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Do beta blockers prevent hard events in patients undergoing major noncardiac surgery? A risk stratification approach
A66
Selected abstracts Cardiology, May
from the XIVth 5-9,2002
World
Congress
of
Heart,
underwent DbE and coronary angiography within 6 months, without an intervening event. Echoes were measured for relative wall thickness (RWT, normal < 0.45), left ventricular (LV) chamber size and LV mass (normal < 131 g/m2 in men and < 100 g/m2 in women). CAD was defined as > 50% stenosis. Circumferential (cESS) and meridional endsystolic wall stress (mESS) at rest and peak DbE in pts without wall motion abnormality (WMA) were calculated according to previously published methods. Results CAD was present in 107/195 pts. Pts without resting WMA (n = 161) were classified using 2D echo into normal (N; normal wall thickness and mass, n = 47), concentric remodelling (increased RWT and normal mass, n = 23), concentric hypertrophy (CH; increased RWT and mass, n = 63) and eccentric hypertrophy (EH; normal wall thickness and increased mass, n = 28). In pts with CR, accuracy of DbE (61%) was lower than either N (85%, P = 0.049) or CH (86%, P = 0.027). In EH, accuracy of DbE (64%, P = 0.04) was lower than that of CH. Sensitivity (N-85%, CR-67%, CH-87%, EH-65%) and specificity (N-85%, CR-50%, CH-84%, EH-63%) for detection CAD showed similar differences between each group. No significant differences in cESS and mESS were detected at peak among each group. Sensitivity, specificity and accuracy were comparable among each quartile in cESS and mESS at rest. Pts with greatest wall stress at peak had significantly higher sensitivity and accuracy than those in lowest quartile (96% vs. 71%, P = 0.042 and 91% vs. 68%, P = 0.019). Conclusion Diagnostic problems for DbE in LVH are posed by pts with large and small LV cavities. Reduced systolic wall stress at peak is associated with lower sensitivity and accuracy. Key words: Coronary artery disease, Hypertrophy, Stress echocardiography Do Beta Blockers Prevent Hard Events in Patients Undergoing Major Noncardiac Surgery? A Risk Stratification Approach Marco Torres, Leanne Short, Terri Baglin, Beatriz Torres, Thomas H Marwick University ofQueensland, Australia Background Trials have suggested beta blockers (BB) may reduce cardiac complications in pts undergoing major noncardiac surgery (NCS). We sought whether these trial findings could be replicated in clinical practice, and the impact of BB at various levels of risk. Methods 135 consecutive pts (age 68 + 9, 79 men) with > 1 Eagle’s clinical risk variables (CRV) or inability to exercise, undergoing 137 major NCS were studied with standard dobutamine-atropine stress echo (DbE). Ischemia was identified by a new or worsening wall motion abnormality, and ischemic threshold was calculated. CRV and DbE results were combined to assess risk as high (HR; predicted risk > 30%), intermediate (IR, 1@30% risk) and low (LR, < 10% risk), based on prior studies without BB. Pts were followed for 15 f 6 months for death or infarction. Results BB were administered peri-operatively in 60 and not or inadequately used in 75 pts; only 6 had revascularization after positive DbE. There were 16 major events (6 cardiac death, 10 infarcts), and events occurred more frequently in pts on BB (11/63 vs. 5/74, P = NS). However, BB were used in higher risk pts; anticipated risk in the BB group was 23 + 26%, compared with 18 + 40% in non-BB pts and there was no difference between HR, IR and LR subgroups (Table). Low risk Beta blocked Non beta-blocked
z/22 (9%) 2/49 (4%)
Intermediate 6/29 (21%) l/19 (5%)
High risk 3/12 (25%) 2/6 (33%)
Conclusion Outcomes of BB and non-BB corrected for underlying appear similar. A significant number of major events occur despite use of BB, especially in high-risk pts. Key words: Prognosis, Stress echocardiography, Vascular surgery
risk the
Non-invasive Risk Stratification in Uncomplicated Acute Coronary Syndromes is Associated with Less Revascularization but Equivalent Outcomes to Angiographic Evaluation Kevin Franklin’, Vinah Anderson’, Richard Lim’, Thomas Marwick ‘University of Queensland, Australia; 2University of Queensland, Australia Background Recent randomised, controlled potential benefits of an early invasive strategy
trials have focused on the in selected pts with acute
Lung
and Circulation
2003; 12
coronary syndromes (ACS). However, current guidelines for risk assessment leave the choice of invasive or noninvasive strategy to the discretion of the treating physician. We sought to define the short-term outcomes of pts presenting to our institution with ACS, according to the adopted strategy. Methods This observational study screened all admissions with ACS over an 18-month period; pts were included in the analysis if stress echo (SE) or coronary angiography (CA) was the initial risk stratification strategy. l’ts were excluded if unstable (recurrent angina, LVF, arrhythmias), had undergone previous revascularisation (CABG, PTCA within 6 months), or if ACS had occurred within the preceding 6 months. Results CA or SE were performed within 3 months of the index admission in 522 pts admitted with ACS, of whom 154 pts met the study criteria, with SE performed in 38, and CA in 116. Baseline data were comparable between groups (Table). CA showed minor CAD in 31 pts (27%), with the equivalent finding of no ischaemia by SE in 8 pts (21%, P = NS). CA was performed after abnormal SE in 15 pts (39%). Follow up was completed in 34 (90%) of the SE group (mean 23 + 8 months), and in 110 (95%) of the CA group (mean 21 f 10 months; P = 0.11 vs. SE). Hard events (cardiac death, MI) occurred in 2 (6%) in the SE group, and in 4 (4%) in the CA group (P = NS). Any adverse event (including readmission for chest pain, unplanned revascularisation) occurred in 7(23%) of SE group, and 26 (25%) of CA group (P = NS). Pts undergoing CA had a significantly greater length of stay (4.4 + 2.7 vs. 2.8 + 1.8 days; P < 0.0001) and higher rates of planned (44% vs. 10%; P < 0.001) revascularisation.
Stress echo Angiography
Stress echo Angiography
Angina
Prior MI
Diabetes
Beta blockers
7 (18%) 16 (14%)
5 (13%) 17 (14%)
4 (11%) 20 (17%)
7 (18%) 23 (20%)
Lysis
Peak CK
6 (16%) 25 (22%)
562 + 694 645 + 874
Multivessel CAD 7 (18%) 20 (17%)
Conclusion Pts with uncomplicated ACS who undergo SE appear to have similar short-term outcomes and shorter hospital stays compared with an invasively managed cohort, despite lower rates of planned revascularisation. Key words: Angiocardiography, Myocardial infarction, treatment, Outcomes assessment, Stress echocardiography Prognostic implications of exercise echo and exercise ECG in hypertensive patients Thomas H Marwick’, Colin Case’, Charles Vasey2, Stephen Sawada”, James D Thomas4 ‘University of Queensland, Australia; 2Asheville Cardiology Associates, United States; 3University of Indiana, United States; 4Cleveland Clinic Foundation, United States Background The stress echocardiography is more accurate than exercise ECG (ExECG) for the diagnosis of coronary disease in hypertensive (HT) pts, largely due to false positive ExECG. The selection of stress echo in all HT pts or only those with a negative ExECG might be governed by the relative prognostic implications of these tests, but these are not well defined. Methods ExECG and EXE were performed to evaluate suspected CAD in 1043 pts (61 f 11 years, 62% men) with hypertension. ExECG were interpreted based on ST change alone and Duke treadmill score. Resting and stress responses of LV function were evaluated by EXE. Pts were followed for up to 10 (mean 5 f 3) years for death; patients undergoing revascularization were censored at the time of this procedure. Results Pts exercised maximally, to 90 f 13% peak heartrate and a workload of 7.3 f 2.6 METS. ExECG was positive on ST segt criteria in 348 pts (33%), although only 24 had angina at stress testing. The Duke treadmill score indicated low risk in 52% pts, intermediate risk in 45% and high risk in 3%. EXE results were normal in 764 (73%) pts, showed ischemia in 176 (17%) and resting LV dysfunction in 15% pts.
Selected abstracts Cardiology, May
from the XIVth 5-9,2002
World
Congress
of
Heart,
underwent DbE and coronary angiography within 6 months, without an intervening event. Echoes were measured for relative wall thickness (RWT, normal < 0.45), left ventricular (LV) chamber size and LV mass (normal < 131 g/m2 in men and < 100 g/m2 in women). CAD was defined as > 50% stenosis. Circumferential (cESS) and meridional endsystolic wall stress (mESS) at rest and peak DbE in pts without wall motion abnormality (WMA) were calculated according to previously published methods. Results CAD was present in 107/195 pts. Pts without resting WMA (n = 161) were classified using 2D echo into normal (N; normal wall thickness and mass, n = 47), concentric remodelling (increased RWT and normal mass, n = 23), concentric hypertrophy (CH; increased RWT and mass, n = 63) and eccentric hypertrophy (EH; normal wall thickness and increased mass, n = 28). In pts with CR, accuracy of DbE (61%) was lower than either N (85%, P = 0.049) or CH (86%, P = 0.027). In EH, accuracy of DbE (64%, P = 0.04) was lower than that of CH. Sensitivity (N-85%, CR-67%, CH-87%, EH-65%) and specificity (N-85%, CR-50%, CH-84%, EH-63%) for detection CAD showed similar differences between each group. No significant differences in cESS and mESS were detected at peak among each group. Sensitivity, specificity and accuracy were comparable among each quartile in cESS and mESS at rest. Pts with greatest wall stress at peak had significantly higher sensitivity and accuracy than those in lowest quartile (96% vs. 71%, P = 0.042 and 91% vs. 68%, P = 0.019). Conclusion Diagnostic problems for DbE in LVH are posed by pts with large and small LV cavities. Reduced systolic wall stress at peak is associated with lower sensitivity and accuracy. Key words: Coronary artery disease, Hypertrophy, Stress echocardiography Do Beta Blockers Prevent Hard Events in Patients Undergoing Major Noncardiac Surgery? A Risk Stratification Approach Marco Torres, Leanne Short, Terri Baglin, Beatriz Torres, Thomas H Marwick University ofQueensland, Australia Background Trials have suggested beta blockers (BB) may reduce cardiac complications in pts undergoing major noncardiac surgery (NCS). We sought whether these trial findings could be replicated in clinical practice, and the impact of BB at various levels of risk. Methods 135 consecutive pts (age 68 + 9, 79 men) with > 1 Eagle’s clinical risk variables (CRV) or inability to exercise, undergoing 137 major NCS were studied with standard dobutamine-atropine stress echo (DbE). Ischemia was identified by a new or worsening wall motion abnormality, and ischemic threshold was calculated. CRV and DbE results were combined to assess risk as high (HR; predicted risk > 30%), intermediate (IR, 1@30% risk) and low (LR, < 10% risk), based on prior studies without BB. Pts were followed for 15 f 6 months for death or infarction. Results BB were administered peri-operatively in 60 and not or inadequately used in 75 pts; only 6 had revascularization after positive DbE. There were 16 major events (6 cardiac death, 10 infarcts), and events occurred more frequently in pts on BB (11/63 vs. 5/74, P = NS). However, BB were used in higher risk pts; anticipated risk in the BB group was 23 + 26%, compared with 18 + 40% in non-BB pts and there was no difference between HR, IR and LR subgroups (Table). Low risk Beta blocked Non beta-blocked
z/22 (9%) 2/49 (4%)
Intermediate 6/29 (21%) l/19 (5%)
High risk 3/12 (25%) 2/6 (33%)
Conclusion Outcomes of BB and non-BB corrected for underlying appear similar. A significant number of major events occur despite use of BB, especially in high-risk pts. Key words: Prognosis, Stress echocardiography, Vascular surgery
risk the
Non-invasive Risk Stratification in Uncomplicated Acute Coronary Syndromes is Associated with Less Revascularization but Equivalent Outcomes to Angiographic Evaluation Kevin Franklin’, Vinah Anderson’, Richard Lim’, Thomas Marwick ‘University of Queensland, Australia; 2University of Queensland, Australia Background Recent randomised, controlled potential benefits of an early invasive strategy
trials have focused on the in selected pts with acute
Lung
and Circulation
2003; 12
coronary syndromes (ACS). However, current guidelines for risk assessment leave the choice of invasive or noninvasive strategy to the discretion of the treating physician. We sought to define the short-term outcomes of pts presenting to our institution with ACS, according to the adopted strategy. Methods This observational study screened all admissions with ACS over an 18-month period; pts were included in the analysis if stress echo (SE) or coronary angiography (CA) was the initial risk stratification strategy. l’ts were excluded if unstable (recurrent angina, LVF, arrhythmias), had undergone previous revascularisation (CABG, PTCA within 6 months), or if ACS had occurred within the preceding 6 months. Results CA or SE were performed within 3 months of the index admission in 522 pts admitted with ACS, of whom 154 pts met the study criteria, with SE performed in 38, and CA in 116. Baseline data were comparable between groups (Table). CA showed minor CAD in 31 pts (27%), with the equivalent finding of no ischaemia by SE in 8 pts (21%, P = NS). CA was performed after abnormal SE in 15 pts (39%). Follow up was completed in 34 (90%) of the SE group (mean 23 + 8 months), and in 110 (95%) of the CA group (mean 21 f 10 months; P = 0.11 vs. SE). Hard events (cardiac death, MI) occurred in 2 (6%) in the SE group, and in 4 (4%) in the CA group (P = NS). Any adverse event (including readmission for chest pain, unplanned revascularisation) occurred in 7(23%) of SE group, and 26 (25%) of CA group (P = NS). Pts undergoing CA had a significantly greater length of stay (4.4 + 2.7 vs. 2.8 + 1.8 days; P < 0.0001) and higher rates of planned (44% vs. 10%; P < 0.001) revascularisation.
Stress echo Angiography
Stress echo Angiography
Angina
Prior MI
Diabetes
Beta blockers
7 (18%) 16 (14%)
5 (13%) 17 (14%)
4 (11%) 20 (17%)
7 (18%) 23 (20%)
Lysis
Peak CK
6 (16%) 25 (22%)
562 + 694 645 + 874
Multivessel CAD 7 (18%) 20 (17%)
Conclusion Pts with uncomplicated ACS who undergo SE appear to have similar short-term outcomes and shorter hospital stays compared with an invasively managed cohort, despite lower rates of planned revascularisation. Key words: Angiocardiography, Myocardial infarction, treatment, Outcomes assessment, Stress echocardiography Prognostic implications of exercise echo and exercise ECG in hypertensive patients Thomas H Marwick’, Colin Case’, Charles Vasey2, Stephen Sawada”, James D Thomas4 ‘University of Queensland, Australia; 2Asheville Cardiology Associates, United States; 3University of Indiana, United States; 4Cleveland Clinic Foundation, United States Background The stress echocardiography is more accurate than exercise ECG (ExECG) for the diagnosis of coronary disease in hypertensive (HT) pts, largely due to false positive ExECG. The selection of stress echo in all HT pts or only those with a negative ExECG might be governed by the relative prognostic implications of these tests, but these are not well defined. Methods ExECG and EXE were performed to evaluate suspected CAD in 1043 pts (61 f 11 years, 62% men) with hypertension. ExECG were interpreted based on ST change alone and Duke treadmill score. Resting and stress responses of LV function were evaluated by EXE. Pts were followed for up to 10 (mean 5 f 3) years for death; patients undergoing revascularization were censored at the time of this procedure. Results Pts exercised maximally, to 90 f 13% peak heartrate and a workload of 7.3 f 2.6 METS. ExECG was positive on ST segt criteria in 348 pts (33%), although only 24 had angina at stress testing. The Duke treadmill score indicated low risk in 52% pts, intermediate risk in 45% and high risk in 3%. EXE results were normal in 764 (73%) pts, showed ischemia in 176 (17%) and resting LV dysfunction in 15% pts.