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This study assesses risk factors in elderly vascular surgery patients and to evaluate whether perioperative cardiac medication can reduce postoperative mortality rate. In a cohort study, 1693 consecutive patients >= 65 years undergoing major non-cardiac vascular surgery were preoperatively screened for cardiac risk factors and medication. During follow-up (median: 8.2 years), mortality was noted. Hospital mortality occurred in 8.1% and long-term mortality in 28.5%. In multivariate analysis, age, coronary artery disease, heart failure, cerebrovascular disease, renal failure and diabetes were significantly associated with increased hospital and long-term mortality. Perioperative aspirin (OR: 0.53, 95% confidence interval: 0.34-0.83), beta-blockers (OR: 0.32, 95% Cl: 0.19-0.54) and statins (OR: 0.35, 95% Cl: 0.18-0.68) were significantly associated with reduced hospital mortality. In addition, aspirin (HR: 0.65, 95% Cl: 0.53-0.81), angiotensin-converting enzyme (ACE)-inhibitors (HR: 0.74, 95% Cl: 0.59-0.92), beta-blockers (HR: 0.61, 95% CI: 0.48-0.76) and statins (HR: 0.65, 95% Cl: 0.49-0.87) were significantly associated with reduced long-term mortality. Heterogeneity tests revealed a gradient decrease of mortality risk in patients from low to high age using statins (p = 0.03). In conclusion, age is an independent predictor of hospital and long-term mortality in elderly patients undergoing major vascular surgery. Aspirin, ACE-inhibitors, beta-blockers and statins reduce long-term mortality risk. Especially the very elderly may benefit from statin therapy. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

Background: Acute myocardial infarction (MI) can occur in patients with previously normal stress myocardial perfusion imaging (MPI). It is not known whether the prognosis of these patients differ from those with MI who had an abnormal MPI on an earlier testing. The aim of this study was to compare the outcome of patients who sustained a MI during follow-up after stress MPI based on the presence or absence of perfusion abnormalities on the earlier test. Methods: We studied 109 patients (age 62 +/- 11 years, 73 men) who developed MI 2.1 +/- 2.7 years after exercise or dobutamine stress Tc-99m tetrofosmin MPI. Subsequently, a follow-up was done for the occurrence of death during or after the acute event. Results: Myocardial perfusion was normal in 31 patients and was abnormal in 78 (45 had reversible defects). During a mean follow-up of 3.1 +/- 2.4 years after MI, death occurred in 35 (32%) patients. The death rate was 19% in patients with previously normal versus 33% in patients with abnormal perfusion (P < 0.01). In a Cox model, independent predictors of death were age (risk ratio (RR) 1.06, 95% Cl: 1.02-1.10), heart failure (RR 2.7, Cl: 1.3-5.5), and abnormal MPI (RR 2.5, Cl: 1.3-4.5). Conclusion: Patients with a previously normal stress MPI are less likely to die after acute MI than patients who had an abnormal MPI.

Dobutamine stress echocardiography is a commonly used imaging modality for the diagnosis of coronary artery disease and the detection of myocardial viability. The major limitations are that it is operator dependent and that the analysis is subjective and qualitative resulting in interobserver variability. It is also tedious and time consuming. Consequently, several quantitative approaches have been proposed, such as acoustic quantification and color kinesis but none of these has proved to be fully quantitative. In this manuscript we describe the development of a new, quantitative technique based on tracking of both endocardium and epicardium providing information of endocardial excursion and myocardial thickening, a crucial parameter of wall function evaluation. Preliminary data indicate that the method is practical and feasible, but clinical trials are required to prove whether it will improve the sensitivity and specificity of dobutamine stress echocardiography.

Le controle glycemique est peut etre un facteur de risque sous-estime chez les malades diabetiques ayant une arteriopathie peripherique (AP). Un traitement au long cours par statines peut ameliorer le controle glycemique et l'evolution de ces malades. Dans une etude observationnelle de cohorte de 425 malades diabetiques consecutifs ayant une AP, le traitement au long cours par statines a ete note, l'indice cheville-bras a ete mesure et des mesures repetees d'hemoglobine glyquee (HbA1c) realisees. Au cours du suivi (mediane 7 ans), la mortalite de toutes causes et la mortalite cardiaque sont survenues respectivement dans 37% et 22% des cas. Les diminutions de l'HbA1c et la variabilite de l'HbA1c ont predit independamment l'evolution en plus des valeurs de base de l'indice cheville-bras. Les malades sous traitement chronique par statines avaient davantage de chance d'avoir des HbA1c diminuees (risque relatif (RR) = 1,86, intervalle de confiance (IC) a 95% = 1,27-2,74 et des valeurs d'HbA1c inferieures a 7% (RR = 2,58, IC 95% = 1,49-4,48) au cours du suivi. Les statines etaient egalement associees de facon significative avec une mortalite de toutes causes plus faible (RR = 0,39, IC 95% = 0,26-0,61) et un taux de deces cardiaque plus faible (RR = 0,40, IC 95% = 0,24-76). D'apres les resultats de la presente etude observationnelle, nous concluons que des mesures repetees de l'HbA1c peuvent ameliorer la stratification des risques chez les malades diabetiques ayant une AP. De plus, le traitement par statines est associe a un meilleur controle glycemique et a de meilleurs resultats a long terme.

Objective The aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients. Methods In a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean: 6+/-4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted. Results The prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53-2.25 and HR, 1.74; 95% CI, 1.46-2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59-2.92 and HR, 1.86; 95% CI, 1.43-2.41, respectively). In patients with unrecognized MI, beta-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia. Conclusions In patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.

This study examines differences in cardiac arrhythmias, perioperative myocardial ischemia, troponin T release, and cardiovascular events between endovascular and open repair of abdominal aortic aneurysms (AAAs). Of 175 patients, 126 underwent open AAA repair and 49 underwent endovascular AAA repair. Continuous 12-lead electrocardiographic monitoring, starting 1 day before surgery and continuing through 2 days after surgery, was used for cardiac arrhythmia and myocardial ischemia detection. Troponin T was measured on postoperative days 1, 3, and 7 and before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted at 30 days and at follow-up (mean 2.3 years). New-onset atrial fibrillation, nonsustained ventricular tachycardia, sustained ventricular tachycardia, and ventricular fibrillation occurred in 5%, 17%, 2%, and 1% of patients, respectively. Myocardial ischemia, troponin T release, and 30-day and long-term cardiac events occurred in 34%, 29%, 6%, and 10% of patients, respectively. Significantly higher heart rates and less heart rate variability were observed in the open AAA repair group. Cardiac arrhythmias were less prevalent in the endovascular AAA repair group (14% vs 29%, p = 0.04). Endovascular repair was also significantly associated with less myocardial ischemia (odds ratio 0.14, 95% confidence interval 0.05 to 0.40, p

Background The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are associated with improved outcome in patients with peripheral arterial disease. Statins may also have beneficial properties beyond their lipid-lowering effect. Methods A prospective, observational cohort study was conducted at a university hospital from 1990 to 2005 to examine whether higher doses of statins and lower low-density lipoprotein (LDL) cholesterol levels are both independently associated with improved outcome in peripheral arterial disease. Enrolled were 1374 consecutive patients (age, 61 ± 10 years, 73% male) with peripheral arterial disease (ankle-brachial index ≤0.90). They were screened for clinical risk factors, statin therapy, and LDL cholesterol levels. Serial LDL cholesterol levels were measured at 6 months and yearly after enrollment. The mean follow-up time was 6.4 ± 3.6 years, and no patients were lost to follow-up. The primary end points were all-cause and cardiac mortality. The secondary end point was the progression to kidney failure. Results Overall mortality, cardiac death, and progression to kidney failure occurred in 29%, 20%, and 5% of patients, respectively. Multivariate analysis revealed that higher doses of statins (per 10% increase) and lower 6-month LDL cholesterol levels (per 10 mg/dL decrease) were both independently associated with lower all-cause mortality (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.62 to 0.80; and HR, 0.96; 95% CI, 0.93 to 0.98, respectively) and cardiac death (HR, 0.76; 95% CI, 0.67 to 0.86; and HR, 0.95; 95% CI, 0.92 to 0.98, respectively). Higher high-density lipoprotein cholesterol levels also correlated significantly with lower all-cause and cardiac mortality. Higher doses of statins (per 10% increase) were associated with less progression to kidney failure (HR, 0.69; 95% CI, 0.54 to 0.89). Conclusions Higher doses of statins and lower LDL cholesterol levels are both independently associated with improved outcome in patients with peripheral arterial disease. These results support the view that statins have beneficial effects beyond their lipid-lowering properties and should be considered in all patients with PAD, irrespective of LDL cholesterol levels.

Background: Myocardial viability assessment in severely dysfunctional segments by dobutamine stress echocardiography (DSE) is less sensitive than nuclear scanning. Aim: To assess the additional value of using the recovery phase of DSE after acute beta-blocker administration for identifying viable myocardium. Methods: The study included 49 consecutive patients with ejection fraction (LVEF) ≤35%. All patients underwent DSE evaluation at low–high dose and during recovery phase, and dual-isotope single photon emission tomography (DISA-SPECT) evaluation for viability of severely dysfunctional segments. Patients with ≥4 viable segments were considered viable. Coronary revascularization followed within 3 months in all patients. Radionuclide evaluation of LVEF was performed before and 12 months after revascularization. Results: Viability with DISA-SPECT was detected in 463 (59%) segments, while 154 (19.7%) segments presented as scar. The number of viable segments increased from 415 (53%) at DSE to 463 (59%) at DSE and recovery, and the number of viable patients increased from 43 to 49 respectively. LVEF improved by ≥5% in 27 patients. Multivariate regression analysis showed that, DSE with recovery phase was the only independent predictor of ≥5% LVEF improvement after revascularization (OR 14.6, CI 1.4–133.7). Conclusion: In this study, we demonstrate that the recovery phase of DSE has an increased sensitivity for viability estimation compared to low–high dose DSE.

Objective To assess the prognostic value of wall motion abnormalities during the recovery phase of dobutamine stress echocardiography in addition to wall motion abnormalities at peak stress. Methods Wall motion abnormalities were assessed at peak and during recovery phase of dobutamine stress echocardiography in 187 consecutive patients, who were followed for occurrence of cardiac events. Results During follow-up (mean 36+/-28 months), 19 patients (10%) died from cardiac causes, 34 (18%) patients suffered nonfatal myocardial infarction, and 77 (41%) patients underwent late revascularization. Univariable predictors of cardiac events by Cox regression analysis were age (hazard ratio: 1.01; confidence interval: 1.00-1.03), dyslipidemia (hazard ratio: 1.41; confidence interval: 1.02-1.95), rest wall motion abnormalities (hazard ratio: 1.37; confidence interval: 1.14-1.64), new wall motion abnormalities (hazard ratio: 1.18; confidence interval: 0.95-1.45) at peak and new wall motion abnormalities (hazard ratio: 1.33; confidence interval: 1.11-1.59) at recovery phase of dobutamine stress echocardiography. The best multivariable model to predict cardiac events included new wall motion abnormality (hazard ratio: 5.34; confidence interval: 1.71-16.59) at recovery phase of dobutamine stress echocardiography, after controlling for clinical and peak dobutamine stress echocardiography data. Conclusions Myocardial ischemia at recovery phase of dobutamine stress echocardiography is an independent predictor of cardiac events and has an incremental value when added to ischemia at peak.

Patients with peripheral arterial disease (PAD) are at increased risk for ESRD and cardiovascular events. The primary objective was to assess the association between ankle-brachial index (ABI) values and renal outcome. The secondary objective was to evaluate whether statins and angiotensin-converting enzyme inhibitors (ACEI) are associated with improved renal and cardiovascular outcome in patients with PAD. In a prospective observational cohort study of 1940 consecutive patients with PAD, ABI was measured and chronic statin and ACEI therapy was noted at baseline. Serial creatinine concentrations were obtained at baseline, 6 mo, and every year after enrollment. End points were ESRD, all-cause mortality, and cardiac events during a median follow-up period of 8 yr. Baseline estimated GFR

Patients with heart failure (HF) scheduled for vascular surgery have an increased risk of adverse postoperative outcome, and stratification usually depends on dichotomous risk factors. A quantitative prognostic model for patients with HF was developed using wall motion patterns during dobutamine stress echocardiography (DSE). A total of 295 consecutive patients (mean age 67 +/- 12 years) with ejection fractionor =35% were studied. During DSE, wall motion patterns of dysfunctional segments were scored as scar, ischemia, or sustained improvement. Cardiac death and myocardial infarction were noted perioperatively and during 5 years of follow-up. Of 4,572 dysfunctional segments; 1,783 (39%) had ischemia, 1,280 (28%) had sustained improvement, and 1,509 (33%) had scar. In 212 patients,or =1 ischemic segment was present; 83 had only sustained improvement. Perioperative and late cardiac event rates were 20% and 30%, respectively. Using multivariate analysis, number of ischemic segments was associated with perioperative cardiac events (odds ratio per segment 1.6, 95% confidence interval 1.05 to 1.8), whereas number of segments with sustained improvement was associated with improved outcome (odds ratio per segment 0.2, 95% confidence interval 0.04 to 0.7). Multivariate independent predictors of late cardiac events were age and ischemia. Sustained improvement was associated with improved survival. In conclusion, DSE provides accurate risk stratification of patients with HF undergoing vascular surgery.

Screening for abdominal aortic aneurysms (AAAs) in patients at risk will become more cost effective if a simple, inexpensive, and reliable ultrasound device is available. The aim of this study was to compare a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner (based on bladder scan technology) with computed tomography (CT) for diagnosing AAA. A total of 146 patients (mean age 69 +/- 10 years; 127 men) were screened for the presence of AAAs (diameter3 cm) using CT. All patients were examined with the handheld ultrasound device and the volume scanner. Maximal diameters and volumes were used for the analyses. AAAs were diagnosed by CT in 116 patients (80%). The absolute difference of aortic diameter between ultrasound and CT was5 mm in 88% of patients. Limits of agreement between ultrasound and CT (-6.6 to 9.4 mm) exceeded the limits of clinical acceptability (+/-5 mm). An excellent correlation between ultrasound and CT was observed (r = 0.98). The correlation coefficient between the volume scanner and CT was 0.86, with agreement of 90% and kappa value of 0.73. Using an optimal cut-off value of56 ml, defined by receiver-operating characteristic curve analysis, sensitivity, specificity, and the positive and negative predictive values of the volume scanner for detecting AAA were 90%, 90%, 97%, and 71%, respectively. In conclusion, this study shows that a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner can effectively identify patients with AAAs confirmed by CT.

Purpose The study's objective was to evaluate the prognostic value of left ventricular ejection fraction and stress-induced ischemia during dobutamine stress echocardiography, in addition to ankle-brachial index measurements and clinical risk factors in patients with suspected or known peripheral arterial disease. Methods In 852 patients with suspected or known peripheral arterial disease (mean age 63 years, 70% male), the ankle-brachial index was measured, left ventricular ejection fraction was assessed, and all patients underwent additional stress testing. Endpoints were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). Results During a mean follow-up of 7.6±4.4 years, death occurred in 288 patients (34%), and hard cardiac events occurred in 216 patients (25%). Mean left ventricular ejection fraction was 50%±17%, and stress-induced ischemia was observed in 352 patients (41%). In multivariate analysis with adjustment for clinical risk factors and ankle-brachial index, each 5% decrease in left ventricular ejection fraction was associated with increased all-cause mortality (hazard ratio [HR] 1.05, 95% confidence interval [CI], 1.02-1.09) and hard events (HR 1.14, 95% CI, 1.08-1.21). Stress-induced ischemia also independently predicted all-cause mortality (HR 2.01, 95% CI, 1.38-2.79) and hard events (HR 2.06, 95% CI, 1.39-3.08). Left ventricular ejection fraction and stress-induced ischemia provided incremental prognostic information over clinical data and ankle-brachial index values ( P Conclusions Left ventricular ejection fraction and stress-induced ischemia independently predict long-term outcome and improve prognostic risk assessment, in addition to ankle-brachial index and clinical risk factors in patients with suspected or known peripheral arterial disease.

Debate surrounds the impact of renal function on the prognostic value of minor troponin T release in vascular surgery patients. The objective of this study was to assess the long-term prognostic value of minor degrees of troponin T release in patients who undergo major vascular surgery, especially those with concomitant renal dysfunction. Survivors of major noncardiac vascular surgery (n = 558) were preoperatively screened for cardiac risk factors and renal function. Serial troponin T was measured on days 1, 3, and 7 after surgery, using a threshold of 0.03 ng/ml. All-cause mortality and major adverse cardiac events (MACEs) were noted during follow-up (mean 3.5 +/- 2.0 years). Minor (0.03 to 0.09 ng/ml) and major (or =0.1 ng/ml) release of troponin T was observed in 5% and 8%, respectively. During follow-up, 21% of the patients died and 15% experienced MACEs. After adjustment for the estimated glomerular filtration rate, patients with minor and major troponin T release were at comparable increased risk for late mortality (hazard ratio [HR] 3.43, 95% confidence interval [CI] 1.79 to 6.58, and HR 3.72, 95% CI 2.37 to 5.85, respectively), and MACEs (HR 5.47, 95% CI 2.60 to 11.48, and HR 6.32, 95% CI 3.82 to 10.48, respectively) compared with patients with troponin T release0.03 ng/ml. Tests for heterogeneity revealed that minor and major troponin T release have prognostic value across the entire spectrum of renal function. In conclusion, marginal elevations of troponin T strongly predict late mortality and MACEs after major vascular surgery, irrespective of renal function. A currently underestimated high-risk subgroup of patients may be identified using a lower troponin T threshold.

BackgroundScreening for abdominal aortic aneurysms (AAA) is cost-effective and timely repair improves outcome. Using standard ultrasound (US) an AAA can be accurately diagnosed or ruled-out. However, this requires training and bulk equipment.AimTo evaluate the diagnostic potential of a new hand-held ultrasound bladder volume indicator (BVI) in the setting of AAA screening.MethodsIn total, 94 patients (66±14 years, 67 men) referred for atherosclerotic disease were screened for the presence of AAA (diameter >30mm using US). All patients underwent both examinations, with US and BVI. Using the BVI, aortic volume was measured at 6 pre-defined points. Maximal diameters (US) and volumes (BVI) were used for analyses.ResultsIn 54 (57%) patients an AAA was diagnosed using US. The aortic diameter by US correlated closely with aortic volume by BVI (r=0.87, p

To determine the relationship between baseline plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and the presence and extent of myocardial ischemia during dobutamine stress echocardiography (DSE).NT-proBNP was measured in 170 consecutive patients prior to DSE. Rest wall motion abnormalities (RWMAs) and new wall motion abnormalities (NWMAs) were scored using a 5-point, 17-segment model. Kruskal-Wallis tests were applied to study differences in NT-proBNP levels between patients with normal DSE, RWMAs but no NWMAs, and NWMAs, and (in patients with NWMAs) between those with 1-2, 3-4 and4 ischemic segments. Univariate and multivariate regression analyses were used to determine the value of NT-proBNP in predicting NWMAs.The median NT-proBNP level was 110 ng/l (interquartile range: 42-389 ng/l). Median NT-proBNP was 59, 321 and 440 ng/l in patients with normal DSE, with RWMAs but no NWMAs, and with NWMAs, respectively (P0001). Among patients with NWMAs, median NT-proBNP was associated with the number of ischemic segments: 364, 710 and 2376 ng/l in patients with 1-2, 3-4 and4 ischemic segments, respectively (P0.001). Elevated NT-proBNP levels were significantly associated with NWMAs (odds ratio per 100 ng/l increase: 1.14, 95% confidence interval: 1.1-1.2) in a multivariate analysis of clinical baseline variables and RWMAs.Elevated baseline levels of NT-proBNP are associated with the presence and extent of myocardial ischemia during DSE, independent of the presence of RWMAs.

Objective To detect origin and course and to evaluate viability in patients with anomalous RCA. Design 3D coronary MR angiography and viability study using gadolinium-enhanced magnetic resonance imaging (Gd-MRI) was performed. Setting A tertiary hospital center. Patients Four patients, selected from the catheter lab, were studied. Results Anomalous RCA from the left sinus of Valsalva was identified in all patients. Inferior myocardial infarction was documented in three patients. Conclusions Magnetic resonance imaging can non-invasively identify anomalous RCA and perform viability study in the same examination.

Dobutamine stress echocardiography (DSE) has a modest sensitivity for detecting single-vessel coronary artery disease (CAD). This study assessed the additional diagnostic value of new or worsening wall motion abnormalities during recovery after acute administration of beta blockers. The study population consisted of 200 patients (mean 59 +/- 11 years of age, 144 men), who underwent DSE. Images were acquired at rest, low dose, peak dose, and during recovery. Patients received intravenous metoprolol (1 to 5 mg/min). The dose was adjusted to achieve a recovery heart rate within a 10% range of heart rate at rest. Coronary angiography was performed within 2 months. Inducible new wall motion abnormalities were observed in 168 patients (84%) at peak stress. An additional 14 patients (7%) developed new or worsening wall motion abnormalities during recovery. CAD was detected in 182 patients (86 had single-vessel CAD). Sensitivity, specificity, and accuracy of DSE were 88%, 65%, and 73% at peak stress and 97%, 65%, and 74% during recovery. Sensitivity was particularly higher during recovery than during peak stress in patients with single-vessel CAD (98% vs 81%, p0.001). In conclusion, assessment of wall motion abnormalities during the recovery phase after acute beta blockade improves sensitivity of DSE, particularly in patients with single-vessel CAD.

Complications of any mechanical prosthesis include thrombus or pannus formation. In our case report we demonstrate that prosthetic aortic valve regurgitation due to pannus formation may be intermittent and non-cyclic in pattern and therefore not obvious at the time of original clinical examination. Under these conditions and as transesophageal echocardiography cannot be repeated promptly, transthoracic 2-D and Doppler echocardiography should be available at any time when symptoms occur and present the method of choice for acute patient evaluation. Thrombolysis seems to be the first treatment of choice in case of thrombus formation and re-do surgery in case of pannus formation.

Aims Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA(1c)) levels are associated with increased cardiac ischaemic events in vascular surgery patients. Methods Baseline glucose and HbA(1c) were measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose >= 7.0 or random glucose >= 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). Results Mean (+/- SD) level for glucose was 6.3 +/- 2.3 mmol/l and for HbA(1c) 6.2 +/- 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA(1c) > 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. Conclusions Impaired glucose regulation and elevated HbA(1c) are risk factors for cardiac ischaemic events in vascular surgery patients.

Prognostic information in peripheral arterial disease (PAD) may provide the basis for optimal management strategies at an early stage. This study aimed to develop a prognostic risk index for long-term mortality in patients with PAD.In a single-center observational cohort study, 2642 patients with an ankle-brachial index of 0.90 or lower were randomly divided into derivation (n = 1332) and validation (n = 1310) cohorts. Cox regression analysis with stepwise backward elimination identified predictors of 1-year, 5-year, and 10-year mortality in the derivation cohort. Weighted points were assigned to each predictor. Index discrimination was determined in both the derivation and validation cohorts.During 10 years of follow-up, 42.2% and 40.4% of patients died in the derivation and validation cohorts, respectively. The risk index for 10-year mortality (+ points) included renal dysfunction (+12), heart failure (+7), ST-segment changes (+5), age greater than 65 years (+5), hypercholesterolemia (+5), ankle-brachial index lower than 0.60 (+4), Q-waves (+4), diabetes (+3), cerebrovascular disease (+3), and pulmonary disease (+3). Statins (-6), aspirin (-4), and beta-blockers (-4) were associated with reduced 10-year mortality. Patients were stratified into low (0 points), low-intermediate (0-5 points), high-intermediate (6-9 points), and high (9 points) risk categories, according to risk score. Ten-year mortality rates were 22.1%, 32.2%, 45.8%, and 70.4%, respectively (P.001) and comparable to mortality in the validation cohort. C statistics demonstrated good discrimination in both the derivation (0.72) and validation cohorts (0.73).A prognostic risk index for long-term mortality stratified patients with PAD into different risk categories. This may be useful for risk stratification, patient counseling, and medical decision making.

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). KaplanMeier 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.

BACKGROUND: Carotid artery stenting (CAS) is less invasive than endarterectomy. This study examined differences in perioperative myocardial ischemia, troponin T release and clinical cardiac events in patients undergoing CAS compared with endarterectomy. METHODS: In an observational study, CAS was performed in 24 and carotid endarterectomy in 44 patients. Before surgery, clinical risk factors were noted and dobutamine stress echocardiography was performed for cardiac risk assessment. Perioperative continuous 72-h 12-lead electrocardiographic monitoring was used for myocardial ischemia detection. Troponin T (>0.03 ng/ml) was measured on postoperative days 1, 3, 7 or before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted during hospital stay and during follow-up (mean: 1.2 years). RESULTS: No significant differences were observed between patients with CAS and endarterectomy in terms of baseline clinical characteristics, dobutamine stress echocardiography results and cardiovascular medication. Perioperative myocardial ischemia was detected in nine patients (13%), perioperative troponin T release in seven patients (10%), early cardiac events in one patient (1%) and late cardiac events in three patients (4%). Significantly less perioperative myocardial ischemia was observed in patients with CAS compared with endarterectomy (0 versus 21%, P=0.02). Troponin T release was also significantly lower in CAS, compared with endarterectomy (0 versus 16%, P=0.04). Early (0 versus 2%, P=0.5) and late (0 versus 7%, P=0.2) cardiac events were lower after CAS, compared with endarterectomy, although these differences were not significant. CONCLUSION: CAS is associated with a lower incidence of perioperative myocardial ischemia and troponin T release, compared with endarterectomy.

Background Peripheral arterial disease (PAD) is a risk factor for cardiovascular events. This study assessed the prognostic significance of repeated ankle-brachial index (ABI) measurements at rest and after exercise in patients with PAD receiving conservative treatment. Methods In a cohort study of 606 patients (mean age 62 ± 12 years, 68% male), ABI at rest and after exercise was measured at baseline and after 1 year. Patients with reductions in ABI were divided into three equally-sized groups (minor, intermediate and major reductions) and were compared to patients without reductions. During a mean follow-up of 5 ± 3 years, all-cause mortality, cardiac events, stroke and progression to kidney failure were noted. Results Death was recorded in 83 patients (14%) of which 49% were due to cardiac causes. Non-fatal myocardial infarction occurred in 38 patients (6%), stroke in 46 (8%) and progression to kidney failure in 35 (6%). By multivariate analysis, patients with major declines in resting (>20%) and post-exercise (>30%) ABI were at increased risk of all-cause mortality (HR: 3.3, 95% CI: 1.5–7.2, HR: 3.0, 95% CI: 1.4–6.4, respectively), cardiac events (HR: 3.1, 95% CI: 1.3–7.2, HR: 2.4, 95% CI: 1.1–5.6, respectively), stroke (HR: 4.2, 95% CI: 1.6–10.4, HR: 3.9, 95% CI: 1.4–10.2, respectively) and kidney failure (HR: 2.7, 95% CI: 1.1–7.5, HR: 6.9, 95% CI: 1.5–31.5, respectively), compared to patients with no declines in ABI. Conclusions This study shows that major 1-year declines in resting and post-exercise ABI are associated with all-cause mortality, cardiac events, stroke and kidney failure in patients with PAD.

Aim We tested the hypothesis that shortening of diastolic pressure half time (PHT) of left anterior descending (LAD) coronary flow in patients with old reperfused anterior myocardial infarction (MI) is related to the presence of permanent myocardial damage of the reperfused area. Methods and results We studied 49 patients divided into: group A: 15 patients with previous anterior MI and evidence of myocardial scar; group B: 10 patients with previous anterior MI and no evidence of myocardial scar and group C: 24 patients without anterior MI. All patients underwent coronary angiography at least 6 months after an index event and any reperfusion procedure. Group A patients had lower PHT (199 +/- 62 ms) than group C (377 +/- 103 ms, p = 0.0001) and group B (316 +/- 154 ms, p = 0.029) patients. No other LAD flow velocity parameter differed among the 3 groups. A PHT value of 265 ms discriminated patients with scarred anteriorwallwith a sensitivity of 79% and a specificity of 94% (0.88, p < 0.001). Conclusion Shortening of the LAD flow diastolic PHT in patients with remote, reperfused anterior MI reflects scarred myocardial tissue in the anteroapical wall while patients who maintain diastolic wall thickness after an acute coronary syndrome have PHT similar to patients without anterior MI.

Background: In patients undergoing exercise testing a hypotensive response is associated with a poor prognosis. There is limited information regarding the prognostic significance of hypotension during dobutamine stress test. This study investigates the association between a severe hypotensive response during DSE and long-term prognosis. Methods: Patients (3381) under-went dobutamine stress echocardiography (DSE). Blood pressure was measured automatically at rest and at the end of every dose-step. Wall motion was scored using a 16-segement, 5-point score. Ischemia was defined by the presence of new wall motion abnormalities. Hypotensive response during DSE was defined as mild (MHR) when systolic blood pressure (SBP) dropped < 20 mmHg between rest and peak stress, and severe (SHR) when SBP dropped < 20 mmHg. During follow-up all cause mortality and MACE (cardiac death or non-fatal myocardial infarction) were noted. Results: MHR and SHR occurred in 936 (28%) and 521 (15%) patients, respectively. Independent predictors of SHR were older age, new or worsening wall motion abnormalities and history of hypertension. During follow-up of 4.5 (+/- 3.3) years, 920 patients died, of which 555 due to cardiac causes, and 713 patients experienced a MACE. After adjustment for baseline characteristics and DSE results SHR during DSE was independently associated with increased long-term cardiac death (HR: 1.3, 95% CI: 1.03 - 1.6) and MACE (HR: 1.34, 95% CI: 1.1 - 1.6), while MHR was not associated with a worse outcome. Conclusions: Severe hypotensive response during DSE independently predicts cardiac death and MACE in patients with known or suspected coronary artery disease. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

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: This study was conducted to determine the association between baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) and myocardial ischemia, troponin T release and heart rate variability (HRV) in patients undergoing major vascular surgery. METHODS: In a prospective study, 182 vascular surgery patients were evaluated by clinical risk factors, dobutamine stress echocardiography and baseline NT-proBNP levels. Myocardial ischemia was detected by continuous 12-lead electrocardiographic monitoring starting 1 day before to 2 days after surgery. Troponin T (>0.03 ng/ml) was measured on day 1, 3 and 7 postoperatively and before discharge. HRV was measured at the day prior to surgery. RESULTS: The median NT-proBNP level was 184 ng/l (interquartile range: 79-483 ng/l). Myocardial ischemia was detected in 21% and troponin T release in 17% of patients. After adjustment for clinical risk factors and stress echocardiography results, higher NT-proBNP levels (per 1 ng/l increase in the natural logarithm of NT-proBNP) were associated with a higher incidence of myocardial ischemia (odds ratio: 1.59, 95% confidence interval: 1.21-2.08, P

Glycemic control may be an underestimated risk factor in diabetic patients with peripheral arterial disease (PAD). Chronic statin therapy may improve glycemic control and outcome in these patients. In an observational cohort study of 425 consecutive diabetic patients with PAD, chronic statin therapy was noted, the ankle-brachial index was measured, and serial glycemic hemoglobin (HbA(1c)) measurements were obtained. During follow-up (median 7 years), all-cause mortality and cardiac death occurred in 37% and 22%, respectively. Decreases in HbA(1c) and HbA(1c) variability independently predicted outcome in addition to baseline ankle-brachial index values. Patients with chronic statin therapy were more likely to have decreasing HbA(1c) values (adjusted hazard ratio [HR]= 1.86, 95% confidence interval [CI] 1.27-2.74) and HbA(1c) values

In patients with left ventricular (LV) dysfunction the mitral leaflet coaptation point (CPMA) is displaced towards the LV apex. The aim of our study was to estimate the value of CPMA measurement as a simple index regarding the acute effects of cardiac resynchronization therapy (CRT), which is coming to be an established method of treatment for congestive heart failure (CHF).We studied 20 patients with CHF (NYHA III-IV) and LV ejection fraction (LVEF) 22 +/- 4%. All patients received CRT and an echocardiogram was performed within 24-48 hours. The echocardiographic indices LV end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD), LVEF, mitral annulus diameter (MAD), and the degree of intraventricular desynchronization, were measured at CRT off and CRT on. The CPMA, the distance between the coaptation point of the mitral leaflets and the mitral annulus, was measured from the apical 4-chamber view in end-systole at both CRT on and CRT off.CRT improved both the contractility and dimensional indices in CHF patients. CPMA decreased from 11.3 +/- 2 mm at CRT off to 9.1 +/- 1.8 mm after CRT on (p0.001) and MAD from 38.9 +/- 3.9 mm at CRT off to 37.5 +/- 3.7 mm at CRT on (p0.002). LVEF improved from 24.5 +/- 5.7% at CRT off to 29.5 +/- 5.1% at CRT on (p0.001). There was an improvement in LV synchronization from 88 +/- 7 ms at CRT off to 48 +/- 3 ms at CRT on (p.001). CPMA was correlated with MAD (r = 0.52, p0.05 and r = 0.59, p0.05 at CRT off and CRT on, respectively). Moreover, the absolute change in CPMA was correlated with LVESD (r = 0.68) and LVEDD (r = 0.65), both p0.05, with the time difference of the basal segments of the septal and lateral wall at CRT on (r = 0.68, p0.01), and inversely correlated with LVEF (r = -0.55, p0.05).In patients with severe LV systolic dysfunction and dilatation CRT was associated with an improvement in both CPMA and MAD.