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Background: Myocardial ischemia can impair myocardial relaxation and result in increased left ventricular (LV) diastolic pressure. Noninvasive measurements of mitral annular velocities have been used to evaluate LV diastolic pressure. We sought to determine whether mitral annular velocities, derived from novel speckle tracking echocardiography (STE), could predict mortality in patients with acute coronary syndrome (ACS). Methods: A total of 246 patients with ACS were retrospectively studied. STE was analyzed offline with the sample volume placed on septal, lateral, inferior, and anterior mitral annulus. Peak early (E′) and late (A′) diastolic velocities of the mitral annulus were measured and averaged from the four regions. Peak early diastolic mitral inflow velocity (E) was obtained using pulsed-wave Doppler. Results: Lower E′ (P = 0.03), lower A′ (P = 0.001), higher E′/A′ ratio (P = 0.007), and higher E/E′ ratio (P = 0.003) were independently associated with increased risk of death with adjustment for clinical and echocardiographic variables over the follow-up period of 21 months. The optimal cutoff value of E/E′ ratio derived from the receiver operating characteristic analysis for predicting death was 30 (area under the curve = 0.65). E/E′ ratio greater than 30 was predictive of death in univariate (HR, 2.40; CI, 1.42–4.06; P = 0.001) and multivariate (adjusted HR, 1.91; CI, 1.09–3.32; P = 0.02) models. Conclusion: The measurements of mitral annular velocities by STE are predictive of mortality in patients with ACS. (Echocardiography 2012;29:560-567)

OBJECTIVES: Nondipping pattern of circadian blood pressure (BP) is associated with increased cardiovascular morbidity and mortality; however, limited data are available among obese African-Americans. We, therefore, aimed to evaluate the pattern of circadian BP variation and to identify clinical conditions associated with nondipping in this population. METHODS: A total of 211 obese African-Americans enrolled in a weight-reduction program underwent 24-h ambulatory BP monitoring. Nondipping was defined as a nocturnal BP reduction of less than 10%. RESULTS: Systolic BP (SBP) nondipping was present in 158 participants (74.9%) and diastolic BP (DBP) nondipping was present in 93 participants (44.1%). In multivariate logistic regression analyses, diabetes was associated with SBP nondipping (adjusted OR, 2.53; CI: 1.16-5.76; P=0.02), and increasing BMI (5 kg/m) was associated with DBP nondipping (adjusted OR, 1.46; CI: 1.17-1.83; P=0.001). In linear regression analyses, BMI was positively correlated to office, 24-h, daytime, and night-time SBP (P=0.03, 0.01, 0.03, and 0.005, respectively) and office, 24-h, daytime, and night-time PP (P=0.01, P

Cardiac troponin elevation has been shown to be associated with adverse outcomes after percutaneous coronary intervention (PCI) for various subgroups of coronary artery disease. We sought to determine the prognostic significance of cardiac troponin I (cTnI) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated with PCI.The study consisted of 760 consecutive patients undergoing PCI for NSTE-ACS. Levels of cTnI were obtained repeatedly every 6 h before PCI. Peak cTnI levels were used for analysis. Patients were followed for major adverse cardiac events (MACE) defined as death, myocardial infarction, and urgent target vessel revascularization for a mean follow-up of 2.9 years.Patients with normal cTnI levels (or=1.0 ng/ml) were classified into subgroup 1. The remaining patients were divided based on an optimal cut-off value derived from the receiver operating characteristic analysis into subgroups 2 (1.1-20 ng/ml) and 3 (20 ng/ml). By multivariate analyses, patients with higher peak preprocedural cTnI levels were independently associated with increased risk of 30-day mortality [adjusted odds ratio, 1.88, 95% confidence interval (CI): 1.11-3.17, P=0.019] and composite MACE [group 1 vs. group 2 (adjusted hazard ratio 2.09, 95% CI: 1.35-3.23, P0.001), group 1 vs. group 3 (adjusted hazard ratio 3.64, 95% CI: 2.39-5.56, P0.001)].Preprocedural cTnI level is a strong and independent predictor of 30-day mortality and long-term MACE after PCI in the setting of NSTE-ACS.

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 coveredor =80%. The outcome was combined mortality and MI. Kaplan-Meier analyses were used to explore the impact of noncomplianceor =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. Noncomplianceor = 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 withor = 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.

Myocardial ischemia can impair myocardial relaxation and result in increased left ventricular (LV) diastolic pressure. Noninvasive measurements of mitral annular velocities have been used to evaluate LV diastolic pressure. We sought to determine whether mitral annular velocities, derived from novel speckle tracking echocardiography (STE), could predict mortality in patients with acute coronary syndrome (ACS).A total of 246 patients with ACS were retrospectively studied. STE was analyzed offline with the sample volume placed on septal, lateral, inferior, and anterior mitral annulus. Peak early (E') and late (A') diastolic velocities of the mitral annulus were measured and averaged from the four regions. Peak early diastolic mitral inflow velocity (E) was obtained using pulsed-wave Doppler.Lower E' (P = 0.03), lower A' (P = 0.001), higher E'/A' ratio (P = 0.007), and higher E/E' ratio (P = 0.003) were independently associated with increased risk of death with adjustment for clinical and echocardiographic variables over the follow-up period of 21 months. The optimal cutoff value of E/E' ratio derived from the receiver operating characteristic analysis for predicting death was 30 (area under the curve = 0.65). E/E' ratio greater than 30 was predictive of death in univariate (HR, 2.40; CI, 1.42-4.06; P = 0.001) and multivariate (adjusted HR, 1.91; CI, 1.09-3.32; P = 0.02) models.The measurements of mitral annular velocities by STE are predictive of mortality in patients with ACS.

Prior studies have reported conflicting findings regarding racial disparities in long-term cardiovascular outcomes after percutaneous coronary intervention (PCI). Our aim was to compare major adverse cardiac events (MACE) following PCI in black versus non-black patients in a Public Health Service (PHS) setting.A cohort of 1,438 consecutive patients undergoing intended PCI at a large public teaching hospital between April 2002 and September 2006 were followed for the development of MACE, defined as a composite of death, myocardial infarction (MI) and urgent target vessel revascularization.The study population consisted of 47.4% blacks, 21.3% whites, 15.2% Hispanics and 16.1% Asians. Overall, 17.4% of patients developed MACE over the mean followup period of 2.9 years. The rate of MACE was significantly higher in blacks compared with non-blacks (21.7% vs. 13.6%, log-rank p0.001). After adjusting for age, gender, cardiovascular risk factors, socioeconomic status (SES) and potential confounding factors, black race remained a strong and independent predictor of MACE (adjusted HR, 1.52; CI, 1.18-1.96; p = 0.001). Blacks had higher rates of death (12.3% vs. 5.2%, log-rank p0.001) and MI (8.7% vs. 4.4%, log rank p = 0.002). There were no racial differences in in-hospital mortality and 3-month and 6-month MACE.In this PHS population, blacks were found to have worse long-term cardiovascular outcomes and mortality following PCI, irrespective of differences in baseline cardiovascular risk factors, SES and health-care access.

The goal of this study was to evaluate the relation between serum levels of carbohydrate antigen 125 (CA125) and prognosis in African American (AA) patients with heart failure (HF). Little is known about the usefulness of CA125 in the AA population, which has different pathophysiology and higher prevalence of HF. The authors enrolled 172 consecutive AA patients (mean age, 55.8 years; 61.1% men) admitted with a clinical diagnosis of acute decompensated HF. CA125 was measured within 48+/-12 hours of presentation. Patients were grouped according to CA125 levels into quartiles. The median CA125 level was 16 U/mL. Serum levels of CA125 were elevated (>35 U/mL) in 58 patients (33.7%). Fifty-two patients (30.8%) died over a median follow-up period of 40 months. The CA125 threshold derived from the receiver operating characteristic curves for the prediction of mortality was 35 U/mL. In a multivariate analysis, CA125 levels >35 U/mL were found to be predictive of 40-month all-cause mortality (adjusted hazard ratio, 2.53; confidence interval, 1.40-4.59; P=.002). However, CA125 levels were not associated with 18-month HF rehospitalization. CA125 value is a strong and independent predictor of long-term mortality in AA patients admitted with a diagnosis of acute decompensated HF. Identifying a higher-risk cohort might allow for a more targeted treatment approach.

Background and objectives: Chronic kidney disease (CKD) increases systemic inflammation, which is implicated in development and maintenance of atrial fibrillation (AF); therefore, we hypothesized that the prevalence of AF would be increased among nondialysis patients with CKD. This study also reports independent predictors of the presence of AF in this population. Design, setting, participants, & measurements: A retrospective, cross-sectional analysis of 1010 consecutive nondialysis patients with CKD from two community-based hospitals was conducted. Estimated GFRs (eGFRs) were calculated using the Modification of Diet in Renal Disease (MDRD) equation. Multivariate logistic regression was used to determine independent predictors. Results: Of 1010 nondialysis patients with CKD, 214 (21.2%) had AF. Patients with AF were older than patients without AF (76 ± 11 versus 63 ± 15 yr). The prevalence of AF among white patients (42.7%) was higher than among black patients (12.7%) or other races (5.7%). In multivariate analyses, age, white race, increasing left atrial diameter, lower systolic BP, and congestive heart failure were identified as independent predictors of the presence of AF. Although serum high-sensitivity C-reactive protein levels were elevated in our population (5.2 ± 7.4 mg/L), levels did not correlate with the presence of AF or with eGFR. Finally, eGFR did not correlate with the presence of AF in our population. Conclusions: The prevalence of AF was increased in our population, and independent predictors were age, white race, increasing left atrial diameter, lower systolic BP, and congestive heart failure.

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. Copyright © 2009 Wiley Periodicals, Inc.

Background Introduction CMR has become the leading technique to define the clinical impact of hypertrophic cardiomyopathy (HCM) providing complete coverage of both ventricles with high spatial resolution. Gadolinium delayed-enhancement (DHE) accurately identifies regions of myocardial fibrosis. Via CMR, innumerable studies have established that LVH is the predominant phenotypic expression of HCM. It is well known that myocardial fibrosis can occur in patients with HCM and is independently linked to a poorer prognosis than those without fibrosis by CMR.