Elevated pulmonary artery pressure. An independent predictor of mortality.

Analyses in this study were based on hemodynamic and angiographic data obtained in a cohort of 1,371 predominantly black patients during right and left heart catheterization. All patients were followed up prospectively for a mean of 117 weeks, and 103 fatal events were recorded. In Cox survival analysis, three variables were found to be independently related to survival: pulmonary artery mean pressure (PAMP), number of stenosed vessels, and left ventricular (LV) ejection fraction (p less than 0.01); in multivariate stepwise analysis, PAMP entered the model first with the largest chi 2 value of the three prognostic variables (chi 2 = 33.4; p less than 0.0001). The PAMP was 32 percent higher in decedents compared with survivors (25 + 11 mm Hg vs 19 + 8 mm Hg, p less than 0.01 [mean, SD]) and a 10 mm Hg increase in PAMP was associated with a more than fourfold increase in the relative risk of dying; this finding was independent of pulmonary vascular resistance and therefore could not be attributed to primary pulmonary vascular or parenchymal disease. In both the subgroup of 1,118 patients with a normal LV ejection fraction (greater than 50 percent) and the 253 patients with a reduced ejection fraction (less than 50 percent), PAMP emerged as an independent predictor of mortality (p less than 0.0001 and 0.01, respectively), and is therefore a marker of cardiac disease beyond impairment of systolic contractile function. Among patients without obstructive coronary artery disease, PAMP alone provided prognostic information in the multivariate survival analysis.

Survival determinants in black patients with angiographically defined coronary artery disease.

Long-term survival of blacks with angiographically defined coronary artery disease was examined in a series of 1233 consecutive patients who underwent cardiac catheterization at a large urban municipal hospital. Vital status information was available at a mean of 86 weeks for the cohort as a whole, and 94 deaths were recorded. As noted in other angiographic series that included blacks, a high proportion of patients in this study had unobstructed coronary arteries (41%), and there was a preponderance of women (56%). Hypertension was present in 82% of the cases, whereas 68% of the sample had left ventricular hypertrophy as revealed by echocardiogram. The cumulative proportion of patients who were surviving at 5 years was 90 +/- 1 (+/- SEM), 79 +/- 4, and 70 +/- 4 for patients with no obstructive lesions, one-vessel disease, and multivessel disease, respectively. The survival rate at 3 years for patients who had undergone bypass surgery (N = 152) was only 82% (+/- 5%). Noninvasive univariate predictors of mortality included male sex, history of myocardial infarction, Q waves on electrocardiogram, exercise duration on treadmill stress testing, and left ventricular hypertrophy. Angiographic predictors included left ventricular end-diastolic pressure, the number of diseased coronary vessels, ejection fraction, and mean pulmonary artery pressure. Regression analysis showed an independent association for all the angiographic variables noted previously as well as for echocardiographically determined left ventricular hypertrophy. Survival rates for blacks with coronary artery disease in this series were considerably lower than those currently reported for whites, particularly for patients who underwent coronary bypass grafting.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular hypertrophy is associated with worse survival independent of ventricular function and number of coronary arteries severely narrowed.

Left ventricular (LV) hypertrophy has been repeatedly shown to be associated with a marked increase in mortality risk. Available data, however, do not provide evidence that the risk associated with the increase in cardiac muscle mass is independent of the severity of preexistent coronary artery disease. In a cohort of predominantly black patients with a high prevalence of hypertension and LV hypertrophy, LV mass as estimated by echocardiography was found to be a powerful prognostic factor independent of ejection fraction and obstructive coronary disease. After excluding patients with either a dilated LV cavity (diastolic internal diameter greater than 5.8 cm) or asymmetric septal hypertrophy (septal:posterior wall ratio greater than 1.5) LV mass/height remained significantly increased in decedents compared to survivors (116 +/- 38 vs 131 +/- 47 g/m, p = 0.014), while the thickness of the ventricular septum and the posterior wall were even more highly predictive of a fatal outcome (p = 0.003 and 0.001, respectively). After exclusion of patients with eccentric LV hypertrophy, differences in LV muscle mass in survivors and decedents were due entirely to increased thickness of the ventricular wall, and no differences in cavity dimensions or LV ejection fraction were noted. Stepwise regression analysis was used to demonstrate that measures of LV hypertrophy were the most important predictors of survival and eliminated the contribution of all other prognostic factors to the model except the number of stenotic vessels. The relative risk associated with a 100-g increase in mass was 2.1, while a 0.1-cm increase in posterior wall thickness was associated with approximately a 7-fold increase in the risk of dying.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypertension as a cause of lower than expected death rates from coronary artery disease among blacks.

Coronary risk factors are more prevalent among blacks than whites in the United States. It is therefore paradoxical that age-adjusted death rates for coronary artery disease (CAD) are similar in the two racial groups. The major risk factor for CAD that is more common among blacks than whites is hypertension, which increases the risk of CAD by two- to fourfold, depending on the presence of smoking, hypercholesterolemia, or other factors. Two general hypotheses have been advanced to explain the lower than expected CAD rates among blacks: (1) the presence of some protective factors, such as increased levels of high density lipoprotein cholesterol (HDL); or (2) selective loss of CAD-prone black individuals due to other causes of mortality. Analysis of age-specific death rates from the vital statistics records strongly suggests that differential survival in the black and white populations, i.e., mortality selection, is the primary explanation of this phenomenon. We sought to test this hypothesis by examining an entirely independent data base. Data from the National Hospital Discharge Survey for the years 1973-1984 were evaluated to determine whether there were age-related differences in case-fatality rates between whites and blacks, and whether a crossover pattern in mortality could be discerned. The results demonstrate that in-hospital case-fatality rates for acute myocardial infarction (MI) were 10% to 70% higher for each of the 10-year age groups for blacks up to age 70 years, at which time a crossover occurred. The median age at which death due to MI occurred in blacks was approximately 5 years earlier than in whites.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial infarction among black patients: poor prognosis after hospital discharge.

Previous studies suggest that long-term survival among symptomatic black patients with coronary artery disease is reduced compared with white patients. Of 342 patients hospitalized with a myocardial infarction over a 3-year period, 285 were black and 249 of these were discharged alive. In this cohort, the all-causes mortality was 14% (95% CI, 9 to 19) at 1 year and 22% (95% CI, 13 to 31) at 2 years. Cardiac causes accounted for 71% and 82% of all deaths at 1 and 2 years, respectively. These mortality rates exceed previous reports of survival after myocardial infarction among white patients in the United States, and confirm that inner-city minority patients served by municipal health care institutions have a particularly poor prognosis for coronary artery disease.

Coronary artery disease in blacks of lower socioeconomic status: angiographic findings from the Cook County Hospital Heart Disease Registry.

During a 4-year period, 1,022 blacks underwent angiography at our institution for the presumptive diagnosis of coronary artery disease (CAD). Among the 454 men, at least one coronary stenosis was demonstrated in 288 cases (63%), while significant narrowing was found in 242 of 568 women (43%). Despite the frequent finding of normal coronary arteries, those patients with significant CAD had severe disease. Thus among men with CAD, left main stenosis was present in 7% and three-vessel narrowing was seen in 53%; among the women, 8% had left main stenosis and three-vessel disease was present in 52%. Two countervailing processes appear to be occurring, namely (1) identification of true coronary symptoms is difficult in this group of patients and (2) diagnosis of true cases occurs late in the course of the disease and the distribution of the number of vessels involved is skewed upwards. Increased echocardiographically determined left ventricular mass and hypertension were prevalent among all groups. These data suggest that the approach to the diagnosis of CAD in the black population is difficult and severe CAD occurs frequently.

Sickle cell heart disease. Two-dimensional echo and Doppler ultrasonographic findings in the hearts of adult patients with sickle cell anemia.

Sickle cell anemia (SCA) is a commonly diagnosed condition in the black population in the United States. With better medical management, patients with SCA are living longer and what were previously uncommon sequelae are being recognized frequently, including those involving the cardiovascular system. Previous reports on the cardiovascular effects of SCA have focused predominantly on children, but the conclusions remain controversial. To study this question further, 40 adult patients with documented SCA were examined using two-dimensional and Doppler cardiac ultrasound. Valvular structures were normal despite an increased incidence of flow murmurs. Abnormalities were found more frequently in the left heart than the right, as manifested primarily by increased left ventricular mass, and left ventricular and left atrial dilatation with preservation of systolic function. Pulmonary hypertension, which was present in two thirds of the sample, was minimal to moderate as assessed by our Doppler technique. The effects of SCA on the heart seem to be minimal and similar to those of other anemias, predominantly confined to the left atrium and ventricle with passive elevation of pulmonary pressures. Clinical murmurs were most often physiologic; there was no association with myxomatous valvular degeneration or mitral valve prolapse.

Outcome of coronary artery bypass grafting in black persons.

Relatively little attention has been given to coronary artery disease in black persons in the United States. During 31 months, 73 consecutive black patients drawn from an urban working class inner city population who had undergone coronary artery bypass grafting were studied. In the total series of elective and emergency operations, 3 patients (4%) died within the first 30 days and 3 more died by the end of the first year of follow-up. Functional capacity was assessed by interviews and a questionnaire in a subset (n = 39) at least 6 months after operation. Although 79% of the patients felt that the operation had resulted in improvement of symptoms, half of them continued to report angina. Only one-third of the patients were working in the period immediately before the operation; 13% were working postoperatively. Coronary artery bypass grafting had an acceptable mortality risk in these patients, although the functional outcome was disappointing.