Methionine loading does not enhance the predictive value of homocysteine serum testing for all-cause mortality or major adverse cardiac events.

BACKGROUND: Hyperhomocysteinaemia is independently associated with atherosclerotic disease. Methionine loading could improve the predictive value of hyperhomocysteinaemia by detecting mild disturbances in enzyme activity. The aims of this study were to determine the beneficial effect of methionine loading on the predictive value of homocysteine testing for long-term mortality and major adverse cardiac events (MACE). METHODS: In an observational study, 1122 patients with suspected or known vascular disease, underwent homocysteine testing, which was measured fasting and again 6 h after methionine loading. Hyperhomocysteinaemia was defined as a fasting level > or =15 micromol/L and post-methionine loading level > or =45 micromol/L or an increase of > or =30 micromol/L above fasting levels. Primary end-points were death and MACE. Multivariate Cox regression analysis was used, adjusting for all cardiac risk factors. RESULTS: During follow up (mean 8.9 +/- 3.4 years), 98 patients died (8.7%), 86 had a MACE (7.7%), 579 patients had normal tests, 134 patients had only fasting hyperhomocysteinaemia, 226 only post-methionine hyperhomocysteinaemia and 183 patients had both. In multivariate analysis, overall survival and MACE-free survival were significantly worse for those with fasting hyperhomocysteinaemia, with hazard ratios of 1.86 (95% confidence interval (CI) 1.20-2.87) and 2.24 (95%CI 1.41-3.53), respectively. The addition of hyperhomocysteinaemia after methionine loading did not significantly increase the risk of death or MACE, with hazard ratios of 0.97 (95%CI 0.52-1.81) and 0.89 (95%CI 0.47-1.69), respectively. CONCLUSION: The presence of post-methionine hyperhomocysteinaemia did not significantly alter risk of death or MACE in patients with normal or increased fasting homocysteine levels, respectively. In conclusion, methionine loading does not improve the predictive value of homocysteine testing with regard to long-term mortality or MACE.

[Perioperative risk reduction in vascular surgery via cardio-protective medication]. / Perioperatieve risicoreductie bij vaatoperaties door cardioprotectieve medicatie.

Cardiovascular complications are the leading cause of death after noncardiac surgery. Preoperative identification of patients with underlying coronary artery disease is important, and appropriate treatment strategies should be implemented in these patients in order to reduce the risk of perioperative complications. Based on recent findings, preoperative risk stratification models have been developed to identify high-, intermediate- or low-risk patients; the concentration of natriuretic peptides is a promising new preoperative risk marker. beta-blockers considerably reduce this risk. In clinical practice, important factors are adequate beta-blocker dosage, tight perioperative heart-rate control and continuation of beta-blockers after discharge. Recently, statins have emerged as drugs with perioperative cardioprotective properties, but more randomized clinical trials are needed before routine administration ofstatins can be recommended. Perioperative medical management should focus on improvements not only in the short-term but also in the long-term.

Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients.

AIMS: Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA(1c)) levels are associated with increased cardiac ischaemic events in vascular surgery patients. METHODS: Baseline glucose and HbA(1c) were measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose > or = 7.0 or random glucose > or = 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). RESULTS: Mean (+/- sd) level for glucose was 6.3 +/- 2.3 mmol/l and for HbA(1c) 6.2 +/- 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA(1c) > 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. CONCLUSIONS: Impaired glucose regulation and elevated HbA(1c) are risk factors for cardiac ischaemic events in vascular surgery patients.

Beta-blockers improve outcomes in kidney disease patients having noncardiac vascular surgery.

Beta-blockers are known to improve postoperative outcome after major vascular surgery. We studied the effects of beta-blockers in 2126 vascular surgery patients with and without kidney disease followed for 14 years. Creatinine clearance was calculated using the Cockcroft-Gault equation, and kidney function was categorized as Stage 1 for a reference group of 550 patients, Stage 2 with 808 patients, Stage 3 with 627 patients, and combined Stages 4 and 5 with 141 patients. Outcome measures were 30-day and long-term all-cause mortality with a mean follow-up of 6 years. Cox proportional hazards models were used to control cardiovascular risk factors, including propensity for beta-blocker use. In all, 129 (6%) and 1190 (56%) patients died respectively. Mortality rates were three- and two-fold higher, respectively, for patients at Stages 3-5 compared to the reference group for the two outcomes. beta-Blocker use was significantly associated with a lower risk of mortality after surgery. The overall adjusted hazard ratio was 0.35 and 0.62, respectively, for individuals at Stages 3-5 compared to the reference group for 30-day and long-term mortality. This study shows that kidney function is a predictor of all-cause mortality and beta-blocker use is associated with a lower risk of death in kidney disease patients undergoing elective vascular surgery.

The influence of aging on the prognostic value of the revised cardiac risk index for postoperative cardiac complications in vascular surgery patients.

OBJECTIVE: The Lee-risk index [Lee-index] was developed to predict major adverse cardiac events [MACE]. However, age is not included as a risk factor. The aim was to assess the value of the Lee-index in vascular surgery patients among different age categories. METHODS: Of 2642 patients cardiovascular risk factors were noted to calculate the Lee-index. Patients were divided into four age categories; < or = 55 (n=396), 56-65 (n=650), 66-75 (n=1058) and > 75 years (n=538). Outcome measures were postoperative MACE (cardiac death, MI, coronary revascularization and heart failure). The performance of the Lee-index was determined using C-statistics within the four age groups. RESULTS: The incidence of MACE was 10.9%, for Lee-index 1, 2 and > or = 3; 6%, 13% and 20%, respectively. However, the prognostic value differed among age groups. The predictive value for MACE was highest among patients under 55 year (0.76 vs 0.62 of patients aged > 75). The prediction of MACE improved in elderly (aged > 75) after adjusting the Lee-index with age, revised risk of operation (low, low-intermediate, high-intermediate and high-risk procedures) and hypertension (0.62 to 0.69). CONCLUSION: The prognostic value of the Lee-index is reduced in elderly vascular surgery patients, adjustment with age, risk of surgical procedure, and hypertension improves the Lee-index significantly.

Prognostic significance of declining ankle-brachial index values in patients with suspected or known peripheral arterial disease.

BACKGROUND: Peripheral arterial disease (PAD) is a risk factor for cardiovascular events. This study assessed the prognostic significance of repeated ankle-brachial index (ABI) measurements at rest and after exercise in patients with PAD receiving conservative treatment. METHODS: In a cohort study of 606 patients (mean age 62+/-12 years, 68% male), ABI at rest and after exercise was measured at baseline and after 1 year. Patients with reductions in ABI were divided into three equally-sized groups (minor, intermediate and major reductions) and were compared to patients without reductions. During a mean follow-up of 5+/-3 years, all-cause mortality, cardiac events, stroke and progression to kidney failure were noted. RESULTS: Death was recorded in 83 patients (14%) of which 49% were due to cardiac causes. Non-fatal myocardial infarction occurred in 38 patients (6%), stroke in 46 (8%) and progression to kidney failure in 35 (6%). By multivariate analysis, patients with major declines in resting (>20%) and post-exercise (>30%) ABI were at increased risk of all-cause mortality (HR: 3.3, 95% CI: 1.5-7.2, HR: 3.0, 95% CI: 1.4-6.4, respectively), cardiac events (HR: 3.1, 95% CI: 1.3-7.2, HR: 2.4, 95% CI: 1.1-5.6, respectively), stroke (HR: 4.2, 95% CI: 1.6-10.4, HR: 3.9, 95% CI: 1.4-10.2, respectively) and kidney failure (HR: 2.7, 95% CI: 1.1-7.5, HR: 6.9, 95% CI: 1.5-31.5, respectively), compared to patients with no declines in ABI. CONCLUSIONS: This study shows that major 1-year declines in resting and post-exercise ABI are associated with all-cause mortality, cardiac events, stroke and kidney failure in patients with PAD.

Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.

OBJECTIVE: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS: Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.

Perioperative cardiac risk stratification and modification in abdominal aortic aneurysm repair.

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.

Abdominal aortic aneurysm screening using non-imaging hand-held ultrasound volume scanner--a pilot study.

BACKGROUND: Screening for abdominal aortic aneurysms (AAA) is cost-effective and timely repair improves outcome. Using standard ultrasound (US) an AAA can be accurately diagnosed or ruled-out. However, this requires training and bulk equipment. AIM: To evaluate the diagnostic potential of a new hand-held ultrasound bladder volume indicator (BVI) in the setting of AAA screening. METHODS: In total, 94 patients (66 +/- 14 years, 67 men) referred for atherosclerotic disease were screened for the presence of AAA (diameter > 30 mm using US). All patients underwent both examinations, with US and BVI. Using the BVI, aortic volume was measured at 6 pre-defined points. Maximal diameters (US) and volumes (BVI) were used for analyses. RESULTS: In 54 (57%) patients an AAA was diagnosed using US. The aortic diameter by US correlated closely with aortic volume by BVI (r = 0.87, p < 0.0001). Using a cut-off value of > or = 50 ml for the presence of AAA by BVI, sensitivity, specificity, positive and negative predictive value of BVI in detection of AAA were 94%, 82%, 88% and 92%, respectively. The agreement between the two methods was 89%, kappa 0.78. CONCLUSION: The bladder volume indicator is a promising tool in screening patients for AAA.

Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth.

OBJECTIVE: To evaluate the effect of statins on aneurysm growth in a group of consecutive patients under surveillance for infrarenal aortic aneurysms (AAA). MATERIALS AND METHODS: All patients (59 statin users, 91 non-users) under surveillance between January 2002 and August 2005 with a follow-up for aneurysm growth of at least 12 months and a minimum of three diameter evaluations were retrospectively included in the analysis. Multiple regression analysis, weighted with the number of observations, was performed to test the influence of statins on AAA growth rate. RESULTS: During a median period of 3.1 (1.1-13.1) years the overall mean aneurysm growth rate was 2.95+/-2.8 mm/year. Statin users had a 1.16 mm/year lower AAA growth rate compared to non-users (95% CI 0.33-1.99 mm/year). Increased age was associated with a slower growth (-0.09 mm/year per year, p = 0.003). Female gender (+1.82 mm/year, p = 0.008) and aneurysm diameter (+0.06 mm/year per mm, p = 0.049) were associated with increased AAA growth. The use of non-steroidal anti-inflammatory drugs, chronic lung disease, or other cardiovascular risk factors were not independently associated with AAA growth. CONCLUSIONS: Statins appear to be associated with attenuation of AAA growth, irrespective of other known factors influencing aneurysm growth.

Beta-blockers improve in-hospital and long-term survival in patients with severe left ventricular dysfunction undergoing major vascular surgery.

OBJECTIVES: To study whether beta-blockers reduce in-hospital and long-term mortality in patients with severe left ventricular dysfunction (LVD) undergoing major vascular surgery. DESIGN: Observational cohort study. MATERIALS: Five hundred and eleven patients with severe LVD (ejection fraction<30%) undergoing major non-cardiac vascular surgery. METHODS: In all patients, cardiac risk factors, medication (including beta-blockers), and dobutamine stress echocardiography (DSE) results were noted prior to surgery. DSE was evaluated for rest and stress-induced new wall motion abnormalities. Endpoint was in-hospital and long-term mortality. Propensity scores for beta-blockers were calculated and regression models were used to analyse the relation between beta-blockers and mortality. RESULTS: Mean age was 64+/-11 years and 383 patients (75%) were male. 139 patients (27%) used beta-blockers. Stress-induced ischemia occurred in 82 patients (16%). Median follow-up was 7 years (interquartile range: 3-10). In-hospital and long-term mortality was observed in 64 (13%) and 171 (33%) patients, respectively. After adjusting for clinical variables, DSE results and propensity scores, beta-blockers were significantly associated with reduced in-hospital and long-term mortality (OR: 0.18, 95% CI: 0.04-0.74 and HR: 0.38, 95% CI: 0.22-0.65, respectively). CONCLUSION: In patients with severe LVD undergoing major vascular surgery, the use of beta-blockers is associated with a reduced incidence of in-hospital and long-term postoperative mortality.

Ischemic heart disease in renal transplant candidates: towards non-invasive approaches for preoperative risk stratification.

This editorial refers to the paper of R. Sharma et al. entitled "Dobutamine stress echocardiography and cardiac troponin T for the detection of significant coronary artery disease and predicting outcome in renal transplant candidates". The editorial discusses different strategies for cardiac risk assessment in patients with end-stage renal disease undergoing renal transplantation.