Preoperative nuclear stress testing in the very old patient population

© The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved. BACKGROUND Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population. AIM To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery. METHODS Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (\u3c 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, \u3e 0) were analyzed. RESULTS A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly (P \u3c 0.01) more likely to develop peri-operative MACE

Implications of Gender Difference in Coronary Calcification as Assessed by CT Coronary Angiography

BACKGROUND: Arterial calcium as measured by 64-slice computed tomography coronary angiography (64-CT) is a reliable predictor of cardiovascular disease risk. Lipid-rich plaques with lower degrees of calcification may pose greater risk for adverse coronary events than more stabilized calcified plaques as a result of the increased risk of plaque rupture, migration, and subsequent acute coronary syndrome. We sought to examine coronary artery calcium scores as measured via 64-CT to assess the extent of calcification and plaque distribution in women compared to men. METHODS: A total of 138 patients referred for 64-CT were evaluated. Computerized tomographic angiography was performed using the GE LightSpeed VCT. Subgroup analysis comparing male and female data (including demographic data) was performed. All major coronary arteries were analyzed for coronary stenosis/plaque characterization as well as total vessel calcium (Agatston) score quantification. Patient demographics and coronary risk factors were recorded. RESULTS: A total of 552 coronary arteries were evaluated in 138 patients (85 men, 53 women). The average age for females was 64.4 +/- 10.8 years and for males 60.0 +/- 12.8 years. The only demographic/cardiovascular risk factor in which the difference between men and women was significant was smoking history, where 23.5% of men had a history of smoking while only 9.6% of females endorsed having a smoking history (P \u3c 0.044). On comparison of all total vessel calcium scores, males had a higher total mean calcium score than females in each individual vessel. The results were as follows for males versus females, respectively: left main total vessel calcium score 46.49 versus 16.71 (P = 0.167); left anterior descending 265.21 versus 109.6 (P \u3c 0.003); left circumflex 130.5 versus 39.7 (P \u3c 0.004); and right coronary 213.5 versus 73.8 (P \u3c 0.01). The odds of having a total calcium score \u3e100 (versus not) was 3.62 times greater in males relative to females, given that all the other cardiovascular risk factors are adjusted for (95% confidence interval: 1.37-9.54). On average, men had an average of 2.1 +/- 1.5 epicardial vessels with a calcium score \u3e/=11 compared to 1.3 +/- 1.4 for women (P \u3c 0.005). CONCLUSION: There are clear differences between males and females regarding total vessel calcium scores and therefore risk of future adverse coronary events. Males tended to have higher average calcium scores in each coronary artery than females with a greater tendency to have multiple vessel involvement. Using this information, more large-scale, randomized controlled studies should be performed to correlate differences in the extent of coronary calcification with the observed variance in clinical presentation during coronary events between males and females as a means to potentially establish gender-specific therapeutic regimens

Multi-Detector Coronary CT Imaging for the Identification of Coronary Artery Stenoses in a Real-World Population

BACKGROUND: Multi-detector computed tomography (CT) has emerged as a modality for the non-invasive assessment of coronary artery disease (CAD). Prior studies have selected patients for evaluation and have excluded many of the real-world patients commonly encountered in daily practice. We compared 64-detector-CT (64-CT) to conventional coronary angiography (CA) to investigate the accuracy of 64-CT in determining significant coronary stenoses in a real-world clinical population. METHODS: A total of 1,818 consecutive patients referred for 64-CT were evaluated. CT angiography was performed using the GE LightSpeed VCT (GE((R)) Healthcare). Forty-one patients in whom 64-CT results prompted CA investigation were further evaluated, and results of the two diagnostic modalities were compared. RESULTS: A total of 164 coronary arteries and 410 coronary segments were evaluated in 41 patients (30 men, 11 women, age 39-85 years) who were identified by 64-CT to have significant coronary stenoses and who thereafter underwent CA. The overall per-vessel sensitivity, specificity, positive predictive value, negative predictive value, and accuracy at the 50% stenosis level were 86%, 84%, 65%, 95%, and 85%, respectively, and 77%, 93%, 61%, 97%, and 91%, respectively, in the per-segment analysis at the 50% stenosis level. CONCLUSION: 64-CT is an accurate imaging tool that allows a non-invasive assessment of significant CAD with a high diagnostic accuracy in a real-world population of patients. The sensitivity and specificity that we noted are not as high as those in prior reports, but we evaluated a population of patients that is typically encountered in clinical practice and therefore see more real-world results

Sleep Deficiency and Deprivation Leading to Cardiovascular Disease

Sleep plays a vital role in an individual’s mental, emotional, and physiological well-being. Not only does sleep deficiency lead to neurological and psychological disorders, but also the literature has explored the adverse effects of sleep deficiency on the cardiovascular system. Decreased quantity and quality of sleep have been linked to cardiovascular disease (CVD) risk factors, such as hypertension, obesity, diabetes, and dyslipidemia. We explore the literature correlating primary sleep deficiency and deprivation as a cause for cardiovascular disease and cite endothelial dysfunction as a common underlying mechanism

Dyslipidemia and Its Role in the Pathogenesis of Atherosclerotic Cardiovascular Disease: Implications for Evaluation and Targets for Treatment of Dyslipidemia Based on Recent Guidelines

The clinical presentations of atherosclerotic disease are the result of a constellation of diverse metabolic and immunologic mechanisms ultimately set into motion by the formation of fatty acid streaks and the accompanying inflammatory cell activation, endothelial damage, smooth muscle proliferation, vascular fibrosis, and end-organ infarction and necrosis. At the heart of atherosclerosis are the byproducts of lipid metabolism, lipoproteins containing triglycerides, phospholipids, and cholesterol, and the changes they undergo that eventually lead to macrophage activation, foam cell formation, and other downstream atherosclerotic changes. Understanding the functionality of cholesterol, triglycerides, and lipoproteins in the cascade of atherosclerotic pathways has tremendous implications on current guidelines for the evaluation and targets in the management of dyslipidemia, and serves as the foundation for future investigations into targets of atherosclerotic therapies

Diabetes and Coronary Artery Disease – Pathophysiologic Insights and Therapeutic Implications

Cardiovascular disease is the leading cause of morbidity and mortality among people with diabetes worldwide, accounting for 60% of all deaths in diabetics. Despite advances in our pathophysiologic understanding of diabetic co-morbidities and measures to help counter these, diabetics still remain at increased risk for cardiovascular disease complicating our overall approach to management. Diabetics, in particularly type 2, are often fraught with additional risk factors contributing to their overall propensity for developing cardiovascular disease. These include, but are not limited to, obesity, dyslipidemia, poor glycemic control, lack of physical activity, and hypertension. In response to this, research driven guidelines focusing on primary prevention have continued to arise with new clinical targets and goals substantially changing our approach with the diabetic population. It is important to note early on, type 1 diabetics carry a higher risk of cardiovascular disease for which the pathophysiology is only recently being elucidated. The underlying relationship between cardiovascular events and risk factors is, however, not well understood. For this reason, management approaches to risk reduction have been extrapolated from experience in type 2 diabetes mellitus. The purpose of this chapter is to present the conclusions of current literature pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the new guidelines, and clinical targets, including preventative measures for subclinical cardiovascular disease for the contemporary management of patients with diabetes mellitus

Diagnostic and treatment utility of echocardiography in the management of the cardiac patient

© The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved. BACKGROUND Echocardiograms are an incredibly useful diagnostic tool due to their lack of harmful radiation, the relative ease and speed with which they can be performed, and their almost ubiquitous availability. Unfortunately, the advantages that support the use of echocardiography can also lead to the overuse of this technology. We sought to evaluate the physician perceived impact echocardiography has on patient management. AIM To evaluate the physician perceived impact echocardiography has on patient management. METHODS Surveys were distributed to the ordering physician for echocardiograms performed at our institution over a 10-wk period. Only transthoracic echocardiograms performed on the inpatient service were included. Surveys were distributed to either the attending physician or the resident physician listed on the echocardiogram order. The information requested in the survey focused on the indication for the study and the perceived importance and effect of the study. Observational statistical analysis was performed on all of the answers from the collected surveys. RESULTS A total of 103 surveys were obtained and analyzed. The internal medicine (57%) and cardiology (37%) specialties ordered the most echocardiograms. The most common reason for ordering an echocardiogram was to rule out a diagnosis (38.2%). Only 27.5% of physicians reported that the echocardiogram significantly affected patient care, with 18.6% reporting a moderate effect, and 30.4% reporting a mild effect. A total of 19.6% of physicians stated that there was no effect on patient management. Additionally, 43.1% of physicians reported that they made changes in patient management due to no change having occurred in the disease, 11.8% reported that changes in management were based on the recommendation of a specialist, and only 9.8% reported that further imaging was ordered due to the results of the echocardiogram. The majority of physicians (67.6%) considered an echocardiogram to be “somewhat essential” in the management of adult inpatients, with only 15.7% considering it “essential”. CONCLUSION The majority of physicians surveyed report the echocardiogram had only a mild effect on management with only 27.5% reporting a significant effect. However, the majority of physicians (83.3%) perceived an echocardiogram to be somewhat or entirely essential for management. Only 9.8% reported the echo led to further imaging. These insights into ordering physician reasoning should help guide better definition of the optimal and ideal use of echocardiography