Coronary Artery Disease: Pfisterer M

Daemen J, Simoons ML, Wijns W, Bagust A, Bos G, Bowen JM, Braunwald E, Camenzind E, Chevaliers B, DiMario C, Fajadeto J, Gitt A, Guagliumi G, Hillege HL, James S, Jüni P, Kastrati A, Kloth S, Kristensen SD, Krucoff M, Legrand V, Pfisterer M, Rothman M, Serruys PW, Silber S, Steg PG, Tariah I, Wallentin L, Windecker SW, Aimonetti A, Allocco D, Berenger M, Boam A, Calle JP, Campo G, Carlier S, de Schepper J, Di Bisceglie G, Dobbels H, Farb A, Ghislain JC, Hellbardt S, ten Hoedt R, Isaia C, de Jong P, Lekehal M, LeNarz L, Mhullain FN, Nagai H, Patteet A, Paunovic D, Potgieter A, Purdy I, Raveau-Landon C, Ternstrom S, Van Wuytswinkel J, Waliszewski M, Anonymous00071. · Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands. · EuroIntervention. · Pubmed #19284063 No free full text.

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Rickenbacher P, Pfisterer M. · No affiliation provided · Eur Heart J. · Pubmed #12093046 No free full text.

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Kaiser C, Pfisterer M. · Abteilung Kardiologie, Universitätsspital Basel, Schweiz. · Herz. · Pubmed #17607536 No free full text.

Abstract: The success story of drug-eluting stents (DES) with which the "last" problem of coronary stenting seemed to be solved and which led to an unprecedented enthusiasm with which cardiologists embraced this new treatment modality of coronary artery disease was recently challenged by the detection of late stent thromboses leading to myocardial infarction and death many months or even years after stent implantation. The BAsel Stent Kosten Effektivitaets Trial (BASKET) and especially the observational BASKET-LAte Thrombotic Events (BASKET-LATE) follow-up study demonstrated that late clinical events related to late DES thrombosis is a real and worrisome complication of DES. In the meantime, these findings have been confirmed by large registry data and meta-analyses of late followups of prospective trials. This has led to vivid discussions and an urgently organized Food and Drug Administration (FDA) panel meeting which cautioned the use of DES particularly in "off-label" use but warned also to put the risks of late events after DES implantation in relation to the early important benefit of these stents indicating that there is no hint for an excess mortality with DES. The FDA suggested that 12 months of dual antiplatelet therapy should be given to all patients treated with DES as long as they are not at increased risk of bleeding. Further studies are needed to identify patients at risk for late stent thrombosis and patient subgroups with a particularly high benefit after implantation of DES. In addition, new second-generation DES with a decreased risk for late stent thrombosis have to be developed.

Claude J, Schindler C, Kuster GM, Schwenkglenks M, Szucs T, Buser P, Osswald S, Kaiser C, Grädel C, Estlinbaum W, Rickenbacher P, Pfisterer M, Anonymous00031. · Division of Cardiology, University Hospital, CH-4031 Basel, Switzerland. · Eur Heart J. · Pubmed #15589636 links to  free full text

Abstract: AIM: To compare benefits and costs of invasive versus medical management in elderly patients with chronic angina. METHODS AND RESULTS: In a predefined subgroup of 188 patients of the Trial of Invasive versus Medical therapy in Elderly patients with chronic angina (TIME), one-year benefits were assessed as freedom from major events and improvements in symptoms and quality of live. Costs were determined as one-year costs of resource utilisation. Invasive patients had higher 30-day, but lower months 2-12 hospital and intervention costs than medical patients, resulting in somewhat higher one-year costs for invasive management (p=0.08). However, billing data available for a subgroup of patients showed higher practitioner's charges in the medical patients (adjusted p=0.0015). Incremental costs to prevent one major event by invasive management averaged CHF 10100 (95% CI: -800 to 28300) or 6965, ranging from average CHF 5100 (euro 3515) to CHF 11600 (euro 8000) in a best, compared to a worst, case scenario. CONCLUSIONS: Early increased costs of revascularization in invasive patients were balanced after one year by increased practitioners' charges and symptom-driven late revascularizations in medical patients. Therefore, the invasive strategy with improved clinical effectiveness at only marginally higher costs as medical management was cost-effective. Costs should not be an argument against invasive management of elderly patients with chronic angina.

Pfisterer M, Buser P, Osswald S, Allemann U, Amann W, Angehrn W, Eeckhout E, Erne P, Estlinbaum W, Kuster G, Moccetti T, Naegeli B, Rickenbacher P, Anonymous00029. · Department of Cardiology, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland. · JAMA. · Pubmed #12622581 links to  free full text

Abstract: CONTEXT: The risk-benefit ratio of invasive vs medical management of elderly patients with symptomatic chronic coronary artery disease (CAD) is unclear. The Trial of Invasive versus Medical therapy in Elderly patients (TIME) recently showed early benefits in quality of life from invasive therapy in patients aged 75 years or older, although with a certain excess in mortality. OBJECTIVE: To assess the long-term value of invasive vs medical management of chronic CAD in elderly adults in terms of quality of life and prevention of major adverse cardiac events. DESIGN: One-year follow-up analysis of TIME, a prospective randomized trial with enrollment between February 1996 and November 2000. SETTING AND PARTICIPANTS: A total of 282 patients with Canadian Cardiac Society class 2 or higher angina despite treatment with 2 or more anti-anginal drugs who survived for the first 6 months after enrollment in TIME (mean age, 80 years [range, 75-91 years]; 42% women), enrolled at 14 centers in Switzerland. INTERVENTIONS: Participants were randomly assigned to undergo coronary angiography followed by revascularization (if feasible) (n = 140 surviving 6 months) or to receive optimized medical therapy (n = 142 surviving 6 months). MAIN OUTCOME MEASURES: Quality of life, assessed by standardized questionnaire; major adverse cardiac events (death, nonfatal myocardial infarction, or hospitalization for acute coronary syndrome) after 1 year. RESULTS: After 1 year, improvements in angina and quality of life persisted for both therapies compared with baseline, but the early difference favoring invasive therapy disappeared. Among invasive therapy patients, later hospitalization with revascularization was much less likely (10% vs 46%; hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.11-0.32; P<.001). However, 1-year mortality (11.1% for invasive; 8.1% for medical; HR, 1.51; 95% CI, 0.72-3.16; P =.28) and death or nonfatal myocardial infarction rates (17.0% for invasive; 19.6% for medical; HR, 0.90; 95% CI, 0.53-1.53; P =.71) were not significantly different. Overall major adverse cardiac event rates were higher for medical patients after 6 months (49.3% vs 19.0% for invasive; P<.001), a difference which increased to 64.2% vs 25.5% after 12 months (P<.001). CONCLUSIONS: In contrast with differences in early results, 1-year outcomes in elderly patients with chronic angina are similar with regard to symptoms, quality of life, and death or nonfatal infarction with invasive vs optimized medical strategies based on this intention-to-treat analysis. The invasive approach carries an early intervention risk, while medical management poses an almost 50% chance of later hospitalization and revascularization.

Arrigo I, Brunner-LaRocca H, Lefkovits M, Pfisterer M, Hoffmann A. · Division of Cardiology, University Hospital, Basel, Switzerland. · Eur J Cardiovasc Prev Rehabil. · Pubmed #18525385 No free full text.

Abstract: BACKGROUND: Methods to ensure sustained benefits of cardiac rehabilitation need to be explored. The aim was to assess the effect of a home-based intervention (INT) on exercise adherence and risk factors after cardiac rehabilitation. DESIGN: Prospective randomized study. METHODS: We evaluated patients who were followed for 1 year after either inpatient (ICR) or outpatient cardiac rehabilitation (OCR) by assessment of exercise capacity, physical activity, risk factors and quality of life, both at the completion of rehabilitation, and after 1 year. Patients were randomized to either be instructed how to use a diary of physical activities complemented by quarterly group meetings (INT) or to receive standard treatment (usual care). RESULTS: Two hundred and sixty-one patients gave consent to be reevaluated after 1 year. Of these patients 33 were lost to follow-up (two deaths); thus 228 patients had complete 1-year follow-up data (195 male and 33 female, 91% with coronary artery disease). At 1-year follow-up significantly more patients of the INT group than of the control group adhered to regular physical activity (73 vs. 40%, P<0.0001). Moreover, INT patients showed a better evolution of body mass index and lipid values. In a stepwise multiple regression analysis the following variables showed a significant impact on regular physical activity at follow-up: study INT [odds ratio (OR): 4.19, P<0.0001], previous cardiac surgery (OR: 2.50, P=0.008), BMI at baseline (OR: 0.89, P=0.018) and quality of life at baseline (OR: 1.58, P=0.041). CONCLUSION: Sustained benefits of cardiac rehabilitation can be documented 1 year after both inpatient and outpatient programmes. Self-monitoring of physical activity greatly increased long-term adherence to regular exercise, which in turn was associated with greater improvements of risk factors and quality of life.

Erne P, Schoenenberger AW, Zuber M, Burckhardt D, Kiowski W, Dubach P, Resink T, Pfisterer M. · Kantonsspital, Luzern, Switzerland. · Eur Heart J. · Pubmed #17644512 links to  free full text

Abstract: AIMS: To determine the effect of anti-ischaemic drug therapy on long-term outcomes of asymptomatic patients without coronary artery disease (CAD) history but silent exercise ST-depression. METHODS AND RESULTS: In a randomized multicentre trial, 263 of 522 asymptomatic subjects without CAD but at least one CAD risk factor in whom silent ischaemia by exercise ECG was confirmed by stress imaging were asked to participate. The 54 (21%) consenting patients were randomized to anti-anginal drug therapy in addition to risk factor control (MED, n = 26) or risk factor control-only (RFC, n = 28). They were followed yearly for 11.2 +/- 2.2 years. During 483 patient-years, cardiac death, non-fatal myocardial infarction, or acute coronary syndrome requiring hospitalization or revascularization occurred in 3 (12%) of MED vs. 17 (61%) of RFC patients (P < 0.001). In addition, MED patients had consistently lower rates of exercise-induced ischaemia during follow-up, and left ventricular ejection fraction remained unchanged (-0.7%, P = 0.597) in contrast to RFC patients in whom it decreased over time (-6.0%, P = 0.006). CONCLUSION: Anti-ischaemic drug therapy and aspirin seem to reduce cardiac events in subjects with asymptomatic ischaemia type I. In such patients, exercise-induced ST-segment depression should be verified by stress imaging; if silent ischaemia is documented, anti-ischaemic drug therapy and aspirin should be considered.

Erne P, Schoenenberger AW, Burckhardt D, Zuber M, Kiowski W, Buser PT, Dubach P, Resink TJ, Pfisterer M. · Division of Cardiology, Kantonsspital Luzern, Luzern, Switzerland. · JAMA. · Pubmed #17488963 links to  free full text

Abstract: CONTEXT: The effect of a percutaneous coronary intervention (PCI) on the long-term prognosis of patients with silent ischemia after a myocardial infarction (MI) is not known. OBJECTIVE: To determine whether PCI compared with drug therapy improves long-term outcome of asymptomatic patients with silent ischemia after an MI. DESIGN, SETTING, AND PARTICIPANTS: Randomized, unblinded, controlled trial (Swiss Interventional Study on Silent Ischemia Type II [SWISSI II]) conducted from May 2, 1991, to February 25, 1997, at 3 public hospitals in Switzerland of 201 patients with a recent MI, silent myocardial ischemia verified by stress imaging, and 1- or 2-vessel coronary artery disease. Follow-up ended on May 23, 2006. INTERVENTIONS: Percutaneous coronary intervention aimed at full revascularization (n = 96) or intensive anti-ischemic drug therapy (n = 105). All patients received 100 mg/d of aspirin and a statin. MAIN OUTCOME MEASURES: Survival free of major adverse cardiac events defined as cardiac death, nonfatal MI, and/or symptom-driven revascularization. Secondary measures included exercise-induced ischemia and resting left ventricular ejection fraction during follow-up. RESULTS: During a mean (SD) follow-up of 10.2 (2.6) years, 27 major adverse cardiac events occurred in the PCI group and 67 events occurred in the anti-ischemic drug therapy group (adjusted hazard ratio, 0.33; 95% confidence interval, 0.20-0.55; P<.001), which corresponds to an absolute event reduction of 6.3% per year (95% confidence interval, 3.7%-8.9%; P<.001). Patients in the PCI group had lower rates of ischemia (11.6% vs 28.9% in patients in the drug therapy group at final follow-up; P = .03) despite fewer drugs. Left ventricular ejection fraction remained preserved in PCI patients (mean [SD] of 53.9% [9.9%] at baseline to 55.6% [8.1%] at final follow-up) and decreased significantly (P<.001) in drug therapy patients (mean [SD] of 59.7% [11.8%] at baseline to 48.8% [7.9%] at final follow-up). CONCLUSION: Among patients with recent MI, silent myocardial ischemia verified by stress imaging, and 1- or 2-vessel coronary artery disease, PCI compared with anti-ischemic drug therapy reduced the long-term risk of major cardiac events. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00387231.

Muzzarelli S, Pfisterer M, Anonymous00439. · Division of Cardiology, University Hospital, Basel, Switzerland. · Am Heart J. · Pubmed #17070178 No free full text.

Abstract: BACKGROUND: Anemia correlates with worse outcome in patients with heart failure, after myocardial infarction or angioplasty. Its prevalence increases with age, but the influence of anemia on outcome of elderly patients with stable symptomatic coronary artery disease (CAD) is unknown. Therefore, we assessed the impact of anemia on long-term outcome in elderly patients with CAD. METHODS: Hemoglobin-related outcome was examined in 253 patients of the TIME study. Patients > or = 75 years old were randomly assigned to an invasive or optimized medical strategy and followed for a median of 4 years for death, nonfatal myocardial infarction, or hospitalization for CAD. Depending on their hemoglobin (Hb) level, patients were divided in quartiles (Q). Anemia was defined as Hb < 13 g/dL for men and < 12 g/dL for women. RESULTS: Compared with nonanemic patients, those with previously unknown anemia were older (79 +/- 3 vs 80 +/- 4 years, P < .01), had more chronic renal failure (6.7% vs 26.4%, P < .01), diabetes (18.9% vs 30.1%, P = .05), and were more likely to have > 2 comorbidities (21.7% vs 38.4%, P < .01). After adjustment for baseline differences, a decrease in 1 g/dL Hb increased the risk of all-cause death by 34% (adjusted risk ratio 1.34, P < .01), of cardiac death by 28% (adjusted risk ratio 1.28, P = .02), and of major adverse clinical events in patients with Hb levels < 13.3 g/dL by 23% (adjusted risk ratio 1.23, P = .01). CONCLUSION: Anemia proved to be an independent predictor of death and major clinical adverse events among elderly patients with stable symptomatic CAD.

Kaiser C, Jeger R, Wyrsch S, Schoeb L, Kuster GM, Buser P, Osswald S, Bernet F, Brett W, Grize L, Pfisterer M, Anonymous00314. · Department of Cardiology, University Hospital, CH-4031 Basel, Switzerland. · Int J Cardiol. · Pubmed #16225942 No free full text.

Abstract: BACKGROUND: Registry patients are generally older and more sick than patients enrolled in trials questioning the generalizability of trial results. We assessed whether such a selection bias also exists in elderly patients with chronic angina referred for catheterization. METHODS AND RESULTS: All 119 patients age>or=75 years with Trial of Invasive versus Medical Therapy in the Elderly (TIME) inclusion but no major exclusion criteria referred for catheterization during the TIME trial inclusion period in four TIME centers were registered and followed-up for one year. Registry patients differed from the 188 trial patients in the same hospitals in that they were younger, somewhat more frequently male, with less antianginal drugs and studied more often after acute chest pain at rest but with more comorbidities than study patients. Left ventricular ejection fraction and vessel disease were similar. One year mortality was 11.4% in registry and 9.6% in invasive TIME patients but differences disappeared after adjustment for baseline differences. Symptomatic status after one year was similar too. CONCLUSIONS: In elderly patients with chronic angina, a bias in the selection for invasive management exists which seems different from that reported in younger patient settings. After adjustment for these selection factors, however, one-year outcome was remarkably similar in registry and trial patients.

Kaiser C, Bremerich J, Haller S, Brunner-La Rocca HP, Bongartz G, Pfisterer M, Buser P. · Division of Cardiology, University Hospital, CH-4031 Basel, Switzerland. · Eur Heart J. · Pubmed #15972287 links to  free full text

Abstract: AIMS: Multislice spiral computed tomography (MSCT) is a promising non-invasive method to diagnose coronary artery disease (CAD). As no detailed comparative evaluation in consecutive patients referred for evaluation of CAD has been reported, this prospective study evaluating 2384 coronary segments in 149 consecutive patients was performed. METHODS AND RESULTS: The coronary artery tree was analysed in 16 segments both for coronary angiography (CA) and MSCT; a luminal narrowing > or = 50% based on visual assessment was considered significant. By MSCT, 77% of 2110 angiographically assessable segments could be evaluated, 94% per patient in proximal and 70% in distal segments (P<0.001). Sensitivity of MSCT to detect significant stenoses was 30% in all, but only 10% in peripheral segments. The main limitations were calcifications in 34% of segments and motion artefacts in 24% of patients. Overall diagnostic sensitivity for the presence of significant CAD was 86% but specificity was only 49%. CONCLUSION: When compared with invasive CA, 16-slice MSCT is of limited diagnostic value for the diagnosis of CAD in consecutive patients. Despite a clinically useful sensitivity for the overall diagnosis of significant CAD, specificity is low. Thus, relevant decisions regarding the need of and suitability for possible revascularization procedures cannot be based on MSCT findings alone.

Schaer BA, Jenni D, Rickenbacher P, Graedel C, Crevoisier JL, Iselin HU, Pfisterer M. · University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland. · Chest. · Pubmed #15821217 links to  free full text

Abstract: STUDY OBJECTIVES: To test the short- and long-term performance of a simple algorithm to detect or rule out acute coronary artery disease (CAD) in patients referred with acute chest pain (CP). DESIGN: Prospective, multicenter study with 30-day and 1-year follow-ups. SETTING: Emergency and coronary care units of two university hospitals and four affiliated teaching hospitals in a suburban region of northern Switzerland. PATIENTS: One hundred sixty-one consecutive patients referred with acute CP with a high CAD risk profile underwent exercise testing (ET) within 24 h if results of two troponin tests and ECG remained normal within 6 h. The patients were discharged if ET results were negative or underwent angiography if the results were positive. MEASUREMENTS AND RESULTS: The primary end point was survival free of death, myocardial infarction (MI), and acute coronary syndrome, as well as the correct diagnosis of CAD in need of revascularization. Failure of the algorithm included events not predicted and false-positive ET results. Symptom-limited ET was performed in 142 patients, and stress imaging was performed in 17 patients. Discharge within 24 h was possible in 76%. Angiography in 21 patients showed no CAD in 4 patients, whereas revascularization was necessary in 17 patients. During follow-up, three patients had an MI (one fatal) and two patients had unstable angina, for an event rate of 3.1%/yr. Overall sensitivity of the algorithm to detect CAD was 71%, whereby six of seven false-positive ET results were due to exercise-induced CP without ECG changes. More importantly, the negative predictive value was 96.4%, indicating that this simple algorithm failed to identify only 3.6% of patients at risk for future events. CONCLUSIONS: Discharge within 24 h after onset of acute CP in high-risk CAD patients is safe, irrespective of CAD history, if ECG findings remain unchanged and troponin test results are normal within 6 h, and if results of adequate ET are negative.

Filipovic M, Jeger RV, Girard T, Probst C, Pfisterer M, Gürke L, Studer W, Seeberger MD. · Department of Anaesthesia, University Hospital Basel, CH 4031 Basel, Switzerland. · Anaesthesia. · Pubmed #15601265 No free full text.

Abstract: The aim of this prospective study was to assess predictors of long-term outcome in patients with documented or suspected coronary artery disease who survive major non-cardiac surgery. The impact of patients' comorbidities, pre-operative heart rate variability and postoperative increase in cardiac troponin I on all-cause mortality and major cardiac events within 2 years was explored using multivariable logistic regression. Six of 173 patients died within the first month after surgery and were excluded from the study. Thirty-four of 167 patients (20%) died 1-24 months after surgery. Independent predictors of all-cause mortality were history of congestive heart failure (odds ratio 6.4 [95%, confidence interval 1.7-24]), pre-operatively depressed heart rate variability (odds ratio 6.4 [95%, confidence interval 1.9-21]), and age > 70 years (odds ratio 4.5 [95%, confidence interval 1.2-16]). In contrast, postoperative elevation of cardiac troponin I did not independently predict all-cause mortality or major cardiac events.

Ammann P, Kiencke S, Schaer B, Cron TA, Sticherling C, Huldi C, Linka A, Buser P, Pfisterer M, Osswald S. · Department of Cardiology, University Hospital Basel, Switzerland. · Swiss Med Wkly. · Pubmed #15243848 links to  free full text

Abstract: OBJECTIVE: To assess the feasibility and longterm outcome of cardiac resynchronization therapy (CRT) in patients with impaired left ventricular function (LVEF <35%), left bundle branch block (QRS >120 ms) and dyspnoea NYHA 0 III at a single centre. METHODS AND RESULTS: Forty-seven patients were referred for implantation of a CRT device. In only 4 patients (9%) the device could not be implanted due to technical problems during the procedure. In the remaining 43 patients (65 +/- 10 years; 7 female) a CRT device was implanted. Follow-up time was 12 +/- 10 months. Twenty-one patients had dilated cardiomyopathy (DCM) and 22 patients had coronary artery disease (CAD). NYHA functional class improved from 3.0 +/- 1.4 to 2.5 +/- 0.7 (p <0.0001), accompanied by an improvement of LVEF [median 20% (range 15-25) vs 32% (range 20-40); p <0.0001]. A significant reduction of hospitalisation time for heart failure was found when the year before and the year after device implantation [18 days (range 5-27) vs 1 day (range 0-3); p <0.0001] were compared. Twelve (28%) patients, 9 with CAD, and 3 with DCM died. Two CAD patients and all patients with DCM who died had a combined CRT device with implantable cardioverter/defibrillator. CONCLUSION: In patients with severely impaired LVEF and wide QRS due to LBBB, CRT is feasible and safe. It improved dyspnoea and LVEF and reduced hospitalisation stays for heart failure during long-term follow-up.

McGuire DK, Newby LK, Bhapkar MV, Moliterno DJ, Hochman JS, Klein WW, Weaver WD, Pfisterer M, Corbalán R, Dellborg M, Granger CB, Van De Werf F, Topol EJ, Califf RM, Anonymous00416. · Donald W. Reynolds Cardiovascular Clinical Research Center at the University of Texas-Southwestern Medical Center, Dallas, Tex, USA. · Am Heart J. · Pubmed #14760321 No free full text.

Abstract: BACKGROUND: Diabetes is associated with an increased risk for coronary artery disease (CAD) and its complications. The relative effect of glucose-lowering strategies of "insulin provision" versus "insulin sensitization" among patients with CAD remains unclear. METHODS: To evaluate the associations of diabetes and hypoglycemic strategies with clinical outcomes after acute coronary syndromes, we analyzed data from 15,800 patients enrolled in the SYMPHONY and 2nd SYMPHONY trials. RESULTS: Compared with nondiabetic patients, patients with diabetes (n = 3101; 19.6%) were older, more often female, more often had prior CAD, hypertension, and hyperlipidemia, and less often were current smokers. The diabetic cohort had higher 90-day unadjusted risk of the composite of death/myocardial infarction (MI)/severe recurrent ischemia (SRI), death/MI, and death alone, as well as a near doubling of 1-year mortality rates. At 1 year, diabetes was associated with significantly higher adjusted risks of death/MI/SRI (OR, 1.3 [95% confidence interval, 1.1, 1.5]) and death/MI (OR, 1.2 [1.0, 1.4]). Hypoglycemic therapy including only insulin and/or sulfonylurea (insulin-providing; n = 1473) was associated with higher 90-day death/MI/SRI compared with therapy that included only biguanide and/or thiazolidinedione therapy (insulin-sensitizing; n = 100) (12.0% vs 5.0%); (adjusted OR, 2.1 [1.2, 3.7]). CONCLUSIONS: Diabetic patients with acute coronary syndromes had worse clinical outcomes. Although the findings regarding the influence of glycemic-control strategies should be interpreted with caution because of the exploratory nature of the analyses and the relatively small sample size of the insulin-sensitizing group, the improved risk-adjusted outcomes associated with insulin-sensitizing therapy underscore the need to further evaluate treatment strategies for patients with diabetes and CAD.

Filipovic M, Jeger R, Probst C, Girard T, Pfisterer M, Gürke L, Skarvan K, Seeberger MD. · Department of Anesthesia, University of Basel/Kantonsspital, Switzerland. · J Am Coll Cardiol. · Pubmed #14642686 No free full text.

Abstract: OBJECTIVES: The aim of this study was to determine whether perioperative measurements of heart rate variability (HRV) and cardiac troponin I (cTnI) add additional prognostic information to established risk scores for first-year mortality in patients at risk of coronary artery disease (CAD) undergoing major noncardiac surgery. BACKGROUND: In cardiac-risk patients undergoing major noncardiac surgery, the short- and long-term prognoses are mainly influenced by perioperative cardiac complications. Heart rate variability and cTnI are important prognostic markers in patients with congestive heart failure and myocardial infarction. METHODS: In a prospective study, 173 patients with CAD or at high risk of CAD undergoing major noncardiac surgery were followed up for one year. The main outcome measure was all-cause mortality. In addition to clinical parameters and established risk scores, HRV and cTnI were assessed perioperatively. RESULTS: Twenty-eight (16%) patients died within one year. Multivariate logistic regression analysis revealed three findings that were independently associated with death within the first year after surgery: the revised cardiac risk index (odds ratio 6.2 [95% confidence interval 1.6 to 25], depressed HRV before induction of anesthesia (16.2 [2.8 to 94]), and elevation of cTnI on postoperative day 1 or 2 (9.8 [3.0 to 32]). CONCLUSIONS: Depressed HRV before induction of anesthesia and elevated cTnI postoperatively are independent and powerful predictors of one-year mortality for patients at risk of CAD undergoing major noncardiac surgery and add incremental prognostic information to established risk scores that only consider preoperative information.

Schindler TH, Hornig B, Buser PT, Olschewski M, Magosaki N, Pfisterer M, Nitzsche EU, Solzbach U, Just H. · Division of Cardiology, Medical Clinic III, University Hospital of the Albert Ludwig University, Freiburg, Germany. · Arterioscler Thromb Vasc Biol. · Pubmed #12615687 links to  free full text

Abstract: OBJECTIVE: We aimed to evaluate prospectively whether patients with normal coronary angiogram but abnormal epicardial vasoreactivity to cold pressor test (CPT) are at increased risk for cardiovascular events. METHODS AND RESULTS: Vasoreactivity in response to CPT and dilation of epicardial arteries to intracoronary application of nitroglycerin were assessed quantitatively (percent change of luminal area, DeltaLA%) in 130 patients with normal coronary angiograms. Cardiovascular events (cardiovascular death, acute coronary syndrome, myocardial infarction, percutaneous transluminal coronary angioplasty, coronary bypass grafting, ischemic stroke, or peripheral revascularization) were assessed as clinical outcome parameters over a mean follow-up period of 45+/-9 months. Based on their vascular responses to CPT, patients were assigned into the following 3 groups: group 1, patients with normal vasodilator response (DeltaLA >0%; n=37); group 2, patients with moderate vasoconstrictor response (DeltaLA between 0% and -15%; n=42); and group 3, patients with severe vasoconstrictor response (DeltaLA < or =-15%; n=51). Although patients from groups 2 and 3 had significantly increased vasoconstrictor response to CPT (group 2, DeltaLA -6+/-3% and group 3, DeltaLA -24+/-6% versus group 1, DeltaLA 11+/-9%; P< or =0.0001), they showed normal endothelial-independent epicardial vasodilation to intracoronary application of nitroglycerin similar to patients from group 1 (DeltaLA 39+/-16% and 34+/-14% versus 41+/-14%; P=NS, respectively). During follow-up, none of the patients from group 1 developed cardiac events. However, 7 cardiovascular events occurred in group 2 and 30 occurred in group 3 in 4 and 22 patients, respectively (P< or =0.0001, univariate by log-rank test). After adjustment for known risk factors for coronary artery disease, impaired epicardial coronary vasoreactivity to CPT remained significantly associated with the risk of developing cardiovascular events (P=0.040, multivariate by Cox regression model). CONCLUSIONS: In patients with normal coronary angiogram, abnormal vasoreactivity of epicardial coronary arteries in response to sympathetic stimulation is associated with the risk of developing cardiovascular events.

Romanens M, Grädel C, Saner H, Pfisterer M. · The Institute of Radiology, Olten, Switzerland. · Eur J Nucl Med. · Pubmed #11504088 No free full text.

Abstract: The ability to identify patients with severe coronary artery disease (CAD) by analysis of perfusion defects is limited. The lung/heart ratio (LHR) and transient ischaemic dilatation (TID) have been used for this purpose in thallium-201 scintigraphy. The value of these parameters in technetium-99m sestamibi single-photon emission tomography (SPET) imaging is controversial. In this study, therefore, we determined TID and LHR in a single-day rest/stress 99mTc-sestamibi SPET perfusion protocol and compared these measurements with perfusion defect size (PDS) and angiographic severity of CAD. Severe CAD was defined as >75% left main coronary stenosis and/or >90% proximal left anterior descending artery stenosis and/or >90% proximal stenosis in the left circumflex and right coronary arteries. LHR was determined from a stress anterior planar image recorded < or =6 min after exercise. TID ratio was derived from automatically calculated left ventricular rest/stress volumes, and PDS was measured based on semi-automated computer software (CEqual). Diagnostic accuracy and predictive values were compared between 22 patients with severe and 98 patients without severe CAD. LHRs showed a higher sensitivity (73%) for the assessment of severe CAD as compared to PDS and TID ratio (41% and 23% respectively, P<0.01), whereas specificity was highest for TID ratio [95%, P<0.01 when compared to PDS (84%) and LHR (82%)]. It is concluded that increased LHR in 99mTc-sestamibi myocardial perfusion imaging seems to yield good diagnostic accuracy in the detection of patients with severe CAD and may be derived from a single-day rest/stress study.