Impact of Pulmonary Artery Catheter Use on Short- and Long-Term Mortality in Patients with Cardiogenic Shock.

OBJECTIVES: The impact of pulmonary artery catheterization (PAC) on survival in patients with cardiogenic shock (CS) is not well established. This study aimed to assess whether Swan-Ganz catheter monitoring is related to short- and long-term mortality in patients with CS. METHODS: One hundred and twenty-nine consecutive patients with a first admission for CS were prospectively enrolled in a single-center registry between December 2005 and May 2009, and were subsequently followed up over 5.3 years. RESULTS: PAC was used in 64% of all patients with a mean age of 68 years (65% men). After adjustment for age, gender and the presence of CS upon admission, PAC was associated with lower short-term mortality [hazard ratio (HR) = 0.55, 95% confidence interval (CI) 0.35-0.86, p = 0.008] as well as lower mortality rates in the long-term follow-up (HR = 0.63, 95% CI 0.41-0.97, p = 0.035). In a subgroup analysis, the use of PAC was associated with reduced mortality in patients without acute coronary syndrome (ACS), i.e. 49% in the Swan-Ganz group vs. 82% (p = 0.010), but there was no difference within the ACS group. CONCLUSIONS: The use of PAC in patients with CS was associated with lower short- and long-term mortality rates after adjustment for age, gender and the presence of shock upon admission. This benefit was only significant in those patients without ACS.

Left ventricular outflow tract obstruction in Takotsubo syndrome with cardiogenic shock: prognosis and treatment.

BACKGROUND: Patients with Takotsubo syndrome (TTS) who develop cardiogenic shock may present with left ventricular outflow tract obstruction (LVOTO). The prognosis and treatment of this population have not been defined in previous studies. The aim of this study is to describe the clinical presentation, management, evolution and prognosis of a subgroup of patients with TTS and cardiogenic shock according to whether they present with LVOTO or not. METHODS: We analysed patients with TTS recruited from 2003 to 2022 in a multicentre registry. Patients were selected if they presented cardiogenic shock during their admission. This analysis was compared according to the presence or absence of LVOTO. RESULTS: 322 patients were included, 58 (18%) of whom had LVOTO. The majority were treated with vasoactive and inotropic therapy (VIT) and its use was strongly associated with having LVOTO (77.6% vs 57.6%, p<0.001). Only five (3.3%) patients without LVOTO and two (4.4%) in the LVOTO group treated with VIT developed or worsened the obstruction. Furthermore, patients with LVOTO presented higher in-hospital complications including ventricular arrhythmias (15.5% vs 8.7%, p=0.017), major bleeding (13.8% vs 6.1%, p=0.042) and acute kidney failure (48.3% vs 28.4%, p=0.003). However, at both 90 days and 5 years, the cumulative incidence of all-cause death was not significantly different between the patients with and without LVOTO (HR 1.20, 95% CI 0.60 to 2.40 for 90 days, and HR 1.69, 95% CI 0.89 to 3.21 for 5 years). CONCLUSIONS: LVOTO is not uncommon in patients with TTS and cardiogenic shock. It is associated with a more aggressive in-hospital course and our data is unable to rule out an association between the presence of LVOTO and long-term prognosis of patients with TTS. The development or worsening of LVOTO directly related to inotropic or vasoactive support was low.

Impact of mechanical circulatory support on outcomes in Takotsubo syndrome complicated by cardiogenic shock: Insights from the RETAKO registry.

BACKGROUND: Cardiogenic shock (CS) complicates Takotsubo syndrome (TTS), significantly affecting patient outcomes. Since avoiding catecholamines, particularly inotropic agents, is recommended in TTS, temporary mechanical circulatory support (MCS) shows promise as a bridge to recovery. However, there is no prospective data on its use in TTS. METHODS: Patients from the prospective nationwide RETAKO registry were included and divided based on the use and type of MCS. RESULTS: From a national TTS registry, 1591 consecutive patients were initially enrolled between 2003 and 2022. Of these, 322 patients (20.2 %) developed CS, and 31 (9.6 %) were treated with MCS [20 intra-aortic balloon pump (IABP) (64.5 %), 8 veno-arterial extracorporeal membrane oxygenation (25.8 %), and 3 Impella-CP (9.7 %)]. Compared to CS patients managed only with drugs, MCS recipients exhibited a more severe clinical profile, with worse ventricular function and more right ventricular involvement. Despite encountering more complications, such as major bleeding and atrial fibrillation, MCS did not significantly influence in-hospital mortality (19.4 % in the MCS group vs 13.1 % in the no MCS group, p = 0.33). After adjusting for other predictors of in-hospital mortality (invasive mechanical ventilation, inotropic-vasoactive score, age, and SCAI stage), MCS was not associated with higher mortality. CONCLUSION: Approximately 10 % of TTS patients complicated by CS were treated with MCS. Despite their more severe CS, patients treated with MCS had similar in-hospital mortality rates as those treated only with drugs, suggesting a potential benefit of MCS in selected cases.

Prognostic Utility of Society for Cardiovascular Angiography and Interventions Shock Stage Approach for Classifying Cardiogenic Shock Severity in Takotsubo Syndrome.

BACKGROUND: Cardiogenic shock (CS) is a significant complication of Takotsubo syndrome (TTS), contributing to heightened mortality and morbidity. Despite this, the Society for Cardiovascular Angiography and Interventions (SCAI) staging system for CS severity lacks validation in patients with TTS and CS. This study aimed to characterize a patient cohort with TTS using the SCAI staging system and assess its utility in cases of TTS complicated by CS. METHODS AND RESULTS: From a TTS national registry, 1591 consecutive patients were initially enrolled and stratified into 5 SCAI stages (A through E). Primary outcome was all-cause in-hospital mortality; secondary end points were TTS-related in-hospital complications and 1-year all-cause mortality. After exclusions, the final cohort comprised 1163 patients, mean age 71.0±11.8 years, and 87% were female. Patients were categorized across SCAI shock stages as follows: A 72.1%, B 12.2%, C 11.2%, D 2.7%, and E 1.8%. Significant variations in baseline demographics, comorbidities, clinical presentations, and in-hospital courses were observed across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage showed a significant association with increased in-hospital mortality (adjusted odds ratio: 1.77-29.31) compared with SCAI shock stage A. Higher SCAI shock stages were also associated with increased 1-year mortality. CONCLUSIONS: In a large multicenter patient cohort with TTS, the functional SCAI shock stage classification effectively stratified mortality risk, revealing a continuum of escalating shock severity with higher stages correlating with increased in-hospital mortality. This study highlights the applicability and prognostic value of the SCAI staging system in TTS-related CS.

Incremental prognostic value of global longitudinal strain to the coronary microvascular resistances in Takotsubo patients.

BACKGROUND: Global longitudinal strain (GLS) allows an accurate assessment of left ventricular function with prognostic value. We aimed to evaluate whether the assessment of GLS in the acute phase of Takotsubo syndrome (TTS) provides incremental prognostic value to the degree of impaired microvascular resistance (MR) in TTS patients at 1-year follow-up. METHODS: We recruited patients admitted for TTS who underwent cardiac angiography and echocardiography from January 2017 to June 2020. Left anterior descending coronary artery non-hyperaemic angiography-derived index of microcirculatory resistance (LAD NH-IMRangio) was calculated. NT-proBNP, high-sensitive cardiac troponin T (hs-cTnT), left ventricular ejection fraction (LVEF) and GLS were measured at admission. Major adverse cardiac events (MACE) were defined as the composite of cardiovascular death, repeat hospitalizations for heart failure (HF) and acute myocardial infarctions. RESULTS: 67 patients had both GLS and NH-IMRangio available and were included in the study. Median age was 75.2 years and 88% were women. Rate of MACE at 1-year was 13.4%. Kaplan-Meier curves showed higher rates of MACE at 1-year in patients with both higher LAD NH-IMRangio and GLS values compared with those with higher LAD NH-IMRangio and lower GLS values (33.3% vs. 11.1%; p = 0.049). NT-proBNP levels at admission and the recovery of LVEF were correlated with GLS values while MR and hs-cTnT were not. CONCLUSION: GLS provides incremental prognostic value to the degree of impaired MR in TTS patients. The combination of a poorer GLS with a higher degree of impaired MR was associated with a higher rate of MACE in these patients.

[Heart rate disorders in patients with Tako-tsubo syndrome]. / Trastornos del ritmo cardiaco en pacientes con síndrome de Tako-tsubo.

OBJECTIVES: This study sought to evaluate the incidence, prognosis and treatment of heart rhythm disorders (HRD) in Tako-tsubo syndrome (TTS). BACKGROUND: TTS is associated with HRD. The HRD prognostic value is not well characterized in TTS yet. METHODS: The HRD of patients included in the National Registry of Tako-tsubo syndrome, admitted between 2002 and 2018 and coming from 38 hospitals throughout the country, was analyzed. We analyzed any heart rhythm disorder in patients presented before admission, at admission and in long-term follow-up. RESULTS: All types of HRD were described in 259 (23.5%) cases, from a cohort of 1,097 consecutive patients with TTS. HRD was more associated with diabetes mellitus, smoking, hyperuricemia, sleep apnea, anemia with a worse LVEF on admission. The most frequent HRD was a new onset of atrial fibrillation. During hospitalization, patients with HRD showed more complications such as shock on admission, major bleeding, acute renal failure, and combined infections. At follow-up, they presented higher mortality and more major adverse cardiac events, but with a non-significant correlation. CONCLUSIONS: The incidence of HRD in patients with TTS is not infrequent. TTS, when associated with HRD, presents more complications and a worse prognosis both in hospital and in the long term.

Comparative electrocardiographic analysis of midventricular and typical takotsubo syndrome.

Introduction: Takotsubo syndrome (TTS) encompasses distinct variants, with midventricular (MV) as the most common atypical subtype. While electrocardiogram (ECG) abnormalities are well documented in typical TTS, they are less explored in MV-TTS. Methods: A retrospective case-control study was conducted where ECGs were reviewed at three time points from symptom onset (within the first 12 h, at 48 h, and at 5-7 days) and compared between patients with typical TTS (n = 33) and those with MV-TTS (n = 27), as classified by ventriculography. Results: 12-h ECG findings revealed that typical TTS featured ST-segment elevation through anterior leads V3-V6, with maximal deviation in V3 (0.98 ± 0.99 mm) and V4 (0.91 ± 0.91 mm), whereas MV-TTS featured ST-segment depression in inferior leads (-0.24 ± 0.57 mm in II, -0.30 ± 0.52 mm in III, and -0.32 ± 0.47 mm in aVF) and in precordial leads V4-V6. In 48-h ECG findings, the most significant change was T wave inversion, which was more widespread and deeper in typical TTS, with the most pronounced negative T wave depths, exceeding 3 mm, observed in leads V3-V5; in contrast, in MV-TTS, T wave inversion was evident in fewer leads and showed less depth, with the most pronounced negative T waves reaching 1 mm at most in leads I, aVL, and V2. While the QTc interval was prolonged in both groups at 48 h, this prolongation was more pronounced in typical TTS than in MV-TTS (523 ± 52 ms vs. 487 ± 66 ms; p = 0.029). In ECGs at 5-7 days, results essentially returned to baseline. Conclusion: Patients with MV-TTS exhibited a distinctive pattern of ECG abnormalities, marked by ST-segment depression in inferolateral leads, less profound and less extensive T wave inversion that mostly affected leads I, aVL and V2, and attenuated QT interval prolongation compared to typical TTS.

Takotsubo Syndrome, Stressful Triggers, and Risk of Recurrence.

The risk of recurrence in takotsubo syndrome (TTS) appears to be low, although previous studies have shown conflicting results and factors associated with recurrences are unclear. The aim of this study is to evaluate the incidence and predictors of TTS recurrences. Adult patients included in the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO) between January 2003 and September 2019 were identified. Patients were categorized based on recurrences during follow-up and a multivariate logistic regression model was used to identify factors associated with recurrences. A total of 1097 patients (mean age 71.0±11.9 years, 87% females) were included, repeated TTS events were documented in 44 patients (4.0%), including 13 patients with prior TTS and 31 patients with recurrent TTS during a median follow-up of 279 days. Two patients (0.02%) had two episodes of recurrence. Compared to patients who had no recurrence of TTS, those with recurrent TTS more frequently had no identifiable stressful trigger in the index admission (20 [64.5%] vs 352 [33.0%], p <0.001). Primary TTS, defined as TTS without physical trigger, was also more common in the recurrence group (93.5% vs 68.3%, p <0.001). The only factor independently associated with recurrences was the absence of an identifiable trigger (odds ratio 3.7 [95% confidence interval 1.8-7.8], p=0.001). In conclusion, our data indicate that for patients presenting with TTS, the rate of early recurrent TTS is approximately 4% per year. Among TTS patients, those who have no identifiable trigger events appear to have a higher rate of recurrence.

Prognostic Value of Microvascular Resistance at Rest in Patients With Takotsubo Syndrome.

BACKGROUND: Microvascular resistance (MR) is increased in takotsubo syndrome (TTS) and can be assessed by a validated pressure-wire-free tool called nonhyperemic angiography-derived index of microcirculatory resistance (NH-IMRangio). OBJECTIVES: The authors aimed to study whether the degree and extent of an altered MR in TTS patients were associated with 1-year prognosis. METHODS: The authors recruited 181 consecutive patients with TTS who underwent cardiac angiography. Impaired MR was defined as an NH-IMRangio ≥25. The degree and extent of impaired MR were assessed by the value of maximum NH-IMRangio in each major coronary artery and by the number of coronary arteries with an NH-IMRangio ≥25, respectively. Major adverse cardiac events (MACE) were a composite of cardiovascular death, heart failure event, acute myocardial infarction, and hospitalization for symptomatic arrhythmias. RESULTS: A total of 166 patients had NH-IMRangio available. The mean age was 74.8 years, and 83% were women. The rate of MACE at 1 year was 21.1%, mainly due to heart failure events that were generally mild. Kaplan-Meier curves showed higher rates of MACE in patients with higher NH-IMRangio (28.9% vs 13.3%; P = 0.019) and in those with 3 coronary arteries with increased MR compared to those with 2 or 1 affected arteries (33.3% vs 15.9% vs 9.5%; P = 0.040 and P = 0.040, respectively). After a multivariable Cox regression analysis, higher values of NH-IMRangio (HR: 3.41 [95% CI: 1.54-7.52]; P = 0.002) and the presence of 3 coronary arteries with increased MR (HR: 6.39 [95% CI: 1.46-27.87]; P = 0.014) were independent predictors of MACE in TTS patients. CONCLUSIONS: The degree and extent of an impaired MR assessed by a validated pressure-wire-free tool were independent predictors of MACE at 1-year follow-up in TTS patients.

CD69 expression on regulatory T cells protects from immune damage after myocardial infarction.

Increasing evidence has pointed to the important function of T cells in controlling immune homeostasis and pathogenesis after myocardial infarction (MI), although the underlying molecular mechanisms remain elusive. In this study, a broad analysis of immune markers in 283 patients revealed significant CD69 overexpression on Tregs after MI. Our results in mice showed that CD69 expression on Tregs increased survival after left anterior descending (LAD) coronary artery ligation. Cd69-/- mice developed strong IL-17+ γδT cell responses after ischemia that increased myocardial inflammation and, consequently, worsened cardiac function. CD69+ Tregs, by induction of AhR-dependent CD39 ectonucleotidase activity, induced apoptosis and decreased IL-17A production in γδT cells. Adoptive transfer of CD69+ Tregs into Cd69-/- mice after LAD ligation reduced IL-17+ γδT cell recruitment, thus increasing survival. Consistently, clinical data from 2 independent cohorts of patients indicated that increased CD69 expression in peripheral blood cells after acute MI was associated with a lower risk of rehospitalization for heart failure (HF) after 2.5 years of follow-up. This result remained significant after adjustment for age, sex, and traditional cardiac damage biomarkers. Our data highlight CD69 expression on Tregs as a potential prognostic factor and a therapeutic option to prevent HF after MI.

Coronary Microvascular Dysfunction in Takotsubo Syndrome Assessed by Angiography-Derived Index of Microcirculatory Resistance: A Pressure-Wire-Free Tool.

BACKGROUND: Coronary microvascular dysfunction (CMD) has been proposed as a key mechanism in Takotsubo syndrome (TTS). The non-hyperaemic angiography-derived index of microcirculatory resistance (NH-IMRangio) has been validated as a pressure-wire-free tool for the assessment of coronary microvasculature. We aimed to study the presence of CMD in TTS patients and its association with levels of cardiac biomarkers and systolic dysfunction patterns. METHODS: We recruited 181 consecutive patients admitted for TTS who underwent cardiac angiography at a tertiary center from January 2014 to January 2021. CMD was defined as an NH-IMRangio ≥ 25. Plasma levels of NT-proBNP, high-sensitive cardiac troponin T (hs-cTnT) and the left ventricular ejection fraction (LVEF) by echocardiography were measured at admission. RESULTS: Mean age was 75.3 years, 83% were women and median LVEF was 45%. All patients presented CMD (NH-IMRangio ≥ 25) in at least one epicardial coronary artery. The left anterior descending artery (LAD) showed higher median NH-IMRangio values than left circumflex (LCx) and right coronary arteries (RCA) (44.6 vs. 31.3 vs. 36.1, respectively; p < 0.001). NH-IMRangio values differed among ventricular contractility patterns in the LAD and RCA (p = 0.0152 and 0.0189, respectively) with the highest values in the mid-ventricular + apical and mid-ventricular + basal patterns. NT-proBNP levels, but not high-sensitive cardiac troponin T (hs-cTnT), were correlated with both the degree and the extent of CMD in patients with TTS. Lower LVEF was also associated with higher NH-IMRangio values. CONCLUSIONS: CMD is highly prevalent in patients admitted for TTS and is associated with both a higher degree of systolic dysfunction and higher BNP levels, but not troponin.

Electrocardiographic Characteristics and Associated Outcomes in Patients with Takotsubo Syndrome. Insights from the RETAKO Registry.

Electrocardiographic disturbances in Takotsubo syndrome have been previously partially described but their consequences remain mostly unknown. Our aim was to describe the prevalence and prognostic significance of different electrocardiographic features in patients with Takotsubo syndrome. Our data come from the Spanish multicenter REgistry of TAKOtsubo syndrome (RETAKO). All patients with an available 12-lead surface electrocardiogram at admission and 48 hours post-admission were included. A total of 246 patients were studied, mean age was 71.3 ± 11.5 and 215 (87.4%) were women. ST-segment elevation was seen in 143 patients (59.1%) and was present in ≥2 wall leads in 97 (39.8%). Exclusive elevation in inferior leads was infrequent (5% - 2.0%). After 48 hours, 198 patients (88.0%) developed negative T waves in a median of 8 leads with a mean amplitude of 0.7 ± 0.5 mV and 137 (60.9%) had pathological Q waves. The mean corrected QT interval was 520 ± 72 ms. Corrected QT interval was independently associated with the primary endpoint of all-cause death and nonfatal cardiovascular events (P = 0.002) and all-cause death (P = 0.008). A higher heart rate at admission was an independent predictor of the primary endpoint (P = 0.001) and of acute pulmonary edema (P = 0.04). ST-segment elevation with reciprocal depression was an independent predictor of all-cause death (P = 0.04). Absence of ST-segment deviation was a protective factor (P = 0.005) for the primary endpoint. Tachyarrhythmias were independently associated with cardiogenic shock (P< 0.001). Takotsubo syndrome patients present with distinct electrocardiographic features. Prolonged corrected QT interval, tachyarrhythmias, heart rate at admission, and more extensive repolarization alterations are associated with poor outcomes.

An Exceptional Cause of Acute Right Heart Failure: Isolated Right Ventricular Takotsubo Syndrome.

We describe a patient with of acute right ventricular dysfunction secondary to right ventricular isolated Takotsubo syndrome (TTS). The importance of appropriate differential diagnosis for acute right ventricular dysfunction differential diagnosis of acute right ventricular dysfunction and the differences in diagnosis and management of right ventricular TTS and typical left ventricular TTS are highlighted. (Level of Difficulty: Intermediate.).

Prevalence and Significance of Interatrial Block in Takotsubo Syndrome (from the RETAKO Registry).

Interatrial block (IAB) represents a conduction delay between right and left atria and is associated with an increased risk of atrial fibrillation and stroke. IAB has not been previously assessed in patients with Takotsubo syndrome (TS). Our aim was to describe the prevalence and prognostic significance of IAB in patients with TS. Data come from the Spanish National prospective registry of patients with definitive TS diagnosis. IAB was defined as a P-wave ≥120 ms and was considered partial when the P-wave was positive in inferior leads and advanced when it was biphasic (+/-). A total of 246 patients were included, normal P-wave was found in 151 (61%), partial IAB in 58 (24%), atrial fibrillation in 18 (7%), advanced IAB in 13 (5%), and 6 (2%) were pacemaker dependent. During a mean follow up of 12 months the composite of all-cause mortality and hospital readmission was significantly higher in patients with advanced IAB (31%) or atrial fibrillation (33%) than in the rest of the cohort (pacemaker stimulation 17%, normal P-wave 13%, partial IAB 12%), p < 0.01. The data regarding P wave characteristics were an independent predictor of the composite end point all-cause death and hospital readmission. IAB has a high prevalence in patients with TS. Advanced IAB and atrial fibrillation are associated with a poor prognosis.

Clinical and prognostic implications of delirium in elderly patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: Elderly patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) may present delirium but its clinical relevance is unknown. This study aimed at determining the clinical associated factors, and prognostic implications of delirium in old-aged patients admitted for NSTE-ACS. METHODS: LONGEVO-SCA is a prospective multicenter registry including unselected patients with NSTE-ACS aged ≥ 80 years. Clinical variables and a complete geriatric evaluation were assessed during hospitalization. The association between delirium and 6-month mortality was assessed by a Cox regression model weighted for a propensity score including the potential confounding variables. We also analysed its association with 6-month bleeding and cognitive or functional decline. RESULTS: Among 527 patients included, thirty-seven (7%) patients presented delirium during the hospitalization. Delirium was more frequent in patients with dementia or depression and in those from nursing homes (27.0% vs. 3.1%, 24.3% vs. 11.6%, and 11.1% vs. 2.2%, respectively; all P < 0.05). Delirium was significantly associated with in-hospital infections (27.0% vs. 5.3%, P < 0.001) and usage of diuretics (70.3% vs. 49.8%, P = 0.02). Patients with delirium had longer hospitalizations [median 8.5 (5.5-14) vs. 6.0 (4.0-10) days, P = 0.02] and higher incidence of 6-month bleeding and mortality (32.3% vs. 10.0% and 24.3% vs. 10.8%, respectively; both P < 0.05) but similar cognitive or functional decline. Delirium was independently associated with 6-month mortality (HR = 1.47, 95% CI: 1.02-2.13, P = 0.04) and 6-month bleeding events (OR = 2.87; 95% CI: 1.98-4.16, P < 0.01). CONCLUSIONS: In-hospital delirium in elderly patients with NSTE-ACS is associated with some preventable risk factors and it is an independent predictor of 6-month mortality.

Short- and Long-Term Prognosis of Patients With Takotsubo Syndrome Based on Different Triggers: Importance of the Physical Nature.

Background Takotsubo syndrome (TTS) is an acute reversible heart condition initially believed to represent a benign pathology attributable to its self-limiting clinical course; however, little is known about its prognosis based on different triggers. This study compared short- and long-term outcomes between TTS based on different triggers, focusing on various physical triggering events. Methods and Results We analyzed patients with a definitive TTS diagnosis recruited for the Spanish National Registry on TTS (RETAKO [Registry on Takotsubo Syndrome]). Short- and long-term outcomes were compared between different groups according to triggering factors. A total of 939 patients were included. An emotional trigger was detected in 340 patients (36.2%), a physical trigger in 293 patients (31.2%), and none could be identified in 306 patients (32.6%). The main physical triggers observed were infections (30.7%), followed by surgical procedures (22.5%), physical activities (18.4%), episodes of severe hypoxia (18.4%), and neurological events (9.9%). TTS triggered by physical factors showed higher mortality in the short and long term, and within this group, patients whose physical trigger was hypoxia were those who had a worse prognosis, in addition to being triggered by physical factors, including age >70 years, diabetes mellitus, left ventricular eyection fraction <30% and shock on admission, and increased long-term mortality risk. Conclusions TTS triggered by physical factors could present a worse prognosis in terms of mortality. Under the TTS label, there could be as yet undiscovered very different clinical profiles, whose differentiation could lead to individual better management, and therefore the perception of TTS as having a benign prognosis should be generally ruled out.

Prognostic value of plasma apelin concentrations at admission in patients with ST-segment elevation acute myocardial infarction.

BACKGROUND: The use of plasma biomarkers is relevant for the prognosis of ST-segment elevation myocardial infarction (STEMI) patients. Apelin, an adipocytokine, plays a pivotal role in the pathophysiology of both ischemia/reperfusion injury and its potential subsequent heart failure. We evaluated apelin concentrations at admission as a biomarker to assess risk of 6-month mortality. METHODS: Consecutive patients with STEMI were recruited from January 2012 to January 2013 (n=250). Plasma apelin, brain natriuretic peptide (BNP) and sensitive troponin I (sTnI) were assessed in EDTA-plasma samples obtained at admission. Clinical, hemodynamic and other laboratory variables were also registered. All-cause mortality was assessed at 6-month follow-up. RESULTS: Increased plasma apelin concentrations at admission were predictive of 6- month mortality, after adjustment for age, diabetes, systolic blood pressure, heart rate, glomerular filtration rate, Killip class, left ventricular ejection fraction, BNP and sTnI. The combination of apelin with BNP and sTnI further improved the apelin predictive value. Finally, apelin concentrations were associated with markers of ischemic heart failure severity, but not with markers of ischemic insult severity. CONCLUSIONS: Increased plasma concentrations of apelin at admission in patients with STEMI were associated with a higher risk of mortality at 6months, adding prognostic value to the provided by BNP. Moreover, apelin levels were also related to markers of ischemic heart failure severity, but not markers of ischemia severity.

[High-sensitivity troponin T testing and coronary computed tomography angiography for rapid diagnosis of chest pain in the emergency department]. / Troponina T de alta sensibilidad y angiotomografía computarizada coronaria para el diagnóstico rápido del dolor torácico en el servicio de urgencias.

OBJECTIVES: To determine the probability of finding significant coronary lesions, the time to diagnosis, and the safety of a new diagnostic approach based on high-sensitivity cardiac troponin T (hsTnT) testing followed by coronary computed tomography angiography (CCTA) in patients with chest pain of possible coronary origin. The method was compared with our hospital emergency department's standard practice. MATERIAL AND METHODS: Unblinded randomized controlled trial in a tertiary level university hospital between February 2011 and April 2013. We included emergency patients with chest pain and nondiagnostic electrocardiographic findings. Patients were assigned randomly to the new approach (hsTnT assay, followed by CCTA if the assay findings were negative) or the conventional approach (fourth generation TnT assay and, if negative, followed by an exercise stress test). Invasive coronary angiography was ordered in all patients if the results of either troponin assay, the CCTA, or the stress test were positive. We recorded the results of angiography, time until diagnosis, and all-cause mortality, new myocardial infarction, new unstable angina, or need for revascularization within the next 3 months. RESULTS: Of 102 patients randomized, 7 were excluded; 50 of the remaining 95 patients were assigned to the new strategy, and 45 to the conventional approach. Coronary angiography demonstrated significant lesions in 92.9% of the patients treated with the new strategy and 66.7% of those diagnosed conventionally. A higher percentage of patients were diagnosed within 6 hours with the new approach (20.0% vs 4.4% of conventional-approach patients, P = .023). During the 3 months following diagnosis, 1 death occurred in the intervention group and none in the conventional-approach group. CONCLUSION: The new strategy could accelerate diagnosis and increase the probability of finding significant coronary lesions, but we found no significant differences in adverse events in the 3 months following diagnosis. These findings should be confirmed in studies with larger numbers of patients.

OBJETIVO: Determinar la probabilidad de encontrar lesiones coronarias significativas, el tiempo diagnóstico y la seguridad de una nueva estrategia basada en la utilización de troponina T de alta sensibilidad (TnT-as) seguida de angiotomografía computarizada coronaria (ATCC) en pacientes con dolor torácico de posible origen coronario, en comparación con la atención clínica habitual en un servicio de urgencias (SU). METODO: Ensayo clínico diagnóstico aleatorizado y abierto realizado en un SU de un hospital terciario universitario entre febrero 2011 y abril 2013. Se incluyó a pacientes atendidos por dolor torácico con electrocardiograma no diagnóstico en urgencias. Se asignó de forma aleatorizada a la estrategia nueva (EN) (seriación de TnT-as seguida de ATCC cuando fue negativa) o la estrategia convencional (EC) (seriación de TnT de cuarta generación seguida de ergometría cuando fue negativa). Se indicó coronariografía invasiva si las troponinas, la ATCC o la ergometría fueron positivas. Se registró el resultado de la coronariografía invasiva, el tiempo diagnóstico y la aparición de un evento adverso (muerte por cualquier causa, nuevo infarto de miocardio, nueva angina inestable o necesidad de revascularización) durante los 3 meses de seguimiento. RESULTADOS: De los 102 pacientes aleatorizados se excluyeron 7. Se incluyeron 95 pacientes, 45 asignados a la EC y 50 a la EN. La coronariografía mostró lesiones significativas en un 92,9% de los casos de la EN y en un 66,7% de la EC. La proporción de pacientes diagnosticados en las primeras 6 horas fue mayor en la EN en comparación con la EC (20,0% vs 4,4%; p = 0,023). Durante el periodo de 3 meses de seguimiento, se registró una muerte en la EN y ningún evento en la EC. CONCLUSIONES: La EN podría aportar un diagnóstico más rápido, así como una mayor probabilidad de encontrar lesiones coronarias significativas, sin diferencias en la aparición de eventos adversos en los 3 primeros meses. Estos hallazgos necesitan ser confirmados en futuros estudios con mayor número de pacientes.