[Show abstract][Hide abstract] ABSTRACT: Renal dysfunction in patients with acute myocardial infarction (MI) is an important predictor of short- and long-term outcome. Cardiac abnormalities dominated by left ventricular (LV) hypertrophy are common in patients with chronic renal dysfunction. However, limited data exists on the association between LV systolic- and diastolic function assessed by comprehensive echocardiography and renal dysfunction in contemporary unselected patients with acute MI.
We prospectively included 1054 patients with acute MI (mean age 63 years, 73% male) and performed echocardiographic assessment of systolic and diastolic function within 48 hours of admission as well as estimated glomerular filtration rate (eGFR).
Reduced eGFR was significantly associated with LV mass, LV ejection fraction, LV global strain (GLS) and E/e' ratio. After multivariable adjustment, E/e' ratio (P = .0096) remained the only echocardiographic measure independently associated with decreasing eGFR. During follow-up a total of 113 patients (10.7%) patients experienced the composite endpoint of all-cause mortality or hospitalization for heart failure. An eGFR <60 mL/min per 1.73 m(2) was significantly associated with outcome (HR, 1.71; 95% CI, 1.12-2.62; P = .0131) after adjustment for age, diabetes, hypertension, Killip class >1, multivessel disease and troponin. The prognostic impact of an eGFR <60 mL/min per 1.73 m(2) was only modestly altered by addition of LV mass or E/e' ratio whereas addition of LV ejection fraction or GLS attenuated its importance considerably.
Renal dysfunction in patients with acute MI is independently associated with echocardiographic evidence of increased LV filling pressure. However, the prognostic importance of renal dysfunction is attenuated to a greater degree by LV longitudinal systolic function.
American heart journal 04/2014; 167(4):506-13. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to test the hypothesis that strain echocardiography might improve arrhythmic risk stratification in patients after myocardial infarction (MI).
Prediction of ventricular arrhythmias after MI is challenging. Left ventricular ejection fraction (LVEF) < 35% is the main parameter for selecting patients for implantable cardioverter-defibrillator therapy.
In this prospective, multicenter study, 569 patients >40 days after acute MI were included, 268 of whom had ST-segment elevation MIs and 301 non-ST-segment elevation MIs. By echocardiography, global strain was assessed as average peak longitudinal systolic strain from 16 left ventricular segments. Time from the electrocardiographic R-wave to peak negative strain was assessed in each segment. Mechanical dispersion was defined as the standard deviation from these 16 time intervals, reflecting contraction heterogeneity.
Ventricular arrhythmias, defined as sustained ventricular tachycardia or sudden death during a median 30 months (interquartile range: 18 months) of follow-up, occurred in 15 patients (3%). LVEFs were reduced (48 ± 17% vs. 55 ± 11%, p < 0.01), global strain was markedly reduced (-14.8 ± 4.7% vs. -18.2 ± 3.7%, p = 0.001), and mechanical dispersion was increased (63 ± 25 ms vs. 42 ± 17 ms, p < 0.001) in patients with arrhythmias compared with those without. Mechanical dispersion was an independent predictor of arrhythmic events (per 10-ms increase, hazard ratio: 1.7; 95% confidence interval: 1.2 to 2.5; p < 0.01). Mechanical dispersion and global strain were markers of arrhythmias in patients with non-ST-segment elevation MIs (p < 0.05 for both) and in those with LVEFs > 35% (p < 0.05 for both), whereas LVEF was not (p = 0.33). A combination of mechanical dispersion and global strain showed the best positive predictive value for arrhythmic events (21%; 95% confidence interval: 6% to 46%).
Mechanical dispersion by strain echocardiography predicted arrhythmic events independently of LVEF in this prospective, multicenter study of patients after MI. A combination of mechanical dispersion and global strain may improve the selection of patients after MI for implantable cardioverter-defibrillator therapy, particularly in patients with LVEFs > 35% who did not fulfill current implantable cardioverter-defibrillator indications.
[Show abstract][Hide abstract] ABSTRACT: This study sought to hypothesize that global longitudinal strain (GLS) as a measure of infarct size, and mechanical dispersion (MD) as a measure of myocardial deformation heterogeneity, would be of incremental importance for the prediction of sudden cardiac death (SCD) or malignant ventricular arrhythmias (VA) after acute myocardial infarction (MI).
SCD after acute MI is a rare but potentially preventable late complication predominantly caused by malignant VA. Novel echocardiographic parameters such as GLS and MD have previously been shown to identify patients with chronic ischemic heart failure at increased risk for arrhythmic events. Risk prediction during admission for acute MI is important because a majority of SCD events occur in the early period after hospital discharge.
We prospectively included patients with acute MI and performed echocardiography, with measurements of GLS and MD defined as the standard deviation of time to peak negative strain in all myocardial segments. The primary composite endpoint (SCD, admission with VA, or appropriate therapy from a primary prophylactic implantable cardioverter-defibrillator [ICD]) was analyzed with Cox models.
A total of 988 patients (mean age: 62.6 ± 12.1 years; 72% male) were included, of whom 34 (3.4%) experienced the primary composite outcome (median follow-up: 29.7 months). GLS (hazard ratio [HR]: 1.38; 95% confidence interval [CI]: 1.25 to 1.53; p < 0.0001) and MD (HR/10 ms: 1.38; 95% CI: 1.24 to 1.55; p < 0.0001) were significantly related to the primary endpoint.
1.24; 95% CI: 1.10 to 1.40; p = 0.0004) and MD (HR/10 ms: 1.15; 95% CI: 1.01 to 1.31; p = 0.0320) remained independently prognostic after multivariate adjustment. Integrated diagnostic improvement (IDI) and net reclassification index (NRI) were significant for the addition of GLS (IDI: 4.4% [p < 0.05]; NRI: 29.6% [p < 0.05]), whereas MD did not improve risk reclassification when GLS was known.
Both GLS and MD were significantly and independently related to SCD/VA in these patients with acute MI and, in particular, GLS improved risk stratification above and beyond existing risk factors.
[Show abstract][Hide abstract] ABSTRACT: AIMS: Diastolic dysfunction in acute myocardial infarction (MI) is associated with adverse outcome. Recently, the ratio of early mitral inflow velocity (E) to global diastolic strain rate (e'sr) has been proposed as a marker of elevated LV filling pressure. However, the prognostic value of this measure has not been demonstrated in a large-scale setting when existing parameters of diastolic function are known. We hypothesized that the E/e'sr ratio would be independently associated with an adverse outcome in patients with MI. METHODS AND RESULTS: We prospectively included patients with MI and performed echocardiography with comprehensive diastolic evaluation including E/e'sr. The relationship between E/e'sr and the primary composite endpoint (all-cause mortality, hospitalization for heart failure (HF), stroke, and new onset atrial fibrillation) was analysed with Cox models. A total of 1048 patients (mean age 63 ± 12, 73% male) were included and 142 patients (13.5%) reached the primary endpoint (median follow-up 29 months). A significant prognostic value was found for E/e'sr [hazard ratio (HR) per 1 unit change: 2.36, 95% confidence interval (CI): 2.02-2.75, P < 0.0001]. After multivariable adjustment E/e'sr remained independently related to the combined endpoint (HR per 1 unit change, 1.50; CI: 1.05-2.13, P = 0.02). The prognostic value of E/e'sr was driven by mortality (HR per 1 unit change, 2.52; CI: 2.09-3.04, P < 0.0001) and HF admissions (HR per 1 unit change, 2.79; CI: 2.23-3.48, P < 0.0001). CONCLUSION: Deformation-based E/e'sr contributes important information about global myocardial relaxation superior to velocity-based analysis and is independently associated with the outcome in acute MI.
European Heart Journal 05/2013; · 14.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: We hypothesized that semi-automated calculation of left ventricular global longitudinal strain (GLS) could identify high risk individuals among MI patients with LVEF>40%. BACKGROUND: Left ventricular ejection fraction (LVEF) is a key determinant in decision making after acute myocardial infarction (MI), yet it is relatively indiscriminant within the normal range. Novel echocardiographic deformation parameters may be of particular clinical relevance in patients with relatively preserved LVEF. METHODS: We prospectively included patients with MI and LVEF>40% within 48 hours of admission for coronary angiography. All patients underwent echocardiography with semi-automated measurement of GLS. The primary composite endpoint (all-cause mortality and hospitalization for heart failure (HF)) was analyzed using Cox regression analyses. The secondary endpoints were cardiac death and HF hospitalization. RESULTS: 849 patients (mean age 61.9±12.0, 73% male) were included and 57 patients (6.7%) reached the primary endpoint (median follow up 30 months). A significant prognostic value was found for GLS (hazard ratio (HR): 1.20, 95% confidence interval (CI): 1.10-1.32, p<0.001). A GLS above -14% was associated with a 3-fold increase in risk of the combined endpoint (HR, 3.21; 95%CI: 1.82-5.67, p<0.001). After adjustment for other variables GLS remained independently related to the combined endpoint (HR, 1.14; 95%CI: 1.04-1.26, p=0.007). For the secondary endpoints a GLS>-14 was significantly associated with cardiovascular death (HR, 12.7; 95%CI 3.0-54.6, p<0.001) and HF hospitalization (HR, 5.31; 95%CI, 1.50-18.82, p<0.001). CONCLUSIONS: Assessment of GLS using a semi-automated algorithm provides important prognostic information in patients with LVEF>40% over and beyond traditional indices of high risk MI.
Journal of the American College of Cardiology 04/2013; · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: -Peak atrial longitudinal strain (PALS) during the reservoir phase has been proposed as a measure of LA function in a range of cardiac conditions with the potential for added pathophysiological insight and prognostic value. However, no studies have assessed the interrelation of PALS and LV longitudinal strain (GLS) in large scale populations in regard to prognosis. METHODS AND RESULTS: -We prospectively included 843 patients (mean age 62.1±11.8, 74% male) with acute myocardial infarction and measured GLS, LA volumes and PALS within 48 hours of admission. PALS was related to a composite outcome of death and heart failure hospitalization. Reduced PALS was associated with hypertension, diabetes and Killip class>1 (All p-values<0.05). Reduced PALS was associated with impairment of all measures of LV systolic and diastolic function and the correlation between GLS and PALS was highly significant (p<0.001, r=-0.71). During follow-up (median 23.0 months Q1-Q3, 16.8-26.0) a total of 76 patients (9.0%) reached the composite endpoint of which 47 patients died (5.6%) and 29 patients were hospitalized for HF (3.4%). PALS was significantly associated with outcome (HR, 0.88; 95%CI 0.85-0.90, p<0.001), however no independent effect of PALS (1.00; 95%CI 0.94-1.05, p=0.87) was found when adjusting for GLS (HR, 1.20; 95%CI 1.09-1.33, p<0.001), LAmax (HR, 1.02; 95%CI 1.01-1.04, p=0.006) and age (HR, 1.06; 95%CI 1.03-1.08, p<0.001). CONCLUSIONS: -PALS provides a composite measure of LV longitudinal systolic function and LAmax and as such contains no added information when these readily obtained measures are known.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Heart failure (HF) complicating acute myocardial infarction (MI) is an ominous prognostic sign frequently caused by left ventricular (LV) systolic dysfunction. However, many patients develop HF despite preserved LV ejection fractions. The aim of this study was to test the hypothesis that LV longitudinal function is a stronger marker of in-hospital HF than traditional echocardiographic indices. METHODS: A total of 548 patients with acute MIs were evaluated (mean age, 63.2 ± 11.7 years; 71.6% men). Within 48 hours of admission, comprehensive echocardiography with assessment of global longitudinal strain (GLS) was performed, along with measurements of N-terminal pro-brain natriuretic peptide. RESULTS: A total 89 patients (16.2%) had in-hospital HF assessed by Killip class > 1 in whom GLS was significantly impaired compared with patients without in-hospital HF (Killip class 1) (-14.6 ± 3.3% vs -10.1 ± 3.5%, P < .0001). In stepwise multiple logistic regression analysis including age, known HF, three-vessel disease, involvement of the left anterior descending coronary artery, episodes of atrial fibrillation, renal function, N-terminal pro-brain natriuretic peptide, troponin T level, LV ejection fraction, wall motion score index, and diastolic dysfunction indices, GLS emerged as the strongest marker of clinical HF (odds ratio, 1.47; 95% confidence interval [CI], 1.33-1.62; P < .0001). GLS remained independently associated with in-hospital HF in patients with LV ejection fractions > 40% (odds ratio, 1.33; 95% CI, 1.14-1.54; P < .05) and improved the C-statistic over other important covariates significantly (0.87 [95% CI, 0.82-0.91] vs 0.82 [95% CI, 0.76-0.89], P = .02). CONCLUSIONS: Global longitudinal function assessed by GLS is significantly impaired in patients with MIs with in-hospital HF, and multivariate analysis suggests that reduced GLS is the single most powerful marker of manifest LV hemodynamic deterioration in the acute phase of MI.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 10/2012; · 2.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: N-terminal pro brain natriuretic peptide (NT-proBNP) is released in response to increased myocardial wall stress and is associated with adverse outcome in acute myocardial infarction. However, little is known about the relationship between longitudinal deformation indices and NT-proBNP.
We prospectively included 611 patients with acute myocardial infarction admitted to a tertiary centre and performed echocardiography within 48 h of admission. Global longitudinal myocardial function was assessed by two-dimensional speckle tracking simultaneously with measurement of plasma NT-proBNP. A significant linear relationship between NT-proBNP and global longitudinal strain (GLS) was found (P < 0.0001, r = 0.62). Weaker correlation was found between NT-proBNP and left ventricular ejection fraction (LVEF; P < 0.0001, r = - 0.44). GLS emerged on multivariable analysis including age, sex, estimated glomerular filtration rate, Killip class ≥2, diabetes, hypertension, presence of ST segment elevation, anterior infarction, troponin level, left atrial volume index, mitral valve deceleration time, and E/e' as the strongest predictor of log(NT-proBNP) (P < 0.0001). In patients with preserved systolic function (LVEF >45%), GLS remained strongly correlated with NT-proBNP (P < 0.0001, r = 0.50). The C-statistic associated with prediction of upper vs. lower quartiles of NT-proBNP was significantly higher for GLS compared with LVEF (0.76 vs. 0.56; P < 0.0001).
Left ventricular longitudinal function assessed by GLS exhibits a stronger association with NT-proBNP levels in acute myocardial infarction compared with LVEF. In patients with apparently preserved systolic function, GLS is superior to LVEF in identifying increased neurohormonal activation.
European Journal of Heart Failure 06/2012; 14(10):1121-9. · 5.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A classical strain pattern of early contraction in one wall and prestretching of the opposing wall followed by late contraction has previously been associated with left bundle branch block (LBBB) activation and short-term response to cardiac resynchronization therapy (CRT). Aims of this study were to establish the long-term predictive value of an LBBB-related strain pattern and to identify changes in contraction patterns during short-term and long-term CRT.
Sixty-seven patients with standard CRT criteria were prospectively enrolled between early 2009 and late 2010. Echocardiography including regional strain analysis by 2-dimensional speckle tracking was performed 1 week before implantation, at day 1, and 6 months after. Response was defined as a decrease in left ventricular end-systolic volume ≥ 15%. The predictive ability of a classical pattern was compared with time-to-peak measurements from velocity and deformation analysis. Forty-three patients (65%) were classified as responders. The presence of a classical pattern showed 91% specificity and 95% sensitivity for response and performed significantly better than time-to-peak parameters in prediction of response to CRT (P < .001, all). In responders, CRT acutely increased septal longitudinal peak systolic strain (-8.7% ± 3.6% to -11.1% ± 3%, P < .001) but not in nonresponders.
The classical pattern is highly predictive of response to CRT and superior to time-to-peak methods. Patients who obtain long-term reverse remodeling are characterized by short-term reversal of the classical strain pattern. These findings emphasize the value of recognizing potentially reversible strain patterns in selection of CRT candidates.
American heart journal 04/2012; 163(4):697-704. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hyponatremia is a known prognostic factor for mortality in patients with heart failure but has not been extensively studied in patients with myocardial infarction (MI). This study was, therefore, designed to evaluate whether plasma sodium and hyponatremia (< 135 mM) are associated with mortality risk in patients with MI.
In retrospective analyses using data from the Trandolapril Cardiac Evaluation (TRACE) study--a randomized, double-blind, placebo-controlled trial of trandolapril in 1749 patients with MI and left ventricular ejection fraction (LVEF) ≤ 35%--associations between plasma sodium or hyponatremia and more than 15-year mortality risk were evaluated in multivariate Cox proportional hazard models including traditional clinical confounders before and after additional adjustment for renal function, use of diuretics or both.
During the extended follow-up time, 1462 patients died. Both hyponatremia [Hazard ratio: 1·30 (95% CI: 1·13-1·50), P < 0·001] and plasma sodium [Hazard Ratio(pro mM increase in P-Na): 0·98 (95% CI: 0·96-0·99), P = 0·004] were associated with mortality risk, and the adjusted parameter estimates were not affected by additional adjustment for renal function, use of diuretics or both.
Hyponatremia and plasma concentrations of sodium are associated with long-term mortality risk in patients with MI complicated by left ventricular systolic dysfunction. Importantly, these associations are independent of renal function and use of diuretics. Whether the associations between plasma sodium or hyponatremia and long-term mortality risk reflect a causation or merely the severity of the underlying cardiac disease remains to be clarified.
European Journal of Clinical Investigation 05/2011; 41(11):1237-44. · 3.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In studies showing benefits of cardiac resynchronization therapy (CRT), individual atrioventricular (AV) delays have been optimized using echocardiography. However, the method for AV delay optimization remains controversial.
In 100 consecutive patients with CRT device implantation, AV delay was optimized using echocardiography. The optimal AV delay was determined by changing the interval in 20-ms increments while measuring displacement in 6 basal left ventricular segments (averaged and reported as left ventricular displacement [D(LV)]) and other echocardiographic measures.
A single optimal AV delay existed for each patient, and the associated highest D(LV) corresponded with the maximal velocity-time integral (VTI) in the left ventricular outflow tract (VTI(LVOT)) and the E/e' ratio. Significant increases in D(LV) and the VTI(LVOT) from before to after implantation with standard settings and from standard to optimal AV delay by displacement were found. Diastolic filling time corresponded poorly with D(LV) and the VTI(LVOT).
Individual optimal AV delay programming provides significant improvement in left ventricular performance and hemodynamics. Displacement analysis and the VTI(LVOT) are interchangeable, whereas diastolic filling time cannot be recommended.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 06/2010; 23(6):621-7. · 2.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Anaemia has been demonstrated as a risk factor in patients with heart failure over periods of a few years, but long term data are not available. We examined the long-term risk of anaemia in heart failure patients during 15 years of follow-up.
We evaluated survival data for 1518 patients with heart failure randomized into the Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) trial. The follow-up time was from 13 to 15 years. After 15 years 11.5% of the patients were still alive.
Anaemia was present in 34% of the patients. 264 (17%) had mild, 152 (10%) had moderate and 98 (7%) had severe anaemia. Hazard ratio of death for patients with mild anaemia compared with patients with no anaemia was 1.27 (1.11-1.45, p<0.001), for moderate anaemia 1.48 (1.24-1.77, p<0.001) and for severe anaemia 1.82 (1.47-2.24, p<0.001), respectively. In multivariable analyses anaemia was still associated with increased mortality with hazard ratios of 1.19 (1.04-1.37, p=0.014) for mild anaemia, 1.23 (1.03-1.48, p=0.024) for moderate anaemia and 1.33 (1.07-1.66, p=0.010) for severe anaemia, respectively. In landmark analysis the increased mortality for mild anaemia was only significant during the first 2 years, while moderate anaemia remained significant for at least 5 years. There were too few patients left with severe anaemia after 5 years to evaluate the importance on mortality beyond this time.
Anaemia at the time of diagnosis of heart failure is an independent factor for mortality during the following years but loses its influence on mortality over time.
The Open Cardiovascular Medicine Journal 01/2010; 4:173-7.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the prognostic value of ST-segment resolution after primary percutaneous coronary intervention (pPCI) versus fibrinolysis.
Resolution of the ST-segment has been used as a surrogate end point in trials evaluating reperfusion in acute myocardial infarction; however, its prognostic significance may be limited to patients treated with fibrinolysis.
In the DANAMI-2 (DANish trial in Acute Myocardial Infarction-2) substudy, including 1,421 patients, the ST-segment elevation at baseline, pre-intervention, 90 min, and 4 h was assessed. The ST-segment resolution was grouped as follows: 1) complete > or =70%; 2) partial 30% to <70%; and 3) no resolution <30%. End points were 30-day and long-term mortality and reinfarction.
The ST-segment resolution at 90 min was more pronounced after pPCI (median 60% vs. 45%, p < 0.0001), and a catch-up phenomenon was observed at 4 h. In the fibrinolysis group, 30-day and long-term mortality rates were significantly higher among patients without ST-segment resolution, whereas reinfarction rates were higher with complete ST-segment resolution. The ST-segment resolution was not associated with the 2 end points in the pPCI group. By multivariate analysis, ST-segment resolution at 4 h was an independent predictor of lower mortality, but higher reinfarction rates among patients receiving fibrinolytic therapy.
The ST-segment resolution at 90 min was more complete after pPCI, suggesting better epicardial and microvascular reperfusion, whereas no difference between treatment strategies was seen at 4 h. The ST-segment resolution at 4 h correlated with decreased mortality, but increased reinfarction rates among patients receiving fibrinolytic therapy, whereas no association was seen for patients receiving pPCI. Consequently, 4-h ST-segment resolution remains an important prognosticator after fibrinolysis, but may be overemphasized as a surrogate end point after pPCI.
Journal of the American College of Cardiology 11/2009; 54(19):1763-9. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: It is unclear whether the completeness of revascularization impacts on the prognostic value of an exercise test after primary percutaneous coronary intervention (PCI).
The DANAMI-2 trial included patients with ST elevation acute myocardial infarction randomized to primary PCI or fibrinolysis. Of the 790 patients randomized to primary PCI, 572 performed an exercise test. Prospectively, 310 patients were classified as having complete and 216 as having incomplete revascularization. Primary endpoint was a composite of reinfarction and/or death.
Patients with incomplete revascularization had lower exercise capacity [6.5 (95% CI: 1.9-12.8) vs. 7.0 (95% CI: 2.1-14.0) METs, p = 0.004] and more frequently ST depression [43 (20%) vs. 39 (13%), p = 0.02] compared to patients with complete revascularization. ST depression was not predictive of outcome in either groups, while multivariable analyses showed that exercise capacity was predictive of reinfarction and/or death in patients with incomplete revascularization [hazard ratio = 0.71 (95% CI: 0.54-0.93), p = 0.012] or of death alone [hazard ratio = 0.56 (95% CI: 0.41-0.77), p = 0.0003], which was not found in patients with complete revascularization.
Exercise capacity was prognostic of reinfarction and/or death in patients with incomplete revascularization, but not in completely revascularized patients. ST segment depression alone did not predict residual coronary stenosis or dismal prognosis.
[Show abstract][Hide abstract] ABSTRACT: The prognostic accuracy of exercise testing after myocardial infarction is low, and different models have been proposed to enhance the predictive value for subsequent mortality. This study tested a simple score against 3 established scores. Patients with ST-elevation myocardial infarctions were randomized in the Danish Trial in Acute Myocardial Infarction-2 (DANAMI-2) to either primary percutaneous coronary intervention or fibrinolysis with predischarge exercise testing. Clinical and exercise test data were collected prospectively and were available for 1,115 patients. A simple score was derived, awarding 1 point for history or new signs of heart failure, 1 point for a left ventricular ejection fraction <40%, 1 point for age >65 years in men and age >70 years in women, and 1 point for exercise capacity <5 METs in men and exercise capacity <4 METs in women. This DANAMI score was compared with the Veterans Affairs Medical Center score, the Duke treadmill score, and the Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico-2 (GISSI-2) score in multivariate Cox models and receiver-operating characteristic plots. All scoring systems were predictive of adverse outcomes. The DANAMI score performed better, with greater chi-square values (142 vs 53 to 88 for the prediction of death). Areas under the receiver-operating characteristic curves were compared and were larger for the DANAMI score (C-statistic 0.79 vs 0.71 to 0.74 for the other tests regarding mortality). The DANAMI score stratified patients into a small high-risk group (8% of the population with 43% mortality in 6 years), an intermediate-risk group (13% with 16% mortality in 6 years), and a low-risk group (79% with 4% mortality in 6 years). In conclusion, a simple exercise test score composed of age, METs, heart failure, and a left ventricular ejection fraction <40% seems to outperform the Duke treadmill score, Veterans Affairs Medical Center score, and GISSI-2 score in risk stratifying patients after myocardial infarction and deserves further evaluation.
The American Journal of Cardiology 11/2007; 100(7):1074-80. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In patients with chronic heart failure (HF), mortality is inversely related to haemoglobin (hgb) concentration. We investigated the prognostic importance of anaemia in patients with acute myocardial infarction (AMI) and left ventricular systolic dysfunction (LVSD) with and without HF.
We studied 1731 patients with AMI and left ventricular ejection fraction </=35% from the TRAndolapril Cardiac Evaluation (TRACE) study. Mild anaemia (110 g/L</=hgb<120 g/L in women and 120 g/L</=hgb<130 g/L in men) was present in 264 patients (15%), 114 (7%) had moderate (100 g/L</=hgb<110 g/L in women and 110 g/L</=hgb<120 g/L in men) and 59 (3%) had severe (hgb <100 g/L in women and <110 g/L in men) anaemia. According to the WHO criteria (hgb </=120 g/L in women and <130 g/L in men), 25% had anaemia. Anaemia was associated with increasing age, higher serum creatinine, lower body mass index, history of chronic HF, and worse NYHA class. In multivariable analyses including other prognostic factors only severe anaemia was associated with increased mortality, hazard ratio 1.59 (1.20-2.11). Anaemia was of prognostic importance in patients with HF, but not without HF. In HF patients the hazard ratios were 1.73 (1.26-2.36), 1.20 (0.93-1.56) and 1.05 (0.88-1.25) for severe, moderate and mild anaemia, respectively.
Anaemia is an independent predictor of mortality in patients with AMI and LVSD, but prognostic importance of anaemia is confined to the first year following AMI. The increased risk is driven by patients with severe anaemia and HF.
European Journal of Heart Failure 10/2006; 8(6):577-84. · 5.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Following the encouraging results of trials testing the effect of primary percutaneous coronary intervention (PCI) more cases of left main arterial stenosis (LMS) as culprit lesions in acute myocardial infarction (AMI) are being handled. Not many cases of primary PCI on LMS have been published. We present 12 cases of primary PCI on LMS. Eighty-three percent of the patients presented with cardiogenic shock and only 42% were discharged alive. Due to the high rate of cardiogenic shock at presentation, PCI seems to be the treatment of choice, over coronary artery bypass grafting (CABG), although one might consider using PCI as a bridge over to CABG.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the prognostic importance of pre-discharge maximal symptom-limited exercise testing (ET) following acute myocardial infarction (AMI) in the era of aggressive reperfusion.
In the DANAMI-2 (the second DANish trial in AMI) study, patients with ST-elevation AMI (STEMI) were randomized to primary angioplasty (PCI) or fibrinolysis. Of 1462 patients discharged alive, 1164 (79.6%) performed an ET. Primary endpoint was a composite of death and re-infarction. Patients randomized to fibrinolysis developed ST-depression to a greater extent than patients randomized to primary PCI (21.7 vs. 15.3%, P=0.007). Multivariable predictors of death and re-infarction included age, gender, diabetes, previous stroke, anterior AMI, randomization to fibrinolysis, and exercise capacity [risk ratio (RR) 0.82 (0.72-0.93); P<0.001]. ST-depression was predictive of the clinical outcome [RR 1.57 (1.00-2.48); P<0.05] in multivariable analysis, but stratified according to treatment groups there was a significant association between ST-depression and outcome in the fibrinolysis group [RR 1.95 (1.11-3.44); P<0.05], but not in the primary PCI group [RR 1.06 (0.47-2.36); P=ns]. However, the P-value for interaction was 0.15.
Exercise testing after contemporary reperfusion therapies for STEMI confers important prognostic information. Exercise capacity is a strong prognostic predictor of death and re-infarction irrespective of treatment strategy, whereas the prognostic significance of ST-depression seems to be strongest in the fibrinolysis-treated patients.
European Heart Journal 01/2005; 26(2):119-27. · 14.10 Impact Factor