Prognostic Significance of Silent Coronary Artery Disease in Type 2 Diabetes

The prevalence of obesity and diabetes is increasing rapidly. Coronary artery disease (CAD) represents the leading cause of death in diabetic patients. Diabetic patients are at a two- to fourfold risk of cardiovascular mortality compared with their nondiabetic counterparts. Silent myocardial ischemia more often occurs in diabetics than in nondiabetics. In general, the prevalence of silent CAD varies depending on the test used for patient screening and on the patient population screened. The prevalence of silent CAD is 6-23% in low-risk diabetic patients. In high-risk diabetic patients the prevalence may be as high as 60%. Over the last years it has been well recognized that silent CAD is not different from symptomatic CAD with respect to prognosis and adverse events. Particular diabetic patients therefore might benefit from routine CAD screening. CAD could be diagnosed at an earlier stage of disease and be treated accordingly. Myocardial perfusion SPECT, stress echocardiography and possibly computed tomography are emerging as effective screening tools beyond risk stratification by risk factor scoring systems alone. There are few studies suggesting that early intervention by medical or also revascularization strategies could lead to a better outcome in diabetic patients with evidence of silent CA

How to evaluate physical fitness without a stress test?

To assess cardiorespiratory fitness (CF), usually a stress test is necessary. Our aims were to assess CF in a patient population with suspected or known coronary artery disease (CAD) based on a questionnaire (quest); to compare estimated CF with achieved workloads, and to evaluate its prediction of stress modality (physical/pharmacologic). Consecutive 612 patients undergoing myocardial perfusion SPECT (MPS) completed quest. They first chose one category which best described their daily physical activities. The second part contained patient characteristics (gender, age, BMI, and resting heart rate). An activity score was calculated and metabolic equivalents (METs) were estimated. Estimated and achieved results were compared. Patients with pharmacologic test (n=208) provided a lower estimate of their performance than physically stressed patients (n=404): 7.0±2.1 and 8.2±2.3 METs, respectively (P<0.0001). The latter showed a good correlation between estimated and achieved METs (r=0.63, P<0.0001). Regarding prediction of the stress modality, area under the curve (ROC) was 0.65 (P<0.0001). The quest can easily be applied in daily practice to assess CF in a patient population with CAD and for estimating whether an adequate physical stress test can be carried ou

Interrelation of ST-segment depression during bicycle ergometry and extent of myocardial ischaemia by myocardial perfusion SPECT

Purpose: The aim of this study was to compare ST-segment depression (STD) during bicycle ergometry and extent of myocardial ischaemia assessed by myocardial perfusion SPECT (MPS) in a large patient cohort. Methods: Consecutive patients (n = 955) referred for MPS with bicycle ergometry and interpretable stress ECG were evaluated with respect to ECG and MPS findings of ischaemia. The maximal STD was recorded and exercise ECG was considered ischaemic if STD was horizontal or downsloping (≥1mm). MPS was interpreted using a 20-segment model with a scale of 0 to 4. A summed stress (SSS), summed rest (SRS) and summed difference score (SDS = SSS−SRS, e.g. extent of ischaemia) were derived. Ischaemia was defined as an SDS ≥ 2. Results: An exercise-induced STD was present in 215 patients (22%) and myocardial ischaemia on MPS was present in 366 patients (38%). The extent of ST-segment depression and the number of ECG leads with significant STD were each strongly and significantly associated with increasing severity of ischaemia and the number of coronary territories involved (p < 0.01 for all correlations). Conclusion: These data demonstrate a strong correlation between the extent of STD, number of ischaemic leads and severity of myocardial ischaemia as assessed by MPS during bicycle ergometr

Gate-keeper to coronary angiography: comparison of exercise testing, myocardial perfusion SPECT and individually tailored approach for risk stratification

We aimed to evaluate the differences between exercise testing (ET), myocardial perfusion SPECT (MPS) and a combination of ET and MPS based risk assessment as outlined by the guidelines with respect to their "gate-keeper” role to coronary angiography (cath) and the associated diagnostic procedural costs if prognostic considerations, as those proposed by the current guidelines and the recent literature, were taken into account. The Duke-score and the summed difference score (SDS; extent of ischemia) were assessed in 955 consecutive patients referred for MPS combined with ET. According to the guidelines and the available literature, three different algorithms for risk stratification were retrospectively applied: (1) ET based risk stratification and cath if intermediate or high risk Duke-score; (2) MPS based risk stratification and cath if SDS≥8; (3) combined approach with ET as first step and MPS in case of intermediate risk Duke-score. A cath would have been suggested in every patient with either high risk Duke-score or SDS≥8 in patients with intermediate risk Duke-score. The referral rate to cath was 27% according to the ET alone, 13% using MPS, and finally 12% applying the combined risk stratification. The cost of the diagnostic work-up including cath were: 615€, 1'299€, and 598€ per patient, respectively. The coronary angiography referral rate widely depends on the diagnostic modality used for risk stratification and according to the referral criteria provided by the guidelines. In the present study, the use of a stress imaging modality (MPS) and published prognostic data was associated with a lower referral rate to cath as compared to exercise testing alone and thus underlines the advantage of a risk based approach applying stress imaging in patients with intermediate risk Duke-scor

Coronary artery disease and depression

Coronary artery disease (CAD) as well as depression are both highly prevalent diseases. Both cause a significant decrease in quality of life for the patient and impose a significant economic burden on society. There are several factors that seem to link depression with the development of CAD and with a worse outcome in patients with established CAD: worse adherence to prescribed medication and life style modifications in depressive patients, as well as higher rates in abnormal platelet function, endothelial dysfunction and lowered heart rate variability. The evidence is growing that depression per se is an independent risk factor for cardiac events in a patient population without known CAD and also in patients with established diagnosis of CAD, particularly after myocardial infarction. Treatment of depression has been shown to improve patients' quality of life. However, it did not improve cardiovascular prognosis in depressed patients even though there is open discussion about the trend to better outcome in treated patients. Large scale clinical trials are needed to answer this question. Selective serotonin reuptake inhibitors seem to be preferable to tricyclic antidepressants for treatment of depressive patients with comorbid CAD because of their good tolerability and absence of significant cardiovascular side effects. Hypericum perforatum (St. John's wort), an increasingly used herbal antidepressant drug should be used with caution due to severe and possibly dangerous interaction with cardioactive drug

Sexual Dysfunction before and after Cardiac Rehabilitation

Background. The aim of this study was to assess sexual function before and after cardiac rehabilitation in relation to medical variables. Methods. Analysis of patients participating in a 12-week exercise-based outpatient cardiac rehabilitation program (OCR) between April 1999 and December 2007. Exercise capacity (ExC) and quality of life including sexual function were assessed before and after OCR. Results. Complete data were available in 896 male patients. No sexual activity at all was indicated by 23.1% at baseline and 21.8% after OCR, no problems with sexual activity by 40.8% at baseline and 38.6% after OCR. Patients showed an increase in specific problems (erectile dysfunction and lack of orgasm) from 18% to 23% (P < .0001) during OCR. We found the following independent positive and negative predictors of sexual problems after OCR: hyperlipidemia, age, CABG, baseline ExC and improvement of ExC, subjective physical and mental capacity, and sense of affiliation. Conclusions. Sexual dysfunction is present in over half of the patients undergoing OCR with no overall improvement during OCR. Age, CABG, low exercise capacity are independent predictors of sexual dysfunction after OCR

Staphylococcus aureus Endocarditis as a Complication of Toxocariasis-Associated Endomyocarditis With Fibrosis: A Case Report

Complications associated with Toxocara canis infection are rare. We present a case of a patient with Staphylococcus aureus endocarditis as a complication of an endomyocardial fibrosis caused by T canis. The epidemiological, pathological, and clinical features of this rare complication are described here