The Prevention of Events with Angiotensin Converting Enzyme inhibition (PEACE) trial evaluated angiotensin-converting enzyme inhibition with trandolapril versus placebo added to conventional therapy in patients with stable coronary disease and preserved left ventricular function. The PEACE hemodynamic substudy evaluated effects of trandolapril on pulsatile hemodynamics. Hemodynamic studies were performed in 300 participants from 5 PEACE centers a median of 52 months (range, 25 to 80 months) after random assignment to trandolapril at a target dose of 4 mg per day or placebo. Central pulsatile hemodynamics and carotid–femoral pulse wave velocity were assessed by using echocardiography, tonometry of the carotid and femoral arteries, and body surface transit distances. Patients randomly assigned to trandolapril tended to be older (mean±SD: 64.2±7.9 versus 62.9±7.7 years; P =0.14), with a higher body mass index (28.5±4.0 versus 27.8±3.9 kg/m 2 ; P =0.09) and lower ejection fraction (57.1±8.1% versus 58.7±8.4%; P <0.01). At the time of the hemodynamic substudy, the trandolapril group had lower mean arterial pressure (93.1±10.2 versus 96.3±11.3 mm Hg; P <0.01) and lower carotid-femoral pulse wave velocity (geometric mean [95% CI]: 10.4 m/s [10.0 to 10.9 m/s] versus 11.2 m/s [10.7 to 11.8 m/s]; P =0.02). The difference in carotid–femoral pulse wave velocity persisted ( P <0.01) in an analysis that adjusted for baseline characteristics and follow-up mean pressure. In contrast, there was no difference in aortic compliance, characteristic impedance, augmentation index, or total arterial compliance. Angiotensin-converting enzyme inhibition with trandolapril produced a modest reduction in carotid–femoral pulse wave velocity, a measure of aortic wall stiffness, beyond what would be expected from blood pressure lowering or differences in baseline characteristics alone.
Background: The ESCAPE trial demonstrated equivalent 6-month heart failure (HF) hospitalization and mortality in patients (pts) randomized to therapy guided by pulmonary artery catheter (PAC) plus clinical assessment versus clinical assessment alone. However, it is unknown to what extent HF pts receiving PAC outside the trial differ from pts randomized using inclusion criteria designed to select for PAC equipoise. Methods: The ESCAPE registry was a concomitant repository of advanced HF pts receiving a PAC who did not fulfill trial entry criteria or were thought by HF specialists to require PAC-guided therapy.
Silent myocardial ischemia is a frequent finding when Holter monitoring is done in patients with advanced coronary disease. Silent ischemia is associated with a worse prognosis in patients with stable or unstable angina, survivors of myocardial infarction, and populations at risk for coronary disease. Whether medical therapy for silent ischemia improves prognosis is not known. In a randomized, placebo-controlled, multicenter trial of 60 patients with documented coronary disease, positive exercise tests, and ischemic episodes on Holter monitoring, long-acting diltiazem reduced ischemic episodes by 50% compared to placebo, from a mean of 5.6 to 2.8 (p less than 0.0001). Efficacy was maintained over 24 h and diltiazem also significantly improved exercise test parameters. Three smaller studies also demonstrated that diltiazem effectively reduces ambulatory ischemia; however, results with nifedipine are conflicting, with several studies showing no benefit. In contrast, beta-blockers reliably reduce ischemic episodes. The role of medical therapy for silent ischemia will be clarified only when its effect upon morbidity and mortality are determined.
Background The objectives were to investigate the factors influencing signal-averaged ECGs (SAECGs) recorded in patients after myocardial infarction (MI) and to develop criteria for predicting arrhythmic events (AEs) that account for these factors. Methods and Results SAECGs were recorded 5 to 15 days after MI in 2461 patients without bundle-branch block. The duration (QRSd), terminal potential (VRMS), and terminal duration (LAS) of the filtered QRS were measured. During follow-up (17±8 months), AEs (arrhythmic death; ventricular tachycardia, VT; ventricular fibrillation, VF) occurred in 80 patients (3.3%). Receiver operating characteristic curves showed that QRSd discriminated patients with all types of AEs, but VRMS and LAS discriminated only VT patients; QRSd minus LAS also discriminated AE patients. Sex, age, and MI location significantly affected the SAECG; survivors without VT or VF were divided into subgroups (2 sex×4 age×2 MI), and QRSd values exceeding the 70th percentile in each subgroup predicted AEs with a sensitivity of 65.4%. An unadjusted QRSd criterion showed the same overall sensitivity and specificity but with less uniform values for each subgroup. A Cox model was constructed by use of multiple prognostic indicators, and in rank order, QRSd, previous MI, and Killip class were predictive of AEs. Conclusions SAECG adjustments for sex, age, and MI location did not improve sensitivity and specificity but produced a more uniform predictive performance. The proposed criteria are based only on QRSd, because late potentials (VRMS and LAS) did not discriminate patients with sudden death. Duration of high-level activity during QRS (QRSd−LAS) can predict AEs, suggesting that the arrhythmogenic substrate involves a large mass of myocardium.
Background Left (LBBB) and right (RBBB) bundle branch block (BBB) patients have an increased incidence of cardiac death after myocardial infarction (Ml). The purpose of this study was to assess the value of the signal‐averaged electrocardiogram (SAECG) and other clinical variables for the prediction of cardiac death after MI in BBB patients. Methods SAECGs were recorded 5–15 days after MI in 76 LBBB and 79 RBBB patients. The SAECG was analyzed in the time domain and the frequency domain (wavelet analysis in 7 frequency bands ranging from 0.05 to 250 Hz). Results During follow‐up (17 ± 8 months), cardiac death occurred in 22 LBBB (28.9%) and 12 RBBB patients (15.2%). None of the SAECG time‐domain variables were significantly different between patients with and without cardiac death. In LBBB patients, univariate analysis showed that one wavelet parameter in the 3.9‐ to 7.8‐ Hz frequency band (P = 0.008), inhospital recurrent Ml (P = 0.002), left ventricular ejection fraction (LVEF) < 30% (P = 0.004), lack of percutaneous transluminal coronary angioplasty (P = 0.02), and history of angina (P = 0.029) were significantly different in cardiac death patients. In RBBB patients, only recurrent angina was significantly different (P = 0.025). In LBBB patients, the combination of recurrent Ml or LVEF < 30% displayed the best predictive values: sensitivity (85.7%), specificity (76.6%), positive (52.2%), negative (94.7%), and total (78.7%) predictive accuracies and risk ratio of 9.9. The effect of recurrent Ml and LVEF < 30% remained after statistical adjustment by means of regression using Cox proportional hazards. Conclusions High‐risk Ml patients can be identified by recurrent Ml and LVEF < 30% in LBBB patients, and by recurrent angina in RBBB patients. SAECG did not demonstrate incremental information for the purpose of risk stratification in BBB patients.
