Endothelial function predicts 5-year adverse outcome in patients hospitalized in an emergency department chest pain unit.

BACKGROUND: Although endothelial function is a marker for cardiovascular risk, endothelial dysfunction assessment is not routinely used in daily clinical practice. A growing challenge has emerged in identifying patients prone to cardiovascular events. We aim to investigate whether abnormal endothelial function may be associated with adverse 5-year outcomes in patients presenting to a chest pain unit (CPU). METHODS: Following endothelial function testing using EndoPAT 2000 in 300 consecutive patients without a history of coronary artery disease, patients underwent coronary computerized tomographic angiography (CCTA) or single-photon emission computed tomography according to availability. RESULTS: Mean 10-year Framingham risk score (FRS) was 6.6 ±â€Š5.9%; mean 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 7.1 ±â€Š7.2%; median reactive hyperemia index (RHI) as a measure of an endothelial function 2.0 and mean was 2.0 ±â€Š0.4. During a 5-year follow-up, the 30 patients who developed major adverse cardiovascular events (MACE), including all-cause mortality, nonfatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting, and percutaneous coronary interventions, had higher 10-year FRS (9.6 ±â€Š7.8 vs. 6.3 ±â€Š5.6%; P  = 0.032), higher 10-year ASCVD risk (10.4 ±â€Š9.2 vs. 6.7 ±â€Š6.9%; P  = 0.042), lower baseline RHI (1.6 ±â€Š0.5 vs. 2.1 ±â€Š0.4; P  < 0.001) and a greater degree of coronary atherosclerotic lesions (53 vs. 3%, P  < 0.001) on CCTA compared with patients without MACE. Multivariate analysis demonstrated that RHI below the median was an independent predictor of 5-year MACE (odds ratio 5.567, 95% confidence interval 1.955-15.853; P  = 0.001). CONCLUSION: Our findings suggest that noninvasive endothelial function testing may contribute to clinical efficacy in triaging patients in the CPU and in predicting 5-year MACE. CLINICAL TRIALSGOV IDENTIFIER: NCT01618123.

Poor outcome among patients undergoing myocardial perfusion imaging with intermediate-zone troponin.

BACKGROUND: Intermediate zone troponin elevation is defined as one to five times the upper limit of normal. Approximately half the patients presenting with chest pain to the emergency department have initial intermediate zone troponin. OBJECTIVES: We aimed to investigate the long-term outcome of patients hospitalized with chest pain and intermediate zone troponin elevation. METHODS: We investigated 8269 patients hospitalized in a tertiary center with chest pain. All patients had serial measurements of troponin during hospitalization. Patients were divided into three groups based on their initial troponin levels: negative troponin (N = 6112), intermediate zone troponin (N = 1329) and positive troponin (N = 828). All patients underwent myocardial perfusion imaging (MPI) as part of the initial evaluation. RESULTS: Mean age of the study population was 68 ± 11, of whom 36% were women. Patients with an intermediate zone troponin were older, more likely to be males, and with significantly more cardiovascular co-morbidities. Multivariate analysis adjusted for age, gender, cardiovascular risk factors, and abnormal MPI result found that patients with intermediate zone troponin had a 70% increased risk of re-hospitalization at 1 year (HR 1.70, 95%CI 1.48-1.96, p-value < 0.001) and 5.3 times higher risk of total mortality at 1-year (HR 5.33, 95%CI 3.65-7.78, p-value < 0.001). sub-group analysis found that among the intermediate zone troponin group, patients with double intermediate zone troponin had the poorest outcome. CONCLUSIONS: Intermediate zone troponin elevation is an independent risk factor associated with adverse outcomes and therefore patients with an initial value in this range should be closely monitored and aggressively managed.

The efficacy and safety of evaluating elderly patients using a comprehensive diagnostic protocol via a chest pain unit.

Elderly patients are often excluded from a chest pain unit (CPU)-based evaluation of chest pain due to concern about adverse events and poorer outcomes. The aim of this study was to assess the feasibility and safety of thoroughly evaluating elderly patients ≥ 65 years of age presented with acute chest pain via a CPU. We evaluated 1220 consecutive patients admitted to our CPU, and stratified them according to age: those over and those under 65 years. Patients were evaluated for outcomes during hospitalization and for a composite endpoint at 60 days post discharge which included: recurrent hospitalization due to chest pain, need for coronary revascularization, acute coronary syndrome, and death. Overall, 241 (20%) patients were in the ≥ 65-year-old group and 979 (80%) patients in the group < 65 years of age. Older patients were more likely to be female, have more co-morbidities, and a history of prior coronary artery disease. There was no difference between the two groups regarding in-hospital course, including hospitalization in the CPU (9.5% vs. 11.6%, p = 0.37), coronary angiography (7.9% vs. 9.8%, p = 0.37), and revascularization performed during the evaluation period (4.5% vs. 3.3%, p = 0.42). Of those discharged, the primary endpoint at 60 days was observed in 11 (1.5%) and 7 (3.9%) patients in those under and over 65 years, respectively, (p = 0.13). No mortalities were recorded. Comprehensive evaluation via a CPU of patients who are ≥ 65 years of age is feasible and safe with in-hospital and short-term outcomes compared to their younger counterparts.

Endothelial function predicts 1-year adverse clinical outcome in patients hospitalized in the emergency department chest pain unit.

BACKGROUND: Endothelial function is a marker for cardiovascular risk. Thus, abnormal endothelial function may be associated with adverse 1-year outcome in patients presenting to the emergency department chest pain unit (CPU). METHODS: Following endothelial function testing, using EndoPAT 2000 in 300 consecutive subjects with chest pain and no history of coronary artery disease (CAD) presenting to CPU, patients underwent coronary computerized tomographic angiography (CCTA) or single-photon emission computed tomography according to availability. RESULTS: Mean 10-year Framingham risk score (FRS) was 6.6±5.9%, median reactive hyperemia index (RHI) as a measure of endothelial function 2.08 and mean was 2.0±0.4. During a 1-year follow-up, the 20 (6.6%) patients who developed major adverse cardiovascular end-points (MACE), including all-cause mortality, non-fatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting and percutaneous coronary interventions, had higher 10-year FRS (10.5±8.2% vs 6.3±5.7%; p<0.001), lower baseline RHI (1.43±0.41 vs 2.10±0.44; p<0.001) and a greater extent of coronary atherosclerosis lesions (70% vs 3.9%, p<0.001) in the CPU CCTA, compared to those without MACE. RHI≤the median was associated with higher 1-year MACE (13% vs 0.7%, p<0.001) compared to RHI>the median. Multivariate analysis demonstrated that RHI≤the median is an independent predictor of coronary atherosclerosis lesions in the CPU CCTA (OR 5.98, 95% CI 03.29-10.88; p<0.001) and 1-year MACE (OR 15.207, 95% CI 2.00-115.33; p<0.01). CONCLUSIONS: Our findings suggest that non-invasive endothelial function testing may have clinical utility in triaging patients in the CPU and in predicting 1-year MACE.