RESUMEN

BACKGROUND: Fragmented QRS (fQRS) complex is associated with increased sudden cardiac death, recurrent cardiovascular events, morbidity and mortality. However, the prognostic role of fQRS has not been comprehensively studied in patients undergoing coronary artery bypass graft (CABG) surgery. In this study, we planned to investigate the relationship of fQRS with prognostic markers and long-term major adverse cardiovascular events (MACEs) following isolated CABG surgery. METHODS: Two hundred and thirteen patients who underwent CABG surgery at our institution were enrolled consecutively. MACE was defined as cardiac death, recurrent myocardial infarction, decompensated heart failure and re-hospitalization. The patients were followed up for a mean duration of 26 ±â€Š10 months for MACE. RESULTS: Patients with fQRS had a higher rate of Q wave on ECG (30 vs. 10%, P < 0.001), more prolonged QRS time (99 ±â€Š11 vs. 88 ±â€Š13 ms, P < 0.001), higher EUROSCORE (4.0 ±â€Š1.9 vs. 2.7 ±â€Š1.5, P < 0.001) and lower left ventricular ejection fraction (44 ±â€Š12 vs. 56 ±â€Š12, P < 0.001) in comparison with patients with non-fQRS. In addition, patients with fQRS had increased short-term and long-term MACE (17 vs. 4%, P = 0.002; 23 vs. 6%, P < 0.001, respectively) after discharge. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of fQRS for predicting MACE were 67, 71, 23, 94 and 70%, respectively. fQRS [odds ratio (OR) 3.110, 95% confidence interval (CI) 1.157-8.362, P = 0.025] and prolonged QRS duration (>100 ms) (OR 3.898, 95% CI 1.463-10.39, P = 0.007) were the only independent predictors of long-term MACE in multivariate logistic regression analysis. However, QRS duration had a better association with MACE than the presence of fQRS. CONCLUSION: fQRS and prolonged QRS duration may have an additional value in predicting cardiac status and long-term prognosis. Fragmentations on admission ECG and prolonged QRS duration may be useful for identifying patients with higher long-term risk who will need more intense treatment and close follow-up after CABG surgery.

Asunto(s)

Arritmias Cardíacas/complicaciones , Puente de Arteria Coronaria/efectos adversos , Anciano , Muerte Súbita Cardíaca/etiología , Electrocardiografía/métodos , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/etiología , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Readmisión del Paciente/estadística & datos numéricos , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Recurrencia , Sensibilidad y Especificidad

RESUMEN

BACKGROUND: Fractional flow reserve (FFR) has become an established tool for guiding treatment, but its graded relationship to clinical outcomes as modulated by medical therapy versus revascularization remains unclear. OBJECTIVES: The study hypothesized that FFR displays a continuous relationship between its numeric value and prognosis, such that lower FFR values confer a higher risk and therefore receive larger absolute benefits from revascularization. METHODS: Meta-analysis of study- and patient-level data investigated prognosis after FFR measurement. An interaction term between FFR and revascularization status allowed for an outcomes-based threshold. RESULTS: A total of 9,173 (study-level) and 6,961 (patient-level) lesions were included with a median follow-up of 16 and 14 months, respectively. Clinical events increased as FFR decreased, and revascularization showed larger net benefit for lower baseline FFR values. Outcomes-derived FFR thresholds generally occurred around the range 0.75 to 0.80, although limited due to confounding by indication. FFR measured immediately after stenting also showed an inverse relationship with prognosis (hazard ratio: 0.86, 95% confidence interval: 0.80 to 0.93; p < 0.001). An FFR-assisted strategy led to revascularization roughly half as often as an anatomy-based strategy, but with 20% fewer adverse events and 10% better angina relief. CONCLUSIONS: FFR demonstrates a continuous and independent relationship with subsequent outcomes, modulated by medical therapy versus revascularization. Lesions with lower FFR values receive larger absolute benefits from revascularization. Measurement of FFR immediately after stenting also shows an inverse gradient of risk, likely from residual diffuse disease. An FFR-guided revascularization strategy significantly reduces events and increases freedom from angina with fewer procedures than an anatomy-based strategy.

Asunto(s)

Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/fisiopatología , Reserva del Flujo Fraccional Miocárdico/fisiología , Índice de Severidad de la Enfermedad , Enfermedad de la Arteria Coronaria/mortalidad , Humanos , Estimación de Kaplan-Meier , Pronóstico , Resultado del Tratamiento

RESUMEN

BACKGROUND: Hypertension, identifiable by elevated blood pressure (BP), is a heterogeneous multifactorial disorder. Epicardial adipose tissue (EAT), a special fat depot that is related to visceral fat rather than total adiposity, shares the same microcirculation with myocardial tissue and coronary vessels. Recent studies have identified EAT as an active organ, which secretes several mediators, called adipokines, affecting the vascular system. The aim of this study was to evaluate the potential association between EAT and BP, endothelial function, carotid intima-media thickness (CIMT), and pulse wave velocity (PWV) independent of conventional and novel metabolic risk factors in patients with previously untreated hypertension. PATIENTS AND METHODS: Our study, which has a cross-sectional design, included 107 consecutive untreated hypertensive patients. Vascular status and functions were evaluated using CIMT, PWV, and flow-mediated dilation (FMD) of the brachial artery. The values of BP were obtained both by the traditional auscultatory method using a sphygmomanometer in an office and by ambulatory BP measurement. RESULTS: When we stratified the patients into three groups according to increased EAT values, CIMT (P<0.001), presence of carotid plaque (P=0.026), and BP values (P=0.001) were increased in the higher tertile compared with the lower tertile. FMD of the brachial artery decreased significantly with increasing EAT thickness (P<0.001). There was a significant, strong, and negative association between CIMT and FMD (r=-0.604, P<0.001). CIMT correlated positively to age (r=0.404, P<0.001), EAT (r=0.517, P<0.001), office systolic BP (r=0.241, P=0.016), ambulatory systolic BP (r=0.419, P<0.001), and diastolic BP (r=0.360, P=0.002). FMD correlated negatively to age (r=-0.390, P<0.001), EAT (r=-0.495, P<0.001), ambulatory systolic (r=-0.338, P=0.006), and diastolic BP (r=-0.281, P=0.024). Multivariate linear regression analyses, carried out to identify predictors of CIMT and FMD, showed only age, EAT, and mean ambulatory BP as independent predictors of both CIMT and FMD. CONCLUSION: Our study showed that EAT is an independent factor of adverse changes in CIMT, FMD, and PWV. Future studies, investigating the vascular influence of EAT at the molecular level, may provide therapeutic options to prevent its adverse vascular interactions.

Asunto(s)

Tejido Adiposo/fisiopatología , Grosor Intima-Media Carotídeo , Endotelio Vascular/fisiopatología , Hipertensión/fisiopatología , Pericardio/patología , Análisis de la Onda del Pulso , Tejido Adiposo/patología , Adulto , Auscultación , Presión Sanguínea/fisiología , Determinación de la Presión Sanguínea/métodos , Monitoreo Ambulatorio de la Presión Arterial , Arteria Braquial/fisiopatología , Estenosis Carotídea/patología , Estenosis Carotídea/fisiopatología , Colesterol/sangre , Estudios Transversales , Humanos , Hipertensión/patología , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Obesidad/patología , Variaciones Dependientes del Observador , Visita a Consultorio Médico , Placa Aterosclerótica/patología , Placa Aterosclerótica/fisiopatología , Valor Predictivo de las Pruebas , Factores de Riesgo , Método Simple Ciego , Vasodilatación

RESUMEN

OBJECTIVE: Myocardial perfusion SPECT (MPS) is a noninvasive method commonly used for assessment of the hemodynamic significance of intermediate coronary stenoses. Fractional flow reserve (FFR) measurement is a well-validated invasive method used for the evaluation of intermediate stenoses. We aimed to determine the association between MPS and FFR findings in intermediate degree stenoses and evaluate the added value of quantification in MPS. METHODS: Fifty-eight patients who underwent intracoronary pressure measurement in the catheterization laboratory to assess the physiological significance of intermediate (40-70%) left anterior descending (LAD) artery lesions, and who also underwent stress myocardial perfusion SPECT either for the assessment of an intermediate stenosis or for suspected coronary artery disease were analyzed retrospectively in the study. Quantitative analysis was performed using the 4DMSPECT program, with visual assessment performed by two experienced nuclear medicine physicians blinded to the angiographic findings. Summed stress scores (SSS) and summed difference scores (SDS) in the LAD artery territory according to the 20 segment model were calculated. A summed stress score of ≥ 3 and an SDS of ≥ 2 were assumed as pathologic, indicating significance of the lesion; a cutoff value of 0.75 was used to define abnormal FFR. Both visual and quantitative assessment results were compared with FFR using Chi-square (χ²) test. RESULTS: The mean time interval between two studies was 13 ± 11 days. FFR was normal in 45 and abnormal in 13 patients. Considering the FFR results as the gold standard method for assessing the significance of the lesion, the sensitivity and specificity of quantitative analysis determining the abnormal flow reserve were 85 and 84%, respectively, while visual analysis had a sensitivity of 77% and a specificity of 51%. There was a good agreement between the observers (κ = 0.856). Summed stress and difference scores demonstrated moderate inverse correlations with FFR values (r = -0.542, p < 0.001 and r = -0.506, p < 0.001, respectively). CONCLUSIONS: Quantitative analysis of the myocardial perfusion SPECT increases the specificity in evaluating the significance of intermediate degree coronary lesions.

Asunto(s)

Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/fisiopatología , Reserva del Flujo Fraccional Miocárdico , Imagen de Perfusión Miocárdica , Tomografía Computarizada de Emisión de Fotón Único , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estándares de Referencia , Estudios Retrospectivos , Sensibilidad y Especificidad

RESUMEN

PURPOSE: The purpose of this study was to evaluate whether a association exits among overweight and obesity and left ventricular systolic and diastolic functions in patients admitted with first ST-elevation myocardial infarction (STEMI). METHODS: The present study was performed on 451 consecutive patients diagnosed with first STEMI (376 men, 75 women; mean age 56.1 ± 10.8 years). The patients were classified into three groups based on their body mass index (BMI) as normal weight (BMI < 25 kg/m2), overweight (BMI: 25-29.9 kg/m2) and obese (BMI > 30 kg/m2). Echocardiographic features were evaluated and compared among the three groups. RESULTS: Mitral annulus E velocities were higher in obese individuals than normal weight group (p < 0.01). In contrast, mitral A velocities were lower (p =0.03); consequently, E\A and E'\A' ratios were lower (both p = 0.01) in the obese group with respect to normal weight group. When the correction of entire variations existing among the groups were performed using multivariate linear regressions analyses, it turned out that BMI was independently associated with E/A (ß = -0.19, p = 0.044) and with E'/A' (ß = -0.016, p = 0.021). Ejection fraction, wall motion score index and myocardial S velocities were comparable among the study groups (p > 0.05). CONCLUSION: These results suggest that while obesity has no adverse effect on the left ventricular systolic function, it has unfavorable consequences on the left ventricular diastolic function in the patients with first STEMI. In contrast, no unfavorable effects of overweight on the left ventricular systolic and diastolic function were detected.

Asunto(s)

Infarto del Miocardio/fisiopatología , Obesidad/fisiopatología , Volumen Sistólico , Función Ventricular Izquierda , Anciano , Velocidad del Flujo Sanguíneo , Índice de Masa Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad

RESUMEN

BACKGROUND: The degree of coronary collateral development is not same in every patient with similar degree of coronary stenosis. In animal studies monocyte chemoattractant protein-1 (MCP-1) has been found to be related to collateral vessel development. In this study we investigated whether a higher serum MCP-1 level is related to better coronary collateral vessel development in patients with stable coronary artery disease. METHOD: Eighty-three patients with stable angina pectoris, who have at least one coronary stenosis equal to or greater than 70% at coronary angiography, were prospectively enrolled. Serum MCP-1 and vascular endothelial growth factor (VEGF) levels were studied. Coronary collateral development was graded according to the Rentrop method. Patients with grade 2-3 collateral developments were included in good collateral group and formed group I. The patients with grade 0-1 collateral developments were included in poor collateral group and formed group II. RESULTS: The serum MCP-1 level was significantly higher in good collateral group (288 ± 277 pg/ml vs. 132 ± 64 pg/ml; P<0.001). There was also a positive correlation between serum MCP-1 level and Rentrop score (r=0.39, P<0.001). The patients in the good collateral group also had a significantly higher number of coronary arteries with significant stenosis (1.7 ± 0.7 vs. 1.4 ± 0.6, P=0.049), and higher VEGF levels (322 ± 147 pg/ml vs. 225 ± 161 pg/ml, P=0.007). In multivariate analysis, only serum MCP-1 level (P=0.014, odds ratio: 1.01, 95% confidence interval: 1.002-1.019) was independently related to good coronary collateral development. CONCLUSION: Higher serum MCP-1 level is related to better coronary collateral development.

Asunto(s)

Quimiocina CCL2/sangre , Circulación Colateral , Circulación Coronaria , Estenosis Coronaria/sangre , Estenosis Coronaria/fisiopatología , Anciano , Biomarcadores/sangre , Angiografía Coronaria , Estenosis Coronaria/diagnóstico por imagen , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Turquía , Factor A de Crecimiento Endotelial Vascular/sangre

RESUMEN

PURPOSE: Quantification of myocardial perfusion scintigraphy is frequently performed to assist physicians in detecting coronary artery disease (CAD). Software packages provide automated quantification of perfusion data. We aimed to compare the three commonly used software packages, Emory Cardiac Toolbox (ECT v2 and ECT v3), 4D-MSPECT (4DM v2 and 4DM v4) and Quantitative Perfusion SPECT (QPS v3 and QPS v4). METHODS: We selected 283 patients who had a myocardial perfusion scintigraphy with (201)Tl followed by coronary angiography within 3 months. Summed stress score (SSS), summed difference score (SDS), total stress defect extent (TDE) and regional stress defect extent values were obtained from programs. A ≥70% stenosis in coronary arteries and their major branches was considered positive for CAD. A subgroup of patients was used to form an institutional normal database for QPS and 4DM. Receiver-operating characteristic (ROC) analysis to detect CAD was performed. RESULTS: Mean SSS ± SD (vendor) for ECT v3, QPS v4 and 4DM v4 were 9.2 ± 7.1, 10.1 ± 6.8 and 5.5 ± 6.1, respectively. Area under the curve (AUC) values of SSS ROC analysis were 0.738 ± 0.031 for QPS v3, 0.755 ± 0.030 for QPS v4, 0.758 ± 0.030 for ECT v2, 0.778 ± 0.029 for ECT v3 and 0.771 ± 0.030 for 4DM v4. The AUC values for TDE were 0.755 ± 0.030 for QPS v4, 0.769 ± 0.030 for ECT v3 and 0.775 ± 0.029 for 4DM v4. The differences were not significant for both SSS and TDE. Differences of AUC between regional stress defect extent values of programs and AUC of SSS between institutional and vendor normal databases were not significant. CONCLUSION: The diagnostic performances of programs to detect CAD are similar. However, there are differences in the magnitudes of the quantitative values produced by the programs.

Asunto(s)

Enfermedad de la Arteria Coronaria/diagnóstico , Imagen de Perfusión Miocárdica/métodos , Programas Informáticos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Estrés Fisiológico/efectos de los fármacos , Tomografía Computarizada de Emisión de Fotón Único

RESUMEN

BACKGROUND: The purpose of this study is to develop and analyze an open-source artificial intelligence program built on artificial neural networks that can participate in and support the decision making of nuclear medicine physicians in detecting coronary artery disease from myocardial perfusion SPECT (MPS). METHODS AND RESULTS: Two hundred and forty-three patients, who had MPS and coronary angiography within three months, were selected to train neural networks. Six nuclear medicine residents, one experienced nuclear medicine physician, and neural networks evaluated images of 65 patients for presence of coronary artery stenosis. Area under the curve (AUC) of receiver operating characteristics analysis for networks and expert was .74 and .84, respectively. The AUC of the other physicians ranged from .67 to .80. There were no significant differences between expert, neural networks, and standard quantitative values, summed stress score and total stress defect extent. CONCLUSIONS: The open-source neural networks developed in this study may provide a framework for further testing, development, and integration of artificial intelligence into nuclear cardiology environment.

Asunto(s)

Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Imagen de Perfusión Miocárdica , Redes Neurales de la Computación , Tomografía Computarizada de Emisión de Fotón Único , Inteligencia Artificial , Angiografía Coronaria , Prueba de Esfuerzo , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Radiofármacos , Sensibilidad y Especificidad , Tecnecio Tc 99m Sestamibi , Radioisótopos de Talio

RESUMEN

OBJECTIVE: To investigate the thrombolysis in myocardial infarction (TIMI) frame count (TFC) in the coronary arteries without visible atherosclerosis in coronary angiography of patients with stable coronary artery disease (CAD). METHODS: Eighty-three patients (mean age 58+/-10, 31 [37%] males), who underwent coronary angiographic evaluation for stable angina in Gazi University, Ankara, Turkey, Cardiology clinic between 2006-2007 were enrolled. Forty patients with normal coronary arteries were defined as group I. Group II consisted of 43 patients, who have one normal coronary artery in the setting of stable CAD defined as stenoses 50% or greater in at least one major coronary artery. Coronary blood flow and microvascular perfusion was evaluated by TFC. RESULTS: In group II, the TFC of left anterior descending artery (LAD) in 15 patients, TFC of circumflex artery (CX) in 18 patient, and TFC of right coronary artery (RCA) in 10 patients were evaluated. In group II, the TFC of LAD (37+/-12 versus 29+/-12, p=0.015) and CX (22+/-8 versus 18+/-9, p=0.035) were significantly higher than those in group I. The TFC of RCA was similar between groups (17+/-9 versus 17+/-8, p=0.990). After the adjustment of the risk factors by multivariate regression analyses, the association between TFC and clinical characteristic was statistically non-significant. CONCLUSION: The TFC decreased in angiographically normal LAD and CX arteries in the setting of stable angina pectoris. The important predictor was CAD alone, irrespective of the clinical parameters.

Asunto(s)

Aterosclerosis/tratamiento farmacológico , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Infarto del Miocardio/tratamiento farmacológico , Terapia Trombolítica , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad

RESUMEN

OBJECTIVE: To investigate the plasma homocysteine level and the relationship between plasma homocysteine level and duke treadmill score (DTS) in cardiac syndrome X (CSX) patients. METHODS: Seventy-nine patients (36 male, 43 female, mean age: 50 +/- 8.8 years) admitted to Gazi University Hospital, Ankara, Turkey with typical effort angina, positive stress test, and angiographically normal coronary arteries between January and September 2006 were included in this prospective and controlled study. Thirty asymptomatic patients (11 male, 19 female, mean age: 47.6 +/- 8.3 years) with 2 cardiovascular risk factors were chosen as a control group. Plasma homocysteine level was measured in both groups and DTS was calculated in the CSX group. Plasma homocysteine was measured with the AxSYM homocysteine immunoassay method in both groups. RESULTS: Plasma homocysteine level was higher in the CSX group compared to the control group (16.5 +/- 4.9 micromol/L, n=79, versus 12.4 +/- 4.1 micromol/L, n=30, p<0.001). The DTS was -2.7 +/- 5.3 in the CSX group. There was a negative correlation between the DTS and homocysteine levels in the CSX group. (r= -0.506, p<0.001). CONCLUSION: Plasma homocysteine level, which is known to cause endothelial dysfunction and microvascular ischemia were higher in CSX patients. Also, this increase in homocysteine level inversely correlated with the DTS, which represents the magnitude of ischemia.

Asunto(s)

Homocisteína/sangre , Angina Microvascular/sangre , Angina Microvascular/diagnóstico , Estudios de Casos y Controles , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Angina Microvascular/clasificación , Persona de Mediana Edad , Isquemia Miocárdica/sangre , Estudios Prospectivos