Incremental prognostic value of RNA ejection fraction measurements during pharmacologic stress testing: a comparison with clinical and perfusion variables.

UNLABELLED: This investigation examined the prognostic power of first-pass radionuclide angiocardiography (RNA) ejection fraction compared with clinical information and myocardial perfusion imaging in patients undergoing pharmacologic stress testing. The value of RNA and myocardial perfusion imaging in predicting death or nonfatal myocardial infarction (MI) is well established. However, limited information exists on the usefulness of combined myocardial perfusion imaging and RNA to predict prognosis, especially in patients undergoing pharmacologic stress testing. METHODS: We identified 240 patients who underwent pharmacologic stress testing with myocardial perfusion imaging and combined RNA. The patients were followed for a mean of 1.4 y. Cox proportional hazards models were used to assess the value in predicting death and MI. Multivariable models were generated to assess the independent incremental predictive value of clinical and nuclear imaging variables. Kaplan-Meier survival and event-free survival estimates were examined in patients with low (< or = 45%) versus high (>45%) ejection fractions. RESULTS: Clinical information, myocardial perfusion imaging, and RNA ejection fraction were significant predictors of the death/MI composite outcome (chi(2) = 7.4, 14.0, and 21.8, respectively). The addition of myocardial perfusion imaging to the clinical information provided incremental prognostic information (chi(2) = 15.2). The addition of RNA ejection fraction provided further predictive information (chi(2) = 22.5). However, when RNA ejection fraction was first added to the clinical information, myocardial perfusion imaging had no incremental prognostic value. CONCLUSION: For hard cardiac events, RNA ejection fraction provides prognostic information besides that provided by clinical and myocardial perfusion imaging. In patients who cannot exercise and are undergoing noninvasive evaluation with pharmacologic stress testing and myocardial perfusion imaging, ejection fraction should be measured simultaneously for risk assessment optimization.

Association between selective serotonin-reuptake inhibitor therapy and heart valve regurgitation.

The identification of an association between fenfluramines and valvular disease has raised the possibility of a similar association between another class of medications that increases local levels of serotonin, the selective serotonin-reuptake inhibitors (SSRIs). The objective of this study was to examine the association between heart valve regurgitation and treatment with SSRIs. We examined 5,437 consecutive patients who underwent echocardiography. Patients with a similar likelihood of SSRI treatment were identified by propensity models. The prevalence of regurgitation according to treatment was compared after adjusting for clinical characteristics associated with regurgitation. We also blindly reinterpreted a subset of 2,000 echocardiograms to identify characteristics associated with fenfluramine-associated valvular heart disease such as posterior mitral leaflet restriction. Among 5,437 consecutively hospitalized patients, we identified 292 who had taken SSRIs before admission. Patients taking SSRIs tended to be younger, female, Caucasian, unmarried, and more likely to have psychiatric illness and hypertension (p < or = 0.05). The overall prevalence of regurgitation meeting Food and Drug Administration criteria (at least moderate mitral regurgitation or mild aortic regurgitation) was 30%, with no significant difference in prevalence between those receiving SSRIs (26.7%) and controls (30.4%) (p = 0.19). The association remained negative when comparing SSRI-treated patients to controls with similar characteristics. Furthermore, the prevalence of features described in conjunction with fenfluramine exposure, such as posterior mitral leaflet restriction, was not higher in SSRI-treated patients. Among a large consecutive cohort of patients, the prevalence of mitral and aortic regurgitation in patients taking SSRIs was not different from that of controls, suggesting that SSRIs are not associated with valvular disease.

The progression of fenfluramine-associated valvular heart disease assessed by echocardiography.

BACKGROUND: An association between the dietary suppressants fenfluramine and dexfenfluramine and valvular heart disease was first described in patients from North Dakota and Minnesota in 1997. Limited data are available on the natural history of this valvulopathy after discontinuation of drug therapy. OBJECTIVE: To follow the progression of fenfluramine-associated valvular heart disease after discontinuation of therapy by using serial echocardiography. DESIGN: Retrospective cohort study. SETTING: Regional medical center in Fargo, North Dakota. PATIENTS: 50 patients with previous exposure to fenfluramines who had at least mild mitral regurgitation or aortic regurgitation after exposure to fenfluramines on serial echocardiography between December 1994 and February 1999 (96% were female, mean body mass index was 36.6 kg/m(2), and mean duration of drug exposure was 447 days). MEASUREMENTS: Serial echocardiograms were reviewed by two echocardiographers who were blinded to the order of image acquisition. The severity of valvular regurgitation and presence or absence of valve leaflet restriction were assessed. RESULTS: As described in the initial report, significant valvular disease on initial postexposure echocardiography was common in this cohort; 38 patients (76%) had at least mild mitral regurgitation and 43 patients (86%) had at least mild aortic regurgitation. On serial echocardiograms obtained an average of 356 days apart, mitral regurgitation improved by at least one grade in 17 patients (P = 0.001) and aortic regurgitation improved by at least one grade in 19 patients (P = 0.004). Nineteen and 22 patients, respectively, experienced no change in severity of mitral and aortic regurgitation. Two patients in each group experienced worsening of regurgitation by at least one grade. Results were similar for tricuspid (P = 0.002) and pulmonic (P = 0.012) regurgitation. CONCLUSION: On serial echocardiography, fenfluramine-associated valvular regurgitation improved or remained stable in most patients after therapy ended. Worsening of valvular regurgitation was uncommon. The potential for stabilization or regression of valvular regurgitation should be taken into account when counseling patients and considering the need for and timing of valve surgery.

Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury.

This study was designed to evaluate factors that affect blood volumes transferred to skin during simulated needlestick injuries in an in vitro paper prefilter model and an ex vivo porcine tissue model. The effect of needle type and size, penetration depth, and glove use on the volume of radiolabeled blood transferred was determined in each model. Blood volumes ranged from 0.47 +/- 0.26 microL (30-gauge needle, 0.5-cm depth, in vitro model) to 5.88 +/- 1.45 microL (18-gauge needle, 2.0-cm depth, in vitro model). Needle size and penetration depth were significantly associated with transfer volume. Glove material reduced the transferred blood volume by 46%-86% in both models. Transfer volumes were within the same order of magnitude for all conditions. Hence, virus titer in the source blood may be a better predictor of needlestick infectivity than is exposure volume. Regardless, gloves may exert some protective effect and should be worn whenever needles are handled.