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Background: A negative result on stress echocardiography (SE) is generally associated with a low risk of cardiovascular events and carries a favorable prognosis. The present study was conducted to identify clinical and echocardiographic characteristics associated with increased risk of myocardial injury following a negative SE (NSE). Methods: We retrospectively identified a total of 4130 SEs performed between 2013 and 2017 at a tertiary care center. NSE was defined as the absence of a new or worsening wall motion abnormality (WMA) with stress. Patients with resting WMA on SE were excluded. The occurrence of myocardial injury following index SE within 1 year was then recorded. Myocardial injury was defined as an elevated (>99 th percentile of the upper reference limit of normal) and changing troponin value (a rise and/or fall of the troponin value observed) following index SE. Results: During the study period, 2962 patients with NSE met inclusion criteria (median age 58 years-old; 50% females). Baseline characteristics were as follows: 35% diabetic, 49% hyperlipidemic, 62% hypertensive, 41% had a history of smoking, 21% had a history of coronary artery disease (CAD), 24% had end-stage liver disease (ESLD), 5% had end-stage renal disease (ESRD) and 1.5% had a left ventricular ejection fraction (LVEF) < 50%. Around 5% of patients developed myocardial injury within 1 year of NSE. Age, diabetes mellitus, ESLD and a LVEF Conclusion: Patients with age > 65 years, diabetes mellitus, ESLD and a LVEF

Background: The yield of myocardial perfusion imaging is low in contemporary patients with suspected coronary artery disease (CAD) selected based on American College of Cardiology Foundation/American Heart Association pretest probability estimate. We compared traditional pretest estimates of CAD probability with the prevalence of abnormal myocardial perfusion single-photon emission computed tomography (MPS). Methods: This was a cohort study from a single academic center. Consecutive stable patients without known CAD referred for stress MPS for suspected CAD between 2004 and 2011 were identified (n=15 777). Angina typicality was determined using standard criteria. Abnormal MPS perfusion was defined as a summed stress score ≥4, ischemia as summed stress score ≥4 and summed difference score ≥2, and extensive ischemia as summed difference score ≥8 using a standard, 17-segment model of the left ventricle. The pretest probability of CAD was determined using the American College of Cardiology Foundation/American Heart Association criteria. Results: Overall, 14% (n=2177) of patients had abnormal MPS of whom 11% (n=1698) had ischemia and 4% (n=684) extensive ischemia. In patients with chest pain who underwent treadmill MPS (n=4764), only 27% reported angina on the treadmill. Typical angina was associated with the highest prevalence for positive MPS (33% in men and 14% in women), ischemia (30% in men and 12% in women), and extensive ischemia (22% in men and 4% in women) when compared with other symptom categories. Prevalence of MPS abnormality was substantially lower than expected based on pretest probability estimates across most sex and age groups. In multivariable analysis, the pretest probability estimate was not an independent predictor of abnormal MPS. Conclusions: Traditional estimates of pretest probability of CAD are not predictive of MPS perfusion abnormality and overestimate its prevalence in stable patients.

A negative result on stress echocardiography (SE) is associated with low risk (

BACKGROUND: Serum albumin is a strong prognostic indicator for many disease processes, yet limited data exist regarding its prognostic relationship in pulmonary arterial hypertension (PAH). Our study aims to assess the relationship of hypoalbuminemia with disease severity and mortality in this population. HYPOTHESIS: Serum albumin concentrations are a predictor of outcomes in PAH. METHODS: A retrospective review of all patients with World Health Organization group 1 PAH evaluated between March 2001 and August 2008 was performed. Patients were stratified into groups based on serum albumin concentration ≤3.3 g/dL (hypoalbuminemia) vs >3.3 g/dL. Clinical, hemodynamic, and survival comparisons were compared between groups using Student t test and χ(2) test, followed by univariate analysis and multivariate logistic regression. RESULTS: A total of 163/273 (59.7%) patients had a documented serum albumin concentration. Hypoalbuminemia was present in 41 (25.2%) patients and serum albumin ≤3.3 g/dL represented the lowest quartile of serum albumin. Patients with hypoalbuminemia had higher rates of renal dysfunction (26.8% vs 9.8%, P =0.0069) and hepatic dysfunction (29.3% vs 6.6%, P

Recent studies indicate that the pretest likelihood of significant coronary artery disease (CAD) is overestimated, and that the frequency and severity of positive stress tests have been decreasing. This suggests an increasing prevalence of false-positive (FP) stress tests. We aim to investigate the

Brain natriuretic peptide (BNP) levels are lower in obese patients with left ventricular failure than in their comparably ill, leaner counterparts. The effect of obesity on BNP in patients with pulmonary arterial hypertension (PAH) is unknown. We reviewed our prospective PAH registry data collected from November 2001 to December 2007 for patients undergoing right heart catheterization who met the criteria for PAH and had the BNP level and body mass index determined at baseline. The median BNP level for the lean, overweight, and obese patients was 285 pg/ml (interquartile range 131 to 548), 315 pg/ml (interquartile range 88 to 531), and 117 pg/ml (interquartile range 58 to 270), respectively (p = 0.029). A greater body mass index was associated with a lower BNP level, adjusted for age, gender, New York Heart Association functional class, hypertension, coronary artery disease, and mean right atrial and pulmonary arterial pressures (p0.001). No statistically significant differences were found among the groups in age, race, medical co-morbidities, underlying etiology of PAH, use of vasoactive medications, New York Heart Association functional class, echocardiographic parameters, or pulmonary function. Obese patients had greater right atrial and pulmonary artery pressures. Increased BNP was associated with worse survival in the lean and overweight patients only. In conclusion, the BNP levels are attenuated in obese patients with PAH despite similar or worse hemodynamics or functional class compared to lean or overweight patients and should therefore be interpreted with caution.

Hypertension is a common, undertreated disease and a major risk factor for cardiovascular, cerebrovascular and renal disease. As many as 20-30% of hypertensive patients have resistant hypertension, defined as uncontrolled blood pressure despite 3 or more antihypertensive drugs including a diuretic, typically combined with a calcium-channel blocker and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patients with resistant hypertension can often be controlled by adding a mineralocorticoid receptor antagonist and/or vasodilating beta-blocker. A significant number of patients will have a treatable secondary cause of resistant hypertension such as obesity, sleep apnea, renal insufficiency, primary aldosteronism or renal artery stenosis. For patients whose hypertension is refractory to preferred antihypertensives, use of third-line antihypertensives such as sympatholytics or vasodilators may be effective but consideration should be given to investigational device-based antihypertensive therapies. Renal artery angioplasty/ stenting can be useful in selected cases of renal artery stenosis, while renal sympathetic denervation holds promise for resistant essential hypertension.

Pulmonary hypertension (PH) is a progressive disease with variable prognosis and expanding treatment options. Guidelines have supported individual echocardiographic prognostic markers, but their ability to predict mortality remain unclear. The aim was to assess the prognostic significance of

Background— Atrial fibrillation (AF) has been linked to inflammatory factors and obesity. Epicardial fat is a source of several inflammatory mediators related to the development of coronary artery disease. We hypothesized that periatrial fat may have a similar role in the development of AF. Methods and Results— Left atrium (LA) epicardial fat pad thickness was measured in consecutive cardiac CT angiograms performed for coronary artery disease or AF. Patients were grouped by AF burden: no (n=73), paroxysmal (n=60), or persistent (n=36) AF. In a short-axis view at the mid LA, periatrial epicardial fat thickness was measured at the esophagus (LA-ESO), main pulmonary artery, and thoracic aorta; retrosternal fat was measured in axial view (right coronary ostium level). LA area was determined in the 4-chamber view. LA-ESO fat was thicker in patients with persistent AF versus paroxysmal AF ( P =0.011) or no AF ( P =0.003). LA area was larger in patients with persistent AF than paroxysmal AF ( P =0.004) or without AF ( P P =0.015). A propensity score–adjusted multivariable logistic regression that included age, body mass index, LA area, and comorbidities was also performed and the relationship remained statistically significant ( P =0.008). Conclusions— Increased posterior LA fat thickness appears to be associated with AF burden independent of age, body mass index, or LA area. Further studies are necessary to examine cause and effect, and if inflammatory, paracrine mediators explain this association.

Background: The natural course of pulmonary arterial hypertension (PAH) is characterized by progressive functional worsening leading to right heart failure and death. Since plasma brain natriuretic peptide (BNP) levels correlate with right ventricular dysfunction, we sought to evaluate the use of BNP as a prognostic indicator in PAH. Methods and Results: We examined our prospective pulmonary hypertension registry for patients who underwent right heart catheterization (RHC) between 1998 and 2008. The BNP values from the time of catheterization until date of last visit or death were analyzed in relationship to overall survival. Of the 626 patients who underwent RHC, 559 met the Venice classification of PAH: 83% category I, 10% category III, 5% category IV, and 2 % category V. Baseline mean pulmonary artery pressures were 47±16 mm Hg and cardiac index 2.6±1 l/min/m 2 . During follow up, patients were treated with prostanoids (27%), endothelin blockers (31%), PDE5 inhibitors (40%), calcium channel blockers (2%), and 56% received combination therapy. BNP values during the first 6 months were higher in patients who died in the first 2 years (n=108) compared to patients surviving more than 5 years (n=82) but the levels had no correlation to survival [R 2 =0.03, p=0.2]. Interestingly, the strongest predictor for survival was the BNP level obtained 12–14 months from RHC [R 2 =0.7, p=0.0001]. All patients who survived over 5 years had BNP value less than 150 ng/L at 12 months and all patients with BNP values >330 ng/L at 12 months were dead by 2 years. Furthermore, there was an accelerated rate of increase in BNP levels in patients who did not survive past 2 years [BNP rise rate (ng/L/month): non- survivors 33 ± 14 while, long-term survivors 0.3 ± 1; p=0.008]. Conclusions: In patients with pulmonary arterial hypertension, initial BNP levels do not appear to have prognostic significance. BNP levels at 1 year, however, are strong predictors of early mortality or long term survival. The rate of rise in BNP levels is a novel concept that may be a useful management tool before the 1 year time point.

Acute ischemic stroke is a cause of troponin elevation which is often attributed to demand, type 2 myocardial infarction (MI). The incidence of spontaneous, type 1 MI is unknown. We reviewed our prospective hospital registry of acute ischemic stroke (2009–2010). All patients had ≥3 troponin I (

Patients presenting to the emergency department (ED) with chest pain and a non-ischemic presenting electrocardiogram (ECG) are usually admitted for serial ECG and Troponin (Tn) assays and if negative, stress testing. We evaluated the additive value of stress myocardial perfusion imaging (MPI) in

Cardiomyopathy (CM) in patients admitted with acute ischemic stroke has not been investigated previously. A prospective registry of 1,761 patients admitted with diagnosis of acute ischemic stroke from 2009-2010 was used to identify patients with systolic CM. Echocardiography was performed on 1,594

Acute ischemic strokes are often accompanied by cardiac events. The prevalence, associated factors, and implications of elevated troponin I (TnI) in acute ischemic stroke merit further study. We reviewed our prospective registry of hospitalized patients with acute ischemic stroke from 2009 to 2010