Alberto Bouzas-Mosquera

Prediction of Mortality and Major Cardiac Events by Exercise Echocardiography in Patients With Normal Exercise Electrocardiographic Testing

OBJECTIVES We sought to assess the value of exercise echocardiography (EE) for predicting outcome in patients with known or suspected coronary artery disease and normal exercise electrocardiogram (ECG) testing. BACKGROUND The prognostic value of EE in patients with normal exercise ECG testing has not been characterized. METHODS We studied 4,004 consecutive patients (2,358 men, mean age [+/- SD] 59.6 +/- 12.5 years) with interpretable ECG who underwent treadmill EE and did not develop chest pain or ischemic ECG abnormalities during the tests. Wall motion score index (WMSI) was evaluated at rest and with exercise, and the difference (DeltaWMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (MACE). RESULTS Overall, 669 patients (16.7%) developed ischemia with exercise. During a mean follow-up of 4.5 +/- 3.4 years, 313 patients died, and 183 patients had a MACE before any revascularization procedure. The 5-year mortality and MACE rates were 6.4% and 4.2% in patients without ischemia versus 12.1% and 10.1% in those with ischemia, respectively (p < 0.001). In the multivariate analysis, DeltaWMSI remained an independent predictor of mortality (hazard ratio [HR]: 2.73, 95% confidence interval [CI]: 1.40 to 5.32, p = 0.003) and MACE (HR: 3.59, 95% CI: 1.42 to 9.07, p = 0.007). The addition of the EE results to the clinical, resting echocardiographic and exercise hemodynamic data significantly increased the global chi-square of the models for the prediction of mortality (p = 0.005) and MACE (p = 0.009). CONCLUSIONS The use of EE provides significant prognostic information for predicting mortality and MACE in patients with interpretable ECG and normal exercise ECG testing.

Nefropatía inducida por contraste y fracaso renal agudo tras cateterismo cardiaco urgente: incidencia, factores de riesgo y pronóstico

Introduction and objectives. The aim was to investigate the incidence and prognosis of, and predictive factors for, acute renal failure following urgent cardiac catheterization. Methods. The study involved 602 consecutive patients who underwent urgent cardiac catheterization. Acute renal failure (ARF) was defined as an increase in serum creatinine level ≥0.5 mg/dL within 72 hours following the procedure. Predictive factors for and the prognosis of ARF were evaluated in an initial cohort of 315 patients, and a risk score was derived. The risk score was validated in a second cohort of 287 patients. The median (interquartile) follow-up time was 1.3 years (0.8-2.0 years). Results. Seventy-two of the 602 patients (12.0%) developed ARF. In the initial cohort of 315 patients, the following factors were predictors of ARF: cardiogenic shock at admission (odds ratio [OR]= 4.56), diabetes mellitus (OR= 2.98), time to reperfusion >6 hours (OR= 3.18), anterior myocardial infarction (OR= 2.61), baseline serum creatinine level ≥1.5 mg/dL (OR= 3.51), and baseline serum urea level ≥50 mg/dL (OR= 3.00). A risk score based on these variables was constructed in which cardiogenic shock = 3 points and each of the remaining variables = 2 points. Patients in the validation cohort were divided into five risk categories: in those with 0 points, the incidence of ARF was 1.2%; with 2-3 points, 8.7%; with 4-5 points, 12.5%; with 6-7 points, 46.2%; and with ≥8 points, 66.7% (P<.0001). Cox regression analysis showed that ARF was a powerful predictor of total mortality (hazard ratio [HR]= 5.97, 95% confidence interval [CI], 2.54-14.03; P<.0001) and of a major cardiovascular event (HR= 3.29, 95% CI, 1.61-6.75; P=.001). Conclusions. The incidence of ARF after urgent cardiac catheterization is high. Cardiogenic shock,

Left atrial size and risk for all-cause mortality and ischemic stroke

Background: Limited data are available on the relation between left atrial size and outcome among patients referred for clinically indicated echocardiograms. Our aim was to assess the association of left atrial size with all-cause mortality and ischemic stroke in a large cohort of patients referred for echocardiography. Methods: Left atrial diameter was measured in 52 639 patients aged 18 years or older (mean age 61.8 [standard deviation (SD) 16.3] years; 52.9% men) who underwent a first transthoracic echocardiogram for clinical reasons at our institution between April 1990 and March 2008. The outcomes were all-cause mortality and nonfatal ischemic stroke. Results: Based on the criteria of the American Society of Echocardiography, 50.4% of the patients had no left atrial enlargement, whereas 24.5% had mild, 13.3% had moderate and 11.7% had severe left atrial enlargement. Over a mean follow-up period of 5.5 (SD 4.1) years, 12 527 patients died, and 2314 patients had a nonfatal ischemic stroke. Cumulative 10-year survival was 73.7% among patients with normal left atrial size, 62.5% among those with mild enlargement, 54.8% among those with moderate enlargement and 45% among those with severe enlargement (p < 0.001). After adjustment in multivariable Cox proportional hazard analysis, left atrial diameter remained a predictor of all-cause mortality in both sexes (hazard ratio [HR] per 1-cm increment in left atrial size 1.17, 95% confidence interval [CI] 1.12–1.22, p < 0.001 in women, and HR 1.09, 95% CI 1.05–1.13, p < 0.001 in men) and of ischemic stroke in women (HR 1.25, 95% CI 1.14–1.37, p < 0.001). Interpretation: Left atrial diameter has a graded and independent association with all-cause mortality in both sexes and with ischemic stroke in women.

Prognostic Value of Exercise Echocardiography in Patients with Hypertrophic Cardiomyopathy

BACKGROUND Although exercise echocardiography may assess left ventricular (LV) function and LV outflow tract (LVOT) gradients during exercise in patients with hypertrophic cardiomyopathy (HCM), its value for predicting outcomes has not been studied. The aim of this study was to determine whether exercise echocardiography predicts outcomes in patients with HCM. METHODS LV function and LVOT gradients were evaluated during exercise echocardiography in 239 patients with HCM. RESULTS Sixty patients (25.1%) had LVOT obstruction at rest, and 43 (18%) developed exercise-induced LVOT obstruction. The mean resting LV ejection fraction was 69 ± 9%, and the mean resting wall motion score index was 1.00 ± 0.06. Wall motion abnormalities during exercise were seen in 19 patients (7.9%). During follow-up of 4.1 ± 2.6 years, 19 patients had hard events (cardiac death, cardiac transplantation, appropriate discharge of a defibrillator, stroke, myocardial infarction, or hospitalization for heart failure), and 41 patients had composite end points of hard or soft events (including atrial fibrillation and syncope). Exercise wall motion abnormalities occurred in 31.5% of patients with hard events compared with 5.9% of patients without hard events (P < .001). After adjustment, LV wall thickness (hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.05-1.21; P = .002), resting wall motion score index (HR, 21.59; 95% CI, 2.38-196.1, P = .006), and metabolic equivalents (HR, 0.74; 95% CI, 0.63-0.88; P = .001) remained independent predictors of hard events. Change in wall motion score index was also independently associated with hard events (HR, 52.30; 95% CI, 3.81-718.5; P = .003) and with the composite end point (HR, 39.51; 95% CI, 3.79-412.4; P = .002). LVOT obstruction was not associated with either end point. CONCLUSIONS Assessment of exercise capacity and LV systolic function during exercise echocardiography may have a role in risk stratification of patients with HCM.

Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease

AIMS Although peak may have higher sensitivity than post-treadmill exercise echocardiography (EE) for the detection of coronary artery disease (CAD), its prognostic value remains unknown. We sought to assess the relative values of peak and post-EE for predicting outcome in patients with known/suspected CAD. METHODS AND RESULTS We studied 2947 patients who underwent EE. Wall motion score index (WMSI) was evaluated at rest, peak, and post-exercise. Ischaemia was defined as the development of new or worsening wall motion abnormalities with exercise. Separate analyses for all-cause mortality and major cardiac events (MACE) were performed. Ischaemia developed in 544 patients (18.5%). Among them, ischaemia was detected only at peak exercise in 124 patients (23%), whereas 414 (76%) had ischaemia at peak plus post-exercise imaging and six patients (1%) had ischaemia only at post-exercise. During follow-up, 164 patients died. The 5-year mortality rate was 3.5% in patients without ischaemia, 15.3% in patients with peak ischaemia alone, and 14% in patients with post-exercise ischaemia (P < 0.001 normal vs. ischaemic groups). In the multivariate analysis, post-exercise WMSI was an independent predictor of MACE [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.09-2.19, P = 0.02]. Peak exercise WMSI was an independent predictor of MACE (HR 2.19, 95% CI 1.30-3.69, P = 0.003) and mortality (HR 1.58, 95% CI 1.07-2.35, P = 0.02). The addition of peak EE results to clinical, resting echocardiography, exercise variables, and post-EE provided incremental prognostic information for MACE (P = 0.04) and mortality (P = 0.04). CONCLUSION Peak treadmill EE provides significant incremental information over post-EE for predicting outcome in patients with known or suspected CAD.

Prognostic value of exercise echocardiography in patients with left bundle branch block.

OBJECTIVES Our aim was to evaluate the role of exercise echocardiography for predicting outcome in a cohort of patients with left bundle branch block (LBBB). BACKGROUND Although the prognostic value of exercise echocardiography has been well established in several subgroups of patients, it has not been specifically assessed in patients with LBBB. METHODS Of the 8,050 patients who underwent treadmill exercise echocardiography, 618 demonstrated complete LBBB. Nine patients were lost to follow-up and 609 patients were included in this study. Wall motion score index (WMSI) was evaluated at rest and at peak exercise, and the difference (DeltaWMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (including cardiac death, myocardial infarction, or cardiac transplantation). Mean follow-up was 4.6 +/- 3.4 years. RESULTS Mean age was 66 +/- 10 years, and 331 patients (54%) were men. A total of 177 patients (29%) developed ischemia with exercise. During follow-up, 124 deaths occurred, and 74 patients had a major cardiac event before any revascularization procedure. Patients with ischemia had a greater 5-year mortality rate (24.6% vs. 12.6%, p < 0.001) and 5-year major cardiac events rate (18.1% vs. 9.7%, p = 0.003). In multivariate analysis, DeltaWMSI remained an independent predictor of mortality (hazard ratio: 2.42, 95% confidence interval: 1.21 to 4.82, p = 0.012) and major cardiac events (hazard ratio: 3.38, 95% confidence interval: 1.30 to 8.82, p = 0.013). Exercise echocardiographic results also provided incremental value over clinical, resting echocardiographic, and treadmill exercise data for the prediction of mortality (p = 0.014) and major cardiac events (p = 0.017). CONCLUSIONS Exercise echocardiography provides significant prognostic information for predicting outcome in patients with LBBB. As compared to patients with normal exercise echocardiograms, patients with abnormal results are at increased risk of mortality and major cardiac events.

Quinolone-related Achilles Tendinopathy in Heart Transplant Patients: Incidence and Risk Factors

BACKGROUND A high incidence of Achilles tendinopathy--tendinitis or rupture--has been observed after quinolone treatment in lung and kidney transplant patients. In the absence of relevant published data, we aimed to determine its incidence, clinical features, risk factors and outcome among heart graft recipients. METHODS We studied the clinical records of all adult heart transplant patients who were prescribed quinolones at our center between August 1995 and September 2006. Achilles tendinopathy had been diagnosed clinically, with ultrasound assessment when necessary. In all cases, quinolone treatment had been terminated upon diagnosis of tendinopathy. RESULTS During this period, quinolones had been given on 242 occasions to 149 heart transplant patients (33 women, 116 men). Achilles tendinopathy developed on 14 occasions (5.8%; 95% confidence interval: 2.8% to 8.7%), affecting 13 men and 1 woman (mean age: 62 years). Three cases involved tendon rupture, and bilateral tendinopathy was present in 8 cases. The median time between the start of treatment and onset of symptoms was 2.5 days, with 12 patients being asymptomatic 2 months after drug withdrawal. Independent risk factors for tendinopathy were renal dysfunction (p = 0.03) and increased time between transplantation and treatment (p = 0.005). Incidence was not influenced by the type, dose or previous administration of quinolones, or by the immunosuppressive regimen. CONCLUSIONS Quinolone-related Achilles tendinopathy is frequent among heart transplant patients, especially in the presence of renal dysfunction or lengthy post-transplantation survival. If no alternative anti-bacterial therapy is available for high-risk patients, close clinical surveillance should be warranted.

Valor pronóstico de la ecocardiografía de ejercicio en cinta rodante

Introduccion y objetivos. Aunque la ecocardiografia de ejercicio es util para el diagnostico de la enfermedadcoronaria, hay menos datos referentes a su valor pronostico. El objetivo de este estudio fue esclarecer: a) si hay un valor incremental de la ecocardiografia en el pico del ejercicio respecto a las variables clinicas, la prueba de esfuerzo y la ecocardiografia en reposo, y b) si el numero y la localizacion de los territorios afectados, asi como el tipo de respuesta al ejercicio, influyen en la estratificacion. Pacientes y metodo. En 2.436 pacientes referidos para ecocardiografia de ejercicio se realizo un seguimiento de 2,1 ±1,5 anos. Hubo 120 eventos (infarto no fatal o muerte cardiovascular) antes de la revascularizacion. Resultados. La ecocardiografia fue anormal en 1.203p acientes (49%). Hubo 89 eventos en pacientes con resultado anormal (7,3%) frente a 31 con resultado normal (2,5%; p < 0,001). Mediante un analisis multivariable de variables clinicas, de la prueba de esfuerzo y de la ecocardiografia en reposo y ejercicio encontramos que las variables asociadas de manera independiente con el riesgo deeventos eran: ser varon (riesgo relativo [RR] = 1,7; intervalo de confianza [IC] del 95%, 1,1-2,8; p = 0,02), los equivalentes metabolicos o MET (RR = 0,9; IC del 95%, 0,9-1,0;p = 0,01), el producto frecuencia cardiaca × presion arterial(RR = 0,9; IC del 95%, 0,9-1,0; p = 0,02), el indice de motilidad segmentaria basal (RR = 2,5; IC del 95%, 1,5-4,1; p <0,0001) y el numero de territorios afectados (RR = 1,4; ICdel 95%, 1,2-1,7; p < 0,0001) (?² final = 170, valor incremental de la ecocardiografia en el maximo esfuerzo; p <0,0001). Las mismas variables, excepto el sexo, estaban asociadas con la muerte (?² final = 169, valor incremental de la ecocardiografia de ejercicio; p = 0,01). Conclusiones. La ecocardiografia en el maximo ejercicio incrementa el valor pronostico de las variables clinicas, la prueba de esfuerzo y la ecocardiografia de reposo.

Statin therapy and contrast-induced nephropathy after primary angioplasty

A recent study suggested that statin therapy may prevent contrast-induced nephropathy (CIN) following primary angioplasty. Our aim was to assess the effect of statins in this setting in a larger population. We evaluated 589 consecutive patients with acute myocardial infarction who underwent primary angioplasty at our institution. Contrast-induced nephropathy was defined as an increase in serum creatinine by > or =0.5 mg/dL within 72 h following the procedure. Overall, 69 patients (11.9%) developed CIN. The incidence of CIN in the group on statins was 15.9%, as compared with 10.8% in the group not taking statins (p=0.2). Thus, we did not observe a protective effect of statin therapy on CIN development after primary angioplasty.

Exercise echocardiography and cardiac magnetic resonance imaging to predict outcome in patients with hypertrophic cardiomyopathy

AIMS We have observed that wall motion abnormalities (WMAs) during exercise echocardiography (ExE) are associated to events in hypertrophic cardiomyopathy (HCM). Our objective was to evaluate ExE and cardiac magnetic resonance (CMR) to predict outcome in HCM. METHODS AND RESULTS ExE and CMR were performed in 148 patients with HCM. During follow-up (7.1 ± 2.7 years), there were 7 hard events (Hard-E) and 26 combined events (Comb-E). Exercise WMAs were observed in 13 patients (8.8%), perfusion defects in 10 (6.8%), and late gadolinium enhancement (LGE) in 48 (32.4%). WMAs were seen in 57% of patients with Hard-E vs. 6% without (P = 0.001) and in 23 and 6% with and without Comb-E (P = 0.005). Perfusion defects were also more frequent in patients with Hard-E than without (43 vs. 5%, P = 0.007) and in patients with Comb-E than without (23 vs. 5%, P = 0.002). LGE (g) was greater in patients with Comb-E than without [median (25th-75th percentile) 0 (0-21.1) vs. 0 (0-9.3) g P = 0.04]. Univariable predictors of Comb-E included NYHA class ≥2, peak double product, ΔWMSI, and CMR data. Peak double product [Hazard ratios (HR) = 0.99, confidence intervals (CI) 95% 0.99-0.99, P = 0.02] and ΔWMSI (HR = 404, CI 95% 12-13681, P = 0.001) remained independent predictors. Peak WMSI correlated with myocardial mass with LGE (r = 0.20, P = 0.02) and with perfusion defect area (r = 0.40, P < 0.001). LGE affecting ≥15% of the left ventricle was observed in 38% of patients with exercise WMAs vs. 12% without (P = 0.009). CONCLUSION CMR data are associated to exercise WMAs in patients with HCM. ExE and CMR may help to predict outcome in them.