Showing papers by "Don Poldermans published in 2008"

Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC).

Abstract: Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding – coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator’s training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC).

Abstract: Stress echocardiography is the combination of echocardiography with a physical, pharmacological, or electrical stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy to radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease. In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …

Impact of Cardioselective β-Blockers on Mortality in Patients with Chronic Obstructive Pulmonary Disease and Atherosclerosis

Abstract: Rationale: β-Blocker use is associated with improved health outcomes in patients with cardiovascular disease. There is a general reluctance to prescribe β-blockers in patients with chronic obstructive pulmonary disease (COPD) because they may worsen symptoms.Objectives: We investigated the relationship between cardioselective β-blockers and mortality in patients with COPD undergoing major vascular surgery.Methods: We evaluated 3,371 consecutive patients who underwent major vascular surgery at one academic institution between 1990 and 2006. The patients were divided into those with and without COPD on the basis of symptoms and spirometry. The major endpoints were 30-day and long-term mortality after vascular surgery. Patients were defined as receiving low-dose therapy if the dosage was less than 25% of the maximum recommended therapeutic dose; dosages higher than this were defined as intensified dose.Measurements and Main Results: There were 1,205 (39%) patients with COPD of whom 462 (37%) received cardios...

Effect of Statin Therapy on Mortality in Patients With Peripheral Arterial Disease and Comparison of Those With Versus Without Associated Chronic Obstructive Pulmonary Disease

Abstract: Chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) are both inflammatory conditions. Statins are commonly used in patients with PAD and have anti-inflammatory properties, which may have beneficial effects in patients with COPD. The relation between statin use and mortality was investigated in patients with PAD with and without COPD. From 1990 to 2006, we studied 3,371 vascular surgery patients. Statin use was noted at baseline and, if prescribed, converted to <25% (low dose) and ≥25% (intensified dose) of the maximum recommended therapeutic dose. The diagnosis of COPD was based on the Global Initiative for Chronic Obstructive Lung Disease guidelines using pulmonary function test. End points were short- (30-day) and long-term (10-year) mortality. A total of 330 patients with COPD (25%) used statins, and 480 patients (23%) without COPD. Statin use was independently associated with improved short- and long-term survival in patients with COPD (odds ratio 0.48, 95% confidence interval [CI] 0.23 to 1.00; hazard ratio 0.67, 95% CI 0.52 to 0.86, respectively). In patients without COPD, statins were also associated with improved short- and long-term survival (odds ratio 0.42, 95% CI 0.20 to 0.87; hazard ratio 0.76, 95% CI 0.60 to 0.95, respectively). In patients with COPD, only an intensified dose of statins was associated with improved short-term survival. However, for the long term, both low-dose and intensive statin therapy were beneficial. In conclusion, statin use was associated with improved short- and long-term survival in patients with PAD with and without COPD. Patients with COPD should be treated with an intensified dose of statins to achieve an optimal effect on both the short and long term.

Renal Insufficiency and Mortality in Patients with Known or Suspected Coronary Artery Disease

Abstract: It remains unclear whether mild renal dysfunction is associated with adverse cardiovascular outcome. We investigated whether estimated glomerular filtration rate (eGFR) was associated with mortality and cardiac death among 6447 patients with known or suspected coronary artery disease over a mean follow-up of 7 yr. Cumulative 5- and 10-yr survival rates decreased in a graded fashion from 88% and 70%, respectively, for those with normal renal function to 43% and 33% for those with eGFR <30 ml/min. Compared with patients with normal renal function, the multivariable adjusted hazard ratios for all-cause mortality among patients with mild, moderate, and severe renal impairment were 1.33 (95% confidence interval [CI], 1.21-1.48), 1.67 (95% CI, 1.44-1.93), and 3.38 (95% CI, 2.73-4.19), respectively. Similar relationships between cardiac death and decreasing renal function were found. In conclusion, renal function is a graded and independent predictor of long-term mortality in patients with known or suspected coronary artery disease. Intense treatment and close surveillance of these patients is encouraged.

Statin use is associated with early recovery of kidney injury after vascular surgery and improved long-term outcome

Abstract: textBackground. Acute kidney injury (AKI) after major vascular surgery is an important risk factor for adverse long-term outcomes. The pleiotropic effects of statins may reduce kidney injury caused by perioperative episodes of hypotension and/or suprarenal clamping and improve long-term outcomes. Methods. Of 2170 consecutive patients undergoing lower extremity bypass or abdominal aortic surgery from 1995 to 2006, cardiac risk factors and medication were noted. A total of 515/1944 (27%) patients were statin users. Creatinine clearance (CrCl) was assessed preoperatively at 1, 2 and 3 days after surgery. Outcome measures were postoperative AKI and long-term mortality. Postoperative kidney injury was defined as a >10% decrease in CrCl on Day 1 or 2, compared to the baseline. Recovery of kidney function was defined as a CrCl >90% of the baseline value at Day 3 after surgery. Multivariable Cox regression analysis, including baseline cardiovascular risk factors, baseline CrCl and propensity score for statin use, was applied to evaluate the influence of statins on early postoperative kidney injury and long-term survival. Results. AKI occurred in 664 (34%) patients [median -25% CrCl, range (-10% to -71%)]. Of these 664 patients, 313 (47%) had a complete recovery of kidney function at Day 3 after surgery. Age, hypertension, suprarenal cross-clamping and baseline CrCl predicted the development of kidney injury during the postoperative period. The incidence of kidney injury was similar among statin users and non-users (29% versus 25%, OR 1.15, 95% CI 0.9-1.5). However, if kidney function deteriorated, statin use was associated with increased odds of complete kidney function recovery (OR 2.0, 95% CI 1.0-3.8). During a mean follow-up of 6.24 years, half of the patients died (55%). Importantly, statin use was also associated with an improved long-term survival, irrespective of kidney function change (HR 0.60, 95% CI 0.48-0.75). Conclusion. Statin use is associated with improved recovery from AKI after major surgery and has a beneficial effect on long-term survival.

Anemia as an independent predictor of perioperative and long-term cardiovascular outcome in patients scheduled for elective vascular surgery

Abstract: Anemia is common in patients scheduled for vascular surgery and is a risk factor for adverse cardiac outcome. However, it is unclear whether this is an independent risk factor or an expression of underlying co-morbidities. In total, 1,211 patients (77% men, 68 ± 11 years of age) were enrolled. Anemia was defined as serum hemoglobin levels <13 g/dl for men and <12 g/dl for women and was divided into tertiles to compare mild (men 12.2 to 13.0, women 11.2 to 12.0), moderate (men 11.0 to 12.1, women 10.2 to 11.1), and severe (men 7.2 to 11.0, women 7.5 to 10.1) anemia with nonanemia. Outcome measurements were 30-day and 5-year major adverse cardiac events (MACEs; cardiac death or myocardial infarction). All risk factors were noted. Multivariable logistic and Cox regression analyses were used, adjusting for all cardiac risk factors, including heart failure and renal disease. Data are presented as hazard ratios with 95% confidence intervals. In total, 74 patients (6%) had 30-day MACEs and 199 (17%) had 5-year MACEs. Anemia was present in 399 patients (33%), 133 of whom had mild anemia, 133 had moderate anemia, and 133 had severe anemia. Presence of anemia was associated with renal dysfunction, diabetes, and heart failure. After adjustment for all clinical risk factors, 30-day hazard ratios for a MACE per anemia group were 1.8 for mild (0.8 to 4.1), 2.3 for moderate (1.1 to 5.4), and 4.7 for severe (2.6 to 10.9) anemia, and 5-year hazard ratios for MACE per anemia group were 2.4 for mild (1.5 to 4.2), 3.6 for moderate (2.4 to 5.6), and 6.1 for severe (4.1 to 9.1) anemia. In conclusion, the presence and severity of preoperative anemia in vascular patients are significant predictors of 30-day and 5-year cardiac events, regardless of underlying heart failure or renal disease.

Influence of renal function on the usefulness of N-terminal pro-B-type natriuretic peptide as a prognostic cardiac risk marker in patients undergoing noncardiac vascular surgery.

Abstract: N-terminal pro-B-type natriuretic peptide (NT–pro-BNP) is related to stress-induced myocardial ischemia and/or volume overload, both common in patients with renal dysfunction. This might compromise the prognostic usefulness of NT–pro-BNP in patients with renal impairment before vascular surgery. We assessed the prognostic value of NT–pro-BNP in the entire strata of renal function. In 356 patients (median age 69 years, 77% men), cardiac history, glomerular filtration rate (GFR, ml/min/1.73 m 2 ), and NT–pro-BNP level (pg/ml) were assessed preoperatively. Troponin T and electrocardiography were assessed postoperatively on days 1, 3, 7, and 30. The end point was the composite of cardiovascular death, Q-wave myocardial infarction, and troponin T release. Multivariate analysis was used to evaluate the interaction between GFR, NT–pro-BNP and their association with postoperative outcome. Median GFR was 78 ml/min/1.73 m 2 and the median concentration of NT–pro-BNP was 197 pg/ml. The end point was reached in 64 patients (18%); cardiac death occurred in 7 (2.0%), Q-wave myocardial infarction in 34 (9.6%), and non–Q-wave myocardial infarction in 23 (6.5%). After adjustment for confounders, NT–pro-BNP levels and GFR remained significantly associated with the end point (p = 0.005). The prognostic value of NT–pro-BNP was most pronounced in patients with GFR ≥90 (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.80 to 1.76) compared with patients with GFR 60 to 89 (OR 1.04, 95% CI 1.002 to 1.07), and with GFR 30 to 59 (OR 1.12, 95% CI 1.03 to 1.21). In patients with GFR 2 , NT–pro-BNP levels have no prognostic value (OR 1.00, 95% CI 0.99 to 1.01). In conclusion, the discriminative value of NT–pro-BNP is most pronounced in patients with GFR ≥90 ml/min/1.73 m 2 and has no prognostic value in patients with GFR 2 .

Usefulness of hypertensive blood pressure response during a single-stage exercise test to predict long-term outcome in patients with peripheral arterial disease.

Abstract: The prognostic value of a hypertensive blood pressure (BP) response is still unclear. Therefore, the prognostic value of a hypertensive BP response in patients during single-stage exercise testing for peripheral arterial disease (PAD) on long-term mortality and major adverse cerebrovascular and cardiac events (MACCEs) was investigated. In addition, effects of statin, β-blocker, and aspirin use in patients with known or suspected PAD were studied. A total of 2,109 patients were enrolled in an observational prospective study from 1993 to 2005. Hypertensive BP response was defined as an increase in systolic BP ≥55 mm Hg (95 th percentile within our population) after a single-stage treadmill exercise test. The outcome was obtained by using the civil registries, and a questionnaire about cardiac events was sent to all survivals. Hypertensive BP response was associated with increased risk of long-term mortality (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.12 to 1.80) and MACCEs (HR 1.47, 95% CI 1.09 to 1.97). After adjustments for clinical risk factors and propensity score, baseline statin use was associated with reduced risk of long-term mortality (HR 0.59, 95% CI 0.44 to 0.79), and statin, β-blocker, and aspirin use were associated with reduced risk of MACCEs (HR 0.59, 95% CI 0.43 to 0.81; HR 0.75, 95% CI 0.60 to 0.95; HR 0.73, 95% CI, 0.57 to 0.92, respectively). In conclusion, hypertensive BP response at exercise in patients with known or suspected PAD is an important independent risk factor for all-cause long-term mortality and MACCEs, whereas statin, β-blocker, and aspirin use were associated with an improved outcome.

Association between serum uric acid and perioperative and late cardiovascular outcome in patients with suspected or definite coronary artery disease undergoing elective vascular surgery.

Abstract: The role of uric acid as an independent marker of cardiovascular risk is unclear. Therefore, our aim was to assess the independent contribution of preoperative serum uric acid levels to the risk of 30-day and late mortality and major adverse cardiac event (MACE) in patients scheduled for open vascular surgery. In total, 936 patients (76% male, age 68 ± 11 years) were enrolled. Hyperuricemia was defined as serum uric acid >0.42 mmol/l for men and >0.36 mmol/l for women, as defined by large epidemiological studies. Outcome measures were 30-day and late mortality and MACE (cardiac death or myocardial infarction). Multivariable logistic and Cox regression analysis were used, adjusting for age, gender, and all cardiac risk factors. Data are presented as odds ratios or hazard ratios, with 95% confidence intervals. Hyperuricemia was present in 299 patients (32%). The presence of hyperuricemia was associated with heart failure, chronic kidney disease, and the use of diuretics. Perioperatively, 46 patients (5%) died and 61 patients (7%) experienced a MACE. Mean follow-up was 3.7 years (range: 0 to 17 years). During follow-up, 282 patients (30%) died and 170 patients (18%) experienced a MACE. After adjustment for all clinical risk factors, the presence of hyperuricemia was not significantly associated with an increased risk of 30-day mortality or MACE, odds ratios of 1.5 (0.8 to 2.8) and 1.7 (0.9 to 3.0), respectively. However, the presence of hyperuricemia was associated with an increased risk of late mortality and MACE, with hazard ratios of 1.4 (1.1 to 1.7) and 1.7 (1.3 to 2.3), respectively. In conclusion, the presence of preoperative hyperuricemia in vascular patients is a significant predictor of late mortality and MACE.

Usefulness of preoperative oral glucose tolerance testing for perioperative risk stratification in patients scheduled for elective vascular surgery.

Abstract: Patients scheduled for major vascular surgery are screened for cardiac risk factors using standardized risk indexes, including diabetes mellitus (DM). Screening in patients without a history of DM includes fasting glucose measurement. However, an oral glucose tolerance test (OGTT) could significantly improve the detection of DM and impaired glucose tolerance (IGT) and the prediction of perioperative cardiac events. In a prospective study, 404 consecutive patients without signs or histories of IGT or DM were included and subjected to OGTT. The primary study end point was the composite of perioperative myocardial ischemia, assessed by 72-hour Holter monitoring using ST-segment analysis and troponin release. The primary end point was noted in 21% of the patients. IGT was diagnosed in 104 patients (25.7%), and new-onset DM was detected in 43 patients (10.6%). The OGTT detected 75% of the patients with IGT and 72% of the patients with DM. Preoperative glucose levels significantly predicted the risk for perioperative cardiac ischemia; odds ratios for DM and IGT were, respectively, 3.2 (95% confidence interval 1.3 to 8.1) and 1.4 (95% confidence interval 0.7 to 3.0). In conclusion, the prevalence of undiagnosed IGT and DM is high in vascular patients and is associated with perioperative myocardial ischemia. Therefore, an OGTT should be considered for all patients who undergo elective vascular surgery.

A numerical model to predict abdominal aortic aneurysm expansion based on local wall stress and stiffness

Abstract: Aneurysms of the abdominal aorta enlarge until rupture occurs. We assume that this is the result of remodelling to restore wall stress. We developed a numerical model to predict aneurysm expansion based on this assumption. In addition, we obtained aneurysm geometry of 11 patients from computed tomography angiographic images to obtain patient specific calculations. The assumption of a wall stress related expansion indeed resulted in a series of local expansions, adjusting global geometry in an exponential fashion similar as in patients. Furthermore, it revealed that location of peak wall stress changed over time. The assumptions of this model are discussed in detail in this manuscript, and the implications are related to literature findings.

Preoperative cardiac risk assessment in vascular surgery patients: seeing beyond the perioperative period.

Abstract: Patients scheduled for non-cardiac vascular surgery are at significant risk of cardiovascular morbidity and mortality due to underlying symptomatic or asymptomatic coronary artery disease (CAD). As was shown by Hertzer et al. in their landmark study in 1984 using coronary angiography in 1000 patients undergoing non-cardiac vascular surgery, 61% of all patients did have at least one significant lesion.1 In fact, only 8% of all patients had no abnormalities. More recent studies using functional tests for CAD such as dobutamine stress echocardiography confirmed these findings. In a study population of 1097 vascular surgical patients, the incidence of rest wall motion abnormalities was nearly 50%, while one-fifth of patients had stress-induced myocardial ischaemia.2 The high prevalence of CAD in vascular surgical patients explains the adverse outcome in this patient population. The incidence of perioperative myocardial infarction, defined as the presence of two out of three of the following markers: (i) the presence of typical chest pain complaints; (ii) ECG abnormalities; and (iii) increased troponin levels, is ∼5%. Importantly, 75% of the perioperative myocardial infarctions remain asymptomatic and may therefore be difficult to assess. This might be attributable to the disguising effects of sedation and the simultaneous occurrence of symptoms directly … *Corresponding author. Tel: +31 10 4634613; fax: +31 10 436 2995. Email: d.poldermans{at}erasmusmc.nl

Safety of contrast-enhanced echocardiography within 24 h after acute myocardial infarction

Abstract: Aims Contrast-enhanced echocardiography is widely used to enhance left ventricular (LV) endocardial border delineation in stable patients with known or suspected coronary artery disease. In patients with acute myocardial infarction, accurate assessment of LV function and size is important, but data on the safety of contrast-enhanced echocardiography in the early stage of myocardial infarction (within 24 h) are lacking. In the current study, the experience on the safety of contrast-enhanced echocardiography within 24 h of acute myocardial infarction is reported. Methods and results A total of 115 consecutive patients (58+ 11 years; 77% male) admitted to the coronary care unit for ST-elevation acute myocardial infarction underwent clinically indicated contrastenhanced echocardiography within 24 h of hospital admission to assess LV size and function. Perflutren (Luminity w , Bristol-Myers Squibb Pharma, Bruxelles, Belgium) was used as contrast agent. Safety was determined evaluating vital signs, physical examination, ECG, and adverse events. On contrastenhanced echocardiography, the mean LV ejection fraction was 44+ 11%, and 56% of patients had an LV ejection fraction � 45%. Administration of echo contrast did not induce any significant change in vital signs, physical examination, and ECG. Major adverse events were not observed whereas minor events occurred in 4% of patients (hypersensitivity at the injection site in three and transient back pain in two). Conclusion These data provide evidence on the safety of contrast-enhanced echocardiography in the first 24 h of myocardial infarction; larger patient cohorts are needed to confirm these findings.

Prognostic value of hypotensive blood pressure response during single-stage exercise test on long-term outcome in patients with known or suspected peripheral arterial disease.

Abstract: ObjectiveA decline in systolic blood pressure during exercise is thought to be a sign of severe coronary artery disease. However, no studies have yet examined this effect in patients with known or suspected peripheral arterial disease. Therefore, we investigated the prognostic value of hypotensive b

[Prevention of perioperative cardiac complications in non-cardiac surgery: an evidence-based guideline]

Abstract: Approximately 25% of the patients undergoing non-cardiac surgery suffer from perioperative cardiac complications These are associated with a mortality of 2060%, a longer stay in hospital and higher costs The risk factors for perioperative cardiac complications are: high-risk surgery, ischaemic heart disease, a history of congestive heart failure, cerebrovascular disease, diabetes, and renal failure Recently, the scope of medical management has shifted from assessing and treating underlying culprit coronary lesions toward coronary plaque stabilisation and prevention of myocardial oxygen supply demand mismatch Currently, the prevention of cardiac problems consists of identification of the patients at risk, optimisation of the preoperatieve condition by modification of underlying risk factors, optimisation of the perioperative medication with adrenergic beta-antagonists, statins, and acetylsalicylic acid, adequate perioperative monitoring and measures to prevent myocardial ischaemia These include adequate sedation and analgesia, adequate oxygenation, oxygen transport, and ventilation, and if necessary additional cardiac medication

Prognostic significance of myocardial ischemia by dobutamine stress echocardiography in patients without angina pectoris after coronary revascularization.

Abstract: The clinical utility of stress testing in patients without angina pectoris after revascularization has been questioned. Dobutamine stress echocardiography (DSE) is an established technique for detection of myocardial ischemia and cardiac risk stratification. We studied the prognostic value of DSE in 393 patients without typical angina pectoris after coronary revascularization. Ischemia was incremental to clinical data in predicting all-cause death (hazard ratio 3.5, 95% confidence interval 1.8 to 6.7) and cardiac death (hazard ratio 4.2, 95% confidence interval 1.8 to 9.8). In conclusion, myocardial ischemia during DSE is independently associated with an increased risk of all-cause mortality and cardiac death in these patients after adjustment for clinical data.