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Negative stress echocardiography (NSE) is associated with low cardiovascular morbidity and overall mortality. We aimed to determine the clinical and echocardiographic predictors of overall and cardiovascular outcomes following NSE. Patients who underwent SE between 2013 and 2017 were reviewed. Patients with a history of solid organ transplant or being evaluated for transplant, history of end-stage renal or liver disease, and positive SE were excluded. NSE results were divided into negative diagnostic if patient reached target heart rate (THR) and had no wall motion abnormality (WMA) at rest or stress; negative non-diagnostic if patient had no WMA but did not reach THR or if image quality was non-diagnostic; and abnormal non-ischemic if patient had a resting WMA not worsened at stress along with a personal history of coronary artery disease (CAD). New CAD lesion at 1 year was defined as ≥ 50% stenosis on cardiac catheterization. Of 4119 patients with SE, 2575 were included. All-cause mortality rate was 1.1%/year and CAD rate was 3.1%/year. Predictors of all-cause mortality were age, male gender, history of smoking and being selected for dobutamine SE. Predictors of a new CAD lesion at 1 year were male gender, diabetes, personal history of CAD and abnormal non-ischemic SE. We identified clinical and echocardiographic characteristics in a subset of NSE patients who are at higher risk for subsequent adverse events. These characteristics should be accounted for during the clinical interpretation of SE, and patients found at increased risk for morbidity and mortality warrant continued follow-up.

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

Negative stress echocardiography (NSE) is associated with low cardiovascular morbidity and overall mortality. We aimed to determine the clinical and echocardiographic predictors of overall and cardiovascular outcomes following NSE. Patients who underwent SE between 2013 and 2017 were reviewed. Patients with a history of solid organ transplant or being evaluated for transplant, history of end-stage renal or liver disease, and positive SE were excluded. NSE results were divided into negative diagnostic if patient reached target heart rate (THR) and had no wall motion abnormality (WMA) at rest or stress; negative non-diagnostic if patient had no WMA but did not reach THR or if image quality was non-diagnostic; and abnormal non-ischemic if patient had a resting WMA not worsened at stress along with a personal history of coronary artery disease (CAD). New CAD lesion at 1 year was defined as ≥ 50% stenosis on cardiac catheterization. Of 4119 patients with SE, 2575 were included. All-cause mortality rate was 1.1%/year and CAD rate was 3.1%/year. Predictors of all-cause mortality were age, male gender, history of smoking and being selected for dobutamine SE. Predictors of a new CAD lesion at 1 year were male gender, diabetes, personal history of CAD and abnormal non-ischemic SE. We identified clinical and echocardiographic characteristics in a subset of NSE patients who are at higher risk for subsequent adverse events. These characteristics should be accounted for during the clinical interpretation of SE, and patients found at increased risk for morbidity and mortality warrant continued follow-up.

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.

Background Recent studies indicate that the pretest likelihood of significant coronary artery disease (CAD) (≥50% luminal stenosis) is over-estimated and that the frequency and severity of positive stress tests have been decreasing. This suggests an increased prevalence of false-positive (FP) stress tests. The aims of this retrospective study were to investigate the predictors of FP stress echocardiography (SE) and to compare the outcomes of patients with FP results to those with true-positive (TP) results. Methods Patients who underwent SE between 2013 and 2017 in a tertiary-care center were reviewed. Included were patients aged ≥40 years who had cardiac catheterization (CC) within 1 year of the index stress test. SE was considered FP if a new or worsening wall motion abnormality was present in the absence of significant corresponding CAD. Results Of the 5100 patients with SE, 1069 satisfied inclusion criteria. A total of 305 patients had positive SE results; of which 162 (53%) were FP. Logistic regression revealed that female gender (p = 0.009), the absence of diabetes (p = 0.03), the absence of a personal history of CAD (p = 0.004), and lower stress WMSI (p = 0.03) were independently associated with FP results. Patients with FP results on SE had similar all-cause mortality to those with TP results. Conclusions Accounting for predictors of FP findings on SE could improve the interpretation of SE results and limit the use of unnecessary CC. Furthermore, patients with FP results on SE could benefit from aggressive risk factor control and careful clinical follow-up.

The significance of cardiac troponin I (TnI) levels in patients with acute ischemic stroke remains unclear.Data were prospectively collected on 1718 patients with acute ischemic stroke (2009-2010). Patients with positive TnI (peak TnI ≥0.1 μg/L) were assigned to the myocardial infarction (MI) group if they met diagnostic criteria. The remaining patients with positive TnI were assigned to the no-MI group. Patients were followed up for 1.4 ± 1.1 years. Primary outcome was inhospital and long-term all-cause mortality.Positive TnI was present in 309 patients (18%), 119 of whom (39%) were classified as having MI. Positive TnI was independently associated with older age, hypertension, smoking, peripheral arterial disease, heart failure, higher systolic blood pressure, higher serum creatinine, and lower heart rate (P.01). Patients with MI had the highest inpatient mortality (P.001) and the lowest survival rate by Kaplan-Meier analysis (P.0001). Peak TnI greater than or equal to 0.5 μg/L, particularly if satisfying criteria for MI, was independently associated with long-term mortality (P.0001); peak TnI less than 0.5 μg/L alone was not when adjusted for covariates.Positive TnI greater than or equal to 0.5 μg/L in patients with acute ischemic stroke was independently associated with worse outcomes. Patients with diagnosis of MI represent a particularly high-risk subgroup.

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

Background Pericardial effusion in pulmonary arterial hypertension (PAH) is an indicator of right heart failure and poor prognosis; its significance on serial transthoracic echocardiograms (TTE) is not clear. Methods Baseline and follow-up TTE (1.0 ± 0.5 years), clinical parameters, and outcomes were studied (N = 200) in consecutive patients with PAH who underwent TTE at our center between October 1999 and November 2007. Study baseline TTE was 2.8 ± 4.0 years from initial PAH diagnosis. Results Over median follow-up of 3.6 ± 2.6 years from baseline TTE, 106 patients (53%) died. Pericardial effusion was present in 20% at baseline, and at any time during the study in 29%. Patients with any pericardial effusion during follow-up were more likely to have underlying connective tissue disease. They also had significantly higher mean right atrial pressure and pulmonary vascular resistance, had lower cardiac output by invasive hemodynamic studies, had higher serum creatinine, and were more likely to be treated with prostanoids. Patients were also significantly likely to have more echocardiographic right atrial dilation and right ventricular dilation and dysfunction, and worse tricuspid regurgitation with higher peak velocity. During follow-up, there was significantly increased use of prostanoids (58% vs. 28%) and combination therapy (8% vs. 2%) compared to baseline. Persistence of pericardial effusion on both baseline and follow-up TTE was associated with worse outcome, and an independent predictor of survival after adjusting for age, creatinine, functional class, and hemodynamics (P

There is scant data about outcomes in patients with left ventricular epicardial (LVE) leads who develop endocarditis or device-related infection. This retrospective study evaluated mortality and recurrence of infection among patients with LVE leads in comparison to patients with endovascular coronary sinus (CS) leads after the development of endocarditis or device-related infection. Patients with cardiac resynchronization therapy (CRT) devices who developed endocarditis or pocket infection over 5 years at Cleveland Clinic were included in the study. The groups were all patients with LVE leads versus CRT devices without epicardial leads that developed endocarditis or pocket infection. Mortality was assessed using the Social Security Death Index and re-infection was assessed by reviews of the medical record. Prospective extraction of the CRT device and leads occurred among all 50 patients with CS leads and 8 of the 14 patients with LVE leads. The survival rate was 92.9 versus 92 % and freedom from re-infection rate was 64.3 versus 80 % in the patients with LVE leads versus CS leads, respectively, over 1 year (P value = 0.918 and 0.226, respectively). At 3 years, the survival rate in LVE lead group was 92.9 % and freedom from re-infection rate was 64.3 % in comparison to survival rate of 90 % and freedom from re-infection rate of 68 % in the CS group (P value = 0.751 and 0.798, respectively). After development of endocarditis or pocket infection, no statistically significant differences were seen in mortality, or recurrent infection between patients with LVE leads and those with CS leads.

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

Background The left atrium (LA) in the transplanted heart (TH) is a surgically created chamber from variable portions of donor and recipient LA. The American Society of Echocardiography (ASE) recommends measuring LA size in native hearts using biplane LA volume index (LAVI) as a more accurate measurement than LA anterior-posterior diameter (LA-APD). We hypothesized that LA-APD underestimates LA size when compared with LAVI in the TH. Methods Patients with a TH from 1/05 to 1/10 who had a transthoracic echocardiogram within 24 months of transplant were studied. Patients were excluded if they had an ejection fraction mild aortic or mitral regurgitation, or poor image quality. Echocardiograms were analyzed for LA-APD and LAVI. LA size was classified as normal, mild, moderate, or severely enlarged based on age and sex specific cutoffs per the ASE. Results Of 297 patients evaluated, 160 met inclusion criteria. Mean age was 57 ± 13 years and 79% were males. Mean LA-APD and LAVI were 4.3 ± 0.6 cm and 36 ± 14 mL/m2, respectively. LAVI correlated with LA-APD (r = 0.43, R2 = 0.18, P

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.

Background The best periprocedural anticoagulation strategy at the time of pulmonary vein isolation (PVI) is not known. Most centers stop administering warfarin (Coumadin) and use bridging with heparin or enoxaparin. Objective The purpose of this study was to evaluate the efficacy and safety of PVI under therapeutic international normalized ratio (INR). Methods Between January 2005 and December 2008, PVI was performed in 3,052 patients with therapeutic INR (≥1.8) at the time of ablation. All patients were evaluated for ischemic strokes and bleeding complications. Results Mean INR was 2.53 ± 0.62. Only 3 (0.098%) patients had ischemic strokes. One patient had a hemorrhagic stroke on the third day postablation but recovered completely by 1-week follow-up. Bleeding complications occurred in 34 (1.11%) patients; most were minor (0.79%). Major hemorrhagic complications occurred in 10 (0.33%) patients (tamponade in 5, hematomas requiring intervention in 2, transfusion necessary in 3). Conclusion In a large patient population, continuation of Coumadin at a therapeutic INR at the time of PVI without use of heparin or enoxaparin for bridging is a safe and efficacious periprocedural anticoagulation strategy. It is an acceptable and potentially better alternative to strategies that use bridging with heparin or enoxaparin.

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

Idiopathic pulmonary arterial hypertension (PAH) is usually associated with a poor outcome but the prognosis with other forms of PAH is not well-described. Advances in therapy have furthered clouded the disease course. We sought to determine the baseline indicators of prognosis in patients with PAH. We reviewed the records of patients with PAH followed up at our institution to identify those who died within 2 years (reduced survival group; n = 21) and those who survived >5 years (long survival group; n = 60). The groups were compared for prognostic significance of the baseline clinical parameters. The reduced survival group were older (p = 0.001) and more likely to have scleroderma-associated PAH (p = 0.01), have pericardial effusion (p = 0.01), have a shorter 6-minute walk test (6MWT) distance (p = 0.001), to require oxygen during 6MWT (p = 0.02), have a worse World Health Organization functional class (p

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.

Thyroid acropachy is a rare complication of thyroid disease most often occurring in patients with a long history of active Graves' disease with ophthalmopathy and dermopathy already present. It presents with digital clubbing and soft tissue swelling with possible pain in the digits. Plain radiographs show a solid periosteal reaction that tends to be bilateral and generally symmetrical involving the tubular bones of the hands and feet. Treatment is directed at the thyroid dysfunction and the accompanying ophthalmopathy and dermopathy. It is important to recognize the association with a more severe ophthalmopathy. In the absence of Graves' ophthalmopathy and dermopathy, a diligent search for other causes of acropachy is warranted.

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