The prognostic implications of lack of palpitations in patients hospitalised with atrial fibrillation: observations from a 20-year registry.

OBJECTIVES: It is well recognised that patients differ in the clinical presentation of atrial fibrillation (AF), ranging from the typical symptom of palpitations, atypical symptoms in others and a substantial that are asymptomatic. Whether the different patterns of presentation are associated with differences in outcomes is not known. The aim of this study was to evaluate the prevalence and the prognostic implications of lack of palpitations among patients hospitalised with AF in a large prospective registry. METHODS: Retrospective analysis of all patients hospitalised with AF in Qatar from 1991 to 2010 was made. Patients were divided into two groups according to the presence or absence of palpitations on presentation. Clinical characteristics and outcome were analysed. RESULTS: During the 20-year period, 3850 patients were hospitalised for AF; 1724 (44.8%) had palpitations on presentation while 2126 (55.2%) had no palpitations. Patients who lacked palpitations were 9 years older, had a higher prevalence of diabetes mellitus (64.7% vs. 35.3%), underlying coronary artery disease (CAD; 14.6% vs. 6.2%) and severe left ventricular dysfunction on echocardiography (25.5% vs. 6.6%), (all, p = 0.001). There were 141 deaths among the group with no palpitations compared with 19 among the group with palpitations (6.6% vs. 1.1%). Multivariate analysis of mortality predictors identified 'lack of palpitations' as an independent predictor of in-hospital mortality (relative risk 5.56; 95% confidence interval 1.20-25.0, p = 0.03). CONCLUSIONS: Our study demonstrates for the first time that lack of palpitations as the presenting symptom of patients with AF is associated with worse in-hospital outcome independent of other risk factors or therapy. The underlying mechanisms and the role of confounders warrant further investigation.

Obesity is associated with premature occurrence of acute myocardial infarction.

BACKGROUND: The American Heart Association has classified obesity as a major modifiable risk factor for coronary artery disease, but its relationship with age at presentation with acute myocardial infarction (AMI) is poorly documented. HYPOTHESIS: The study was undertaken to evaluate the impact of obesity on age at presentation, and on in-hospital morbidity and mortality in patients with AMI. METHODS: Our analysis includes a consecutive series of 906 Olmsted County patients (mean age 67.7 years, 51% male) admitted with AMI to the Mayo Clinic Coronary Care Unit (CCU). The patients were entered into the Mayo CCU Database, a prospective registry of data pertaining to patients admitted to the Mayo Clinic CCU with AMI. Age at AMI occurrence and in-hospital morbidity and mortality were noted. RESULTS: Obese patients (body mass index [BMI] >30) with AMI were significantly younger than patients with AMI in the overweight (BMI 25-30) and normal-weight (BMI < 30) groups (62.3+/-13.1 vs. 66.9+/-13.2 and 72.9+/-13.4, respectively. p < 0.001). Obesity and overweight status were associated with male gender, diabetes mellitus, hypercholesterolemia, and smoking history; however, after multivariate adjustment for these risk factors, excess weight and premature AMI remained significantly associated. Compared with normal-weight patients, overweight patients presenting with AMI were 3.6 years younger (p < 0.001, confidence interval [CI] 1.9-5.4) and obese patients 8.2 years younger (p < 0.001, Cl 6.2-10.1). No significant increase in in-hospital morbidity and mortality was seen. CONCLUSION: In this population-based study, overweight and obese status are independently associated with the premature occurrence of AMI, but not with an increased incidence of in-hospital complications.

Immediate and one-year outcome of intracoronary stent implantation in small coronary arteries with 2.5-mm stents.

BACKGROUND: The role of coronary stenting in the treatment of stenoses in small coronary arteries with use of 2.5-mm stents is not well defined. METHODS AND RESULTS: Between January 1995 and August 1999, 651 patients with stenoses in small coronary arteries were treated with 2.5-mm stents (n = 108) or 2.5-mm conventional balloon angioplasty (BA) (n = 543). Patients who received treatment with both 2.5-mm and > or =3.0-mm stent placement or balloons were excluded. Procedural success and complication rates as well as 1-year follow-up outcomes were examined. Baseline clinical characteristics were similar between the two groups, except patients in the stent group were more likely to have hypertension and a family history of coronary artery disease and less likely to have prior myocardial infarction. Angiographic success rates were higher in the stent group (97.2% vs 90.2%, P =.02). In-hospital complication rates were comparable between the two groups. Among successfully treated patients, 1-year follow-up revealed no significant differences in the survival (96.2% vs 95.2%, P =.89) or the frequency of Q-wave myocardial infarction (0% vs 0.4%, P =.60) or coronary artery bypass grafting (8.4% vs 6.8%, P =.89) between the stent and BA groups, respectively. However, patients in the stent group were more likely to have adverse cardiac events (35.4% vs 22.1%, P =.05). Stent use after excluding GR II stent use, however, was not independently associated with reduced cardiac events at follow-up (relative risk 1. 3 [95% confidence interval 0.8-2.3], P =.30). CONCLUSIONS: Intracoronary stent implantation of stenoses in small coronary arteries with 2.5-mm stents can be carried out with high success and acceptable complication rates. However, compared with BA alone, stent use was not associated with improved outcome through 1 year of follow-up.

Long-term follow-up of patients with mild coronary artery disease and endothelial dysfunction.

BACKGROUND: Coronary endothelial dysfunction is characterized by vasoconstrictive response to the endothelium-dependent vasodilator acetylcholine. Although endothelial dysfunction is considered an early phase of coronary atherosclerosis, there is a paucity of information regarding the outcome of these patients. Thus, this study was designed to evaluate the outcome of patients with mild coronary artery disease on the basis of their endothelial function. METHODS AND RESULTS: Follow-up was obtained in 157 patients with mildly diseased coronary arteries who had undergone coronary vascular reactivity evaluation by graded administration of intracoronary acetylcholine, adenosine, and nitroglycerin and intracoronary ultrasound at the time of diagnostic study. Patients were divided on the basis of their response to acetylcholine into 3 groups: group 1 (n=83), patients with normal endothelial function; group 2 (n=32), patients with mild endothelial dysfunction; and group 3 (n=42), patients with severe endothelial dysfunction. Over an average 28-month follow-up (range, 11 to 52 months), none of the patients from group 1 or 2 had cardiac events. However, 6 (14%) with severe endothelial dysfunction had 10 cardiac events (P<0.05 versus groups 1 and 2). Cardiac events included myocardial infarction, percutaneous or surgical coronary revascularization, and/or cardiac death. CONCLUSIONS: Severe endothelial dysfunction in the absence of obstructive coronary artery disease is associated with increased cardiac events. This study supports the concept that coronary endothelial dysfunction may play a role in the progression of coronary atherosclerosis.

Cholesterol-lowering treatment is associated with improvement in coronary vascular remodeling and endothelial function in patients with normal or mildly diseased coronary arteries.

Coronary vascular remodeling and altered endothelial function have been described in the early stages of native atherosclerosis. The purpose of this study was to evaluate the association between cholesterol-lowering therapy and coronary vascular remodeling and endothelial function in patients with normal or mildly diseases coronary arteries. Patients (N=101) with normal or mildly diseased coronary arteries by coronary angiography underwent intravascular ultrasound examination of the left anterior descending coronary artery. Vessel and lumen area, atherosclerotic plaque area, and plaque morphology were evaluated. Vascular reactivity was examined with the use of intracoronary adenosine, acetylcholine, and nitroglycerin. Patients were divided into 3 groups based on the total cholesterol levels: group 1 (n=25), patients with a history of hypercholesterolemia adequately treated (total cholesterol <240 mg/dL); group 2 (n=26), patients with hypercholesterolemia not adequately controlled (total cholesterol >/=240 mg/dL); and group 3 (n=50), patients without hypercholesterolemia. Vessel area and lumen area were significantly greater in groups 1 and 3 than in group 2 (for respective values in groups 1, 2, and 3: vessel area 11.9+/-0.5, 10.6+/-0.4, and 11.8+/-0.4 mm(2), both P<0.05; lumen area 8.3+/-0.4, 6.9+/-0.3, and 8.9+/-0.3 mm(2), both P<0.01). However, plaque areas in groups 1 and 2 were similar. Furthermore, acetylcholine-induced percent increases in coronary blood flow were significantly greater in groups 1 and 3 than in group 2 (for respective values in groups 1, 2, and 3: 70.5+/-20.1%, 22.8+/-13.7%, and 68.6+/-14.8%, both P<0. 05). Cholesterol-lowering treatment is associated with an improvement in coronary lumen area that results not from a decrease in plaque area but from an increase in vessel area, reflecting vascular remodeling. Additionally, this adaptive process may occur in association with an improvement of endothelium-dependent vasodilation of the resistance coronary artery.