Coronary artery disease
Long-Term Prognostic Role of Flow-Mediated Dilatation of the Brachial Artery After Acute Coronary Syndromes Without ST Elevation

https://doi.org/10.1016/j.amjcard.2006.06.043Get rights and content

Coronary endothelial vasodilator dysfunction is associated with increased cardiac events; the close relation between coronary vasomotor dysfunction and brachial artery vasoreactivity has been previously described. This study assessed the prognostic value of noninvasively assessed brachial artery vasoreactivity in survivors of acute coronary syndromes without ST-segment elevation. We examined 98 men (63.1 ± 10.8 years) who were referred to our hospital for acute coronary syndromes without ST-segment elevation. Brachial artery endothelium-dependent flow-mediated dilation (FMD) and endothelium-independent nitrate-mediated dilation were examined in all patients using high-resolution echocardiographic Doppler ultrasound within 24 hours of admission. Plasma malondialdehyde, a marker of oxidative stress, and left ventricular ejection fraction were also assessed. Twenty-seven patients underwent coronary revascularization. Patients were followed for 24.8 ± 5.9 months. Cardiovascular death, myocardial infarction, stroke, and unstable angina were designated as cardiovascular events (CEs). Twenty CEs were recorded. Kaplan-Meyer analysis showed that patients with FMD <1.9% (tertile 1 of FMD values) were more likely to have CEs than those with FMD >1.9% (log rank 5.29, p = 0.021). Multivariate Cox regression analysis showed that FMD <1.9% predicted CEs with an adjusted hazard ratio of 3.035 (95% confidence interval 1.148 to 8.023, p = 0.025) after adjustment for age, risk factors, troponin T, ejection fraction, revascularization procedures, number of diseased vessels, and medication. In conclusion, endothelium-dependent dilation of the brachial artery is a strong independent predictor of adverse outcome in survivors of acute coronary syndromes without ST-segment elevation.

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Methods

Ninety-eight men (63.15 ± 10.78 years) were studied on the second day after their admission for an acute coronary syndrome, defined as angina at rest and ST alterations, without ST-segment elevation, with or without increased troponin T. Presence of hepatic or renal insufficiency, inflammatory or malignant disease, recent (previous 3 months) myocardial infarction, or recent revascularization procedures, and an ejection fraction <40% were considered exclusion criteria. FMD and nitrate-mediated

Results

Twenty-two of 98 patients presented with high troponin levels. Patients were followed for 24.79 ± 5.92 months and 20 CEs were recorded (6 myocardial infarctions, 1 fatal; 3 deaths, 1 after infarction and 2 strokes; and 10 hospitalizations for unstable angina). Further, 27 revascularizations were performed, 18 of them (9 percutaneous coronary interventions, 9 coronary artery bypass graftings) within 1 month. Table 1 lists baseline characteristics of the study population.

Survival tables showed

Discussion

In the present study, we demonstrated for the first time that impairment of brachial artery FMD is associated with increased risk of future CEs in men surviving an acute coronary syndrome without ST elevation.

A series of previous studies has shown that endothelial dysfunction in the coronary or peripheral circulation assessed invasively or noninvasively can predict future CEs in various populations and clinical settings.23, 24 Recently, in 198 patients with an acute coronary syndrome,

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