Stefanos E. Karagiannis

Plasma N-terminal pro-B-type natriuretic peptide as long-term prognostic marker after major vascular surgery

Objective: To assess the long-term prognostic value of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) after major vascular surgery. Design: A single-centre prospective cohort study. Patients: 335 patients who underwent abdominal aortic aneurysm repair or lower extremity bypass surgery. Interventions: Prior to surgery, baseline NT-proBNP level was measured. Patients were also evaluated for cardiac risk factors according to the Revised Cardiac Risk Index. Dobutamine stress echocardiography (DSE) was performed to detect stress-induced myocardial ischaemia. Main outcome measures: The prognostic value of NT-proBNP was evaluated for the endpoints all-cause mortality and major adverse cardiac events (MACE) during long-term follow-up. Results: In this patient cohort (mean age: 62 years, 76% male), median NT-proBNP level was 186 ng/l (interquartile range: 65–444 ng/l). During a mean follow-up of 14 (SD 6) months, 49 patients (15%) died and 50 (15%) experienced a MACE. Using receiver operating characteristic curve analysis for 6-month mortality and MACE, NT-proBNP had the greatest area under the curve compared with cardiac risk score and DSE. In addition, an NT-proBNP level of 319 ng/l was identified as the optimal cut-off value to predict 6-month mortality and MACE. After adjustment for age, cardiac risk score, DSE results and cardioprotective medication, NT-proBNP ⩾319 ng/l was associated with a hazard ratio of 4.0 for all-cause mortality (95% CI: 1.8 to 8.9) and with a hazard ratio of 10.9 for MACE (95% CI: 4.1 to 27.9). Conclusion: Preoperative NT-proBNP level is a strong predictor of long-term mortality and major adverse cardiac events after major non-cardiac vascular surgery.

Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients

Aims  Cardiac morbidity and mortality is high in patients undergoing high‐risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA1c) levels are associated with increased cardiac ischaemic events in vascular surgery patients.

Lower Progression Rate of End-Stage Renal Disease in Patients with Peripheral Arterial Disease Using Statins or Angiotensin-Converting Enzyme Inhibitors

Patients with peripheral arterial disease (PAD) are at increased risk for ESRD and cardiovascular events. The primary objective was to assess the association between ankle-brachial index (ABI) values and renal outcome. The secondary objective was to evaluate whether statins and angiotensin-converting enzyme inhibitors (ACEI) are associated with improved renal and cardiovascular outcome in patients with PAD. In a prospective observational cohort study of 1940 consecutive patients with PAD, ABI was measured and chronic statin and ACEI therapy was noted at baseline. Serial creatinine concentrations were obtained at baseline, 6 mo, and every year after enrollment. End points were ESRD, all-cause mortality, and cardiac events during a median follow-up period of 8 yr. Baseline estimated GFR <60 ml/min per 1.73 m(2) was assessed in 27% of patients. ESRD, all-cause mortality, and cardiac events occurred in 10, 46, and 31% of patients, respectively. In multivariate analysis, a lower baseline ABI was significantly associated with a higher progression rate of ESRD (hazard ratio [HR] per 0.10 decrease 1.34; 95% confidence interval [CI] 1.21 to 1.49). Chronic use of statins and ACEI were significantly associated with lower ESRD (HR 0.41 [95% CI 0.28 to 0.63] and 0.74 [95% CI 0.54 to 0.98], respectively), mortality (HR 0.66; [95% CI 0.55 to 0.82] and 0.84 [95% CI 78 to 0.95], respectively), and cardiac events (HR 0.71 [95% CI 0.56 to 0.91] and 0.81 [95% CI 0.68 to 0.96], respectively). In patients with PAD, low ABI values independently predict the onset of ESRD. Less progression toward ESRD and improved cardiovascular outcome was observed among patients who were on long-term statins and ACEI.

Elderly patients undergoing major vascular surgery: Risk factors and medication associated with risk reduction

This study assesses risk factors in elderly vascular surgery patients and to evaluate whether perioperative cardiac medication can reduce postoperative mortality rate. In a cohort study, 1693 consecutive patients > or =65 years undergoing major non-cardiac vascular surgery were preoperatively screened for cardiac risk factors and medication. During follow-up (median: 8.2 years), mortality was noted. Hospital mortality occurred in 8.1% and long-term mortality in 28.5%. In multivariate analysis, age, coronary artery disease, heart failure, cerebrovascular disease, renal failure and diabetes were significantly associated with increased hospital and long-term mortality. Perioperative aspirin (OR: 0.53, 95% confidence interval: 0.34-0.83), beta-blockers (OR: 0.32, 95% CI: 0.19-0.54) and statins (OR: 0.35, 95% CI: 0.18-0.68) were significantly associated with reduced hospital mortality. In addition, aspirin (HR: 0.65, 95% CI: 0.53-0.81), angiotensin-converting enzyme (ACE)-inhibitors (HR: 0.74, 95% CI: 0.59-0.92), beta-blockers (HR: 0.61, 95% CI: 0.48-0.76) and statins (HR: 0.65, 95% CI: 0.49-0.87) were significantly associated with reduced long-term mortality. Heterogeneity tests revealed a gradient decrease of mortality risk in patients from low to high age using statins (p=0.03). In conclusion, age is an independent predictor of hospital and long-term mortality in elderly patients undergoing major vascular surgery. Aspirin, ACE-inhibitors, beta-blockers and statins reduce long-term mortality risk. Especially the very elderly may benefit from statin therapy.

The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery

ObjectiveThe aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients. MethodsIn a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean: 6±4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted. ResultsThe prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53–2.25 and HR, 1.74; 95% CI, 1.46–2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59–2.92 and HR, 1.86; 95% CI, 1.43–2.41, respectively). In patients with unrecognized MI, &bgr;-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia. ConclusionsIn patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.

Increased distance between mitral valve coaptation point and mitral annular plane: significance and correlations in patients with heart failure

Objective: To measure the distance between the mitral leaflet coaptation point and the mitral annulus (CPMA) and assess the relation of this index to structural and functional characteristics of the failing left ventricle. Design: Echocardiographic indices and CPMA were measured at baseline and again during dobutamine infusion and leg lifting. Left ventricular diastolic and systolic dimensions, left ventricular ejection fraction (LVEF) by Simpson’s rule, mitral annulus dimension, and E point septal separation were correlated with CPMA. Setting: Tertiary referral centre. Patients: The total study population of 129 patients included 94 with LVEF < 35% and 35 with LVEF 35%–45%; 76 had coronary artery disease and 53 had dilated cardiomyopathy. Interventions: A dobutamine infusion was given in 18 patients and preload increase by leg lifting in 28. Main outcome measures: Correlations between CPMA and contractility indices at baseline and during interventions. Results: CPMA was correlated with left ventricular diastolic dimension (r = 0.52), left ventricular systolic dimension (r = 0.53), LVEF (r = −0.44), fractional shortening (r = −0.42), E point septal separation (r = 0.48), and mitral annulus dimension (r = 0.44) (all p < 0.001). Dobutamine decreased CPMA from (mean (SD)) 12.04 (3.64) mm to 8.92 (2.56) mm and increased LVEF from 27 (6.2)% at baseline to 33.4 (6.9)% at 10 μg/kg/min (both p < 0.001). These changes were strongly related (r = 0.68, p < 0.007). After leg lifting, CPMA decreased from 13 (4) mm at baseline to 10 (3) mm (p < 0.001), and LVEF increased from 32 (11)% at baseline to 39 (11)% (p < 0.001). Fractional shortening and left ventricular diastolic dimension also increased (p < 0.001) and mitral annulus dimension and E point septal separation decreased (p < 0.002), but left ventricular systolic dimension did not change. Conclusions: The mechanism displacing the mitral coaptation point towards the left ventricular apex is multifactorial. The correlations between CPMA difference (before versus after interventions) and ejection fraction difference (before versus after interventions) shows that this index depends mainly on left ventricular function.

The long prognostic value of wall motion abnormalities during the recovery phase of dobutamine stress echocardiography after receiving acute ??-blockade

ObjectiveTo assess the prognostic value of wall motion abnormalities during the recovery phase of dobutamine stress echocardiography in addition to wall motion abnormalities at peak stress. MethodsWall motion abnormalities were assessed at peak and during recovery phase of dobutamine stress echocardiography in 187 consecutive patients, who were followed for occurrence of cardiac events. ResultsDuring follow-up (mean 36±28 months), 19 patients (10%) died from cardiac causes, 34 (18%) patients suffered nonfatal myocardial infarction, and 77 (41%) patients underwent late revascularization. Univariable predictors of cardiac events by Cox regression analysis were age (hazard ratio: 1.01; confidence interval: 1.00–1.03), dyslipidemia (hazard ratio: 1.41; confidence interval: 1.02–1.95), rest wall motion abnormalities (hazard ratio: 1.37; confidence interval: 1.14–1.64), new wall motion abnormalities (hazard ratio: 1.18; confidence interval: 0.95–1.45) at peak and new wall motion abnormalities (hazard ratio: 1.33; confidence interval: 1.11–1.59) at recovery phase of dobutamine stress echocardiography. The best multivariable model to predict cardiac events included new wall motion abnormality (hazard ratio: 5.34; confidence interval: 1.71–16.59) at recovery phase of dobutamine stress echocardiography, after controlling for clinical and peak dobutamine stress echocardiography data. ConclusionsMyocardial ischemia at recovery phase of dobutamine stress echocardiography is an independent predictor of cardiac events and has an incremental value when added to ischemia at peak.

Baseline plasma N-terminal pro-B-type natriuretic peptide is associated with the extent of stress-induced myocardial ischemia during dobutamine stress echocardiography.

OBJECTIVE To determine the relationship between baseline plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and the presence and extent of myocardial ischemia during dobutamine stress echocardiography (DSE). METHODS NT-proBNP was measured in 170 consecutive patients prior to DSE. Rest wall motion abnormalities (RWMAs) and new wall motion abnormalities (NWMAs) were scored using a 5-point, 17-segment model. Kruskal-Wallis tests were applied to study differences in NT-proBNP levels between patients with normal DSE, RWMAs but no NWMAs, and NWMAs, and (in patients with NWMAs) between those with 1-2, 3-4 and >4 ischemic segments. Univariate and multivariate regression analyses were used to determine the value of NT-proBNP in predicting NWMAs. RESULTS The median NT-proBNP level was 110 ng/l (interquartile range: 42-389 ng/l). Median NT-proBNP was 59, 321 and 440 ng/l in patients with normal DSE, with RWMAs but no NWMAs, and with NWMAs, respectively (P<0001). Among patients with NWMAs, median NT-proBNP was associated with the number of ischemic segments: 364, 710 and 2376 ng/l in patients with 1-2, 3-4 and >4 ischemic segments, respectively (P<0.001). Elevated NT-proBNP levels were significantly associated with NWMAs (odds ratio per 100 ng/l increase: 1.14, 95% confidence interval: 1.1-1.2) in a multivariate analysis of clinical baseline variables and RWMAs. CONCLUSION Elevated baseline levels of NT-proBNP are associated with the presence and extent of myocardial ischemia during DSE, independent of the presence of RWMAs.

Baseline natriuretic peptide levels in relation to myocardial ischemia, troponin T release and heart rate variability in patients undergoing major vascular surgery.

BackgroundThis study was conducted to determine the association between baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) and myocardial ischemia, troponin T release and heart rate variability (HRV) in patients undergoing major vascular surgery. MethodsIn a prospective study, 182 vascular surgery patients were evaluated by clinical risk factors, dobutamine stress echocardiography and baseline NT-proBNP levels. Myocardial ischemia was detected by continuous 12-lead electrocardiographic monitoring starting 1 day before to 2 days after surgery. Troponin T (>0.03 ng/ml) was measured on day 1, 3 and 7 postoperatively and before discharge. HRV was measured at the day prior to surgery. ResultsThe median NT-proBNP level was 184 ng/l (interquartile range: 79–483 ng/l). Myocardial ischemia was detected in 21% and troponin T release in 17% of patients. After adjustment for clinical risk factors and stress echocardiography results, higher NT-proBNP levels (per 1 ng/l increase in the natural logarithm of NT-proBNP) were associated with a higher incidence of myocardial ischemia (odds ratio: 1.59, 95% confidence interval: 1.21–2.08, P<0.001) and troponin T release (odds ratio: 1.76, 95% confidence interval: 1.33–2.34, P<0.001). The optimal cutoff value of NT-proBNP to predict ischemia and/or troponin T release was 270 ng/l (area under the curve: 0.70). Higher baseline NT-proBNP levels were also associated with a larger ischemic burden at electrocardiographic monitoring (r=0.22, P=0.03). No significant correlation, however, was found between NT-proBNP and preoperative HRV (r=−0.024, P=0.78). ConclusionElevated baseline NT-proBNP levels are significantly associated with perioperative myocardial ischemia and troponin T release, but not with preoperative HRV in patients undergoing major vascular surgery.

Carotid artery stenting versus endarterectomy in relation to perioperative myocardial ischemia, troponin T release and major cardiac events.

BackgroundCarotid artery stenting (CAS) is less invasive than endarterectomy. This study examined differences in perioperative myocardial ischemia, troponin T release and clinical cardiac events in patients undergoing CAS compared with endarterectomy. MethodsIn an observational study, CAS was performed in 24 and carotid endarterectomy in 44 patients. Before surgery, clinical risk factors were noted and dobutamine stress echocardiography was performed for cardiac risk assessment. Perioperative continuous 72-h 12-lead electrocardiographic monitoring was used for myocardial ischemia detection. Troponin T (>0.03 ng/ml) was measured on postoperative days 1, 3, 7 or before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted during hospital stay and during follow-up (mean: 1.2 years). ResultsNo significant differences were observed between patients with CAS and endarterectomy in terms of baseline clinical characteristics, dobutamine stress echocardiography results and cardiovascular medication. Perioperative myocardial ischemia was detected in nine patients (13%), perioperative troponin T release in seven patients (10%), early cardiac events in one patient (1%) and late cardiac events in three patients (4%). Significantly less perioperative myocardial ischemia was observed in patients with CAS compared with endarterectomy (0 versus 21%, P=0.02). Troponin T release was also significantly lower in CAS, compared with endarterectomy (0 versus 16%, P=0.04). Early (0 versus 2%, P=0.5) and late (0 versus 7%, P=0.2) cardiac events were lower after CAS, compared with endarterectomy, although these differences were not significant. ConclusionCAS is associated with a lower incidence of perioperative myocardial ischemia and troponin T release, compared with endarterectomy.