273 research outputs found
Lessons from contemporary trials of cardiovascular prevention and rehabilitation: A systematic review and meta-analysis
Background: Meta-analyses of cardiac rehabilitation trials up to 2010 showed a significant reduction in all-cause mortality but many of these trials were conducted before the modern management of acute coronary syndromes. Methods: We undertook a meta-analysis of contemporary randomised controlled trials published in the period 2010 to 2015, including patients with other forms of atherosclerotic cardiovascular disease, to investigate the impact of cardiovascular prevention and rehabilitation on hard outcomes including survival. Results: 18 trials randomising 7691 patients to cardiovascular prevention and rehabilitation or usual care were selected. All-cause mortality was not reduced (RR 1.00, 95% CI 0.88 to 1.14), but cardiovascular mortality was by 58% (95% CI 0.21, 0.88). Myocardial infarction was also reduced by 30% (95% CI 0.54, 0.91) and cerebrovascular events by 60% (95% CI 0.22, 0.74). Comprehensive programmes managing six or more risk factors reduced all-cause mortality in a subgroup analysis (RR 0.63, 95% CI 0.43, 0.93) but those managing less did not. In the three programmes that prescribed and monitored cardioprotective medications for blood pressure and lipids all-cause mortality was also reduced (RR 0.35, 95% CI 0.18, 0.70). Conclusions: Comprehensive prevention and rehabilitation programmes managing six or more risk factors, and those prescribing and monitoring medications within programmes to lower blood pressure and lipids, continue to reduce all-cause mortality. In addition, these comprehensive programmes not only reduced cardiovascular mortality and myocardial infarction but also, for the first time, cerebrovascular events, and all these outcomes across a broader spectrum of patients with atherosclerotic disease
Prediction of 8-year cardiovascular outcomes in patients with systemic arterial hypertension: Value of stress Tc-99m-tetrofosmin myocardial perfusion imaging in a high-risk cohort
Systemic arterial hypertension is a strong and prevalent cardiovascular risk factor. Currently, information on the very long-term prognostic value of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with systemic arterial hypertension is lacking. The aim of this study was to assess the value of stress Tc-99m-tetrofosmin MPI for the prediction of very long-term outcome in these patients. The study population consisted of 608 patients with systemic arterial hypertension who underwent exercise or dobutamine stress Tc-99m-tetrofosmin MPI for the assessment of known or suspected coronary artery disease. Follow-up was successful in 600 (99%) patients. The endpoints were all-cause mortality, cardiac death, nonfatal infarction, and coronary revascularization. Kaplan-Meier survival cures were constructed and univariate and multivariate analyses were performed to identify predictors of v The mean age of the patients was 59 +/- A 10 years, and 65% of them were male. MPI findings were normal in 301 patients (50%). Myocardial perfusion abnormalities were fixed in 162 (27%) and reversible in 137 (23%) patients. During a median 8.1-year follow-up, 241 (40%) patients died (121 cardiac deaths), 52 (9%) had a nonfatal myocardial infarction, and 128 (21%) underwent coronary revascularization. Survival curves in patients with a low vs a high summed difference score diverged up to 5 years Stress Tc-99m-tetrofosmin MPI provides incremental prognostic information for the prediction of cardiovascular outcome in patients with systemic arterial hypertension. Patients with normal stress MPI have a significantly better prognosis as compared with those with an abnormal study, up to 5 years after the test is performed
Ischemia burden on stress SPECT MPI predicts long-term outcomes after revascularization in stable coronary artery disease
Background: It is not entirely clear whether ischemia burden on stress single-photon emission computed tomography (SPECT) effectively identifies patients who have a long-term benefit from coronary revascularization. Methods: The study population consisted of 719 patients with ischemia on stress SPECT. Early coronary revascularization was defined as percutaneous coronary intervention or coronary artery bypass grafting ≤90 days after SPECT. Patients who underwent late revascularization (>90 days after SPECT) were excluded (n = 164). Results: Of the 538 patients (73% men, mean age 59.8 ± 11 years), 348 patients had low ischemia burden (<3 ischemic segments) and 190 patients had moderate to high ischemia burden (≥3 ischemic segments). A total of 76 patients underwent early revascularization. During a median follow-up of 12 years (range 4-17), 283 patients died of whom 125 due to cardiac causes. Early revascularization was beneficial on all-cause mortality (HR 0.46, 95% CI 0.30-0.46) and cardiac mortality (HR 0.54, 95% CI 0.29-0.99). Conclusions: Patients with myocardial ischemia on stress SPECT who underwent early revascularization had a lower all-cause mortality and cardiac mortality during long-term follow-up as compared to patients who received pharmacological therapy alone. This difference in long-term outcomes was mainly influenced by the survival benefit of early revascularization in the patients with moderate to high ischemia burden
Long-term prognostic value of dobutamine stress 99mTc-sestamibi SPECT: single-center experience with 8-year follow-up
PURPOSE: To determine the long-term prognostic value of dobutamine stress
technetium 99m (99mTc)-labeled sestamibi single photon emission computed
tomography (SPECT) in patients with limited exercise capacity. MATERIALS
AND METHODS: Clinical data and SPECT results were analyzed in 531
consecutive patients. Follow-up was successful in 528 (99.4%) patients; 55
underwent early revascularization and were excluded. Normal or abnormal
findings were considered in the absence or presence of fixed and/or
reversible perfusion defects. A summed stress score was calculated to
estimate the extent and severity of perfusion defects. Univariate and
multivariate Cox proportional hazards regression models were used to
identify independent predictors of late cardiac events. The incremental
value of myocardial perfusion scintigraphy over clinical variables in
predicting events was determined according to two models. The probability
of survival was calculated by using the Kaplan-Meier method. RESULTS:
Findings were abnormal in 312 patients. During 8.0 years +/- 1.5 of
follow-up (range, 4.5-10.6 years), cardiac death occurred in 67 patients
(total deaths, 165); nonfatal myocardial infarction, in 34; and late
revascularization, in 49. The annual rates for cardiac death, cardiac
death or infarction, and all events were 0.9%, 1.2%, and 1.5%,
respectively, after normal findings and 2.7%, 3.4%, and 4.4%,
respectively, after abnormal findings (P <.05). In a multivariable Cox
proportional hazards model, not only an abnormal finding but also the
summed stress score provided incremental prognostic information in
addition to clinical data. The hazard ratio for cardiac death was 1.09
(95% CI: 1.01, 1.18) per 1-unit increment of the summed stress score.
CONCLUSION: The incremental prognostic value of dobutamine stress
99mTc-sestamibi SPECT over clinical data was maintained over an 8-year
follow-up in patients with limited exercise capacity
Safety, hemodynamic profile, and feasibility of dobutamine stress technetium myocardial perfusion single-photon emission CT imaging for evaluation of coronary artery disease in the elderly
OBJECTIVES: Cardiovascular disease is the leading cause of morbidity and
mortality in the elderly. The evaluation of coronary artery disease by
exercise stress testing is frequently limited by the patient's inability
to exercise. Although pharmacologic stress testing with dobutamine is an
alternative, the safety of dobutamine myocardial perfusion scintigraphy in
the elderly has not been previously studied. PATIENTS AND METHODS: We
studied the safety and feasibility of dobutamine (up to 40
microg/kg/min)-atropine (up to 1 mg) stress myocardial perfusion
scintigraphy using technetium single-photon emission CT imaging in 227
patients > or = 70 years old (mean +/- SD age, 75 +/- 4 years). A control
group of 227 patients < 70 years old (mean age, 55 +/- 11 years; matched
for gender, prevalence of previous infarction, beta-blocker therapy, and
severity of resting perfusion abnormalities) was studied to assess
age-related differences in the safety and the hemodynamic response. A
feasible test was defined as the achievement of the target heart rate
and/or an ischemic end point (angina, ST-segment depression, or reversible
perfusion abnormalities). RESULTS: No myocardial infarction or death
occurred during the test. The target heart rate was achieved more
frequently in the elderly patients (87% vs 79%; p < 0.05). The elderly
patients had a higher prevalence of supraventricular tachycardia (7% vs
1%; p < 0.005) and premature ventricular contraction (74% vs 32%; p <
0.005) during the test, as compared to the younger patients. There was a
trend to a higher prevalence of ventricular tachycardia (5% vs 2%) and
atrial fibrillation (3% vs 0.4%) in the elderly patients. Arrhythmias were
terminated spontaneously by termination of dobutamine infusion or by
administration of metoprolol. Independent predictors of supraventricular
tachyarrhythmias and ventricular tachycardia were older age (p < 0.001;
chi(2), 9.8) and myocardial perfusion defect score at rest (p < 0.01;
chi(2), 6.8) respectively, by using a multivariate analysis of clinical
and stress test variables. Elderly patients had a higher prevalence of
systolic BP drop > 20 mm Hg during the test (37% vs 12%; p < 0.05). The
test was terminated due to hypotension in 2% of the elderly patients and
in 1% of the control group. Age was the most powerful predictor of
hypotension (p < 0.005; chi(2), 10.3). The test was considered feasible in
216 elderly patients (95%) and in 209 patients of the control group (92%).
CONCLUSION: Dobutamine-atropine stress myocardial perfusion scintigraphy
is a highly feasible method for the evaluation of coronary artery disease
in the elderly. Elderly patients have a higher risk for developing
hypotension and supraventricular tachyarrhythmias during a dobutamine
stress test. However, dobutamine-induced hypotension is often asymptomatic
and rarely necessitates the termination of the test
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