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PubMed2002

Cardiac troponin I for risk stratification following percutaneous coronary artery intervention in acute coronary syndromes.

The cardiac troponins have been shown to provide prognostic information allowing risk stratification of patients with acute coronary syndromes (ACS). The benefit of early percutaneous coronary intervention (PCI) in this setting has been highlighted by the FRISC II study. We assessed the pattern of release of cardiac troponin I (cTnI) following PCI in patients with ACS and evaluated its prognostic value for major adverse cardiac events (MACE): death, Q-wave myocardial infarction (QWMI), and repeat revascularization at follow-up. cTnI was sampled at baseline and 6, 14, and 24 hr following PCI in 73 patients presenting with unstable and post-MI angina. Clinical follow-up was obtained in all 73 patients at a mean period of 43 +/- 19.9 weeks (range, 11-68 weeks). Patients were stratified into two groups according to whether cTnI remained unchanged or fell below baseline 24 hr post-PCI (group 1, n = 47) or increased above baseline 24 hr following PCI (group 2, n = 26). MACE occurred in 4 (8.5%) of patients in group 1 (QWMI = 1, CABG = 1, re-PCI = 2) and in 19 (73%) of patients in group 2 (death = 1, QWMI = 2, CABG = 2, re-PCI = 14; chi-square = 32.34, P < 0.0001). The positive predictive value of rising cTnI within 24 hr following PCI for MACE at follow-up was 0.73 and the negative predictive value was 0.92 (specificity = 83%, sensitivity = 86%; odds ratio = 29.18, 95% CI = 7.62-110.64, P < 0.0001). cTnI is an inexpensive and widely applicable tool that offers reliable prognostic information for the risk stratification of patients undergoing coronary revascularization in the setting of acute coronary syndromes and may identify a group of patients at particular risk of repeat PCI.

Aged↗

PubMed2000

Comparison of cardiac troponin T versus creatine kinase-MB for risk stratification in a chest pain evaluation unit.

We evaluated cardiac troponin T (cTnT) and creatine kinase-MB (CK-MB) for risk stratification of chest pain unit (CPU) patients. We studied 383 consecutive patients with chest pain assigned to our CPU by emergency department physicians. At baseline all had normal or nondiagnostic electrocardiograms, no high-risk clinical features, and negative CK/CK-MB. CK-MB and electrocardiograms were taken at 0, 4, 8, and 12 hours and cTnT at 0, 4, and 8 hours. Eight patients (2.1%) were CK-MB positive and 39 (10.2%) were cTnT positive, including all but 1 CK-MB-positive patient. All marker-positive patients were detected by 8 hours. Seven cTnT-positive patients and 1 cTnT-negative patient had myocardial infarction (p <0.0001). cTnT-positive patients were older, less likely to be women or smokers, and more often had diabetes mellitus or known coronary disease (CAD). Seventy-one percent of patients underwent diagnostic testing. cTnT-positive patients more often underwent angiography (46% vs 20%) and underwent stress testing less often (28% vs 57%) than cTnT-negative patients. When performed, their stress tests were more often positive (46% vs 14%) and they more often had angiographically significant lesions (89% vs 49%) and multivessel disease (67% vs 29%). There were no short-term deaths. Long-term mortality was higher in cTnT-positive patients (27% vs 7%, p <0.0001). Thus, cTnT identified more CPU patients with myocardial necrosis and multivessel CAD than CK-MB and a population with high long-term mortality risk. Routine use of cTnT in CPUs could facilitate risk stratification and management.

Aged↗

PubMed2000

A comparison of T-wave alternans, signal averaged electrocardiography and programmed ventricular stimulation for arrhythmia risk stratification.

OBJECTIVES: The goal of this study was to compare T-wave alternans (TWA), signal-averaged electrocardiography (SAECG) and programmed ventricular stimulation (EPS) for arrhythmia risk stratification in patients undergoing electrophysiology study. BACKGROUND: Accurate identification of patients at increased risk for sustained ventricular arrhythmias is critical to prevent sudden cardiac death. T-wave alternans is a heart rate dependent measure of repolarization that correlates with arrhythmia vulnerability in animal and human studies. Signal-averaged electrocardiography and EPS are more established tests used for risk stratification. METHODS: This was a prospective, multicenter trial of 313 patients in sinus rhythm who were undergoing electrophysiologic study. T-wave alternans, assessed with bicycle ergometry, and SAECG were measured before EPS. The primary end point was sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation or appropriate implantable defibrillator (ICD) therapy, and the secondary end point was any of these arrhythmias or all-cause mortality. RESULTS: Kaplan-Meier survival analysis of the primary end point showed that TWA predicted events with a relative risk of 10.9, EPS had a relative risk of 7.1 and SAECG had a relative risk of 4.5. The relative risks for the secondary end point were 13.9, 4.7 and 3.3, respectively (p < 0.05). Multivariate analysis of 11 clinical parameters identified only TWA and EPS as independent predictors of events. In the prespecified subgroup with known or suspected ventricular arrhythmias, TWA predicted primary end points with a relative risk of 6.1 and secondary end points with a relative risk of 8.0. CONCLUSIONS: T-wave alternans is a strong independent predictor of spontaneous ventricular arrhythmias or death. It performed as well as programmed stimulation and better than SAECG in risk stratifying patients for life-threatening arrhythmias.

Aged↗

PubMed2003

Validation of four different risk stratification systems in patients undergoing off-pump coronary artery bypass surgery: a UK multicentre analysis of 2223 patients.

BACKGROUND: Various risk stratification systems have been developed in coronary artery bypass graft surgery (CABG), based mainly on patients undergoing procedures with cardiopulmonary bypass. OBJECTIVE: To assess the validity and applicability of the Parsonnet score, the EuroSCORE, the American College of Cardiology/American Heart Association (ACC/AHA) system, and the UK CABG Bayes model in patients undergoing off-pump coronary artery bypass surgery (OPCAB) in the UK. METHODS: Data on 2223 patients who underwent OPCAB in eight cardiac surgical centres were collected. Predicted mortality risk scores were calculated using the four systems and compared with observed mortality. Calibration was assessed by the Hosmer-Lemeshow (HL) test. Discrimination was assessed using the receiver operating characteristic (ROC) curve area. RESULTS: 30 of 2223 patients (1.3%) died in hospital. For the Parsonnet score the HL test was significant (p < 0.001) and the receiver operating characteristic curve (ROC) area was 0.74. For the EuroSCORE the HL test was also significant (p = 0.008) and the ROC area was 0.75. For the ACC/AHA system the HL test was non-significant (p = 0.7) and the ROC area was 0.75. For the UK CABG Bayes model the HL test was also non-significant (p = 0.3) and the ROC area was 0.81. CONCLUSIONS: The UK CABG Bayes model is reasonably well calibrated and provides good discrimination when applied to OPCAB patients in the UK. Among the other three systems, the ACC/AHA system is well calibrated but its discrimination power was less than for the UK CABG Bayes model. These data suggest that the UK CABG Bayes model could be an appropriate risk stratification system to use for patients undergoing OPCAB in the UK.

Coronary Artery Bypass↗

PubMed1999

Spitz tumors in children: a grading system for risk stratification.

OBJECTIVE: To describe a grading system for risk stratification of atypical Spitz tumors in children and adolescents. In some circumstances, unequivocal distinction between Spitz nevus and melanoma is practically impossible. It is likely that these lesions for which we lack specific diagnostic criteria represent a broad histological continuum extending from benign to malignant tumors. Therefore, we propose that Spitz tumors be categorized into low-, intermediate-, or high-risk categories based on the accumulation of abnormal features. DESIGN: Retrospective study. SETTINGS: Institutional practice. PATIENTS: We present 30 cases of atypical Spitz tumors in patients younger than 18 years evaluated for at least 3 years or in whom a metastatic event developed during this period. INTERVENTION: None. MAIN OUTCOME MEASURE: The grading system was formulated after data collection. RESULTS: Among the parameters studied, only diagnosis at age greater than 10 years, diameter of the lesion greater than 10 mm, presence of ulceration, involvement of the subcutaneous fat (level V), and mitotic activity of at least 6/mm2 carried a likelihood ratio greater than 1.50 and were therefore used for the grading system. CONCLUSION: The application of an objective grading system, such as the one described herein for the first time, is the first step in providing useful information for the management of atypical Spitz tumors.

Adolescent↗

PubMed2002

Natural history of Brugada syndrome: insights for risk stratification and management.

BACKGROUND: Treatment of patients with Brugada syndrome is complicated by the incomplete information on the natural history of the disease related to the small number of cases reported. Furthermore, the value of programmed electrical stimulation (PES) for risk stratification is highly debated. The objective of this study was to search for novel parameters to identify patients at risk of sudden death. METHODS AND RESULTS: Clinical data were collected for 200 patients (152 men, 48 women; age, 41+/-18 years) and stored in a dedicated database. Genetic analysis was performed, and mutations on the SCN5A gene were identified in 28 of 130 probands and in 56 of 121 family members. The life-table method of Kaplan-Meier used to define the cardiac arrest-free interval in patients undergoing PES failed to demonstrate an association between PES inducibility and spontaneous occurrence of ventricular fibrillation. Multivariate Cox regression analysis showed that after adjusting for sex, family history of sudden death, and SCN5A mutations, the combined presence of a spontaneous ST-segment elevation in leads V1 through V3 and the history of syncope identifies subjects at risk of cardiac arrest (HR, 6.4; 95% CI, 1.9 to 21; P<0.002). CONCLUSIONS: The information on the natural history of patients obtained in this study allowed elaboration of a risk-stratification scheme to quantify the risk for sudden cardiac death and to target the use of the implantable cardioverter-defibrillator.

Adolescent↗

PubMed1998

Use of dobutamine echocardiography for cardiac risk stratification of patients with chronic renal failure.

OBJECTIVES: This study sought to define the value of dobutamine echocardiography (DbE) for cardiac risk stratification in patients with chronic renal failure (CRF). DESIGN: Outcome study correlating results of DbE with late cardiac events in patients with CRF. SETTING: Academic medical centre. SUBJECTS: All patients with CRF (serum creatinine > 2.5 mg dL-1) undergoing DbE were studied; we analysed 193 consecutive patients (aged 63 +/- 13 years, 73 men). INTERVENTIONS: A standard dobutamine-atropine stress was administered until attainment of peak dose, or the development of severe ischaemia or side-effects. The electrocardiogram (ECG) and echocardiogram were obtained before, during and after stress. Ischaemia was identified by new or worsening wall-motion abnormalities with stress. OUTCOME MEASURES: Patients were followed up after 38 +/- 14 months for cardiac death, myocardial infarction or coronary disease progression requiring revascularization. RESULTS: DbE demonstrated ischaemia in 36 patients (19%), scar in 36 (19%) and a normal study in 121 patients. The heart-rate response to dobutamine was submaximal (< 85% age-predicted heart rate) in the absence of wall-motion abnormalities in 69 patients (36%), 54 of whom completed the protocol. Follow-up data were complete in 191 patients (99%); cardiac events occurred in 33 patients (17%), including 17 with cardiac death, 7 with infarction, and 9 requiring late revascularization. Spontaneous events occurred in 7 patients with ischaemia, 3 with scar (8%), 11 with a nondiagnostic study (16%) and 3 patients with a normal study (6%). Over the entire follow-up, the event-free survival in patients with ischaemia (66%) was markedly lower than those without ischaemia (84%, P = 0.006). However, the event rate in patients with nonischaemic responses increased from 8% to 16% between 24 and 40 months, and whilst ischaemia was an independent predictor of outcome at 24 months, it was not at 40 months. CONCLUSIONS: In patients with CRF, the identification of ischaemia at DbE is associated with a significant risk of adverse cardiac events. Patients with nonischaemic scans have a low frequency of events over short-term follow-up, but this increases at later follow-up. These later events may reflect progressive coronary disease, attributable to the atherogenic milieu of these patients, and imply that repeated testing may be required to maintain cardiac risk stratification in patients with CRF.

Adrenergic beta-Agonists↗

PubMed2004

Post infarction risk stratification using the 3-D angle between QRS complex and T-wave vectors.

Present experience with prospective identification of patients who might benefit from prophylactic antiarrhythmic intervention is restricted to risk stratification using left ventricular ejection fraction (LVEF). The precision of LVEF-based identification of high risk patients is neither highly sensitive nor highly specific. This study investigated risk stratification of 466 survivors of acute myocardial infarction (86 women, mean age 57.5 years) for whom a 5-year follow-up was available. During the follow-up 67 patients died and 24 of these events were sudden arrhythmic deaths. In addition to LVEF, patients were stratified by mean heart rate, heart rate variability and the slope of heart rate turbulence, all derived from 24-hour Holter recording obtained before hospital discharge, and by the 3D angle between QRS complex and T wave vectors (total cosine R-to-T, TCRT) obtained from digital resting electrocardiogram before hospital discharge. Individual risk characteristics and their combinations were evaluated by calculating the areas under the receiver operator characteristics (ROC). The bootstrap technology was used to investigate these statistically. For the stratification of both all cause mortality and sudden arrhythmic death, TCRT was the strongest risk stratifier (area under ROC of 0.6857 +/- 0.0367, and 0.7275 +/- 0.0544, respectively) that compared very favourably to LVEF (area under the ROC of 0.6610 +/- 0.0362 and 0.6346 +/- 0.0595, for all cause and arrhythmic death prediction, both P < 10(-10) for the comparison with TCRT). TCRT was also stronger in combination with other stratifiers, eg, TCRT + LVEF (area under ROC of 0.7631 +/- 0.0325 and 0.8057 +/- 0.0473, for all cause and arrhythmic death prediction) was stronger than mean heart rate + LVEF (area under ROC of 0.7396 +/- 0.0298 and 0.7673 +/- 0.0445, respectively, both P < 10(-10) for comparison with TCRT + LVEF). Hence the 3D QRS-T angle is a very powerful risk stratifier especially suited for the prediction of sudden arrhythmic death. It should be prospectively investigated in future trials of prophylactic antiarrhythmic interventions.

Adult↗

PubMed2001

Risk stratification analysis of operative mortality in coronary artery bypass surgery.

OBJECTIVE: We assessed the operative mortality of coronary artery bypass grafting (CABG) surgery using risk stratification. METHODS: In 294 consecutive patients who underwent CABG with or without concomitant surgery from August 1994 to December 1999, we compared operative mortality calculated conventionally and by risk stratification. Scores for each patient were calculated using the Parsonnet additive model and stratified based on the probability of operative mortality. RESULTS: Overall crude hospital mortality was 4.8%-4.0% among patients younger than 80 years and 14% among those 80 years of age or older (p = 0.0692). Hospital mortality was 12% in urgent/emergency surgery, and 1.5% in elective surgery (p < 0.0002), and 4.5% in CABG alone and 7.4% in CABG with concomitant surgery (p = 0.3763), and 25% in patients receiving vein grafts only and 3.0% in those receiving at least 1 artery graft (p = 0.0003). Overall patient distribution was 32% good, 20% fair, 20% poor, 11% high-risk, and 16% extremely high-risk. Predicted mortality was 2.2% for patients who were a good risk, 6.7% for fair-risk, 12% for poor-risk, 16% for high-risk, and 25% for extremely high-risk patients. Actual operative mortality was 1.0% for good-risk, 0% for fair-risk, 3.4% for poor-risk, 6.3% for high-risk, and 18% for extremely high-risk patients, making actual mortality significantly lower than that predicted. CONCLUSION: Comparing predicted mortality and actual mortality enabled us to objectively calculate operative results and assess operative quality.

Age Factors↗

PubMed2026

Genome-wide association, polygenic risk scores, and machine learning for chronic post-surgical pain risk stratification: A UK biobank study.

Chronic post-surgical pain is a prevalent and debilitating complication following surgery, representing a clinical challenge. Despite the established heritability of pain phenotypes, large-scale genetic studies remain limited. This study aimed to identify genetic variants associated with chronic post-surgical pain, develop polygenic risk scores, and integrate these with clinical features for risk prediction. UK Biobank data from 47,836 participants (2490 cases and 45,346 controls) were split into training (80%; n = 38,268) and validation (20%; n = 9568) sets prior to analysis. A genome-wide association study was conducted on the training set only, across 19 million variants, and polygenic risk scores were constructed and integrated with clinical features in a logistic regression framework. Two close, rare, imputed signals crossed the genome-wide significance threshold but lacked local linkage-disequilibrium support, while 220 variants crossed the suggestive threshold. In the held-out validation set, cases had higher mean polygenic risk scores than controls (0.138 vs. -0.021; Cohen's d = 0.16, p < 0.001). A logistic regression model integrating clinical features and polygenic risk scores achieved an area under the curve of 0.639 (95% CI: 0.583-0.693), higher than models using either feature set alone. The polygenic risk score for chronic post-surgical pain was among the most important predictors. Risk stratification revealed the top quartile had 3.84-fold higher odds of chronic post-surgical pain than the bottom quartile (95% CI: 2.00-7.37). These findings suggest a possible modest genetic contribution to chronic post-surgical pain. Polygenic risk scores may complement clinical factors in surgical risk stratification. PERSPECTIVE: Chronic post-surgical pain may have a modest genetic contribution. This UK Biobank study identified over 220 variants at suggestive significance and constructed a polygenic risk score that was significantly elevated in cases. A combined clinical-genomic model achieved a 3.84-fold difference in odds across predicted-risk quartiles.

Chronic post-surgical pain↗

PubMed2002

Improvement of risk-stratification by use of a new combination of Holter variables in survivors of myocardial infarction.

OBJECTIVE: Holter monitoring is one option in risk-stratification after acute myocardial infarction (MI). Measurements of heart rate variability (HRV), ventricular tachycardia (VT) and ST-segment elevation (ST upward arrow ) have been useful in predicting clinical outcome. We investigated if a combination of different Holter variables could optimize risk-stratification. DESIGN: One hundred and twenty-one men < 70 years old with a first MI were studied. Holter monitoring for 24 h was started 11 +/- 5 days after MI and analysed for HRV, VT and ST. Follow-up was 10-12 years with cardiac death as endpoint. RESULTS: Thirty-six patients were positive for > or = 1 Holter variable (HRV in 15, VT in 16, ST in 10). At follow-up 22 cardiac deaths had occurred. The prognostic sensitivity of individual Holter variables ranged from 23 to 36%, but increased to 64% if combined. The cardiac death rate in Holter positive patients (39%) was significantly higher than in Holter negative patients (9%) (p < 0.0001). CONCLUSION: By combining measurements of HRV, VT and ST the prognostic importance of Holter monitoring can be significantly improved. The patients can be stratified in a low-risk group with an annual mortality < 1% vs a high-risk group with a cardiac death rate around 40% over the following decade.

Aged↗

PubMed2006

Combined utility of brain natriuretic peptide and cardiac troponin T may improve rapid triage and risk stratification in normotensive patients with pulmonary embolism.

BACKGROUND: Evaluation of the combined utility of brain natriuretic peptide (BNP) and cardiac troponin T (cTnT) for risk stratification in normotensive patients with acute pulmonary embolism. The changing patterns of BNP and cTnT levels during the initial management of pulmonary embolism and their correlation with clinical outcome were the focus of this study. METHODS: BNP and cTnT levels were measured in 28 consecutive normotensive on admission patients (age 53+/-18 years) with acute pulmonary embolism. Twenty-seven healthy age-matched volunteers served as controls (age 42+/-12 years). Blood samples from all patients were obtained during the first hour of presentation. Follow-up blood samples were acquired after 90 days. RESULTS: Six patients (2%) had increased BNP (59+/-30 pmol/L) and cTnT (0.044+/-0.025 ng/mL) and RV dysfunction as diagnosed by echocardiography. Two of these patients died during follow-up as a consequence of RV failure due to pulmonary embolism. Eight patients (29%) had increased BNP (40.6+/-32.6 pmol/L) and normal cTnT at presentation. In four of these patients BNP levels remained increased after treatment (46.9+/-21.0 pmol/L). During follow-up these patients were diagnosed with chronic PE and RV pressure overload (RVSP>40 mm Hg). Fourteen patients (50%) with confirmed pulmonary embolism had normal BNP and cTnT levels at presentation, which remained normal during follow-up. These 14 patients were in good clinical condition during follow-up. CONCLUSIONS: Combined use of BNP and cTnT may be useful in risk stratification of normotensive patients with acute pulmonary embolism. Patients with increased BNP and cTnT are at risk for adverse outcome. Future studies in larger numbers of patients are needed to confirm the usefulness of biomarkers in the clinical management of individual patients.

Adult↗

PubMed2000

Predicting acute renal failure after coronary bypass surgery: cross-validation of two risk-stratification algorithms.

BACKGROUND: Acute renal failure (ARF) requiring dialysis after coronary artery bypass grafting (CABG) occurs in 1 to 5% of patients and is independently associated with postoperative mortality, even after case-mix adjustment. A risk-stratification algorithm that could reliably identify patients at increased risk of ARF could help improve outcomes. METHODS: To assess the validity and generalizability of a previously published preoperative renal risk-stratification algorithm, we analyzed data from the Quality Measurement and Management Initiative (QMMI)1 patient cohort. The QMMI includes all adult patients (N = 9498) who underwent CABG at 1 of 12 academic tertiary care hospitals from August 1993 to October 1995. ARF requiring dialysis was the outcome of interest. Cross-validation of a recursive partitioning algorithm developed from the VA Continuous Improvement in Cardiac Surgery Program (CICSP) was performed on the QMMI. An additive severity score derived from logistic regression was also cross-validated on the QMMI. RESULTS: The CICSP recursive partitioning algorithm discriminated well (ARF vs. no ARF) in QMMI patients, even though the QMMI cohort was more diverse. Rates of ARF were similar among risk subgroups in the CICSP tree, as was the overall ranking of subgroups by risk. Using logistic regression, independent predictors of ARF in the QMMI cohort were similar to those found in the CICSP. The CICSP additive severity score performed well in the QMMI cohort, successfully stratifying patients into low-, medium-, high-, and very high-risk groups. CONCLUSIONS: The CICSP preoperative renal-risk algorithms are valid and generalizable across diverse populations.

Acute Kidney Injury↗

PubMed2000

Dobutamine stress echocardiography and exercise electrocardiography for risk stratification in medically treated unstable angina.

UNLABELLED: Previous reports have demonstrated the superiority of exercise echocardiography over exercise electro-cardiography (ex-ECG) for risk stratification in patients with medically stabilized unstable angina (UA). We sought to analyze the prognostic value of dobutamine stress echocardiography (DSE) compared with ex-ECG for risk stratification in patients with UA. METHODS: Ninety-two patients with medically treated UA were studied (mean age 65 +/- 11 years, 24 women, 42% of patients had electrocardiographic abnormalities on admission). Dobutamine stress echocardiography and treadmill ex-ECG were performed on the third day after hospital admission. End points were recurrent UA, myocardial infarction (MI), or cardiac death. RESULTS: Mean follow-up was 24 +/- 7 months. During follow-up, 22 patients had cardiac events (18 recurrent UA, 2 MI, 2 cardiac deaths). The event-free survival rate was 80% for patients with negative DSE results for ischemia and 52% for those with positive DSE results (log rank 9.57; P =.002), compared with an event-free survival rate of 79% for patients with negative ex-ECG results and 66% for those with positive ex-ECG results (log rank 2.06; P = not significant). Left ventricular dysfunction (P =.01) and a positive dobutamine stress echocardiogram (P =.03), but not a positive exercise electrocardiogram, were independent predictors of cardiac events during follow-up. CONCLUSIONS: Dobutamine stress echocardiography performed early in medically treated patients with UA predicts cardiac events during follow-up more accurately and with more specificity than ex-ECG does in this population.

Aged↗

PubMed2002

Coronary risk stratification in patients with end-stage lung disease.

BACKGROUND: Significant coronary artery disease (CAD) has been a contraindication for listing patients for lung transplantation. We hypothesize that coronary risk stratification can help identify a sub-set of patients who need additional diagnostic tools and intervention. METHODS: We performed a retrospective review of 72 consecutive patients who underwent lung transplantation at our institution from 1995 to 2000. Further, a review of patients who are currently listed for transplantation yielded 48 patients. We then identified the various risk factors for CAD, the diagnostic tools used, and pre-operative intervention. Risk factors identified included smoking history, diabetes, hypertension, hypercholesterolemia, CAD, congestive heart failure, age >50, and arrhythmias. Based on these risk factors, the patients were then classified into 2 groups: low risk (< or =1 risk factors) and high risk (> or =2 risk factors). We identified the patients in each group who underwent coronary angiography (CA), those with angiographic evidence of CAD, and those who received pre-operative intervention. RESULTS: Of the 72 patients who underwent lung transplantation, 48 were identified as at high risk for CAD. Of these, 5 patients had CAD diagnosed before surgery using CA, and 1 patient received pre-operative intervention. Of the 48 patients currently on the lung transplant list, we identified 28 patients as high risk for CAD, 12 of whom were noted to have CA, and 2 of whom received pre-operative intervention. CONCLUSIONS: Although CAD was once a contraindication for lung transplantation, pre-operative risk stratification allows identification of CAD with CA in a high-risk group. We believe that by using appropriate pre-operative cardiac intervention, patients with severe CAD could successfully undergo lung transplantation.

Adolescent↗

PubMed2004

[Risk stratification after acute myocardial infarction: limitations of dobutamine stress echocardiography in females].

BACKGROUND: Dobutamine stress echocardiography (DSE) is an imaging test widely used for risk stratification of patients after acute myocardial infarction. METHODS: We evaluated the sensitivity of DSE with respect to the gender and the stenotic coronary artery in patients who survived a myocardial infarction and with angiographic evidence of single-vessel coronary artery disease. RESULTS: The sensitivity of DSE was generally low. In particular, it was significantly lower in the presence of stenosis of the left circumflex and right coronary arteries with respect to the left anterior descending coronary artery. In females it was lower, especially when the stenosis involved the right coronary and left circumflex arteries. CONCLUSIONS: Our data suggest that in female gender the use of other imaging tests and particularly of coronarography should be strongly recommended for risk stratification after acute myocardial infarction.

Coronary Angiography↗

PubMed2005

Risk stratification of patients with advanced squamous cell carcinoma of cervix treated by radiotherapy alone.

PURPOSE: To identify prognostic factors for local and distant relapse and perform risk stratification for patients with advanced cervical cancer treated with radiotherapy (RT) alone. METHODS AND MATERIALS: A total of 1031 patients with Stage IB-IVA squamous cell carcinoma of the cervix treated with full-course RT but without any chemotherapy were included for analysis. Of these, 311 patients with nonbulky Stage IB-IIA disease were designated the reference group and the other 720 patients were the study group. The associations of stage, squamous cell carcinoma antigen (SCC-ag) level, hemoglobin level, age, cell differentiation, and pelvic lymph node status with treatment failure were evaluated. The independent prognostic factors were identified by multivariate analysis. The study group was further stratified into subgroups using combinations of these risk factors. RESULTS: In the study group, independent risk factors for local relapse were advanced stage and age <45 years. The 5-year local relapse-free survival rate was 86% for patients > or =45 years with bulky Stage IB-IIA or IIB disease, and was even greater, up to 90% if the SCC-ag level was <2. In contrast, it was 65% for patients with Stage IIIB who were <45 years old. The independent risk factors for distant failure were advanced stage, SCC-ag level >2, and positive pelvic lymph nodes. The 5-year distant relapse-free survival rate was 83% for patients with bulky Stage IB-IIA and IIB disease, SCC-ag level <2, and negative lymph nodes and 43% for patients with Stage III, SCC-ag level >2, and positive lymph nodes. CONCLUSION: The risk of treatment failure in advanced-stage cervical cancer patients treated by RT alone can be more precisely predicted by risk stratification. A certain subgroup of patients had better control than the others. The benefit of treating these relatively low-risk patients with additional treatment such as concurrent chemotherapy should be further evaluated in prospective studies or meta-analyses.

Adult↗

PubMed1998

Impact of early risk stratification on the length of hospitalization in patients with acute Q-wave myocardial infarction. 'The 60-minutes myocardial infarction project'.

UNLABELLED: An assessment of individual risk factors may identify a subgroup of postinfarction patients at low risk, i.e. patients appropriate for early discharge. Using a large unselected population of the national registry, 'The 60-Minutes Myocardial Infarction Project', we (1) attempted to provide a retrospective analysis of clinical factors and in-hospital mortality in a population living on the 6th hospital day following admission to define a low-risk patient group with a residual in-hospital mortality of less than 1% eligible for early discharge, and (2) to analyze the current impact of risk stratification based on these clinical factors on the length of hospitalization. The study group consisted of 12,045 survivors on the 6th day after admission out of 14,980 patients of the registry with proven Q-wave myocardial infarction. Risk modeling was performed with multiple logistic regression. RESULTS: A total of 873 patients (7.3%) died after day 6 in hospital. The most important prognostic factors were cardiopulmonary resuscitation prior to admission (odds ratio, OR: 7.2, confidence interval, CI: 5.11-10.22), thrombolysis complicated by severe bleedings (OR: 6.2, CI: 1.2-31. 2) and age >70 years (OR 4.7, CI 3.51-6.39). The other more significant independent predictors of increased mortality were end-stage renal disease, age between 56 and 70 years, systolic blood pressure <95 mm Hg on admission, history of trauma </=2 months, cancer and left-bundle-branch block. Summarizing these nine groups of patients with the strongest association to in-hospital mortality, we defined a high-risk group comprising 79% of the AMI patients with a residual in-hospital mortality of 8.8%. On the other hand, by excluding these nine high-risk patient groups, a low-risk group of 21% of all AMI patients seems to be appropriate for early discharge (residual in-hospital mortality = 1.07%). However, in the current practice, there was no difference regarding the median length of hospital stay between the two risk groups. The low-risk patients were hospitalized 20 days compared to 22 days in the high-risk patients. CONCLUSION: Using a simple logistic regression model, which considers clinical factors of the early hospital phase, one fifth of the infarction patients can be stratified to be at low risk, and might be eligible for early hospital discharge. Currently, an individual risk stratification has no impact on the length of hospital stay in Germany.

Aged↗