Faculty Bibliography

OBJECTIVES: We sought to evaluate the risk stratification ability and incremental prognostic value of stress echocardiography over historic, clinical, and stress electrocardiographic (ECG) variables, over a wide spectrum of bayesian pretest probabilities of coronary artery disease (CAD). BACKGROUND: Stress echocardiography is an established technique for the diagnosis of CAD. However, data on incremental prognostic value of stress echocardiography over historic, clinical, and stress ECG variables in patients with known or suggested CAD is limited. METHODS: We evaluated 3259 patients (60 +/- 13 years, 48% men) undergoing stress echocardiography. Patients were grouped into low (<15%), intermediate (15-85%), and high (>85%) pretest CAD likelihood subgroups using standard software. The historical, clinical, stress ECG, and stress echocardiographic variables were recorded for the entire cohort. Follow-up (2.7 +/- 1.1 years) for confirmed myocardial infarction (n = 66) and cardiac death (n = 105) was obtained. RESULTS: For the entire cohort, an ischemic stress echocardiography study confers a 5.0 times higher cardiac event rate than the normal stress echocardiography group (4.0% vs 0.8%/y, P < .0001). Furthermore, Cox proportional hazard regression model showed incremental prognostic value of stress echocardiography variables over historic, clinical, and stress ECG variables across all pretest probability subgroups (global chi2 increased from 5.1 to 8.5 to 20.1 in the low pretest group, P = .44 and P = .01; from 20.9 to 28.2 to 116 in the intermediate pretest group, P = .47 and P < .0001; and from 17.5 to 36.6 to 61.4 in the high pretest group, P < .0001 for both groups). CONCLUSIONS: A normal stress echocardiography portends a benign prognosis (<1% event rate/y) in all pretest probability subgroups and even in patients with high pretest probability and yields incremental prognostic value over historic, clinical, and stress ECG variables across all pretest probability subgroups. The best incremental value is, however, in the intermediate pretest probability subgroup

Recent studies have shown that beta-blockers in patients with hypertension is associated with an increased risk of cardiovascular events, in particular stroke, leading to headlines speculating the end of the beta-blocker era. The objective of this review is to critically examine the usefulness of beta-blockers in cardiovascular diseases. We reviewed the currently available evidence for the usefulness of beta-blockers in patients with hypertension and also assessed the efficacy of its use for other indications, like, chronic heart failure, stable angina, myocardial infarction, arrhythmias etc. The review of the currently available literature shows that for patients with uncomplicated hypertension, there is paucity of data or absence of evidence to support use of beta-blockers as monotherapy or as first line agent. Given the risk of stroke and numerous unacceptable adverse effects, the risk benefit ratio for beta-blockers is not acceptable for this indication. However, beta-blockers are very efficacious agents for the treatment of heart failure, certain types of arrhythmia, and post myocardial infarction. The various guideline committees should seriously reconsider their decision about their endorsement of beta-blockers as first line therapy for uncomplicated hypertension. However, this is applicable for hypertension and beta-blockers continue to be efficacious for other indications