The impact of patient-reported frailty on cardiovascular outcomes in elderly patients after non-ST-acute coronary syndrome.

BACKGROUND: As life expectancy increases, the population of older individuals with coronary artery disease and frailty is growing. We aimed to assess the impact of patient-reported frailty on the treatment and prognosis of elderly early survivors of non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS: Frailty data were obtained from two prospective trials, POPular Age and the POPular Age Registry, which both assessed elderly NSTE-ACS patients. Frailty was assessed one month after admission with the Groningen Frailty Indicator (GFI) and was defined as a GFI-score of 4 or higher. In these early survivors of NSTE-ACS, we assessed differences in treatment and 1-year outcomes between frail and non-frail patients, considering major adverse cardiovascular events (MACE, including cardiovascular mortality, myocardial infarction, and stroke) and major bleeding. RESULTS: The total study population consisted of 2192 NSTE-ACS patients, aged ≥70 years. The GFI-score was available in 1320 patients (79 ± 5 years, 37% women), of whom 712 (54%) were considered frail. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.01-2.43, p = 0.04), but not for major bleeding (3.7% vs. 2.8%, adjusted HR 1.23, 95% CI 0.65-2.32, p = 0.53). Cubic spline analysis showed a gradual increase of the risk for clinical outcomes with higher GFI-scores. CONCLUSIONS: In elderly NSTE-ACS patients who survived 1-month follow-up, patient-reported frailty was independently associated with a higher risk for 1-year MACE, but not with major bleeding. These findings emphasize the importance of frailty screening for risk stratification in elderly NSTE-ACS patients.

Aortic aneurysm formation following coarctation repair by Dacron patch aortoplasty.

We describe the finding of an aortic aneurysm in an asymptomatic 43-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 25 years before. The role of magnetic resonance angiography as standard imaging technique in lifelong postoperative surveillance is discussed subsequently. (Neth Heart J 2010;18:376-7.).

Long-term outcome after balloon angioplasty of coarctation of the aorta in adolescents and adults: Is aneurysm formation an issue?

OBJECTIVES: The purpose was to evaluate long-term outcome following balloon angioplasty for coarctation in adults. BACKGROUND: Long-term results of balloon angioplasty for native coarctation in adults remain incomplete, especially concerning the occurrence of aneurysm formation. METHODS: Long-term follow-up data were collected in consecutive patients retrospectively. Results of balloon angioplasty (29 patients, age 15-71 years, during 1995-2005) for discrete, native coarctation were evaluated, including MRI or CT. RESULTS: Mean follow-up ranged from 2.2 to 13 years (mean 8.5 +/- 3.2). Immediate success was obtained in all patients. Early mortality or complications were not encountered. Peak systolic pressure gradient decreased from 52 +/- 21 to 7.2 +/- 7.6 mm Hg (P < 0.001). Intima tear was detected in eight procedures angiographically, without signs of dissection. Three-month follow-up angiography in these patients showed unchanged (4/8 patients) or diminished abnormalities (4/8 patients). One asymptomatic patient, known with left ventricular dysfunction due to significant aortic valve insufficiency, died suddenly 5 years after balloon angioplasty. Recoarctation occurred in one patient (3%). Late aneurysm formation was excluded by MR in 24/29 and CT in remaining 5/29 patients during follow-up, including those patients in whom intima tear was encountered immediately postangioplasty. In three of seven patients an irregular aortic contour persisted, without indication of progression or aneurysm formation. Hypertension was completely relieved in 67% (14/21 patients) and improved in 33% (7/21 patients). CONCLUSIONS: Balloon angioplasty for native coarctation yields low reintervention probability in adult patients. Despite occurrence of angiographically established intimal tearing, aortic dissection and aneurysm formation were not encountered.

Aborted sudden cardiac death in a 52-yearold man without structural heart disease.

Sudden cardiac death in the absence of apparent structural heart disease is an uncommon phenomenon. The majority of these patients do not have 'normal' hearts and specific diagnostic tools are required to identify structural or functional abnormalities. We describe the history of a 50-yearold man who survived ventricular fibrillation. Clinical investigation, including a coronary angiography and electrophysiological study, appeared to be normal. An implantable cardioverter defibrillator was inserted. Follow-up Holter monitoring was performed after a recurrent episode of ventricular tachycardia. It demonstrated transient ST-segment elevation. An acetylcholine provocation test was subsequently carried out. Reversible coronary spasm of the left descending coronary artery was found, during which a diagonal branch was occluded. It may be concluded that coronary spasm provocation is of value in the routine diagnostic work-up of patients surviving sudden cardiac death without apparent heart disease. (Neth Heart J 2008;16:239-41.).

Hemi-epiphysiodesis for unclassified congenital scoliosis: immediate results and mid-term follow-up.

Complex spinal anomalies involved in congenital scoliosis consist of a jumble of vertebral defects. Progressive scoliotic curves are frequently encountered in these patients. We evaluated the results of hemi-epiphysiodesis for this patient population. A series of ten patients with unclassified scoliosis, involving multiple hemivertebrae and/or bars, was reviewed retrospectively. Hemi-epiphysiodesis was the primary treatment in all patients. Mortality, complications and wound healing problems did not occur. The average Cobb angle for all patients changed from 54 degrees (range: 40 degrees -74 degrees), preoperatively, to 58 degrees (range: 30 degrees -104 degrees), postoperatively. Applying the criterion of a minimum change of 20 degrees, to take into account measurement variability, an epiphysiodesis effect was achieved in two procedures, progression was arrested in six procedures and failure occurred in two procedures. The mean rate of Cobb angle change per annum decreased from 2.9 degrees (range: -35 degrees to 14 degrees), preoperatively, to 2.4 degrees (range: -4 degrees to 13 degrees), following surgery. Repeat surgery was necessitated by coexisting progressive kyphosis and pseudoarthrosis in one patient, and involved extension of primary epiphysiodesis in two patients. A mean intervention-free period of 58 months was established. These results suggest that hemi-epiphysiodesis stabilized the unclassified congenital scoliosis. Being under 5 years of age, having a thoracolumbar curve location, and the absence of coexisting kyphosis were found to be associated with a more favorable outcome.

[Balloon angioplasty as the primary treatment for coarctation of the aorta in 30 children; immediate results and follow-up]. / Ballonangioplastiek als primaire behandeling van coarctatio aortae bij 30 kinderen; directe resultaten en follow-up.

OBJECTIVE: Evaluation of the results of balloon dilatation in coarctation of the aorta in children. DESIGN: Retrospective. METHOD: In the years 1990-1999 30 patients with a congenital coarctation of the aorta were treated with balloon angioplasty in the Children's Heart Centre of Utrecht University Medical Centre, the Netherlands. The group comprised 5 girls and 25 boys, with a mean age of 4.8 years (range 1 month-16 years) without severe associated congenital heart defects or a long segment coarctation. Follow-up included Doppler echocardiography and MRI within the first 6 years after the procedure. The fall of the pressure gradient was assessed with Student's t-test for paired observations and the reintervention period was calculated by the Kaplan-Meier method. RESULTS: No children died. Of 30 procedures performed, 28 (93%) were considered successful. Mean pressure gradient was reduced from 36.2 mmHg (SD: 12.7) to 13.1 mmHg (SD: 9.3) (p < 0.001). Mean follow-up was 4.1 years; the follow-up of 11 patients was longer than 5 years. Four patients (13%) developed a recoarctation. No aneurysm formation was encountered (n = 14). CONCLUSION: Balloon angioplasty for the treatment of native coarctation of the aorta in children may be an efficient and not very damaging solution for this selected group of patients.