Abstract 19396: Impaired Autonomic Modulation During the Valsalva Maneuver Predicts Ischemia in Patients With Coronary Artery Disease

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Amit J Shah ◽  
Ayman Alkhoder ◽  
Malik Obideen ◽  
Ronnie Ramadan ◽  
Kobina Wilmot ◽  
...  
Keyword(s):  
Myocardial Ischemia ◽  
Autonomic Function ◽  
Valsalva Maneuver ◽  
Standing Position ◽  
Deep Breathing ◽  
Cardiac Events ◽  
Pharmacological Stress ◽  
Increased Risk ◽  
Autonomic Reflexes ◽  
Artery Disease

Introduction: Previous studies have found that lower resting short-term heart rate variability (HRV), a measure of autonomic dysfunction, predicts adverse cardiac events. Abnormal autonomic function may precipitate myocardial ischemia. Physiologic challenges like Valsalva and deep breathing may also provide important data by modulating preload/afterload and stimulating various autonomic receptors. Methods: We examined autonomic function in 166 patients with CAD using the ANSAR method (ANX 3.0, ANSAR Inc. Philadelphia, PA). HRV was measured in the sitting position, standing position, during deep breathing, and during Valsalva. After ANSAR testing, patients underwent 99m Tc[[Unable to Display Character: ‐]]sestamibi myocardial perfusion imaging at rest and with exercise or pharmacological stress. A summed difference score (SDS) was computed to quantify ischemia using a 17-segment model with observer-independent software. Multivariable models adjusted for CAD risk factors, psychiatric comorbidities, and medications. Results: The mean (SD) age was 62 (9) years, 75% were men, and 31% had ischemia (SDS ≥ 4). Both low (LF) and high (HF) frequency HRV during all 4 conditions were associated with ischemia in unadjusted models (table), but after multivariable adjustment, only LF and HF HRV during Valsalva and deep breathing were still associated with ischemia. The strongest association was found with LF HRV during Valsalva, such that every 10% decrease in LF HRV during Valsalva (p=0.003, adjusted) associated with a 1 point increase in SDS. When dividing patients into 4 categories of SDS score (0, 1-3, 4-7, ≥ 8), the SDS ≥ 8 category had a lower LF HRV during Valsalva than all other categories, most notably compared to SDS=0 (78% reduction in LF HRV). Conclusion: Low HF and LF HRV are associated with increased risk of myocardial ischemia in CAD patients. Most notably, autonomic inflexibility during Valsalva may help uncover underlying vulnerabilities in autonomic reflexes that predict ischemia burden.

Novel Oral Anticoagulants in Peripheral Artery Disease: Current Evidence

2019 ◽  
Vol 24 (38) ◽  
pp. 4511-4515 ◽  
Author(s):  
A. Koutsoumpelis ◽  
C. Argyriou ◽  
K.M. Tasopoulou ◽  
E.I. Georgakarakos ◽  
G.S. Georgiadis
Keyword(s):  
Peripheral Artery Disease ◽  
Oral Anticoagulants ◽  
Novel Oral Anticoagulants ◽  
Current Evidence ◽  
Peripheral Artery ◽  
Cardiac Events ◽  
Traditional Therapy ◽  
Cardiovascular Morbidity And Mortality ◽  
Increased Risk ◽  
Artery Disease

Background: Peripheral artery disease is a common manifestation of systemic atherosclerosis which strongly correlates to cardiovascular morbidity and mortality. In addition, the progression of peripheral artery disease leads to an increased risk of limb loss. In order to reduce these events, the benchmark of treatment and research over the last years has been the antiplatelet therapy which aims at inhibition of platelet aggregation. Over the last years, new studies combining antiplatelet agents in different therapeutic schemes have been proven efficacious. Unfortunately, patients remain still at high risk of CV events. Novel Oral Anticoagulants have been introduced as alternatives to warfarin, in the prevention and treatment of venous thromboembolism. The rationale of using medication which acts on platelet activation and the coagulation pathway of thrombosis has led investigators to examine the role of Noac's in preventing CV events in patients with peripheral artery disease, stable or unstable. Methods: The aim of this study is to review the current evidence with respect to recently published studies concerning the use of Novel anticoagulants in peripheral artery disease. Results: The Compass trial has shown that a combination of rivaroxaban with traditional therapy may produce promising results in reducing amputation rates, stroke, cardiac events, and mortality, however, there are still safety issues with bleeding requiring acute care. The ePAD study has provided us with insight concerning safety and efficacy after peripheral angioplasty or stenting and actually the need for further research. The Voyager Pad study, following the steps of Compass, is studying the effect and safety of the addition of rivaroxaban to traditional therapy in the highest risk population aka patients undergoing peripheral revascularization. The evidence concerning patients with concomitant atrial fibrillation appears to be insufficient, however, recent guidelines propose the use of novel oral anticoagulants. Conclusion: For the time being, novel oral anticoagulants in combination with aspirin may provide an alternative treatment in PAD, however, it is deemed necessary to identify patient subgroups who will benefit the most.

scholarly journals Prognostic Value of VEGF in Patients Submitted to Percutaneous Coronary Intervention

2014 ◽  
Vol 2014 ◽  
pp. 1-7 ◽  
Author(s):  
Catarina Ramos ◽  
Patrícia Napoleão ◽  
Mafalda Selas ◽  
Cláudia Freixo ◽  
Ana Maria Viegas Crespo ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Intervention ◽  
Drug Eluting Stent ◽  
Cardiac Events ◽  
Positive Role ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
Previous Medication ◽  
Drug Eluting ◽  
Artery Disease

We examined the longitudinal changes of VEGF levels after percutaneous coronary intervention for predicting major adverse cardiac events (MACE) in coronary artery disease (CAD) patients. VEGF was measured in 94 CAD patients’ serum before revascularization, 1-month and 1-year after. Independently of clinical presentation, patients had lower VEGF concentration than a cohort of healthy subjects (median, IQ: 15.9, 9.0–264 pg/mL versus 419, 212–758 pg/mL;P<0.001) at baseline. VEGF increased to 1-month (median, IQ: 276, 167–498 pg/mL;P<0.001) and remained steady to 1-year (median, IQ: 320, 173–497 pg/mL;P<0.001) approaching control levels. Drug eluting stent apposition and previous medication intake produced a less steep VEGF evolution after intervention (P<0.05). Baseline VEGF concentration <40.8 pg/mL conveyed increased risk for MACE in a 5-year follow-up. Results reflect a positive role of VEGF in recovery and support its importance in CAD prognosis.

Heart Rate/Stroke Volume Relationship During Upright Exercise in Long-Term Diabetics

1993 ◽  
Vol 18 (2) ◽  
pp. 148-162
Author(s):  
R. G. Haennel ◽  
K. K. Teo ◽  
A. Suthijumroon ◽  
M. P. J. Senaratne ◽  
M. Hetherington ◽  
...  
Keyword(s):  
Heart Rate ◽  
Stroke Volume ◽  
Cardiac Function ◽  
Autonomic Function ◽  
Valsalva Maneuver ◽  
Peak Exercise ◽  
Initial Increase ◽  
Key Words Diabetes Mellitus ◽  
Key Words Diabetes ◽  
Deep Breathing

The changes in stroke volume (SV) during upright exercise were studied in 20 insulin-dependent diabetics (IDDM) and 20 age- and sex-matched controls. None of the diabetics had any cardiovascular symptoms. In addition, tests of autonomic function were conducted in the diabetics, assessing changes in heart rate (HR) during deep breathing and the Valsalva maneuver. During exercise the SV in the controls gradually increased and then remained essentially unchanged until maximum HR was achieved. Seven of the diabetics failed to sustain an initial increase in SV (fall > 15%), eight showed a "delayed" increase in SV, and the remaining five demonstrated an increasing SV over the range from rest to peak exercise. Abnormal autonomic function results were found during deep breathing (four diabetics) and the Valsalva maneuver (four diabetics). Findings indicate that cardiac function could be abnormal in IDDM without evidence of autonomic dysfunction. This abnormality could be due to a specific cardiomyopathy. Key words: diabetes mellitus, cardiac function, upright exercise, autonomic neuropathy, cardiomyopathy

scholarly journals Clinical Values of Resting Electrocardiography in Patients with Known or Suspected Chronic Coronary Artery Disease: A Stress Perfusion Cardiac MRI Study

2021 ◽  
Author(s):  
Yodying Kaolawanich ◽  
Rawiwan Thongsongsang ◽  
Thammarak Songsangjinda ◽  
Thananya Boonyasirinant
Keyword(s):  
Heart Failure ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Myocardial Ischemia ◽  
Multivariable Analysis ◽  
Stress Perfusion ◽  
Cardiac Events ◽  
Chronic Coronary Artery Disease ◽  
Artery Disease ◽  
Ecg Abnormalities

Abstract Background Electrocardiography (ECG) is an essential investigation in patients with chronic coronary artery disease (CAD). However, evidence regarding the diagnostic and prognostic value of ECG in this population is limited. Therefore, we sought to determine whether baseline ECG abnormalities were associated with myocardial ischemia and cardiac events in patients with known or suspected chronic CAD. Methods Consecutive patients with known (n=146) or suspected chronic CAD (n=349) referred for adenosine stress cardiac magnetic resonance (CMR) between 2011 and 2014 were enrolled. Resting ECGs were classified as major, minor and no abnormalities. Predictors of myocardial ischemia on CMR and major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, hospitalization for heart failure and late revascularization (>180 days after CMR) were evaluated.Results Average age was 69±11 years (51% men). One hundred and eighty-five patients (37.4%) had major and 154 (31.1%) had minor ECG abnormalities. In patients with suspected CAD, myocardial ischemia was present in 83 patients (23.8%). Multivariable analysis demonstrated major ECG abnormality as the strongest predictor of myocardial ischemia (HR 2.88; 95% CI 1.69-4.92; p<0.001). Adding ECG to clinical pretest probability models improved the prediction of myocardial ischemia in ROC analyses (p=0.04). In the whole cohort (n=495), 91 MACE occurred during the median follow-up period of 4.8 years. Multivariable analysis showed that diastolic blood pressure, history of heart failure, prior revascularization, ischemia, myocardial scarring, and major ECG abnormality were independent predictors of MACE.Conclusion Abnormal resting ECG is common in patients with known or suspected chronic CAD. ECG had important diagnostic and prognostic values in this population.

scholarly journals Association of the Extent of Myocardial Ischemia with Outcomes in Patients with Suspected Coronary Artery Disease

2020 ◽  
Author(s):  
Takao Kato ◽  
Mitsuru Momose ◽  
Yukari Uemura ◽  
Masanao Naya ◽  
Naoya Matsumoto ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Myocardial Ischemia ◽  
Single Photon ◽  
Heart Diseases ◽  
Photon Emission ◽  
Suspected Coronary Artery Disease ◽  
Emission Computed Tomography ◽  
Cardiac Events ◽  
Artery Disease

Abstract Background: There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial. We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan.Methods: From the data of 2780 patients with stable angina, who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referred non-invasive imaging tests, 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1 year. Results: Patients with ≥10% myocardial ischemia (n=173) were older than patients with <10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (9.1% vs. 1.2%, P<0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to <10% myocardial ischemia for MACEs remained significant (adjusted hazard ratio [95% confidence interval], 2.40 [1.09-5.26], P=0.029).Conclusion: The presence of ≥10% myocardial ischemia was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.

scholarly journals Machine Learning to Predict Long-Term Cardiac-Relative Prognosis in Patients With Extra-Cardiac Vascular Disease

2021 ◽  
Vol 8 ◽  
Author(s):  
Guisen Lin ◽  
Qile Liu ◽  
Yuchen Chen ◽  
Xiaodan Zong ◽  
Yue Xi ◽  
...  
Keyword(s):  
Machine Learning ◽  
Unstable Angina ◽  
Cardiac Events ◽  
Coronary Ct ◽  
Framingham Risk ◽  
Increased Risk ◽  
History Of ◽  
Artery Disease ◽  
Ischemic Attack

Aim: Patients with ischemic stroke (IS), transient ischemic attack (TIA), and/or peripheral artery disease (PAD) represent a population with an increased risk of coronary artery disease. Prognostic risk assessment to identify those with the highest risk that may benefit from more intensified treatment remains challenging. To explore the feasibility and capability of machine learning (ML) to predict long-term adverse cardiac-related prognosis in patients with IS, TIA, and/or PAD.Methods: We analyzed 636 consecutive patients with a history of IS, TIA, and/or PAD. All patients underwent a coronary CT angiography (CCTA) scan. Thirty-five clinical data and 34 CCTA metrics underwent automated feature selection for ML model boosting. The clinical outcome included all-cause mortality (ACM) and major adverse cardiac events (MACE) (ACM, unstable angina requiring hospitalization, non-fatal myocardial infarction (MI), and revascularization 90 days after the index CCTA).Results: During the follow-up of 3.9 ± 1.6 years, 21 patients had unstable angina requiring hospitalization, eight had a MI, 23 had revascularization and 13 deaths. ML demonstrated a significant higher area-under-curve compared with the modified Duke index (MDI), segment stenosis score (SSS), segment involvement score (SIS), and Framingham risk score (FRS) for the prediction of ACM (ML:0.92 vs. MDI:0.66, SSS:0.68, SIS:0.67, FRS:0.51, all P &lt; 0.001) and MACE (ML:0.84 vs. MDI:0.82, SSS:0.76, SIS:0.73, FRS:0.53, all P &lt; 0.05).Conclusion: Among the patients with IS, TIA, and/or PAD, ML demonstrated a better capability of predicting ACM and MCAE than clinical scores and CCTA metrics.

Abstract 19: Prognostic Value of Plasma Choline and Betaine Depend on the Intestinal Microflora-generated Metabolite Trimethylamine N-oxide

2013 ◽  
Vol 33 (suppl_1) ◽  
Author(s):  
Zeneng Wang ◽  
W. H. Wilson Tang ◽  
Xiaoming Fu ◽  
Earl B Britt ◽  
Yuping Wu ◽  
...  
Keyword(s):  
Intestinal Microflora ◽  
Study Cohort ◽  
Cardiac Events ◽  
Model Studies ◽  
Stable Isotope Dilution ◽  
Increased Risk ◽  
Adverse Cardiac Events ◽  
Myocardial Infraction ◽  
Traditional Risk Factors ◽  
Artery Disease

Background Recent metabolomics and animal model studies show trimethylamine-N-oxide (TMAO), an intestinal microbiota-dependent metabolite formed from dietary phosphatidylcholine (PC), is linked with coronary artery disease (CAD) pathogenesis. Prognostic determinants of other PC metabolites recently associated with prevalent CAD risk, such as choline and betaine, have not been described. Methods We examined the relationship between fasting plasma choline, betaine, and TMAO and future risk of major adverse cardiac events (MACE=death, myocardial infraction, stroke) over 3-year follow-up in 3,916 subjects undergoing elective coronary angiography. All analytes were quantified by stable isotope dilution LC/MS/MS. Results In our study cohort (mean age 63±11 years, 64% male), median [IQR] TMAO, choline, and betaine levels were 3.7 [2.4-6.2] μM, 9.8 [7.9-12.2] μM, and 41.1 [32.5-52.1] μM, respectively. Modest but statistically significant correlations were noted between TMAO and choline (r=0.33, p<0.001) and between TMAO and betaine (r=0.09, p<0.001). Higher plasma TMAO, choline and betaine levels were associated with a 2.7-fold, 1.9-fold, and 1.4-fold increased risk of MACE, respectively (Quartiles 4 vs 1: p<0.01, each). Following adjustments for traditional risk factors and hsCRP, elevated TMAO (Quartiles 4 vs 1: Hazard ratio, 1.97 [95% CI 1.50-2.60], p<0.01), choline (HR 1.34 [95% CI 1.03-1.74], p<0.05) and betaine levels (HR 1.33 [95% CI 1.03-1.73], p<0.05) each predicted increased MACE risk, but only TMAO predicted MACE risk when all 3 metabolites were included in the model (HR, 1.73 [95% CI 1.3-2.31], p<0.01). Choline and betaine only predicted increased MACE risk in those with elevated TMAO levels. Conclusion Elevated plasma levels of TMAO, and to a lesser extent choline and betaine, are associated with incident MACE risk. However, high choline and betaine levels are only associated with higher risk of future MACE with concomitant increase in TMAO. Collectively, these findings further support the atherogenic associations between intestinal-microflora dependent metabolism of PC and atherosclerosis in humans.

Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation

2013 ◽  
Vol 110 (09) ◽  
pp. 560-568 ◽  
Author(s):  
Anne Bernard ◽  
Céline Pellegrin ◽  
Nicolas Clementy ◽  
Christophe Saint Etienne ◽  
Amitava Banerjee ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stent Implantation ◽  
Target Lesion ◽  
Coronary Stent ◽  
Cardiac Events ◽  
Risk Of Death ◽  
Coronary Stent Implantation ◽  
Increased Risk ◽  
History Of ◽  
Artery Disease

SummaryIn patients with atrial fibrillation (AF) undergoing coronary stent implantation, the optimal antithrombotic strategy is unclear. We evaluated whether use of oral anticoagulation (OAC) was associated with any benefit in morbidity or mortality in patients with AF, high risk of thromboembolism (TE) (CHA2DS2-VASC score ≥2) and coronary stent implantation. Among 8,962 unselected patients with AF seen between 2000 and 2010, a total of 2,709 (30%) had coronary artery disease and 417/2,709 (15%) underwent stent implantation while having CHA2DS2-VASC score ≥2. During follow-up (median=650 days), all TE, bleeding episodes, and major adverse cardiac events (i.e. death, acute myocardial infarction, target lesion revascularisation) were recorded. At discharge, 97/417 patients (23%) received OAC, which was more likely to be prescribed in patients with permanent AF and in those treated for elective stent implantation. The incidence of outcome event rates was not significantly different in patients treated and those not treated with OAC. However, in multivariate analysis, the lack of OAC at discharge was independently associated with increased risk of death/stroke/systemic TE (relative risk [RR] =2.18, 95% confidence interval [CI] 1.02-4.67, p=0.04), with older age (RR =1.12, 1.04-1.20, p=0.003), heart failure (RR =3.26, 1.18-9.01, p=0.02), and history of stroke (RR =18.87, 3.11-111.11, p=0.001). In conclusion, in patients with AF and high thromboembolic risk after stent implantation, use of OAC was independently associated with decreased risk of subsequent death/stroke/systemic TE, suggesting that OAC should be systematically used in this patient population.

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