Risk Factors of Postoperative Hospital-Acquired Pneumonia in Patients Undergoing Cardiac Surgery.

Background and Objectives. Hospital-acquired pneumonia is one of the complications that may occur in the postoperative period in patients undergoing heart valve surgery, which may result in prolonged hospitalization, development of respiratory failure requiring mechanical ventilation or even death. This study investigated the preoperative risk factors of postoperative pneumonia after heart valve surgery. Materials and Methods: This was a prospective study in a group of consecutive patients with hemodynamically significant valvular heart disease undergoing valve surgery. The primary endpoint at the in-hospital follow-up was hospital-acquired pneumonia after heart valve surgery. Logistic regression analysis was used to assess which variables were predictive of the primary endpoint, and odds ratios (ORdis) were calculated with a 95% confidence interval (CI). Multivariate analysis was based on the results of single-factor logistic regression, i.e., in further steps all statistically significant variables were taken into consideration. Results: The present study included 505 patients. Postoperative pneumonia occurred in 23 patients. The mean time to diagnosis of pneumonia was approximately 3 days after heart valve surgery (±2 days). In multivariate analysis, preoperative level of high-sensitivity Troponin T (hs-TnT) (OR 2.086; 95% CI 1.211-3.593; p = 0.008) and right ventricular systolic pressure (RVSP) (OR 1.043; 95% CI 1.018-1.067; p 0.004) remained independent predictors of the postoperative pneumonia. Of the patients with postoperative pneumonia, 3 patients died due to the development of multiple organ dysfunction syndrome (MODS). Conclusions: Preoperative determination of serum hs-TnT concentration and echocardiographic measurement of the RVSP parameter may be useful in predicting postoperative pneumonia in patients undergoing heart valve surgery.

Heart-Type Fatty Acid Binding Protein, Cardiovascular Outcomes, and Death: Findings From the German CKD Cohort Study.

RATIONALE & OBJECTIVE: Heart-type fatty acid binding protein (H-FABP) is a biomarker that has been shown to provide long-term prognostic information in patients with coronary artery disease independently of high-sensitivity troponin T (hs-TNT). We examined the independent associations of H-FABP with cardiovascular outcomes in patients with chronic kidney disease (CKD). STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 4,951 patients enrolled in the German Chronic Kidney Disease (GCKD) study with an estimated glomerular filtration rate of 30-60 mL/min/1.73 m2 or overt proteinuria (urinary albumin-creatinine ratio > 300 mg/g or equivalent). EXPOSURE: Serum levels of H-FABP and hs-TNT were measured at study entry. OUTCOME: Noncardiovascular (non-CV) death, CV death, combined major adverse CV events (MACE), and hospitalization for congestive heart failure (CHF). ANALYTICAL APPROACH: Hazard ratios (HRs) for associations of H-FABP and hs-TNT with outcomes were estimated using Cox regression analyses adjusted for established risk factors. RESULTS: During a maximum follow-up of 6.5 years, 579 non-CV deaths, 190 CV deaths, 522 MACE, and 381 CHF hospitalizations were observed. In Cox regression analyses adjusted for established risk factors, H-FABP was associated with all 4 outcomes, albeit with lower HRs than those found for hs-TNT. After further adjustment for hs-TNT levels, H-FABP was found to be associated with non-CV death (HR, 1.57 [95% CI, 1.14-2.18]) and MACE (HR, 1.40 [95% CI, 1.02-1.92]) but with neither CV death (HR, 1.64 [95% CI, 0.90-2.99]) nor CHF hospitalizations (HR, 1.02 [95% CI, 0.70-1.49]). LIMITATIONS: Single-point measurements of H-FABP and hs-TNT. Uncertain generalizability to non-European populations. CONCLUSIONS: In this large cohort of patients with CKD, H-FABP was associated with non-CV death and MACE, even after adjustment for hs-TNT. Whether measurement of H-FABP improves cardiovascular disease risk prediction in these patients warrants further studies.

Change in Cardiac Biomarkers and Risk of Incident Heart Failure and Atrial Fibrillation in CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study.

RATIONALE & OBJECTIVE: Circulating cardiac biomarkers may signal potential mechanistic pathways involved in heart failure (HF) and atrial fibrillation (AF). Single measures of circulating cardiac biomarkers are strongly associated with incident HF and AF in chronic kidney disease (CKD). We tested the associations of longitudinal changes in the N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hsTnT), galectin-3, growth differentiation factor 15 (GDF-15), and soluble ST-2 (sST-2) with incident HF and AF in patients with CKD. STUDY DESIGN: Observational, case-cohort study design. SETTING & PARTICIPANTS: Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort study. EXPOSURES: Biomarkers were measured at baseline and 2 years later among those without kidney failure. We created 3 categories of absolute change in each biomarker: the lowest quartile, the middle 2 quartiles, and the top quartile. OUTCOMES: The primary outcomes were incident HF and AF. ANALYTICAL APPROACH: Cox proportional hazards regression models were used to test the associations of the change categories of each cardiac biomarker with each outcome (with the middle 2 quartiles of change as the referent group), adjusting for potential confounders and baseline concentrations of each biomarker. RESULTS: The incident HF analysis included 789 participants (which included 138 incident HF cases), and the incident AF analysis included 774 participants (123 incident AF cases). In multivariable models, the top quartile of NT-proBNP change (>232pg/mL over 2years) was associated with increased risk of incident HF (HR, 1.79 [95% CI, 1.06-3.04]) and AF (HR, 2.32 [95% CI, 1.37-3.93]) compared with the referent group. Participants in the top quartile of sST2 change (>3.37ng/mL over 2years) had significantly greater risk of incident HF (HR, 1.89 [95% CI, 1.13-3.16]), whereas those in the bottom quartile (≤-3.78ng/mL over 2years) had greater risk of incident AF (HR, 2.43 [95% CI, 1.39-4.22]) compared with the 2 middle quartiles. There was no association of changes in hsTnT, galectin-3, or GDF-15 with incident HF or AF. LIMITATIONS: Observational study. CONCLUSIONS: In CKD, increases in NT-proBNP were significantly associated with greater risk of incident HF and AF, and increases in sST2 were associated with HF. Further studies should investigate whether these markers of subclinical cardiovascular disease can be modified to reduce the risk of cardiovascular disease in CKD.

Emergency Department Clinician Perceptions of Implementing High-Sensitivity Troponin T Assay in an Academic Hospital Emergency Department.

PURPOSE: A newly approved, high-sensitivity troponin T (hsTnT) assay may offer opportunities to more rapidly assess for acute coronary syndrome and identify lower thresholds of myocardial injury. As more emergency departments begin to use the hsTnT assay, anticipating barriers to hsTnT implementation success are critical to realizing potential benefits in rapid, accurate patient assessment. METHODS: At a tertiary health system emergency department, hsTnT was implemented along with a diagnostic algorithm and a decision tree to aid in utilization. Qualitative interviews with 18 physicians and advance practice providers were conducted 2 months' postimplementation and again 4 to 6 months postimplementation to capture clinician perceptions to hsTnT implementation efforts. Deductive coding was performed using implementation science determinants frameworks to identify emerging themes related to this topic. RESULTS: Four themes emerged from the interviews: 1) the need for additional clinician education, 2) challenges with care handoffs, 3) lack of buy-in from the hospital community, and 4) key successes. CONCLUSION: Interviews demonstrated that implementation of hsTnT was associated with several implementation barriers from the perspective of emergency department clinicians. Future implementation efforts should focus on diverse and sustained staff educational efforts, models that address challenges with care handoffs between emergency department clinicians and inpatient clinicians, and operational teams that include inpatient clinicians to facilitate buy-in.

Prognostic Value of Undetectable hs Troponin T in Suspected Acute Coronary Syndrome.

BACKGROUND: The search for improved strategies for safe and early discharge of patients with suspected acute coronary syndrome in emergency departments is ongoing. This Biomarkers in Cardiology (BIC)-8 biomarker substudy evaluated the usefulness of high-sensitivity troponin T (hsTnT) below or above the limit of detection (LoD) in low-to-intermediate-risk patients with suspected acute coronary syndrome in the emergency department. METHODS: Patients were categorized into hsTnT ≥ the 99th percentile, between the 99th percentile and LoD, or undetectable hsTnT (