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Introduction: Coronary artery disease and malignancy occur more frequently in patients with type 2 diabetes. They may share inflammation as a possible common pathogenetic mechanism, but it is unclear whether a clinical correlation exists between them. Methods: This prospective cohort study followed 735 asymptomatic diabetics, aged 63.4 ± 5.3 years (mean ± standard deviation) for 12.2 ± 0.6 years after baseline coronary artery calcium scoring and cardiac computed tomography angiography. We examined extent and nature of coronary atherosclerosis and incidence of clinical cardiovascular (CV) events (death or myocardial infarction) and sought a relation to incidence of malignancy and malignancy mortality. Results: Total mortality was 16.5% (121/735 patients): malignancy was cause of death in 48/121 (39.7%) of these and CV events in 44/121 (36.3%). There was no relation between extent of coronary atherosclerosis and incident malignancy (plaque volume 127 [21, 427] mm3 (median [interquartile range]) for incident malignancy versus 153 [24, 427] mm3 no malignancy, p = 0.71) or death from malignancy (plaque volume 176 [26, 646] versus 144 [22, 411] mm3, p = 0.32). There was also no relation between presence of high-risk plaque and incident malignancy (high-risk plaque in 27.1% with malignancy vs. 21.6% without, p = 0.18) or fatal malignancy (p = 0.16). Incident and fatal malignancy were not related to clinical CV events. Independent predictors of incident and fatal malignancy were age, smoking at baseline, and elevated C-reactive protein. Conclusion: This study found no relation between extent of coronary atherosclerosis or incidence of CV events and malignancy. Malignancy surpassed CV disease as the commonest long-term cause of mortality in middle-aged and older diabetics. [ABSTRACT FROM AUTHOR]

Objectives: Predictive models for heart failure (HF) in heterogeneous populations have had limited success. We examined cardiac computed tomography angiography (CTA) predictors of HF or cardiovascular death (HF-CVD) in a prospective study of asymptomatic diabetics undergoing baseline assessment by CTA. Methods: The subjects (n = 735, aged 55-74 years, 51.2% women) had no clinical history of cardiovascular disease at study entry. Coronary artery calcium (CAC) score, CTA-defined coronary atherosclerosis, cardiac chamber volumes, and clinical data were collected and late outcome events recorded over 8.4 ± 0.6 years (range 7.3-9.3). Results: HF-CVD occurred in 41 (5.6%) subjects, with HF occurring mostly (19/23, 82.6%) in subjects without preceding myocardial infarction. Baseline univariate clinical outcome predictors of HF-CVD included older age (p = 0.027), the duration of diabetes (p = 0.004), HbA1c (p < 0.0001), mi-crovascular disease (retinopathy, microalbuminuria) (p < 0.0001), and systolic blood pressure (p = 0.035). Baseline univariate CTA predictors included CAC score (p = 0.004), coronary stenosis (p = 0.047), and a CTA-defined left/right atrial (LA/RA) volume ratio >1 (p < 0.0001). Independent predictors were an LA/RA volume ratio >1, microvascular disease, and systolic blood pressure (model C-statistic 0.792, 95% CI 0.758-0.824). Measures of the extent of coronary artery disease (CAD) were not independent predictors of HF-CVD. Conclusions: In a low- to moderate-risk asymptomatic diabetic population, CTA LA enlargement (LA/RA volume ratio) but not the extent of CAD had independent prognostic value for HF-CVD in addition to the clinical variables. [ABSTRACT FROM AUTHOR]

Objectives: Predictive models for heart failure (HF) in heterogeneous populations have had limited success. We examined cardiac computed tomography angiography (CTA) predictors of HF or cardiovascular death (HF-CVD) in a prospective study of asymptomatic diabetics undergoing baseline assessment by CTA. Methods: The subjects (n = 735, aged 55-74 years, 51.2% women) had no clinical history of cardiovascular disease at study entry. Coronary artery calcium (CAC) score, CTA-defined coronary atherosclerosis, cardiac chamber volumes, and clinical data were collected and late outcome events recorded over 8.4 ± 0.6 years (range 7.3-9.3). Results: HF-CVD occurred in 41 (5.6%) subjects, with HF occurring mostly (19/23, 82.6%) in subjects without preceding myocardial infarction. Baseline univariate clinical outcome predictors of HF-CVD included older age (p = 0.027), the duration of diabetes (p = 0.004), HbA1c (p < 0.0001), mi-crovascular disease (retinopathy, microalbuminuria) (p < 0.0001), and systolic blood pressure (p = 0.035). Baseline univariate CTA predictors included CAC score (p = 0.004), coronary stenosis (p = 0.047), and a CTA-defined left/right atrial (LA/RA) volume ratio >1 (p < 0.0001). Independent predictors were an LA/RA volume ratio >1, microvascular disease, and systolic blood pressure (model C-statistic 0.792, 95% CI 0.758-0.824). Measures of the extent of coronary artery disease (CAD) were not independent predictors of HF-CVD. Conclusions: In a low- to moderate-risk asymptomatic diabetic population, CTA LA enlargement (LA/RA volume ratio) but not the extent of CAD had independent prognostic value for HF-CVD in addition to the clinical variables. [ABSTRACT FROM AUTHOR]

Objectives: Inflammation and serum oxidative stress (OS) are important components in heart failure (HF) deterioration. In this study we tested the hypothesis that an increase in patients' sera OS levels is associated with acute HF (AHF) readmissions. Methods: Thirty consecutive patients (mean age 71 ± 10 years) admitted with AHF were included in the study. Serum OS in these patients was measured in-hospital and repeatedly after discharge over a period of 8 weeks of follow-up in which we reordered patients' HF readmissions. Of the 30 patients, 13 (43%) were readmitted (RAD group) and 17 (57%) did not require readmission (NRAD group). Results: OS levels before discharge from the first hospital admission in the 2 groups were similar (p = 0.84 and p = 0.56, respectively). However, using repeated measures ANOVA, we found that the interaction between the time points and the 2 groups of patients (RAD and NRAD) was statistically significant (p = 0.037). It is important to note that OS serum levels were more predictive of HF readmissions than were repeated simultaneous serum measurements of NT-proBNP (p = 0.97). Conclusions: Increased OS levels in AHF patients, after they have been discharged from the hospital, are associated with higher HF readmission rates. In AHF, OS is a dynamic parameter associated with HF deterioration. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: Angiotensin II plays a key role in the pathophysiology of heart failure (HF). This study examined the angiotensin II type 1 receptor (AT1R) polymorphism in patients with systolic HF and its relation to clinical manifestations and patient outcome. Methods: We genotyped 134 patients with HF and reduced systolic function for the AT1R A1166C genotype using polymerase chain reaction and restriction fragment length polymorphism. We analyzed the relationship between the AT1R A1166C polymorphism and clinical, electrocardiographic, echocardiographic and laboratory parameters in patients with ischemic and non-ischemic etiology and examined the relation between the AT1R genotype and long-term (30 months) patient survival. Results: In HF patients, frequency of the AT1R 1166C allele and specifically the CC genotype was similar to the general population, but associated with an ischemic and not a non-ischemic etiology (p = 0.02). The CC genotype was associated with more advanced disease and more severe abnormalities of renal function (p = 0.008). Survival analysis showed that AT1R CC homozygous patients had significantly higher mortality (p = 0.008; adjusted odds ratio for mortality 6.35, 95% confidence interval 1.49–11.21, p = 0.01). Conclusion: The CC AT1R genotype was associated with poor prognostic markers and increased mortality. The findings support the principle of genome-based therapies in the future treatment of HF patients. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Contrast-enhanced multidetector-row computed tomography (MDCT) is now capable of providing high-quality noninvasive views of cardiac anatomy and ‘instant’ noninvasive coronary angiography. With current generation 64-slice scanners, MDCT can be performed in most patients with minimal patient discomfort and high diagnostic accuracy. MDCT may obviate the need for invasive diagnostic angiography in patients with borderline symptoms or equivocal noninvasive testing. It is useful in assessing the symptomatic patient postrevascularization and in emergency room triage in selected patients with chest pain. Calcified vessels are still difficult to assess, as is the accurate evaluation of implanted coronary stents. The volume of contrast material required for proper opacification limits the use of MDCT in patients with renal dysfunction, but newer emerging technologies will greatly improve these disadvantages in the near future. MDCT is expected to become an integral part of our diagnostic armamentarium in the cardiac patient. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Aims: The value of multi-detector row computed tomography (MDCT) in routine cardiology practice is uncertain. We examined the applicability of MDCT imaging for the diagnosis of obstructive coronary artery disease in a routine clinical setting. Methods: MDCT scanning (40 slice) was performed in 111 unselected patients referred for invasive coronary angiography (ICA) and findings were compared to an independent quantitative assessment of the ICA on a segmental, vessel and patient basis. Results: Sensitivity and positive predictive value for segmental disease (72.2 and 70.9% respectively, overall) were higher in patients aged ≥60 years and history of disease ≥1 year, whereas specificity and negative predictive value were high in all groups. In the patient-based analysis, sensitivity and positive predictive value (84.7 and 87.8%, respectively) were higher, the latter in keeping with the high-patient prevalence of disease, but specificity and negative predictive value (61.5 and 55.2%) were low. Conclusions: Usefulness of MDCT was significantly influenced by age, duration of coronary artery disease and female gender, and on a patient-based analysis its diagnostic accuracy was not sufficient to replace ICA in a routine clinical setting. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes. Methods: A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29–92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%). Results: Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome. Conclusions: Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Aims: While current guidelines recommend a selective invasive approach after low-risk ST-elevation myocardial infarction (STEMI) treated by thrombolysis, based on noninvasive identification of patients with residual or inducible myocardial ischemia, in many instances physicians employ a strategy of routine angiography. The present study was undertaken to reexamine the correlation between noninvasive testing and coronary angiography in patients recovering from uncomplicated STEMI with regard to detection and management of residual infarct artery stenosis and to identify patients with multivessel (MVD) or high-risk coronary disease. Methods: We prospectively performed predischarge exercise testing (ETT) and myocardial perfusion scintigraphy (MPS) prior to routine predischarge coronary angiography in 83/276 consecutive STEMI patients, who after treatment with initial and early thrombolysis, were defined as low risk by ACC/AHA risk classification. Results: ETT was positive for myocardial ischemia in 11/43 (26%) patients with single-vessel disease (SVD) and 11/22 (50%) patients with MVD, but normal or nondiagnostic in the remainder. MPS revealed significant reversible perfusion defects in 13/40 (32%) patients with SVD and 13/22 (59%) patients with MVD. A selective strategy of ETT followed by MPS for nondiagnostic ETT missed residual infarct-related artery stenosis and/or MVD in 31/81 (38%) of the cohort. Among patients who may not otherwise have been referred for angiography, severe (≥70%) residual stenosis of the infarct-related artery was present in 56% and MVD in 16%. Conclusions: Early predischarge ETT and/or MPS had limited sensitivity for the detection of coronary disease in low-risk post-STEMI patients. The study supports a simpler strategy of routine coronary angiography in most patients after low-risk STEMI. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

An anonymous patient perception comprehension and satisfaction questionnaire was sent to 438 patients 1-3 months after they had participated in a clinical cardiovascular trial to examine the level of patient comprehension as perceived by the patient. We compared perceived comprehension in acute (acute myocardial infarction) and chronic (outpatient heart failure) clinical trials. Partially or fully completed questionnaires were received from 220 patients (70 chronic, 150 acute). The findings were similar in the 2 patient groups. Perceived full comprehension (understood most or all) of the trial was reported by 18 (27%) of chronic and 40 (31%) of 129 acute patients, while almost 20% of both groups reported little or no understanding of the trial. The level of comprehension was related to the recollected duration of explanation (p = 0.003 chronic, p < 0.001 acute). Perceived comprehension was not related to the personnel explaining the study (physician or nurse) or to whether the explanation as recollected was oral or written. However, in both acute and chronic patients, the majority (51% chronic; 63% acute) preferentially recalled the oral rather than written explanation of the trial. The very similar findings in the acute and chronic situation suggest that perceived understanding reflects human nature and willingness to be involved in medical issues. Considerable effort should be directed to improve the duration of explanation (particularly oral), if we are to achieve our goal of true informed consent in clinical cardiovascular trials. [ABSTRACT FROM AUTHOR]

We investigated the incidence and determinants of early and late repeat hospitalization for cardiac causes in 378 patients following myocardial revascularization [199 coronary balloon angioplasty (PTCA), 179 coronary bypass surgery (CABG)] in a single cardiovascular center and followed for a median period of 13 years. Data were available for repeat rehospitalization in 91% and for mortality in all. Patients in the upper quartile for repeat hospitalization (≥4 rehospitalizations) were defined as having multiple repeat hospitalizations. In the PTCA cohort, the rehospitalization rate was high (48%) in the first year, partly due to restenosis and to a group of patients who underwent planned repeat angiography, and then 15–26% annually. In the surgical cohort, annual repeat hospitalization was 8–12% during the first 4 years, but increased to a level similar to that in PTCA patients (19–26%) in the second half of the follow-up period. Independent predictors of multiple (≥4) repeat hospitalizations included systemic hypertension (odds ratio 2.4, 95% CI 1.4–4.0), incomplete revascularization (odds ratio 2.0, 95% CI 1.1–3.4) and less extensive (<3 vessels) disease at the time of the index procedure (odds ratio 2.0, 95% CI 1.1–3.4). Predictors of repeat hospitalization were different from those of mortality (diabetes mellitus, 3-vessel disease). Late repeat hospitalizations after myocardial revascularization impose a considerable burden on the patient and the health care system, and represent an issue which should be better addressed.Copyright © 2002 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective: We prospectively examined the prevalence of reversible perfusion defects on very early (12–24 h) thallium-201 single photon emission computed tomography (SPECT) scintigraphy after angiographically successful percutaneous coronary intervention (PCI) by stenting and/or stand-alone balloon angioplasty and the predictive value of these defects for late target lesion revascularization (TLR). Patients and Methods: 83 consecutive patients undergoing PCI for 88 lesions (38 balloon angioplasties, 50 stents) underwent very early (12–24 h) SPECT thallium-201 scintigraphy at rest and following administration of 0.7 mg/kg intravenous dipyridamole after PCI. Univariate and multivariate clinical, procedural and scintigraphic correlates of target lesion revascularization during long-term follow-up were examined. Results: Coronary stenting achieved a larger immediate post-PCI minimal luminal dimension (2.7 ± 0.4 vs. 2.1 ± 0.4 mm, p < 0.001) and less residual stenosis (4 ± 12 vs. 19 ± 11%, p < 0.001) than stand-alone balloon angioplasty. Nonetheless, early reversible perfusion defects were similarly present in the territory supplied by 36% of stented lesions and 32% of lesions treated by balloon angioplasty (NS). Of 81 lesions (76 patients) available for long-term clinical follow-up, TLR was performed in 11% of the stent group and 14% of the balloon angioplasty group (NS). By multivariate logistic regression analysis, diabetes mellitus was the only predictor of late TLR (p < 0.05). The type of intervention (balloon or stent) predicted neither early perfusion defects nor late TLR. Conclusions: Early 201-thallium SPECT scintigraphy was abnormal in a third of patients treated by stand-alone balloon angioplasty or by stent placement. The very early SPECT scintigraphic findings did not differentiate between balloon and stent and did not predict late TLR.Copyright © 2002 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Aims: Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied. Methods: Oral isosorbide-5-mononitrate (ISMN) (50 mg once daily) or placebo was administered to 136 patients (NYHA Class 2–3) treated for heart failure, all receiving captopril and most also furosemide. Endpoints were treadmill exercise time at 12 weeks by modified Naughton protocol (primary), with an additional 12-week follow-up period. Secondary endpoints included left ventricular dimensions, ejection fraction, cardiothoracic ratio, functional class, quality of life, hospitalizations and plasma norepinephrine and atrial natriuretic peptide in a four-center substudy. Results: Intention-to-treat analysis showed that mean change in treadmill exercise duration tended to be greater in patients receiving ISMN than placebo (treatment difference +42 s, 95% CI –5, +90 s at 12 weeks and +21 s, 95% CI –25, +74 s after 24 weeks) (NS). Treatment difference was greater in the prespecified subgroup with ejection fraction 31–40% (+55 s, 95% CI –11, +136 s at 12 weeks and +65 s, 95% CI +3, +147 s) (p = 0.035) at 24 weeks. No deleterious effects (i.e. hypotension) were observed with ISMN, although headache was reported in 19% of the active treatment group (p = 0.0001). Conclusions: ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant. [ABSTRACT FROM AUTHOR]

In this prospective study, we examined the diagnostic accuracy of exercise-induced left QRS axis deviation as a marker of LAD coronary artery stenosis. The mean frontal QRS axis of 66 consecutive patients with chest pain and exercise-induced ST segment depression referred for diagnostic coronary angiography was analyzed and related to the angiographic findings. An exercise-induced leftward QRS axis deviation was found in 9/40 patients with and 0/26 patients without obstructive (≥70%) LAD disease (sensitivity 23%, specificity 100%, p = 0.025). In 7 of the 9 patients with left axis deviation, the lesion was proximal to and in 2 in the region of the first septal perforator. Inclusion of patients with 0° exercise-induced QRS axis deviation provided a more sensitive but less specific marker of LAD disease [sensitivity 53% (21/40), specificity 81% (21/26), p = 0.015]. The findings were similar in patients with single and with multivessel coronary artery disease. Grouping all patients in the present prospective and two previous retrospective studies (n = 165), the sensitivity was 29% and specificity 100% (p < 0.0001). Exercise-induced left QRS axis deviation was a highly specific marker of LAD coronary artery stenosis. [ABSTRACT FROM AUTHOR]

Information on topics discussed at the 11th International Congress on Coronary Artery Disease (ICCAD) that was held in Florence, Italy is presented. Topics discussed at the conference include stem cell therapy, percutaneous coronary interventions, and lecture on reperfusion injury presented by professor Roberto Ferrari.