Prognosis of Patients with Peripheral and Coronary Atherosclerotic Disease

PERIPHERAL ARTERIAL DISEASE (PAD) affects more than 30 million people worldwide. In the United States, more than 8 million people suffer from this disease. The American College of Cardiology and the American Heart Association have recognized the importance of identifying and treating this disease and have initiated national campaigns to increase its awareness. Many patients, however, do not exhibit warning signs of the disease and remain undiagnosed. These missed diagnoses create a major health burden. When left untreated, PAD can lead to walking impairment and in more severe stages, to gangrene and leg amputation. Patients with PAD often have atherosclerotic disease in other parts of the body, which places the patient at risk for myocardial infarction, stroke and death. Especially coronary artery disease has been recognized as a complice of PAD. This thesis provides an insight in the prognosis of patients with peripheral and coronary artery disease and attempts to find solutions in improving the identification and management of this disease

Plasma natriuretic peptide levels reflect changes in heart failure symptoms, left ventricular size and function after surgical mitral valve repair

Background and aim: N-terminal pro-B-type natriuretic peptide (NT-proBNP) has diagnostic and prognostic value in patients with heart failure. The present prospective study was designed to assess whether changes in NT-proBNP levels after surgical mitral valve repair reflect changes in heart failure symptoms an

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

The long-term prognostic value of the resting and postexercise ankle-brachial index

Background: Peripheral arterial disease is associated with a high incidence of cardiovascular mortality. Peripheral arterial disease can be detected by using the ankle-brachial index (ABI). This study assessed the prognostic value of the postexercise ABI in addition to the resting ABI on long-term mortality in patients with suspected peripheral arterial disease. Methods: In this prospective cohort study of 3209 patients (mean ± SD age, 63 ± 12 years; 71.1% male), resting and postexercise ABI values were measured and a reduction of postexercise ABI over baseline resting readings was calculated. The mean follow-up was 8 years (interquartile range, 4-11 years). Results: During follow-up, 1321 patients (41.2%) died. After adjusting for clinical risk factors, lower resting ABI values (hazard ratio per 0.10 lower ABI, 1.08; 95% confidence interval [CI], 1.06-1.10), lower postexercise ABI values (hazard ratio per 0.10 lower ABI, 1.09; 95% CI, 1.08-1.11), and higher reductions of ABI values over baseline readings (hazard ratio per 10% lower ABI, 1.12; 95% CI, 1.09-1.14) wer

Prognostic significance of renal function in patients undergoing dobutamine stress echocardiography

Background. Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings. Methods. We studied 2292 patients, divided into 729 (32%) patients with normal renal function [creatinine clearance (CrCl) >90 ml/min] and 1563 (68%) with renal dysfunction, classified as mild (CrCl: 60-90 ml/min) in 933, moderate (CrCl: 30-60 ml/min) in 502 and severe (CrCl < 30ml/min) in 128 patients. All patients underwent DSE for the evaluation of known or suspected CAD and were followed for a mean of 8 years. Results. New wall motion abnormalities during DSE and mildly, moderately and severely abnormal CrCl were powerful independent predictors for all-cause mortality, cardiac death and hard cardiac events (cardiac death and non-fatal myocardial infarction). Kaplan-Meier curves demonstrated that patients with normal DSE and renal dysfunction have greater probability for cardiac death and hard cardiac events compared to those with normal renal function. The warranty of a normal DSE in the presence of moderate renal dysfunction was 15 and 36 months for 10 and 20% risk for cardiac death and hard cardiac events, respectively. Conclusions. The presence and severity of renal dysfunction has additional independent prognostic value over DSE findings. The low-risk warrantee period after a normal DSE is determined by the severity of renal dysfunction