Russell F. Kelly

Utility of history, physical examination, electrocardiogram, and chest radiograph for differentiating normal from decreased systolic function in patients with heart failure

To determine whether clinical parameters alone can differentiate normal versus decreased systolic left ventricular function in patients with heart failure. Detailed clinical data were collected prospectively from 225 consecutive patients who were hospitalized with heart failure. Findings in patients with normal (ejection fraction > or =45%) or decreased (ejection fraction <45%) left ventricular function were compared. Systolic function was normal in 104 patients (46%) and decreased in 121 patients (54%). Patients with normal function were older (mean [+/- SD] age, 59 +/- 13 years vs. 54 +/- 13 years, P = 0.007) and more likely to be female (56% vs. 35%, P = 0.001), obese (body mass index > or =30 kg/m(2), 62% vs. 48%, P = 0.04), have marked systolic (> or =160 mm Hg, 50% vs. 27%, P <0.001) and diastolic (> or =110 mm Hg, 25% vs. 13%, P = 0.02) hypertension, and use calcium antagonists (34% vs. 14%, P = 0.001). Patients with decreased function were more likely to use alcohol (37% vs. 20%, P = 0.007), angiotensin-converting enzyme (ACE) inhibitors (85% vs. 62%, P <0.001), and digoxin (57% vs. 27%, P <0.001); and more likely to have tachycardia (51% vs. 32%, P = 0.004), rales (89% vs. 80%, P = 0.05), electrocardiographic left ventricular hypertrophy (42% vs. 22%, P = 0.002), left atrial abnormality (52% vs. 22%, P <0.001), or flow cephalization on chest radiograph (91% vs. 79%, P = 0.02). Only sex, tachycardia, and use of digoxin and ACE inhibitors were associated with ventricular function in multivariable analysis. However, the sensitivity, specificity, and predictive values for all clinical variables were low. Differences in clinical parameters in heart failure patients with decreased versus normal systolic function cannot predict systolic function in these patients, supporting recommendations that heart failure patients should undergo specialized testing to measure ventricular function.

Effect of coronary angioplasty on QT dispersion

Increased QT dispersion (QTmax-QTmin [QTd]) reflects inhomogeneous ventricular repolarization that may provide a substrate for serious arrhythmias and is associated with adverse clinical outcomes in patients with heart disease. Effective treatment of acute myocardial infarction or ventricular arrhythmias may reduce QTd, but the effect of coronary revascularization on QTd in patients without these conditions is unknown. In this study, QTd was measured before and 4 and 24 hours after successful angioplasty in 94 patients without ongoing symptomatic myocardial ischemia or malignant arrhythmias. QTd decreased from 434 +/- 17 msec before angioplasty to 354 +/- 15 msec 4 hours (p < 0.05) and 33 +/- 14 msec 24 hours after angioplasty (p < 0.05). QTd was improved in 64% of patients, worse in 28%, and unchanged in 8%. Thus angioplasty significantly improves QTd. This may reflect increased myocardial perfusion and may be inherently beneficial by reducing the propensity for arrhythmias.

Utilization of coronary angiography and revascularization after acute myocardial infarction in men and women risk stratified by the American College of Cardiology/American Heart Association guidelines.

OBJECTIVES We sought to determine whether men and women are equally likely to receive coronary angiography and revascularization after acute myocardial infarction (AMI) when they are risk stratified according to American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines for post-MI care. BACKGROUND Several previous studies have suggested that women may undergo angiography and revascularization procedures less frequently than men. METHODS In 439 consecutive patients admitted to a public hospital with AMI, rates of coronary angiography and revascularization were compared in men and women categorized, according to ACC/AHA practice guidelines, as having strong (class I or IIa) or weaker (class IIb) indications for angiography. RESULTS Women were older and more likely to be diabetic or hypertensive, but men and women were equally likely to meet class I/IIa criteria for post-MI angiography (both 51%). Angiography rates were nearly identical in men and women overall (63% vs. 64%), as well as in patients in class I/IIa (80% vs. 82%) and class IIb (46% vs. 46%) (all p > 0.80, with >80% power to detect important differences); the only multivariate predictors of post-MI angiography were age and ACC/AHA class. Significant coronary artery disease was equally prevalent in men and women undergoing angiography, and men and women were equally likely to undergo revascularization, whether they were in class I/IIa (both 55%, p = 0.90) or class IIb (59% vs. 58%, p = 0.88). No significant differences in mortality were noted between men and women. CONCLUSIONS Despite being older and having more risk factors than men, women were equally likely to undergo coronary angiography and revascularization procedures after AMI, and they had in-hospital clinical outcomes that were at least as favorable.

Effect of 100% oxygen administration on infarct size and left ventricular function in a canine model of myocardial infarction and reperfusion

High oxygen concentrations reduced infarct size in prereperfusion era studies; however, with reperfusion therapy, high oxygen tension carries the theoretical risk of exacerbating reperfusion injury by increasing toxic oxygen-derived free radicals. In this study, two groups of dogs underwent 90 minutes of coronary occlusion and 72 hours of reperfusion. The oxygen group (n = 16) received 100% inspired oxygen from 20 minutes before reperfusion through 3 hours of reperfusion, whereas the room-air group (n = 19) was ventilated with room air. Infarct size (as a percentage of risk area) was reduced by 38% in the oxygen group (26.7% +/- 4.7% vs 43.3% +/- 4.3%; p = 0.017). This benefit was independent of underlying variability in collateral blood flow in individual dogs (p = 0.016 by analysis of covariance [ANCOVA]). Left ventricular ejection fraction was significantly improved in the oxygen group (43% +/- 3% vs 33% +/- 2%; p = 0.008), as was regional function in the infarct zone (p < 0.05). These data suggest that high concentrations of inspired oxygen may also benefit patients with acute myocardial infarction who undergo reperfusion therapy.

Association of medical noncompliance and long-term adverse outcomes, after myocardial infarction in a minority and uninsured population

The association of noncompliance with evidence-based medical therapies after myocardial infarction (MI) on long-term outcomes is not well recognized in minority and uninsured populations. Consecutive MI patients at a large urban hospital were followed for compliance with evidence-based medications (aspirin, clopidogrel, statins, beta blockers, and angiotensin converting enzyme inhibitors [ACEIs]/angiotensin receptor blockers [ARBs]). Noncompliance was defined as proportion of days covered < or =80%. The outcome was combined mortality and MI. Kaplan-Meier analyses were used to explore the impact of noncompliance > or =4 medications. Of the 509 patients (86% minorities, 77% uninsured, and 54% diabetics), 132 (25.9%) presented with ST segment elevation with myocardial infarction (STEMI) and 377 (74.1%) with a non-ST segment elevation with myocardial infarction (NSTEMI), revascularization was performed in 297 (58.4%) patients, 72 (14.2%) patients died, 22 (4.3%) patients had an MI, and 91 (17.9%) patients had either event at a median follow-up of 2 (0.5-2.9) years. Noncompliance > or = 4 medications was significantly associated with adverse survival compared with compliant patients (29.7% vs 78.9%). After adjusting for traditional risk factors, The Global Registry of Acute Coronary Events risk score for predicting death during 6 months post-discharge, revascularization, left ventricular (LV) function, coronary artery disease (CAD) severity, and punctual clinic visits, noncompliance with > or = 4 evidence-based medications was an independent factor associated with death or MI (hazard ratio [HR], 2.83; 95% confidence interval [CI]=1.60-5.01) in this minority and uninsured population.

Predictors of diastolic dysfunction among minority patients with newly diagnosed type 2 diabetes

AIM To determine mutable risk factors for asymptomatic diastolic dysfunction in ethnic minority patients newly diagnosed with type 2 diabetes. METHODS We recruited consecutive adults with newly diagnosed diabetes who had no signs or symptoms or history of heart disease. All patients received standardized evaluation including interview, physical examination, laboratory tests and echocardiogram with tissue Doppler studies. We used logistic regression models to identify mutable risk factors for diastolic dysfunction. RESULTS Among 126 study subjects (52% women, age 45+/-10 years, BMI 33+/-7, 42% with hypertension, 100% ejection fraction > or =50%), evidence of diastolic dysfunction was present in 64 (51%). After controlling for age, heart rate and blood pressure, independent predictors of diastolic dysfunction included physical inactivity (OR: 2.3; 95% CI: 0.9-6.1; P=0.08) and glucose (OR: 4.9; 95% CI: 1.4-17.8; P=0.02). Physical inactivity was associated with early diastolic dysfunction (impaired relaxation), whereas epicardial fat thickness and glucose levels were associated with late diastolic dysfunction (impaired compliance). The hs-CRP and BNP levels were not associated with diastolic dysfunction. CONCLUSIONS Asymptomatic diastolic dysfunction was prevalent among urban minority patients newly diagnosed with diabetes. Important differences exist among factors that affect early and late diastolic function that may have prognostic and therapeutic implications.

Value of Early Cardiac Troponin I to Predict Long-Term Adverse Events After Coronary Artery Bypass Graft Surgery in Patients Presenting with Acute Coronary Syndromes

High values of both preoperative and postoperative cardiac troponin I (cTnI) contribute to higher rates of short‐term cardiac events following coronary artery bypass graft (CABG) surgery in patients with acute coronary syndrome (ACS). The prognostic value of very early cTnI in this context is unclear.

Association Between Height and Coronary Artery Disease in Black Men and Women

A of studies have documented that shorter stature is associated with an increased risk of coronary events1–9 and an increased prevalence and severity of angiographically documented coronary artery disease (CAD) in men.10 These data come from populations that are overwhelmingly white and male.1–6,10 No previous studies have focused on the relation between height and CAD in black men or women. The purpose of the present study was to determine whether short stature was associated with prevalence and extent of CAD in a population of black patients who underwent coronary angiography. • • • The records of all black patients who underwent a first diagnostic coronary angiography at an inner-city public hospital from January 1993 to December 1997 were reviewed in this retrospective study. Clinical data collected included age, gender, coronary risk factors, height as reported by the patient, weight, and indication for coronary angiography. Body mass index (BMI), calculated as weight (kilograms) divided by height (square meters), was recorded as a measure of obesity. Angiographic data included the presence and extent of significant CAD (.50% diameter stenosis) and left ventricular ejection fraction. Patients in whom any of these data could not be obtained (except ejection fraction) were excluded from the study. A total of 1,682 black patients (798 men and 884 women) were included in the study. For each gender, the prevalence of significant CAD and the extent of CAD (number of vessels with significant CAD) was compared with height in 3 ways. First, the mean height and SD for men and for women were determined, then patients whose height was .1 SD below or above the mean were compared. Second, patients were divided into quintiles by height. Third, height was considered to be a continuous variable. Continuous variables were compared using 2-sided t tests. Categorical variables were compared using chi-square tests. Multivariate analysis, including variables with a univariate p ,0.10, was performed to identify independent predictors of CAD. A p value ,0.05 was considered significant. This study was approved by the Scientific Committee of Cook County Hospital. There were many differences in clinical characteristics and angiographic findings between men and women in the study (Table I). With respect to height, for men and women, the shortest and tallest quintiles were the same groups as patients whose height was .1 SD shorter or taller than the mean. Men ranged from 58 to 83 inches (in). The shortest quintile included men #67 in (n 5 153), and the tallest quintile included men

High Sensitivity C - Reactive Protein is Associated with Diastolic Dysfunction in Young African Americans without Clinically Evident Cardiac Disease

73 in (n 5 120); the other height quintiles comprised men 67 to 68 in (n 5 180), 69 to 70 in (n 5 174), and 71 to 72 in (n 5 171). The women ranged in height from 51 to 72 in. The shortest quintile included women #61 in (n 5 135), and the tallest quintile included women

RHEUMATIC HEART DISEASE IN MODERN URBAN AMERICA: A COHORT STUDY OF IMMIGRANT AND INDIGENOUS PATIENTS IN CHICAGO

67 in (n 5 156); the other height quintiles comprised women 62 to 63 in (n 5 265), 64 in (n 5 124), and 65 to 66 in (n 5 204). For men and for women, there were no significant differences across the quintiles or between the shortest and tallest quintiles with respect to age, CAD risk factors (except BMI), indications for angiography, or ejection fraction. The shortest men had a significantly higher BMI than the tallest men (p ,0.001), with a significant gradation of BMI across height quintiles (p ,0.001). Similarly, the shortest women had a significantly higher BMI than the tallest women (p ,0.02), with a significant gradation of BMI across height quintiles (p 5 0.002). In men, shorter stature was associated with an increased prevalence of CAD when height was analyzed by quintiles (Figure 1) or as a continuous variable (p ,0.01). CAD was significantly more prevalent in the shortest quintile compared with the tallest (p 5 0.04). Other significant predictors of CAD included age (p ,0.001), diabetes (p ,0.002), hyperlipidemia (p ,0.01), and smoking (p ,0.05). Hypertension (p 5 0.12), BMI (p 5 0.82), and family history of CAD (p 5 1.00) were not significant. On multivariate analysis, shorter height remained an independent predictor of CAD prevalence when analyzed by quintiles (p ,0.03) or as a continuous variable (p 5 0.02). An association between height and extent of CAD was also noted in men when analyzed by quintiles (Figure 2) or as a continuous variable (p 5 0.01), but was only borderline significant when the shortest quintile was compared with the tallest (p 5 0.08). On multivariate analysis, height was a borderline significant predictor of extent of CAD when analyzed by quintiles (p 5 0.056) or as a continuous variable (p 5 0.052). In women, shorter height was not associated with an increased prevalence of CAD when analyzed by quintiles (Figure 1) or as a continuous variable (p 5 0.67), and there was no difference in CAD prevalence between the shortest quintile and the tallest (p 5 0.71). Other predictors of CAD in women included age (p ,0.001), diabetes (p ,0.001), smoking (p 5 From the Section of Cardiology, Rush-Presbyterian-St. Luke’s Medical Center, and the Division of Cardiology, Cook County Hospital, Chicago, Illinois. Dr. Kelly’s address is: Rush-Presbyterian-St. Luke’s Medical Center, 1725 W. Congress Parkway, Suite 1159, Chicago, Illinois 60612. E-mail: rkelly@rush.edu. Manuscript received September 13, 1999; revised manuscript received and accepted November 29, 1999.