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Coronary artery disease (CAD) is a major cause of systolic heart failure (HF). Identifying CAD as a cause of systolic HF has prognostic and treatment implications. Whether all patients with systolic HF of unclear etiology should undergo coronary angiography has been controversial. We sought to derive and validate a clinical prediction rule to exclude CAD as a cause of systolic HF. A derivation cohort was formed of consecutive patients who had undergone coronary angiography with a primary diagnosis of systolic HF of unclear etiology (ejection fraction <50%). Using multivariate logistic regression analysis, we derived a prediction rule for severe CAD (≥50% diameter stenosis in the left main, 3-vessel CAD, and 2-vessel CAD involving the proximal left anterior descending artery). The diagnostic performance of the defined prediction rule was prospectively validated in a separate cohort recruited from 2 institutions. Of the 124 patients in the derivation cohort, 27% had CAD, including 15% with severe CAD. The independent predictors of severe CAD included diabetes (odds ratio 5.1, p = 0.005), electrocardiographic Q waves or left bundle branch block (odds ratio 3.8, p = 0.02), and ≥2 nondiabetes risk factors: age (men ≥55 or women ≥65 years), dyslipidemia, hypertension, and tobacco use (odds ratio 4.8, p = 0.02). A prediction rule of having ≥1 independent predictor identified 97% of the patients with CAD and 100% of the patients with severe CAD. In the prospective validation cohort of 143 patients, the prediction rule had 98% sensitivity and 18% specificity for CAD but 100% sensitivity for severe CAD. In conclusion, a simple clinical prediction rule can accurately identify patients with CAD and eliminate the need for angiography in a substantial proportion of patients with systolic HF, with potentially significant cost savings and risk avoidance., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The prognostic implications of transient ischemic dilatation (TID) of the left ventricle with otherwise normal single-photon emission computed tomography myocardial perfusion imaging (MPI) remain controversial. Whether this finding may have prognostic implications only in high-risk populations, such as patients with diabetes or manifest coronary artery disease (CAD), is uncertain., Methods: We conducted a prospective cohort study of 1,236 consecutive patients with normal (99m)Tc-sestamibi MPI, defined as normal perfusion (summed stress score = 0) and normal left ventricle volume and function. TID was defined as >2 standard deviations above the mean of patients with low likelihood of CAD., Results: The study subjects were followed for 27 ± 9 months. The 76 (6%) patients with TID had a greater rate of cardiac death or myocardial infarction (MI) [4 (5.3%) vs 11 (0.6%), P = .003] independent of covariates [hazard ratio = 6.4, P = .004]. This finding was entirely derived from the subgroup of 294 patients with diabetes or CAD [4 (13.3%) with TID vs 1 (0.4%) without TID, P = .001] independent of covariates. However, TID was not predictive of cardiac death or MI among the 941 patients without diabetes or CAD. Furthermore, TID was not predictive of coronary revascularization., Conclusions: This study confirms a benign prognosis of TID with otherwise normal MPI in patients without diabetes or CAD, but cautions against extending this conclusion to high-risk individuals, particularly those with diabetes or CAD.

Background: Diastolic dysfunction (DD) is associated with myocardial fibrosis mediated by inflammation. Higher levels of inflammation found in African Americans (AAs) may predict DD among asymptomatic individuals. We tested the hypothesis that high sensitivity C-reactive protein (hs-CRP), a biomarker of inflammation, is associated with DD in asymptomatic AAs., Methods: We prospectively recruited 107 asymptomatic AAs without any history of cardiac, renal or inflammatory diseases or alcoholism. We measured hs-CRP and B-type Natriuretic peptide (BNP) levels and estimated left ventricular end diastolic pressure (LVEDP), mass and systolic function with echocardiography. Multivariate logistic regression analysis was used to define whether hs-CRP is an independent predictor of LVEDP., Results: Among 107 subjects: the mean age was 48±10 yrs, 58 (54%) were men, 59 (55%) had diabetes (DM), 48 (45%) had hypertension (HTN), the mean BMI was 30.5±4.8 and the mean ejection fraction was 63.1±5.8%. DD was present in 56(52%) subjects, 38 (36%) of whom also had a high LVEDP. On multivariate analysis, hs-CRP was independently associated with DD [odds ratio 3.36 (95% CI= 1.07 - 10.5, p = 0.04]. There was a 61% and 133% increase in the prevalence of any DD and DD with high LVEDP, respectively, between the lowest and the highest hs-CRP quartiles., Conclusion: Diastolic dysfunction is prevalent among asymptomatic African Americans and it is independently associated with elevated level of hs-CRP, an inflammation marker.

Aim: To determine mutable risk factors for asymptomatic diastolic dysfunction in ethnic minority patients newly diagnosed with type 2 diabetes., Methods: We recruited consecutive adults with newly diagnosed diabetes who had no signs or symptoms or history of heart disease. All patients received standardized evaluation including interview, physical examination, laboratory tests and echocardiogram with tissue Doppler studies. We used logistic regression models to identify mutable risk factors for diastolic dysfunction., Results: Among 126 study subjects (52% women, age 45+/-10 years, BMI 33+/-7, 42% with hypertension, 100% ejection fraction > or =50%), evidence of diastolic dysfunction was present in 64 (51%). After controlling for age, heart rate and blood pressure, independent predictors of diastolic dysfunction included physical inactivity (OR: 2.3; 95% CI: 0.9-6.1; P=0.08) and glucose (OR: 4.9; 95% CI: 1.4-17.8; P=0.02). Physical inactivity was associated with early diastolic dysfunction (impaired relaxation), whereas epicardial fat thickness and glucose levels were associated with late diastolic dysfunction (impaired compliance). The hs-CRP and BNP levels were not associated with diastolic dysfunction., Conclusions: Asymptomatic diastolic dysfunction was prevalent among urban minority patients newly diagnosed with diabetes. Important differences exist among factors that affect early and late diastolic function that may have prognostic and therapeutic implications., (Copyright 2010. Published by Elsevier Ireland Ltd.)

The association of noncompliance with evidence-based medical therapies after myocardial infarction (MI) on long-term outcomes is not well recognized in minority and uninsured populations. Consecutive MI patients at a large urban hospital were followed for compliance with evidence-based medications (aspirin, clopidogrel, statins, beta blockers, and angiotensin converting enzyme inhibitors [ACEIs]/angiotensin receptor blockers [ARBs]). Noncompliance was defined as proportion of days covered < or =80%. The outcome was combined mortality and MI. Kaplan-Meier analyses were used to explore the impact of noncompliance > or =4 medications. Of the 509 patients (86% minorities, 77% uninsured, and 54% diabetics), 132 (25.9%) presented with ST segment elevation with myocardial infarction (STEMI) and 377 (74.1%) with a non-ST segment elevation with myocardial infarction (NSTEMI), revascularization was performed in 297 (58.4%) patients, 72 (14.2%) patients died, 22 (4.3%) patients had an MI, and 91 (17.9%) patients had either event at a median follow-up of 2 (0.5-2.9) years. Noncompliance > or = 4 medications was significantly associated with adverse survival compared with compliant patients (29.7% vs 78.9%). After adjusting for traditional risk factors, The Global Registry of Acute Coronary Events risk score for predicting death during 6 months post-discharge, revascularization, left ventricular (LV) function, coronary artery disease (CAD) severity, and punctual clinic visits, noncompliance with > or = 4 evidence-based medications was an independent factor associated with death or MI (hazard ratio [HR], 2.83; 95% confidence interval [CI]=1.60-5.01) in this minority and uninsured population.

Objectives: To assess if early revascularization offers any survival benefit in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) who are > or = 75 years of age., Background: CS after AMI continues to pose formidable therapeutic challenges in elderly patients., Methods: We conducted survival analyses of 310 consecutive subjects (including 80 patients > or = 75 years of age) who developed cardiogenic shock after AMI at two study centers - Rush University Medical Center and the John H. Stroger Jr. Hospital of Cook County (both in Chicago, Illinois). The data were collected over a 6-year period. Where appropriate, we used Kaplan-Meier survival plots, multivariate Cox proportional hazards modeling, stepwise multivariate Poisson regression analyses and unconditional logistic regression analysis., Results: Early revascularization was associated with a statistically significant survival benefit both in patients < 75 years of age (relative hazard 0.40, 95% confidence interval [CI] 0.28-0.59; p < 0.001), as well as in patients > or = 75 years of age (relative hazard 0.56, 95% CI 0.32-0.99; p = 0.049). This benefit remained significant even after adjusting for the simultaneous effects of several putative confounders. In patients > or = 75 years of age, this survival benefit was evident very early and was sustained all through the period of follow up of the cohort., Conclusions: These retrospective data suggest a significant survival benefit of early revascularization in elderly patients > or = 75 years of age developing CS after AMI, albeit less as compared to those aged < 75 years.

Background: High values of both preoperative and postoperative cardiac troponin I (cTnI) contribute to higher rates of short-term cardiac events following coronary artery bypass graft (CABG) surgery in patients with acute coronary syndrome (ACS). The prognostic value of very early cTnI in this context is unclear., Hypothesis: Measurement of cTnI very early after admission to the emergency room can be used as a prognosticator for long-term outcomes after CABG., Methods: We conducted a cohort study on 160 consecutive patients with ACS undergoing CABG at The John H. Stroger Jr. Hospital of Cook County (Chicago, IL) representing a total follow-up of 290.42 person-years. Adverse outcomes were defined as death or reinfarction. We used robust multivariate survival analyses to determine whether early cTnI measurement can independently predict the adverse outcomes in the study subjects., Results: In univariate and stepwise multivariate Cox proportional hazards modeling we found that unit rise in early cTnI is associated with a 3% (95% confidence interval [CI]: 2%- 5%, p < 0.001) faster progression to long-term adverse events after CABG even after adjusting for the type of ACS. Prognostically, the most informative cut off value for cTnI was 5.6 ng/mL. Above this value, CABG patients progressed 2.58 times faster to adverse outcomes (95% CI: 1.05-6.36, p = 0.039). This effect remained after adjustment for other significant confounders namely, poor compliance to medications, female sex, Medicaid insurance, and electrocardiographic ischemia., Conclusion: Early cTnI measurement after admission can predict adverse outcomes after CABG. This association extends to long-term adverse events after CABG.

Prior studies of premature coronary artery disease (CAD) in young adults did not address the association of race/ethnicity and risk factors. Therefore, the authors conducted a study of 400 patients 40 years and older undergoing coronary angiography at a large, urban public hospital that serves predominantly minority, uninsured populations. The prevalence of risk factors and their association with premature CAD varied markedly by ethnic group. Among blacks, dyslipidemia, diabetes, and smoking were independently associated with premature CAD. Among Hispanics, dyslipidemia, male sex, and family history of CAD were independently associated with premature CAD. Smoking was the only risk factor in whites, and no independent risk factor was identified in Asian Indians. Whites and Asian Indians had a higher prevalence of disease than blacks or Hispanics--before and after adjusting for risk factor imbalances across ethnic groups. In this ethnically diverse population, the authors' findings underscore the importance of identifying distinctive risk factors in various ethnic groups.

Early detection of asymptomatic left ventricular systolic dysfunction (LVSD) is beneficial in managing heart failure. Recent studies have cast doubt on the usefulness of cardiac output as an indicator of LVSD. In impedance cardiography (ICG), the dZ/dt waveform has a systolic wave called the E wave. This study looked at measurements of the amplitude and area of the E wave compared with ICG-derived cardiac output, stroke volume, cardiac index, and stroke index as methods of assessing LVSD. ICG data were obtained from patients (n=26) admitted to a coronary care unit. Clinical LVSD severity was stratified into 4 groups (none, mild, moderate, and severe) based on echocardiography data and standard clinical assessment by a cardiologist blinded to ICG data. Statistical analysis showed that the E wave amplitude and area were better indicators of the level of LVSD than cardiac output, stroke volume, cardiac index, or stroke index. ICG waveform analysis has potential as a simple point-of-care test for detecting LVSD in asymptomatic patients at high risk for developing heart failure and for monitoring LVSD in patients being treated for heart failure.

For the diagnosis and management of heart failure, it would be useful to have a simple point-of-care test for assessing ventricular function that could be performed by a nurse. An impedance cardiography (ICG) parameter called systolic amplitude (SA) can serve as an indicator of left ventricular systolic function (LVSF). This study tested the hypothesis that patients with normal LVSF should have a significant increase in SA in response to an increase in end-diastolic volume caused by postural change from sitting upright to supine, while patients with depressed LVSF associated with heart failure should have a minimal increase or a decrease in SA from upright to supine. ICG data were obtained in 12 patients without heart disease and with normal LVSF and 18 patients with clinically diagnosed heart failure. Consistent with the hypothesis, patients with normal LVSF had a significant increase in SA from upright to supine, whereas heart failure patients had a minimal increase or a decrease in SA from upright to supine. This ICG procedure may be useful for monitoring the trend of patient response to titration of beta blockers and other medications. ICG potentially could be used to detect worsening LVSF and provide a means of measurement for adjusting treatment.

Rates of cardiologists' recommendations for revascularization and rates of performance of these procedures were compared in 1,961 black and white patients who underwent cardiac catheterization at a larger inner-city public hospital. After adjustment for clinical and angiographic characteristics, recommendations to undergo revascularization were similar in blacks and whites who had coronary disease. Blacks and whites were equally likely to undergo recommended angioplasty, but blacks were significantly less likely to undergo recommended surgical revascularization.

Sarcoidosis is a rare granulomatous disease of unknown etiology that can affect any organ. Cardiac involvement, although uncommon, has a wide spectrum of clinical manifestations and is potentially fatal. Although there is no agreement upon a strategy for the diagnosis (which is difficult to make based on clinical information alone), the introduction of newer technology is promising and may be useful both for the early diagnosis of cardiac involvement and for the evaluation of response to therapy. Early treatment is crucial in improving symptoms and prognosis. ICD implantation and cardiac transplantation may offer improvements in management, as steroid therapy and pacemaker implantation has led to improved outcomes over the past three decades.

Background: Cocaine produces adverse cardiovascular effects, some of which cannot be explained by epicardial coronary artery disease (CAD) or spasm., Hypothesis: The hypothesis of this study was that cocaine users would have increased coronary microvascular resistance, even in the absence of recent myocardial infarction (MI), CAD, or spasm., Methods: Microvascular resistance was assessed by the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC) method in a consecutive series of 59 cocaine users without acute or recent MI or angiographically significant epicardial stenosis (> 50%) or spasm. The cTFCs in these patients were compared with 21 normal controls and with published normal cTFC values., Results: The cTFC was significantly elevated (by 26-54%) in cocaine users. The cTFCs in the left anterior descending (LAD), circumflex (LCx), and right coronary (RCA)arteries in cocaine users were 30.0 +/- 10.9,34.1 +/- 11.5, and 28.6 +/- 11.8, respectively, compared with values in normal controls of 21.3 +/- 4.3 (p = 0.001), 24.4 +/- 7.2 (p = 0.001), and 22.7 +/- 5.1 (p = 0.04), respectively, and published normal cTFC values (all p < 0.01). An abnormally high cTFC was present in 61% of patients in the LAD, 69% in the LCx, and 47% in the RCA., Conclusions: Markedly decreased coronary blood flow velocity, indicating increased microvascular resistance, is present in cocaine users, even in the absence of acute or recent MI, or significant epicardial CAD or spasm. Increased microvascular resistance may explain many important cardiovascular manifestations of cocaine use and has therapeutic implications. Slow coronary filling may also suggest the possibility of cocaine use in patients in whom it was not otherwise suspected.

Transcutaneous cardiac pacing is a temporary method of pacing that may be indicated in patients with severe symptomatic or hemodynamically unstable bradyarrhythmias. It is particularly helpful in patients with reversible or transient conditions, such as digoxin toxicity and atrioventricular block in the setting of inferior wall myocardial infarction, or when transvenous pacing is not immediately available or carries a high risk of complications. Most patients with minimal hemodynamic compromise require a current of 40 to 80 mA; pacing thresholds tend to be higher in patients who have emphysema or pericardial effusion and in those who receive positive pressure ventilation. On electrocardiography, successful capture usually is characterized by a widened QRS complex, followed by a distinct ST segment and broad T wave. The hemodynamic response to pacing also must be confirmed by assessing the patient's arterial pulse. Proper skin preparation and electrode positioning ensure successful capture in most situations. Adequate sedation and analgesia are essential in ensuring patient comfort.

To determine whether clinical parameters alone can differentiate normal versus decreased systolic left ventricular function in patients with heart failure. Detailed clinical data were collected prospectively from 225 consecutive patients who were hospitalized with heart failure. Findings in patients with normal (ejection fraction > or =45%) or decreased (ejection fraction <45%) left ventricular function were compared. Systolic function was normal in 104 patients (46%) and decreased in 121 patients (54%). Patients with normal function were older (mean [+/- SD] age, 59 +/- 13 years vs. 54 +/- 13 years, P = 0.007) and more likely to be female (56% vs. 35%, P = 0.001), obese (body mass index > or =30 kg/m(2), 62% vs. 48%, P = 0.04), have marked systolic (> or =160 mm Hg, 50% vs. 27%, P <0.001) and diastolic (> or =110 mm Hg, 25% vs. 13%, P = 0.02) hypertension, and use calcium antagonists (34% vs. 14%, P = 0.001). Patients with decreased function were more likely to use alcohol (37% vs. 20%, P = 0.007), angiotensin-converting enzyme (ACE) inhibitors (85% vs. 62%, P <0.001), and digoxin (57% vs. 27%, P <0.001); and more likely to have tachycardia (51% vs. 32%, P = 0.004), rales (89% vs. 80%, P = 0.05), electrocardiographic left ventricular hypertrophy (42% vs. 22%, P = 0.002), left atrial abnormality (52% vs. 22%, P <0.001), or flow cephalization on chest radiograph (91% vs. 79%, P = 0.02). Only sex, tachycardia, and use of digoxin and ACE inhibitors were associated with ventricular function in multivariable analysis. However, the sensitivity, specificity, and predictive values for all clinical variables were low. Differences in clinical parameters in heart failure patients with decreased versus normal systolic function cannot predict systolic function in these patients, supporting recommendations that heart failure patients should undergo specialized testing to measure ventricular function.