Jeroen J. Bax

The Prognostic Value of Impaired Walking Distance on Long-term Outcome in Patients with Known or Suspected Peripheral Arterial Disease

OBJECTIVESnTo assess the predictive value of walking distance after an exercise test on long-term outcome in patients with normal and impaired ankle-brachial index (ABI).nnnDESIGNnA total of 2191 patients with known or suspected peripheral arterial disease (PAD), who were referred for a single-stage treadmill exercise test to diagnose or evaluate their PAD, were enrolled in an observational study between 1993 and 2006.nnnMATERIALS AND METHODSnThey were divided into two groups: normal ABI (>or=0.90) and impaired ABI (<0.90). Walking distance was divided into quartiles (no (reference), mild, moderate or severe impairment).nnnRESULTSnIn patients with normal ABI, severe walking distance was, after adjustment, associated with higher mortality risk (hazard ratio (HR): 2.60 (range: 1.16-5.78)). In patients with impaired ABI, all walking distance impairment quartiles were associated with higher mortality (mild HR: 1.26 (range: 0.95-1.67), moderate HR: 1.52 (range: 1.13-2.05) and severe HR: 1.69 (range: 1.26-2.27)). Furthermore, comparable associations were observed between all walking distance quartiles, cardiac death or major adverse cerebrovascular and cardiac events.nnnCONCLUSIONSnOur study illustrated that walking impairment is a strong prognostic indicator of long-term outcome in patients with impaired and normal ABI, which should be a warning sign to physicians to monitor these patients carefully and to provide them optimal treatment.

Usefulness of Hypertensive Blood Pressure Response During a Single-Stage Exercise Test to Predict Long-Term Outcome in Patients With Peripheral Arterial Disease

The prognostic value of a hypertensive blood pressure (BP) response is still unclear. Therefore, the prognostic value of a hypertensive BP response in patients during single-stage exercise testing for peripheral arterial disease (PAD) on long-term mortality and major adverse cerebrovascular and cardiac events (MACCEs) was investigated. In addition, effects of statin, beta-blocker, and aspirin use in patients with known or suspected PAD were studied. A total of 2,109 patients were enrolled in an observational prospective study from 1993 to 2005. Hypertensive BP response was defined as an increase in systolic BP > or = 55 mm Hg (95(th) percentile within our population) after a single-stage treadmill exercise test. The outcome was obtained by using the civil registries, and a questionnaire about cardiac events was sent to all survivals. Hypertensive BP response was associated with increased risk of long-term mortality (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.12 to 1.80) and MACCEs (HR 1.47, 95% CI 1.09 to 1.97). After adjustments for clinical risk factors and propensity score, baseline statin use was associated with reduced risk of long-term mortality (HR 0.59, 95% CI 0.44 to 0.79), and statin, beta-blocker, and aspirin use were associated with reduced risk of MACCEs (HR 0.59, 95% CI 0.43 to 0.81; HR 0.75, 95% CI 0.60 to 0.95; HR 0.73, 95% CI, 0.57 to 0.92, respectively). In conclusion, hypertensive BP response at exercise in patients with known or suspected PAD is an important independent risk factor for all-cause long-term mortality and MACCEs, whereas statin, beta-blocker, and aspirin use were associated with an improved outcome.

Exercise ankle brachial index adds important prognostic information on long-term out-come only in patients with a normal resting ankle brachial index.

BACKGROUNDnThe clinical value of exercise ankle brachial index (ABI) is still unclear, especially in patients with normal resting ABI.nnnMETHODn2164 patients performed a single-stage treadmill exercise test to diagnose or evaluate PAD. The population was divided into two groups: a normal resting ABI (resting ABI≥0.90) and PAD (resting ABI<0.90). Patients with a normal resting ABI were divided into 4 exercise ABI groups: exercise ABI<0.90, 0.90-0.99, 1.00-1.09 and 1.10-1.29 (reference).nnnRESULTSnMean follow-up was 5 years. Exercise ABI added significant prognostic information on all cause long-term mortality only in patients with normal resting ABI (p-value 0.014, HR 0.99 95% CI (0.98-0.99)), not in patients with PAD. Fifty years or older (OR 2.93 95% CI (1.65-5.20)) and resting systolic blood pressure>140 mmHg (OR 2.18 95% CI (1.35-3.55)) were associated with an abnormal exercise ABI in patients with a normal resting ABI. Mortality rate increased when the exercise ABI became worse (p trend 0.0001) with a 2.5-fold increase mortality risk in patients with a normal resting ABI but exercise ABI <0.90 (HR 2.56, 95% CI (1.11-5.91)).nnnCONCLUSIONnIn patients with a normal resting ABI, treadmill exercise ABI added important prognostic information on long-term mortality. Based on our results we recommend that at least all patients suspected for PAD, with a resting ABI≥0.90, who are 50 years or older and having hypertension should undergo treadmill exercise testing.

A decline in walking distance predicts long-term outcome in patients with known or suspected peripheral artery disease

Aim To assess the predictive value of a decline in total walking distance and ankle brachial index (ABI) on all-cause mortality and cardiac death in patients with known or suspected peripheral artery disease. Methods Two hundred and sixty-one patients, who performed single-stage treadmill walking test twice to evaluate their peripheral artery disease, were enrolled in an observational study. Patients who underwent surgery during follow-up were excluded. Delta total walking distance and delta resting and exercise ABI consisted of the difference between the first and the second test. All three variables were categorized into two groups: stable/improvement or a decline. Results The mean follow-up period was 6 years. At both 5 years and total follow-up, a decline in total walking distance was independent and highly associated with an increased mortality risk and cardiac death [hazard ratio: 2.31 (95% confidence interval 1.35-3.96); hazard ratio: 3.55 (95% confidence interval: 1.53-8.21), respectively]. A decline in resting or exercise ABI after adjustment for delta walking distance was not significantly associated with all-cause mortality or cardiac death. Conclusion A decline in total walking distance in single-stage treadmill exercise tests is a strong prognostic predictor of all-cause mortality and cardiac death in the short term and long term. Eur J Cardiovasc Prev Rehabil 17:321-328

SAT0230 Progression of Left Ventricular Myocardial Dysfunction in Systemic Sclerosis: Using Speckle Tracking Strain Echocardiography To Identify Patients at Risk

Background Cardiac involvement is a main cause of mortality in systemic sclerosis (SSc)1. Its detection remains challenging using conventional echocardiographic parameters and little is known about which patients are at risk for deterioration of cardiac function. Speckle-tracking strain analysis of echocardiographic images can detect subtle myocardial dysfunction in patients with SSc, and decreased strain has been shown to associate with lower functional capacity and rhythm disturbances2 Objectives This study evaluated: 1. changes in cardiac performance over time in SSc patients including echocardiographic myocardial speckle tracking strain analysis, and 2. baseline characteristics associated with deterioration of cardiac function. Methods 205 SSc patients (171 female, 52±14 years) were evaluated at baseline and follow-up (2.25years IQR1.3–3.8), including complete physical examination and screening for organ involvement with at least HRCT-thorax, pulmonary function test, cardiopulmonary exercise test, electrocardiography and echocardiography. Results Left ventricular (LV) ejection fraction did not change significantly (61%±7 vs 61%±8,p=0.148) while global longitudinal strain (LS) decreased significantly (-21%±2 vs -19%±3, p<0.001). 39 patients showed progression of LV dysfunction as defined by ≥15% decline in LS. These patients showed significant worsening of LV diastolic function (figure) and TAPSE (22mm±4 vs 19mm±4, p=0.003) and 8% developed pulmonary hypertension. Baseline parameters associated with progression of LV dysfunction were proximal muscle weakness (OR: 4.264 IQR: 1.473–12.342, p=0.007), diffusing capacity of carbon monoxide (DLCO, OR: 0.972 IQR: 0.948–0.995, p=0.020) and LV diastolic dysfunction (OR: 2.245 IQR: 1.019–4.946, p=0.045). Conclusions In SSc patients, progression of LV systolic dysfunction was detected by speckle tracking strain analysis but not by LV ejection fraction. Proximal muscle weakness, DLCO and LV diastolic function may identify patients at higher risk and in need of closer cardiac monitoring. References Rubio-Rivas M, Royo C et al. Mortality and survival in systemic sclerosis: systematic review and meta-analysis. Semin Arthritis Rheum 2014 Oct;44(2):208–19. Yiu KH, Schouffoer AA, et al. Left ventricular dysfunction assessed by speckle-tracking strain analysis in patients with systemic sclerosis: relationship to functional capacity and ventricular arrhythmias. Arthritis Rheum 2011 Dec;63(12):3969–78. Disclosure of Interest None declared

REPRODUCIBILITY OF HEART TO MEDIASTINUM RATIO ON 123IODINE-META-IODOBENZYLGUANIDINE (123I-MIBG) MYOCARDIAL SCINTIGRAPHY IN PATIENTS WITH HEART FAILURE

Although 123Iodine- meta-iodobenzylguanidine (123I-MIBG) myocardial scintigraphy provides important prognostic information in heart failure (HF) patients, widespread clinical implementation is hampered due to lack of validation and standardization. Therefore, the purpose of this study was to assess

High field MR carotid vessel wall imaging: reproducibility of five different MR-weightings

Magnetic Resonance Imaging (MRI) has emerged as a promising noninvasive imaging modality for the serial assessment of vessel wall thickness in the carotid artery as an early marker of atherosclerosis. For clinical application of this technique, Scan-Rescan reproducibility is paramount. Currently, a multicontrast protocol, including a combination of MR-weightings is used as reference standard for quantitative and morphologic measurements.

Association between pulse wave velocity from velocity-encoded MRI and advanced diastolic function indices assessed by speckle tracking strain analysis in Diabetes Mellitus type 1

Increased pulse wave velocity (PWV), a marker for aortic stiffness, has been linked to worse outcome such as heart failure. This potent marker can be accurately assessed with velocity-encoded MRI according to the transit-time method (Grotenhuis. JMRI 2009). Whether an increase in PWV translates in early diastolic dysfunction in diabetic patients remains unexplored.