Cardiac Magnetic Resonance Imaging Versus Computed Tomography to Guide Transcatheter Aortic Valve Replacement: A Randomized, Open-Label, Noninferiority Trial.

BACKGROUND: Computed tomography (CT) is recommended for guiding transcatheter aortic valve replacement (TAVR). However, a sizable proportion of TAVR candidates have chronic kidney disease, in whom the use of iodinated contrast media is a limitation. Cardiac magnetic resonance imaging (CMR) is a promising alternative, but randomized data comparing the effectiveness of CMR-guided versus CT-guided TAVR are lacking. METHODS: An investigator-initiated, prospective, randomized, open-label, noninferiority trial was conducted at 2 Austrian heart centers. Patients evaluated for TAVR according to the inclusion criteria (severe symptomatic aortic stenosis) and exclusion criteria (contraindication to CMR, CT, or TAVR, a life expectancy <1 year, or chronic kidney disease level 4 or 5) were randomized (1:1) to undergo CMR or CT guiding. The primary outcome was defined according to the Valve Academic Research Consortium-2 definition of implantation success at discharge, including absence of procedural mortality, correct positioning of a single prosthetic valve, and proper prosthetic valve performance. Noninferiority was assessed using a hybrid modified intention-to-treat/per-protocol approach on the basis of an absolute risk difference margin of 9%. RESULTS: Between September 11, 2017, and December 16, 2022, 380 candidates for TAVR were randomized to CMR-guided (191 patients) or CT-guided (189 patients) TAVR planning. Of these, 138 patients (72.3%) in the CMR-guided group and 129 patients (68.3%) in the CT-guided group eventually underwent TAVR (modified intention-to-treat cohort). Of these 267, 19 patients had protocol deviations, resulting in a per-protocol cohort of 248 patients (121 CMR-guided, 127 CT-guided). In the modified intention-to-treat cohort, implantation success was achieved in 129 patients (93.5%) in the CMR group and in 117 patients (90.7%) in the CT group (between-group difference, 2.8% [90% CI, -2.7% to 8.2%]; P<0.01 for noninferiority). In the per-protocol cohort (n=248), the between-group difference was 2.0% (90% CI, -3.8% to 7.8%; P<0.01 for noninferiority). CONCLUSIONS: CMR-guided TAVR was noninferior to CT-guided TAVR in terms of device implantation success. CMR can therefore be considered as an alternative for TAVR planning. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03831087.

Improved in-hospital outcome for radial access in a large contemporary cohort of primary percutaneous coronary intervention.

BACKGROUND: Randomised controlled trials have shown diverse results for radial access in patients undergoing primary percutaneous coronary intervention (PPCI). Moreover, it is questionable whether radial access improves outcome in patients with cardiogenic shock undergoing PPCI. We aimed to investigate the outcome according to access site in patients with or without cardiogenic shock, in daily clinical practice. METHODS: For the present analysis we included 9,980 patients undergoing PPCI between 2012 and 2018, registered in the multi-centre, nationwide registry on PCI for myocardial infarction (MI). In-hospital mortality, major adverse cardiovascular events (MACE), and net adverse clinical events (NACE) until discharge were compared between 4,498 patients with radial (45%) and 5,482 patients with femoral (55%) access. RESULTS: Radial compared to femoral access was associated with lower in-hospital mortality (3.5% vs. 7.7%; P<0.01). Multivariable logistic regression analysis confirmed reduced in-hospital mortality [odds ratio (OR) 0.57, 95% confidence interval (CI): 0.43 to 0.75]. Furthermore, MACE (OR 0.60, 95% CI: 0.47 to 0.78) as well as NACE (OR 0.59, 95% CI: 0.46 to 0.75) occurred less frequently in patients with radial access. Interaction analysis with cardiogenic shock showed an effect modification, resulting in lower mortality in PCI via radial access in patients without, but no difference in those with cardiogenic shock (OR 1.78, 95% CI: 1.07 to 2.96). CONCLUSIONS: Radial access for patients with acute MI undergoing PPCI is associated with improved survival in a large contemporary cohort of daily practice. However, this beneficial effect is restricted to hemodynamically stable patients.

Effect of the COVID-19 Pandemic on Treatment Delays in Patients with ST-Segment Elevation Myocardial Infarction.

Coronavirus disease 19 (COVID-19) and its associated restrictions could affect ischemic times in patients with ST-segment elevation myocardial infarction (STEMI). The objective of this study was to investigate the influence of the COVID-19 outbreak on ischemic times in consecutive all-comer STEMI patients. We included consecutive STEMI patients (n = 163, median age: 61 years, 27% women) who were referred to seven tertiary care hospitals across Austria for primary percutaneous coronary intervention between 24 February 2020 (calendar week 9) and 5 April 2020 (calendar week 14). The number of patients, total ischemic times and door-to-balloon times in temporal relation to COVID-19-related restrictions and infection rates were analyzed. While rates of STEMI admissions decreased (calendar week 9/10 (n = 69, 42%); calendar week 11/12 (n = 51, 31%); calendar week 13/14 (n = 43, 26%)), total ischemic times increased from 164 (interquartile range (IQR): 107-281) min (calendar week 9/10) to 237 (IQR: 141-560) min (calendar week 11/12) and to 275 (IQR: 170-590) min (calendar week 13/14) (p = 0.006). Door-to-balloon times were constant (p = 0.60). There was a significant difference in post-interventional Thrombolysis in myocardial infarction (TIMI) flow grade 3 in patients treated during calendar week 9/10 (97%), 11/12 (84%) and 13/14 (81%; p = 0.02). Rates of in-hospital death and re-infarction were similar between groups (p = 0.48). Results were comparable when dichotomizing data on 10 March and 16 March 2020, when official restrictions were executed. In this cohort of all-comer STEMI patients, we observed a 1.7-fold increase in ischemic time during the outbreak of COVID-19 in Austria. Patient-related factors likely explain most of this increase. Counteractive steps are needed to prevent further cardiac collateral damage during the ongoing COVID-19 pandemic.

Radial versus femoral access site for percutaneous coronary intervention in patients suffering acute myocardial infarction : A randomized prospective multicenter trial.

BACKGROUND: Transradial access (TRA) in percutaneous coronary intervention (PCI) is a widely used standard technique with lower complication rates compared to transfemoral access (TFA). The aim of this study was to evaluate the impact of TRA versus TFA for PCI on clinically significant vascular access complications in the setting of acute myocardial infarction (AMI). METHODS: This multicenter study randomly assigned 250 patients in a 1:1 fashion (TRA vs. TFA) admitted with or without ST-segment elevation AMI undergoing immediate PCI. The primary endpoint was defined as the occurrence of hematoma, pseudo-aneurysm or local bleeding at the access site requiring any further intervention and/or prolonged hospital stay. Radiation exposure to the patient and operator was also investigated. RESULTS: In the study cohort (N = 250 patients, mean age 62 ± 12.7 years, 76% males) 5 patients (2%) achieved the primary endpoint without a significant difference between groups, 4 out of 125 (3.2%) in the TFA group and 1 out of 125 (0.8%) in the TRA group (p = 0.17). Access site hematoma was significantly more frequent in the TFA group compared to the TRA group (24.8% vs. 8.8%, respectively; p < 0.0007). Local bleeding was only seen in the TFA group (3.2% vs. 0%, p = 0.04). Time intervals from admission to catheter laboratory to first balloon inflation were longer in the TRA compared to the TFA group (34 ± 17 min vs 29.5 ± 13 min, respectively; p = 0.018). Radiation exposure to the patient and operator was identical. CONCLUSION: The use of TRA was accompanied by lower rates of access site complications; however, the need for subsequent treatment or prolonged hospital stays was not observed using either of the two access approaches.

Life-threatening heat stroke presenting with ST elevations: a report of consecutive cases during the heat wave in Austria in July 2013.

Heat stroke is a life-threatening condition due to an acute thermoregulatory failure during exposure to high environmental temperatures. We report a series of four cases (three exertional, one classic heat stroke) during the heat wave of July 2013 in Austria. All of them presented with a core temperature > 41 °C, central nervous dysfunction, acute respiratory and renal failure, disseminated intravascular coagulation, rhabdomyolysis, and severe electrocardiographic changes, two cases even mimicking ST-elevation myocardial infarction. The patients were cooled to normal temperature with the "Arctic sun" external cooling system within hours. Electrocardiographic changes resolved quickly. All patients primarily recovered from multiple organ dysfunction and could be discharged from intensive care unit. Unfortunately, the two elder patients died 1 week and 5 weeks later because of late complications.

Pulse waveform characteristics predict cardiovascular events and mortality in patients undergoing coronary angiography.

OBJECTIVES: Pulse waveform characteristics (Augmentation Index--AIx and pulse wave transit time) are measures of the timing and extent of arterial wave reflections. Although previous studies reported an independent association with cardiovascular morbidity, it remains to be established that waveform characteristics, derived from noninvasive pulse waveform analysis, predict cardiovascular outcomes independent of and additional to brachial blood pressure. METHODS: We prospectively assessed AIx, heart-rate corrected AIx, and pulse wave transit time, using radial applanation tonometry and a validated transfer function to generate the aortic pressure curve, in 520 male patients undergoing coronary angiography. Primary endpoint was a composite of all-cause mortality, myocardial infarction, stroke, cardiac, cerebrovascular, and peripheral revascularization. RESULTS: During a follow-up of 49 months, 170 patients reached the primary endpoint. On the basis of Cox proportional hazards regression models, all pressure waveform characteristics predicted the primary endpoint. A 10% increase of AIx and heart-rate corrected AIx was associated with a 20.5% (95% confidence interval 6.5-36.4, P = 0.003) and 31.4% (95% confidence interval 13.2-52.6, P = 0.0004) increased risk of the primary endpoint, respectively. A 10-ms increase of pulse wave transit time was associated with a 20.8% (95% confidence interval 10.8-29.6, P = 0.0001) lower risk of the primary endpoint. In multiple adjusted models, AIx, heart-rate corrected AIx, and pulse wave transit time were independently associated with the combined endpoint even after adjustments for brachial blood pressure, age, extent of coronary artery disease, clinical characteristics, and medications. CONCLUSION: The study provides evidence that pulse waveform characteristics consistently and independently predict cardiovascular events in coronary patients.

Long-term outcomes following coronary drug-eluting- and bare-metal-stent implantation.

BACKGROUND: Although drug-eluting stents (DES) reduce restenosis rates relative to bare-metal stents (BMS), recent reports have indicated that the use of DES may be associated with an increased risk of stent thrombosis. Our study focused on the effect of stent type on clinical outcomes in a "real world" setting. METHODS: 889 patients undergoing percutaneous coronary intervention (PCI) with either DES (Cypher or Taxus; n=490) or BMS (n=399) were enrolled in a prospective single center registry. The outcome analysis covered a period of up to 3.2 years (mean 2.7 years+/-0.5 years) and was based on 65 deaths, 27 myocardial infarctions, 76 clinically driven target lesion revascularizations (TLR), and 15 angiographically confirmed cases of definite stent thrombosis and was adjusted for differences in baseline characteristics. RESULTS: In total 1277 stents (613 BMS and 664 DES) were implanted in 1215 lesions. Despite a significantly different unadjusted death rate (10.1% and 5.1% in BMS and DES patients, respectively; p<0.05), the patient groups did not differ significantly in the risk of myocardial infarction during 2.7 years of follow-up. After adjustment for differences in baseline characteristics between groups, the difference in the cumulative incidence of death did not remain statistically significant (p=0.22). Target lesion revascularizations occurred significantly less frequently in patients with DES compared to individuals after BMS implantation (5.9% and 11.8% in patients with DES and BMS, respectively; p<0.05). The rate of angiographically confirmed stent thrombosis was 2.1% in patients with DES and 1.1% in BMS patients (p=0.31). There was a significantly lower unadjusted event rate (including deaths, myocardial infarction, target lesion revascularization, and stent thrombosis) in patients with drug-eluting stents than in those with bare-metal stents (16.4% and 25.8%, respectively), with 9.4 fewer such events per 100 patients (unadjusted hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.46 to 0.87). After adjustment, the relative risk for all outcome events in patients with drug-eluting stents was 0.79 (95% CI, 0.67 to 0.95). However, the adjusted relative risk for death and myocardial infarction did not differ significantly between groups (adjusted relative risk in patients with drug-eluting stents 0.94 (95% CI, 0.77 to 1.37)). CONCLUSIONS: In this real-world population, the beneficial effect of first generation DES in reducing the need for new revascularization compared with BMS extends to more than 2.5 years without evidence of a worse safety profile. The minor risk of stent thrombosis and myocardial infarction within this period after implantation of DES seems unlikely to outweigh the benefit of these stents.

Pheochromocytoma crisis presenting with shock and tako-tsubo-like cardiomyopathy.

Pheochromocytoma usually presents with hypertension but it may also be an unusual aetiology of cardiogenic shock in order to catecholamine induced myocardial dysfunction. We report the devastating course of a patient with tako-tsubo like apical cardiomyopathy during pheocytoma crisis who presented with classical transient left ventricular apical ballooning 6 months before.

Whipple's disease: misdiagnosed as sarcoidosis with further tricuspid valve endocarditis and pulmonary embolism - a case report.

GH Whipple described a 36-year-old physician in 1907 with gradual loss of weight and strength, stools consisting chiefly of neutral fat and fatty acids, indefinite abdominal signs and a peculiar multiple arthritis. The patient died of this progressive illness. Whipple called it intestinal lipodystrophy since he observed accumulation of large masses of neutral fats and fatty acids in the lymph spaces. It was renamed Whipple's disease in 1949. An infectious aetiology was suspected as early as Whipple's initial report. However, successful treatment with antibiotics was not reported until 1952, which resulted in dramatic clinical responses. The cause is now known to be Tropheryma whipplei. Light and electron microscopy of infected tissue identified a gram-positive, non-acid-fast, periodic acid-Schiff (PAS) positive bacillus with a characteristic trilamellar plasma membrane resembling that of gram-negative bacteria. Whipple's disease is extremely rare. It is a systemic infectious disorder affecting mostly middle-aged white men. The clinical presentation is often non-specific, which may make its diagnosis difficult. The four cardinal clinical manifestations are arthralgias, weight loss, diarrhoea and abdominal pain. The frequently vague articular symptoms can precede the diagnosis of Whipple's disease by an average of 6-8 years. Lymph nodes and other tissues may present diagnostic problems, since the changes in routinely stained sections may mimic those of sarcoidosis. The detection of PAS-positive histiocytes in the small intestine remains the mainstay of the diagnosis, although Whipple's disease without gastrointestinal involvement is described. We illustrate a case in which, retrospectively, the clinical presentation would have been typical for Whipple's disease. However, the clinical presentation and the histological examinations of lymph nodes, liver biopsies and ascites initially were misinterpreted as sarcoidosis with consecutive immunosuppressive therapy and progressive worsening of the patient's health presenting at least as sepsis with endocarditis.

Arterial wave reflections and determinants of endothelial function a hypothesis based on peripheral mode of action.

BACKGROUND: Pulse waveform analysis (PWA) for determination of augmentation index (AIx), a measure of arterial wave reflections, has been used to assess endothelial function, but only in combination with provocative pharmacologic testing. We hypothesized that AIx under basal conditions would be related to endothelial function as well. METHODS: We quantified arterial wave reflections as aortic AIx, using applanation tonometry of the radial artery, and PWA in 424 patients (mean age 64.6 years) undergoing coronary angiography. Plasma levels of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of endothelial nitric oxide (NO) synthase, were determined with a validated ELISA assay. In a group of the patients (n = 160), pulse wave velocity (PWV) was measured invasively during catheter pullback. Statistics were Spearman's correlation coefficient and multiple linear regression models. RESULTS: We observed a positive, statistically significant correlation between AIx and ADMA (R = 0.11, P = .03), that was closer in 134 patients up to 60 years of age (R = 0.28, P = .001). In the latter group, the correlation was independent of age, gender, smoking, lipids, heart rate, diastolic blood pressure (BP), the presence of hypertension or diabetes, and the extent of coronary artery disease. In contrast, we observed a significant (R = 0.19, P = .02) correlation between PWV and ADMA that disappeared after correction for age and BP. CONCLUSIONS: Our cross-sectional data indicate that ADMA levels are associated with increased arterial wave reflections, most likely due to decreased NO activity in small arteries and arterioles. This relationship is more pronounced in patients up to 60 years of age.

Ability of neuron-specific enolase to predict survival to hospital discharge after successful cardiopulmonary resuscitation.

BACKGROUND: Accurate prediction of survival to hospital discharge in patients who achieve return of spontaneous circulation after cardiopulmonary resuscitation (CPR) has significant ethical and socioeconomic implications. We investigated the prognostic performance of serum neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, after successful CPR. METHODS: In-hospital or out-of-hospital patients with nontraumatic normothermic cardiac arrest who achieved return of spontaneous circulation (ROSC) following at least 5 minutes of CPR were eligible. Neuron-specific enolase levels were assessed immediately, 6 hours, 12 hours and 2 days after ROSC. Subjects were followed to death or hospital discharge. RESULTS: Seventeen patients (7 men, 10 women) were enrolled during a 1-year period. Median (range) NSE levels in survivors and non-survivors respectively were as follows: immediately after ROSC: 14.0 microg/L (9.1-51.4 microg/L) versus 25.9 microg/L (10.2-57.5 microg/L); 6 hours after ROSC: 15.2 microg/L (9.7-30.8 microg/L) versus 25.6 microg/L (12.7-38.2 microg/L); 12 hours after ROSC: 14.0 microg/L (8.6-32.4 microg/L) versus 28.5 microg/L (11.0-50.7 microg/L); and 48 hours after ROSC: 13.1 microg/L (7.8-29.5 microg/L) versus 52.0 microg/L (29.1-254.0 microg/L). Non-survivors had significantly higher NSE levels 48 hours after ROSC than surivors (p = 0.04) and showed a trend toward higher values during the entire time course following ROSC. An NSE concentration of >30 microg/L 48 hours after ROSC predicted death with a high specificity (100%: 95% confidence interval [CI] 85%-100%), and a level of 29 microg/L or less at 48 hours predicted survival with a high specificity (100%: 95% CI 83%-100%). CONCLUSIONS: Serum NSE levels may have clinical utility for the prediction of survival to hospital discharge in patients after ROSC following CPR over 5 minutes in duration. This study is small, and our results are limited by wide confidence intervals. Further research on ability of NSE to facilitate prediction and clinical decision-making after cardiac arrest is warranted.

Increased arterial wave reflections predict severe cardiovascular events in patients undergoing percutaneous coronary interventions.

AIMS: Increased arterial wave reflections are associated with the presence and extent of coronary atherosclerosis and with cardiovascular mortality in selected populations. We prospectively evaluated their prognostic value in the short- and long-term following percutaneous coronary interventions (PCIs). METHODS AND RESULTS: We non-invasively quantified wave reflections [expressed as augmentation index corrected for heart rate of 75 b.p.m. (AIx@75)] using applanation tonometry of the radial artery and a validated transfer function to obtain the corresponding aortic values in 262 patients undergoing PCI. During 2-year follow-up, 61 patients reached the primary endpoint [death, myocardial infarction (MI), and restenosis]. Increasing tertiles of Alx@75 were related to the rate of patients reaching the primary endpoint [15.2, 20 and 35.3%, respectively (P = 0.001)], as well as the secondary endpoints total mortality, myocardial infarction and death plus myocardial infarction (RR for the third vs. the first tertile 4.33, 3.25 and 3.46, respectively, P < 0.05). In a multivariable Cox-regression model, AIx@75 added prognostic value above and beyond clinical risk factors, angiographic variables, and medications (RR 1.8, 95%CI 1.18-2.76 per increasing AIx@75-tertile, P < 0.01). CONCLUSION: Increased arterial wave reflections are independently associated with an increased risk for severe short- and long-term cardiovascular events in patients undergoing PCI.

[Infection sources in HNO- and jawbone regions in patients before valve replacement surgery]. / Infektionsherde im HNO- und Kieferbereich bei Patienten mit bevorstehender Klappenoperation.

BACKGROUND: Prosthetic valve endocarditis is a life-threatening complication after valve replacement surgery. Therefore, it is common to perform a screening for potential sources of infection before surgery in order to be able to do a prophylactic treatment. PATIENTS AND METHOD: The incidence of potential infectious sources of bacteremia in the dental, jaw and nasopharyngeal area was evaluated in 92 patients going to have valve replacement surgery. Screening examinations were an X-ray of the paranasal sinuses and a panoramic radiograph of the dental arch. Chronic apical periodontitis, cysts and remaining radices were counted as dental sources. Each shadow in the paranasal sinuses X-ray was seen as pathological and was further investigated by an otorhinolaryngologist. RESULTS: A potential infectious source was found in 49 patients. 42 patients had a dental infectious source with need for treatment. 19 patients showed a pathologic sinus X-ray (three aspergillomas, three sinusitis, the others had a chronic polyposis with no need for treatment). Twelve patients had dental as well as sinusoidal sources. Erythrocyte sedimentation rate did not refer to the appearance of infectious sources. Patients going to have a mitral valve replacement had most dental sources (61%), 47% of the patients with planned aortic valve replacement, 50% of the patients planned to get more than one heart valve replaced, 50% of the patients getting mitral valve replacement and CABG and 40% of the patients waiting for aortic valve replacement and CABG had dental foci. CONCLUSION: Screening for infectious foci before valve replacement surgery diagnosed foci in a high percentage of the patients. Nevertheless current data concerning whether a prophylactic treatment may reduce the incidence of prosthetic valve endocarditis are conflicting.

A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomized, placebo-controlled trial.

BACKGROUND: Atrial fibrillation (AF) frequently occurs after cardiac surgical procedures, and beta-blockers, sotalol, and amiodarone may reduce the frequency of AF after open heart surgery. This pilot trial was designed to test whether each of the active oral drug regimens is superior to placebo for prevention of postoperative AF and whether there are differences in favor of 1 of the preventive strategies. METHODS AND RESULTS: We conducted a randomized, double-blinded, placebo-controlled trial in which patients undergoing cardiac surgery in the absence of heart failure and without significant left ventricular dysfunction (n = 253; average age, 65 +/- 11 years) received oral amiodarone plus metoprolol (n = 63), metoprolol alone (n = 62), sotalol (n = 63), or placebo (n = 65). Patients receiving combination therapy (amiodarone plus metoprolol) and those receiving sotalol had a significantly lower frequency of AF (30.2% and 31.7%; absolute difference, 23.6% and 22.1%; odds ratios [OR], 0.37 [95% CI, 0.18 to 0.77, P <.01 vs placebo] and 0.40 [0.19 to 0.82, P =.01 vs placebo]) compared with patients receiving placebo (53.8%). Treatment with metoprolol was associated with a 13.5% absolute reduction of AF (P =.16; OR, 0.58 [0.29 to 1.17]. Treatment effects did not differ significantly between active drug groups. Adverse events including cerebrovascular accident, postoperative ventricular tachycardia, nausea, and dyspepsia, in hospital death, postoperative infections, and hypotension, were similar among the groups. Bradycardia necessitating dose reduction or drug withdrawal occurred in 3.1% (placebo), 3.2% (combined amiodarone and metoprolol; P =.65 vs placebo), 12.7% (sotalol; P <.05 vs placebo), and 16.1% (metoprolol; P <.05 vs placebo). Patients in the placebo group had a nonsignificantly longer length of hospital stay as compared with the active treatment groups (13.1 +/- 8.9 days vs 11.3 +/- 7; P =.10), with no significant difference between the active treatment groups. CONCLUSIONS: Oral active prophylaxis with either sotalol or amiodarone plus metoprolol may reduce the rate of AF after cardiac surgery in a population at high risk for postoperative AF. Treatment with metoprolol alone resulted in a trend to a lower risk for postoperative AF.

Arterial stiffness, wave reflections, and the risk of coronary artery disease.

BACKGROUND: Increased arterial stiffness, determined invasively, has been shown to predict a higher risk of coronary atherosclerosis. However, invasive techniques are of limited value for screening and risk stratification in larger patient groups. METHODS AND RESULTS: We prospectively enrolled 465 consecutive, symptomatic men undergoing coronary angiography for the assessment of suspected coronary artery disease. Arterial stiffness and wave reflections were quantified noninvasively using applanation tonometry of the radial artery with a validated transfer function to generate the corresponding ascending aortic pressure waveform. Augmented pressure (AP) was defined as the difference between the second and the first systolic peak, and augmentation index (AIx) was AP expressed as a percentage of the pulse pressure. In univariate analysis, a higher AIx was associated with an increased risk for coronary artery disease (OR, 4.06 for the difference between the first and the fourth quartile [1.72 to 9.57; P<0.01]). In multivariate analysis, after controlling for age, height, presence of hypertension, HDL cholesterol, and medications, the association with coronary artery disease risk remained significant (OR, 6.91; P<0.05). The results were exclusively driven by an increase in risk with premature vessel stiffening in the younger patient group (up to 60 years of age), with an unadjusted OR between AIx quartiles I and IV of 8.25 (P<0.01) and a multiple-adjusted OR between these quartiles of 16.81 (P<0.05). CONCLUSIONS: AIx and AP, noninvasively determined manifestations of arterial stiffening and increased wave reflections, are strong, independent risk markers for premature coronary artery disease.

[Cardiovascular risk factor profiles and angiography results in young patients]. / Kardiovaskuläres Risikoprofil und koronarangiografischer Befund bei jungen Patienten.

There is a clear correlation between the incidence of coronary artery disease and existing cardiovascular risk factors. Therefore, it is a matter of interest if there is an accumulation of risk factors in younger patients with premature coronary artery disease compared to those without. We evaluated 1708 consecutive patients who underwent coronary angiography at our institution between August 2001 to February 2002; 85 symptomatic patients under the age of 46 were included in our analysis. In 46 patients (54.1%)--mean age 41.5 +/- 3.6 years--a coronary artery disease was documented, in 39 patients (45.9%)--mean age 39.9 +/- 5.6 years (n.s.)--normal coronary arteries were shown at angiography. Regarding the cardiovascular risk factors in young patients with coronary artery disease compared to young patients without we found a family history of premature coronary artery disease in 54.5% versus 43.6% (n.s.), hypercholesterolemia in 56.5% versus 53.8% (n.s.), LDL cholesterol of 138 +/- 40 mg/dl versus 123.3 +/- 27 mg/dl (s.), HDL cholesterol of 39 +/- 9 mg/dl versus 45.6 +/- 12.6 mg/dl (s.), serum triglycerides of 194.6 +/- 114.9 mg/dl versus 162.1 +/- 98.4 mg/dl (n.s.), diabetes mellitus in 15.2% versus 10.3% (n.s.), hypertension in 45.7% versus 46.4% (n.s.), body mass index > 24.9 kg/m2 in 67.4% versus 69.2% (n.s.), cigarette smoking in 54.6% versus 56.4% (n.s.). And finally, a minimum of two of those risk factors was found in 93.5% versus 87.2% (n.s.). Due to the high prevalence of cardiovascular risk factors in both groups it is impossible to reliably predict the incidence of coronary artery disease from those risk factors. This has to be considered while deciding about the indication for coronary angiography.