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Prognostic Value of Stress Echocardiography in Octogenarians
Abstracts
in Cohort 2 (mean age 65 ± 10 yrs, median follow-up 23 months. MACE and independent outcomes were not significantly different during follow up with low TVR and ST reported in both cohorts (Table).
Age Male All-cause mortality MI TVR ST MACE
Cohort 1(≤2.75 mm EES) n = 91
Cohort 2(≥3.00 mm EES) n = 118
61 + 12 yrs 59% 5 (6%) 2 (2%) 3 (3%) 1 (1%) 11 (12%)
65 ± 10 yrs 70% 6 (5%) 1 (1%) 3 (3%) 0 (0%) 10 (9%)
P Value
0.11 1.00 0.58 1.00 0.44 0.34
Conclusion: Everolimus-eluting stent use in the real world is associated with good clinical outcomes and low adverse event rates in both small and large coronary vessels. Conflicts of interests: Nil. doi:10.1016/j.hlc.2011.03.055 Post-Transcatheter Aortic Valve Implantation (TAVI) Related New Onset Left-Bundle Branch Block and Its Short-Term Effect on Left Ventricular Ejection Fraction M. Liang ∗ , G. Devlin, S. Pasupati Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Background: TAVI is performed at Waikato hospital for patients with severe symptomatic aortic stenosis considered unsuitable for aortic valve surgery due to high risk. Concern exists regarding the potential development of new left-bundle branch block (LBBB) post TAVI and the possible deleterious effect of this rhythm disturbance on left ventricular function. We report our observed incidence of new onset of LBBB and the changes of ejection fraction at one-month follow-up. Methods: Over a two-year period, from August 2008, 47 patients underwent successful TAVI 30 patients had selfexpandable CoreValves (Medtronic, Minneapolis, USA) and 17 had balloon-expandable Edwards Sapien (Edward Lifescience, Irvine, USA). All patients had electrocardiography and echocardiography pre-procedure and at one-month follow-up. Left ventricular ejection fraction (LVEF) was assessed by Simpson’s bi-plane method. The change of LVEF for individual patients was calculated (LVEF at one-month - LVEF before procedure). Twelve patients were excluded from the study: Two did not survive the procedure, seven had pre-existing LBBB, one was pacemaker dependent prior to the procedure and two did not survive pass one month. Results: Thirty-seven patients were included in the analysis with a mean age of 80 ± 8 years-old; 57% were male. Fourteen (38%) patients had new onset of LBBB (n = 10, 27%) or pacemaker-related LBBB (n = 4, 11%). The results are summarised in the table below.
New LBBB + PPM
No LBBB
Patient No. Age, years Male, % CoreValve (MCV) n,%
12 79 ± 9 7 (58%) 11 (44%)
23 80 ± 6 14 (61%) 14 (56%)
Edwards Sapien Valve (EV) n, % Baseline LVEF, % LVEF at 1 month, % Change of LVEF at 30 days, % No. of patients LVEF reduced ≥ 5% at 30 days.
1 (10%)
9 (90%)
53 ± 17 62 ± 7 +9 ± 16%
55 ± 15 60 ± 8 +5 ± 13
0.74 0.33 0.36
2, 17%
6, 26%
0.69
395
P Value 0.55 1.00 MCV vs EV 0.11
Conclusion: A new onset of LBBB post TAVI does not appear to have an adverse effect on the left ventricular ejection fraction in the short-term. doi:10.1016/j.hlc.2011.03.056 Prognostic Value of Stress Echocardiography in Octogenarians Y.M. Lin ∗ , J.P. Christiansen Cardiovascular Division, North Shore Hospital, Auckland, New Zealand Background: Stress Echocardiography (SE) is well established in the assessment of patients with possible or pre-existing coronary disease (CAD). Abnormal results are associated with worse outcome, and conversely a normal result predicts an excellent intermediate term prognosis. However data are lacking for elderly patients. We investigated the prognostic value of SE in patients aged over 80 years. Methods: We reviewed 184 patients aged ≥80 referred for SE. Clinical details, scan results and outcomes were obtained from medical records. Major adverse cardiac events (MACE) were defined as death, myocardial infarction (MI) and unstable angina (USA).
Results: Forty-seven patients (26%) did not undergo SE and therefore 137 patients (average age 82 ± 2 yrs) were
ABSTRACTS
Heart, Lung and Circulation 2011;20:376–419
396
Heart, Lung and Circulation 2011;20:376–419
Abstracts
ABSTRACTS
analysed. The majority of patients were female (59%), had known CAD (57%), class 1–2 symptoms (84%) and referred for evaluation of ischaemia (77%). Notably 34% had resting regional wall motion abnormalities. Dobutamine was used in 83 (61%). An abnormal result (ischaemia) occurred in 31 (23%) patients, who had significantly higher rates of angina, prior MI and revascularisation (p < 0.05). At mean follow-up of 1.6 years there were 11 deaths (8%) 11 MI (8%) and 5 (3.6%) USA. On Kaplan–Meier analysis the presence of ischaemia predicted a significantly higher risk of MACE (p < 0.05) (Graph). Conclusion: Octogenarians undergoing SE have high rates of pre-existing CAD, and demonstration of ischaemia predicts worse outcome. Patients without ischaemia have a significant rate of MACE, reflecting disease prevalence. The predictive value of SE reported in younger cohorts cannot be extrapolated to older patients. doi:10.1016/j.hlc.2011.03.057 Primary Percutaneous Coronary Intervention for all Patients with ST Elevation Myocardial Infarction—The Initial Experience at Auckland City Hospital 2006/2007 A. Lin ∗ , K.L. Looi, J.L. Looi, K.L. Chow, F. Roberts, H.D. White, M. Webster, C.J. Ellis Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: Primary percutaneous coronary intervention (PPCI) is the optimal reperfusion strategy for patients (pts) with ST elevation myocardial infarction (STEMI) when initiated in a timely fashion. A door-to-balloon time (DTBT) of ≤90 min is regarded as best practice. PPCI became the routine STEMI management at Auckland City Hospital (ACH) in 2006. We assess our initial experience. Method: Data on all pts with STEMI admitted to ACH Coronary Care Unit (CCU) was obtained from a prospective database which included their DTBT. Results: From 1/6/2006 to 31/7/2007, there were 1580 admissions to ACH CCU (1474 pts). Of 338 pts whose index admission was for STEMI, 196 were from ACH catchment area (142 were transferred from other hospitals; these pts were excluded). Ninety-seven (49%) of 196 ACH pts had PPCI. Of these, 52 pts were “clear cut” cases, with median DTBT of 92 (IQR 74–104) min; 25 (48%) had a DTBT ≤90 min. Of 45 “non-clear cut” pts, delays were: late presentation STEMI (11), imaging to exclude aortic dissection (5), initial emergency stabilisation (6), unable to cross lesion (1), initially non-STEMI presentation then developed STEMI (12), referred for urgent surgery (10). Of the 99 non-PPCI pts, 35 received thrombolytic therapy, 13 with subsequent rescue PCI.
Conclusion: Our initial experience of routine PPCI for STEMI demonstrated that, in the real world, only half of “clear cut” STEMI pts had a DTBT of <90 min. Ongoing changes within ACH STEMI management pathways are needed to optimise service provision and improve DTBT. Conflict of interest: None. doi:10.1016/j.hlc.2011.03.058 ST Elevation Myocardial Infarction Patients have Poor Cholesterol Control and Significant Adverse Events at Review Four Years Later A. Lin ∗ , K.L. Looi, J.L. Looi, K.L. Chow, F. Roberts, H.D. White, C.J. Ellis Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: ST elevation myocardial infarction (STEMI) patients (pts) are at significant risk for future Major Adverse Cardiovascular Events (MACE). Aggressive LDL-cholesterol (LDL-C) lowering to <2.0 mmol/L (New Zealand Guidelines Group) or ≤1.6 mmol/L (TIMI-22 Study and Green Lane CVS Service Target) reduces MACE. We assessed LDL-C control of STEMI pts from the Auckland City Hospital (ACH) catchment area. Method: Using a prospective database of all pts admitted to ACH Coronary Care Unit (CCU), we contacted General Practitioners for current pt data which was supplemented by using the hospital pt records. Results: From 1/6/2006 to 31/7/2007, we recorded 1580 CCU admissions from 1474 pts. 338 pts’ index admissions were classified as STEMI; of these, 196 were within ACH catchment area. Of these 196 pts, nine died in hos-
in Cohort 2 (mean age 65 ± 10 yrs, median follow-up 23 months. MACE and independent outcomes were not significantly different during follow up with low TVR and ST reported in both cohorts (Table).
Age Male All-cause mortality MI TVR ST MACE
Cohort 1(≤2.75 mm EES) n = 91
Cohort 2(≥3.00 mm EES) n = 118
61 + 12 yrs 59% 5 (6%) 2 (2%) 3 (3%) 1 (1%) 11 (12%)
65 ± 10 yrs 70% 6 (5%) 1 (1%) 3 (3%) 0 (0%) 10 (9%)
P Value
0.11 1.00 0.58 1.00 0.44 0.34
Conclusion: Everolimus-eluting stent use in the real world is associated with good clinical outcomes and low adverse event rates in both small and large coronary vessels. Conflicts of interests: Nil. doi:10.1016/j.hlc.2011.03.055 Post-Transcatheter Aortic Valve Implantation (TAVI) Related New Onset Left-Bundle Branch Block and Its Short-Term Effect on Left Ventricular Ejection Fraction M. Liang ∗ , G. Devlin, S. Pasupati Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Background: TAVI is performed at Waikato hospital for patients with severe symptomatic aortic stenosis considered unsuitable for aortic valve surgery due to high risk. Concern exists regarding the potential development of new left-bundle branch block (LBBB) post TAVI and the possible deleterious effect of this rhythm disturbance on left ventricular function. We report our observed incidence of new onset of LBBB and the changes of ejection fraction at one-month follow-up. Methods: Over a two-year period, from August 2008, 47 patients underwent successful TAVI 30 patients had selfexpandable CoreValves (Medtronic, Minneapolis, USA) and 17 had balloon-expandable Edwards Sapien (Edward Lifescience, Irvine, USA). All patients had electrocardiography and echocardiography pre-procedure and at one-month follow-up. Left ventricular ejection fraction (LVEF) was assessed by Simpson’s bi-plane method. The change of LVEF for individual patients was calculated (LVEF at one-month - LVEF before procedure). Twelve patients were excluded from the study: Two did not survive the procedure, seven had pre-existing LBBB, one was pacemaker dependent prior to the procedure and two did not survive pass one month. Results: Thirty-seven patients were included in the analysis with a mean age of 80 ± 8 years-old; 57% were male. Fourteen (38%) patients had new onset of LBBB (n = 10, 27%) or pacemaker-related LBBB (n = 4, 11%). The results are summarised in the table below.
New LBBB + PPM
No LBBB
Patient No. Age, years Male, % CoreValve (MCV) n,%
12 79 ± 9 7 (58%) 11 (44%)
23 80 ± 6 14 (61%) 14 (56%)
Edwards Sapien Valve (EV) n, % Baseline LVEF, % LVEF at 1 month, % Change of LVEF at 30 days, % No. of patients LVEF reduced ≥ 5% at 30 days.
1 (10%)
9 (90%)
53 ± 17 62 ± 7 +9 ± 16%
55 ± 15 60 ± 8 +5 ± 13
0.74 0.33 0.36
2, 17%
6, 26%
0.69
395
P Value 0.55 1.00 MCV vs EV 0.11
Conclusion: A new onset of LBBB post TAVI does not appear to have an adverse effect on the left ventricular ejection fraction in the short-term. doi:10.1016/j.hlc.2011.03.056 Prognostic Value of Stress Echocardiography in Octogenarians Y.M. Lin ∗ , J.P. Christiansen Cardiovascular Division, North Shore Hospital, Auckland, New Zealand Background: Stress Echocardiography (SE) is well established in the assessment of patients with possible or pre-existing coronary disease (CAD). Abnormal results are associated with worse outcome, and conversely a normal result predicts an excellent intermediate term prognosis. However data are lacking for elderly patients. We investigated the prognostic value of SE in patients aged over 80 years. Methods: We reviewed 184 patients aged ≥80 referred for SE. Clinical details, scan results and outcomes were obtained from medical records. Major adverse cardiac events (MACE) were defined as death, myocardial infarction (MI) and unstable angina (USA).
Results: Forty-seven patients (26%) did not undergo SE and therefore 137 patients (average age 82 ± 2 yrs) were
ABSTRACTS
Heart, Lung and Circulation 2011;20:376–419
396
Heart, Lung and Circulation 2011;20:376–419
Abstracts
ABSTRACTS
analysed. The majority of patients were female (59%), had known CAD (57%), class 1–2 symptoms (84%) and referred for evaluation of ischaemia (77%). Notably 34% had resting regional wall motion abnormalities. Dobutamine was used in 83 (61%). An abnormal result (ischaemia) occurred in 31 (23%) patients, who had significantly higher rates of angina, prior MI and revascularisation (p < 0.05). At mean follow-up of 1.6 years there were 11 deaths (8%) 11 MI (8%) and 5 (3.6%) USA. On Kaplan–Meier analysis the presence of ischaemia predicted a significantly higher risk of MACE (p < 0.05) (Graph). Conclusion: Octogenarians undergoing SE have high rates of pre-existing CAD, and demonstration of ischaemia predicts worse outcome. Patients without ischaemia have a significant rate of MACE, reflecting disease prevalence. The predictive value of SE reported in younger cohorts cannot be extrapolated to older patients. doi:10.1016/j.hlc.2011.03.057 Primary Percutaneous Coronary Intervention for all Patients with ST Elevation Myocardial Infarction—The Initial Experience at Auckland City Hospital 2006/2007 A. Lin ∗ , K.L. Looi, J.L. Looi, K.L. Chow, F. Roberts, H.D. White, M. Webster, C.J. Ellis Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: Primary percutaneous coronary intervention (PPCI) is the optimal reperfusion strategy for patients (pts) with ST elevation myocardial infarction (STEMI) when initiated in a timely fashion. A door-to-balloon time (DTBT) of ≤90 min is regarded as best practice. PPCI became the routine STEMI management at Auckland City Hospital (ACH) in 2006. We assess our initial experience. Method: Data on all pts with STEMI admitted to ACH Coronary Care Unit (CCU) was obtained from a prospective database which included their DTBT. Results: From 1/6/2006 to 31/7/2007, there were 1580 admissions to ACH CCU (1474 pts). Of 338 pts whose index admission was for STEMI, 196 were from ACH catchment area (142 were transferred from other hospitals; these pts were excluded). Ninety-seven (49%) of 196 ACH pts had PPCI. Of these, 52 pts were “clear cut” cases, with median DTBT of 92 (IQR 74–104) min; 25 (48%) had a DTBT ≤90 min. Of 45 “non-clear cut” pts, delays were: late presentation STEMI (11), imaging to exclude aortic dissection (5), initial emergency stabilisation (6), unable to cross lesion (1), initially non-STEMI presentation then developed STEMI (12), referred for urgent surgery (10). Of the 99 non-PPCI pts, 35 received thrombolytic therapy, 13 with subsequent rescue PCI.
Conclusion: Our initial experience of routine PPCI for STEMI demonstrated that, in the real world, only half of “clear cut” STEMI pts had a DTBT of <90 min. Ongoing changes within ACH STEMI management pathways are needed to optimise service provision and improve DTBT. Conflict of interest: None. doi:10.1016/j.hlc.2011.03.058 ST Elevation Myocardial Infarction Patients have Poor Cholesterol Control and Significant Adverse Events at Review Four Years Later A. Lin ∗ , K.L. Looi, J.L. Looi, K.L. Chow, F. Roberts, H.D. White, C.J. Ellis Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: ST elevation myocardial infarction (STEMI) patients (pts) are at significant risk for future Major Adverse Cardiovascular Events (MACE). Aggressive LDL-cholesterol (LDL-C) lowering to <2.0 mmol/L (New Zealand Guidelines Group) or ≤1.6 mmol/L (TIMI-22 Study and Green Lane CVS Service Target) reduces MACE. We assessed LDL-C control of STEMI pts from the Auckland City Hospital (ACH) catchment area. Method: Using a prospective database of all pts admitted to ACH Coronary Care Unit (CCU), we contacted General Practitioners for current pt data which was supplemented by using the hospital pt records. Results: From 1/6/2006 to 31/7/2007, we recorded 1580 CCU admissions from 1474 pts. 338 pts’ index admissions were classified as STEMI; of these, 196 were within ACH catchment area. Of these 196 pts, nine died in hos-