Importance of clinical measures of ischemia in the prognosis of patients with documented coronary artery disease

AbstractTo examine the value of clinical measures of ischemia for stratifying prognosis, 5,886 consecutive patients who had symptomatic significant (≥75% stenosis) coronary artery disease were studied. Using the Cox regression model in a randomly selected half of the patients, the prognostically independent clinical variables were weighted and arranged into a simple angina score: angina score = angina course × (1 + daily angina frequency) + ST-T changes, where angina course was equal to 3 if unstable or variant angina was present, 2 if the patient's angina was progressive with nocturnal episodes, 1 if it was progressive without nocturnal symptoms and 0 if it was stable; 6 points were added for the presence of “ischemic” ST-T changes. This angina score was then validated in an independent patient sample.The score was a more powerful predictor of prognosis than was any individual anginal descriptor. Furthermore, the angina score added significant independent prognostic information to the patient's age, sex, coronary anatomy and left ventricular function. Patients with three vessel disease and a normal ventricle (n = 1,233) had a 2 year infarction-free survival rate of 90% with an angina score of 0 and a 68% survival rate with an angina score ≥9. With an ejection fraction <50% and three vessel disease (n = 1,116), the corresponding infarction-free survival figures were 76 and 56%. Thus, a careful summarization of clinical markers of ischemia in the form of an angina score can provide a powerful prognostic tool and may aid clinicians in identifying high risk patients who are candidates for aggressive therapeutic interventions

Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries

ObjectiveAbdominal aortic aneurysm (AAA) screening remains largely underutilized in the U.S., and it is likely that the proportion of patients with aneurysms requiring prompt treatment is much higher compared with well-screened populations. The goals of this study were to determine the proportion of AAAs that required prompt repair after diagnostic abdominal imaging for U.S. Medicare beneficiaries and to identify patient and hospital factors contributing to early vs late diagnosis of AAA.MethodsData were extracted from Medicare claims records for patients at least 65 years old with complete coverage for 2 years who underwent intact AAA repair from 2006 to 2009. Preoperative ultrasound and computed tomography was tabulated from 2002 to repair. We defined early diagnosis of AAA as a patient with a time interval of greater than 6 months between the first imaging examination and the index procedure, and late diagnosis as patients who underwent the index procedure within 6 months of the first imaging examination.ResultsOf 17,626 patients who underwent AAA repair, 14,948 met inclusion criteria. Mean age was 77.5 ± 6.1 years. Early diagnosis was identified for 60.6% of patients receiving AAA repair, whereas 39.4% were repaired after a late diagnosis. Early diagnosis rates increased from 2006 to 2009 (59.8% to 63.4%; P < .0001) and were more common for intact repair compared with repair after rupture (62.9% vs 35.1%; P < .0001) and for women compared with men (66.3% vs 59.0%; P < .0001). On multivariate analysis, repair of intact vs ruptured AAAs (odds ratio, 3.1; 95% confidence interval, 2.7-3.6) and female sex (odds ratio, 1.4; 95% confidence interval, 1.3-1.5) remained the strongest predictors of surveillance. Although intact repairs were more likely to be diagnosed early, over one-third of patients undergoing repair for ruptured AAAs received diagnostic abdominal imaging greater than 6 months prior to surgery.ConclusionsDespite advances in screening practices, significant missed opportunities remain in the U.S. Medicare population for improving AAA care. It remains common for AAAs to be diagnosed when they are already at risk for rupture. In addition, a significant proportion of patients with early imaging rupture prior to repair. Our findings suggest that improved mechanisms for observational management are needed to ensure optimal preoperative care for patients with AAAs

Clinical judgement and therapeutic decision making

AbstractClinical decision making is under increased scrutiny due to concerns about the cost and quality of medical care. Variability in physician decision making is common, in part because of deficiencies in the knowledge base, but also due to the difference in physicians' approaches to clinical problem solving. Evaluation of patient prognosis is a critical factor in the selection of therapy, and careful attention to methodology is essential to provide reliable information.Randomized controlled clinical trials provide the most solid basis for the establishment of broad therapeutic principles. Because randomized studies cannot be performed to address every question, observational studies will continue to play a complementary role in the evaluation of therapy. Randomized studies in progress, meta analyses of existing data, and increased use of administrative and collaborative clinical data bases will improve the knowledge base for decision making in the future

The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials.

OBJECTIVES: This study sought to assess whether patient age modifies the comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). BACKGROUND: Increasingly, CABG and PCI are performed in older patients to treat multivessel disease, but their comparative effectiveness is uncertain. METHODS: Individual data from 7,812 patients randomized in 1 of 10 clinical trials of CABG or PCI were pooled. Age was analyzed as a continuous variable in the primary analysis and was divided into tertiles for descriptive purposes (≤56.2 years, 56.3 to 65.1 years, ≥65.2 years). The outcomes assessed were death, myocardial infarction and repeat revascularization over complete follow-up, and angina at 1 year. RESULTS: Older patients were more likely to have hypertension, diabetes, and 3-vessel disease compared with younger patients (p < 0.001 for trend). Over a median follow-up of 5.9 years, the effect of CABG versus PCI on mortality varied according to age (interaction p < 0.01), with adjusted CABG-to-PCI hazard ratios and 95% confidence intervals (CI) of 1.23 (95% CI: 0.95 to 1.59) in the youngest tertile; 0.89 (95% CI: 0.73 to 1.10) in the middle tertile; and 0.79 (95% CI: 0.67 to 0.94) in the oldest tertile. The CABG-to-PCI hazard ratio of less than 1 for patients 59 years of age and older. A similar interaction of age with treatment was present for the composite outcome of death or myocardial infarction. In contrast, patient age did not alter the comparative effectiveness of CABG and PCI on the outcomes of repeat revascularization or angina. CONCLUSIONS: Patient age modifies the comparative effectiveness of CABG and PCI on hard cardiac events, with CABG favored at older ages and PCI favored at younger ages

Cross-cultural adaptation and assessment of reproducibility of the Duke Activity Status Index for COPD patients in Brazil

OBJECTIVE: To cross-culturally adapt the Duke Activity Status Index (DASI) for use in Brazil and evaluate the reproducibility of the new (Brazilian Portuguese-language) version. METHODS: We selected stable patients with clinical and spirometric diagnosis of COPD. Initially, the DASI was translated into Brazilian Portuguese, and the cross-cultural adaptation was performed by an expert committee. Subsequently, 12 patients completed the questionnaire, so that their questions and difficulties could be identified and adjustments could be made. An independent translator back-translated the final version into English, which was then submitted to and approved by the original author. The final Brazilian Portuguese-language version of the DASI was applied to 50 patients at three distinct times. For the assessment of interobserver reproducibility, it was applied twice within a 30-min interval by two different interviewers. For the assessment of intraobserver reproducibility, it was applied again 15 days later by one of the interviewers. RESULTS: The mean age of the patients was 62.3 ± 10.0 years, the mean FEV1 was 45.2 ± 14.7% of the predicted value, and the mean body mass index was 26.8 ± 5.8 kg/m². The intraclass correlation coefficients for intraobserver and interobserver reproducibility were 0.95 and 0.90, respectively. The correlations between the DASI and the Saint George's Respiratory Questionnaire (SGRQ) domains were all negative and statistically significant. The DASI correlated best with the SGRQ activity domain (r = -0.70), the total SGRQ score (r = -0.66), and the six-minute walk distance (r = 0.55). CONCLUSIONS: The Brazilian Portuguese-language version of the DASI is reproducible, fast, and simple, correlating well with the SGRQ.OBJETIVO: Adaptar culturalmente e avaliar a reprodutibilidade do Duke Activity Status Index (DASI) para o português do Brasil. MÉTODOS: Foram selecionados pacientes estáveis com diagnóstico clínico e espirométrico de DPOC. Inicialmente, o DASI foi traduzido para o português, e a adaptação cultural foi realizada por uma comissão de especialistas. Em seguida, o questionário foi aplicado em 12 pacientes para saber suas dúvidas e dificuldades, sendo realizadas as devidas adaptações. Um tradutor independente fez a tradução retrógrada, que foi submetida e aprovada pelo autor original. A versão final do DASI foi aplicada em 50 pacientes em dois momentos, com intervalo de 30 minutos (reprodutibilidade interobservador) e, num terceiro momento, após 15 dias (reprodutibilidade intraobservador). RESULTADOS: A média de idade dos pacientes foi de 62,3 ± 10,0 anos, a média do VEF1 foi de 45,2 ± 14,7% do valor previsto, e a do índice de massa corpórea foi de 26,8 ± 5,8 kg/m². Os coeficientes de correlação intraclasse intraobservador e interobservador foram de 0,95 e 0,90, respectivamente. As correlações do DASI com todos os domínios do Saint George's Respiratory Questionnaire (SGRQ) foram negativas e estatisticamente significantes. As melhores correlações ocorreram com o domínio atividade (r = -0,70) e a pontuação total do SGRQ (r = -0,66), assim como com a distância percorrida no teste de caminhada de seis minutos (r = 0,55). CONCLUSÕES: A versão em língua portuguesa do Brasil do DASI é reprodutível, de rápida e fácil aplicação e apresentou uma boa correlação com o SGRQ.Secretaria Estadual de Saúde Secretaria Municipal de SaúdeUniversidade Federal de Sergipe Hospital Universitário Serviço de PneumologiaUniversidade Federal de São Paulo (UNIFESP) Centro de Reabilitação PulmonarAssociação de Assistência à Criança DeficienteUniversidade Estadual de Ciências da Saúde de Alagoas Núcleo de Propedêutica e TerapêuticaStanford University School of MedicineUNIFESP, Centro de Reabilitação PulmonarSciEL

Metabolic Syndrome and Early-Onset Coronary Artery Disease Is the Whole Greater Than Its Parts?

ObjectivesWe sought to examine the association between the metabolic syndrome (MetS) (defined both by the 2001 National Cholesterol Educational Program Adult Treatment Panel III [ATP-III] definition and the American Heart Association/National Heart, Lung and Blood Institute [AHA/NHLBI] revision incorporating the lower threshold for impaired fasting glucose [IFG]) and early-onset coronary artery disease (CAD).BackgroundThe impact of MetS on premature CAD has not been studied extensively. Lowering the threshold to define the IFG component (from 110 to 100 mg/dl) and the value of the syndrome as a whole versus its individual components are subjects of intense debate.MethodsWe performed a case-control study with 393 early-onset CAD subjects (acute myocardial infarction, angina with ≥50% stenosis, or coronary revascularization) in men under age 46 years or women under age 56 years and 393 control subjects individually matched for gender, age, and race/ethnicity.ResultsBy conditional logistic regression, presence of ATP-III MetS without diabetes (adjusted odds ratio [adj-OR] 4.9; 95% confidence interval [CI] 3.4 to 8.0) and with diabetes (adj-OR 8.0, 95% CI 4.39 to 14.6) was a strong independent determinant of early-onset CAD. Using the AHA/NHLBI revision, these ORs became slightly stronger. However, neither definition of MetS remained significantly associated with early-onset CAD in multivariate models adjusting for individual components.ConclusionsThe presence of MetS imparts a high risk of early-onset clinical CAD, but the prognostic information associated with the syndrome is not greater than the sum of its parts

Race and Ethnicity, Obesity, Metabolic Health, and Risk of Cardiovascular Disease in Postmenopausal Women

Background It is unclear whether obesity unaccompanied by metabolic abnormalities is associated with increased cardiovascular disease risk across racial and ethnic subgroups. Methods and Results We identified 14 364 postmenopausal women from the Women\u27s Health Initiative who had data on fasting serum lipids and serum glucose and no history of cardiovascular disease or diabetes at baseline. We categorized women by body mass index (in kg/m2) as normal weight (body mass index 18.5 to P=0.05). Obese black women without metabolic syndrome had higher adjusted risk (HR 1.95) than obese white women (HR 1.07; interaction P=0.02). Among women with only 2 metabolic abnormalities, cardiovascular risk was increased in black women who were overweight (HR 1.77) or obese (HR 2.17) but not in white women who were overweight (HR 0.98) or obese (HR 1.06). Overweight and obese women with ≤1 metabolic abnormality did not have increased cardiovascular risk, regardless of race or ethnicity. Conclusions Metabolic abnormalities appeared to convey more cardiovascular risk among black women