Circulation. 2002;105:1567-1572
Published online before print March 11, 2002, doi: 10.1161/01.CIR.0000012543.55874.47
Published online before print March 11, 2002, doi: 10.1161/01.CIR.0000012543.55874.47
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(Circulation. 2002;105:1567.)
© 2002 American Heart Association, Inc.
Clinical Investigation and Reports |
Risk Stratification for Postoperative Cardiovascular Events via Noninvasive Assessment of Endothelial Function
A Prospective Study
From Evans Department of Medicine and Whitaker Cardiovascular Institute (N.G., J.F.K., L.M.H., J.A.V.), Boston University School of Medicine, Boston, Mass; Surgical Service (M.T.W.), VA Boston Healthcare System and Department of Surgery, Boston University School of Medicine, Boston, Mass; and Department of Surgery (J.O.M.), Boston University School of Medicine, Boston, Mass.
Correspondence to Joseph A. Vita, MD, Section of Cardiology, Boston Medical Center, 88 E Newton St, Boston, MA 02118. E-mail jvita{at}bu.edu
Background— Brachial artery endothelial function is impaired in individuals with atherosclerosis and coronary risk factors and improves with risk reduction therapy. However, the predictive value of brachial artery endothelial dysfunction for future cardiovascular events is unknown.
Methods and Results— We preoperatively examined brachial artery vasodilation using ultrasound in 187 patients undergoing vascular surgery. Patients were prospectively followed for 30 days after surgery. Forty-five patients had a postoperative event, including cardiac death (3), myocardial infarction (12), unstable angina/ischemic ventricular fibrillation (2), stroke (3), or elevated troponin I, reflecting myocardial necrosis (25). Preoperative endothelium-dependent flow-mediated dilation was significantly lower in patients with an event (4.9±3.1%) than in those without an event (7.3±5%; P<0.001), whereas endothelium-independent vasodilation to nitroglycerin was similar in both groups. In a Cox proportional-hazards model, the independent predictors of events were age (P=0.001), renal insufficiency (P=0.03), noncarotid surgery (P=0.05), and lower brachial artery flow-mediated dilation (P=0.007). If troponin I elevation was not considered an event, low flow-mediated dilation remained an independent predictor of risk (odds ratio 9.0, 95% CI 1.2 to 68; P=0.03). When a flow-mediated dilation cutpoint of 8.1% was used, endothelial function had a sensitivity of 95%, specificity of 37%, and negative predictive value of 98% for events.
Conclusions— Impaired brachial artery endothelial function independently predicts postoperative cardiac events, which supports a role for endothelial dysfunction in the pathogenesis of cardiovascular disease. The strong negative predictive value of preserved endothelial function raises the possibility that assessment of brachial artery flow-mediated dilation will be useful in the management of patients undergoing vascular surgery.
Key Words: endothelium • surgery • risk factors
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S. Fichtlscherer, S. Breuer, and A. M. Zeiher Prognostic Value of Systemic Endothelial Dysfunction in Patients With Acute Coronary Syndromes: Further Evidence for the Existence of the "Vulnerable" Patient Circulation, October 5, 2004; 110(14): 1926 - 1932. [Abstract] [Full Text] [PDF]
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S. Verma, C.-H. Wang, E. Lonn, F. Charbonneau, J. Buithieu, L. M. Title, M. Fung, S. Edworthy, A. C. Robertson, T. J. Anderson, et al. Cross-sectional evaluation of brachial artery flow-mediated vasodilation and C-reactive protein in healthy individuals Eur. Heart J., October 1, 2004; 25(19): 1754 - 1760. [Abstract] [Full Text] [PDF]
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T. Kondo, M. Hayashi, K. Takeshita, Y. Numaguchi, K. Kobayashi, S. Iino, Y. Inden, and T. Murohara Smoking Cessation Rapidly Increases Circulating Progenitor Cells in Peripheral Blood in Chronic Smokers Arterioscler Thromb Vasc Biol, August 1, 2004; 24(8): 1442 - 1447. [Abstract] [Full Text] [PDF]
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 S. I. Sokol, E. L. Portnay, J. P. Curtis, M. A. Nelson, P. R. Hebert, J. F. Setaro, and J. M. Foody Modulation of the renin-angiotensin-aldosterone system for the secondary prevention of stroke Neurology, July 27, 2004; 63(2): 208 - 213. [Abstract] [Full Text] [PDF]
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S. Fichtlscherer, S. Breuer, C. Heeschen, S. Dimmeler, and A. M. Zeiher Interleukin-10 serum levels and systemic endothelial vasoreactivity in patients with coronary artery disease J. Am. Coll. Cardiol., July 7, 2004; 44(1): 44 - 49. [Abstract] [Full Text] [PDF]
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A. H. Slyper What Vascular Ultrasound Testing Has Revealed about Pediatric Atherogenesis, and a Potential Clinical Role for Ultrasound in Pediatric Risk Assessment J. Clin. Endocrinol. Metab., July 1, 2004; 89(7): 3089 - 3095. [Abstract] [Full Text] [PDF]
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J E Macdonald, N Kennedy, and A D Struthers Effects of spironolactone on endothelial function, vascular angiotensin converting enzyme activity, and other prognostic markers in patients with mild heart failure already taking optimal treatment Heart, July 1, 2004; 90(7): 765 - 770. [Abstract] [Full Text] [PDF]
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J. N. Cohn, A. A. Quyyumi, N. K. Hollenberg, and K. A. Jamerson Surrogate Markers for Cardiovascular Disease: Functional Markers Circulation, June 29, 2004; 109(25_suppl_1): IV-31 - IV-46. [Full Text] [PDF]
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J. Davignon Beneficial Cardiovascular Pleiotropic Effects of Statins Circulation, June 15, 2004; 109(23_suppl_1): III-39 - III-43. [Abstract] [Full Text]
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T. Suhara, K. Fukuo, O. Yasuda, M. Tsubakimoto, Y. Takemura, H. Kawamoto, T. Yokoi, M. Mogi, T. Kaimoto, and T. Ogihara Homocysteine Enhances Endothelial Apoptosis via Upregulation of Fas-Mediated Pathways Hypertension, June 1, 2004; 43(6): 1208 - 1213. [Abstract] [Full Text] [PDF]
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M. E. Otto, A. Svatikova, R. B. d. M. Barretto, S. Santos, M. Hoffmann, B. Khandheria, and V. Somers Early Morning Attenuation of Endothelial Function in Healthy Humans Circulation, June 1, 2004; 109(21): 2507 - 2510. [Abstract] [Full Text] [PDF]
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U. Landmesser, B. Hornig, and H. Drexler Endothelial Function: A Critical Determinant in Atherosclerosis? Circulation, June 1, 2004; 109(21_suppl_1): II-27 - II-33. [Abstract] [Full Text] [PDF]
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I. Eskurza, K. D. Monahan, J. A. Robinson, and D. R. Seals Effect of acute and chronic ascorbic acid on flow-mediated dilatation with sedentary and physically active human ageing J. Physiol., April 1, 2004; 556(1): 315 - 324. [Abstract] [Full Text] [PDF]
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R. Fathi, B. Haluska, N. Isbel, L. Short, and T. H. Marwick The relative importance of vascular structure and function in predicting cardiovascular events J. Am. Coll. Cardiol., February 18, 2004; 43(4): 616 - 623. [Abstract] [Full Text] [PDF]
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G. B. J. Mancini Vascular structure versus function: is endothelial dysfunction of independent prognostic importance or not? J. Am. Coll. Cardiol., February 18, 2004; 43(4): 624 - 628. [Full Text] [PDF]
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 V. Fonseca, C. Desouza, S. Asnani, and I. Jialal Nontraditional Risk Factors for Cardiovascular Disease in Diabetes Endocr. Rev., February 1, 2004; 25(1): 153 - 175. [Abstract] [Full Text] [PDF]
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S. Verma and P. E. Szmitko Coxibs and the endothelium J. Am. Coll. Cardiol., November 19, 2003; 42(10): 1754 - 1756. [Full Text] [PDF]
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P. Ganz and J. A. Vita Testing Endothelial Vasomotor Function: Nitric Oxide, a Multipotent Molecule Circulation, October 28, 2003; 108(17): 2049 - 2053. [Full Text] [PDF]
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S. Verma, M. R. Buchanan, and T. J. Anderson Endothelial Function Testing as a Biomarker of Vascular Disease Circulation, October 28, 2003; 108(17): 2054 - 2059. [Full Text] [PDF]
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G. Brevetti, A. Silvestro, V. Schiano, and M. Chiariello Endothelial Dysfunction and Cardiovascular Risk Prediction in Peripheral Arterial Disease: Additive Value of Flow-Mediated Dilation to Ankle-Brachial Pressure Index Circulation, October 28, 2003; 108(17): 2093 - 2098. [Abstract] [Full Text] [PDF]
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M. E. Widlansky, N. Gokce, J. F. Keaney Jr, and J. A. Vita The clinical implications of endothelial dysfunction J. Am. Coll. Cardiol., October 1, 2003; 42(7): 1149 - 1160. [Abstract] [Full Text] [PDF]
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S. Y. Chan, G. B. J. Mancini, L. Kuramoto, M. Schulzer, J. Frohlich, and A. Ignaszewski The prognostic importance of endothelial dysfunction and carotid atheromaburden in patients with coronary artery disease J. Am. Coll. Cardiol., September 17, 2003; 42(6): 1037 - 1043. [Abstract] [Full Text] [PDF]
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M. E. Widlansky, D. T. Price, N. Gokce, R. T. Eberhardt, S. J. Duffy, M. Holbrook, C. Maxwell, J. Palmisano, J. F. Keaney Jr, J. D. Morrow, et al. Short- and Long-Term COX-2 Inhibition Reverses Endothelial Dysfunction in Patients With Hypertension Hypertension, September 1, 2003; 42(3): 310 - 315. [Abstract] [Full Text] [PDF]
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T. Suzuki, K. Fukuo, T. Suhara, O. Yasuda, N. Sato, Y. Takemura, M. Tsubakimoto, and T. Ogihara Eicosapentaenoic Acid Protects Endothelial Cells Against Anoikis Through Restoration of cFLIP Hypertension, September 1, 2003; 42(3): 342 - 348. [Abstract] [Full Text] [PDF]
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S. Amar, N. Gokce, S. Morgan, M. Loukideli, T. E. Van Dyke, and J. A. Vita Periodontal Disease Is Associated With Brachial Artery Endothelial Dysfunction and Systemic Inflammation Arterioscler Thromb Vasc Biol, July 1, 2003; 23(7): 1245 - 1249. [Abstract] [Full Text] [PDF]
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J. T. Kuvin and R. H. Karas Clinical Utility of Endothelial Function Testing: Ready for Prime Time? Circulation, July 1, 2003; 107(25): 3243 - 3247. [Full Text] [PDF]
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R. J. Bisoendial, G. K. Hovingh, J. H.M. Levels, P. G. Lerch, I. Andresen, M. R. Hayden, J. J.P. Kastelein, and E. S.G. Stroes Restoration of Endothelial Function by Increasing High-Density Lipoprotein in Subjects With Isolated Low High-Density Lipoprotein Circulation, June 17, 2003; 107(23): 2944 - 2948. [Abstract] [Full Text] [PDF]
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R. A. Vogel Heads and Hearts: The Endothelial Connection Circulation, June 10, 2003; 107(22): 2766 - 2768. [Full Text] [PDF]
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P. V. Targonski, P. O. Bonetti, G. M. Pumper, S. T. Higano, D. R. Holmes Jr, and A. Lerman Coronary Endothelial Dysfunction Is Associated With an Increased Risk of Cerebrovascular Events Circulation, June 10, 2003; 107(22): 2805 - 2809. [Abstract] [Full Text] [PDF]
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J. M. Meinders, L. Kornet, and A. P. G. Hoeks Assessment of spatial inhomogeneities in intima media thickness along an arterial segment using its dynamic behavior Am J Physiol Heart Circ Physiol, June 5, 2003; 285(1): H384 - H391. [Abstract] [Full Text] [PDF]
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N. Gokce, J. F. Keaney Jr, L. M. Hunter, M. T. Watkins, Z. S. Nedeljkovic, J. O. Menzoian, and J. A. Vita Predictive value of noninvasivelydetermined endothelial dysfunction for long-term cardiovascular events inpatients with peripheral vascular disease J. Am. Coll. Cardiol., May 21, 2003; 41(10): 1769 - 1775. [Abstract] [Full Text] [PDF]
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