Hypertrophic cardiomyopathy in a large community-based population: clinical outcome and identification of risk factors for sudden cardiac death and clinical deterioration

AbstractObjectivesThis study evaluates the clinical course and identifies risk factors for sudden cardiac death (SCD) and clinical deterioration in hypertrophic cardiomyopathy (HCM) in a large community-based population. Comparison was made with data from six tertiary referral and six nonreferral institutions.BackgroundHypertrophic cardiomyopathy is a disease with marked heterogeneity in clinical presentation and prognosis. Risk factors for SCD are not well defined in patients free of referral bias.MethodsBetween 1970 and 1999, 225 consecutive patients (mean age [±SD] 41±16 years) were examined and followed at yearly intervals.ResultsForty-four deaths were recorded of which 27 cases were cardiovascular. Fourteen patients died suddenly, six were successfully resuscitated, and seven patients died of congestive heart failure. The annual mortality, annual cardiac mortality, and annual mortality due to sudden death were 1.3%, 0.8%, and 0.6%, respectively. At least one New York Heart Association (NYHA) functional class deterioration was reported in 33% of the patients with a significant (≥50 mm Hg) left ventricular outflow tract (LVOT) gradient in contrast to 7% without obstruction. The presence of syncope was related to SCD (p < 0.05). Younger age and more severe functional limitation distinguishes patients from in hospital-based centers from the ones in community-based centers.ConclusionsHypertrophic cardiomyopathy is a benign disease in an unselected population with a low incidence of cardiac death. Syncope was associated with a higher incidence of SCD and patients with a significant LVOT obstruction were more susceptible to clinical deterioration

Nonfatal reinfarction as an independent riskfactor for subsequent mortality in post-myocardial infarction patients

Pericas, Enric;Ordóñez, Estrell

Prognostic markers in young patients with premature coronary heart disease

AbstractObjectivesTo evaluate the survival and prognostic implications of cardiovascular, inflammatory and prothrombotic risk factors in young patients with premature coronary heart disease (CHD).MethodsFollow-up data were obtained from 353 young patients with a first cardiac event (men ≤45 years and women ≤55 years). Baseline characteristics on traditional risk factors were collected at the time of the first event, and plasma levels of C-reactive protein (CRP), von Willebrand Factor (VWF), and fibrinogen were measured one to three months after the first event to exclude an acute phase response. We performed age and sex adjusted Cox regression analyses to assess the relationship between these factors and recurrent events with three different endpoints: all cause mortality, recurrent cardiac event (myocardial infarction or revascularisation procedure), and any recurrent event (cardiac event, cerebrovascular event or all cause mortality).ResultsDuring a total follow-up time of 1483 person years (mean 4.2 years), 11 patients died (3%), 42 patients had a recurrent cardiac event (12%), and 53 patients had any recurrent event (15%). CRP was associated with an increased risk of any recurrent event (HR 1.28[95% CI = 1.02–1.59] per unit increase in lnCRP). Also, both CRP (5.00[1.04–24.04]) and fibrinogen (5.04[1.05–24.23]) were associated with all cause mortality when levels were above the 50th percentile.ConclusionsFifteen percent of young patients with a first cardiac event have a recurrent event or die within a median follow-up of 4.2 years. In these young patients we have shown that, independently of cardiovascular risk factors, high CRP levels contribute to the risk of recurrent events, including all cause mortality, and high fibrinogen levels are associated with all cause mortality

Prognostic stratification of obese patients by stress ^99mTc- tetrofosmin myocardial perfusion imaging

Obesity is a major heath problem associated with increased cardiovascular mortality. There are currently no data to support a role for stress imaging techniques in the risk stratification of obese patients. The aim of this study was to assess the independent value of stress 99mTc-tetrofosmin SPECT in predicting mortality and hard cardiac events in obese patients. Methods: We studied 265 patients with a body mass index greater than 30 kg/m2 by exercise or dobutamine stress 99mTc-tetrofosmin myocardial perfusion tomography. Endpoints during follow-up were cardiac death and death of any cause. Results: The mean patient age (±SD) was 59 ± 10 y, and 110 of the patients were men (42%). The mean body mass index was 37 ± 7 kg/m2. Scan findings were normal in 113 patients (43%). Myocardial perfusion abnormalities were fixed in 62 patients (23%) and reversible in 90 patients (34%). During a mean follow-up period of 5.5 ± 2 y, 41 patients (15%) died. Death was considered cardiac in 22 patients (8%). Nonfatal myocardial infarction occurred in 20 patients (7.5%). The annual cardiac death rate was 0.6% in patients with normal perfusion and 3.3% in patients with abnormal perfusion. Patients with a multiple-vessel distribution of abnormalities had a higher cardiac death rate than did patients with a single-vessel distribution (4.1%vs. 2.5%, P &lt; 0.05). The annual mortality rate was 1.3% in patients with normal perfusion and 4.2% in patients with abnormal perfusion. In a multivariate analysis, perfusion abnormalities were independently predictive of cardiac mortality (risk ratio, 3.2; 95% confidence interval, 1.5-6.7) and overall mortality (risk ratio, 2.7; 95% confidence interval, 1.4-4.3). Conclusion: Stress 99mTc-tetrofosmin myocardial perfusion imaging is a useful tool for predicting cardiac and overall mortality in obese patients.</p

Prognostic stratification of obese patients by stress ^99mTc- tetrofosmin myocardial perfusion imaging

Obesity is a major heath problem associated with increased cardiovascular mortality. There are currently no data to support a role for stress imaging techniques in the risk stratification of obese patients. The aim of this study was to assess the independent value of stress 99mTc-tetrofosmin SPECT in predicting mortality and hard cardiac events in obese patients. Methods: We studied 265 patients with a body mass index greater than 30 kg/m2 by exercise or dobutamine stress 99mTc-tetrofosmin myocardial perfusion tomography. Endpoints during follow-up were cardiac death and death of any cause. Results: The mean patient age (±SD) was 59 ± 10 y, and 110 of the patients were men (42%). The mean body mass index was 37 ± 7 kg/m2. Scan findings were normal in 113 patients (43%). Myocardial perfusion abnormalities were fixed in 62 patients (23%) and reversible in 90 patients (34%). During a mean follow-up period of 5.5 ± 2 y, 41 patients (15%) died. Death was considered cardiac in 22 patients (8%). Nonfatal myocardial infarction occurred in 20 patients (7.5%). The annual cardiac death rate was 0.6% in patients with normal perfusion and 3.3% in patients with abnormal perfusion. Patients with a multiple-vessel distribution of abnormalities had a higher cardiac death rate than did patients with a single-vessel distribution (4.1%vs. 2.5%, P &lt; 0.05). The annual mortality rate was 1.3% in patients with normal perfusion and 4.2% in patients with abnormal perfusion. In a multivariate analysis, perfusion abnormalities were independently predictive of cardiac mortality (risk ratio, 3.2; 95% confidence interval, 1.5-6.7) and overall mortality (risk ratio, 2.7; 95% confidence interval, 1.4-4.3). Conclusion: Stress 99mTc-tetrofosmin myocardial perfusion imaging is a useful tool for predicting cardiac and overall mortality in obese patients.</p

Ischemia burden on stress SPECT MPI predicts long-term outcomes after revascularization in stable coronary artery disease

Background: It is not entirely clear whether ischemia burden on stress single-photon emission computed tomography (SPECT) effectively identifies patients who have a long-term benefit from coronary revascularization. Methods: The study population consisted of 719 patients with ischemia on stress SPECT. Early coronary revascularization was defined as percutaneous coronary intervention or coronary artery bypass grafting ≤90 days after SPECT. Patients who underwent late revascularization (>90 days after SPECT) were excluded (n = 164). Results: Of the 538 patients (73% men, mean age 59.8 ± 11 years), 348 patients had low ischemia burden (<3 ischemic segments) and 190 patients had moderate to high ischemia burden (≥3 ischemic segments). A total of 76 patients underwent early revascularization. During a median follow-up of 12 years (range 4-17), 283 patients died of whom 125 due to cardiac causes. Early revascularization was beneficial on all-cause mortality (HR 0.46, 95% CI 0.30-0.46) and cardiac mortality (HR 0.54, 95% CI 0.29-0.99). Conclusions: Patients with myocardial ischemia on stress SPECT who underwent early revascularization had a lower all-cause mortality and cardiac mortality during long-term follow-up as compared to patients who received pharmacological therapy alone. This difference in long-term outcomes was mainly influenced by the survival benefit of early revascularization in the patients with moderate to high ischemia burden

Association of ischemia on stress ^99mTc-tetrofosmin myocardial perfusion imaging with all-cause mortality in patients with diabetes mellitus

Stress myocardial perfusion imaging is a useful method for evaluation of coronary artery disease (CAD) in patients with diabetes mellitus. However, its role in predicting all-cause mortality is not well defined. The aim of this study was to determine whether myocardial ischemia on stress myocardial perfusion imaging can predict all causes of death in patients with diabetes mellitus. Methods: We studied 297 patients with diabetes mellitus and known or suspected CAD by exercise or dobutamine stress 99mTc-tetrofosmin myocardial perfusion tomographic imaging. Ischemia was defined as reversible perfusion abnormalities. The endpoints were death from any cause and hard cardiac events (cardiac death and nonfatal myocardial infarction). Results: An abnormal scan was detected in 179 (60%) patients. Myocardial perfusion abnormalities were fixed in 76 (26%) patients and were reversible in 103 (35%) patients. During a mean follow-up of 6 ± 2.1 y, 80 (27%) patients died. Nonfatal myocardial infarction occurred in 14 (5%) patients. The annual mortality rate was 2.5% in patients with normal perfusion, 4.5% in patients with fixed defects, and 6% in patients with ischemia. The annual cardiac death rate was 4.2% in patients with ischemia and 2.6% in patients with fixed defects. In patients with normal perfusion, the annual cardiac death rate was 0.9% during the 5 y after the stress test. In a Cox multivariate analysis model, predictors of death were age, history of heart failure, peripheral vascular disease, and reversible perfusion defects. Conclusion: Myocardial ischemia on stress 99mTc-tetrofosmin myocardial perfusion imaging is associated with an increased risk of all-cause mortality during long-term follow-up among patients with diabetes mellitus. Patients with normal perfusion have a lower mortality rate and may require less frequent follow-up stress perfusion imaging.</p

Association of ischemia on stress ^99mTc-tetrofosmin myocardial perfusion imaging with all-cause mortality in patients with diabetes mellitus

Stress myocardial perfusion imaging is a useful method for evaluation of coronary artery disease (CAD) in patients with diabetes mellitus. However, its role in predicting all-cause mortality is not well defined. The aim of this study was to determine whether myocardial ischemia on stress myocardial perfusion imaging can predict all causes of death in patients with diabetes mellitus. Methods: We studied 297 patients with diabetes mellitus and known or suspected CAD by exercise or dobutamine stress 99mTc-tetrofosmin myocardial perfusion tomographic imaging. Ischemia was defined as reversible perfusion abnormalities. The endpoints were death from any cause and hard cardiac events (cardiac death and nonfatal myocardial infarction). Results: An abnormal scan was detected in 179 (60%) patients. Myocardial perfusion abnormalities were fixed in 76 (26%) patients and were reversible in 103 (35%) patients. During a mean follow-up of 6 ± 2.1 y, 80 (27%) patients died. Nonfatal myocardial infarction occurred in 14 (5%) patients. The annual mortality rate was 2.5% in patients with normal perfusion, 4.5% in patients with fixed defects, and 6% in patients with ischemia. The annual cardiac death rate was 4.2% in patients with ischemia and 2.6% in patients with fixed defects. In patients with normal perfusion, the annual cardiac death rate was 0.9% during the 5 y after the stress test. In a Cox multivariate analysis model, predictors of death were age, history of heart failure, peripheral vascular disease, and reversible perfusion defects. Conclusion: Myocardial ischemia on stress 99mTc-tetrofosmin myocardial perfusion imaging is associated with an increased risk of all-cause mortality during long-term follow-up among patients with diabetes mellitus. Patients with normal perfusion have a lower mortality rate and may require less frequent follow-up stress perfusion imaging.</p

Anhedonia is associated with poor health status and more somatic and cognitive symptoms in patients with coronary artery disease

Purpose: The effectiveness of cardiac rehabilitation (CR) in patients with coronary artery disease (CAD) is moderated by negative emotions and clinical factors, but no studies evaluated the role of positive emotions. This study examined whether anhedonia (i.e. the lack of positive affect) moderated the effectiveness of CR on health status and somatic and cognitive symptoms. Methods: CAD patients (n = 368) filled out the Hospital Anxiety and Depression Scale (HADS) to assess anhedonia at the start of CR, and the Short-Form Health Survey (SF-36) and the Health Complaints Scale (HCS) at the start of CR and at 3 months to assess health status and somatic and cognitive symptoms, respectively. Results: Adjusting for clinical and demographic factors, health status improved significantly during the follow-up (F(1,357) = 10.84, P = .001). Anhedonic patients reported poorer health status compared with non-anhedoni

Effects of two behavioral cardiac rehabilitation interventions on physical activity:A randomized controlled trial

Background: Standard cardiac rehabilitation (CR) is insufficient to help patients achieve an active lifestyle. The effects of two advanced and extended behavioral CR interventions on physical activity (PA) and sedentary behavior (SB) were assessed.Methods: In total, 731 patients with ACS were randomized to 1) 3 months of standard CR (CR-only); 2) 3 months of standard CR with three pedometer-based, face-to-face PA group counseling sessions followed by 9 months of after care with three general lifestyle, face-to-face group counseling sessions (CR+F); or 3) 3 months of standard CR, followed by 9 months of aftercare with five to six general lifestyle, telephonic counseling sessions (CR + T). An accelerometer recorded PA and SB at randomization, 3 months, 12 months, and 18 months.Results: The CR+ F group did not improve their moderate-to-vigorous intensity PA (MVPA) or SB time compared to CR-only (between-group difference= 0.24% MVPA, P= 0.349; and 0.39% SB, P= 0.529). However, step count (between-group difference = 513 steps/day, P = 0.021) and time in prolonged MVPA (OR = 2.14, P= 0.054) improved at 3 months as compared to CR-only. The improvement in prolonged MVPA was maintained at 18 months (OR = 1.91, P = 0.033). The CR + T group did not improve PA or SB compared to CR-only.Conclusions: Adding three pedometer-based, face-to-face group PA counseling sessions to standard CR increased daily step count and time in prolonged MVPA. The latter persisted at 18 months. A telephonic after-care program did not improve PA or SB. Although after-care should be optimized to improve long-term adherence, face-to-face group counseling with objective PA feedback should be added to standard CR. (C) 2017 Elsevier B.V. All rights reserved