Prognostic variables for clinical outcomes in valvular heart disease patients with moderate to severe secondary tricuspid regurgitation.

BACKGROUND AND AIM OF THE STUDY: Secondary tricuspid regurgitation (STR) is frequently seen in cardiology practice. Currently, few data are available on the prognostic variables associated with moderate or severe STR on death and progression to valve surgery. Hence, the study aim was to identify these prognostic variables. METHODS: In this retrospective study, patients with at least moderate STR were identified from an ongoing database and followed until death, any valvular heart surgery, or the end of the study. Clinical and echocardiographic variables including age, gender, coronary artery disease, device implantation (defibrillator or pacemaker), pulmonary disease, left ventricular ejection fraction, right ventricular size, right ventricular systolic pressure (RVSP), STR severity and concomitant valve disease were recorded. End-points were death and valve surgery. RESULTS: The average age of the 92 study participants was 68 +/- 16 years. During a mean follow up of 43 +/- 24 months, there were 13 deaths (14%) and 12 surgeries (13%). In multivariate analysis, both an elevated RVSP and device implantation were significant predictors of death (p = 0.0038 and 0.0487, respectively). Only an elevated RVSP was predictive of surgery (p = 0.05) and surgery-free survival (p = 0.0005). A RVSP > 48 mmHg had a hazard ratio of 3.93 (p = 0.0012) and a high diagnostic accuracy for predicting death, with an area under the receiver operating characteristic curve of 0.73. CONCLUSION: In patients with valvular heart disease and at least moderate STR, an elevated RVSP of at least 48 mmHg was associated with significantly increased mortality and decreased surgery-free survival.

Management of coronary artery disease in patients with chronic kidney disease.

Patients with chronic kidney disease (CKD) are considered to belong to the highest risk group for the development of cardiovascular events. These patients should be subject to aggressive risk-factor modification. However, management of coronary artery disease in patients with CKD can be uniquely challenging. Many of the medications used in the treatment and prevention of coronary artery disease are metabolized or excreted by the kidney. Thus, patients with CKD are more likely to experience adverse effects from any attempt to aggressively modify risk factors for coronary artery disease. Little is known regarding revascularization in patients with CKD. Patients with CKD may benefit from off-pump strategies during coronary artery bypass. Percutaneous coronary intervention in patients with CKD is associated with lower procedural success and increased peri-procedural myocardial infarction, ischemia, and target vessel revascularization. In this review, we discuss the unique challenges of managing coronary artery disease in patients with CKD.

Utility of echocardiography in the evaluation of coronary artery disease in patients with end-stage renal disease.

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events. Echocardiography is an integral part of the evaluation of coronary artery disease. Chronic kidney disease has a predictable and unique effect on the myocardium and the epicardial circulation that may be detected by echocardiography. In particular dobutamine stress echocardiography has proved to be an invaluable tool in the detection of cardiovascular disease in patients with CKD. Here, we review the usefulness of echocardiography in the detection and evaluation of coronary artery disease in patients with CKD.

Assessing cardiovascular disease in the dialysis patient.

Cardiac causes account for nearly half of all deaths in patients with end-stage renal disease (ESRD). Coronary artery disease (CAD) is present in 38% - 40% of patients starting dialysis. Both traditional and chronic kidney disease-related cardiovascular risk factors contribute to this high prevalence rate. In patients with ESRD, CAD--particularly acute myocardial infarction--is underdiagnosed. Dobutamine stress echocardiography and, to a lesser extent, stress myocardial perfusion imaging have proved useful in screening for CAD in such patients. Coronary artery calcium scoring is less useful. Acute myocardial infarction is associated with high short- and long-term mortality in dialysis patients. Cardiac troponin I appears to be more specific than cardiac troponin T or CK-MB in the diagnosis of acute myocardial infarction.