The American journal of cardiology
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Exercise is a classic trigger of ventricular arrhythmias in the setting of coronary artery disease (CAD). The aim of this study was to examine the changes of novel indexes of repolarization in patients with stable CAD who underwent exercise stress testing. Sixty-seven consecutive patients (mean age 62 ± 9 years, 60 men) who underwent treadmill exercise stress testing according to the Bruce protocol and completed the test without evidence of ischemia were enrolled. ⋯ In the control group, the QTc interval did not change significantly, the Tpe interval decreased at peak exercise (62 ms [41 ms, 80 ms] vs 48 ms [40 ms, 78 ms], p = 0.05), and the Tpe/QT ratio did not show a significant change (0.18 [0.12, 0.22] vs 0.16 [1.14, 0.21], p = 0.39). In patients with stable CAD and normal treadmill exercise stress test results, the QTc interval, the Tpe interval, and the Tpe/QT ratio increased during exercise. In conclusion, it is reasonable to assume that despite the absence of inducible ischemia, the spatial dispersion of repolarization is increased during exercise, exposing these patients to increased arrhythmic risk.
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Comparative Study
Impact of clinical presentation and pretest likelihood on the relation between calcium score and computed tomographic coronary angiography.
The purpose of the present study was to assess the impact of clinical presentation and pretest likelihood on the relation between coronary calcium score (CCS) and computed tomographic coronary angiography (CTA) to determine the role of CCS as a gatekeeper to CTA in patients presenting with chest pain. In 576 patients with suspected coronary artery disease (CAD), CCS and CTA were performed. CCS was categorized as 0, 1 to 400, and >400. ⋯ In patients with CCS >400, prevalence of significant CAD on CT angiogram remained high (>72%) regardless of clinical presentation and pretest likelihood. In conclusion, the relation between CCS and CTA is influenced by clinical presentation and pretest likelihood. These factors should be taken into account when using CCS as a gatekeeper for CTA.
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Risk stratification in patients with acute coronary syndromes (ACS) is achieved today by clinical models, "blind" to the prognostic support of imaging methods. To assess the value of simple at rest cardiac chest sonography in predicting the intra- and extrahospital risk of death or myocardial infarction, we enrolled 470 consecutive in-patients (312 men, age 71 ± 12 years) who had been admitted for ACS. On admission, all had received a clinical score using the Global Registry in Acute Coronary Events and Thrombolysis in Myocardial Infarction systems and, within 1 to 12 hours, a comprehensive cardiac-chest ultrasound scan. ⋯ On multivariate Cox analysis, ejection fraction (hazard ratio 1.45, 95% confidence interval 1.02 to 2.08, p = 0.040), tricuspid annular plane systolic excursion (hazard ratio 1.66, 95% confidence interval 1.13 to 2.45, p = 0.010) and ultrasound lung comets (hazard ratio 1.69, 95% confidence interval 1.25 to 2.27, p = 0.001) were independent predictors of cardiac events. The 3-variable echocardiographic score (from 0, normal to 9, severe abnormalities in ejection fraction, ultrasound lung comets, and tricuspid annular plane systolic excursion) effectively stratified patients and added value (hazard ratio 2.52, 95% confidence interval 1.89 to 3.37, p <0.0001) to the Global Registry in Acute Coronary Events score (hazard ratio 1.60, 95% confidence interval 1.07 to 2.39, p = 0.003). In conclusion, for patients with ACS, effective risk stratification can be achieved with cardiac and chest ultrasound imaging parameters, adding prognostic value to the clinical risk scores.
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Comparative Study
Impact of recovery of renal function on long-term mortality after coronary artery bypass grafting.
Whether prognosis differs in acute renal failure (ARF) after coronary artery bypass grafting (CABG) in patients with and without recovery of renal function is not known. We studied patients who had CABG at Duke University Medical Center (1995 to 2008). ARF was defined as an increase in peak creatinine ≥50% after CABG or ≥0.7 mg/dl above baseline or need for new dialysis. ⋯ Mortality was lower in patients with ARF compared to those without complete recovery of renal function (p = 0.0083). In conclusion, in patients with ARF after CABG, complete recovery of renal function was associated with significantly lower long-term mortality compared to those without such recovery, although this was significantly higher than in those without ARF. Thus, major emphasis should be on prevention of ARF in patients undergoing CABG.
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Systematic evaluation of left ventricular (LV) endocardial fibroelastosis (EFE) in the fetus has not been reported. The role of EFE in the pre- and postnatal evolution of hypoplastic left heart disease, and the implications of EFE for outcomes after prenatal intervention for fetal aortic stenosis with evolving hypoplastic left heart syndrome have also not been determined. A 4-point grading system (0-3) was devised for the assessment of fetal LV echogenicity, which was presumed to be due to EFE. ⋯ In conclusion, echocardiographic grading of EFE is possible, with reasonable intra- and interobserver reliability in midgestation fetuses with evolving hypoplastic left heart syndrome. EFE severity corresponded to some indexes of left heart size, geometry, and function and with the probability of a biventricular outcome postnatally. Additional experience and external validation of the EFE grading scoring system are necessary.