Utility of the SENIORS elderly heart failure risk model applied to the RICA registry of acute heart failure

Background: Heart failure (HF) is predominantly a disease of the elderly. Reliable risk stratification would help in the management of this population, but no model has been well evaluated in elderly HF patients in both acute and chronic settings and not being restricted by ejection fraction. To evaluate the utility of the SENIORS risk model, developed from a clinical trial of elderly patients with chronic HF, in an independent cohort (National Spanish Registry: RICA) of elderly acute HF patients. Methods: We applied the SENIORS risk model to 926 patients in RICA to estimate risk at one year of a) composite outcome of all-cause mortality or cardiovascular hospital admission and b) all-cause mortality. Results: In the RICA registry mean age was 78 years, mean ejection fraction 51% and 87% were in NYHA II and III. At one year death/CV hospitalization occurred in 31.9% and all-cause mortality in 19.5%. The risk model provided good separation of Kaplan Meier curves stratified by tertile for death/CV hospitalization and all-cause mortality. The observed versus expected rates of death/CV hospitalization in the lowest, middle and highest risk tertiles were (%) 34/24, 45/41 and 57/67, and for death 13/16, 32/38 and 44/70 respectively. C-statistic for all-cause mortality or CV hospitalization was 0.60 and for all-cause mortality 0.66. Conclusion: The SENIORS risk model was a reliable tool for relative risk stratification among acute heart failure patients in a “real world” registry, but predicted versus observed risk showed some variability. The model provides a useful basis for clinical risk prediction

ACE inhibitor use in patients with myocardial infarction. Summary ofevidence from clinical trials

Experimental evidence for the beneficial effects on heart failure of chronic treatment with ACE inhibitors accumulated from early 1980 in experimental models of LV dysfunction secondary to AMI. These studies demonstrated an improvement in hemodynamics, LV remodeling, and mortality with ACE inhibitor treatment. The effect of ACE inhibitors during the acute phase of AMI was less clear, although there was evidence of protection from ischemic damage, possibly mediated by an increase in collateral coronary blood flow

B-type natriuretic peptide trumps other prognostic markers in patients assessed for coronary disease

Background: Risk prediction for patients with suspected coronary artery disease is complex due to the common occurrence of prior cardiovascular disease and extensive risk modification in primary care. Numerous markers have the potential to predict prognosis and guide management, but we currently lack robust 'real-world' evidence for their use. Methods: Prospective, multicentre observational study of consecutive patients referred for elective coronary angiography. Clinicians were blinded to all risk assessments, consisting of conventional factors, radial artery pulse wave analysis, 5-minute heart rate variability, high-sensitivity C-reactive protein and B-type natriuretic peptide (BNP). Blinded, independent adjudication was performed for all-cause mortality and the composite of death, myocardial infarction or stroke, analysed with Cox proportional hazards regression. Results: Five hundred twenty-two patients were assessed with median age 66 years and 21% prior revascularization. Median baseline left ventricular ejection fraction was 64%, and 62% had ≥ 50% stenosis on angiography. During 5.0 years median follow-up, 30% underwent percutaneous and 16% surgical revascularization. In multivariate analysis, only age and BNP were independently associated with outcomes. The adjusted hazard ratio per log unit increase in BNP was 2.15 for mortality (95% CI 1.45-3.19; p = 0.0001) and 1.27 for composite events (1.04-1.54; p = 0.018). Patients with baseline BNP > 100 pg/mL had substantially higher mortality and composite events (20.9% and 32.2%) than those with BNP ≤ 100 pg/mL (5.6% and 15.5%). BNP improved both classification and discrimination of outcomes (p ≤ 0.003), regardless of left ventricular systolic function. Conversely, high-sensitivity C-reactive protein, pulse wave analysis and heart rate variability were unrelated to prognosis at 5 years after risk modification and treatment of coronary disease. Conclusions: Conventional risk factors and other markers of arterial compliance, inflammation and autonomic function have limited value for prediction of outcomes in risk-modified patients assessed for coronary disease. BNP can independently identify patients with subtle impairment of cardiac function that might benefit from more intensive management. Trial registration: Clinicaltrials.gov, NCT00403351 Registered on 22 November 200

Incidence and clinical implications of intraoperative BITA grafts conversion. Insights from the Arterial Revascularization Trial

Background: The arterial revascularization trial (ART) has been designed to answer the question whether the use of bilateral internal thoracic arteries (BITA) can improve 10-year outcomes when compared to single internal thoracic artery (SITA). In the ART, a significant proportion of patients initially allocated to BITA received other conduit strategies. We sought to investigate the incidence and clinical implication of BITA grafts conversion in the ART. Methods: Among patients enrolled in the ART (n=3102), we excluded those allocated to SITA (n=1554), those who did not undergo surgery (n=16) and those operated on but withdrew after randomization (n=7). Propensity score matching was used to compare converted vs non-converted BITA groups. Results: A total of 1525 patients were operated with intention to receive BITA grafting. Of those, 233 (15.3%) were converted to other conduit selection strategies. Incidence of conversion largely varied across 28 centres involved (from 0% to 42.9%). The most common reason for BITA grafts conversion was the evidence of at least one internal thoracic artery not suitable which was reported in 77 cases. Patients with intraoperative BITA graft conversion received a lower number of grafts (2.95±0.84 vs 3.21±0.74; P<0.001). However, hospital mortality rate was comparable to those who did not require BITA graft conversion (0 vs 1.6%; P=0.1) as well as the incidence of major complications. At 5 years we found a non-significant excess of deaths (11.9% vs 8.4%; P=0.1) and major adverse events (17.1% 13.2%; P=0.1) mainly driven by an excess of revascularization in patients requiring conversion. Conclusions: The incidence of intraoperative BITA graft conversion is not irrelevant . BITA graft conversion is not associated with increased operative morbidity but its effect on late outcomes remain uncertain

Impact of dual antiplatelet therapy after coronary artery bypass surgery on 1-year outcomes in the Arterial Revascularization Trial

OBJECTIVES: There is still little evidence to boldport routine dual antiplatelet therapy (DAPT) with P2Y12 antagonists following coronary artery bypass grafting (CABG). The Arterial Revascularization Trial (ART) was designed to compare 10-year survival after bilateral versus single internal thoracic artery grafting. We aimed to get insights into the effect of DAPT (with clopidogrel) following CABG on 1-year outcomes by performing a post hoc ART analysis. METHODS: Among patients enrolled in the ART (n  = 3102), 609 (21%) and 2308 (79%) were discharged on DAPT or aspirin alone, respectively. The primary end-point was the incidence of major adverse cerebrovascular and cardiac events (MACCE) at 1 year including cardiac death, myocardial infarction, cerebrovascular accident and reintervention; safety end-point was bleeding requiring hospitalization. Propensity score (PS) matching was used to create comparable groups. RESULTS: Among 609 PS-matched pairs, MACCE occurred in 34 (5.6%) and 34 (5.6%) in the DAPT and aspirin alone groups, respectively, with no significant difference between the 2 groups [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.59-1.59; P  = 0.90]. Only 188 (31%) subjects completed 1 year of DAPT, and in this subgroup, MACCE rate was 5.8% (HR 1.11, 95% CI 0.53-2.30; P  = 0.78). In the overall sample, bleeding rate was higher in DAPT group (2.3% vs 1.1%; P  = 0.02), although this difference was no longer significant after matching (2.3% vs 1.8%; P  = 0.54). CONCLUSIONS: Based on these findings, when compared with aspirin alone, DAPT with clopidogrel prescribed at discharge was not associated with a significant reduction of adverse cardiac and cerebrovascular events at 1 year following CABG

Assessment of data quality in an international multi-centre randomised trial of coronary artery surgery

ART is a multi-centre randomised trial of cardiac surgery which provided a unique opportunity to evaluate the data from a large number of centres from a variety of countries. We attempted to assess data quality, including recruitment rates, timeliness and completeness of the data obtained from the centres in different socio-economic strata

Post-operative atrial fibrillation and long-term risk of stroke after isolated coronary artery bypass graft surgery

Background: Post-operative atrial fibrillation (pAF) following coronary artery bypass graft-ing (CABG) is a common complication. Whether pAF is associated with an increased risk of cerebrovascular accident (CVA) remains uncertain. We investigated the association between pAF and long-term risk of CVA by performing a post-hoc analysis of 10-year outcomes of the Arterial Revascularization Trial (ART). Methods: For the present analysis, among patients enrolled in the ART (n=3102), we ex-cluded those who did not undergo surgery (n=25), had a prior history of atrial fibrillation (n=45), or had no information regarding the incidence of pAF (n=9). The final population consisted of 3023 patients of whom 734 (24.3%) developed pAF with the remaining 2289 maintaining sinus rhythm (SR). Competing risk and Cox regression analysis were used to investigate the association between pAF and the risk of CVA. Results: At 10 years, the cumulative incidence of CVA was 6.3% (4.6-8.1) vs 3.7% (2.9-4.5) in patients with pAF and SR respectively. pAF was an independent predictor of CVA at 10 years (HR 1.53; 95%CI 1.06-2.23; P-value=0.025) even when CVAs that occurred during the index admission were excluded from the analysis (HR 1.47; 95% 1.02-2.11; P=0.04). Conclusions: Patients with pAF after CABG are at higher risk of CVA. These findings chal-lenge the notion that pAF is a benign complication.</p

Safety of Perioperative Aprotinin Administration During Isolated Coronary Artery Bypass Graft Surgery: Insights From the ART (Arterial Revascularization Trial)

Background There is still uncertainty about the safety of aprotinin for coronary artery bypass graft surgery. The ART (Arterial Revascularization Trial) was designed to compare survival after bilateral versus single internal thoracic artery grafting. Many of the ART patients (≈30%) received perioperative aprotinin. We investigated the association between perioperative aprotinin administration and short‐term (in‐hospital) and long‐term outcomes by performing a post hoc analysis of the ART. Methods and Results Among patients enrolled in the ART (n=3102) from 2004 to 2007, we excluded those who did not undergo surgery (n=18) and those with no information about use of perioperative aprotinin (n=9). Finally, 836 of 3076 patients (27%) received aprotinin. Propensity matching was used to select 536 pairs for final comparison. Aprotinin was also associated with an increased risk of hospital mortality (9 [1.7%] versus 1 [0.2%]; odds ratio, 9.12; 95% confidence interval [CI], 1.15–72.2; P=0.03), intra‐aortic balloon pump insertion (37 [6.9%] versus 17 [3.2%]; odds ratio, 2.26; 95% CI, 1.26–4.07; P=0.006), and acute kidney injury (102 [19.0%] versus 76 [14.2%]; odds ratio, 1.42; 95% CI, 1.03–1.97; P=0.03). Aprotinin was not associated with a lower incidence of transfusion (37 [6.9%] versus 28 [5.2%]; odds ratio, 1.34; 95% CI, 0.81–2.23; P=0.25) and reexploration (26 [4.9%] versus 19 [3.5%]; hazard ratio, 1.39; 95% CI, 0.76–2.53; P=0.28). At 5 years, all‐cause mortality was significantly increased in the aprotinin group (56 [10.6%] versus 38 [7.3%]; hazard ratio, 1.51; 95% CI, 1.0–2.28; P=0.045). Conclusions In the present post hoc ART analysis, aprotinin was associated with a significantly increased risk of early and late mortality

Associations between adding a radial artery graft to single and bilateral internal thoracic artery grafts and outcomes. Insights from the Arterial Revascularization Trial

Background—Whether the use of the radial artery (RA) can improve clinical outcomes in coronary artery bypass graft (CABG) surgery remains unclear. The Arterial Revascularization Trial (ART) was designed to compare survival after bilateral internal thoracic artery (BITA) over single left internal thoracic artery (SITA). In the ART, a large proportion of patients (~20%) also received a RA graft instead of a saphenous vein graft (SVG). We aimed to investigate the associations between using the RA instead of SVG to supplement SITA or BITA grafts and outcomes by performing a post-hoc analysis of the ART.  Methods—Patients enrolled in the ART (n=3102) were classified based on conduits actually received (as treated). The analysis included 2737 patients who received a RA graft (RA group, n=632) or SVG only (SVG group, n=2105) in addition to SITA or BITA grafts. The primary endpoint was the composite of myocardial infarction, cardiovascular death and repeat revascularization at 5 years. Propensity score matching and stratified Cox regression were used to compare the two strategies.  Results—MI, cardiovascular death and repeat revascularization cumulative incidence was 2.3% (95%CI 1.1-3.4), 3.5% (95%CI 2.1-5.0) and 4.4% (95%CI 2.8-6.0) in the RA group and 3.4% (95%CI 2.0-4.8), 4.0% (95%CI 2.5-5.6) and 7.6% (95%CI 5.5- 9.7) in the SVG group respectively. The composite endpoint was significantly lower in the RA group (8.8%; 95%CI 6.5-11.0) when compared with the SVG group (13.6%; 95%CI 10.8-16.3) (P=0.005). This association was present when a RA graft was used to supplement both SITA and BITA grafts (interaction P=0.62).  Conclusions—This post-hoc ART analysis showed that an additional RA was associated with lower risk for mid-term major adverse cardiac events when used to supplement SITA or BITA grafts