Complementary prognostic values of stress myocardial perfusion and late gadolinium enhancement imaging by cardiac magnetic resonance in patients with known or suspected coronary artery disease.

BACKGROUND: Recent studies have demonstrated the significant prognostic value of stress cardiac magnetic resonance (CMR) myocardial perfusion imaging. Apart from characterizing reversible perfusion defect (RevPD) from flow-limiting coronary stenosis, CMR late gadolinium enhancement (LGE) imaging is currently the most sensitive method for detecting subendocardial infarction (MI). We therefore tested the hypothesis that characterization of these 2 processes from coronary artery disease by CMR can provide complementary prognostic values. METHODS AND RESULTS: We performed CMR myocardial perfusion imaging followed by LGE imaging on 254 patients referred with symptoms of myocardial ischemia. At a median follow-up of 17 months, 49 cardiac events occurred, including 12 cardiac deaths, 16 acute MIs, and 21 cardiac hospitalizations. RevPD and LGE both maintained a >3-fold association with cardiac death or acute MI (death/MI) when adjusted for each other and for the effects of patient age and gender (adjusted hazard ratio, 3.31; P=0.02; and hazard ratio, 3.43; P=0.01, respectively). In patients without a history of MI who had negative RevPD, LGE presence was associated with a >11-fold hazards increase in death/MI. Patients with neither RevPD nor LGE had a 98.1% negative annual event rate for death/MI. For association with major adverse cardiac events, RevPD was the strongest multivariable variable in the best overall model (hazard ratio, 10.92; P<0.0001). CONCLUSIONS: CMR imaging provides robust risk stratification for patients who present with symptoms of ischemia. Characterization of RevPD and LGE by CMR provides strong and complementary prognostic implication for cardiac death or acute MI.

Plasma from patients with sepsis up-regulates the expression of CD49d and CD64 on blood neutrophils.

An excessive interaction of blood neutrophils with microvascular walls may underlie the organ failure of sepsis. In this study, flow cytometric analysis was used to investigate whether plasma from 22 patients with sepsis altered the expression of the adhesion molecules (CD11a, CD11b, CD49d, and CD62L) on normal blood neutrophils and enhanced their binding to cultured endothelium. Most of the plasma samples from patients with sepsis increased the percentage of neutrophils bearing CD49d (86% samples versus 22% normal plasma samples; P < 0.001) and CD64 (69% samples versus 17% normal plasma samples; P < 0.001). This effect was not seen with plasma from patients with community-acquired infections who did not develop sepsis, nor with plasma from patients with acute or chronic inflammation who had no evidence of infection. A direct association was noted between the percentage of neutrophils expressing CD64 in the blood of patients with sepsis and the ability of plasma from these patients to up-regulate CD64 on normal neutrophils. Although CD62L was present on the majority of neutrophils after incubation with sepsis plasma, it was less apparent when the cells were cultured with normal plasma. The patients' plasma had no effect on neutrophils expressing CD11a and CD11b. High levels of TNF-alpha, IL-6, IL-8, and IL-10 were detected in the patients' blood, but incubation of the recombinant forms of these cytokines with neutrophils, even in the presence of LPS, did not increase CD49d and CD64 expression. The sepsis plasma also enhanced the attachment of neutrophils to untreated and TNF-alpha-treated endothelium, and this binding was impeded by anti-CD49d and anti-CD64 antibodies. We suggest that changes in the phenotype of neutrophils by circulating factors may facilitate their attachment to endothelium, which may be an important factor in the induction of organ dysfunction in severe sepsis.

Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction.

BACKGROUND: Silent myocardial infarctions (MIs) are prevalent among diabetic patients and inflict significant morbidity and mortality. Although late gadolinium enhancement (LGE) imaging by cardiac magnetic resonance (CMR) can provide sensitive characterization of myocardial scar, its prognostic significance in diabetic patients without any clinical evidence of MI is unknown. METHODS AND RESULTS: We performed clinically indicated CMR imaging in 187 diabetic patients who were grouped by the absence (study group, n=109) or presence (control group, n=78) of clinical evidence of MI (clinical history of MI or Q waves on ECG). CMR imaging and follow-up were successful in 107 study patients (98%) and 74 control patients (95%). Cox regression analyses were performed to associate LGE with major adverse cardiovascular events (MACE), including death, acute MI, new congestive heart failure or unstable angina, stroke, and significant ventricular arrhythmias. LGE by CMR was present in 30 of 107 study patients (28%). At a median follow-up of 17 months, 38 of 107 patients (36%) experienced MACE, which included 18 deaths. Presence of LGE was associated with a >3-fold hazards increase for MACE and for death (hazard ratio, 3.71 and 3.61; P<0.001 and P=0.007, respectively). Adjusted to a model that combines patient age, sex, ST or T changes on ECG, and left ventricular end-systolic volume index, LGE maintained a >4-fold hazards increase for MACE (adjusted hazard ratio, 4.13; 95% confidence interval, 1.74 to 9.79; P=0.001). In addition, LGE provided significant prognostic value with MACE and with death adjusted to a diabetic-specific risk model for 5-year events. The presence of LGE was the strongest multivariable predictor of MACE and death by stepwise selection in the study patients. CONCLUSIONS: CMR imaging can characterize occult myocardial scar consistent with MI in diabetic patients without clinical evidence of MI. This imaging finding demonstrates strong association with MACE and mortality hazards that is incremental to clinical, ECG, and left ventricular function combined.

Right ventricular dysfunction assessed by cardiovascular magnetic resonance imaging predicts poor prognosis late after myocardial infarction.

OBJECTIVES: We sought to determine whether right ventricular (RV) function late after myocardial infarction (MI) impacts long-term prognosis. BACKGROUND: Right ventricular failure predicts early mortality in patients with acute MI. The prognostic impact of RV function late after MI is not well defined. Accordingly, we determined whether RV dysfunction late after MI influences survival beyond traditional risk predictors, including patient age, left ventricular ejection fraction (LVEF), and infarct size. METHODS: We studied 147 consecutive patients >30 days after MI (mean age of infarct 6.7 +/- 8.2 years) who were referred for contrast-enhanced cardiovascular magnetic resonance imaging. We assessed hazard ratios for death by RV ejection fraction (RVEF). The association of RVEF with mortality adjusted to traditional risk predictors was examined by using multivariable Cox proportional hazards regression models. RESULTS: A total of 26 deaths occurred during a median follow-up of 17 months (range 6 to 53 months). By univariable analysis, RVEF <40% was strongly associated with mortality (unadjusted hazard ratio 4.02; p = 0.0007). By multivariable analysis that adjusted for patient age, left ventricular (LV) infarct size, and LVEF, RVEF <40% remained a significant independent predictor of mortality (adjusted hazard ratio 2.86; p = 0.03). CONCLUSIONS: Right ventricular ejection fraction quantified late after MI is an important predictor of prognosis adjusted for patient age, LV infarct size, and LVEF. Accordingly, evaluation of RVEF using cardiovascular magnetic resonance imaging can improve risk-stratification and potentially refine patient management after MI.

Procedures for the collection of dental records for person identification.

Dental treatment records offer a valuable resource for establishing the identification of deceased persons by means of dental comparison as required for forensic purposes. The creation, maintenance, storage and custody of such records is a legal and ethical duty of each dental practitioner. Dentists in Australia are also bound by federal and state legislation to protect their patients' confidentiality at all times. They are also required by law to note and report evidence of child abuse observed in the course of their treatment. When dental records are required for forensic purposes certain procedures should be followed for their release and collection. This paper discusses these procedures, and illustrates by reference to an actual case the possible consequences of deviating from established protocols.

ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy--a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an industry relationship or personal interest of the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please see Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care. If these guidelines are used as the basis for regulatory/payer decisions, the ultimate goal is quality of care and serving the patient's best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient.

Guías ACC/AHA 2006. Estado del arte de la evaluación cardiovascular perioperatoria para cirugía no cardiaca: Enfocado en la terapia perioperatoria con betabloqueadores / Guides ACC/AHA 2006. State-of-the-art of the cardiovascular evaluation perioperatoria for surgery noncardiac: Focused in the therapy perioperatoria with betabloqueadores

Reporte de la fuerza de Trabajo sobre Guías de Práctica del Colegio Americano de Cardiología ACC y la Asociación Americana del Corazón AHA (Comité de actualización de las Guías para la evaluación cardiovascular preoperatoria para cirugía no cardiaca). Desarrollado en colaboración con la American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Angiography and Interventions, Society for Cardiovascular Medicine and Biology. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. Notas: Este documento fue aprobado por la Fundación Comité del Colegio Americano de Cardiología (ACC) en Marzo de 2006 y por el Consejo Asesor y Consultor de Ciencias de la Asociación Americana de Corazón (AHA) en febrero de 2006. Cuando cite este documento el Colegio Americano de Cardiología requiere el siguiente formato de citación: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular...