Long-term recurrent events in ST-elevation myocardial infarction and multivessel disease. The impact of different revascularization strategies.

INTRODUCTION: The benefit of complete revascularization (CR) on long-term total event reduction in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), still remains unclear. We assessed the efficacy of three different revascularization strategies on long-term total recurrent events. METHODS: We retrospectively analyzed 414 consecutive patients admitted with STEMI and MVD who were categorized according to the revascularization strategy used: culprit-vessel-only percutaneous coronary intervention (PCI) (n=163); in-hospital CR (n=136); and delayed CR (n=115). The combined endpoint assessed was all-cause mortality, the total number of myocardial infarctions, ischemia-driven revascularizations or strokes. Negative binomial regression was used to assess the association between the revascularization strategy and total events; risk estimates were expressed as an incidence rates ratio (IRR). RESULTS: At a median follow-up of four years (1.2-6), rates of the combined endpoint per 10 patient-years were 18, 0.8, and 0.6 in culprit-vessel-only PCI, in-hospital CR, and delayed CR strategies, respectively (p<0.001). After multivariable adjustment and when compared with culprit-vessel-only PCI, both in-hospital and delayed CR strategies were significantly associated with a reduction in the combined endpoint (IRR=0.40: 95% confidence interval (CI), 0.25-0.64; p<0.001; and IRR 0.40: 95% CI, 0.24-0.62; p<0.001, respectively). No differences were observed across in-hospital and delayed CR strategies. CONCLUSIONS: Complete revascularization of non-culprit lesions in patients with STEMI and MVD reduces the risk of total recurrent events during long-term follow-up. No differences between in-hospital and delayed CR strategies were found.

Invasive management of significant tricuspid regurgitation in clinical practice.

BACKGROUND: Tricuspid regurgitation (TR) is a prevalent condition inside valvular heart disease (VHD) with relevant prognosis implications. However, concordance between real management in clinical practice and invasive treatment recommendations of European Society of Cardiology (ESC) guidelines is unknown. METHODS: A substudy of ESC VHD II survey was performed to evaluate the real treatment of TR compared to the clinical ESC guidelines recommendations published in 2012, 2017 and 2021 was performed. TR cases with surgical indication were divided in 3 groups: 1: severe isolated TR without previous left VHD; 2: moderate/severe TR and concomitant severe left VHD; 3: severe TR plus previous left VHD surgery. RESULTS: Of 902 patients assessed, 123 had significant TR. Fifty (41%) cases demonstrated ESC guidelines 2012-2017 Class I or IIa recommendations for invasive treatment: 9(18%) of group 1, 37(74%) of group 2 and 4(8%) of group 3. Surgery was performed in 24 patients (48%); 1 in group 1(4%), 22 in group 2(92%) and 1 in group 3(4%). Overall concordance was 48% (group 1: 11%; group 2: 59%; group 3: 25%). Regarding the 2021 ESC guidelines only one patient changed groups with an overall concordance of 47% (group 1: 10%; group 2: 59%; group 3: 25%). CONCLUSION: Concordance between 2012, 2017 and 2021 ESC guidelines recommendations and clinical practice for TR surgical intervention is low, especially in those without concomitant severe left VHD. These results suggest the need to improve further guideline implementation and alternative treatments, such as percutaneous, which could resolve potential discrepancies in those clinical scenarios.

Human dental pulp stem cells improve left ventricular function, induce angiogenesis, and reduce infarct size in rats with acute myocardial infarction.

Human dental pulp contains precursor cells termed dental pulp stem cells (DPSC) that show self-renewal and multilineage differentiation and also secrete multiple proangiogenic and antiapoptotic factors. To examine whether these cells could have therapeutic potential in the repair of myocardial infarction (MI), DPSC were infected with a retrovirus encoding the green fluorescent protein (GFP) and expanded ex vivo. Seven days after induction of myocardial infarction by coronary artery ligation, 1.5 x 10(6) GFP-DPSC were injected intramyocardially in nude rats. At 4 weeks, cell-treated animals showed an improvement in cardiac function, observed by percentage changes in anterior wall thickening left ventricular fractional area change, in parallel with a reduction in infarct size. No histologic evidence was seen of GFP+ endothelial cells, smooth muscle cells, or cardiac muscle cells within the infarct. However, angiogenesis was increased relative to control-treated animals. Taken together, these data suggest that DPSC could provide a novel alternative cell population for cardiac repair, at least in the setting of acute MI.

Urinary B-type natriuretic peptide levels in the diagnosis and prognosis of heart failure.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) is a useful biomarker for diagnosis and prognosis of heart failure (HF); however, urine BNP has never been calculated. We sought to compare urinary and plasma BNP levels and to investigate the potential diagnostic and prognostic value of this peptide in HF. METHODS AND RESULTS: Urine and plasma BNP levels were measured in 92 HF patients and 30 control subjects. Urinary BNP levels were higher in HF patients than in control subjects (P < .0001), correlating with plasma BNP levels (r = 0.64, P < .0001). Urine BNP was a good tool for the diagnosis of HF, the area under the curve (AUC) being 0.91 +/- 0.06 (P < .0001). Urinary BNP levels had prognostic power for cardiac events (cardiac admissions + mortality) with an odds ratio of 6.6 (P < .05). To determine the prognostic power of urinary BNP in detecting 12-month cardiac mortality, we obtained an AUC of 0.76 +/- 0.6 (P = .014). CONCLUSIONS: The data suggest that urine BNP is a new candidate marker for diagnosis and prognosis of HF mortality and cardiac events. This raises the possibility of using this relatively simple noninvasive test in primary care settings or in specific conditions where the collection of blood samples could be difficult.

Functional Mitral Regurgitation Predicts Short-Term Adverse Events in Patients With Acute Heart Failure and Reduced Left Ventricular Ejection Fraction.

Functional mitral regurgitation (FMR) is a common finding in patients with acute heart failure (AHF) and reduced left ventricular ejection fraction (heart failure and reduced ejection fraction [HFrEF]). However, its clinical impact remains unclear. We aimed to evaluate the association between the severity of FMR after clinical stabilization and short-term adverse outcomes after a hospitalization for AHF. We prospectively included 938 consecutive patients with HFrEF discharged after a hospitalization for AHF, after excluding those with organic valve disease, congenital heart disease, or aortic valve disease. FMR was assessed semiquantitatively by color Doppler analysis of the regurgitant jet area, and its severity was categorized as none or mild (grade 0 or 1), moderate (grade 2), or severe (grade 3 or 4). FMR was assessed at 120 ± 24 hours after admission. The primary end point was the composite of all-cause mortality and rehospitalization at 90 days. At discharge, 533 (56.8%), 253 (26.9%), and 152 (16.2%) patients showed none-mild, moderate, and severe FMR. At the 90-day follow-up, 161 patients (17.2%) either died (n = 49) or were readmitted (n = 112). Compared with patients with none or mild FMR, rates of the composite end point were higher for patients with moderate and severe FMRs (p <0.001). After the multivariable adjustment, those with moderate and severe FMRs had a significantly higher risk of reaching the end point (hazard ratio = 1.50, 95% confidence interval 1.04 to 2.17, p = 0.027; and hazard ratio = 1.63, 95% confidence interval 1.07 to 2.48, p = 0.023, respectively). In conclusion, FMR is a common finding in patients with HFrEF, and its presence, when moderate or severe, identifies a subgroup at higher risk of adverse clinical outcomes at short term.

Diagnostic and prognostic value of urine NT-proBNP levels in heart failure patients.

BACKGROUND: Plasma NT-proBNP levels are sensitive markers of ventricular dysfunction. However, studies of natriuretic peptides in urine are limited. AIMS: To compare urine and plasma NT-proBNP levels and to investigate the diagnostic and prognostic value of urine levels in heart failure (HF). METHODS: Urinary and plasma NT-proBNP levels were measured in 96 HF patients and 20 control subjects. The patients were functionally classified according to the NYHA criteria. RESULTS: Urine NT-proBNP was higher in HF patients than in control subjects (94+/-31 pg/ml vs. 67+/-6 pg/ml, p<0.0001), correlating with plasma NT-proBNP levels (r=0.78, p<0.0001). Urinary levels were elevated in the more severe functional classes and diminished in obese patients. Urine NT-proBNP was a good tool for diagnosis of HF, the area under the curve (AUC) being 0.96+/-0.02 (p<0.0001), and for predicting 12-month cardiac events (p=0.011). To determine the prognostic power of urinary NT-proBNP in detecting 12-month cardiac mortality, we obtained an AUC of 0.75+/-0.10 (p=0.015). CONCLUSION: Urinary NT-proBNP, a relatively simple non-invasive test, is a new candidate marker for the diagnosis and evaluation of prognosis in HF and for the characterization of functional status in these patients.

[8-hydroxy-2'-deoxyguanosine and lipid peroxidation in patients with heart failure]. / Valores de 8-hidroxi-2'-desoxiguanosina y de peroxidación lipídica en pacientes con insuficiencia cardiaca.

INTRODUCTION AND OBJECTIVES: Heart failure is associated with increased free radical production, which leads to a state of oxidative stress. Known markers of oxidative stress include 8-hydroxy-2'-deoxyguanosine, which reflects oxidative damage to DNA, and lipid peroxidation, which can be used to quantify damage to lipid-rich structures. The aims of this study were to compare 8-hydroxy-2'-deoxyguanosine and lipid peroxidation levels in heart failure patients and healthy subjects and to assess how these levels are influenced by heart failure etiology. METHODS: The study included 78 patients (57 male, age 64 [14] years) with heart failure and 12 control subjects. Patients completed a questionnaire and were graded according to the New York Heart Association classification. Doppler echocardiography was performed and blood samples were obtained. 8-hydroxy-2'-deoxyguanosine and lipid peroxidation levels were determined. RESULTS: Significant differences were observed between patients and control subjects in 8-hydroxy-2'-deoxyguanosine and lipid peroxidation levels, at 0.34 (0.54) ng/mL vs 0.04 (0.07) ng/mL (P<.05), and 18 (10) microM vs 8 (3) microM (P<.01), respectively. Subsequent analysis showed that heart failure etiology had a significant effect on the levels of the two markers (P<.05), which were highest in patients with hypertensive cardiomyopathy. CONCLUSIONS: Levels of 8-hydroxy-2'-deoxyguanosine and lipid peroxidation were higher in heart failure patients than in control subjects. The most significant increases were found in patients with hypertensive cardiomyopathy.

[Myocardial remodeling and immunologic activation in patients with heart failure]. / Remodelado miocárdico y activación inmunitaria en pacientes con insuficiencia cardiaca.

INTRODUCTION AND OBJECTIVES: Immune response-mediated regulation of myocardial collagen remains poorly understood. Our objective was to investigate the relationship between ventricular remodeling and immunologic activation in patients with heart failure (HF) by comparing dilated and ischemic cardiomyopathy. METHODS: We studied 94 patients with HF and dilated cardiomyopathy (n=46) or ischemic cardiomyopathy (n=48). We recorded left ventricular (LV) volumes, E/A ratio, and ejection fraction. Plasma concentrations of tumor necrosis factor alpha (TNFalpha), soluble TNFa receptor I (sTNF-RI), sTNF-RII, interleukin-6 (IL-6) and IL-10 were measured. The serum procollagen type-III amino-terminal propeptide (PIIINP) level was also obtained. RESULTS: Ventricular volumes were greater in the dilated cardiomyopathy than in the ischemic cardiomyopathy group (P< .05). However, sTNF-RI, sTNF-RII and PIIINP levels were higher in the ischemic group (P< .05). In this group, there were significant correlations between ventricular volumes and IL-10 and sTNF-RII levels. There was also a significant correlation between PIIINP and sTNF-RII levels (r=0.30; P< .05). In the dilated cardiomyopathy group, there was a significant correlation between ventricular volumes and IL-10 level, and between PIIINP level and IL-6 (r=0.32; P< .05) and sTNF-RII levels (r=0.32; P< .05). Multiple linear regression analysis, which included cytokine levels, age, sex and ventricular function, showed that the sTNF-RII level was an independent predictor of the PIIINP level (adjusted r(2)=0.16; P< .0001) and of ventricular volumes (LV end-systolic volume index, adjusted r(2)=0.034; P< .05; and LV end-diastolic volume index, adjusted r(2)=.048; P< .05) in both groups. CONCLUSIONS: In HF, there is an interaction between proinflammatory cytokines and the extracellular matrix. Immunologic implications vary according to disease etiology. The elevation in proinflammatory cytokine and PIIINP levels is greater in patients with ischemic cardiomyopathy. Multiple regression analysis showed that the sTNF-RII level was an independent predictor of ventricular remodeling.

Midterm clinical and echocardiographic results with patch glue repair of left ventricular free wall rupture.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a dramatic complication after myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with an epicardial patch without cardiopulmonary bypass. METHODS: From February 1993 to May 2001, 17 patients underwent surgery for LVFWR. The mean age+/-SD of 12 males and 5 females was 68+/-10 years. All patients presented for emergency surgery with cardiac tamponade confirmed on echocardiography. After opening the chest and identification of the site of rupture, a Goretex patch was fashioned and applied with enbucrilate surgical glue. RESULTS: Effective control of bleeding was achieved in all cases. There were no on-table deaths. The operative (30 day) mortality was 23.5% (4/17). One death occurred because of patch failure, two because of cardiogenic shock, and one from pneumonia. On follow-up at a median of 2.2 years (interquartile range, 1.1 to 4.3 years), two further deaths occurred, one from myocardial infarction and another of undetermined etiology. Echocardiography did not reveal any evidence of restriction to left ventricular free wall motion. CONCLUSIONS: Patch glue repair is expedient, simple and effective; with no adverse effects on mid-term ventricular dynamics. In view of superior published results to infarctectomy and repair with extra corporeal circulation, it should be considered to be the initial procedure of choice for the surgical repair of LVFWR.

Obese subjects with heart failure have lower N-terminal pro-brain natriuretic peptide plasma levels irrespective of aetiology.

N-terminal pro-brain natriuretic peptide (NT-proBNP) may be useful in the diagnosis of heart failure and ventricular dysfunction. Obesity is an independent cardiovascular risk factor. The purpose of this study was to measure NT-proBNP plasma levels in obese and non-obese subjects with heart failure and to compare levels in subjects with ischaemic and dilated aetiology. In this study, obese subjects had 63% lower NT-proBNP plasma levels than non-obese subjects (p < 0.01). In multivariate analysis, BMI was inversely associated with NT-proBNP plasma levels (p < 0.05) and a 17% decrease in natriuretic peptide levels was attributed to obesity (p < 0.036). When we analyzed data according to the aetiology of heart failure, we found that both groups (ischaemic and dilated) had a 65% decrease in NT-proBNP plasma levels in obese subjects compared to non-obese subjects.

Complications during pharmacological stress echocardiography: a video-case series.

BACKGROUND: Stress echocardiography is a cost-effective tool for the modern noninvasive diagnosis of coronary artery disease. Several physical and pharmacological stresses are used in combination with echocardiographic imaging, usually exercise, dobutamine and dipyridamole. The safety of a stress is (or should be) a major determinant in the choice of testing. Although large scale single center experiences and multicenter trial information are available for both dobutamine and dipyridamole stress echo testing, complications or side effects still can occur even in the most experienced laboratories with the most skilled operators. CASE PRESENTATION: We decided to present a case collection of severe complications during pharmacological stress echo testing, including a ventricular tachycardia, cardiogenic shock, transient ischemic attack, torsade de pointe, fatal ventricular fibrillation, and free wall rupture. CONCLUSION: We believe that, in this field, every past complication described is a future complication avoided; what happens in your lab is more true of what you read in journals; and Good Clinical Practice is not "not having complications", but to describe the complications you had.

Septal rupture with right ventricular wall dissection after myocardial infarction.

BACKGROUND: In patients with inferior myocardial infarction, septal rupture generally involves basal inferoposterior septum, and the communicating tract between left and right ventricle is often serpiginous with a variable degree of right ventricular wall extension. Right ventricular wall dissection following septal rupture related with previous myocardial infarction has been reported in a very few cases, in many of them this condition has been diagnosed in post-mortem studies. In a recent report long-term survival has been achieved after promptly echocardiographic diagnosis and surgical repair. CASE PRESENTATION: We present a case of a 59-year-old man who had a septal rupture with right ventricular wall dissection after inferior and right ventricular myocardial infarction. Transthoracic echocardiography, as first line examination, established the diagnosis, and prompt surgical repair allowed long-term survival in our patient. CONCLUSION: Outcomes after right ventricular intramyocardial dissection following septal rupture related to myocardial infarction has been reported to be dismal. Early recognition of this complication using transthoracic echocardiography at patient bedside, and prompt surgical repair are the main factors to achieve long-term survival in these patients.

[Non-invasive assessment of coronary artery bypass grafts by computed tomography: comparison with conventional coronary angiography]. / Valoración no invasiva de injertos coronarios con tomografía computarizada: comparación con la angiografía convencional.

INTRODUCTION AND OBJECTIVES: Although it has been demonstrated that the diagnostic accuracy of computed tomography in the non-invasive assessment of major epicardial coronary arteries is high, only a few studies have evaluated the technique's reliability in assessing coronary artery bypass grafts. The aim of this study was to determine the diagnostic accuracy of multidetector computed tomography in the assessment of coronary grafts. PATIENTS AND METHOD: We prospectively evaluated 117 coronary grafts in 38 patients who had undergone coronary artery bypass graft surgery and who had a clinical indication for angiographic graft assessment. All patients were in sinus rhythm and had a heart rate below 75 bpm. A 16-detector scanner was used for non-invasive assessment of the coronary grafts at a slice thickness of 1.2 mm. The diagnostic accuracy of computed tomography in the non-invasive assessment of significant lesions (i.e., occluded lesions or those with a stenosis greater than 50%) in coronary artery bypass grafts was evaluated by comparison with the results of conventional angiography. RESULTS: Of the 117 grafts evaluated, 99 (84.6%) were visualized by conventional angiography and 109 (93.2%) by computed tomography. Overall, 98 grafts were analyzed using both techniques. The sensitivity and specificity of computed tomography in detecting significant lesions were: 92% and 97.3%, respectively, for all grafts; 89.5% and 97.6%, respectively, for venous grafts; and 100% and 96.8%, respectively, for arterial grafts. CONCLUSIONS: The diagnostic accuracy of multidetector computed tomography in coronary artery bypass graft assessment was high.

[Plasma concentration of big endothelin-1 and its relation with plasma NT-proBNP and ventricular function in heart failure patients]. / Relación de los valores plasmáticos de big endotelina-1 con NT-proBNP y la función ventricular de pacientes con insuficiencia cardíaca.

INTRODUCTION AND OBJECTIVES: Elevated plasma concentrations of big endothelin-1 (big ET-1) are related with severity and prognosis in patients with heart failure, and N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of ventricular remodeling. The purpose of this study was to investigate the relationship between plasma levels of big ET-1 and NT-proBNP, and between the former and ventricular function. PATIENTS AND METHOD: We studied 103 patients with heart failure (75 men, mean age 63 [13] years). Each participant completed a questionnaire and underwent Doppler echocardiographic study to measure ejection fraction (EF), mitral flow propagation velocity (Vp) and atrioventricular plane displacement (AVPD). Blood samples were also taken to determine plasma levels of big ET-1, aldosterone and NT-proBNP. RESULTS: For the whole population big ET-1 concentration was 1.03 [0.75] fmol/m, NT-proBNP 619 (307-1328) pg/mL, aldosterone 168 [102] pg/mL, EF 37 [10], Vp 37 [11] cm/s, and AVPD 8.0 [1.7] mm. Plasma big ET-1 correlated positively with plasma NT-proBNP (r=0.50, P<.0001). However, a negative correlation was found between big ET-1 and EF (r=-0.30, P<.01), Vp, (r=-0.30, P<.01) and AVPD (r=-0.21, P<.05). When ET-1 levels were divided into quartiles and the corresponding NT-proBNP, EF, Vp and AVPD values were compared, we found significant differences (ANOVA P<.0001, P<.01, P<.05 and P<.05, respectively). CONCLUSIONS: Plasma levels of big ET-1 correlated positively with NT-proBNP levels and inversely with EF, Vp and AVPD. These findings help clarify the relationships between ventricular function and the neurohormonal activation involved in heart failure, and may aid the search for therapeutic interventions.

Soluble TNF-alpha and interleukin-6 receptors in the urine of heart failure patients. Their clinical value and relationship with plasma levels.

BACKGROUND: Proinflammatory cytokines are important mediators in heart failure (HF). Recently, urinary levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) have been determined. AIMS: The purpose of this study was to measure the urinary levels of TNF-alpha and IL-6 receptors, sTNF-RI, sTNF-RII, sIL-6R, and the relationship with plasma levels and NYHA classes in HF. METHODS: Plasma and urine were collected from 114 HF patients and sTNF-RI, sTNF-RII and sIL-6R (ng/ml) were analyzed. RESULTS: For the whole population, plasma levels of sTNF-RI were 2.1+/-0.1, of sTNF-RII were 5.0+/-0.3 and of sIL-6R were 49.8+/-2.5. Urinary levels were: sTNF-RI, 2.8+/-0.5, r=0.5, p<0.001; sTNF-RII, 12.6+/-2.1, r=0.4, p<0.001; and sIL-6R, 4.2+/-0.4, NS. In NYHA III subjects, we found sTNF-RI, r=0.6, p<0.01, sTNF-RII, r=0.5, p<0.05, and sILR-6, r=0.5, p<0.05. Both plasma TNF receptors and urinary levels of sTNF-RII were higher in patients in a more severe NYHA class (p<0.05). CONCLUSIONS: Urine is a good environment to study sTNF-RI and sTNF-RII, and this fact has diagnostic and prognostic implications. Plasma and urinary levels of TNF receptors showed a fair correlation, which was increased in higher NYHA classes. Plasma and urinary levels of sIL6R showed a good correlation in NYHA III. The TNF receptor levels in urine increased in patients with more severe HF.

Ventricular hypertrophy increases NT-proBNP in subjects with and without hypertension.

BACKGROUND: It has been published that hypertension (HT) must be taken into account when using NT-proBNP, but left ventricular (LV) hypertrophy without HT could be a cause of NT-proBNP elevation. In a population study we compared NT-proBNP in subjects with hypertrophy, with and without diagnosis of HT. METHODS: We studied 215 subjects from a random sample of 432 people who had declared to suffer from dyspnea. These 432 subjects were referred to their hospital where blood samples were taken, an echo-Doppler study was performed and a specific questionnaire was completed. We got a positive answer from 215, and 52 (24%) have LV hypertrophy. RESULTS: When we compared NT-proBNP in non-hypertrophic population, 148 +/- 286 pg/ml, with NT-proBNP in LV hypertrophic population, 202 +/- 209 pg/ml, we found P < 0.001. In the hypertrophic group, when we compared NT-proBNP (199 +/- 201 pg/ml) in normotensive subjects (LV mass index 170 +/- 70 g/m2, Vp 50 +/- 18 cm/s, LVEF 62 +/- 8) with NT-proBNP (205 +/- 220 pg/ml) in subjects with diagnosis of HT (LV mass index 169 +/- 37 g/m2, Vp 55 +/- 20 cm/s, LVEF 64 +/- 10), we found NS. CONCLUSIONS: This population study shows that NT-proBNP is elevated in patients with LV hypertrophy with or without HT. In LV hypertrophy the presence of HT does not influence the peptide levels significantly.

[Aortic valve replacement in patients over 70 years old: determinants of early death]. / Recambio valvular aórtico en pacientes mayores de 70 años: determinantes de mortalidad temprana.

INTRODUCTION AND OBJECTIVES: There is controversy regarding the risk factors associated with early death in geriatric patients undergoing aortic valve replacement. We analyzed the risks in these patients and established an accurate model for predicting in-hospital mortality. PATIENTS AND METHOD: Univariate and multivariate analyses were made of the risk factors associated with early death in a group of 129 patients older than 70 years who underwent aortic valve replacement (May 1994-June 2001). The variables obtained by multivariate logistic regression were combined to produce an equation for the prediction of early death. The equation was tested using a receiver operating characteristic curve. RESULTS: Univariate analysis identified four factors related to early death: NYHA III-IV (p < 0.0001), ejection fraction < 40% (p < 0.05), aortic regurgitation (p < 0.05) and high left ventricular mass index (p < 0.05). Multivariate analysis revealed three independent risk factors: NYHA III-IV (p < 0.01), aortic regurgitation (p < 0.05), and small body surface area (p < 0.05). A lower mortality was observed in patients with a larger body surface area (0% for > 1.90 m2, 20% for < 1.40 m2). The estimated mortality with the predictive model was 7.06%, which was similar to the observed mortality of 7.80% (area under the ROC curve 0.87) and better than estimates obtained with the EuroSCORE (6.5%; area under the ROC curve 0.56). CONCLUSIONS: Risk factors associated with early death after aortic valve replacement in geriatric patients include functional status, aortic regurgitation, and small body surface area. Our model based on these factors accurately predicted operative mortality in our patients. Gender, prosthesis size, and pump time were not identified as risk factors.

[NT-proBNP levels and hypertension. Their importance in the diagnosis of heart failure]. / Hipertensión y valores de NT-proBNP. Su importancia en el diagnóstico de insuficiencia cardíaca.

INTRODUCTION: N-terminal pro-brain natriuretic peptide (NT-proBNP) is useful in the diagnosis of heart failure. We compared NT-proBNP levels in patients with and without a diagnosis of arterial hypertension. PATIENTS AND METHOD: Participants were recruited from a random sample of 999 inhabitants from the Community of Valencia (eastern Spain). Of these patients, 432 said they suffered from dyspnea and were referred to their hospital (10 hospitals involved), where blood samples were taken, an echo-Doppler study was performed, and the patients completed a questionnaire. Of the 432 participants with dyspnea, 215 gave informed consent for their inclusion in the study, and 202 completed the study. Hypertension was diagnosed in 72 participants and 130 were normotensive. RESULTS: For the whole population, NT-proBNP, expressed as the median and range, was 88 (0-2586) pg/mL. When we compared hypertensive with normotensive participants, we found higher NT-proBNP levels in the former group: median 123, range 0-2184 pg/mL, versus median 77, range 0-2586 pg/mL (P<.01). When we excluded subjects with systolic left ventricular dysfunction, we found higher levels in participants with hypertension: 119 (0-2184 pg/mL) vs 72 (0-997 pg/mL) (P<.01). When we also excluded subjects with diastolic dysfunction, we found (median 85, range 0-430 pg/mL) and (median 66, range 0-997 pg/mL), respectively (p = NS). CONCLUSION: In a population study of subjects with dyspnea, hypertensive patients have higher NT-proBNP levels than subjects with normal blood pressure. This difference disappeared when patients with diastolic dysfunction were excluded from the analysis. Hypertension can thus be a confounding factor that potentially decreases the specificity of NT-proBNP levels for the diagnosis of heart failure. These findings should be taken into account when conducting clinical and epidemiological studies in which patients with both heart failure and hypertension are included.

[NT-proBNP and atrioventricular plane displacement. Relationship and diagnostic implications]. / NT-proBNP y desplazamiento del plano auriculoventricular. Relación e implicaciones diagnósticas.

INTRODUCTION AND OBJECTIVES: NT-proBNP is useful in the diagnosis of heart failure and ventricular dysfunction. Left atrioventricular plane displacement (AVPD) is a consolidated index of ventricular function. Our objective was to carry out a multicenter population-based study to establish the relationship between plasma NT-proBNP levels with AVPD values. PATIENTS AND METHOD: We studied 215 subjects (age 66 9 years; 57.7% women) chosen from a random sample of 432 people from the Community of Valencia, who previously reported suffering from some degree of dyspnea. Doppler echocardiography was done, AVPD was calculated and plasma NT-proBNP concentrations were determined. All studies were completed in 194 patients. RESULTS: For the whole population NT-proBNP was 88 (0-2,586) pg/ml and AVPD was 11.9 1.6 mm. NT-proBNP concentration correlated well with AVPD (r = 0.44; p < 0.00001), and higher peptide levels were obtained in AVPD quartiles that indicated less displacement (p < 0.05). When NT-proBNP values were grouped according to their association with AVPD lower or higher than the 50th percentile AVPD, the difference was significant at p < 0.01. When AVPD values lower and higher than 10 mm were compared, NT-proBNP values were higher in persons with AVPD lower than 10 mm (p < 0.05). CONCLUSIONS: This population study found higher NT-proBNP concentrations in subjects with lower AVPD, and illustrates the potential diagnostic usefulness of NT-proBNP in clinical practice.