at baseline and after 2 years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management. RESULTS: Only mental QoL scores but not physical QoL scores or traditional cardiovascular risk factors were predictive of new ischemia (n = 11/306) during follow-up. The prognostic value for new ischemia as quantified by the area under the receiver operating characteristics curve (AUC) amounted to 0.784 (95% confidence interval (CI) 0.654-0.914, P = 0.002) for HADS-D and to 0.737 (95% CI 0.580-0.893, P = 0.011) for HADS-A. This finding was confirmed by SF-36 mental sum score (AUC 0.688, 95% CI 0.539-0.836, P = 0.036), but not SF-36 physical sum score. QoL scores did not change after 2 years in patients with ischemia at baseline. CONCLUSIONS: QoL scores assessing mental health, particularly depression and anxiety, predicted the development of new cardiac ischemia in asymptomatic diabetic patients. The study is limited by a small number of events (new ischemia) and so the results should be considered hypothesis generating rather than conclusive.

Prognostic value of "routine" cardiac stress imaging 5 years after percutaneous coronary intervention: the prospective long-term observational BASKET (Basel Stent Kosteneffektivitäts Trial) LATE IMAGING study.

OBJECTIVE: This study sought to evaluate the prognostic value of routine stress myocardial perfusion scintigraphy (MPS) 5 years after percutaneous coronary intervention (PCI). BACKGROUND: Current appropriate use criteria define routine cardiac stress imaging <2 years after PCI as inappropriate and >2 years as uncertain in asymptomatic patients. METHODS: All 339 of 683 BASKET (Basel Stent Kosteneffektivitäts Trial) 5-year survivors (55%) consenting to undergo protocol-mandated MPS and subsequent evaluation irrespective of symptoms were followed for major adverse cardiac events (MACE) (cardiac death, myocardial infarction [MI], or revascularization). For MPS, summed perfusion scores were calculated and perfusion defects were related to treated-vessel or remote myocardial areas. RESULTS: Patients were 72 ± 10 years of age, 18% were female, and 90% were free of angina. MPS findings were abnormal in 205 of 339 patients (60%) with complete follow-up. During 3.7 ± 0.3 years, there were 7 cardiac deaths, 18 MIs, and 47 revascularizations, resulting in a MACE rate of 4.4% and a cardiac mortality rate of 0.6% per year. Patients with abnormal MPS findings had higher hazard ratios (HR) for MACE (HR: 1.95; 95% confidence interval [CI]: 1.06 to 3.59; p = 0.032), and cardiac death/MI (HR: 2.50; 95% CI: 0.93 to 6.69; p = 0.066) than patients with normal MPS finding. MACE rates were similar in patients with symptomatic and silent ischemia (p = 0.61) but higher than in patients with normal MPS findings (p < 0.05 for both comparisons). MACE rates were independently predicted by remote ischemia but not by treated-vessel ischemia or scar. CONCLUSIONS: Abnormal MPS findings 5 years after PCI are frequent irrespective of symptoms. The predictive power of abnormal MPS lies more in the detection of persistent or progressing coronary artery disease in remote vessel areas than in the diagnosis of late intervention-related problems in treated vessels.

Gender differences in acute congestive heart failure.

BACKGROUND: Little is known about sex differences in baseline characteristics and outcomes in patients with acute congestive heart failure (CHF). METHODS AND RESULTS: This prospective observational study evaluated gender differences among 217 consecutive patients (124 men and 93 women) presenting with acute CHF to the emergency department. The primary endpoint was all-cause mortality. Women were older, and had less pulmonary comorbidity, but more noticeable jugular venous distension, as well as higher diastolic blood pressure and troponin level at presentation. Among contributing causes of acute CHF, myocardial ischaemia and anaemia were more frequent in women. Adequate medical CHF therapy was initiated more rapidly in women. Initial resource utilisation, time to discharge, and mortality were similar. Important differences to the disadvantage of women were noted during long-term follow-up. Mean cumulative survival was 619 (95% CI, 533-705) days in women as compared with 669 (95% CI, 601-737; p = 0.0663) in men. However, after multivariate adjustment female sex was not an independent predictor of long-term mortality (hazard ratio 1.14, 95% CI, 0.68-1.90; p = 0.619). Total spending for treatment cost was 11,858 US dollars University of Basel, University Hospital, Department of Internal Medicine, Switzerland (95% CI, 8921-14794) in women compared to 15,965 US dollars (95% CI, 12328-18003; p = 0.115) in men after 1 year. Functional status was similar in women and men at 6 and 12 months. CONCLUSIONS: The trend towards lower survival in women seems primarily related to higher age and other factors rather than gender itself. Female sex is not an independent predictor of long-term mortality in acute CHF.