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Biomedical subjects

Eric Lim

Publications and source records attributed to Eric Lim.

At least 19 recordsLinked to original sources
PubMed2007

Dose-related efficacy of aspirin after coronary surgery in patients With Pl(A2) polymorphism (NCT00262275).

BACKGROUND: To evaluate the impact of the genetic polymorphisms affecting aspirin response using platelet aggregation and the response to different aspirin doses after cardiopulmonary bypass, we performed a subanalysis of the results from a randomized trial evaluating low- and medium-dose aspirin and clopidogrel. METHODS: Blood was collected from consenting patients and DNA extracted. Polymerase chain reaction and restriction fragment length polymorphism analysis was performed to detect Pl(A2), C807T, and A842/C50T polymorphisms. Aspirin efficacy was assessed using light transmission platelet aggregometry, and reported as percentage aggregation and EC50 concentrations using the technique of Born. RESULTS: Of 90 patients, 80 consented to further genetic testing, of whom 63 patients were randomly assigned to medium- (325 mg) or low-dose (100 mg) aspirin. The Pl(A2), C807T, and A842/C50T gene frequencies were 30%, 66%, and 21%, respectively, with no identifiable differences in the baseline platelet aggregation. Postoperatively, after 5 days of aspirin, platelet aggregation was consistently but not significantly impaired with Pl(A2) and A842/C50T carriers and consistently but not significantly improved with C50T carriers. An interaction term was identified on percentage aggregation and EC50 using epinephrine. The interaction coefficient describes a higher aggregation of 19% (95% confidence interval: 2 to 36; p = 0.03) and less inhibition with an EC50 of -2.07 (-4.19 to 0.04; p = 0.06) in patients who were both Pl(A2) positive and receiving low-dose aspirin. CONCLUSIONS: Genetic polymorphisms that affect the response to aspirin are common. The impaired response of persons with the Pl(A2) polymorphism to aspirin may be dose related, with significant improvement observed in patients using medium- rather than low-dose aspirin.

Aged↗
PubMed2007

Invited commentary.

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Carcinoma, Non-Small-Cell Lung↗
PubMed2006

Detected troponin elevation is associated with high early mortality after lung resection for cancer.

BACKGROUND: Myocardial infarction can be difficult to diagnose after lung surgery. As recent diagnostic criteria emphasize serum cardiac markers (in particular serum troponin) we set out to evaluate its clinical utility and to establish the long term prognostic impact of detected abnormal postoperative troponin levels after lung resection. METHODS: We studied a historic cohort of patients with primary lung cancer who underwent intended surgical resection. Patients were grouped according to known postoperative troponin status and survival calculated by Kaplan Meier method and compared using log rank. Parametric survival analysis was used to ascertain independent predictors of mortality. RESULTS: From 2001 to 2004, a total of 207 patients underwent lung resection for primary lung cancer of which 14 (7%) were identified with elevated serum troponin levels within 30 days of surgery, with 9 (64%) having classical features of myocardial infarction.The median time to follow up (interquartile range) was 22 (1 to 52) months, and the one and five year survival probabilities (95% CI) for patients without and with postoperative troponin elevation were 92% (85 to 96) versus 60% (31 to 80) and 61% (51 to 71) versus 18% (3 to 43) respectively (p < 0.001).T stage and postoperative troponin elevation remained independent predictors of mortality in the final multivariable model. The acceleration factor for death of elevated serum troponin after adjusting for tumour stage was 9.19 (95% CI 3.75 to 22.54). CONCLUSION: Patients with detected serum troponin elevation are at high risk of early mortality with or without symptoms of myocardial infarction after lung resection.

Aged↗
PubMed2006

Comparison of segmental and global markers of dyssynchrony in predicting clinical response to cardiac resynchronization.

AIMS: Cardiac resynchronization therapy (CRT) reduces inter- and intraventricular dyssynchrony and shortens total isovolumic time (t-IVT). We compared the extent to which the values of ventricular dyssynchrony and t-IVT predict clinical benefits of CRT. METHODS AND RESULTS: Ventricular dyssynchrony was assessed in 39 patients with heart failure before and 6 months after CRT. Segmental dyssynchrony was identified from time to onset and peak systolic velocity of wall motion. T-IVT (s/min) was derived as [60-(total ejection time+total filling time)]. The difference between ventricular pre-ejection periods (D-PEP) was calculated. Outcome measures were fall in New York Heart Association (NYHA) class and increase in cardiac output (CO). Following CRT, NYHA class fell in 29/39 patients, CO increased (by 1.0 L/min, P < 0.001), and intraventricular delay (Intra-VD), interventricular delay (Inter-VD), t-IVT, and D-PEP shortened (by 25 ms, 72 ms, 6 s/min, and 38 ms, P < 0.01). NYHA class and CO were unchanged with CRT in 10/39, and Intra-VD, Inter-VD, t-IVT, and D-PEP lengthened (by 43 ms, 52 ms, 7 s/min, and 35 ms, P < 0.05). Though univariate predictors of CO increment with CRT were Intra-VD, Inter-VD, t-IVT, and D-PEP, only pre-CRT values of CO (P < 0.001), t-IVT (P < 0.001), and D-PEP (P = 0.025) were independent. CONCLUSION: Global, rather than segmental, measures of ventricular dyssynchrony are powerful, independent predictors of clinical response to CRT.

Aged↗
PubMed2006

Impact of the European Working Time Directive on exposure to operative cardiac surgical training.

OBJECTIVE: To evaluate the impact of the reduced working hours, an anticipated decline in case load and increasing patient risk profile, we performed a cohort study to determine the factors that influenced operative surgical training. METHODS: A historic cohort study design was utilised, and data were acquired from a prospective operative surgical database a year before, and a year after the introduction of the European Working Time Directive (EWTD) compliant rota (1st August 2004). Logistic regression was used to determine the predictors of operative surgical training, and individual variables were ranked by likelihood ratio. RESULTS: In total, 3312 cardiac surgical operations were performed over a 2-year period between 3rd August 2003 and 31st July 2005. The proportion of cases performed by trainees was 39% (626/1587) in the year before and 40% (695/1725) in the year after the introduction of WTD compliant rota. There were no differences in operative risk (logistic EuroSCORE of 8, P=0.853). Independent predictors for surgery performed by a trainee (in descending order of influence) were the consultant in charge (chi11(2) 273.1; P<0.001), procedure performed (chi5(2) 163.5; P<0.001), increasing seniority of trainee (chi2(2) 142.3; P<0.001), revision surgery (chi1(2) 45.9; P<0.001), lower EuroSCORE (chi1(2) 17.6; P<0.001), and better ventricular function (chi2(2) 7.8; P=0.020). The odds ratio of an operation performed by a trainee increased after the introduction of the EWTD compliant rota to 1.19 (95% CI 1.00-1.41; P=0.045). CONCLUSIONS: With a successful institution-specific training module and a commitment to training, exposure to operative surgical training can be sustained despite shortening of working hours.

Cardiovascular Surgical Procedures↗
PubMed2006

Biological efficacy of low versus medium dose aspirin after coronary surgery: results from a randomized trial [NCT00262275].

BACKGROUND: The beneficial effect of aspirin after coronary surgery is established; however, a recent study reported the inability of low doses (100 mg) to inhibit postoperative platelet function. We conducted a double-blind randomised trial to establish the efficacy of low dose aspirin and to compare it against medium dose aspirin. METHODS: Patients undergoing coronary surgery were invited to participate and consenting patients were randomised to 100 mg or 325 mg of aspirin daily for 5 days. Our primary outcome was the difference in platelet aggregation (day 5 - baseline) using 1 microg/ml of collagen. Secondary outcomes were differences in EC50 of collagen, ADP and epinephrine (assessed using the technique of Born). RESULTS: From September 2002 to April 2004, 72 patients were randomised; 3 patients discontinued, leaving 35 and 34 in the low and medium dose aspirin arms respectively. The mean aggregation (using 1.1 microg/ml of collagen) was reduced in both the medium and low dose aspirin arms by 37% and 36% respectively. The baseline adjusted difference (low - medium) was 6% (95% CI -3 to 14; p = 0.19). The directions of the results for the differences in EC50 (low - medium) were consistent for collagen, ADP and epinephrine at -0.07 (-0.53 to 0.40), -0.08 (-0.28 to 0.11) and -4.41 (-10.56 to 1.72) respectively, but none were statistically significant. CONCLUSION: Contrary to recent findings, low dose aspirin is effective and medium dose aspirin did not prove superior for inhibiting platelet aggregation after coronary surgery.

Adenosine Diphosphate↗
PubMed2006

Regional ventricular dynamics during acute coronary occlusion: a comparison of invasive with non-invasive echocardiographic markers to detect and quantify myocardial ischaemia-observations made during off-pump coronary surgery.

OBJECTIVES: To investigate the performance of non-invasive markers used in stress echocardiography to detect the presence and depth of myocardial ischaemia. We therefore sought to compare these non-invasive markers during acute coronary occlusion in humans. METHODS: 27 patients with stable angina and normal LV cavity size were studied during off-pump coronary artery bypass grafting to the left anterior descending coronary artery using transoesophageal echocardiography and simultaneous high fidelity LV pressure. Regional power development of the anterior wall was plotted throughout the cardiac cycle, allowing the measurement of its time course, peak value and time integral (intrinsic work). Regional effective myocardial work was calculated and its reduction during acute occlusion was used as the invasive standard for ischaemic dysfunction. RESULTS: In all patients acute coronary occlusion led to a delay in the onset of regional wall thickening which persisted after aortic valve closure. These time intervals of myocardial thickening had the highest qualitative concordance with the gold standard of a fall in effective work. Regression models identified three significant predictors of the depth of myocardial ischaemia; the interval from Q wave to the onset of regional thickening, duration of post-ejection thickening and peak thickening rate. Objective wall thickening and thinning rates were not significant predictors. CONCLUSIONS: The regional timing of myocardial thickening and peak thickening rate accurately predicted the presence and indicated the depth of local ischaemia during acute coronary occlusion. These markers may complement subjective wall motion scores aimed at predicting the presence of epicardial coronary artery disease. CONDENSED ABSTRACT: We compared non-invasive markers commonly used in stress echocardiography using measurements of the fall in regional myocardial work with coronary occlusion as a standard. 27 patients were studied using transoesophageal echocardiography and simultaneous high fidelity left ventricular pressure during off-pump coronary surgery. Delayed myocardial thickening had the highest qualitative concordance with the gold standard of a fall in effective work, while regression models identified three significant predictors; the interval Q wave to the onset of regional thickening, duration of post-ejection thickening and peak thickening rate. These markers may complement current non-invasive indices of ischaemia during clinical stress testing.

Acute Disease↗
PubMed2006

The relationship between plasma osteoprotegerin levels and coronary artery calcification in uncomplicated type 2 diabetic subjects.

OBJECTIVES: This study sought to prospectively evaluate the relationship between plasma osteoprotegerin (OPG), inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin-6 [IL-6], coronary artery calcification (CAC), and cardiovascular events in patients with type 2 diabetes. BACKGROUND: Arterial calcification is a prominent feature of atherosclerosis and is associated with an increased risk of cardiovascular events. Osteoprotegerin is a cytokine that has recently been implicated in the regulation of vascular calcification. METHODS: A total of 510 type 2 diabetic patients (53 +/- 8 years; 61% male) free of symptoms of cardiovascular disease were evaluated by CAC imaging. Risk factors, hs-CRP, IL-6, and OPG levels were measured. Patients were followed up for cardiovascular events (cardiac death, myocardial infarction, acute coronary syndrome, late revascularization, and nonhemorrhagic stroke). RESULTS: Significant CAC (>10 Agatston units) was seen in 236 patients (46.3%); OPG was significantly elevated in patients with increased CAC. In multivariable analyses, OPG retained a strong association with elevated CAC scores after adjustment for age, gender, and other risk factors (odds ratio = 2.84, 95% confidence interval 2.2 to 3.67; p < 0.01). Sixteen cardiovascular events occurred during a mean follow-up of 18 +/- 5 months. The waist-to-hip ratio, United Kingdom Prospective Diabetes Study (UKPDS) risk score, OPG level, and CAC score were significant predictors of time to cardiovascular events in a univariate Cox proportional hazards model. In the multivariate model, the CAC score was the only independent predictor of adverse events. Levels of hs-CRP and IL-6 were related to neither the extent of CAC nor short-term events. CONCLUSIONS: A high proportion of asymptomatic diabetic patients have significant subclinical atherosclerosis. Of the biomarkers studied, only OPG predicted both subclinical disease and near-term cardiovascular events. Therefore, measurement of OPG merits further investigation as a simple test for identifying high-risk type 2 diabetic patients.

Biomarkers↗
PubMed2006

Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy.

AIMS: To determine the prevalence and clinical predictors of subclinical atherosclerosis and myocardial ischaemia in uncomplicated type 2 diabetes and assess their relationship to short-term outcome. METHODS AND RESULTS: Established risk factors and coronary artery calcium (CAC) scores were prospectively measured in 510 asymptomatic type 2 diabetic subjects (mean age 53+/-8 years, 61% males) without prior cardiovascular disease. Myocardial perfusion scintigraphy (MPS) was performed in all subjects with CAC > 100 Agatston units (AU) (n=127), and a random sample of the remaining patients with CAC < or = 100 AU (n=53). Significant CAC (> 10 AU) was found in 46.3%. Twenty events occurred (two coronary deaths, nine non-fatal myocardial infarctions, three acute coronary syndromes, three non-haemorrhagic strokes, and three late revascularisations) during a median follow-up of 2.2 years (25th-75th percentile = 1.9-2.5 years). The age, systolic blood pressure, the duration of diabetes, United Kingdom Prospective Diabetes Study risk score, CAC score, and extent of myocardial perfusion abnormality were significant predictors of time to cardiovascular events in a univariable Cox proportional hazard model. No cardiac events or perfusion abnormalities occurred in subjects with CAC < or = 10 AU up until 2 years of follow-up. CAC and MPS findings were synergistic for the prediction of short-term cardiovascular events. CONCLUSION: Subclinical atherosclerosis, measured by CAC imaging, is superior to the established cardiovascular risk factors for predicting silent myocardial ischaemia and short-term outcome. Further studies evaluating the impact of CAC imaging on clinical outcomes and its cost effectiveness are warranted.

Calcinosis↗
PubMed2006

A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks.

OBJECTIVE: The use of tissue glues has been advocated to reduce post-thoracotomy alveolar air leaks, but outcomes have been inconclusive. The aim of this study was to determine the effectiveness of BioGlue (CryoLife Europa Ltd, Hampshire, United Kingdom) in eliminating post-thoracotomy alveolar air leaks. METHODS: A prospective, randomized, single-blind, controlled trial was conducted in which patients were stratified according to the severity of post-thoracotomy air leak that could not be controlled by conventional surgical techniques. They were allocated to a control arm (surgical treatment only) or an interventional arm (surgical treatment and BioGlue). Duration of air leak, intercostal drainage, and hospital stay comprised primary study end points. RESULTS: From December 2002 to January 2005, 52 patients were randomized, 29 (56%) of whom were men. The mean age was 59 +/- 15 years, and other characteristics were comparable in both groups. Indications for surgery were malignancy in 46 patients (88%), carcinoid tumor in 2 patients (4%), and infective disease in 4 patients (8%). Patients in the BioGlue arm had shorter median duration of air leaks, 1 (0-2) versus 4 (2-6) days (P < .001); intercostal chest drainage, 4 (3-4) versus 5 (4-6) days (P = .012); and hospital stay, 6 (5-7) versus 7 (7-10) days (P = .004), compared with controls. No major complications were encountered using BioGlue. CONCLUSIONS: This study demonstrates clear benefit from BioGlue in the treatment of alveolar air leaks through reduction of air leak duration, chest drainage time, and hospital stay. Systematic use of BioGlue may be warranted in adult thoracic surgical procedures (except pneumonectomy and decortication) when an air leak remains after all other steps to control it have failed.

Adult↗
PubMed2006

A systematic review of randomized trials comparing revascularization rate and graft patency of off-pump and conventional coronary surgery.

OBJECTIVE: Although many trials have been conducted to evaluate the benefits of off-pump coronary surgery, few have concentrated on graft patency. We sought to evaluate the impact of off-pump surgery on completeness of revascularization and graft patency compared with conventional surgery. METHODS: A systematic literature search was undertaken of all randomized trials of off-pump coronary surgery in MEDLINE, EMBASE, the Cochrane Library Controlled Trials Register, the National Research Register, and abstracts from major conferences. RESULTS: In total, 132 publications were identified. From this number, we excluded 43 without a conventional surgery arm and 80 that did not evaluate graft patency. One trial was excluded for selective angiography and one abstract was excluded because of insufficient information. A total of 7 trials were eligible for overview. On initial analysis, the relative risk of graft patency in off-pump coronary surgery compared with conventional surgery was 0.959 (95% confidence interval 0.936-0.983; P = .001). The analysis was repeated after excluding one specific trial because of clinical and statistical heterogeneity (chi2(6) = 27.78; P < .001), and a relative risk of 0.953 (95% confidence interval 0.927-0.980; P = .001) was obtained with no further evidence of heterogeneity (chi2(5) = 5.35; P = .374). In 5 trials that included the mean number of grafts performed per arm, the standardized mean difference in revascularization comparing off-pump with conventional surgery was -0.164 (-0.286 to -0.043; P = .008). CONCLUSION: In a meta-analysis of randomized trials, patients undergoing off-pump coronary surgery had a lower rate of revascularization and lower graft patency than did patients undergoing conventional coronary surgery.

Coronary Artery Bypass, Off-Pump↗
PubMed2006

Biological efficacy of low against medium dose aspirin regimen after coronary surgery: analysis of platelet function.

The failure of aspirin to inhibit platelet function has been documented in patients undergoing coronary artery bypass graft (CABG) surgery, but the causes of "aspirin-resistance" remain uncertain. The aim of this study was to investigate the efficacy of aspirin in patients undergoing CABG surgery receiving either 100 mg or 325 mg of oral aspirin for 5-days. Platelet function was tested the day before surgery and on day +1 and day +5, and evaluated by changes in collagen-induced thromboxane-A2 (TxA2) release and platelet aggregation following stimulation with collagen, ADP and epinephrine. In all patients, baseline platelet aggregation was significantly inhibited by pre-incubation with in vitro aspirin (150 micromol/l), with a mean reduction in TxA2-release of >or=95.5% (82.3,99.1). After 5-days of oral aspirin, platelet aggregation was significantly inhibited, and was not further inhibited by in vitro aspirin. Oral aspirin was also associated with a >or=99.5% (97.8, 99.7) reduction in TxA2-release, and with the reversal of the second-phase of ADP-induced aggregation which is TxA2-dependent. In addition a single-dose of 325 mg aspirin on the first post-operative morning may have a greater inhibitory effect on collagen-induced aggregation than 100 mg aspirin. Western blot analysis provided no evidence for the presence of COX-2 in platelets, while the up-regulation of p38-MAPK following platelet-stimulation and surgery was seen. The inhibition of COX-2 (NS398) or p38-MAPK (SB203580) activity did not affect platelet aggregation and TxA2-release on day +5. In summary, there was no evidence for inherent or acquired aspirin-resistance in this surgical population, or for the involvement of either COX-2 or p38-MAPK.

Adenosine Diphosphate↗
PubMed2005

The role of non-invasive imaging in the risk stratification of asymptomatic diabetic subjects.

AIMS: Coronary artery disease (CAD) is the leading cause of death in patients with diabetes. Patients often present with advanced and asymptomatic disease. Proposed strategies that may favourably affect CAD risk and outcomes in this patient population include identifying diabetic patients with subclinical disease at high risk of future cardiac events. The purpose of this article was to review the role of both atherosclerosis imaging tests (coronary calcium imaging and high-resolution ultrasound assessment of carotid intima-media thickness) and functional imaging techniques [stress echocardiography and radionuclide myocardial perfusion imaging (MPI)] in the diagnostic and prognostic evaluation of asymptomatic diabetic subjects. METHODS AND RESULTS: We identified studies using MEDLINE searches (1966 to April 2005) and by reviewing reference lists. A comprehensive list of search terms was applied. All stress echocardiography and MPI studies evaluating the prevalence and/or prognostic value of myocardial ischaemia (n = 19) and coronary calcium imaging studies (n = 2) evaluating the prognostic value of subclinical atherosclerosis in diabetic patients were included. CONCLUSION: Asymptomatic myocardial ischaemia can be detected in a significant proportion of diabetic subjects by non-invasive imaging tests such as MPI and stress echocardiography. The results of ongoing and future studies may be helpful in guiding the selection of asymptomatic diabetic subjects to undergo non-invasive imaging, establishing the cost-effectiveness of various testing strategies and their impact on prognosis.

Calcinosis↗
PubMed2005

Effect of dobutamine stress on left ventricular filling in ischemic dilated cardiomyopathy: pathophysiology and prognostic implications.

OBJECTIVES: The purpose of this research was to study the effect of dobutamine on left ventricular (LV) filling in ischemic cardiomyopathy (ICM) and to determine whether restrictive filling pattern (RFP) at peak stress has prognostic value. BACKGROUND: The prognostic value of RFP at peak stress in ICM is unknown. METHODS: A total of 69 patients with ICM were studied by Doppler echocardiography at rest and stress; RFP was defined as transmitral E:A ratio > or =1.0, isovolumic relaxation time (IVRT) <80 ms, and E-wave deceleration time (EDT) <120 ms. RESULTS: A total of 42 of 69 had RFP at rest, which reverted to non-RFP at stress in 24 (EA), but persisted in 18 (EE); 27 of 69 had non-RFP at rest and peak stress (AA). In EA, IVRT and EDT lengthened (by 43 ms and 46 ms), and tricuspid regurgitation (TR) decreased (by 26 mm Hg, p < 0.01), suggesting a fall in left atrial (LA) pressure. The stress response in AA was similar to EA. In EE, IVRT and EDT shortened (by 21 ms) and TR increased (by 13 mm Hg, p < 0.01), suggesting a rise in LA pressure. Peak aortic acceleration (LV inotropy) increased by 0.8 g in EA but only by 0.2 g in EE (difference p < 0.001). Median follow-up (interquartile range) was 34 (20 to 57) months. Three-year survival for EE, EA, and AA was 49%, 79%, and 89%, respectively (p < 0.001). Compared with AA, the hazard ratio for EE was 9.5 (p < 0.001) and for EA was 1.9 (p = 0.30). CONCLUSIONS: In ischemic cardiomyopathy, persistence of restrictive filling during stress implies a striking rise in LA pressure, greatly attenuated LV inotropic response, and markedly reduced survival. Stress echocardiography uniquely identifies these high-risk patients.

Aged↗
PubMed2005

Comparison of survival by allocation to medical therapy, surgery, or heart transplantation for ischemic advanced heart failure.

BACKGROUND: To ascertain survival of ischemic advanced heart failure patients by treatment allocation, we examined the outcome of transplant assessment patients allocated to medical therapy, high-risk conventional surgery, or transplantation. METHODS: Patients were identified from the Papworth transplant database and excluded if primary etiology was not ischemic. Grouping was undertaken according to treatment allocation at initial assessment, and analysis was performed by intention to treat. Survival was computed from the time of assessment and Cox regression used to stratify patients according risk with the Heart Failure Survival Score. RESULTS: From May 1993 to September 2001, a total of 755 patients were admitted for transplant assessment, with 348 (46.1%) identified as having heart failure of ischemic origin. Variables required for calculation of the Heart Failure Survival Score was available in 273 patients (78.4%), and 20 patients (7.3%) were lost to follow-up. Of the remaining 253 patients, 89 (35.2%) were allocated to medical therapy, 32 (12.6%) to surgery, and 132 (52.2%) to transplantation. The relative risk (95% confidence limit) of death compared with medical therapy was 0.62 (0.28, 1.40) for surgery and 0.38 (0.24, 0.61) for transplantation in medium- to high-risk patients. For low-risk patients, the relative risks for death compared with medical therapy were 1.87 (0.63, 5.60) for surgery and 1.97 (0.79, 4.96) for transplantation. CONCLUSIONS: Transplantation improved survival of medium- and high-risk patients compared with medical therapy. In the low-risk group, this was not evident. However, repeated assessment of risk is required because the hazard for death rises steadily after the third year in these patients.

Cardiac Surgical Procedures↗
PubMed2005

A validated simple model to predict coexistent coronary disease in patients undergoing mitral valve surgery.

OBJECTIVE: The primary limitation of the American Heart Association/American College of Cardiology guidelines is specificity. To improve the selection process, we proposed a simple additive model including age (1 point for every 5 years above 50), male sex (2 points), hypercholesterolemia (2 points), angina (3 points), and electrocardiographic evidence of ischemia (3 points). We recommend screening angiography at 3 or more points. This model was previously derived from 359 patients at Papworth Hospital. METHODS: The validation cohort was a consecutive series of patients who underwent mitral valve surgery at the Royal Brompton Hospital. Preoperative coronary angiography reports were obtained, and coronary disease was defined as luminal narrowing of 50% in 2 or more views. Sensitivities and specificities were calculated for the American Heart Association/American College of Cardiology criteria, the simple additive model, and a logistic regression model. Receiver operating characteristic curves were used to validate accuracy and compare discrimination with logistic regression. RESULTS: From 1998 through 2003, angiographic details were available for 342 (86%) of 396 patients who underwent mitral valve surgery. The sensitivity and specificity of the American Heart Association/American College of Cardiology guidelines were 100% and 5%, respectively; those of the simple additive model were 91% and 44%, respectively; and those of logistic regression were 93% and 41%, respectively. The receiver operating characteristic areas for the simple additive and logistic regression model were 0.78 (95% confidence interval, 0.73-0.84) and 0.80 (95% confidence interval, 0.74-0.85), respectively. CONCLUSIONS: This is the third independent cohort to highlight the poor specificity of the American Heart Association/American College of Cardiology guidelines. Although high sensitivity is achieved, the cost is the majority of patients requiring screening angiography. Our validated simple model improved the specificity and selection; however, this was achieved at the expense of decreased sensitivity.

Aged↗