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Methods and results: A total of 5083 patients with symptoms concerning for coronary artery disease (CAD) and atherosclerosis on CCTA were enrolled at 38 international sites from 15 July 2015 to 20 October 2017. Demographics, symptom status, CCTA and FFRCT findings, treatment plans, and 90 days outcomes were recorded. The primary endpoint of reclassification between core lab CCTA alone and CCTA plus FFRCT-based management plans occurred in 66.9% [confidence interval (CI): 64.8-67.6] of patients. Non-obstructive coronary disease was significantly lower in ICA patients with FFRCT ≤0.80 (14.4%) compared to patients with FFRCT >0.80 (43.8%, odds ratio 0.19, CI: 0.15-0.25, P < 0.001). In total, 72.3% of subjects undergoing ICA with FFRCT ≤0.80 were revascularized. No death/myocardial infarction (MI) occurred within 90 days in patients with FFRCT >0.80 (n = 1529), whereas 19 (0.6%) MACE [hazard ratio (HR) 19.75, CI: 1.19-326, P = 0.0008] and 14 (0.3%) death/MI (HR 14.68, CI 0.88-246, P = 0.039) occurred in subjects with an FFRCT ≤0.80.Conclusions: In a large international multicentre population, FFRCT modified treatment recommendation in two-thirds of subjects as compared to CCTA alone, was associated with less negative ICA, predicted revascularization, and identified subjects at low risk of adverse events through 90 days.Aims: Non-invasive assessment of stable chest pain patients is a critical determinant of resource utilization and clinical outcomes. Increasingly coronary computed tomography angiography (CCTA) with selective CCTA-derived fractional flow reserve (FFRCT) is being used. The ADVANCE Registry, is a large prospective examination of using a CCTA and FFRCT diagnostic pathway in real-world settings, with the aim of determining the impact of this pathway on decision-making, downstream invasive coronary angiography (ICA), revascularization, and major adverse cardiovascular events (MACE).

Background: Both preoperative left ventricular dysfunction (LVD) and acute kidney injury (AKI) in the postoperative period are independently associated with mortality. We evaluated the prevalence and prognostic implications of AKI in a cohort of vascular surgery patients. Methods: Before vascular surgery, 1,158 patients were screened for LVD. Development of AKI, defined by RIFLE classification, was detected by serial serum creatinine measurements at days 1 to 3 after surgery. Primary end point was cardiovascular mortality during a median follow-up of 2.2 years (interquartile range [IQR] 1.0-4.0). Results: LVD was present in 558 patients (48%), and 120 patients (10%) developed postoperative AKI. Subjects with LVD developed postoperative AKI more often than patients without LVD (8% vs. 13%, p=0.01). Patients were categorized as (i) no LVD, without AKI (n=551, 48%), (ii) LVD without AKI (n=487, 42%), (iii) no LVD, with AKI (n=49, 4%) and (iv) LVD with AKI (n=71/6%). Patients with LVD prior to surgery who developed postoperative AKI had the highest cardiovascular mortality risk (hazard ratio = 4.9; 95% confidence interval, 2.9-8.2). Conclusion: Patients with preoperatively LVD have an increased risk of developing AKI after vascular surgery. The occurrence of AKI in patients with LVD has an incremental predictive value toward cardiovascular mortality risk during long-term follow-up.

Background-: The relative merits of left ventricular (LV) dyssynchrony, LV lead position, and myocardial scar to predict long-term outcome after cardiac resynchronization therapy remain unknown and were evaluated in the present study. Methods and results-: In 397 ischemic heart failure patients, 2-dimensional speckle tracking imaging was performed, with comprehensive assessment of LV radial dyssynchrony, identification of the segment with latest mechanical activation, and detection of myocardial scar in the segment where the LV lead was positioned. For LV dyssynchrony, a cutoff value of 130 milliseconds was used. Segments with <16.5% radial strain in the region of the LV pacing lead were considered to have extensive myocardial scar (>50% transmurality, validated in a subgroup with contrast-enhanced magnetic resonance imaging). The LV lead position was derived from chest X-ray. Long-term follow-up include

Aims Multidetector computed tomography coronary angiography (CTA) has emerged as a feasible imaging modality for non-invasive assessment of coronary artery disease (CAD). Recently, 320-row CTA systems were introduced, with 16 cm anatomical coverage, allowing image acquisition of the entire heart within a single heart beat. The aim of the present study was to assess the diagnostic accuracy of 320-row CTA in patients with known or suspected CAD. Methods and resultsA total of 64 patients (34 male, mean age 61 ± 16 years) underwent CTA and invasive coronary angiography. All CTA scans were evaluated for the presence of obstructive coronary stenosis by a blinded expert, and results were compared with quantitative coronary angiography. Four patients were excluded from initial analysis due to non-diagnostic image quality. Sensitivity, specificity, and positive and negative predictive values to detect ≥50 luminal narrowing on a patient basis were 100, 88, 92, and 100, respectively. Moreover, sensitivity, specificity, and positive and negative predictive values to detect ≥70 luminal narrowing on a patient basis were 94, 95, 88, and 98, respectively. With inclusion of non-diagnostic imaging studies, sensitivity, specificity, and po

Background. Atherosclerotic disease is often extended to multiple affected vascular beds (AVB). Polyvascular disease (PVD) and chronic kidney disease (CKD) have both separately been associated with an adverse cardiovascular outcome. We assessed the prevalence of PVD in vascular surgery patients with preoperative CKD and studied the influence on long-term cardiovascular survival.Methods. Consecutive patients (2933) were preoperatively screened for PVD, defined as 1-, 2-or 3-AVB. Preoperative glomerular filtration rate (GFR in ml/min/1.73 m2body-surface area) was estimated by the Modification of Diet in Renal Disease (MDRD) prediction equation, and patients were categorized according their estimated GFR. Primary end point was (cardiovascular) mortality during a median follow-up of 6.0 years (IQR 2-9).Results. Preoperative MDRD-GFR was classified as normal kidney function (GFR ≥ 90) or mild (GFR 60-89), moderate (GFR 30-59) and severe (GFR < 30) kidney disease in 779 (27%), 1423 (48%), 605 (21%) and 124 (4%) patients, respectively. One-vessel disease was present in 54% of the patients with normal kidney function, while 62% of the patients with CKD (GFR < 60) had PVD. In patients with moderate or severe kidney disease, the presence of PVD was independently associated with even higher cardiovascular mortality rates (2-AVB: HR 1.65 95%CI 1.09-2.48; 3-AVB: 2.07 95%CI 1.08-3.99), compared to 1-AVB.Conclusion. Patients with CKD had a high prevalence of PVD, which was independently associated with increased all-cause and cardiovascular mortality.

Background: The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography. Methods: Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality. Results: Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4-3.6 and 1.8, 95% CI 1.1-2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4-8.5 and 3.0, 95% CI 1.5-6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1-2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4-19.3). Conclusions: This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open va

BACKGROUND: Few data are available that systematically describe rates and trends of postoperative mortality for fairly large, unselected patient populations. METHODS: This population-based study uses a registry of 3.7 million surgical procedures in 102 hospitals in The Netherlands during 1991-2005. Patients older than 20 yr who underwent an elective, nonday case, open surgical procedure were enrolled. Patient data included main (discharge) diagnosis, secondary diagnoses, dates of admission and discharge, death during admission, operations, age, sex, and a limited number of comorbidities classified according to the International Classification of Diseases 9th revision Clinical Modification. The main outcome measure was postoperative all-cause mortality. Univariable and multivariable logistic regression analyses were applied to evaluate the relationship between type of surgery and the main outcome. RESULTS: Postoperative all-cause death was observed in 67,879 patients (1.85%). In a model based on a classification into 11 main surgical categories, breast surgery was associated with lowest mortality (adjusted incidence, 0.07%), and vascular surgery was associated with highest mortality (adjusted incidence, 5.97%). In a model based on 36 surgical subcategories, the adjusted mortality ranged from 0.07% for hernia nuclei pulposus surgery to 18.5% for liver transplant. The c-index of the 36-category model was 0.88, which was significantly (P < 0.001) higher than the c-index that was associated with the simple surgical classification (low vs. high risk) in the commonly used Revis

Background and objectives: Acute kidney injury is an independent predictor of short- and long-term survival; however, data on the relationship between reversible transitory decline of kidney function and chronic kidney disease (CKD) are lacking. We assessed the prognostic value of temporary renal function decline on the development of long-term CKD. Design, setting, participants, & measurements: The study included 1308 patients who were undergoing major vascular surgery (aortic aneurysm repair, lower extremity revascularization, or carotid surgery), divided into three groups on the basis of changes in Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated GFR (eGFR) on days 1, 2, and 3 after surgery, compared with baseline: Group 1, improved or unchanged (change in CKD-EPI eGFR ±10%); group 2, temporary decline (decline >10% at day 1 or 2, followed by comp

AimsPatients with peripheral atherosclerotic disease often have multiple affected vascular beds (AVB), however, data on long-term follow-up and medical therapy are scarce. We assessed the prevalence and prognostic implications of polyvascular disease on long-term outcome in symptomatic peripheral arte

Background-Data on the association between right ventricular (RV) function and adverse events after acute myocardial infarction (AMI) are scarce. The purpose of the current study was to evaluate the relation between RV function and adverse events in patients treated with primary percutaneous coronary intervention for AMI. Methods and Results-Consecutive patients admitted with AMI treated with primary percutaneous coronary intervention underwent echocardiography within 48 hours of admission to assess left ventricular and RV function. RV function was quantified with RV fractional area change (RVFAC), tricuspid annular plane systolic excursion, and RV strain. The end point was defined as a composite of all-cause mortality, reinfarction, and hospitalization for heart failure. All patients (n=621) were followed prospectively, and during a mean follow-up of 24 months, 86 patients reached the composite end point. RVFAC, tricuspid annular plane systolic excursion, and RV strain were all univariable predictors of worse outcome. After multivar

Objective: In patients with active Cushing's syndrome (CS), cardiac structural and functional changes have been described in a limited number of patients. It is unknown whether these changes reverse after successful treatment. We therefore evaluated the changes in cardiac structure and dysfunction after successful treatment of CS, using more sensitive echocardiographic parameters (based on two-dimensional strain imaging) to detect subtle changes in cardiac structure and function. Methods: In a prospective study design, we studied 15 consecutive CS patients and 30 controls (matched for age, sex, body surface area, hypertension, and left ventricular (LV) systolic function). Multidirectional LV strain was evaluated by two-dimensional speckle tracking strain imaging. Systolic (radial thickening, and circumferential and longitudinal shorteni

Background: We sought to evaluate the diagnostic accuracy of 64-slice multi-detector row computed tomography (MDCT) compared with invasive coronary angiography for in-stent restenosis (ISR) detection. Methods: MEDLINE, Cochrane library, and BioMed Central database searches were performed until April 2009 for original articles. Inclusion criteria were (1) 64-MDCT was used as a diagnostic test for ISR, with >50% diameter stenosis selected as the cut-off criterion for significant ISR, using invasive coronary angiography and quantitative coronary angiography as the standard of reference; (2) absolute numbers of true positive, false positive, true negative, and false negative results could be derived. Standard meta-analytic methods were applied. Results: Nine studies with a total of 598 patients with 978 stents included were considered eligible. On average, 9% of stents were unassessable (range 0-42%). Accuracy tests with 95% confidence intervals (CIs) comparing 64-MDCT vs invasive coronary angiography showed that pooled sensitivity, specificity, positive and negative likelihood ratio (random effect model) values were: 86% (95% CI 80-91%), 93% (95% CI 91-95%), 12.32 (95% CI 7.26-20.92), 0.18 (95% CI 0.12-0.28) for binary ISR detection. The symmetric area under the curve value was 0.94, indicating good agreement between 64-MDCT and invasive coronary angiography. Conclusions: 64-MDCT has a good diagnostic accuracy for ISR detection with a particularly high negative predictive value. However, still a relatively large proportion of stents remains uninterpretable. Accordingly, only in selected patients, 64-MDCT may serve as a potential alternative noninvasive method to rule out ISR.

Aims to assess the long-term rate of mortality and the recurrence of potentially life-threatening ventricular arrhythmias in secondary prevention implantable cardioverter defibrillator (ICD) patients and to construct a model for baseline risk stratification.Methods and resultsSince 1996, all patients with ischaemic heart disease, receiving ICD therapy for secondary prevention of sudden death, were included in the current study. Patients were evaluated at implantation and during long-term follow-up. A total of 456 patients were included in the analysis and followed for 54 ± 35 months. During follow-up, 100 (22) patients died and ICD therapy was noted in 216 (47) patients, of which 138 (30) for fast, potentially life-threatening ventricular arrhythmia. Multivariate analysis revealed a history of atrial fibrillation or flutter (AF), ventricular tachycardia as presenting arrhythmia, and wide QRS and poor left ventricular ejection fraction as independent predictors of life-threatening ventricular arrhythmias. The strongest predictor was AF with a hazard ratio of 2.1 (95 confidence interval 1.3-3.2). On the basis of the available clinical data, it was not possible to identify a group which exhibited no risk on recurrence of potentially life-threatening ventricular arrhythmias.ConclusionIschaemic secondary prevention ICD recipients exhibit a high recurrence rate of potentially life-threatening ventricular arrhythmias. Factors that increase risk can be identified but, even with these factors, it was not possible to distinguish a recurrence-free group.

Background: The aim of this study was to assess the prognostic value of technetium-99m tetrofosmin gated SPECT imaging in women using quantitative gated single photon emission computed tomography (SPECT) imaging. Methods: We followed 453 consecutive female patients. Average follow-up was 1.33 years (max. 2.55). Hard endpoints were cardiac death, acute myocardial infarction, or documented ventricular fibrillation. Event-free survival curves were obtained. Optimal cutoff values for left ventricular (LV) volumes, LV ejection fraction (LVEF), and perfusion data to predict outcome were determined by ROC curve analysis. Results: A total of 236 patients had an abnormal study, of whom 27 patients experienced hard events (16 deaths) and 47 patients soft events. For hard events summed stress score (SSS) and LVEF, and for any cardiac event SSS showed independent incremental prognostic value. The survival curves were maximally separated when using cutoff values for SSS of ≥ 22 and LVEF < 52% (P < 0.001, HR 4.61 and P < 0.001 HR 5.24 for SSS and LVEF resp.), and SSS ≥ 14 (P < 0.001 HR 3.76) for any cardiac event. Conclusion: In women, perfusion and functional parameters derived from quantitative gated technetium-99m tetrofosmin SPECT imaging can adequately be used for cardiac risk assessment. Using quantitative gated SPECT, female patients with an LVEF < 52% or an SSS ≥ 22 are at increased risk for subsequent hard events. Furthermore, patients with an SSS ≥ 14 are at increased risk for any cardiac events.

BACKGROUND: Adverse cardiac events are common after vascular surgery. We hypothesized that perioperative statin therapy would improve postoperative outcomes. METHODS: In this double-blind, placebo-con

Background. Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings. Methods. We studied 2292 patients, divided into 729 (32%) patients with normal renal function [creatinine clearance (CrCl) >90 ml/min] and 1563 (68%) with renal dysfunction, classified as mild (CrCl: 60-90 ml/min) in 933, moderate (CrCl: 30-60 ml/min) in 502 and severe (CrCl < 30ml/min) in 128 patients. All patients underwent DSE for the evaluation of known or suspected CAD and were followed for a mean of 8 years. Results. New wall motion abnormalities during DSE and mildly, moderately and severely abnormal CrCl were powerful independent predictors for all-cause mortality, cardiac death and hard cardiac events (cardiac death and non-fatal myocardial infarction). Kaplan-Meier curves demonstrated that patients with normal DSE and renal dysfunction have greater probability for cardiac death and hard cardiac events compared to those with normal renal function. The warranty of a normal DSE in the presence of moderate renal dysfunction was 15 and 36 months for 10 and 20% risk for cardiac death and hard cardiac events, respectively. Conclusions. The presence and severity of renal dysfunction has additional independent prognostic value over DSE findings. The low-risk warrantee period after a normal DSE is determined by the severity of renal dysfunction.

Aims: Contrast-enhanced echocardiography is widely used to enhance left ventricular (LV) endocardial border delineation in stable patients with known or suspected coronary artery disease. In patients with acute myocardial infarction, accurate assessment of LV function and size is important, but data on the safety of contrast-enhanced echocardiography in the early stage of myocardial infarction (within 24 h) are lacking. In the current study, the experience on the safety of contrast-enhanced echocardiography within 24 h of acute myocardial infarction is reported. Methods and results: A total of 115 consecutive patients (58 ± 11 years; 77% male) admitted to the coronary care unit for ST-elevation acute myocardial infarction underwent clinically indicated contrast-enhanced echocardiography within 24 h of hospital admission to assess LV size and function. Perflutren (Luminity®, Bristol-Myers Squibb Pharma, Bruxelles, Belgium) was used as contrast agent. Safety was determined evaluating vital signs, physical examination, ECG, and adverse events. On contrast-enhanced echocardiography, the mean LV ejection fraction was 44 ± 11%, and 56% of patients had an LV ejection fraction ≤45%. Administration of echo contrast did not induce any significant change in vital signs, physical examination, and ECG. Major adverse events were not observed whereas minor events occurred in 4% of patients (hypersensitivity at the injection site in three and transient back pain in two). Conclusion: These data provide evidence on the safety of contrast-enhanced echocardiography in the first 24 h of myocardial infarction; larger patient cohorts are needed to confirm these findings.

Background. Acute kidney injury (AKI) after major vascular surgery is an important risk factor for adverse long-term outcomes. The pleiotropic effects of statins may reduce kidney injury caused by perioperative episodes of hypotension and/or suprarenal clamping and improve long-term outcomes. Methods. Of 2170 consecutive patients undergoing lower extremity bypass or abdominal aortic surgery from 1995 to 2006, cardiac risk factors and medication were noted. A total of 515/1944 (27%) patients were statin users. Creatinine clearance (CrCl) was assessed preoperativ

Background: Cardiac events are the predominant cause of late mortality in patients with peripheral arterial disease (PAD). In these patients, mortality decreases with increasing body mass index (BMI). COPD is identified as a cardiac risk factor, which preferentially affects underweight individuals. Whether or not COPD explains the obesity paradox in PAD patients is unknown. Methods: We studied 2,392 patients who underwent major vascular surgery at one teaching institution. Patients were classified according to COPD status and BMIs (ie, underweight, normal, overweight, and obese), and the relationship between these variables and all-cause mortality was determined using a Cox regression analysis. The median follow-up period was 4.37 years (interquartile range, 1.98 to 8.47 years). Results: The overall mortality rates among underweight, normal, overweight, and obese patients were 54%, 50%, 40%, and 31%, respectively (p < 0.001). The distribution of COPD severity classes showed an increased prevalence of moderate-to-severe COPD in underweight patients. In the entire population, BMI (continuous) was associated with increased mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94 to 0.98). In addition, patients who were classified as being underweight were at increased risk for mortality (HR, 1.42; 95% CI, 1.00 to 2.01). However, after adjusting for COPD severity the relationship was no longer significant (HR, 1.29; 95% CI, 0.91 to 1.93). Conclusions: The excess mortality among underweight patients was largely explained by the overrepresentation of individuals with moderate-to-severe COPD. COPD may in part explain the "obesity pa

Aims: The aim of the current study was to evaluate the relationship between the presence of left ventricular (LV) dyssynchrony at baseline and acute vs. late improvement in mitral regurgitation (MR) after cardiac resynchronization therapy (CRT). Methods and results: Sixty eight patients consecutive (LV ejection fraction 23 ± 8%) with at least moderate MR (≥grade 2+) were included. Echocardiography was performed at baseline, 1 day after CRT initiation and at 6 months follow-up. Speckle tracking radial strain was used to assess LV dyssynchrony at baseline. The majority of patients improved in MR after CRT, with 43% improving immediately after CRT, and 20% improving late (after 6 months) after CRT. Early and late responders had similar extent of LV dyssynchrony (209 ± 115 ms vs. 190 ± 118 ms, P = NS); however, the site of latest activation in early responders was mostly inferior or posterior (adjacent to the posterior papillary muscle), whereas the lateral wall was the latest activated segment in late responders. Conclusion: Current data suggest that the presence of baseline LV dyssynchrony is related to improvement in MR after CRT. LV dyssynchrony involving the posterior papillary muscle may lead to an immediate reduction in MR, whereas LV dyssynchrony in the lateral wall resulted in late response to CRT.

Aims: To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development. Methods and results: A committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation. Conclusion: Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.

Objective: Treatment with ergot-derived dopamine agonists, pergolide, and cabergoline has been associated with an increased frequency of valvular heart disease in Parkinson's disease. The aim of the present study was to assess the prevalence of valvular heart disease in patients treated with dopamine agonists for prolactinomas. Design: This was a cross-sectional study. Patients: We performed two-dimensional and Doppler echocardiography in 78 consecutive patients with prolactinoma (mean age 47 ± 1.4 yr, 26% male, 31% macroprolactinoma) treated with dopamine agonists for at least 1 yr (mean 8 ± 0.6 yr) and 78 control subjects. Patients were classified according to treatment: patients treated with cabergoline (group 1: n = 47) and patients not treated with cabergoline (group 2: n = 31). Results: Clinically relevant valvular heart disease was present in 12% of patients (nine of 78) vs. 17% of controls (13 of 78) (P = 0.141) and 17% (eight of 47) of patients treated with cabergoline vs. 3% (one of 31) of patients not treated with cabergoline (P = 0.062). Mild tricuspid regurgitation was present in 41% of patients vs. 26% of controls (P = 0.042), and aortic valve calcification was present in 40% of patients, compared with 18% of controls (P = 0.003). There was no relation between the cumulative dose of cabergoline and the presence of mild, moderate, or severe valve regurgitation. Conclusion: Several years of dopamine agonist treatment in patients with prolactinomas is associated with increased prevalence of aortic valve calcification and mild tricuspid regurgitation but not with clinically relevant valvular heart disease. Therefore, additional studies on the adverse cardiac effects of dopaminergic drugs in prolactinoma are warranted, especially in patients with much longer use of these drugs. Copyright

As a consequence of improved technology, there is growing clinical interest in the use of multi-detector row computed tomography (MDCT) for non-invasive coronary angiography. Indeed, the accuracy of MDCT to detect or exclude coronary artery stenoses has been high in many published studies. This report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT (WG 5) of the European Society of Cardiology and the European Council of Nuclear Cardiology summarizes the present state of cardiac CT technology, as well as the currently available data concerning its accuracy and applicability in certain clinical situations. Besides coronary CT angiography, the use of CT for the assessment of cardiac morphology and function, evaluation of perfusion and viability, and analysis of heart valves is discussed. In addition, recommendations for clinical applications of cardiac CT imaging are given and limitations of the technique are described.

Background and aim: N-terminal pro-B-type natriuretic peptide (NT-proBNP) has diagnostic and prognostic value in patients with heart failure. The present prospective study was designed to assess whether changes in NT-proBNP levels after surgical mitral valve repair reflect changes in heart failure symptoms and

Objective: To assess the long-term prognostic value of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) after major vascular surgery. Design: A single-centre prospective cohort study. Patients: 335 patients who underwent abdominal aortic aneurysm repair or lower extremity bypass surgery. Interventions: Prior to surgery, baseline NT-proBNP level was measured. Patients were also evaluated for cardiac risk factors according to the Revised Cardiac Risk Index. Dobutamine stress echocardiography (DSE) was performed to detect stress-induced myocardial ischaemia. Main outcome measures: The prognostic value of NT-proBNP was evaluated for the endpoints all-cause mortality and major adverse cardiac events (MACE) during long-term follow-up. Results: In this patient cohort (mean age: 62 years, 76% male), median NT-proBNP level was 186 ng/l (interquartile range: 65-444 ng/l). During a mean follow-up of 14 (SD 6) months, 49 patients (15%) died and 50 (15%) experienced a MACE. Using receiver operating characteristic curve analysis for 6-month mortality and MACE, NT-proBNP had the greatest area under the curve compared with cardiac risk score and DSE. In addition, an NT-proBNP level of 319 ng/l was identified as the optimal cut-off value to predict 6-month mortality and MACE. After adjustment for age, cardiac risk score, DSE results and cardioprotective medication, NT-proBNP ≥319 ng/l was associated with a hazard ratio of 4.0 for all-cause mortality (95% CI: 1.8 to 8.9) and with a hazard ratio of 10.9 for MACE (95% CI: 4.1 to 27.9). Conclusion: Preoperative NT-proBNP level is a strong predictor of long-term mortality and major adverse cardiac events after major non-cardiac vascular surgery.

Background: Repeat coronary artery bypass grafting (redo-CABG) in patients with ischaemic cardiomyopathy is associated with high perioperative risk and worse long-term outcome compared with patients undergoing their first CABG. Objective: To assess whether patients with viable myocardium undergoing redo-CABG have a better outcome. Methods: 18 patients with ischaemic cardiomyopathy underwent redo-CABG and 34 underwent their first CABG; all had substantial viability (≥25% of the left ventricle) on

Background: The aim of this study was to assess the accuracy of stress 99m technetium tetrofosmin myocardial perfusion imaging for the diagnosis of in stent stenosis (ISS). Methods: We studied 72 patients who underwent exercise or dobutamine stress 99m technetium tetrofosmin imaging, 0.9-0.5 years after percutaneous coronary interventions in which stents were deployed. Coronary angiography was performed within 3 months of the stress test. ISS was defined as ≥50% stenosis in a coronary segment with previous stenting. Significant coronary artery disease (CAD) was defined as ≥50% stenosis within or outside the stented coronary segment. Results: The stent was deployed in 1 coronary artery in 52 patients, and in 2 coronary arteries in 20 patients (a total of 92 detected in 42 (58%) patients (51 stents). Reversible perfusion abnormalities were present in 34 of patients w

Objective: To evaluate the relative merits of viability and ischaemia for prognosis after revascularisation. Methods: Low-high dose dobutamine stress echocardiography (DSE) was performed before revascularisation in 128 consecutive patients with ischaemic cardiomyopathy (mean (SD) left ventricular ejection fraction (LVEF) 31 (8)%). Viability (defined as contractile reserve (CR)) and ischaemia were assessed during low and high dose dobutamine infusion, respectively. Cardiac death was evaluated during a five year follow up. Clinical, angiographic, and echocardiographic data were analysed to identity predictors of events. Results: Univariable predictors of cardiac death were the presence of multivessel diseas

OBJECTIVE: To evaluate prospectively the response of left ventricular ejection fraction (LVEF) to high dose dobutamine infusion in patients showing substantial viability, with and without improved resting LVEF after revascularisation. METHODS: Before and 9-12 months after revascularisation, 50 patients with ischaemic cardiomyopathy (LVEF 32 (8)%) and substantial myocardial viability (> or = 4 viable segments) underwent radionuclide ventriculography and dobutamine stress echocardiography. Patients were divided into group 1, patients with, and group 2, patients without significant improvement in resting LVEF (> or = 5% by radionuclide ventriculography) after revascularisation. The response of LVEF during dobutamine stress echocardiography was compared in these two groups. RESULTS: Groups 1 and 2 were comparable in baseline characteristics, resting LVEF, and number of viable segments (mean (SD) 7 (4) v 6 (2), not significant). After revascularisation, the LVEF response during dobutamine stress echocardiography improved significantly in both groups (group 1, 34 (10)% to 56 (8)%; group 2, 32 (10)% to 46 (11)%; both p < 0.001). Interestingly, although resting LVEF did not improve in group 2, peak stress LVEF after revascularisation did (p < 0.001). Group 1 patients had, however, a greater increase in peak stress LVEF (group 1, 22 (10)%; group 2, 13 (9)%; p < 0.01). New York Heart Association and Canadian Cardiovascular Society classes decreased in both groups. CONCLUSIONS: Although patients with viable myocardium did not always have improved rest LVEF after revascularisation, peak stress LVEF improved. Assessment of improvement of resting function may not be the ideal end point to evaluate successful revascularisation.

OBJECTIVES: To compare the long term prognosis of patients having silent versus symptomatic ischaemia during dobutamine stress echocardiography (DSE). DESIGN: Observational study. SETTING: Tertiary referral centre. PATIENTS: 931 patients who experienced stress induced myocardial ischaemia during DSE. RESULTS: Silent ischaemia was present in 643 of 931 patients (69%). The number of dysfunctional segments at rest (mean (SD) 9.6 (5.1) v 8.8 (5.0), p = 0.1) and of ischaemic segments (3.5 (2.2) v 3.8 (2.1), p = 0.2) was comparable in both groups. During a mean (SD) follow up of 5.5 (3.3) years, there were 169 (18%) cardiac deaths and 86 (9%) non-fatal infarctions. Multivariable Cox regression analysis showed age (hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02 to 1.05), previous myocardial infarction (HR 1.4, 95% CI 1.1 to 2.0), and number of ischaemic segments during the test (HR 2.0, 95% CI 1.0 to 3.7) as independent predictors of cardiac death and myocardial infarction. For every additional ischaemic segment there was a twofold increment in risk of late cardiac events. The annual cardiac death or myocardial infarction rate was 3.0% in patients with symptomatic ischaemia and 4.6% in patients with silent ischaemia (p < 0.01). Silent induced ischaemia was an independent predictor of cardiac death and myocardial infarction (HR 1.7, 95% CI 1.1 to 2.0). During follow up symptomatic patients were treated more often with cardioprotective therapy (p < 0.01) and coronary revascularisation (145 of 288 (50%) v 174 of 643 (27%), p < 0.001). CONCLUSIONS: Patients with silent ischaemia had a similar extent of myocardial ischaemia during DSE compared to patients with symptomatic ischaemia but received less cardioprotective treatment and coronary revascularisation and experienced a higher cardiac event rate.

Objectives: To compare the long term prognosis of patients having silent versus symptomatic ischaemia during dobutamine stress echocardiography (DSE). Design: Observational study. Setting: Tertiary referral centre. Patients: 931 patients who experienced stress induced myocardial ischaemia during DSE. Results: Silent ischaemia was present in 643 of 931 patients (69%). The number of dysfunctional segments at rest (mean (SD) 9.6 (5.1) v 8.8 (5.0), p = 0.1) and of ischaemic segments (3.5 (2.2) v 3.8 (2.1), p = 0.2) was comparable in both groups. During a mean (SD) follow up of 5.5 (3.3) years, there were 169 (18%) cardiac deaths and 86 (9%) non-fatal infarctions. Multivariable Cox regression analysis showed age (hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02 to 1.05), previous myocardial infarction (HR 1.4, 95% CI 1.1 to 2.0), and number of ischaemic segments during the test (HR 2.0, 95% CI 1.0 to 3.7) as independent predictors of cardiac death and myocardial infarction. For every additional ischaemic segment there was a twofold increment in risk of late cardiac events. The annual cardiac death or myocardial infarction rate was 3.0% in patients with symptomatic ischaemia and 4.6% in patients with silent ischaemia (p < 0.01). Silent induced ischaemia was an independent predictor of cardiac death and myocardial infarction (HR 1.7, 95% CI 1.1 to 2.0). During follow up symptomatic patients were treated more often with cardioprotective therapy (p < 0.01) and coronary revascularisation (145 of 288 (50%) v 174 of 643 (27%), p < 0.001). Conclusions: Patients with silent ischaemia had a similar extent of myocardial ischaemia during DSE compared to patients with symptomatic ischaemia but received less cardioprotective treatment and coronary revascularisation and experienced a higher cardiac event rate.

Objectives We sought to develop and validate a risk score combining both clinical and dobutamine echocardiographic (DbE) features in 4,890 patients who underwent DbE at three expert laboratories and were followed for death or myocardial infarction for up to five years. Background In contrast to exercise scores, no score exists to combine clinical, stress, and echocardiographic findings with DbE. Methods Dobutamine echocardiography was performed for evaluation of known or suspected coronary artery disease in 3,156 patients at two sites in the U.S. After exclusion of patients with incomplete follow-up, 1,456 DbEs were randomly selected to develop a multivariate model for prediction of events. After simplification of each model for clinical use, the models were internally validated in the remaining DbE patients in the same series and externally validated in 1,733 patients in an independent series. Results The following score was derived from regression models in the modeling group (160 events): DbE risk = (age·0.02) + (heart failure + rate-pressure product <15,000)·0.4 + (ischemia + scar)·0.6. The presence of each variable was scored as 1 and its absence scored as 0, except for age (continuous variable). Using cutoff values of 1.2 and 2.6, patients were classified into groups with five-year event-free survivals >95%, 75% to 95%, and <75%. Application of the score in the internal validation group (265 events) gave equivalent results, as did its application in the external validation group (494 events, C index = 0.72). Conclusions A risk score based on clinical and echocardiographic data may be used to quantify the risk of events in patients undergoing DbE.

Objectives We sought to develop and validate a risk score combining both clinical and dobutamine echocardiographic (DbE) features in 4,890 patients who underwent DbE at three expert laboratories and were followed for death or myocardial infarction for up to five years. Background In contrast to exercise scores, no score exists to combine clinical, stress, and echocardiographic findings with DbE. Methods Dobutamine echocardiography was performed for evaluation of known or suspected coronary artery disease in 3,156 patients at two sites in the U.S. After exclusion of patients with incomplete follow-up, 1,456 DbEs were randomly selected to develop a multivariate model for prediction of events. After simplification of each model for clinical use, the models were internally validated in the remaining DbE patients in the same series and externally validated in 1,733 patients in an independent series. Results The following score was derived from regression models in the modeling group (160 events): DbE risk = (age·0.02) + (heart failure + rate-pressure product <15,000)·0.4 + (ischemia + scar)·0.6. The presence of each variable was scored as 1 and its absence scored as 0, except for age (continuous variable). Using cutoff values of 1.2 and 2.6, patients were classified into groups with five-year event-free survivals >95%, 75% to 95%, and <75%. Application of the score in the internal validation group (265 events) gave equivalent results, as did its application in the external validation group (494 events, C index = 0.72). Conclusions A risk score based on clinical and echocardiographic data may be used to quantify the risk of events in patients undergoing DbE.

OBJECTIVES: To assess whether quantification of myocardial systolic velocities by pulsed wave tissue Doppler imaging can differentiate between stunned, hibernating, and scarred myocardium. DESIGN: Observational study. SETTING: Tertiary referral centre. PATIENTS: 70 patients with reduced left ventricular function caused by chronic coronary artery disease. METHODS: Pulsed wave tissue Doppler imaging was done close to the mitral annulus at rest and during low dose dobutamine; systolic ejection velocity (Vs) and the difference in Vs between low dose dobutamine and the resting value (DeltaVs) were assessed using a six segment model. Assessment of perfusion (with Tc-99m-tetrofosmin SPECT) and glucose utilisation (by 18F-fluorodeoxyglucose SPECT) was used to classify dysfunctional regions (by resting cross sectional echocardiography) as stunned, hibernating, or scarred. RESULTS: 253 of 420 regions (60%) were dysfunctional. Of these, 132 (52%) were classified as stunned, 25 (10%) as hibernating, and 96 (38%) as scarred. At rest, Vs in stunned, hibernating, and scar tissue was, respectively, 6.3 (1.8), 6.6 (2.2), and 5.5 (1.5) cm/s (p = 0.001 by ANOVA). There was a gradual decline in Vs during low dose dobutamine infusion between stunned, hibernating, and scar tissue (8.3 (2.6) v 7.8 (1.5) v 6.8 (1.9) cm/s, p < 0.001 by ANOVA). DeltaVs was higher in stunned (2.1 (1.9) cm/s) than in hibernating (1.2 (1.4) cm/s, p < 0.05) or scarred regions (1.3 (1.2) cm/s, p = 0.001). CONCLUSIONS: Quantitative tissue Doppler imaging showed a gradual reduction in regional velocities between stunned, hibernating, and scarred myocardium. Dobutamine induced contractile reserve was higher in stunned regions than in hibernating and scarred myocardium, reflecting different severities of myocardial damage

BACKGROUND: In ischaemic cardiomyopathy, raised plasma concentrations of natriuretic peptides are associated with a poor long term prognosis, while the presence of contractile reserve is a favourable sign. OBJECTIVE: To assess the relation between plasma natriuretic peptides and contractile reserve. DESIGN: Prospective observational study. SETTING: Tertiary referral centre. PATIENTS: 66 consecutive patients undergoing low dose dobutamine stress echocardiography to evaluate contractile reserve in regions with contractile dysfunction at rest, divided into two groups: group 1, 31 patients with ischaemic cardiomyopathy (left ventricular ejection fraction < or = 40%) and heart failure symptoms; group 2, 35 patients with normal left ventricular function. MAIN OUTCOME MEASURES: Plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), measured using immunoradiometric assays. Contractile reserve was defined as an improvement in segmental wall motion score during infusion of low dose dobutamine. RESULTS: Plasma ANP and BNP concentrations were higher in group 1 than in group 2 (mean (SD): ANP, 17.8 (32.8) v 7.2 (9.7), p < 0.005; BNP, 24.4 (69.0) v 5.0 (14.3) pmol/l, respectively; p < 0.001). In group 1, the presence of contractile reserve was inversely related to ANP and BNP levels; however, patients with contractile reserve

OBJECTIVE: The aim of this study was to assess the incremental value of dobutamine stress echocardiography (DSE) for the risk stratification of diabetic patients who are unable to perform an adequate exercise stress test. Exercise capacity is frequently impaired in patients with diabetes. The role of pharmacologic stress echocardiography in the risk stratification of diabetic patients has not been well defined. RESEARCH DESIGN AND METHODS: We studied 396 diabetic patients (mean age 61 +/- 11 years, 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of known or suspected coronary artery disease (CAD). End points were hard cardiac events (cardiac death and nonf

Stress echocardiography and myocardial perfusion imaging are commonly used noninvasive imaging modalities for the evaluation of ischaemic heart disease. Both modalities have proved clinically useful in the entire spectrum of coronary artery disease. Both techniques can detect coronary artery disease and provide prognostic information. Both techniques can identify low-risk and high-risk subsets among patients with known or suspected coronary artery disease and thus guide patient management decisions. In patients with acute myocardial infarction, both techniques have been used to identify residual viable tissue and predict improvement of function over time. In patients with chronic ischaemic left ventricular (LV) dysfunction, viability assessment with either modality can be used to predict improvement of function after revascularisation and thus guide patient treatment.

Dobutamine stress echocardiography is an established diagnostic method for the detection of myocardial viability in patients with severe left ventricular dysfunction[1]. The presence of viable myocardium identifies patients who will benefit from coronary revascularization, by improving both functional capacity and long-term survival. Occasionally, dobutamine infusion has been combined with other stressors, such as post-extrasystolic potentiation, in order to improve accuracy. The contractile reserve after combined dobutamine infusion and post-extrasystolic potentiation can be quantified by pulsed wave tissue Doppler imaging. We describe a patient with severe left ventricular dysfunction, in which pulsed wave tissue Doppler imaging allowed to demonstrate that post-extrasystolic potentiation super-imposed on dobutamine infusion is able to further recruit contractile reserve, as compared to dobutamine infusion alone. A nuclear scan assessing glucose utilization was used as a reference.

OBJECTIVE: To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. DESIGN: Meta-analysis of published reports. METHODS: Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. RESULTS: In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). CONCLUSIONS: On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular

OBJECTIVE: To quantify regional left ventricular (LV) function and contractile reserve in Q wave and non-Q wave regions in patients with previous myocardial infarction. DESIGN: An observational study. SETTING: Tertiary care centre. PATIENTS: 81 patients with previous myocardial infarction and depressed LV function. INTERVENTIONS: All patients underwent surface ECG at rest and pulsed wave tissue Doppler imaging at rest and during low dose dobutamine infusion. The left ventricle was divided into four major regions (anterior, inferoposterior, septal, and lateral). Severely hypokinetic, akinetic, and dyskinetic regions on two dimensional echocardiography at rest were considered dysfunctional. MAIN OUTCOME MEASURES: Regional myocardial systolic velocity (Vs) at rest and the change in Vs during low dose dobutamine infusion (DeltaVs) in dysfunctional regions with and without Q waves on surface ECG. RESULTS: 220 (69%) regions were dysfunctional; 60 of these regions corresponded to Q waves and 160 were not related to Q waves. Vs and DeltaVs were lower in dysfunctional than in non-dysfunctional regions (mean (SD) Vs 6.2 (1.9) cm/s v 7.1 (1.7) cm/s (p < 0.001), and DeltaVs 1.9 (1.9) cm/s v 2.6 (2.5) cm/s (p = 0.009), respectively). There were no significant differences in Vs and DeltaVs among dysfunctional regions with and without Q waves (Q wave regions: Vs 6.2 (1.8) cm/s, DeltaVs 1.6 (2.2) cm/s; non-Q wave regions: Vs 6.3 (1.9) cm/s, DeltaVs 2.0 (2.0) cm/s). CONCLUSIONS: Quantitative pulsed wave tissue Doppler demonstrated that, among dysfunctional regions, Q waves on the ECG do not indicate more severe dysfunction, and myocardial contractile reserve is comparable in Q wave and non-Q wave dysfunctional myocardium.

PURPOSE: To determine the long-term prognostic value of dobutamine stress technetium 99m (99mTc)-labeled sestamibi single photon emission computed tomography (SPECT) in patients with limited exercise capacity. MATERIALS AND METHODS: Clinical data and SPECT results were analyzed in 531 consecutive patients. Follow-up was successful in 528 (99.4%) patients; 55 underwent early revascularization and were excluded. Normal or abnormal findings were considered in the absence or presence of fixed and/or reversible perfusion defects. A summed stress score was calculated to estimate the extent and severity of perfusion defects. Univariate and multivariate Cox proportional hazards regression models were used to identify independent predictors of late cardiac events. The incremental value of myocardial perfusion scintigraphy over clinical variables in predicting events was determined according to two models. The probability of survival was calculated by using the Kaplan-Meier method. RESULTS: Findings were abnormal in 312 patients. During 8.0 years +/- 1.5 of follow-up (range, 4.5-10.6 years), cardiac death occurred in 67 patients (total deaths, 165); nonfatal myocardial infarction, in 34; and late revascularization, in 49. The annual rates for cardiac death, cardiac death or infarction, and all events were 0.9%, 1.2%, and 1.5%, respectively, after normal findings and 2.7%, 3.4%, and 4.4%, respectively, after abnormal findings (P <.05). In a multivariable Cox proportional hazards model, not only an abnormal finding but also the summed stress score provided incremental prognostic information in addition to clinical data. The hazard ratio for cardiac death was 1.09 (95% CI: 1.01, 1.18) per 1-unit increment of the summed stress score. CONCLUSION: The incremental prognostic value of dobutamine stress 99mTc-sestamibi SPECT over clinical data was maintained over an 8-year follow-up in patients with limited exercise capacity.