Masoor Kamalesh

Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes.

OBJECTIVES This study sought to determine the optimal coronary revascularization strategy in patients with diabetes with severe coronary disease. BACKGROUND Although subgroup analyses from large trials, databases, and meta-analyses have found better survival for patients with diabetes with complex coronary artery disease when treated with surgery, a randomized trial comparing interventions exclusively with drug-eluting stents and surgery in patients with diabetes with high-risk coronary artery disease has not yet been reported. METHODS In a prospective, multicenter study, 198 eligible patients with diabetes with severe coronary artery disease were randomly assigned to either coronary artery bypass grafting (CABG) (n = 97) or percutaneous coronary intervention (PCI) with drug-eluting stents (n = 101) and followed for at least 2 years. The primary outcome measure was a composite of nonfatal myocardial infarction or death. Secondary outcome measures included all-cause mortality, cardiac mortality, nonfatal myocardial infarction, and stroke. RESULTS The study was stopped because of slow recruitment after enrolling only 25% of the intended sample size, leaving it severely underpowered for the primary composite endpoint of death plus nonfatal myocardial infarction (hazard ratio: 0.89; 95% confidence interval: 0.47 to 1.71). However, after a mean follow-up period of 2 years, all-cause mortality was 5.0% for CABG and 21% for PCI (hazard ratio: 0.30; 95% confidence interval: 0.11 to 0.80), while the risk for nonfatal myocardial infarction was 15% for CABG and 6.2% for PCI (hazard ratio: 3.32; 95% confidence interval: 1.07 to 10.30). CONCLUSIONS This study was severely underpowered for its primary endpoint, and therefore no firm conclusions about the comparative effectiveness of CABG and PCI are possible. There were interesting differences in the components of the primary endpoint. However, the confidence intervals are very large, and the findings must be viewed as hypothesis generating only. (Coronary Artery Revascularization in Diabetes; NCT00326196).

Long Term Postischemic Stroke Mortality in Diabetes. A Veteran Cohort Analysis

Background and Purpose— Recent data on stroke mortality in diabetics in the United States is lacking. We investigated trends in diabetes prevalence and stroke morality among diabetics in a large veteran cohort. Methods— The Patient Treatment File was used to identify all patients discharged from any Veterans hospital between October 1990 and September 1997 with a diagnosis of ischemic stroke (ICD-9-CM codes 434, 436) listed as primary diagnosis. Demographic, morbidity, and mortality data were recorded. Chi-square tests were used to examine differences between diabetics and nondiabetics, and t tests were used for continuous variables. Cox proportional hazards regression was used to examine the effects of diabetes (DM) on the survival times controlling for multiple covariates. Results— Of 48 733 ischemic stroke patients identified, 98% were male and 13 925 (25%) had DM. Mean age was similar between DM and non-DM (67.2 versus 67.5, P=NS). Prevalence of DM among stroke subjects increased from 25% to 31%. Charlson index >2 was much higher in DM (68.2% versus 47.9%, P<0.001). Mortality at 60 days and 1 year was similar in both groups (2.9 versus 2.7%, P=NS; 12.6 versus 13.1, P=NS). Kaplan–Meier survival plot showed that DM had shorter long term survival time (log-rank, P<0.001). Multivariate Cox proportional hazards regression showed a higher risk of death for diabetics (HR=1.15, 95% CI 1.11 to 1.19, P<0.001). Conclusion— Despite greater comorbidity, postacute ischemic stroke mortality at 60 days and 1 year is not different between subjects with and without DM. Long term mortality after stroke is much lower among DM than that reported in older studies.

Decreased survival in diabetic patients with heart failure due to systolic dysfunction.

Prognosis of patients with heart failure (HF) has improved in recent years due to advances in therapy. Whether this is also true for diabetic subjects with HF in clinical practice has not been studied in a prospective manner.

Does diabetes accelerate progression of calcific aortic stenosis

AIMS Calcific aortic valve stenosis (CAS) is an active disease like atherosclerosis. Effect of diabetes (D) on severity of CAS is not well documented. METHODS AND RESULTS We retrospectively analysed 166 consecutive patients with CAS and multiple echocardiograms from January 1997 to March 2005. Aortic valve area (AVA) was measured using the continuity equation. CAS severity was categorized using AVA. D and non-D patients were compared for differences in sex, hypertension, smoking, statin use using chi(2) tests. Comparisons between D and non-D for changes in AVA per year were performed using ANOVA. Study cohort included 166 males with age 70 +/- 9 years, of which 72 (43%) had D. Baseline CAS was mild in 66 subjects, moderate in 75, and severe in 25. D subjects smoked less (P = 0.02), but all other variables were similar (P > 0.05). The interaction between D and baseline CAS severity was significant (P = 0.0191), indicating comparisons should be viewed by baseline CAS severity. D had significantly larger change in AVA than non-D (P = 0.0016) for those with moderate CAS at baseline only. Adjusting for statin use did not alter the results. CONCLUSION CAS severity progresses faster in D than in non-D in subjects with moderate CAS at baseline. Statins do not affect progression of CAS.

Prediction of Ischemic Events by Anatomic M-mode Strain Rate Stress Echocardiography

OBJECTIVE We assessed the prognostic value of anatomic M-mode strain rate stress echocardiography (SRSE) in patients with known or suspected coronary artery disease. Previous studies showing that M-mode SRSE may be an accurate method for detection of coronary artery disease suggest that this technique may be useful for risk stratification. METHODS M-mode SRSE, using a color-coded display of strain rate (SR), was performed in 358 patients (48, dobutamine; 68, bicycle; 242, treadmill). SR was graded by visual assessment of the color-coded display in 12 apical segments. Abnormal rest SR was defined as SR more positive than -1/s (green-yellow). Ischemia was defined by the development of post-systolic shortening or lack of improvement of SR to more negative than -2/s (brown hue) with stress. Patients were followed for cardiac events. RESULTS Twelve patients with early intervention for an abnormal two-dimensional stress echocardiogram or stress electrocardiogram were excluded. Follow-up (mean 10.7 months) was completed in 98% (338/346) of the remaining patients. Events occurred in 1.7% (4/230) of patients with normal SRSE compared with 10% (11/108) with abnormal SRSE (P = .002). The annualized hard event (infarction, death) rate in those with normal SRSE was 0.5% versus 7.2% in those with abnormal SRSE (P = .001). Smoking (P = .048, relative risk 2.91), nitrate use (P = .001, relative risk 7.81), and the severity of the abnormality on SRSE (P = .009, relative risk 1.75) independently predicted events. Wall motion assessment was not predictive. Patients with normal SRSE had better event-free survival compared with those with abnormal SRSE (P < .001). CONCLUSION SRSE is an independent predictor of outcome. A normal SRSE predicts a low risk of infarction or death in short-term follow-up.

Stress-induced wall motion abnormalities with low-dose dobutamine infusion indicate the presence of severe disease and vulnerable myocardium

Background: Patients with left ventricular (LV) systolic dysfunction due to coronary artery disease (CAD) may develop stress‐induced wall motion abnormalities (SWMA) with low‐dose (10 μg/kg/min) dobutamine infusion. The clinical significance of low‐dose SWMA is unknown. Objective: We investigated the clinical, hemodynamic and angiographic correlates of low‐dose SWMA in patients with chronic ischemic LV systolic dysfunction. Methods: Seventy patients with chronic ischemic LV systolic dysfunction who had dobutamine stress echocardiography were studied. Clinical, hemodynamic, and angiographic parameters at rest and low‐dose were compared between 38 patients (mean ejection fraction (EF) of 30 ± 8%) with low‐dose SWMA and 32 patients (EF 30 ± 11%) without low‐dose SWMA. Results: Multivariate analysis showed that the number of coronary territories with severe disease (stenosis ≥70%)(P = 0.001, RR = 6.3) was an independent predictor of low‐dose SWMA. An increasing number of collateral vessels protected patients from low‐dose SWMA (P = 0.011, RR = 0.25). A higher resting heart rate was a negative predictor of low‐dose SWMA (P = 0.015, RR = 0.92) but no other hemodynamic variables were predictors. In the patients with low‐dose SMA, regions with low‐dose SWMA were more likely to be supplied by vessels with severe disease than regions without low‐dose SWMA (92% vs 58%, P < 0.001). Conclusion: In patients with ischemic LV systolic dysfunction, the extent of severe disease and a lower numbers of collaterals predict the occurrence of low‐dose SWMA. Low‐dose SWMA is a highly specific marker for severe disease.

Similar Decline in Post-Myocardial Infarction Mortality among Subjects with and without Diabetes

Background:Data from the 1970s and 1980s suggest that the rate of mortality from coronary disease for patients with diabetes has changed less than that for patients without diabetes. We evaluated trends in post-myocardial infarction mortality and morbidity in patients with and without diabetes over a 7-year period from 1990 through 1997, when substantial changes occurred in the management of coronary disease. Methods:All patients discharged with the primary diagnosis of acute myocardial infarction (MI) from any Veterans Affairs Medical Center in the country between October 1990 and September 1997 were identified. Demographic, comorbid conditions, inpatient, outpatient, mortality, and readmission data were extracted. Mortality, trends in mortality over time, revascularization, readmissions, and length of hospital stay for MI were compared for the group with diabetes and the group without diabetes. Independent predictors of survival using a Cox regression model were examined. Results:We identified 67,889 patients with MI, of whom 17,756 (26%) had diabetes. At 60 days post-MI, there was a 29% higher mortality rate in the group with diabetes (5.2% versus 4.0%, P < 0.001), which increased to 35% at 1 year (16.1% versus 11.9%, P < 0.001). Diabetes was independently associated with increased overall mortality. Age-adjusted 1-year post-MI mortality from 1991 to 1998 had a significant downward trend (4.9% decrease in odds of mortality per year, P < 0.001) regardless of diabetes status. Conclusions:Patients with diabetes showed a trend toward declining 1-year post-MI mortality rate that was not significantly different from that seen in patients without diabetes. Further work needs to be done to narrow the gap between the two groups.

Stroke mortality and race : Does access to care influence outcomes?

Background:Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies. Methods:Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admissions discharge diagnoses. Patients were followed through 1998. Results:Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA. Conclusions:Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.

Perilous Pearl -Papillary Fibroelastoma of Aortic Valve : A Case Report and Literature Review

Papillary fibroelastomas of the heart valves are benign, slow-growing, rare tumors of the heart. These lesions are primarily responsible for embolic events that can clinically manifest with neurological and cardiovascular symptoms. Early diagnosis is very important, as surgical excision of these tumors can prevent cerebrovascular and cardiovascular complications. The case of a 60-year-old man who presented with a neurological deficit caused by a papillary fibroelastoma of the noncoronary cusp of the aortic valve is described. Diagnosis was made by transesophageal echocardiogram, and the tumor was resected surgically.

Effect of improvement in left ventricular ejection fraction on long-term survival in revascularized patients with ischaemic left ventricular systolic dysfunction

AIMS The importance of improvement in the ejection fraction to the prognosis of revascularized patients with ischaemic left ventricular (LV) dysfunction is uncertain. METHODS AND RESULTS Eighty-seven patients with ischaemic LV dysfunction (mean ejection fraction 29 ± 8% by biplane Simpsons) had dobutamine echocardiography before revascularization (coronary bypass graft surgery-81, percutaneous intervention-6). Follow-up echocardiograms were performed a mean of 4.8 ± 6.2 months after revascularization. An 8% increase in the ejection fraction was considered significant (two times the inter-observer difference of 3.7%). Patients were followed for cardiac death. During a mean follow-up of 5.2 ± 3.9 years, there were 20 (23%) cardiac deaths. Class 3/4 heart failure, increasing low-dose wall motion score, increasing % non-viable myocardium, and digoxin use in follow-up were univariate predictors of death. Beta-blocker use, ejection fraction improvement, angina, aspirin use, and increasing fractional shortening were univariate predictors of survival. Ejection fraction improvement [P= 0.02, hazard ratio (HR) = 0.26], digoxin use in follow-up (P= 0.006, HR = 5.85), and low-dose wall motion score (P= 0.017, HR = 4.78) were independent predictors of outcome. In step-wise analysis, low-dose wall motion score added incremental prognostic value to ejection fraction improvement (P= 0.003), and digoxin use in follow-up (P= 0.003) added incremental value to a low-dose score and ejection fraction improvement. CONCLUSION Ejection fraction improvement is an independent predictor of long-term outcome in revascularized patients but viability (low-dose wall motion score) and digoxin use in follow-up are also independent predictors and add incremental prognostic value to ejection fraction improvement.