Ajay Bahl

Indian Heart Journal

PubMed

Bahl, Ajay

Elsevier - Publisher Connector 

i n d i a n h e a r t j o u rn a l 6 5 ( 2 0 1 3 ) 3 4 7e3 5 2 351Prognostic Impact of the Presence and Absence of Angina onMortality and Cardiovascular Outcomes in Patients With
Type 2 Diabetes and Stable Coronary Artery Disease. Results
from the BARI 2D (Bypass Angioplasty Revascularization
Investigation 2 Diabetes) Trial
Objectives: The purpose of this analysis was to assess in
patients with type 2 diabetes and stable coronary artery dis-
ease, (CAD) whether the risk of all-cause mortality and car-
diovascular events varied according to the presence or
absence, of angina and angina equivalent symptoms.
Background: Data on the prognostic value of symptoms in
these patients are limited. Methods Post-hoc analysis was
performed in 2,364 patients with type 2 diabetes and docu-
mented CAD enrolled in the, BARI 2D (Bypass Angioplasty
Revascularization Investigation 2 Diabetes) trial to determine
the occurrence of, death and composite of death, myocardial
infarction, and stroke during a 5-year follow-up according to
cardiac symptoms at baseline.
Results:Therewere 1,434 patientswith angina (A), 506with
angina equivalents (E), and 424 with neither of these (N). The
cumulative death rates (total 316) were 12% in A, 14% in E, and
10% in N (p 0.3), and cardiovascular composite rates (total 548)
were 24% in A, 24% in E, and 21% in N (p 0.5). ComparedwithN,
the hazard ratios adjusted for confounders were not different
for death in A (1.11; 99%CI: 0.81 to 1.53) and E (1.17; 99%CI: 0.81
to 1.68) or for cardiovascular events in A (1.17; 99% CI: 0.92 to
1.50) and E (1.11; 99% CI: 0.84 to 1.48).
Conclusions: Whatever their symptom status, patients
with type 2 diabetes and stable CAD were at similar risk of
cardiovascular events and death. These findings suggest that
these patients may be similarly managed in terms of risk
stratification and preventive therapies. (Bypass Angioplasty
Revascularization Investigation 2 Diabetes [BARI 2D];
NCT00006305) (J AmColl Cardiol 2013;61:702e11)ª 2013 by the
American College of Cardiology Foundation
Diabetes mellitus (DM) is a global epidemic. Accelerated
atherosclerosis inDMleads tohigh incidenceofCardiovascular
Disease (CVD). Coronary Artery Disease (CAD) accounts for
large fraction of morbidity, mortality and cost of DM.
In Bypass Angioplasty Revascularization Investigation 2
Diabetes (BARI 2D) trial, it was analyzed whether symptoms
affect prognosis or not in Type 2 DM and CAD with docu-
mented ischemia.
A total of 2368 patientswith Type 2DMand stable CADwith
documented ischemia were followed up for 5.3 years. Patients
were divided into those with angina, angina equivalent
(dyspnea, palpitation or diaphoresis on exertion) or no cardiac
symptom.
Stable CAD and Type 2DM had similar long term prognosis
across a variety of cardiovascular outcome irrespective of
their symptomatic status. Five-year death rate was 12% with
angina, 14%with angina equivalent, and 10% in asymptomatic
patient. Cumulative 5-year composite outcome rate were 24%,
24% and 21%, respectively. Asymptomatic patients were at the
same relative high risk for all cause mortality, the composite
outcome, CVD death, nonfatal myocardial infarction (MI) and
nonfatal stroke, compared to patients with angina or anginaequivalent. These were independent of baseline character-
istics, severity of CAD and coronary revascularization. In
separate analysis of optimized medical therapy and revascu-
larization, the outcome remained unchanged. Left ventricular
systolic function was normal in all three groups. Exercise
induced ischemia causing diastolic dysfunction could be
responsible for exertional dyspnea qualifying angina
equivalent.
Summarizing, the take home message of this study is that
Type 2DM, stable CAD with documented ischemia and no
symptoms are at the same high risk for all causemortality and
major cardiovascular outcomes compared to those with
angina or angina equivalent. These patients should be sim-
ilarly managed in terms of risk stratification and preventive
therapy.
Contributed by
Ajay Kumar Sinha
Associate Editor, Indian Heart Journal, India
E-mail address: sinha_ajaykr@yahoo.co.inB.J. Maron, E.J. Rowin, S.A. Casey, et al., Risk stratification andoutcome of patients with hypertrophic cardiomyopathy ‡60
years of age. Circulation 2013;127:585e593.Objectives: The purpose of this study was to describe the
clinical courseand risk stratifyolderpatientswithhypertrophic
cardiomyopathy (HCM) who were more than 60 years of age.
Background: Twomajor problems associatedwith HCM are
risk for sudden death and disease progression. These are rel-
atively well defined in young patients. Whether patients of
moreadvancedageharborsimilar risks isunresolvedandoften
creates clinical dilemmas, particularly in decisions for primary
prevention of sudden death with implantable defibrillators.
Methods: Patients for this study were selected from data-
bases of 2 large HCM centers in USA. Consecutively presenting
patients with HCM, who were 60 years of age at first pre-
sentation to these centers were selected for this study. These
patientswere followedupbyhospital visit or telephonecontact.
Results: 428 consecutive older HCM patients were followed
for 5.8 4.8 years. Of these, 279 (65%) survived to 73 7 years of
age, most with no/mild symptoms including 135 with 1 con-
ventional sudden death risk factors and 50 (37%) with late
gadoliniumenhancement.Onfollow-up,149 (35%)diedat808
years of age, mostly from non-HCM related causes (n ¼ 133,
31%), including a substantial proportion from non-cardiac dis-
ease (n¼ 54). Sixteen patients (3.7%) had HCM relatedmortality
events (0.64%/year), including embolic stroke (n ¼ 6), pro-
gressive heart failure or transplantation (n ¼ 3), postoperative
complications (n ¼ 2), and arrhythmic sudden death events
(n ¼ 5, 1.2% [0.20%/year]). All-cause mortality was increased in
HCM patients60 years of age comparedwith an age-matched
US general population, predominantly as a result of non-HCM
related diseases (p < 0.001; standardmortality ratio, 1.5).
Conclusions: HCM patients surviving into the seventh
decade of life are at low risk for disease-related morbidity,
mortality and sudden death, even in presence of conventional
Table 1 e Causes of death (n[ 149) in elderly HCM
patients.
i n d i a n h e a r t j o u r n a l 6 5 ( 2 0 1 3 ) 3 4 7e3 5 2352risk factors. Other cardiac or non-cardiac comorbidities have a
greater impact on survival than HCM in older patients.Causes of death Number (%)
HCM Related
n ¼ 16 (10.7%)
Embolic stroke 6 (4.0%)
Sudden death 5 (3.4%)
Heart failure 2 (1.3%)
Miscellaneous 3 (2.0%)
Non-HCM cardiovascular
n ¼ 52 (34.9%)
Coronary artery disease 14 (9.4%)
Multiorgan including
cardiac or pulmonary
comorbidities
32 (21.5%)
Operative complications 6 (4.0%)
Non-cardiac n ¼ 54
(36.2%)
Cancer 28 (18.8%)
Other causes 26 (17.4%)
Unknown causes 27 (18.1%)1. Clinical perspective
Once regarded as a diseasemost relevant to the young, HCM is
being increasing identified in older patients. The two major
complications associated with HCM are sudden death and
heart failure progression. Sudden death is more clinically
relevant since it can be prevented with defibrillator implan-
tation. Most natural history studies of HCM have largely
included younger patients. Standard guidelines on risk strat-
ification for sudden death and defibrillator implantation are
thus based mainly on data from younger patients. Sudden
death rates at 0.2%/year were very low in this study on older
HCM patients. This is despite around 50% of the overall cohort
having 1 conventional risk markers for sudden death. This
suggests that conventional risk factors of sudden death do not
necessarily assume the same significance in older patients.
Thus, aggressive prophylactic defibrillator implantation at
advanced ages in HCM patients is not supported by this study.
Since the incidence of sudden death is low, defibrillator
implantation should be considered on a case-to-case basis
with prudent restraint till specific guidelines targeting the
elderly are available. This study is also reassuring that pro-
gression of heart failure is also uncommon in older patients
with very few patients havingworsening of symptoms on over
5 years follow-up.
This study highlights the fact that non-HCM related car-
diac and non-cardiac conditions are responsible for around90% of deaths in elderly HCM patients (Table 1). These asso-
ciated diseases are themajor cause of mortality and pose a far
greater threat to long-term survival than HCM itself. These
patients should thus be aggressively evaluated for other
associated comorbidities rather than focusing on HCM alone.
Contributed by
Ajay Bahl
Associate Professor, Department of Cardiology,
Postgraduate Institute of Medical Education and Research,
Sector 12, Chandigarh 160012, India
E-mail address: drajaybahl@hotmail.com


Risk stratification and outcome of patients with hypertrophic cardiomyopathy ≥60 years of age B.J.MaronE.J.RowinS.A.CaseyRisk stratification and outcome of patients with hypertrophic cardiomyopathy ≥60 years of ageCirculation1272013585593 

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Risk stratification and outcome of patients with hypertrophic cardiomyopathy ≥60 years of age

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Risk stratification and outcome of patients with hypertrophic cardiomyopathy ≥60 years of age

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