2,329 research outputs found
Long-term prognostic value of dobutamine stress echocardiography in patients with atrial fibrillation
STUDY OBJECTIVE: To assess the long-term prognostic value of dobutamine
stress echocardiography (DSE) for cardiac events (cardiac death,
myocardial infarction, and late revascularization) in patients with atrial
fibrillation (AF). METHODS: Baseline ECGs were studied in patients
undergoing DSE between 1989 and 1998. Sixty-nine patients had AF before
DSE. Prognostic value of DSE in these patients was compared with a control
group who had sinus rhythm (n = 1,664). The presence of stress-induced
ischemia was noted for every patient. The mean follow-up period was 35
months (range, 6 to 84 months). Data are presented as hazards ratio (HR)
with 95% confidence interval (CI). RESULTS: Heart rate at rest was higher
in patients with AF (77 +/- 15 beats/min vs 73 +/- 14 beats/min; p =
0.04); however, double product at peak stress was not different between
patients with AF and sinus rhythm (17,602 vs 17,169, respectively; p =
0.46). In patients with AF, target heart rate was achieved at a lower
dobutamine dose (33 +/- 8 microg/kg/min vs 35 +/- 9 microg/kg/min; p =
0.01). Cardiac arrhythmias occurred more frequently (12% vs 5%; p = 0.001)
in patients with AF during DSE. During a follow-up period of 7 years,
cardiac death occurred in 5 patients, myocardial infarction in 2 patients,
and late revascularization in 10 patients. Prognostic value of DSE for all
late cardiac events was similar in patients with AF (HR, 3.0; 95% CI, 0.9
to 9.5) and sinus rhythm (HR, 3.4; 95% CI, 2.7 to 4.3; p = 0.85).
CONCLUSION: The prognostic value of DSE for late cardiac events is
maintained in patients with AF
Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: A single-center experience
BACKGROUND--The purpose of this study was to assess the long-term value of
dobutamine-atropine stress echocardiography (DSE) for prediction of late
cardiac events in patients with proven or suspected coronary artery
disease. METHODS AND RESULTS--Clinical data and DSE results were analyzed
in 1734 consecutive patients undergoing DSE between 1989 and 1997.
Seventy-four patients who underwent revascularization within 3 months of
DSE and 1 patient lost to follow-up were excluded; the remaining 1659
(median age, 62 years; range, 14 to 99 years) were followed up for 36
months (range, 6 to 96 months). Wall motion abnormalities at rest and the
presence and extent of stress-induced wall motion abnormalities (ischemia)
were scored for each patient. Cardiac events were related to clinical and
ECG data and DSE results. Four hundred twenty-eight cardiac events
occurred in 366, documented cardiac death in 108 (total death, 247),
nonfatal infarction in 128, and late revascularization in 192 patients. In
a multivariable Cox proportional-hazards model, the ratio of documented
cardiac death or (re)infarction was increased in the presence of
stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and
extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3
to 2.6). The number of ischemic segments was predictive for late cardiac
events. A normal DSE carried a relatively good prognosis, wit
Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography?
Stress echocardiography and myocardial perfusion imaging are commonly used noninvasive imaging modalities for the evaluation of ischaemic heart disease. Both modalities have proved clinically useful in the entire spectrum of coronary artery disease. Both techniques can detect coronary artery disease and provide prognostic information. Both techniques can identify low-risk and high-risk subsets among patients with known or suspected coronary artery disease and thus guide patient management decisions. In patients with acute myocardial infarction, both techniques have been used to identify residual viable tissue and predict improvement of function over time. In patients with chronic ischaemic left ventricular (LV) dysfunction, viability assessment with either modality can be used to predict improvement of function after revascularisation and thus guide patient treatment
Long-Term Prognostic Value of Dobutamine-Atropine Stress Echocardiography in 1737 Patients With Known or Suspected Coronary Artery Disease
Background—The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease.
Methods and Results—Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with
Prevalence of myocardial viability assessed by single photon emission computed tomography in patients with chronic ischaemic left ventricular dysfunction
OBJECTIVE: To assess the prevalence of myocardial viability by
technetium-99m (Tc-99m)-tetrofosmin/fluorine-18-fluorodeoxyglucose (FDG)
single photon emission computed tomography (SPECT) in patients with
ischaemic cardiomyopathy. DESIGN: A retrospective observational study.
SETTING: Thoraxcenter Rotterdam (a tertiary referral centre). PATIENTS:
104 patients with chronic coronary artery disease and severely depressed
left ventricular function presenting with heart failure symptoms. MAIN
OUTCOME MEASURES: Prevalence of myocardial viability as evaluated by
Tc-99m-tetrofosmin/FDG SPECT imaging. Two strategies for assessing
viability in dysfunctional myocardium were used: perfusion imaging alone,
and the combination of perfusion and metabolic imaging. RESULTS: On
perfusion imaging alone, 56 patients (54%) had a significant amount of
viable myocardium, whereas 48 patients (46%) did not. Among the 48
patients with no significant viability by perfusion imaging alone, seven
additional patients (15%) had significantly viable myocardium on combined
perfusion and metabolic imaging. Thus with a combination of perfusion and
metabolic imaging, 63 patients (61%) had viable myocardium and 41 (39%)
did not. CONCLUSIONS: On the basis of the presence of viable dysfunctional
myocardium, 61% of patients with chronic coronary artery disease and
depressed left ventricular ejection fraction presenting with heart failure
symptoms may be considered for coronary revascularisation. The combination
of perfusion and metabolic imaging identified more patients with
significant viability than myocardial perfusion imaging alone
A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery
OBJECTIVE: To evaluate the discriminatory value and compare the predictive
performance of six non-invasive tests used for perioperative cardiac risk
stratification in patients undergoing major vascular surgery. DESIGN:
Meta-analysis of published reports. METHODS: Eight studies on ambulatory
electrocardiography, seven on exercise electrocardiography, eight on
radionuclide ventriculography, 23 on myocardial perfusion scintigraphy,
eight on dobutamine stress echocardiography, and four on dipyridamole
stress echocardiography were selected, using a systematic review of
published reports on preoperative non-invasive tests from the Medline
database (January 1975 and April 2001). Random effects models were used to
calculate weighted sensitivity and specificity from the published results.
Summary receiver operating characteristic (SROC) curve analysis was used
to evaluate and compare the prognostic accuracy of each test. The relative
diagnostic odds ratio was used to study the differences in diagnostic
performance of the tests. RESULTS: In all, 8119 patients participated in
the studies selected. Dobutamine stress echocardiography had the highest
weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and
a reasonable specificity of 70% (95% CI 62% to 79%) for predicting
perioperative cardiac death and non-fatal myocardial infarction. On SROC
analysis, there was a trend for dobutamine stress echocardiography to
perform better than the other tests, but this only reached significance
against myocardial perfusion scintigraphy (relative diagnostic odds ratio
5.5, 95% CI 2.0 to 14.9). CONCLUSIONS: On meta-analysis of six
non-invasive tests, dobutamine stress echocardiography showed a positive
trend towards better diagnostic performance than the other tests, but this
was only significant in the comparison with myocardial perfusion
scintigraphy. However, dobutamine stress echocardiography may be the
favoured test in situations where there is valvar or left ventricular
dysfunction
Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy
CONTEXT: Patients who undergo major vascular surgery are at increased risk
of perioperative cardiac complications. High-risk patients can be
identified by clinical factors and noninvasive cardiac testing, such as
dobutamine stress echocardiography (DSE); however, such noninvasive
imaging techniques carry significant disadvantages. A recent study found
that perioperative beta-blocker therapy reduces complication rates in
high-risk individuals. OBJECTIVE: To examine the relationship of clinical
characteristics, DSE results, beta-blocker therapy, and cardiac events in
patients undergoing major vascular surgery. DESIGN AND SETTING: Cohort
study conducted in 1996-1999 in the following 8 centers: Erasmus Medical
Centre and Sint Clara Ziekenhuis, Rotterdam, Twee Steden Ziekenhuis,
Tilburg, Academisch Ziekenhuis Utrecht, Utrecht, and Medisch Centrum
Alkmaar, Alkmaar, the Netherlands; Ziekenhuis Middelheim, Antwerp,
Belgium; and San Gerardo Hospital, Monza, Istituto di Ricovero e Cura a
Carattere Scientifico, San Giovanni Rotondo, Italy. PATIENTS: A total of
1351 consecutive patients scheduled for major vascular surgery; DSE was
performed in 1097 patients (81%), and 360 (27%) received beta-blocker
therapy. MAIN OUTCOME MEASURE: Cardiac death or nonfatal myocardial
infarction within 30 days after surgery, compared by clinical
characteristics, DSE results, and beta-blocker use. RESULTS: Forty-five
patients (3.3%) had perioperative cardiac death or nonfatal myocardial
infarction. In multivariable analysis, important clinical determinants of
adverse outcome were age 70 years or older; current or prior angina
pectoris; and prior myocardial infarction, heart failure, or
cerebrovascular accident. Eighty-three percent of patients had less than 3
clinical risk factors. Among this subgroup, patients receiving
beta-blockers had a lower risk of cardiac complications (0.8% [2/263])
than those not receiving beta-blockers (2.3% [20/855]), and DSE had
minimal additional prognostic value. In patients with 3 or more risk
factors (17%), DSE provided additional prognostic information, for
patients without stress-induced ischemia had much lower risk of events
than those with stress-induced ischemia (among those receiving
beta-blockers, 2.0% [1/50] vs 10.6% [5/47]). Moreover, patients with
limited stress-induced ischemia (1-4 segments) experienced fewer cardiac
events (2.8% [1/36]) than those with more extensive ischemia (>/=5
segments, 36% [4/11]). CONCLUSION: The additional predictive value of DSE
is limited in clinically low-risk patients receiving beta-blockers. In
clinical practice, DSE may be avoided in a large number of patients who
can proceed safely for surgery without delay. In clinically intermediate-
and high-risk patients receiving beta-blockers, DSE may help identify
those in whom surgery can still be performed and those in whom cardiac
revascularization should be considered
Safety and Efficacy of Erythrocyte Encapsulated Thymidine Phosphorylase in Mitochondrial Neurogastrointestinal Encephalomyopathy.
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an ultra-rare autosomal recessive disorder of nucleoside metabolism that is caused by mutations in the nuclear thymidine phosphorylase gene (TYMP) gene, encoding for the enzyme thymidine phosphorylase. There are currently no approved treatments for MNGIE. The aim of this study was to investigate the safety, tolerability, and efficacy of an enzyme replacement therapy for the treatment of MNGIE. In this single centre study, three adult patients with MNGIE received intravenous escalating doses of erythrocyte encapsulated thymidine phosphorylase (EE-TP; dose range: 4 to 108 U/kg/4 weeks). EE-TP was well tolerated and reductions in the disease-associated plasma metabolites, thymidine, and deoxyuridine were observed in all three patients. Clinical improvements, including weight gain and improved disease scores, were observed in two patients, suggesting that EE-TP is able to reverse some aspects of the disease pathology. Transient, non-serious adverse events were observed in two of the three patients; these did not lead to therapy discontinuation and they were managed with pre-medication prior to infusion of EE-TP. To conclude, enzyme replacement therapy with EE-TP demonstrated biochemical and clinical therapeutic efficacy with an acceptable clinical safety profile
Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident’s training
Background: In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training. Methods: A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005. Results: The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates. Conclusions: Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training
Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy
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