Kumar Kalapatapu

Relation of Bone Mineral Density to Frequency of Coronary Heart Disease

Coronary angiography was performed because of chest pain in 198 patients (146 women, 52 men; mean age 66 years) who had dual-energy x-ray absorptiometry scans of the spine and left hip because of suspected osteoporosis or osteopenia. Of the 198 patients, 53 (27%) had osteoporosis, 79 (40%) had osteopenia, and 66 (33%) had normal bone mineral density (BMD). Obstructive coronary artery disease with >50% narrowing of > or =1 major coronary artery was present in 40 of 53 patients (76%) with osteoporosis, in 54 of 79 patients (68%) with osteopenia, and in 31 of 66 patients (47%) with normal BMD (p <0.005 comparing osteoporosis with normal BMD, p <0.01 comparing osteopenia with normal BMD). In conclusion, in patients who undergo coronary angiography because of chest pain, patients with osteoporosis or osteopenia have a higher prevalence of obstructive coronary artery disease than those with normal BMD.

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography.

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.

Incidence of Appropriate Cardioverter-Defibrillator Shocks and Mortality in Patients With Heart Failure Treated With Combined Cardiac Resynchronization Plus Implantable Cardioverter-Defibrillator Therapy Versus Implantable Cardioverter-Defibrillator Therapy

Of 529 patients with heart failure and a mean left ventricular ejection fraction of 29%, 209 (40%) were treated with cardiac resynchronization therapy (CRT) plus an implantable cardioverter-defibrillator (ICD) and 320 (60%) with an ICD. Mean follow-up was 34 months for both groups. Stepwise logistic regression analysis showed that significant independent variables for appropriate ICD shocks were statins (risk ratio = 0.35, P < .0001), smoking (risk ratio = 2.52, P < .0001), and digoxin (risk ratio = 1.92, P = .0001). Significant independent variables for time to deaths were use of CRT (risk ratio = 0.32, P = .0006), statins (risk ratio = 0.18, P < .0001), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (risk ratio = 0.10, P < .0001), hypertension (risk ratio = 24.15, P < .0001), diabetes (risk ratio = 2.54, P = .0005), and age (risk ratio = 1.06, P < .0001). In conclusion, statins reduced and smoking and digoxin increased appropriate ICD shocks. Use of CRT, statins, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers reduced mortality and hypertension, diabetes, and older age increased mortality.

Incidence of Myocardial Infarction or Stroke or Death at 47‐Month Follow‐Up in Patients With Diabetes and a Predicted Exercise Capacity ≤85% vs >85% During an Exercise Treadmill Sestamibi Stress Test

A treadmill exercise sestamibi stress test (TESST) was performed in 609 consecutive diabetic persons with a mean age of 70 years and no history of coronary artery disease (CAD) who were referred for a TESST because of chest pain or dyspnea. Of 609 patients, 301 (49%) had a predicted exercise capacity <or=85% (group A) and 308 (51%) had a predicted exercise capacity >85% (group B). Group A patients had a higher prevalence of myocardial ischemia (43% vs 30%, P=.0005), 2- or 3-vessel obstructive CAD (38% vs 18%, P=.001), myocardial infarction (17% vs 9%, P=.004), death (10% vs 4%, P=.008), and myocardial infarction or stroke or death at 47-month follow-up (21% vs 12%, P=.001). Stepwise Cox regression analysis showed that the only significant independent predictor for the time to development of myocardial infarction or stroke or death was a predicted exercise capacity >85% (hazard ratio, 0.52; 95% confidence interval, 0.34-0.78; P=.002). Diabetic persons with a predicted exercise capacity >85% had a 48% lower chance of myocardial infarction, stroke, or death than those with a predicted exercise capacity <or=85%.

Major adverse cardiac events in patients with moderate to severe renal insufficiency treated with first-generation drug-eluting stents.

No data are available comparing the long-term outcome of sirolimus-eluting stents (SESs) versus paclitaxel-eluting stents (PESs) in patients with moderate to severe renal insufficiency. The incidence of major adverse cardiac events (MACE), including death, myocardial infarction, and target vessel revascularization, during long-term follow-up were studied in patients with a glomerular filtration rate of <60 ml/min/1.73 m(2), as measured by the Modification of Diet in Renal Disease (MDRD) study equation, who also underwent percutaneous coronary intervention with drug-eluting stents. Of 428 patients studied, PESs were placed in 287 patients and SESs in 141 patients. Stepwise Cox regression analyses were performed to identify significant independent risk factors for MACE. At 47 + or - 19 months of follow-up, MACE had occurred in 49 (17%) of 287 patients in the PES group (mean age 71 + or - 11 years, 55% men) and in 31 (22%) of 141 patients in the SES group (mean age 71 + or - 12 years, 53% men). No significant difference was found in the MACE rate between the PES and SES groups. This persisted even after controlling for stent length, lesion complexity, and other co-morbidities. Also, all-cause mortality was not significantly different between the PES and SES groups (7.1% vs 8.5%, respectively). In conclusion, during long-term follow-up of patients with moderate to severe renal insufficiency, the rates of MACE and all-cause mortality were similar in the PES and SES groups.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease.

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

Incidence of in-hospital mortality or nonfatal myocardial infarction or nonfatal stroke in 216 diabetics and 552 nondiabetics undergoing percutaneous coronary intervention with stenting.

We investigated the incidence of in-hospital mortality or nonfatal myocardial infarction or nonfatal stroke in 216 patients with diabetes mellitus and in 552 patients without diabetes mellitus (68% men and 32% women, mean age 66 ± 14 y) who underwent percutaneous coronary intervention with stenting. Symptomatic chest pain was present in 95% of diabetics and in 95% of nondiabetics. Unstable symptoms were present in 67% of diabetics and in 68% of nondiabetics. Aspirin was used in 99% of diabetics and nondiabetics. Clopidogrel was used in 98% of diabetics and nondiabetics. Beta blockers were used in 85% of diabetics and nondiabetics. Lipid-lowering drugs were used in 96% of diabetics and in 95% of nondiabetics. In-hospital mortality occurred in 2 of 216 diabetics (0.9%) and in 2 of 552 nondiabetics (0.4%), P not significant. In-hospital mortality or nonfatal myocardial infarction or nonfatal stroke occurred in 3 of 216 diabetics (1.4%) and in 6 of 552 nondiabetics (1.1%), P not significant.

Risk factors for major bleeding and for minor bleeding after percutaneous coronary intervention in 634 consecutive patients with acute coronary syndromes.

Of 634 consecutive patients who had percutaneous coronary intervention (PCI) for acute coronary syndromes, 34 (5%) had major bleeding after PCI, 253 (40%) had minor bleeding after PCI, and 347 (55%) had no bleeding after PCI. Significant independent risk factors for major bleeding after PCI were increased troponin I level (P = 0.004; odds ratio [OR] = 4.7), prior coronary artery disease (P = 0.029; OR = 3.7), platelet glycoprotein IIb/IIIa inhibitors (P = 0.002; OR = 9.8), glomerular filtration rate (GFR) <30 versus ≥60 mL/min/1.73 m2 (P < 0.0001; OR = 39.7), GFR 30-59 versus ≥60 mL/min/1.73 m2 (P = 0.0001; OR = 9.4), and clopidogrel loading dose >300 mg (P = 0.0001; OR = 8.9). Significant independent risk factors for minor bleeding after PCI were increased troponin I level (P = 0.0004; OR = 2.1), platelet glycoprotein IIb/IIIa inhibitors (P = 0.039; OR = 2.4), GFR 30-59 versus ≥60 mL/min/1.73 m2 (P < 0.0001; OR = 2.5), thrombolytics (P = 0.01; OR = 2.7), clopidogrel loading dose >300 mg (P < 0.0001; OR = 4.2), and systolic blood pressure during PCI (P < 0.0001; OR = 1.03 per mm Hg). In-hospital deaths included 5 of 34 patients (15%) with major bleeding, none of 253 patients (0%) with minor bleeding, and none of 347 patients (0%) with no bleeding (P < 0.0001). Hospital duration was 11.0 days in patients with major bleeding, 3.4 days in patients with minor bleeding, and 1.8 days in patients with no bleeding (P < 0.0001).

Major Adverse Cardiac Events at Follow-Up After Bare-Metal Stenting Versus Drug-Eluting Stenting in ST-Elevated Myocardial Infarction

After thrombolytic therapy with tenecteplase for ST-segment elevation acute myocardial infarction, 376 patients were transferred from their hospital to Westchester Medical Center for percutaneous coronary intervention with stenting. Of 376 patients, 102 (27%) received bare-metal stents and 274 (73%) received drug-eluting stents with sirolimus-eluting or paclitaxel-eluting stents. At 43 months of follow-up, major adverse cardiac events occurred in 25 (25%) of 102 patients treated with bare-metal stents versus 40 (15%) of 274 patients treated with drug-eluting stents (p = 0.024). Cox regression analysis showed that significant independent prognostic factors for major adverse cardiac events were previous coronary artery bypass surgery (hazard ratio 2.2, p = 0.019), width of stent (hazard ratio 0.44, p = 0.006), and bare-metal stent (hazard ratio 1.8, p = 0.019). In conclusion, patients with bare-metal stents had a 1.8 times greater risk of developing major adverse cardiac events than did those using drug-eluting stents after controlling the confounding effects of previous coronary artery bypass surgery and stent width.

Obstructive coronary artery disease in high-risk diabetic patients with and without atrial fibrillation.

ObjectiveTo investigate the severity of coronary artery disease by coronary angiography in age-matched and sex-matched patients with diabetes mellitus with atrial fibrillation versus sinus rhythm. MethodsThe patients included 245 men and women, mean age of 70 years, with diabetes and atrial fibrillation and 245 age-matched and sex-matched patients with diabetes and sinus rhythm who underwent coronary angiography. Baseline characteristics and indications for coronary angiography were similar in both groups. ResultsGreater than 50% narrowing of one, two, or three major coronary arteries were present in 229 of 245 patients (94%) with diabetes and atrial fibrillation and in 211 of 245 patients (86%) with diabetes and with sinus rhythm (P<0.01). Greater than 50% narrowing of three major coronary arteries were present in 150 of 245 patients (61%) with diabetes and atrial fibrillation and in 75 of 245 patients (31%) with diabetes and sinus rhythm (P<0.001). ConclusionPatients with diabetes and atrial fibrillation have a significantly higher prevalence of greater than 50% narrowing of one or more major coronary arteries and of three major coronary arteries than patients with diabetes and sinus rhythm.