Biliopancreatic diversion reduces QT interval and dispersion in severely obese patients

Objectives: The objectives were to evaluate QT interval (QTc) and QT‐interval dispersion (QTd) in severely obese individuals and to determine the effects of biliopancreatic diversion (BPD) and weight loss after BPD on ventricular repolarization parameters. Background: People with severe obesity (SO) have a 50% to 100% increased risk of death associated with a 1.6‐fold increased risk of sudden death. BPD surgery induces rapid and considerable weight loss through severe lipid malabsorption, thus achieving long‐term weight control. Research Methods and Procedures: A total of 85 subjects with SO (age, 42 ± 12 years; 66 females; mean body weight, 120 ± 29 kg; BMI, 45 ± 11 kg/m²) of 330 who had a bariatric surgical consultation between January 2001 and July 2002 were enrolled. Inclusion criteria were sinus rhythm, unremarkable 12 leads surface electrocardiogram, no atrioventricular blocks and/or bundle branch blocks, normal serum electrolyte profile, and no medical therapies exerting known effects on QTc. Exclusion criteria were previous diagnosis of coronary artery disease, known cardiovascular disease, atrial fibrillation or any other known cardiac arrhythmias, cancer, or renal dysfunction. Results: A total of 86% of patients had QTc >440 ms and/or QTd >60 ms. Subjects with SO showed a mean maximum QTc of 446 ± 28 ms and a mean QTd of 52 ± 20 ms. A close correlation was found between QTc and QTd (p < 0.0001; R² = 0.33). One month after BPD, mean QTc was 420 ms and remained stable at follow‐up; QTd was 32 ms at 1 and 6 months and became 35 ms at 1 year. Conclusions: Ventricular repolarization abnormalities are significantly increased in subjects with SO. Reduction of QT abnormalities after BPD is independent of weight loss and is caused by the 100% reduction of glucose plasma shortly after surgery. This effect may be related to surgical interruption of the entero‐insular axis.     

The Impact of Cardiac Diseases during Pregnancy on Severe Maternal Morbidity and Mortality in Brazil

Background

To evaluate maternal heart disease as a cause or complicating factor for severe morbidity in the setting of the Brazilian Network for Surveillance of Severe Maternal Morbidity.

Methods and Findings

Secondary data analysis of this multicenter cross-sectional study was implemented in 27 referral obstetric units in Brazil. From July 2009 to June 2010, a prospective surveillance was conducted among all delivery hospitalizations to identify cases of severe maternal morbidity (SMM), including Potentially Life-Threatening Conditions (PLTC) and Maternal Near Miss (MNM), using the new criteria established by the WHO. The variables studied included: sociodemographic characteristics, clinical and obstetric history of the women; perinatal outcome and the occurrence of maternal outcomes (PLTC, MNM, MD) between groups of cardiac and non-cardiac patients. Only heart conditions with hemodynamic impact characterizing severity of maternal morbidity were considered. 9555 women were included in the Network with severe pregnancy-related complications: 770 maternal near miss cases and 140 maternal death cases. A total of 293 (3.6%) cases were related to heart disease and the condition was known before pregnancy in 82.6% of cases. Maternal near miss occurred in 15% of cardiac disease patients (most due to clinical-surgical causes, p<0.001) and 7.7% of non-cardiac patients (hemorrhagic and hypertensive causes, p<0.001). Maternal death occurred in 4.8% of cardiac patients and in 1.2% of non-cardiac patients, respectively.

Conclusions

In this study, heart disease was significantly associated with a higher occurrence of severe maternal outcomes, including maternal death and maternal near miss, among women presenting with any severe maternal morbidity.     

24 h动态心电图对冠心病心律失常的临床监测价值

目的:研究24 h动态心电图对冠心病心律失常的临床监测价值。方法:对2014年7月至2015年7月在我院确诊的315例冠心病患者先后实施常规心电图及24 h动态心电图检测。对比两种检测方法对对冠心病的阳性检出结果,并调查患者对不同检测方式的评价情况。结果:24 h动态心电图的冠心病阳性检出率为81.90%,与常规心电图的76.51%相比,差异无统计学意义(P0.05)。24 h动态心电图室性二、三联律,室性早搏成对,房性早搏早发,房性早搏二、三联律,房性早搏成对,以及短阵室上速的检出率均较常规心电图明显更高,差异均有统计学意义(均P0.05)。患者对24 h动态心电图的准确性认可度高于常规心电图,差异有统计学意义(P0.05)。结论:24 h动态心电图对冠心病心律失常患者的监测价值较好,能够更加准确地呈现患者的心功能状态,值得推广。     

Influence of oral magnesium supplementation on cardiac events among survivors of an acute myocardial infarction.

OBJECTIVE--To investigate the effect of long term oral magnesium treatment on incidence of cardiac events among survivors of an acute myocardial infarction. DESIGN--Double blind, placebo controlled parallel study in which patients were randomised to treatment or placebo. SETTING--Two coronary care units and corresponding outpatient clinics. SUBJECTS--468 survivors of an acute myocardial infarction (289 men and 178 women) aged 31-92. INTERVENTIONS--One tablet of 15 mmol magnesium hydroxide or placebo daily for one year. MAIN OUTCOME MEASURES--Incidences of reinfarction, sudden death, and coronary artery bypass grafting in one year. RESULTS--There was no significant difference between treatment and placebo groups in the incidence of each of the three cardiac events, but when the events were combined and drop outs were excluded from calculations there was a significantly higher incidence of events in the treatment group (56/167 v 33/153; relative risk 1.55 (95% confidence interval 1.07 to 2.25); p = 0.02). When the timing of events was incorporated by means of a Kaplan-Meier plot the treatment group showed a significantly higher incidence of events whether drop outs were included or excluded (p < 0.025). CONCLUSION--Long term oral treatment with 15 mmol magnesium daily doses not reduce the incidence of cardiac events in survivors of an acute myocardial infarction and, indeed, seems to increase the risk of developing a cardiac event. Consequently, this treatment cannot be recommended as secondary prophylaxis for such patients.     

Presence and extent of cardiac computed tomography angiography defined coronary artery disease in patients presenting with syncope

Background

In syncope patients, presence of coronary artery disease (CAD) is associated with poor prognosis. However, data concerning CAD prevalence in syncope patients without known cardiovascular disease are lacking. Therefore, the aim of this study was to investigate presence and extent of CAD in syncope patients.

Methods

We included 142 consecutive patients presenting with syncope at the outpatient cardiology clinic who underwent coronary computed tomography (CT) angiography. Syncope type was ascertained by two reviewers, blinded for coronary CT angiography results. Of the patients, 49 had cardiac syncope (arrhythmia or structural cardiopulmonary disease) and 93 had non-cardiac syncope (reflex [neurally-mediated], orthostatic or of unknown cause). Cardiac syncope patients were compared with matched stable chest pain patients regarding age, gender, smoking status, diabetes mellitus type 2 and systolic blood pressure.

Results

Distribution of CAD presence and extent in cardiac and non-cardiac syncope patients was as follows: 72% versus 48% any CAD; 31% versus 26% mild, 8% versus 14% moderate and 33% versus 7% severe CAD.Compared with non-cardiac syncope, patients with cardiac syncope had a significantly higher CAD presence and extent (p = 0.001). Coronary calcium score, segment involvement and stenosis score were also higher in cardiac syncope patients (p-values ≤0.004). Compared to the chest pain control group, patients with cardiac syncope showed a higher, however, non-significant, prevalence of any CAD (72% versus 63%) and severe CAD (33% versus 19%).

Conclusion

Patients with cardiac syncope show a high presence and extent of CAD in contrast to non-cardiac syncope patients. These results suggest that CAD may play an important role in the occurrence of cardiac syncope.

     

QT interval and QT dispersion before and after diet therapy in patients with simple obesity

To evaluate whether a disordered QT interval and its dispersion in obese patients, if any, may be improved by therapeutic weight reduction, 36 obese patients admitted to our university hospital were examined over a 5-year period from April 1, 1992 to March 31, 1997. Participants included 18 males and 18 females whose mean age +/- SD was 28 +/- 9 and 33 +/- 14 years, respectively, and whose mean body mass index +/- SD was 35 +/- 5 and 38 +/- 6 kg/m2, respectively. Thirty-six control patients were matched in age and gender with the obese patients. All the obese patients were treated with behavioral therapy together with very-low-calorie conventional Japanese diet (VLCD: 370 kcal/day). A standard 12-lead electrocardiogram (ECG) revealed longer maximum (445 +/- 32 msec, mean +/- SD) and minimum (388 +/- 29 msec) heart rate corrected QT intervals (QTc intervals) in the obese group than in the control group (P < 0.0001 for each). QTc dispersion, defined as the difference between maximum and minimum QTc intervals derived from 12-lead ECG, was greater in the obese group (57 +/- 19 msec) than in the control group (32 +/- 13 msec) (P < 0.0001). Both the maximum and minimum QTc intervals in the obese patients were shortened, respectively, to 434 +/- 28 msec and 377 +/- 29 msec (P < 0.05 for each) with no significant change in either QTc dispersion, QRS voltage, or QRS duration following weight reduction. The coefficient value from the linear regression line between QT interval and RR interval in the obese group was less than in the control group. Together, the results show that obesity per se causes both a prolongation of QTc interval and an increase in QTc dispersion, and that weight reduction improves the prolonged QTc interval observed in obese patients.     

心肌酶谱、动态心电图及冠状动脉CT血管造影诊断嗜铬细胞瘤儿茶酚胺性心脏损害价值研究

摘要 目的：探讨心肌酶谱、动态心电图及冠状动脉CT血管造影诊断嗜铬细胞瘤儿茶酚胺性心脏损害的临床价值。方法：收集2013年1月-2020年4月在我院诊断为嗜铬细胞瘤患者114例,其中嗜铬细胞瘤儿茶酚胺性心脏损害的患者27例。所有患者均完善术前常规检查（血常规、胸片、动态心电图）、心肌酶谱、心脏超声、冠状动脉CTA等临床资料,并收集患者一般临床资料,如血压、临床症状等。结果：114例嗜铬细胞瘤患者中,27例患者存在嗜铬细胞瘤儿茶酚胺性心脏损害。嗜铬细胞瘤儿茶酚胺性心脏损害患者一般临床资料与嗜铬细胞瘤无儿茶酚胺性心脏损害的患者差异无统计学意义（P＞0.05）。嗜铬细胞瘤儿茶酚胺性心脏损害以高血压为主要表现,临床症状表现多样,可伴有头痛、心悸、多汗三联征表现。114例患者中,26例患者出现心肌酶谱升高,36例患者存在不同程度的心电图异常、24例患者冠状动脉CTA异常,嗜铬细胞瘤儿茶酚胺性心脏损害患者在心肌酶谱、动态心电图及冠状动脉CTA异常例数与嗜铬细胞瘤无儿茶酚胺性心脏损害患者中差异均有统计学意义（P＜0.05）。114例患者中心肌酶谱或心电图或冠状动脉CTA异常的患者总共56例,其中嗜铬细胞瘤儿茶酚胺性心脏损害患者23例,嗜铬细胞瘤无儿茶酚胺性心脏损害患者有33例,差异有统计学意义（P＜0.05）。嗜铬细胞瘤儿茶酚胺性心脏损害患者中,心律失常最为常见。结论：嗜铬细胞瘤儿茶酚胺性心脏损害患者心肌酶谱、动态心电图及冠状动脉CTA均可存在异常表现,但特异性、敏感性不高,三者同时综合分析可以提高临床诊断。     

High dose propranolol in the treatment of angina pectoris: relationship of dose to blood levels and hemodynamic consequences

Propranolol blood levels and the effect of these levels on hemodynamic parameters were evaluated in 25 patients with coronary artery disease undergoing cardiac catheterization and coronary angiography. Fifteen patients were receiving high doses of propranolol (320--1920 mg/day) while ten patients were receiving conventional doses (80--240 mg/day). The high dose propranolol group had significantly higher plasma propranolol levels than the conventional dose group (788 +/- 134 SD vs. 43 +/- 7.2 ng/ml SD), and there was a direct linear relationship between propranolol dose and plasma drug levels (r = 0.85, P < 0.001). There were no significant differences between high and conventional dose propranolol groups in terms of all hemodynamic parameters measured, namely ejection fraction, ventricular volume, cardiac index, or peripheral vascular resistance. Despite high drug dosage and blood levels, only mild side effects were seen.     

QRS、QT、QTc及LVEF预测心源性猝死的价值分析

摘要 目的：探讨QRS时限值（QRS）、QT间期延长（QT）、QTc间期（QTc）及左室射血分数（LVEF）预测心源性猝死的价值分析。方法：选择2018年1月至2019年12月川北医学院附属医院心血管内科治疗的356例心源性猝死患者进行研究,设为病例组,并选择同期体检的健康人200例作为对照组,分析QRS、QT、QTc及LVEF水平变化情况及其预测价值。结果：病例组QRS、QTc水平显著高于对照组,QT、LVEF水平显著低于对照组,差异显著（P＜0.05）;轻度QRS、QTc显著低于中度、重度患者,QT、LVEF水平显著高于中度、重度患者;中度患者QRS、QTc显著低于重度患者,QT、LVEF水平显著高于重度患者,差异显著（P＜0.05）;ROC结果显示,QRS预测心源性猝死的AUC为0.989,灵敏度△为84.59%,特异度为87.68%,截断值为115.59ms;QT预测心源性猝死的AUC为0.944,灵敏度85.12%,特异度为88.45%,截断值为21.69ms;QTc预测心源性猝死的AUC为0.984,灵敏度为86.05%,特异度为88.61%,截断值为416.39ms,LVEF预测心源性猝死的AUC为0.997,灵敏度87.15%,特异度为89.05%,截断值为45.63%,（P＜0.05）。结论：QRS、QT、QTc及LVEF在心源性猝死患者中检查,可显著提高心源性猝死临床诊断效能。     

Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review.

OBJECTIVE: To identify risk factors for operative stroke and death from carotid endarterectomy. DESIGN: Systematic review of all studies published since 1980 which related risk of stroke and death to various preoperative clinical and angiographic characteristics, including unpublished data on 1729 patients from the European carotid surgery trial. MAIN OUTCOME MEASURE: Operative risk of stroke and death. RESULTS: Thirty six published studies fulfilled our criteria. The effect of 14 potential risk factors was examined. The odds of stroke and death were decreased in patients with ocular ischaemia alone (amaurosis fugax or retinal artery occlusion) compared with those with cerebral transient ischaemic attack or stroke (seven studies; odds ratio 0.49; 95% confidence interval 0.37 to 0.66; P < 0.00001). The odds were increased in women (seven studies; 1.44; 1.14 to 1.83; P < 0.005), subjects aged > or = 75 years (10 studies: 1.36; 1.09 to 1.71; P < 0.01), and with systolic blood pressure > 180 mm Hg (four studies; 1.82; 1.37 to 2.41; P < 0.0001), peripheral vascular disease (one study; 2.19; 1.40 to 3.60; P < 0.0005), occlusion of the contralateral internal carotid artery (14 studies; 1.91; 1.35 to 2.69; P < 0.0001), stenosis of the ipsilateral internal carotid siphon (five studies; 1.56; 1.03 to 2.36; P = 0.02), and stenosis of the ipsilateral external carotid artery (one study; 1.61; 1.05 to 2.47; P = 0.03). Operative risk was not significantly related to presentation with cerebral transient ischaemic attack versus stroke, diabetes, angina, recent myocardial infarction, current cigarette smoking, or plaque surface irregularity at angiography. Multiple regression analysis of data from the European carotid surgery trial identified cerebral versus ocular events at presentation, female sex, systolic hypertension, and peripheral vascular disease as independent risk factors. CONCLUSIONS: The risk of stroke and death from carotid endarterectomy is related to several clinical and angiographic characteristics. These observations may help clinicians to estimate operative risks for individual patients and will also facilitate more meaningful comparison of the operative risks of different surgeons or at different institutions by allowing some adjustment for differences in case mix.     

Utility of Corrected QT Interval in Orthostatic Intolerance

We performed this study to determine whether electrocardiographic corrected QT (QTc) interval predicts alterations in sympathovagal balance during orthostatic intolerance (OI). We reviewed 1,368 patients presenting with symptoms suggestive of OI who underwent electrocardiography and composite autonomic function tests (AFTs). Patients with a positive response to the head-up tilt test were classified into orthostatic hypotension (OH), neurocardiogenic syncope (NCS), or postural orthostatic tachycardia syndrome (POTS) groups. A total of 275 patients (159 OH, 54 NCS, and 62 POTS) were included in the final analysis. Between-group comparisons of OI symptom grade, QTc interval, QTc dispersion, and each AFT measure were performed. QTc interval and dispersion were correlated with AFT measures. OH Patients had the most severe OI symptom grade and NCS patients the mildest. Patients with OH showed the longest QTc interval (448.8±33.6 msec), QTc dispersion (59.5±30.3 msec) and the lowest values in heart rate response to deep breathing (HRDB) (10.3±6.0 beats/min) and Valsalva ratio (1.3±0.2). Patients with POTS showed the shortest QTc interval (421.7±28.6 msec), the highest HRDB values (24.5±9.2 beats/min), Valsalva ratio (1.8±0.3), and proximal and distal leg sweat volumes in the quantitative sudomotor axon reflex test. QTc interval correlated negatively with HRDB (r = −0.443, p<0.001) and Valsalva ratio (r = −0.425, p<0.001). We found negative correlations between QTc interval and AFT values representing cardiovagal function in patients with OI. Our findings suggest that prolonged QTc interval may be considered to be a biomarker for detecting alterations in sympathovagal balance, especially cardiovagal dysfunction in OH.     

Global revascularization: the role of the cardiologist

There are compelling reasons for cardiologists to undertake a more global approach to patients with peripheral vascular diseases: atherosclerosis is a 'systemic' disease frequently causing both coronary and peripheral vascular problems in the same patient; coronary artery disease is the most common cause of morbidity and mortality in patients with peripheral vascular disease; and peripheral vascular disease negatively impacts the management of angina pectoris and congestive heart failure. There are four major areas of special interest to the cardiologist: (1) iliac arteries (vascular access), (2) renal arteries (hypertension and volume overload), (3) subclavian arteries (coronary steal with a left internal mammary artery [LIMA] graft), and (4) carotid arteries (stroke). Technical skills necessary to perform coronary angioplasty are transferable to the peripheral vasculature. However, an understanding of the natural history of peripheral disease, patient and lesion selection criteria, and knowledge of other treatment alternatives are essential to performing these procedures safely and effectively. Appropriate preparation and training, and a team approach, including an experienced vascular surgeon, are both desirable and necessary before interventional cardiologists who are inexperienced in the treatment of peripheral vascular disease attempt percutaneous peripheral angioplasty. There are inherent advantages for patients when the cardiologist performing the procedure is also a clinician. Judgments regarding the indications, timing, and risk/benefit ratio of procedures are enhanced by a long-term relationship between physician and patient. Finally, in view of the increased incidence of coronary artery disease in patients with atherosclerotic peripheral vascular disease, the participation of a cardiologist in their care seems appropriate.     

Prolonged ventricular repolarization measured by corrected QT interval (QTc) in subclinical hyperthyroidism.

Overt hyperthyroidism and hypothyroidism exert a major effect on cardiac function and on ECG. The influence of subclinical hyperthyroidism on the circulatory system is still under debate. Few studies examined the effect of thyroid hormones on ventricular repolarization measured by corrected QT interval (QTc). Longer QTc is associated with increased risk of arrhythmia and cardiac mortality. The aim of this study was to examine the influence of subclinical hyperthyroidism on ventricular repolarization measured by corrected QTc in a standard 12-lead electrocardiogram. The examined group consisted of thirty-two patients with subclinical hyperthyroidism; the controls were thirty-nine healthy individuals. In the group with subclinical hyperthyroidism, we observed a significant increase in heart rate (80.3 +/- 10.59 vs. 73.7 +/- 11.37 bpm, p < 0.05). The mean corrected QTc was 0.434 +/- 0.0207 seconds and 0.414 +/- 0.0208 in the examined groups and in controls, respectively (p < 0.001). QTc did not correlate with free thyroxin concentrations (p = 0.5084). Conclusion: Corrected QT intervals were significantly longer in patients with subclinical hyperthyroidism.     

心率减速力及连续心率减速力对冠心病心脏性猝死的预警价值

目的：通过心率减速力（DC）及连续心率减速力（DRs）检测技术对老年冠心病患者进行风险分层,探讨其对心脏性猝死的预警价值。方法：随机选择经冠状动脉造影（CAG）确诊为冠心病（CHD）的患者218例作为观察组,其中隐匿性CHD 55例,急性心肌梗死（AMI）56例,心绞痛（AP）53例,缺血性心力衰竭（IHF）54例。同期选取在本院进行健康体检者55例（对照组）,对各组患者行24 h动态心电图检查,应用软件系统分析并计算出DC值及DRs值进行统计分析。结果：CHD各亚组（AMI组、AP组、IHF组、隐匿性CHD组）的DC值及DRs值均明显降低,与正常组比较,差异有统计学意义（P < 0.01）;DC值与DRs值所提示CAD各亚组的危险分级明显高于正常组,差异有统计学意义（P < 0.01）;冠状动脉造影显示冠脉病变数量越多范围越大,病情越重,这与DC、DRs所提示CHD各亚组的危险分级相一致。结论：心率减速力和连续心率减速力能够测定分析迷走神经功能,对冠心病患者进行危险分级,对高危人群有较高的预警价值,可作为预警冠心病患者发生心脏性猝死的敏感指标。     

Antiplatelet therapy mitigates cardiac remodeling and dysfunction in congestive heart failure due to myocardial infarction

Antiplatelet agents such as sarpogrelate (SAR), a 5-hydroxytryptamine antagonist, and cilostazol (CIL), a phosphodiesterase-III inhibitor, are used in the management of peripheral vascular disease. In this study, we tested the hypothesis that both SAR and CIL prevent cardiac remodeling and improve cardiac function in congestive heart failure (CHF) due to myocardial infarction (MI). Post-MI rats (3 weeks after the occlusion of coronary artery) received either vehicle (MI+V, n = 36), SAR (MI+SAR; 5 mg xc kg(-1) x day(-1), n = 35) or CIL (MI+CIL; 5 mg x kg(-1) x day(-1), n = 34) from day 21 to day 56. Sham-operated rats (n = 29) served as controls. Electrocardiographic, echocardiographic, and hemodynamic parameters were measured on day 56. Treatment of infarcted animals with SAR or CIL significantly improved the left ventricular (LV) dimensions, LV fractional shortening, cardiac output, stroke volume, mean arterial pressure, LV diastolic function, and LV systolic pressure, as well as rates of LV pressure development and pressure decay. Although cardiac hypertrophy was reduced, both SAR and CIL had no effect on infarct size or MI-associated QTc prolongation. However, SAR decreased whereas CIL increased the incidence of ventricular arrhythmias and the mean number of episodes in infarcted animals. Mortality during the treatment period was decreased by 17% with SAR and increased by 10% with CIL, but these changes were not significant statistically. The data in this study suggest that both SAR and CIL prevent cardiac remodeling and improve cardiac function in MI-induced CHF; however, CIL unlike SAR increased the incidence of arrhythmias and adversely affected patient mortality.     

Prediction of Perioperative Cardiac Events through Preoperative NT-pro-BNP and cTnI after Emergent Non-Cardiac Surgery in Elderly Patients

Objectives

Clinical risk stratification has an important function in preoperative evaluation of patients at risk for cardiac events prior to non-cardiac surgery. The aim of this study was to determine whether the combined measurement of pre-operative N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and cardiac troponin I (cTnI) could provide useful prognostic information about postoperative major adverse cardiac events (MACE) within 30 days in patients aged over 60 years undergoing emergent non-cardiac surgery.

Methods

The study group comprised 2519 patients aged over 60 years that were undergoing emergent non-cardiac surgery between December 2007 and December 2013. NT-pro-BNP and cTnI were measured during hospital admission. The patients were monitored for MACE (cardiac death, non-fatal myocardial infarction, or cardiac arrest) during the 30-day postoperative follow-up period.

Results

MACE occurred in 251 patients (10.0%). Preoperative NT-pro-BNP and cTNI level were significantly higher in the individuals that experienced MACE than in those who did not (P < 0.001). The confounding factors of age, sex, co-morbidities and preoperative medications were adjusted in a multivariate logistic regression analysis. This analysis showed that preoperative NT-proBNP level > 917 pg/mL (OR 4.81, 95% CI 3.446–6.722, P < 0.001) and cTnI ≥ 0.07 ng/mL (OR 8.74, 95% CI 5.881–12.987, P < 0.001) remained significantly and independently associated with MACE after the adjustment of the confounding factors. Kaplan-Meier event-free survival curves demonstrated that patients with preoperative simultaneous NT-proBNP level > 917 pg/mL and cTnT ≥0.07 ng/mL had worse event-free survival than individual assessments of either biomarker.

Conclusion

Preoperative plasma NT-proBNP and cTnI are both independently associated with an increased risk of MACE in elderly patients after emergent non-cardiac surgery. The combination of these biomarkers provides better prognostic information than using either biomarker separately.     

QT Dispersion in Uncomplicated Human Obesity

Objective: Because obese patients generally may be prone to ventricular arrhythmias, this study was designed to measure the interval between Q‐ and T‐waves of the electrocardiogram (QT) interval dispersion (QTD) in uncomplicated overweight and obese patients. QTD is an electrocardiographic parameter whose prolongation is thought to be predictive of the possibility of sudden death caused by ventricular arrhythmias. To better evaluate the association between obesity per se and QTD, the study population was intentionally selected because they were free of complications. Research Methods and Procedures: QTD (defined as the difference between the maximum and the minimum QT corrected interval [QTc] across the 12‐lead electrocardiogram) was measured manually in 54 obese patients (Group A: mean body mass index [BMI] of 38.1 ± 0.9 kg/m² [SEM], 15 males and 39 females), 35 overweight patients (Group B: mean BMI of 27.3 ± 0.2 kg/m², 10 males and 25 females), and 57 normal weight healthy control subjects (Group C: mean BMI of 21.9 ± 0.2 kg/m², 17 males and 40 females). The obese and overweight patients had no heart disease, hypertension, diabetes, or impaired glucose tolerance and did not have any hormonal, hepatic, renal or electrolyte disorders. The study subjects were matched in terms of age (mean age 38.4 ± 1.2 years) and sex. Results: The QTDs were comparable among the three groups: Group A, 56.4 ± 2.6 ms; Group B, 56.7 ± 2.1 ms; and Group C, 59.4 ± 2.1 ms; not significant. The QTc intervals of Group A and Group B were similar to that of Group C (411.8 ± 3.3, 407.2 ± 3.9, and 410.3 ± 3.9 ms, respectively [not significant]) and did not correlate with BMI. An association was found between QTD and QTc (r = 0.24, p < 0.005). Using multivariate stepwise regression analysis of the study population, QTD did not correlate with age, BMI, waist circumference, or abdominal sagittal diameter. Discussion: These data suggest that QTD in uncomplicated obese or overweight subjects is comparable with that in age‐ and sex‐matched normal weight healthy controls. In this study population, no association was found between QTD and anthropometric parameters reflecting body fat distribution.     

The Impact of Renal Impairment on Long-Term Safety and Effectiveness of Drug-Eluting Stents

Background

Renal impairment (RI) is associated with impaired prognosis in patients with coronary artery disease. Clinical and angiographic outcomes of patients undergoing percutaneous coronary intervention (PCI) with the use of drug-eluting stents (DES) in this patient population are not well established.

Methods

We pooled individual data for 5,011 patients from 3 trials with the exclusive and unrestricted use of DES (SIRTAX - N = 1,012, LEADERS - N = 1,707, RESOLUTE AC - N = 2,292). Angiographic follow-up was available for 1,544 lesions. Outcomes through 2 years were stratified according to glomerular filtration rate (normal renal function: GFR≥90 ml/min; mild RI: 90<GFR≥60 ml/min; moderate/severe RI GFR<60 ml/min).

Results

Patients with moderate/severe RI had an increased risk of cardiac death or myocardial infarction ([MI], OR 2.14, 95%CI 1.36–3.36), cardiac death (OR 2.21, 95%CI 1.10–4.46), and MI (OR 2.02, 95%CI 1.19–3.43) compared with patients with normal renal function at 2 years follow-up. There was no difference in cardiac death or MI between patients with mild RI compared to those with normal renal function (OR 1.10, 95%CI 0.75–1.61). The risk of target-lesion revascularization was similar for patients with moderate/severe RI (OR 1.17, 95%CI 0.70–1.95) and mild RI (OR 1.16, 95%CI 0.81–1.64) compared with patients with normal renal function. In-stent late loss and in-segment restenosis were not different for patients with moderate/severe RI, mild RI, and normal renal function.

Conclusions

Renal function does not affect clinical and angiographic effectiveness of DES. However, prognosis remains impaired among patients with moderate/severe RI.     

Cardiac evaluation and risk reduction in patients undergoing major vascular operations.

Occult coronary artery disease often accompanies symptomatic peripheral vascular disease and has an important effect on survival. Most perioperative and late fatalities after peripheral vascular operations are due to cardiac causes. Noninvasive cardiac testing can identify patients at increased risk for postoperative cardiac complications, although controversy exists regarding the optimal preoperative evaluation. Risk reduction strategies for patients known to be at high risk are also controversial. Some authors advocate coronary revascularization with coronary artery bypass grafting or percutaneous transluminal coronary angioplasty before the vascular procedure. Others believe that the combined morbidity and mortality of 2 operations exceed those of a peripheral vascular operation performed with aggressive monitoring and medical therapy. Continuous electrocardiographic monitoring after an operation has identified silent myocardial ischemia as a powerful predictor of cardiac complications. Ongoing research is likely to provide insights into the pathogenesis of postoperative cardiac complications and may lead to specific therapeutic interventions. Few prospective studies have been done in this area, and the threshold for preoperative and postoperative intervention is unknown. I review the literature and present an algorithm to guide cardiac testing and risk reduction in patients undergoing elective vascular surgical procedures.     

负荷量阿托伐他汀对稳定型冠心病患者非心脏手术围手术期保护作用的研究

目的:探讨负荷量阿托伐他汀对稳定型冠心病患者非心脏的择期外科手术围手术期主要不良心脏事件的保护作用。方法:将拟行非心脏外科手术的60名稳定型冠心病患者随机分为负荷量阿托伐他汀组(n=30)和对照组(n=30),其中负荷量阿托伐他汀治疗组在术前12小时给予阿托伐他汀80 mg顿服,术前2小时阿托伐他汀40 mg顿服,且每晚服用阿托伐他汀40 mg,对照组术前每晚服用阿托伐他汀20 mg,而后进行非心脏的外科手术(主要病种为慢性胆囊结石胆囊炎、慢性阑尾炎、消化性溃疡、疝气),术后负荷量组给予每晚服用阿托伐他汀40 mg,对照组每晚服用阿托伐他汀20 mg。比较两组围手术期主要不良心脏事件(包括心脏性猝死,急性心肌梗死,非计划性血运重建)的发生情况。结果:对照组出现1例急性前壁ST段抬高型心肌梗死并行急诊前降支介入再灌注治疗和7例无症状型心肌梗死,负荷量阿托伐他汀组出现1例无症状型心肌梗死,围手术期心肌梗死发生率较对照组明显降低(P0.05)。结论:负荷量阿托伐他汀可显著降低稳定型冠心病患者非心脏的择期外科手术围手术期主要不良心脏事件如心肌梗死,特别是无症状型心肌梗死的发生率,但该结果尚需大样本多中心随机对照临床试验进一步证实。