Preoperative predictors of late postoperative outcome among patients with nonischemic mitral regurgitation with 'high risk' descriptors and comparison with unoperated patients.

Among patients with chronic nonischemic mitral regurgitation (MR), high short-term mortality risk can be identified by left (LV) and/or right ventricular (RV) ejection fraction (EF) criteria (LVEF 20%, MVR significantly improved survival versus medical treatment (rest: p < 0.0001, exercise: p = 0.0003). In high risk MR patients, MVR improves survival; preoperative RV performance can define subgroups with different long-term postoperative survival.

Prognostication in 3-vessel coronary artery disease based on left ventricular ejection fraction during exercise : influence of coronary artery bypass grafting.

BACKGROUND: Previous data indicate that left ventricular ejection fraction (LVEF) provides prognostic information among patients with coronary artery disease (CAD), but the value of such testing specifically for defining benefits of coronary artery bypass grafting (CABG) may relate to severity of exercise-inducible ischemia measured noninvasively before surgery. METHODS AND RESULTS: To determine the independent prognostic importance of preoperative ischemia severity for predicting outcomes of CABG among patients with extensive CAD, we monitored 167 stable patients with angiographically documented 3-vessel CAD (average follow-up of 9 years in event-free patients) who previously had undergone rest and exercise radionuclide cineangiography. Their course was correlated with data obtained during initial radionuclide testing, coronary arteriography, and clinical evaluation at study entry. Fifty-two patients received medical treatment only, and 115 underwent CABG (44 early [

Assessing research methodology training needs in emergency medicine.

OBJECTIVE: To determine the perceptions of emergency medicine (EM) academic faculty leaders and other academic emergency physicians regarding importance and knowledge of specific research methodology content areas and training priorities. METHODS: The authors conducted a confidential mail survey of 52 EM academic chairs, 112 residency directors, 116 research directors, and 400 randomly selected other members of the Society for Academic Emergency Medicine (SAEM). Respondents rated the importance of knowledge about each of 12 content areas for enhancing research productivity, rated their own knowledge of these areas, and identified training priorities. Standard descriptive statistics were used to characterize the study population; subgroup differences were examined by nonparametric statistics. RESULTS: 551 (81%) of those sampled returned surveys. Most (90%) respondents thought that knowledge about all selected content areas was important for enhancing research productivity; however, 7-37% (depending on the topic) reported little knowledge or experience in specific areas. Research directors reported highest overall knowledge levels (p < 0.001), followed by chairs, residency directors, and other SAEM members. Top training priorities (identified by all subgroups) included study planning (70%), problem identification/hypothesis construction (41%), and proposal writing (38%). CONCLUSIONS: These data support the continued need to offer broad training in research methodology, but suggest that greater emphasis be given to concepts involved in initiating and planning a study and to strengthening research proposal writing skills. These results should be of interest to academic departments who must address their own training needs, and help support the development of research methodology curricula on regional and national levels to advance the state of research in the specialty of EM.

Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aortic regurgitation and normal left ventricular performance.

BACKGROUND: Optimal criteria for valve replacement are unclear in asymptomatic/minimally symptomatic patients with aortic regurgitation (AR) and normal left ventricular (LV) performance at rest. Moreover, previous studies have not assessed the prognostic capacity of load-adjusted LV performance ("contractility") variables, which may be fundamentally related to clinical state. Therefore, 18 years ago, we set out to test prospectively the hypothesis that objective noninvasive measures of LV size and performance and, specifically, of load-adjusted variables, assessed at rest and during exercise (ex), could predict the development of currently accepted indications for operation for AR. METHODS AND RESULTS: Clinical variables and measures of LV size, performance, and end-systolic wall stress (ESS) were assessed annually in 104 patients by radionuclide cineangiography at rest and maximal ex and by echocardiography at rest; ESS was derived during ex. During an average 7.3-year follow-up among patients who had not been operated on, 39 of 104 patients either died suddenly (n = 4) or developed operable symptoms only (n = 22) or subnormal LV performance with or without symptoms (n = 13) (progression rate=6.2%/y). By multivariate Cox model analysis, change (delta) in LV ejection fraction (EF) from rest to ex, normalized for deltaESS from rest to ex (deltaLVEF-deltaESS index), was the strongest predictor of progression to any end point or to sudden cardiac death alone. Unadjusted deltaLVEF was almost as efficient. Symptom status modified prediction on the basis of the deltaLVEF-deltaESS index. The population tercile at highest risk by deltaLVEF-deltaESS progressed to end points at a rate of 13.3%/y, and the lowest-risk tercile progressed at 1.8%/y. CONCLUSIONS: Currently accepted symptom and LV performance indications for valve replacement, as well as sudden cardiac death, can be predicted in asymptomatic/minimally symptomatic patients with AR by load-adjusted deltaLVEF-deltaESS index, which includes data obtained during exercise.

Relation of ultra-low frequency heart rate variability to the clinical course of chronic aortic regurgitation.

We examined the relation of the standard deviation of the 5-minute mean RR intervals over 24 hours (SDANN), a measure of ultra-low frequency heart rate variability (HRV) (<0.0033 Hz), and other measures of HRV to clinical outcome events in 50 asymptomatic or minimally symptomatic patients with chronic severe aortic regurgitation (AR) who underwent ambulatory electrocardiography as part of a prospective study of the natural history of regurgitant valvular diseases. At entry, all patients were in sinus rhythm and had New York Heart Association functional class I or minimal II congestive heart failure, with left ventricular (LV) ejection fraction > or = 45% and LV end-diastolic dimension > or = 5.5 cm in women and > or = 5.9 cm in men. End points were defined as progression to aortic valve replacement (n = 19) or sudden cardiac death (n = 1) during the mean follow-up period of 8.1 +/- 3.8 years. With the median SDANN of 145 ms as a partition value, the average annual risk of end-point events in patients with low SDANN was significantly greater than the event rate in patients with high SDANN (11%/year vs 2%/year, p <0.0003). In multivariate analysis, reduced SDANN was associated with end-point events independent of LV function, LV end-systolic dimension, and symptom status (p = 0.001). We conclude that reduced ultra-low frequency HRV measured as SDANN is strongly related to progression to valve surgery in asymptomatic and minimally symptomatic patients with chronic AR.

Reduced left ventricular mechanical efficiency in elderly patients with coronary artery disease.

We evaluated left ventricular (LV) mechanical efficiency in 23 elderly patients (mean age 67 +/- 2) with coronary artery disease (CAD) and in 22 patients younger than 65 years (mean age 49 +/- 8) with similar severity of CAD (2.4 +/- 0.8 and 2.2 +/- 0.8 vessels per patient, respectively) and history of myocardial infarction (34% and 41%, respectively). LV mechanical efficiency was calculated as the ratio of LV work per minute and myocardial O2 consumption. LV stroke volume was calculated from left ventriculography. Coronary blood flow was measured by thermodilution. Older patients had lower values of LV stroke volume (49 +/- 16 vs 73 +/- 16 mL, p < 0.005), ejection fraction (41 +/- 17 vs 58 +/- 17%, p < 0.05), LV stroke work (93 +/- 26 vs 131 +/- 41 g.m., p < 0.02) and LV work per minute (6.7 +/- 2.6 vs 9.3 +/- 2.7 kg.m./min, p < 0.05). Since myocardial O2 consumption was similar in the two groups, LV mechanical efficiency was lower in older CAD patients (16.2 +/- 15 vs 23.8 +/- 12%, p < 0.05). Thus, elderly patients with CAD show a reduced LV mechanical pump performance and efficiency, compared with younger patients with similar disease severity and history of myocardial infarction. These observations may contribute to understanding the higher frequency of congestive heart failure in elderly patients with CAD.

[Reduced endothelium-dependent peripheral vasodilation in the aged]. / Ridotta vasodilatazione periferica endotelio-dipendente nel sogetto anziano.

Endothelial dysfunction may be present years before the clinical manifestations of atherosclerosis, which is particularly frequent in the late decades of life. Therefore, we have evaluated the presence of endothelial dysfunction in the elderly by measuring, by echo-Doppler technique, the vasodilatation of brachial artery in response to the hyperemia following forearm occlusion and decompression, a response that is dependent on endothelial function. We studied 10 subjects > 65 years (mean 72 +/- 8) and 10 subjects < 65 years (mean 40 +/- 6) all without clinical signs and without risk factors for atherosclerosis. The increase in brachial arterial flow during reactive hyperemia was similar in the young and elderly subjects (152 +/- 74% vs 129 +/- 63%, NS). While in the young at peak hyperemia we found a significant increase in brachial artery diameter from 3.4 +/- 0.9 to 4.1 +/- 1.0 mm (p < 0.005), there was no significant change in the elderly (from 3.0 +/- 0.7 to 3.1 +/- 0.7 mm, NS). In both groups sublingual glyceryl trinitrate produced a significant increase in brachial artery diameter (from 3.0 +/- 0.7 to 3.5 +/- 0.8 mm in the elderly, p < 0.01, and from 3.4 +/- 0.9 to 3.9 +/- 0.9 mm in the young subjects, p < 0.01, NS among groups), showing the absence in the elderly of structural vascular changes potentially responsible for absence of dilatation. In conclusion, elderly subjects without clinical signs or risk factors for atherosclerosis have a vascular endothelial dysfunction that may play an important role in pathologic processes of the cardiovascular system in the late decades of life.

Natural history of the asymptomatic/minimally symptomatic patient with severe mitral regurgitation secondary to mitral valve prolapse and normal right and left ventricular performance.

The natural history of patients with severe nonischemic mitral regurgitation (MR) from mitral valve prolapse, who are asymptomatic or minimally symptomatic and have normal right ventricular (RV) and left ventricular (LV) performance, has not been evaluated previously. To define natural history in this population and to determine if any objective variables could predict disease progression, 31 patients were followed annually with severe MR due to prolapse, who at entry were asymptomatic or minimally symptomatic and had normal RV and LV performance at rest by radionuclide cineangiography. Average follow-up in patients not reaching surgical end point was 4.7 years. The Kaplan-Meier product limit estimates were used to determine the rate of progression to either "operable" symptoms or to previously defined "high risk" ventricular performance descriptors, if the latter occurred first. Univariate comparisons of Kaplan-Meier curves and multivariate Cox proportional hazards analyses were used to define prognostically important variables measured at entry. Fourteen patients developed symptoms warranting referral for operation; none developed high-risk ventricular performance descriptors. The annual end point risk was 10.3%. Of all covariates, only change in RV ejection fraction from rest to exercise was significantly associated with disease progression. Annual risk of progression to surgical end point was 4.9% in the subgroup in which this parameter increased with exercise and 14.7% in the subgroup without an increase (p = 0.04). Patients with severe MR due to mitral valve prolapse, who are asymptomatic or minimally symptomatic with normal ventricular performance, can be expected to progress to surgical indications at an annual rate of 10.3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of coronary artery disease by radionuclide cineangiography. History, current applications, and new directions.

In recent years, the utility of radionuclide cineangiography in prognostication has made it a mainstay of management decision making. With evolution of therapeutic modalities and concomitant alteration in management strategies, however, the technique and its application are undergoing parallel evolution to optimize response to current needs. Thus, in addition to standard planar rest and exercise assessment of left ventricular function, newer approaches are involving combined perfusion and function assessment, application of pharmacological stress to permit technically advantageous variations in imaging protocols, and application of SPECT technology in collecting blood pool data for tomographic display and analysis.

Risk stratification in the elderly patient after coronary artery bypass grafting: the prognostic value of radionuclide cineangiography.

BACKGROUND: Recent data have shown that assessment of left ventricular function by radionuclide cineangiography (RNCA) predicts survival and cardiac events among non-age-selected patients who have previously undergone coronary artery bypass grafting (CABG). However, the prognostic value of this noninvasive approach is not known for elderly patients who now undergo CABG with progressively increasing frequency and who survive longer because of operation. Such easily applied prognostic indexes may be useful to determine whether survival benefits are likely to be maintained or additional therapy should be considered. METHODS AND RESULTS: To obtain information on factors related to long-term survival and cardiac events among elderly patients after CABG and, specifically, to determine the prognostic implications of left ventricular performance at rest and during exercise for predicting all causes of death, major nonsurgical cardiac events (death or myocardial infarction), and event-free or surgery-free survival, we evaluated the late postoperative course of 41 patients, aged 65 years and older, who had undergone RNCA 1 month or more (mean 2.3 +/- 2.4 years; range 0.1 to 9 years) after CABG. Average follow-up among patients with event-free survival was 8.8 years after index radionuclide assessment. During follow-up 13 patients died with no known intercurrent event, five patients had nonfatal myocardial infarctions, and five underwent late (> or = 3 months after RNCA) repeat CABG or percutaneous transluminal coronary angioplasty. Log-rank comparisons of Kaplan-Meier product limit estimate curves identified only left ventricular ejection fraction at rest as significantly predictive of survival (p < 0.04). Patients with left ventricular ejection fraction at rest of less than 45% had a 7.8% average annual mortality risk, which was more than three times that of patients with normal resting function. Statistical trends also were found between mortality rates and completeness of revascularization (p < 0.06), major nonsurgical cardiac events and extent of anatomic disease (p < 0.08), and event-free or surgery-free survival and our index of completeness of revascularization (p = 0.08) and age at index RNCA (p < 0.07). CONCLUSIONS: Assessment of left ventricular ejection fraction at rest is prognostically useful after CABG among elderly patients. The efficacy and timing of this approach should be confirmed in further investigations with larger and more varied patient subgroups.

Prognostic value of left ventricular ejection fraction response to exercise during long-term follow-up after coronary artery bypass graft surgery.

BACKGROUND: Recent data, albeit based on operations often performed more than 15 years ago, suggest that survival benefits of coronary artery bypass graft surgery (CABG) generally are lost within 10 years after operation. A reliable noninvasive method for periodic assessment of ischemia severity after operation might permit optimal timing of additional therapy to minimize loss of benefits. METHODS AND RESULTS: To determine the impact of left ventricular ejection fraction (LVEF) during exercise on prognosis in patients who have undergone CABG, results of rest and exercise radionuclide cineangiography were correlated with mortality, major nonsurgical cardiac events, and cardiac event-free or surgery-free survival in 192 patients who underwent index radionuclide study > or = 1 month (average, 26 months) after CABG. Average follow-up after study was 8.7 years among event-free patients. Initial events during follow-up included 31 deaths, 19 nonfatal myocardial infarctions, and 33 late repeat CABG or angioplasties (PTCA). Stepwise Cox regression analysis identified change (delta) in LVEF with exercise as the strongest independent predictor of cardiac death, major nonsurgical cardiac events, and cardiac event-free or surgery-free survival (P < .0001, all outcomes). Change in heart rate with exercise, completeness of revascularization, and New York Heart Association functional class for angina provided additional independent information. With each 10% decrement in delta LVEF, the hazard of cardiac death increased more than twofold, and the hazard of major nonsurgical cardiac events considered alone or in combination with repeat CABG or PTCA increased > 1.5 times. CONCLUSIONS: Thus, assessment of delta LVEF is prognostically useful after CABG. Assessment of this variable may help determine the need for repeat CABG. The utility of this approach now should be confirmed by longitudinal prognostic study.

Prevalence of anticardiolipin antibody in isolated mitral or aortic regurgitation, or both, and possible relation to cerebral ischemic events.

Anticardiolipin antibodies (acLa) are associated with a thrombotic tendency (often involving cerebral ischemic events), are frequently present with systemic lupus erythematosus and have been found together with cardiac valve abnormalities. Previous studies evaluated patients characterized by the presence of acLa or lupus, precluding assessment of the frequency of acLa in those with valvular disease. This study aims to establish the prevalence of acLa in patients with valve disease in the absence of lupus and, furthermore, to determine the influence of acLa on the risk of cerebral events in valve disease. Eighty-seven consecutive patients with mitral or aortic regurgitation, or both, prospectively underwent enzyme-linked immunosorbent assay testing for immunoglobulin G (IgG) and M acLa, as did 24 normal subjects. AcLa values greater than or equal to 3 SD above the normal mean were considered "positive." Prior cerebral events were defined retrospectively. Of 87 patients with valvular disease, 26 had positive IgG acLa levels compared with 0 of 24 normal subjects (p less than 0.01). AcLa values did not vary with valve disease etiology. Focal cerebral events had occurred in 8 patients and were embolic or probably embolic in 7, including 7 of 26 IgG acLa-positive and 1 of 60 IgG acLa-negative patients (p less than 0.001). In the absence of lupus, IgG acLa is highly prevalent among patients with aortic or mitral regurgitation, or both; this association may indicate a relatively high risk for cerebral emboli.

Participant evaluation and cost of a community-based health promotion program for elders.

There is little information on how best to provide health promotion and disease prevention services to elderly persons. This paper reports participants' perceptions of the effectiveness of a health promotion program consisting of health education classes and case management services. A single-group, posttest only design was used for the county-wide program, which operated independent of participants' primary care physicians. Each person received a thorough screening evaluation, was invited to health education classes, and was assigned a case manager for a 2-year health promotion period. Community residents 64-71 years of age were recruited; 475 entered the study, and 378 (79.6 percent) completed the followup evaluation interview. Only one-third of the participants attended at least one class, but a majority of those attending each class rated it very or extremely effective in increasing knowledge. To determine the effectiveness of the case managers, each participant identified the three health problems that were of greatest concern to him or her and indicated which of these priority problems were discussed with the case manager. Discussion with the case manager was significantly associated with continuing to see a personal physician for the problem, following the physician's recommendations, the problem's being under control, and the problem's improving over the 2-year followup. The classes and case management services benefited the participants who used them. How to best deliver these services to the target group needs further study.

Natural history of left ventricular performance at rest and during exercise after aortic valve replacement for aortic regurgitation.

Previous studies of left ventricular performance in aortic regurgitation uniformly indicate improvement within the year after aortic valve replacement but differ regarding the likelihood of additional later improvement. To resolve this difference, to more precisely define the pattern of postoperative left ventricular performance variation, and to assess the impact of valve replacement on ejection fraction during exercise, we evaluated radionuclide cineangiograms obtained annually or nearly annually for approximately 5 years in 21 prospectively studied patients who had undergone valve replacement for aortic regurgitation. Ejection fraction rose from less than 8 months before operation to 5-11 (average 7) months after operation and continued to rise for 1 additional year (rest) and 2 additional years (exercise) before reaching a stable plateau until the final study 54-72 (average 63) months postoperatively. Mean ejection fractions at rest were 45% preoperatively, 50% less than 1 year postoperatively (p = 0.12), 54% at year 1-2 (p = 0.01 versus less than 1 year), 56% at year 2-3 (NS versus year 1-2) and year 4-6 (NS versus year 1-2 or 2-3), and during exercise were 39% preoperatively, 49% less than 1 year postoperatively (p less than 0.01), 54% at year 1-2 (p less than 0.01 versus less than 1 year, NS versus year 2-3, p less than 0.05 versus year 4-6), 60% at year 2-3, and 61% at year 4-6 (NS versus year 2-3). Late improvement was found most consistently among patients with relatively depressed performance before operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Target groups for screening elderly outpatients.

A low-risk target group of 475 individuals 64-71 years of age was recruited from the community and received comprehensive screening assessments. Four hundred four unknown/untreated medical conditions were detected in 74.5% of the participants, but less than 5% of these conditions would have been detected using the most conservative screening procedures recommended for this age group. A more liberal, yet still focused, clinical evaluation could detect the medical conditions noted in 5% or more of the participants. However, 43% of the 279 unknown/untreated laboratory abnormalities were noted on tests that fulfill the more liberal of the accepted screening criteria. Despite a large number of detected conditions, an unfocused, comprehensive screening assessment is not recommended for this particular target group; rather, the use of a selective screening package is supported.