Aortic valve replacement in asymptomatic and symptomatic patients with preserved left ventricular ejection fraction.

BACKGROUND AND AIM OF THE STUDY: Patients with moderate-severe aortic stenosis (AS) who maintain that they have no symptoms pose a decision-making dilemma. In order to determine whether or not preoperative symptoms were related to outcomes in these patients, results were compared after aortic valve replacement (AVR) in asymptomatic and symptomatic AS patients with a preserved left ventricular ejection fraction (LVEF). METHODS: Twenty asymptomatic and 18 symptomatic AS patients were investigated retrospectively, with clinical and echocardiographic studies being performed before and at 610 +/- 409 days after AVR. The patients' cardiopulmonary function was monitored using spiroergometry. RESULTS: Symptomatic AS patients improved their exercise tolerance after surgery more than asymptomatic patients, although exercise tolerance and LVEF remained lower in symptomatic patients. On comparing all postoperative objective changes between the groups, a difference was observed only for aortic valve area index. Improvements in left ventricular structure, diastolic function, and filling pressures after AVR were similar in both groups. Systolic function, as assessed by tissue Doppler, was improved only in the symptomatic group. Regression analyses identified preoperative exercise tolerance as the strongest independent determinant of postoperative functional outcome. The postoperative LVEF was independently predicted by the preoperative LVEF and exercise tolerance. CONCLUSION: Asymptomatic patients with moderate-severe AS and preserved systolic function exhibited similar improvements in cardiac remodeling, diastolic function, and filling pressures following AVR, compared to symptomatic patients. Differences in exercise tolerance and systolic function observed preoperatively between these groups were decreased after AVR.

Fluvastatin reduces the 4-year cardiac risk in patients with multivessel disease.

BACKGROUND: To evaluate the impact of the extent of coronary disease (single- or multivessel) and of fluvastatin treatment on the incidence of long-term cardiac atherosclerotic complications in the Lescol Intervention Prevention Study (LIPS). METHODS: A total of 1063 patients with single-vessel disease and 614 patients with multivessel disease were randomized to receive fluvastatin (40 mg bid) or placebo for at least 3 years following a first successful percutaneous coronary intervention. The incidence of cardiac atherosclerotic events (cardiac death, non-fatal myocardial infarction, and coronary re-interventions not related to restenosis) was evaluated. RESULTS: Patients with multivessel disease tended to be older and presented a higher prevalence of associated risk factors and cardiovascular antecedents. The presence of multivessel disease markedly increased the risk of cardiac atherosclerotic events compared with single-vessel disease among patients allocated to placebo (RR 1.67 [95% CI: 1.24-2.25]; p<0.001). In patients treated with fluvastatin, however, no significant differences in long-term outcomes were observed between patients with multivessel disease and patients single-vessel disease (RR 1.28 [95% CI: 0.90-1.81]; p=0.2). CONCLUSIONS: Multivessel coronary disease impaired the 4-year outcomes after percutaneous intervention. However, the hazardous effect of multivessel disease was significantly reduced by long-term fluvastatin treatment.

Influence of acute and chronic myocardial loading conditions, function, structural changes and extracardiac factors on NT-proBNP in asymptomatic patients with preserved ejection fraction.

BACKGROUND: We compared the effect of different loading conditions, parameters of structural heart disease and extracardiac confounders on NT-proBNP to validate the application of NT-proBNP for a characterisation of loading conditions and clinical course of patients with chronic heart diseases. METHODS: NT-proBNP was measured in 15 controls and 34 patients with preserved ejection fraction and chronic pressure (by aortic stenosis) or volume overload (by aortic or mitral regurgitation) before and after physical as well as dobutamine stress. Myocardial fibrosis was evaluated by contrast-enhanced cardiovascular magnetic resonance. RESULTS: In patients with elevated NT-proBNP due to chronic pressure or volume overloaded ventricles, physical and dobutamine stress were associated with only marginal nonsignificant additional NT-proBNP responses. Univariate analyses showed that myocardial fibrosis has the greatest effect on NT-proBNP (P < 0.01). Forward regression analyses revealed left ventricular filling, systolic function, the presence of valvular heart disease, serum creatinine and responses to dobutamine stress as independent determinants of NT-proBNP (P < 0.05 each). CONCLUSION: NT-proBNP cannot be used simply to characterise intensity of ventricular load. Character and duration of loading conditions, cardiac structure and function, as well as confounders should be considered when NT-proBNP is used for clinical follow-up assessment.

WITHDRAWN: Corrigendum to "High-sensitive cardiac troponin I (hs-cTnl) values in patients with stable cardiovascular disease: An initial foray" [Clinica Chimica Acta 411 (2010) 812--817].

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High-sensitive cardiac troponin I (hs-cTnI) values in patients with stable cardiovascular disease: an initial foray.

BACKGROUND: How to use the information from novel high sensitivity troponin assays in stable cardiac patients is unclear. Preliminary data from randomized controlled trial analyses suggest it helps with risk stratification. We investigated the determinants, diagnostic impact and prognostic value of a novel high-sensitive cardiac troponin I (hs-cTnI) assay in patients with stable cardiac disease. METHODS: hs-cTnI was measured with a pre-commercial assay in 222 outpatients after clinical testing before cardiac catheterization. Mean follow-up was 1103+/-299 days. RESULTS: hs-cTnI was detectable in all patients (median (interquartile range) 6.20 (4.85;8.25) ng/l). Creatinine (p<0.001), systolic wall stress (p=0.004), the presence of myocardial impairment (p=0.049) and coronary artery stenosis > or = 70% (p=0.050) were predictors of hs-cTnI concentration. hs-cTnI values could not distinguish elevations due to myocardial abnormalities from those related to coronary artery abnormalities. Patients with elevations above the 99th percentile had a higher rate of hospitalizations but otherwise prognosis was not predicted robustly by hs-cTnI values. CONCLUSION: Stable cardiovascular patients have detectable hs-cTnI concentrations irrespective of their underlying disease. In this heterogeneous group of patients with diverse etiologies for cardiac disease, values were not helpful in distinguishing the etiology of the elevations or in predicting prognosis.