Showing papers in "European Heart Journal in 2002"

Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Abstract: The full text of this document is available on the Website of the European Society of Cardiology: www.escardio.org in the section ‘Scientific Information’, Guidelines. Introduction 1809 Pathophysiology 1810 Plaque rupture and erosion 1810 Inflammation 1812 Thrombosis 1812 Vasoconstriction 1812 Myocardium 1813 Diagnosis 1813 Clinical presentation 1813 Physical examination 1813 Electrocardiogram 1813 Biochemical markers of myocardial damage 1814 Recommendations 1815 Risk assessment 1815 Risk factors 1815 Clinical presentation 1815 Electrocardiogram 1816 Markers of myocardial damage 1816 Markers of inflammatory activity 1816 Markers of thrombosis 1817 Echocardiography 1817 Predischarge stress testing 1817 Coronary angiography 1817 Recommendations for risk stratification 1818 Treatment options 1818 Anti-ischaemic agents 1818 Beta-blockers 1818 Nitrates 1818

A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin. The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS)

Abstract: AIMS: To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. METHODS AND RESULTS: We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. CONCLUSIONS: This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region

Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction.

Abstract: Aims Although recognized as an important feature of atherosclerotic coronary disease, little is known about the frequency and prognostic importance of distal embolization during primary angioplasty for acute myocardial infarction. Methods and Results As part of a randomized trial of thrombolysis vs primary angioplasty, 178 patients with acute myocardial infarction were treated with primary angioplasty. In these patients the occurrence of distal embolization after angioplasty was assessed. Embolization was defined as a distal filling defect with an abrupt ‘cutoff’ in one of the peripheral coronary artery branches of the infarct-related vessel, distal to the site of angioplasty. We analysed myocardial blush grade, ST-T segment elevation resolution, enzymatic infarct size and left ventricular ejection fraction in patients with and without distal embolization. Clinical information was collected for a mean of 5 years. Distal embolization was present in 27 patients (15·2%). Mean age and gender were not different from patients without distal embolization. Angiographic success (thrombolyis in myocardial infarction flow grade 3 and residual stenosis <50%) after primary angioplasty was less frequently observed in patients with distal embolization (70% vs 90%, P <0·01). Myocardial blush and ST-T segment elevation resolution after angioplasty were reduced when distal embolization was present. Patients with distal embolization had a larger enzymatic infarct size (mean cumulative lactate dehydrogenase measured over 72h, 1612 vs 847, P <0·05) and a lower left ventricle ejection fraction at discharge (42% vs 51%, P <0·01). Long-term mortality was higher in patients with distal embolization (44% vs 9%, P <0·001). Conclusion Distal embolization in patients treated with primary angioplasty is visible on the coronary angiogram in 15·2% of patients. It is related to reduced myocardial reperfusion, more extensive myocardial damage and a poor prognosis. Additional pharmacological interventions and/ or mechanical devices should be studied to prevent and/or treat distal embolization. Copyright 2001 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.

Management of acute coronary syndromes. Variations in practice and outcome. Findings from the Global Registry of Acute Coronary Events (GRACE)

Abstract: Aims Despite advances in the treatment of acute coronary syndromes based on randomized trial data and published guidelines, the extent to which such treatments are applied in practice remains uncertain. Data from clinical trials derive from selected geographical areas and in highly selected populations of patients, and hence may not reflect the overall population. The aim of the study was to investigate variations in hospital management and outcome using unselected data collected in the prospective Global Registry of Acute Coronary Events (GRACE). Methods and Results The 95 hospitals in GRACE were organized into 18 population-based clusters in 14 countries. Information was recorded about patient management and outcome during hospitalization and after discharge. Data on treatments administered were analysed by baseline condition, hospital type, by the presence or absence of a catheterization laboratory, and by geographical region. Of 11543 patients, 44% had an admission diagnosis of unstable angina, 36% presented with myocardial infarction, 9% were admitted to rule out a myocardial infarction, 7% had chest pain and 4% were hospitalized for ‘other cardiac’ and ‘non-cardiac’ diagnoses. Of the total GRACE population 38% had a final diagnosis of unstable angina, 30% ST-segment elevation myocardial infarction, 25% non-ST-segment elevation myocardial infarction, and 7% of ‘other cardiac’ and ‘non-cardiac’ final diagnoses. The event rates for hospital death or reinfarction were six and 2% for non-ST-segment elevation myocardial infarction, seven and 3% for ST-segment elevation myocardial infarction, and 3% hospital death for unstable angina. The use of aspirin was similar across all hospital types and geographical regions. In contrast, the use of percutaneous coronary intervention and glycoprotein IIb/IIIa inhibitors was higher ( P <0·0001) in teaching hospitals and hospitals with catheterization laboratories and was also higher in the United States. At discharge a higher percentage ( P <0·0001) of patients received angiotensin-converting enzyme inhibitors in hospitals without catheterization laboratories. The use of statins was lower in non-teaching hospitals and in centres without a catheterization laboratory. Conclusions The GRACE study reveals substantial differences in the management of patients based on hospital type and geographical location. Further analyses will determine whether such variations translate into differences in longer term outcomes. GRACE provides a multinational reference for the implementation of therapies of proven efficacy. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

Safety and efficacy of a novel calcium sensitizer, levosimendan, in patients with left ventricular failure due to an acute myocardial infarction. A randomized, placebo-controlled, double-blind study (RUSSLAN)

Abstract: Aims To evaluate the safety and efficacy of levosimendan in patients with left ventricular failure complicating acute myocardial infarction. Methods and Results Levosimendan at different doses (0·1–0·4μg.kg−1.min−1) or placebo were administered intravenously for 6h to 504 patients in a randomised, placebo-controlled, double-blind study. The primary end-point was hypotension or myocardial ischaemia of clinical significance adjudicated by an independent Safety Committee. Secondary end-points included risk of death and worsening heart failure, symptoms of heart failure and all-cause mortality. The incidence of ischaemia and/or hypotension was similar in all treatment groups ( P =0·319). A higher frequency of ischaemia and/or hypotension was only seen in the highest levosimendan dose group. Levosimendan-treated patients experienced lower risk of death and worsening heart failure than patients receiving placebo, during both the 6h infusion (2·0% vs 5·9%; P =0·033) and over 24h (4·0% vs 8·8%; P =0·044). Mortality was lower with levosimendan compared with placebo at 14 days (11·7% vs 19·6%; hazard ratio 0·56 [95% CI 0·33–0·95]; P =0·031) and the reduction was maintained at the 180-day retrospective follow-up (22·6% vs 31·4%; 0·67 [0·45-1·00], P =0·053). Conclusions Levosimendan at doses 0·1–0·2μg.kg−1.min−1 did not induce hypotension or ischaemia and reduced the risk of worsening heart failure and death in patients with left ventricular failure complicating acute myocardial infarction. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

Comparative effects of permanent biventricular and right-univentricular pacing in heart failure patients with chronic atrial fibrillation.

Abstract: Background One third of chronic heart failure patients have major intraventricular conduction and uncoordinated ventricular contraction. Non-controlled studies suggest that biventricular pacing may improve haemodynamics and well-being by reducing ventricular asynchrony. The aim of this trial was to assess the clinical efficacy and safety of this new therapy in patients with chronic atrial fibrillation. Methods Fifty nine NYHA class III patients with left ventricular systolic dysfunction, chronic atrial fibrillation, slow ventricular rate necessitating permanent ventricular pacing, and a wide QRS complex (paced width ≥200ms), were implanted with transvenous biventricular-VVIR pacemakers. This single-blind, randomized, controlled, crossover study compared the patients’ parameters, as monitored during two 3-month treatment periods of conventional right-univentricular vs biventricular pacing. The primary end-point was the 6-min walked distance, secondary end-points were peak oxygen uptake, quality-of-life, hospitalizations, patients’ preferred study period and mortality. Results Because of a higher than expected drop-out rate (42%), only 37 patients completed both crossover phases. In the intention-to-treat analysis, we did not observe a significant difference. However, in the patients with effective therapy the mean walked distance increased by 9·3% with biventricular pacing (374±108 vs 342±103m in univentricular; P =0·05). Peak oxygen uptake increased by 13% ( P =0·04). Hospitalizations decreased by 70% and 85% of the patients preferred the biventricular pacing period ( P <0·001). Conclusion As compared with conventional VVIR pacing, effective biventricular pacing seems to improve exercise tolerance in NYHA class III heart failure patients with chronic atrial fibrillation and wide paced-QRS complexes. Further randomized controlled studies are required to definitively validate this therapy in such patients. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

The problem of chronic refractory angina - Report from the ESC Joint Study Group on the Treatment of Refractory Angina

Abstract: It has been recognized that there is a group of patients with severe disabling angina and coronary artery disease who are refractory to conventional forms of treatment. Although this issue has already been debated at the level of the National Societies, we felt that it was appropriate to also tackle it at the European level. This is particularly important in view of the rapid pace of growth of this problem and the lack of a standardized approach. This has encouraged the development of a variety of treatments that vary considerably in terms of cost-effectiveness and safety and require proper validation procedures. The aim of this paper is to draw attention to the problem and start a process that will lead to improvement and harmonization of the care of patients with refractory angina.

Impact of heart failure and left ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population.

Abstract: Background Heart failure and left ventricular systolic dysfunction (LVSD) are increasingly common disorders, with outcomes worse than many cancers. Evidence-based therapies, such as ACE inhibitors and beta-blockers, improve prognosis and symptoms, and reduce healthcare expenditure. However, despite the high prevalence and malignant prognosis, few studies have reported the impact of heart failure and LVSD on overall quality of life and, more crucially, have not researched the elderly or those in the community. Methods All patients attending the Echocardiographic Heart of England Screening (ECHOES) study of the prevalence of heart failure and LVSD in the community were assessed by clinical history and examination, electrocardiogram and echocardiography, and also completed the SF36 health status questionnaire. Quality of life in patients found to have heart failure, LVSD, and other cardiac and medical conditions are compared with the randomly selected general population sample. Data are generalisable to the UK. Results 6162 people in the community were screened in the ECHOES study, of whom 5961 (97%) completed the SF36. The health perceptions of 3850 people aged 45 years or older selected randomly from the population were compared with those of 426 patients diagnosed as having definite heart failure. Those with heart failure had significant impairment of all the measured aspects of physical and mental health, in addition to declines in physical functioning. Significantly worse impairment was found in those with more severe heart failure by NYHA class: indeed, NYHA functional class was closely correlated to SF36 score. Patients with asymptomatic left ventricular dysfunction and patients rendered asymptomatic by treatment had similar scores to the random population sample. Those with heart failure reported more severe physical impairment of quality of life than people giving a history of chronic lung disease or arthritis, with less impact on mental health than patients reporting depression. Conclusions Patients with heart failure have statistically significant impairment of all aspects of quality of life, not simply physical functioning. The physical (role and functioning) health burden was significantly greater than that suffered in other serious common chronic disorders, whether cardiac or other systems. Optimising treatment to improve NYHA class appears to improve perceptions of quality of life for patients with heart failure. Given the dramatic decline in quality of life with heart failure, this end-point should be a much more important target for healthcare interventions, especially treatments such as ACE inhibitors and beta-blockers that are shown to improve quality of life.

Abdominal obesity is associated with increased risk of acute coronary events in men

Abstract: Aims The purpose of the study was to investigate the associations of abdominal obesity and overall obesity with the risk of acute coronary events. Methods and Results Body mass index indicating overall obesity and waist-to-hip ratio and waist circumference indicating abdominal obesity were measured for 1346 Finnish men aged 42–60 years who had neither cardiovascular disease nor cancer at baseline. There were 123 acute coronary events during an average follow-up of 10·6 years. In Cox regression analyses adjusted for confounding factors, waist-to-hip ratio ( P =0·009), waist circumference ( P =0·010) and body mass index ( P =0·013) as continuous variables were associated directly with the risk of coronary events. These associations were in part explained by blood pressure, diabetes, fasting serum insulin, serum lipids, plasma fibrinogen, and serum uric acid. Waist-to-hip ratio of ≥0·91 was associated with a nearly threefold risk of coronary events. Waist-to-hip ratio provided additional information beyond body mass index in predicting coronary heart disease, whereas body mass index did not add to the predictive value of waist-to-hip ratio. Abdominal obesity combined with smoking and poor cardiorespiratory fitness increased the risk of coronary events 5·5 and 5·1 times, respectively. Conclusions Abdominal obesity is an independent risk factor for coronary heart disease in middle-aged men and even more important than overall obesity. Since the effect of abdominal obesity was strongest in smoking and unfit men, the strategy for lifestyle modification to prevent coronary heart disease should address these issues jointly.

Proposed Diagnostic Criteria for the Brugada Syndrome

Abstract: (see 3,4 for review). TheBrugada syndrome is a familial disease displaying anautosomal dominant mode of transmission with incom-plete penetrance and an incidence ranging between 5 and66 per 10 000. In regions of Southeast Asia where it isendemic, the clinical presentation of Brugada syndromeis distinguished by a male predominance (8:1 ratio ofmales:females) and the appearance of arrhythmic eventsat an average age of 40 years (range: 1 to 77 years)

Long-lasting sport practice and lone atrial fibrillation

Abstract: Aims To analyse whether the proportion of patients with lone atrial fibrillation engaged in chronic sport practice was higher than that observed in the general population. Methods and Results The records of 1160 patients, seen at the arrhythmia outpatient clinic, were reviewed. A total of 70 patients (6%) suffered lone atrial fibrillation and were younger than 65 years. Thirty two of them had been engaged in long-term sport practice. All patients in the sport group were men as compared to only 50% in the sedentary group ( P <0·0001). To avoid the confounding effect of sex distribution, women were excluded. Sportsmen started their episodes of atrial fibrillation at a younger age, they had a lower incidence of mild hypertension and their episodes of atrial fibrillation were predominantly vagal in contrast to the sedentary patients. The echocardiographic parameters were similar to those observed in the sedentary patients, but when compared with 20 healthy controls, they showed greater atrial and ventricular dimensions and a higher ventricular mass. The proportion of sportsmen among patients with lone atrial fibrillation is much higher than that reported in the general population of Catalonia: 63% vs 15% ( P <0·05). Conclusion Long-term vigorous exercise may predispose to atrial fibrillation.

Plasma tumour necrosis factor-alpha and early carotid atherosclerosis in healthy middle-aged men.

Abstract: Aims Tumour necrosis factor-alpha (TNF-alpha) is a proinflammatory cytokine, which is implicated in some metabolic disorders and may play a role in the development of cardiovascular disease. We examined whether plasma TNF-alpha is related to established cardiovascular risk indicators, plasma levels of soluble cellular adhesion molecules and carotid artery intima-media thickness determined by ultrasound examination in a population-based cohort of 96 healthy 50-year-old men. Methods and Results TNF-alpha and cellular adhesion molecules were measured with enzyme-linked immunosorbent assays. Plasma TNF-alpha concentration was associated with systolic and diastolic blood pressure, degrees of alimentary lipaemia, plasma very low density lipoprotein triglyceride, low density lipoprotein (LDL) cholesterol concentrations and peak LDL particle size. Two indices of insulin resistance as well as all soluble cellular adhesion molecules correlated positively with TNF-alpha. The plasma TNF-alpha concentration was associated with common carotid intima-media thickness in univariate analysis. In contrast, soluble E-selectin and postprandial triglycerides, but not TNF-alpha, were independent determinants of common carotid intima-media thickness. Conclusion The plasma TNF-alpha concentration is associated with degrees of early atherosclerosis and correlates with metabolic and cellular perturbations that are considered important for the vascular process. (Less)

Clinical characteristics and outcome of patients with early ( 4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction.

Abstract: Aims We examined the clinical characteristics and outcome of patients with early ( 4h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction. Methods and Results We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2h), intermediate presentation (2–4h), and late presentation (≥4h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5·8% in the angioplasty group vs 12·5% in the thrombolysis group, in patients with intermediate presentation, 8·6% vs 14·2%, respectively, and in patients presenting late 7·7% vs 19·4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event. Conclusions Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.

Prospective evaluation and outcome of patients admitted for syncope over a 1 year period.

Abstract: Aims Syncope is a frequent and potentially dangerous symptom. The epidemiological data are based on series mainly collected 20 years ago in the U.S.A. and do not adequately assist in the management of patients admitted now for this symptom in Europe. Methods and Results To evaluate prospectively the epidemiological aspects and the management of the patients admitted in the emergency department of an adult university hospital for a ‘verified’ syncope, charts of all the patients consecutively admitted between June 1999 and June 2000 were systematically reviewed by a member of the cardiology staff. Those with a loss of consciousness were selected and those with a definite syncope were included in the study group and followed until they were discharged from the hospital. Among the 37475 patients who presented to the emergency department, 454 (1·21%) had a definite syncope. For 296 it was the first episode and 169 (mean age 43±23 years) were discharged straight away; 285 (mean age 66±19 years; P <0·0001) were admitted to internal medicine (n=151), cardiology (n=65), neurology (n=44), endocrinology (n=14) and surgery (n=11) services. In 75·7% of all the patients a diagnosis was reported but it was inadequate to explain a syncopal episode in 56 cases (16·3%). Management differed by department: 36% of the patients had ‘neurological’ investigations mainly in internal medicine and neurology. Except in cardiology very few had ‘cardiological’ investigations particularly tilt test and electrophysiological studies (5%). Conclusion Syncope is a frequent symptom but its cause often remains unknown partly due to inadequate management. Precise and simple guidelines are urgently needed.

Non-invasive coronary angiography with high resolution multidetector-row computed tomography. Results in 102 patients

Abstract: Aims A new generation of multidetector-row CT (MDCT) scanners allows complete coronary coverage using retrospective ECG gating and 1mm slices. The purpose of this study was to investigate the potential of high resolution MDCT angiography with retrospective gating for detection of coronary artery stenoses. Methods and Results A total of 102 patients underwent both conventional and MDCT coronary angiography. After intravenous injection of a non-ionic contrast medium the entire heart was scanned within a single breath hold using 1mm slices. All MDCT data sets were reconstructed with retrospective gating at 20% to 80% in increments of 10% relative to the cardiac cycle. Two blinded independent reviewers analysed image quality for segments 1–4 (right coronary artery), 5–8 (left main, left anterior descending), and 11, 12 (left circumflex). These segments were evaluated for the presence or absence of significant (≥50%) stenoses. The results were compared with those of invasive coronary angiography in a blinded fashion. Overall sensitivity for the detection of significant stenoses (≥50%) were 0·86 (reader 1) and 0·93 (reader 2), specificity 0·96 (reader 1) and 0·97 (reader 2), negative predictive value 0·98 (reader 1) and 0·99 (reader 2). Conclusions High resolution MDCT angiography with retrospective gating permits the non-invasive detection of coronary artery stenoses with high accuracy if image quality is optimized for each of the three major coronary arteries. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

von Willebrand factor and coronary heart disease: prospective study and meta-analysis.

Abstract: Aims To determine whether circulating von Willebrand factor concentrations are prospectively related to risk of coronary heart disease in the general population. Methods and Results We measured baseline von Willebrand factor values in the stored serum samples of 625 men with major coronary events and in 1266 controls ‘nested’ in a prospective study of 5661 men aged 40–59 years, recruited from general practices in 18 British towns in 1978–1980 and followed up for 16 years for fatal coronary heart disease and non-fatal myocardial infarction. We conducted a meta-analysis of previous relevant studies to place our results in context. Men in the top third of baseline von Willebrand factor values (tertile cutoff >126 IU . dl 1 ) had an odds ratio for coronary heart disease of 1·83 (95% confidence interval 1·43–2·35; 2P<0·0001) compared with those in the bottom third (tertile cutoff <90 IU . dl 1 ), after adjustments for age and town. The odds ratio was little changed after further adjustment for risk factors (1·82, 95% CI 1·37–2·41), and was not significantly different in an analysis restricted to the 404 cases and 1007 controls without baseline evidence of coronary heart disease (odds ratio 1·53, 95% CI 1·10–2·12). A meta-analysis of all relevant population-based prospective studies (including the present study) yielded a combined odds ratio of 1·5 (95% CI 1·1–2·0). von Willebrand factor values were strongly correlated with Helicobacter pylori seropositivity and circulating concentrations of C-reactive protein (2P<0·0001 for each), but not with smoking, blood lipids, or most other measured risk factors. Conclusion Though circulating von Willebrand factor concentrations may be associated with incident coronary heart disease, further studies are needed to determine the extent to which this is causal.

The role of psychobiological pathways in socio-economic inequalities in cardiovascular disease risk

Abstract: Socio-economic inequalities in mortality and morbidity occur in most countries in the modern world, and are of major concern to public health authorities. Research on socio-economic status and health has become a priority for the National Institutes of Health, the European Science Foundation and other funding agencies. Coronary heart disease is perhaps the most prominent and best established disorder for which socioeconomic inequalities have been observed in the U.K., U.S.A. and other countries. Effects are graded, with a progressively higher incidence with lower socioeconomic position as defined by occupational status, income or education. With appropriate classifications of socio-economic status, the differences in premature coronary heart disease appear as great in women as in men. Variations by socio-economic status in subclinical coronary artery disease have also been documented. This article concerns the pathways through which social inequalities are translated into differential disease risk, highlighting the likely role of psychobiological processes. Psychobiological processes can be defined as the pathways through which psychosocial factors stimulate biological systems via central nervous system activation of automomic, neuroendocrine and immunological responses. We are particularly concerned with the pathways responsible for the gradient in ill health and coronary heart disease; that is, the differences between high and medium status individuals, as well as high compared with low status groups. These pathways may be different from those mediating the effects of

Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study.

Abstract: Aims To determine the effect of an integrated heart failure management programme, involving patient and family, primary and secondary care, on quality of life and death or hospital readmissions in patients with chronic heart failure. Methods and Results This trial was a cluster randomized, controlled trial of integrated primary/secondary care compared with usual care for patients with heart failure. The intervention involved clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic. Follow-up was for 12 months. One hundred and ninety-seven patients admitted to Auckland Hospital with an episode of heart failure were enrolled in the study. There was no significant difference between the intervention and control groups for the combined end-point of death or hospital readmission. The physical dimension of quality of life showed a greater improvement in the intervention group from baseline to 12 months compared with the control group (−11·1 vs −5·8 respectively, 2 P =0·015). The main effect of the intervention was attributable to the prevention of multiple admissions (56 intervention group vs 95 control group, 2 P =0·015) and associated reduction in bed days. Conclusions This integrated management programme for patients with chronic heart failure improved quality of life and reduced total hospital admissions and total bed days.

Hospitalization of patients with heart failure: a population-based study.

Abstract: Aims To describe the clinical course of heart failure in a population-based sample of incident cases, and to identify factors predicting hospitalization and mortality. Methods and Results Three hundred and thirty-two incident cases were identified over 15 months; 208 inpatients and 124 outpatients. Thirty-eight inpatients died during the first hospital admission (case fatality 18%) leaving 294 at risk of subsequent hospitalization. Over an average follow-up of 19 months, 173 cases were hospitalized on 311 occasions. Two hundred and twenty-four (72%) of these admissions were unplanned, with 51% due to worsening heart failure. One hundred and ten cases died over the same period. Cases diagnosed as an inpatient had 26 more admissions for worsening heart failure per 100 cases during follow-up (95%CI 9 to 44) compared to cases diagnosed as an outpatient, and also a higher mortality (hazard ratio 3·1 (95%CI 1·9 to 5·1)). Age was the only factor associated with an increased risk of hospitalization for worsening heart failure, but age, functional class and serum creatinine were predictive of mortality. Conclusions New cases of heart failure are at high risk of subsequent hospitalization, especially during the first months after diagnosis. Whilst predicting which patients will be hospitalized is difficult, interventions designed to reduce hospitalizations for worsening heart failure should be targeted at elderly inpatients with a new diagnosis. Copyright 2001 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved

Predictors and outcomes of stent thrombosis. An intravascular ultrasound registry

Abstract: Aims To investigate whether intravascular ultrasound provides additional information regarding the prediction of stent thrombosis, a retrospective multicentre registry was designed to enrol patients with stent thrombosis following stent deployment under ultrasound guidance. Methods and Results A total of 53 patients were enrolled (mean age 61±9 years) with stable angina (43%), unstable angina (36%), and post-infarct angina (21%) who underwent intracoronary stenting. The majority had balloon angioplasty alone prior to stenting (94%) with 6% also undergoing rotational atherectomy. The indication for stenting was elective (53%), suboptimal result (32%) and bailout (15%). There were 1·6±0·8 stents/artery with 87% undergoing high-pressure dilatation (≥14 atmospheres). The minimum stent area was 7·7±2·8mm2with a mean stent expansion of 81·5±21·9%. Overall, 94% of cases demonstrated one abnormal ultrasound finding (stent under-expansion, malapposition, inflow/outflow disease, dissection, or thrombus). Angiography demonstrated an abnormality in only 32% of cases (chi-square=30·0, P <0·001). Stent thrombosis occurred at 132±125h after deployment. Myocardial infarction occurred in 67% and there was an overall mortality of 15%. Conclusion On comparison with angiography, the vast majority of stents associated with subsequent thrombosis have at least one abnormal feature by intravascular ultrasound at the time of stent deployment.

Recommendations on the management of the asymptomatic patient with valvular heart disease.

Abstract: The management of asymptomatic patients with valve disease has become an important medical problem. There are two main reasons for this: firstly such patients are currently being diagnosed more frequently because of the widespread availability of echocardiography; secondly, the opportunity to perform less invasive interventions is an incentive to intervene earlier. However, data concerning the management of asymptomatic patients are limited. For this reason this topic remains a particularly rich source of debate. There are no specific guidelines on the management of asymptomatic patients with valvular heart disease and recommendations can be drawn only from general guidelines such as those produced by the ACC/AHA and some national societies in Europe. Moreover, published guidelines are not always consistent due to the lack of randomized trials and also the constant evolution of practice. It is for this reason that the Working Group on Valvular Heart Disease of the European Society of Cardiology have produced these recommendations. The major types of acquired valve disease will be dealt with in the following order: aortic stenosis (AS), aortic regurgitation (AR), mitral stenosis (MS), mitral regurgitation (MR).

Task force on the management of chest pain.

Abstract: The Task Force on the management of chest pain was created by the committee for Scientific and Clinical Initiatives on 28 June 1997 after formal approval by the Board of the European Society of Cardiology. The document was circulated to the members of the Committee for Scientific and Clinical Initiatives, to the members of the Board and to the following reviewers: J. Adgey, C. Blomstro¨m-Lundqvist, R. Erbel, W. Klein, J. L. Lopez-Sendon, L. Ryde´n, M. L. Simoons, C. Stefanadis, M. Tendera, K. Thygesen. After further revision it was submitted for approval to the Committee for Practise Guidelines and Policy Conferences. The Task Force Report was supported financially in its entirety by The European Society of Cardiology and was developed without any involvement of the pharmaceutical industry.

Carotid intima-media thickness at different sites: relation to incident myocardial infarction; The Rotterdam Study.

Abstract: Aims We examined whether intima–media thickness of the common carotid artery, carotid bifurcation, internal carotid artery and the combined measure are predictive of future myocardial infarction and which of the measurements has the strongest predictive value. Methods and Results We used a case–cohort approach in the Rotterdam Study. Ultrasound images of the common carotid artery, carotid bifurcation and the internal carotid artery were made. We selected the first 194 myocardial infarctions in the total population (mean follow-up 4·6 years). Analyses were done using Cox regression with adjustment for age and sex. The risk ratios (RR) for myocardial infarction associated with mean maximum common carotid, bifurcation, internal carotid intima-media thickness and the combined measurements were 3·18 (95% confidence interval, 1·83–5·54), 4·11 (2·10–8·05), 5·31 (1·77–15·9) and 6·27 (3·27–12·0), respectively, for the highest compared to the lowest quartile. The RRs for myocardial infarction per standard deviation increase of common carotid, bifurcation, internal carotid artery and combined intima-media thickness were 1·44 (1·28–1·62), 1·34 (1·17–1·53), 1·12 (0·94–1·33) and 1·47 (1·31–1·65), respectively. The areas under the ROC curves for the three measurements and the combined measure were not significantly different. Conclusions Increased carotid intima-media thickness is a strong predictor of future myocardial infarction and all measurement sites have the same ability to predict future myocardial infarction. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes. Application of the TIMI Risk Score for UA/NSTEMI in PRISM-PLUS

Abstract: Aims We evaluated the TIMI Risk Score for Unstable Angina and Non-ST Elevation Myocardial Infarction for predicting clinical outcomes and the efficacy of tirofiban in non-ST elevation acute coronary syndromes. Methods and Results Developed in TIMI 11B, the risk score is calculated as the sum of seven presenting characteristics (age ≥65 years, ≥3 cardiac risk factors, documented coronary disease, recent severe angina, ST deviation ≥0·5mm, elevated cardiac markers, prior aspirin use). The risk score was validated in the PRISM-PLUS database (n=1915) and tested for interaction with the efficacy of tirofiban+heparin vs heparin alone. The risk score revealed an increasing gradient of risk for death, myocardial infarction or recurrent ischaemia at 14 days ranging from 7·7–30·5% ( P <0·001). Dichotomized at the median, patients with a score ≥4 derived a greater relative risk reduction with tirofiban ( P (Interaction)=0·025). Among patients with normal creatine kinase myocardial bands, the risk score showed a 3·5-fold gradient of risk ( P <0·001) and identified a population that derived significant benefit from tirofiban (RR 0·73, P =0·027). Conclusion The TIMI Risk Score is a simple clinical tool for risk assessment that may aid in the early identification of patients who should be considered for treatment with potent antiplatelet therapy.

Stress responsivity and socioeconomic status. A mechanism for increased cardiovascular disease risk

Abstract: Aims Low socioeconomic status is associated with increased cardiovascular disease risk. We hypothesized that psychobiological pathways, specifically slow recovery in blood pressure and heart rate variability following mental stress, partly mediate social inequalities in risk. Methods and Results Participants were 123 men and 105 women in good health aged 47–58 years drawn from the Whitehall II cohort of British civil servants. Grade of employment was the indicator of socioeconomic status. Cardiovascular measures were monitored during performance of two behavioural tasks, and for 45 min following stress. Post-stress return of blood pressure and heart rate variability to resting levels was less complete after 45 min in the medium and low than in the high grade of employment groups. The odds of failure to return to baseline by 45 min in the low relative to the high grade of employment groups were 2·60 (95% CI 1·20–5·65) and 3·85 (1·48–10·0) for systolic and diastolic pressure, respectively, and 5·19 (1·88–18·6) for heart rate variability, adjusted for sex, age, baseline levels and reactions to tasks. Subjective ratings of task difficulty, involvement and stress did not differ by socioeconomic status. Conclusions Lower socioeconomic status is associated with delayed recovery in cardiovascular function after mental stress. Impaired recovery may reflect heightened allostatic load, and constitute a mechanism through which low socioeconomic status enhances cardiovascular disease risk.

A non-invasively determined surrogate of cardiac power (‘circulatory power’) at peak exercise is a powerful prognostic factor in chronic heart failure

Abstract: Objectives This study was designed to assess the prognostic value of a new variable derived from a cardiopulmonary exercise test, the circulatory power, a surrogate of cardiac power, at peak exercise, in patients with chronic heart failure. Background Peak exercise cardiac power and stroke work are invasive parameters with recently proven prognostic value. It is unclear whether these variables have better prognostic value than peak oxygen uptake (VO2). Methods The study population comprised 175 patients with chronic heart failure (ejection fraction <45%) who underwent a cardiopulmonary exercise test. Circulatory power and circulatory stroke work were defined as the product of systolic arterial pressure and VO2 and oxygen pulse, respectively. Prognostic value was assessed by survival curves (Kaplan–Meier method) and uni- and multivariate Cox analyses. Results With a mean follow-up of 25±10 months, ejection fraction, heart rate, systolic arterial pressure, peak VO2, VCO2, the anaerobic threshold, minute ventilation, the ventilatory equivalents of oxygen and carbon dioxide, the half times of VO2 and VCO2 recoveries, and the circulatory stroke work and power predicted outcome. Multivariate analysis demonstrated that the peak circulatory power (chi-square=19·9, P <0·001) (but not peak circulatory stroke work) was the only variable predictive of prognosis. Conclusion The prognostic value of cardiopulmonary exercise tests in heart failure patients can be improved by assessing a new variable, the circulatory power—a surrogate of cardiac power—at peak exercise.

Coronary heart disease risk factors ranked by importance for the individual and community. A 21 year follow-up of 12 000 men and women from The Copenhagen City Heart Study.

Abstract: Aims The importance of coronary heart disease risk factors may differ between individuals and community and by sex and age. Methods and Results The Copenhagen City Heart Study followed for 21 years a random sample of 5599 men and 6478 women aged 30 to 79 years at baseline. The importance of risk factors in individuals and the community were evaluated as relative- and population-attributable risks. We traced 2180 coronary events. In Cox regression analysis with ten risk factors entered simultaneously, relative risks for coronary heart disease in men ranged from 1·69 to 1·20 with the highest risks for diabetes, hypertension, smoking, and physical inactivity. In women, relative risks ranged from 2·74 to 1·19 with the highest risks for diabetes, smoking, hypertension, and physical inactivity. Population-attributable risks in men ranged from 22% to 3% with the highest risks for smoking, hypertension, and no daily alcohol intake. In women, attributable risks ranged from 37% to 3% with the highest risks for smoking, hypertension, and hypercholesterolaemia. Several of these rankings differed by age. Conclusions The importance of coronary heart disease risk factors may differ for individuals, the community, and by sex and age. Consequently, prevention strategies should be tailored accordingly.

Guidelines for the interpretation of the neonatal electrocardiogram A Task Force of the European Society of Cardiology

Abstract: Department of Cardiology, University of Pavia and IRCCS Policlinico S. Matteo, Pavia, Italy; University of Virginia, Charlottesville, VA, U.S.A.; The Children’s Heart Program of South Carolina, Medical University of South Carolina, Charleston, SC, U.S.A.; Pediatric Arrhythmias Center, IRCCS Istituto Auxologico Italiano, Milan, Italy; Division of Pediatric Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A.; Division of Pediatric Cardiology, Department of Pediatrics, Hopital Necker Enfants Malades, Paris, France; Department of Paediatric Cardiology, Freeman Hospital, Newcastle upon Tyne, U.K.

Chromogranin A in heart failure; a novel neurohumoral factor and a predictor for mortality.

Abstract: Background In chronic heart failure, several hormonal systems are activated with diagnostic and prognostic implications. We tested the hypotheses that serum Chromogranin-A (CgA)—a 49kDa acid protein present in the secretor granules of neuroendocrine cells—is increased in chronic heart failure and that CgA levels are a predictive factor for mortality. Methods and Results In 160 patients with chronic heart failure, we measured serum CgA and other neuroendocrine hormones. The results showed that CgA is increased in chronic heart failure and the increase is related to the clinical severity of the syndrome: CgA levels in New York Heart Failure (NYHA) class II (median 146·9ng.ml−1, inter-quartiles 108·3–265·5) were significantly higher ( P <0·05) than in class I (median 109·7ng.ml−1, inter-quartiles 96·7–137·6), and significantly lower ( P <0·05) than in class III (median 279·0ng.ml−1, inter-quartiles 203·6–516·1). Class IV patients showed the highest serum levels of CgA (median 545·0ng.ml−1, inter-quartiles 231·8–1068·3), being statistically significantly different from class III patients ( P <0·001). The association between survival and some recognized variables of prognostic significance, including CgA was also studied. The results showed that ejection fraction, noradrenaline, atrial natriuretic peptide, NYHA class and CgA were significant univariate prognosticators; however, in the multivariate analysis by the Cox proportional-hazard model, CgA and NYHA class were the only independent predictive factors for mortality ( P <0·005, RR=1·22, 95% CI=1·06–1·41 and P =0·04, RR=1·58, 95% CI=1·02–2·46, respectively). Conclusions CgA is a pro-hormone, precursor of several active fragments likely to exert biological effects in chronic heart failure. CgA serum levels are increased in patients with chronic heart failure and are a predictive factor for mortality.