Six-minute walk distance after coronary artery bypass grafting compared with medical therapy in ischaemic cardiomyopathy

Background: In patients with ischaemic left ventricular dysfunction, coronary artery bypass surgery (CABG) may decrease mortality, but it is not known whether CABG improves functional capacity. Objective: To determine whether CABG compared with medical therapy alone (MED) increases 6 min walk distance in patients with ischaemic left ventricular dysfunction and coronary artery disease amenable to revascularisation. Methods: The Surgical Treatment in Ischemic Heart disease trial randomised 1212 patients with ischaemic left ventricular dysfunction to CABG or MED. A 6 min walk distance test was performed both at baseline and at least one follow-up assessment at 4, 12, 24 and/or 36 months in 409 patients randomised to CABG and 466 to MED. Change in 6 min walk distance between baseline and follow-up were compared by treatment allocation. Results: 6 min walk distance at baseline for CABG was mean 340±117 m and for MED 339±118 m. Change in walk distance from baseline was similar for CABG and MED groups at 4 months (mean +38 vs +28 m), 12 months (+47 vs +36 m), 24 months (+31 vs +34 m) and 36 months (−7 vs +7 m), P>0.10 for all. Change in walk distance between CABG and MED groups over all assessments was also similar after adjusting for covariates and imputation for missing values (+8 m, 95% CI −7 to 23 m, P=0.29). Results were consistent for subgroups defined by angina, New York Heart Association class ≥3, left ventricular ejection fraction, baseline walk distance and geographic region. Conclusion: In patients with ischaemic left ventricular dysfunction CABG compared with MED alone is known to reduce mortality but is unlikely to result in a clinically significant improvement in functional capacity

Associations between tooth loss and prognostic biomarkers and the risk for cardiovascular events in patients with stable coronary heart disease

Background: Underlying mechanisms behind the hypothesized relationship between periodontal disease (PD) and coronary heart disease (CHD) have been insufficiently explored. We evaluated associations between self-reported tooth loss- a marker of PD- and prognostic biomarkers in 15,456 (97%) patients with stable CHD in the global STABILITY trial. Methods and results: Baseline blood samples were obtained and patients reported their number of teeth according to the following tooth loss levels: “26–32 (All)” [lowest level], “20–25”, “15–19”, “1–14”, and “No Teeth” [highest level]. Linear and Cox regression models assessed associations between tooth loss levels and biomarker levels, and the relationship between tooth loss levels and outcomes, respectively. After multivariable adjustment, the relative biomarker increase between the highest and the lowest tooth loss level was: high-sensitivity C-reactive protein 1.21 (95% confidence interval, 1.14–1.29), interleukin 6 1.14 (1.10–1.18), lipoprotein-associated phospholipase A2 activity 1.05 (1.03–1.06), growth differentiation factor 15 1.11 (1.08–1.14), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) 1.18 (1.11–1.25). No association was detected for high-sensitivity troponin T 1.02 (0.98–1.05). Some attenuation of the relationship between tooth loss and outcomes resulted from the addition of biomarkers to the multivariable analysis, of which NT-proBNP had the biggest impact. Conclusions: A graded and independent association between tooth loss and several prognostic biomarkers was observed, suggesting that tooth loss and its underlying mechanisms may be involved in multiple pathophysiological pathways also implicated in the development and prognosis of CHD. The association between tooth loss and cardiovascular death and stroke persisted despite comprehensive adjustment including prognostic biomarkers

Living longer by sitting less and moving more

PURPOSE OF REVIEW: Regular exercise, physical fitness and sedentary behaviours are each known to be associated with cardiovascular and total mortality. This review evaluates recent research on these associations and its implications for guidelines on physical activity. RECENT FINDINGS: In several large cohort studies, modest levels of exercise, much less than recommended in current guidelines, were associated with lower mortality. Avoiding prolonged sitting has also been associated with lower mortality risk. Most research suggests graded decreases in long-term mortality with an increase in usual physical activity and fitness. However, at very high exercise levels, these benefits may be attenuated, particularly in patients with known coronary heart disease. SUMMARY: In sedentary persons, a modest increase in physical activity and avoiding prolonged sitting are likely to have important health benefits. Further research is needed to determine the most effective strategies for increasing physical activity

Eosinophilia and Coronary Artery Vasospasm

Objective: To describe the clinical features, natural history and response to treatment of coronary vasospasm associated with eosinophilia. Methods: Two patients with eosinophilia who had recurrent acute coronary events due to multi-vessel coronary artery spasm are described. The clinical presentation and outcomes of these 2 patients and 17 additional cases of eosinophilia and coronary artery vasospasm identified on a systematic literature review are presented. Results: Patients were usually admitted because of repeated episodes of angina at rest and raised plasma markers of myocyte necrosis. Dynamic ST elevation was observed in 15 (83%) patients. Coronary angiography was performed in all patients. Spontaneous (n = 7) or provoked (n = 8) coronary artery spasm, which was usually multi-focal, was observed in 15 (83%) patients. Symptoms often continued despite high dose vasodilators but responded well to prednisone. Recurrent coronary events were frequent, and included sudden death (n = 4), resuscitated cardiac arrest (n = 2), myocardial infarction (n = 10) and unstable angina (n = 11). Recurrent events were more frequent when not taking compared to when taking prednisone (4.2 versus 0.4 events/year, p = 0.002, hazard ratio 11, 95% confidence interval 2.4-50). Conclusion: Published case reports suggest that coronary vasospasm associated with eosinophilia responds poorly to conventional vasodilator treatment and the risk of recurrent coronary events is high. Most patients respond to treatment which suppresses the eosinophilia

Post-operative aspartate aminotransferase levels independently predict mortality after isolated coronary artery bypass grafting

Background: Since troponins have become widely available, the roles of other less specific biomarkers for myocardial necrosis following coronary artery bypass grafting (CABG) have been seldom studied. Aspartate aminotransferase (AST) may not only be released from the heart but also from the liver or skeletal muscle. We assessed whether post-operative AST levels were associated with mortality and morbidity after contemporary (CABG). Method: Patients undergoing isolated CABG during July 2010–June 2012 at Auckland City Hospital were included if they had a post-operative AST measurement within 48 h (n = 804 of 818). The prognostic utility of 2× upper limit of normal of AST (>90 U/L) pre-specified for adverse outcomes was assessed. Results: Median post-operative AST level was 37 U/L (lower quartile 30, upper quartile 48). In multivariable analysis, including baseline characteristics, AST >90 U/L was independently associated with 30-day mortality (OR 12.0, 95% CI 2.99–47.9, P < 0.001), long-term mortality (OR 12.0, 95% CI 1.69–34.8, P < 0.001) and composite morbidity (OR 3.31, 95% CI 1.56–7.02, P = 0.002). AST as a continuous parameter remained an independent predictor for 30-day and long-term mortality when hs-TnT was adjusted for but not for composite morbidity. Independent predictors of AST >90 U/L included female sex, unstable angina and operation time. Conclusion: Increase in AST levels within 48 hours of CABG was a strong independent predictor of 30 day mortality. Although AST increase is not specific to myocardial necrosis, it remains useful for prognosis in cardiac surgery

Diagnosis of myocardial infarction and prognostic utility of high-sensitivity troponin T after isolated aortic valve replacement

Background: The Universal Definition for type 5 myocardial infarction (MI) applies to coronary artery bypass grafting (CABG), while MIs for other cardiac surgery are not specifically defined. We assessed whether elevated high-sensitivity troponin (hs-TnT), with electrocardiogram (ECG) changes and/or new wall motion abnormalities on echocardiography as defined by the Universal Definition, predicted mortality and/or morbidity after aortic valve replacement (AVR) (n = 219). Methods: Consecutive patients with isolated AVR performed during July 2010–December 2012 and followed-up for 2.3 ± 0.8 years. Hs-TnT was measured 12–24 h post-operatively. ECG and/or echocardiographic changes with hs-TnT >140 ng/L (10 times 99th percentile upper reference limit and >500 ng/L (10 times the coefficient of variation of 10% for 4th generation troponin T applied to hs-TnT) were pre-specified as the criteria for MI diagnosis. Results: There were 9.1% (20) and 3.7% (8) patients with ECG and/or echocardiographic changes and hs-TnT > 140 ng/L and hs-TnT > 500 ng/L respectively. Neither criterion was independently associated with 30-day mortality (2.7%). Hs-TnT > 500 ng/L and ECG and/or echocardiographic changes was independently associated with mortality (5.5%) during follow-up, hazards ratio 5.23, 95% confidence interval 1.09–25.2, p = 0.039. Hs-TnT per 100 ng/L as a continuous parameter was independently associated with 30-day mortality, mortality during follow-up and composite morbidity. Conclusion: The Universal Definition of MI, using 10 times the URL for the 4th generation troponin T and 35 times the URL for hs-TnT with a cutpoint of > 500 ng/L with ECG and/or echocardiographic changes, independently predicted median term mortality after AVR. Hs-TnT as a continuous parameter was independently associated with mortality at both time points and morbidity

Excessive daytime sleepiness, morning tiredness, and prognostic biomarkers in patients with chronic coronary syndrome

Background Sleep-related breathing disorders (SRBD) are related to cardiovascular outcomes in patients with chronic coronary syndrome (CCS). Whether SRBD-related symptoms are associated with prognostic biomarkers in patients with CCS is not established. Methods Associations between frequency (never/rarely, sometimes, often, always) of self-reported SRBD-related symptoms (excessive daytime sleepiness [EDS]; morning tiredness [MT]; loud snoring; multiple awakenings/night; gasping, choking, or apnea when asleep) and levels of biomarkers related to cardiovascular prognosis (high-sensitivity C-reactive protein [hs-CRP], interleukin 6 [IL-6], high-sensitivity cardiac troponin T [hs-cTnT], N-terminal pro B-type natriuretic peptide [NT-proBNP], cystatin C, growth differentiation factor 15 [GDF-15] and lipoprotein-associated phospholipase A2 activity) were assessed at baseline in 15,640 patients with CCS on optimal secondary preventive therapy in the STABILITY trial. Cross-sectional associations were assessed by adjusted linear regression models testing for trends with the never/rarely category serving as reference. Results EDS was associated (geometric mean ratio, 95% confidence interval) with increased levels of IL-6 (often 1.07 [1.03–1.10], always 1.15 [1.10–1.21]), GDF-15 (often 1.03 [1.01–1.06], always 1.07 [1.03–1.11]), NT-proBNP (always 1.22 [1.12–1.33]), and hs-cTnT (always 1.07 [1.01–1.12]). MT was associated with increased levels of IL-6 (often 1.05 [1.01–1.09], always 1.09 [1.04–1.15]), and GDF-15 (always 1.06 [1.03–1.10]). All symptoms were to some degree associated with higher levels of hs-CRP and loud snoring was also associated with decreased levels of NT-proBNP and hs-cTnT. Conclusions In patients with CCS, stepwise increased frequency of SRBD-related symptoms, such as EDS and MT, were associated with gradually higher levels of IL-6 and GDF-15, each reflecting distinct pathophysiological pathways