Infection in Patients with Decompensated Heart Failure: In-Hospital Mortality and Outcome.

BACKGROUND: Heart failure (HF) is a syndrome, whose advanced forms have a poor prognosis, which is aggravated by the presence of comorbidities. OBJECTIVE: We assessed the impact of infection in patients with decompensated HF admitted to a tertiary university-affiliated hospital in the city of São Paulo. METHODS: This study assessed 260 patients consecutively admitted to our unit because of decompensated HF. The presence of infection and other morbidities was assessed, as were in-hospital mortality and outcome after discharge. The chance of death was estimated by univariate logistic regression analysis of the variables studied. The significance level adopted was P < 0.05. RESULTS: Of the patients studied, 54.2% were of the male sex, and the mean age ± SD was 66.1 ± 12.7 years. During hospitalization, 119 patients (45.8%) had infection: 88 (33.8%) being diagnosed with pulmonary infection and 39 patients (15.0%), with urinary infection. During hospitalization, 56 patients (21.5%) died, and, after discharge, 36 patients (17.6%). During hospitalization, 26.9% of the patients with infection died vs 17% of those without infection (p = 0.05). However, after discharge, mortality was lower in the group that had infection: 11.5% vs 22.2% (p = 0.046). CONCLUSIONS: Infection is a frequent morbidity among patients with HF admitted for compensation of the condition, and those with infection show higher in-hospital mortality. However, those patients who initially had infection and survived had a better outcome after discharge.

Sensitive Troponin I Assay in Patients with Chest Pain - Association with Significant Coronary Lesions with or Without Renal Failure.

INTRODUCTION: Despite having higher sensitivity as compared to conventional troponins, sensitive troponins have lower specificity, mainly in patients with renal failure. OBJECTIVE: Study aimed at assessing the sensitive troponin I levels in patients with chest pain, and relating them to the existence of significant coronary lesions. METHODS: Retrospective, single-center, observational. This study included 991 patients divided into two groups: with (N = 681) and without (N = 310) significant coronary lesion. For posterior analysis, the patients were divided into two other groups: with (N = 184) and without (N = 807) chronic renal failure. The commercial ADVIA Centaur® TnI-Ultra assay (Siemens Healthcare Diagnostics) was used. The ROC curve analysis was performed to identify the sensitivity and specificity of the best cutoff point of troponin as a discriminator of the probability of significant coronary lesion. The associations were considered significant when p < 0.05. RESULTS: The median age was 63 years, and 52% of the patients were of the male sex. The area under the ROC curve between the troponin levels and significant coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or without renal failure, the areas under the ROC curve were 0.703 (95% CI: 0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff points to discriminate the presence of significant coronary lesion were: in the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%); in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%; specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL (sensitivity, 80.6%; specificity, 42%). CONCLUSION: In patients with chest pain, sensitive troponin I showed a good correlation with significant coronary lesions when its level was greater than 0.605 ng/dL. In patients with chronic renal failure, a significant decrease in specificity was observed in the correlation of troponin levels and severe coronary lesions.

Is There Any Relationship between TSH Levels and Prognosis in Acute Coronary Syndrome?

BACKGROUND: Some small studies have related higher levels of thyrotropin (TSH) to potentially worse prognosis in acute coronary syndromes. However, this relationship remains uncertain. OBJECTIVE: To analyze the outcomes of patients with acute coronary syndromes in relation to the value of TSH at admission. METHODS: Observational and retrospective study with 505 patients (446 in group I [TSH ≤ 4 mIU/L] and 59 in group II [TSH > 4 mIU/L]) with acute coronary syndromes between May 2010 and May 2014. We obtained data about comorbidities and the medications used at the hospital. The primary endpoint was in-hospital all-cause death. The secondary endpoint included combined events (death, non-fatal unstable angina or myocardial infarction, cardiogenic shock, bleeding and stroke). Comparisons between groups were made by one-way ANOVA and chi-square test. Multivariate analysis was determined by logistic regression. Analyses were considered significant when p < 0.05. RESULTS: Significant differences between groups I and II were observed regarding the use of enoxaparin (75.2% vs. 57.63%, p = 0.02) and statins (84.08% vs. 71.19%, p < 0.0001), previous stroke (5.83% vs. 15.25%, p = 0.007), combined events (14.80% vs. 27.12%, OR = 3.05, p = 0.004), cardiogenic shock (4.77% vs. 6.05%, OR = 4.77, p = 0.02) and bleeding (12.09% vs. 15.25%, OR = 3.36, p = 0.012). CONCLUSIONS: In patients with acute coronary syndromes and TSH > 4 mIU/L at admission, worse prognosis was observed, with higher incidences of in-hospital combined events, cardiogenic shock and bleeding.

Infection in Patients with Decompensated Heart Failure: In-Hospital Mortality and Outcome / Infecção em Pacientes com Insuficiência Cardíaca Descompensada: Mortalidade Hospitalar e Evolução

Abstract Background: Heart failure (HF) is a syndrome, whose advanced forms have a poor prognosis, which is aggravated by the presence of comorbidities. Objective: We assessed the impact of infection in patients with decompensated HF admitted to a tertiary university-affiliated hospital in the city of São Paulo. Methods: This study assessed 260 patients consecutively admitted to our unit because of decompensated HF. The presence of infection and other morbidities was assessed, as were in-hospital mortality and outcome after discharge. The chance of death was estimated by univariate logistic regression analysis of the variables studied. The significance level adopted was P < 0.05. Results: Of the patients studied, 54.2% were of the male sex, and the mean age ± SD was 66.1 ± 12.7 years. During hospitalization, 119 patients (45.8%) had infection: 88 (33.8%) being diagnosed with pulmonary infection and 39 patients (15.0%), with urinary infection. During hospitalization, 56 patients (21.5%) died, and, after discharge, 36 patients (17.6%). During hospitalization, 26.9% of the patients with infection died vs 17% of those without infection (p = 0.05). However, after discharge, mortality was lower in the group that had infection: 11.5% vs 22.2% (p = 0.046). Conclusions: Infection is a frequent morbidity among patients with HF admitted for compensation of the condition, and those with infection show higher in-hospital mortality. However, those patients who initially had infection and survived had a better outcome after discharge.

Resumo Fundamento: A insuficiência cardíaca (IC) é uma síndrome cujas formas avançadas têm mau prognóstico, que é mais agravado pela presença de comorbidades. Objetivo: Avaliamos o impacto da infecção em pacientes com IC descompensada que internaram em hospital universitário terciário de São Paulo. Métodos: Estudamos 260 pacientes consecutivos que internaram em nossa unidade com IC descompensada. Avaliamos a presença de infecção e de outras morbidades. Avaliaram-se mortalidade hospitalar e evolução após a alta. A chance de óbito foi estimada pela análise de regressão logística univariada para as variáveis estudadas. Considerou-se P < 0,05 significativo. Resultados: Dos pacientes estudados, 54,2% eram homens, sendo a idade média ± DP de 66,1 ± 12,7 anos. Durante a internação, 119 pacientes (45,8%) apresentaram infecção: 88 (33,8%) tiveram diagnóstico de infecção pulmonar e 39 (15%), de infecção urinária. A mortalidade hospitalar ocorreu em 56 pacientes (21,5%) e, após a alta, 36 pacientes (17,6%) morreram no seguimento. Durante a internação, 26,9% do grupo com infecção morreu vs 17% do grupo sem infecção (p = 0,05). Entretanto, após a alta, a mortalidade foi menor no grupo com infecção: 11,5% vs 22,2% (p = 0,046). Conclusões: Infecção é uma comorbidade frequente entre os pacientes com IC internados para compensação, causando um aumento da mortalidade durante a hospitalização. Entretanto, após a alta, os pacientes inicialmente com infecção apresentaram melhor evolução.

Is There Any Relationship between TSH Levels and Prognosis in Acute Coronary Syndrome? / Existe Alguma Relação entre Níveis de TSH e Prognóstico em Síndrome Coronariana Aguda?

Abstract Background: Some small studies have related higher levels of thyrotropin (TSH) to potentially worse prognosis in acute coronary syndromes. However, this relationship remains uncertain. Objective: To analyze the outcomes of patients with acute coronary syndromes in relation to the value of TSH at admission. Methods: Observational and retrospective study with 505 patients (446 in group I [TSH ≤ 4 mIU/L] and 59 in group II [TSH > 4 mIU/L]) with acute coronary syndromes between May 2010 and May 2014. We obtained data about comorbidities and the medications used at the hospital. The primary endpoint was in-hospital all-cause death. The secondary endpoint included combined events (death, non-fatal unstable angina or myocardial infarction, cardiogenic shock, bleeding and stroke). Comparisons between groups were made by one-way ANOVA and chi-square test. Multivariate analysis was determined by logistic regression. Analyses were considered significant when p < 0.05. Results: Significant differences between groups I and II were observed regarding the use of enoxaparin (75.2% vs. 57.63%, p = 0.02) and statins (84.08% vs. 71.19%, p < 0.0001), previous stroke (5.83% vs. 15.25%, p = 0.007), combined events (14.80% vs. 27.12%, OR = 3.05, p = 0.004), cardiogenic shock (4.77% vs. 6.05%, OR = 4.77, p = 0.02) and bleeding (12.09% vs. 15.25%, OR = 3.36, p = 0.012). Conclusions: In patients with acute coronary syndromes and TSH > 4 mIU/L at admission, worse prognosis was observed, with higher incidences of in-hospital combined events, cardiogenic shock and bleeding.

Resumo Fundamento: Estudos pequenos têm relacionado níveis mais elevados de hormônio tireoestimulante (TSH) a pior prognóstico em pacientes com síndrome coronariana aguda (SCA). Tal relação, no entanto, permanece incerta. Objetivo: Analisar os desfechos de pacientes com SCA, relacionando-os aos níveis de TSH medidos no setor de emergência. Métodos: Estudo retrospectivo observacional incluindo 505 pacientes com SCA (446 no grupo I: TSH ± 4 mUI/L; 59 no grupo II: TSH > 4 mUI/L) entre maio de 2010 e maio de 2014. Dados sobre comorbidades e medicamentos usados foram obtidos. O desfecho primário foi mortalidade intra-hospitalar por todas as causas. O desfecho secundário incluiu eventos combinados (morte, angina instável não fatal ou infarto do miocárdio, choque cardiogênico, sangramento e acidente vascular encefálico). A comparação entre grupos foi realizada através de ANOVA de uma via e teste do qui-quadrado. A análise multivariada foi realizada por regressão logística, adotando-se o nível de significância de p < 0,05. Resultados: Diferenças significativas foram observadas entre os grupos I e II relacionadas ao uso de enoxaparina (75,2% vs. 57,63%; p = 0,02) e estatinas (84,08% vs. 71,19%; p < 0,0001), acidente vascular encefálico prévio (5,83% vs. 15,25%; p = 0,007), eventos combinados (14,80% vs. 27,12%, OR = 3,05; p = 0,004), choque cardiogênico (4,77% vs. 6,05%, OR = 4,77; p = 0,02) e sangramento (12,09% vs. 15,25%, OR = 3,36; p = 0,012). Conclusão: Em pacientes com SCA e TSH > 4 mUI/L à admissão hospitalar, observou-se pior prognóstico associado à maior incidência de eventos combinados intra-hospitalares, choque cardiogênico e sangramentos.

Sensitive Troponin I Assay in Patients with Chest Pain - Association with Significant Coronary Lesions with or Without Renal Failure / Troponinas I Sensíveis em Pacientes com Dor Torácica - Associação com Lesões Coronarianas Significativas e Variação em Insuficiência Renal Crônica

Abstract Introduction: Despite having higher sensitivity as compared to conventional troponins, sensitive troponins have lower specificity, mainly in patients with renal failure. Objective: Study aimed at assessing the sensitive troponin I levels in patients with chest pain, and relating them to the existence of significant coronary lesions. Methods: Retrospective, single-center, observational. This study included 991 patients divided into two groups: with (N = 681) and without (N = 310) significant coronary lesion. For posterior analysis, the patients were divided into two other groups: with (N = 184) and without (N = 807) chronic renal failure. The commercial ADVIA Centaur® TnI-Ultra assay (Siemens Healthcare Diagnostics) was used. The ROC curve analysis was performed to identify the sensitivity and specificity of the best cutoff point of troponin as a discriminator of the probability of significant coronary lesion. The associations were considered significant when p < 0.05. Results: The median age was 63 years, and 52% of the patients were of the male sex. The area under the ROC curve between the troponin levels and significant coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or without renal failure, the areas under the ROC curve were 0.703 (95% CI: 0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff points to discriminate the presence of significant coronary lesion were: in the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%); in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%; specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL (sensitivity, 80.6%; specificity, 42%). Conclusion: In patients with chest pain, sensitive troponin I showed a good correlation with significant coronary lesions when its level was greater than 0.605 ng/dL. In patients with chronic renal failure, a significant decrease in specificity was observed in the correlation of troponin levels and severe coronary lesions.

Resumo Fundamento: Apesar de apresentar maior sensibilidade em comparação às troponinas convencionais, as troponinas sensíveis apresentam menor especificidade, principalmente em pacientes com insuficiência renal. Objetivo: Avaliar os valores de troponina I sensível em pacientes com dor torácica, relacionando-os à presença de lesões coronarianas significativas. Métodos: Estudo retrospectivo, unicêntrico e observacional. Foram incluídos 991 pacientes, divididos em dois grupos: com (N = 681) ou sem lesão coronariana (N = 310). Para análise posterior, os pacientes foram separados em outros dois grupos: com (N = 184) ou sem insuficiência renal (N = 807). A troponina utilizada pertence ao kit comercial ADVIA Centaur® TnI-Ultra (Siemens Healthcare Diagnostics). A análise foi feita por curva ROC para identificar a sensibilidade e a especificidade do melhor ponto de corte da troponina como discriminador de probabilidade de lesão coronariana. As associações foram consideradas significativas quando p < 0,05. Resultados: Cerca de 52% dos pacientes eram do sexo masculino e a idade mediana da amostra foi de 63 anos. A área sob a curva ROC entre os valores de troponina e lesões coronarianas significativas foi de 0,685 (IC 95%: 0,65 - 0,72). Em pacientes sem e com insuficiência renal, as áreas sob a curva foram 0,703 (IC 95%: 0,66 - 0,74) e 0,608 (IC 95%: 0,52 - 0,70), respectivamente. Os melhores pontos de corte para discriminar a presença de lesão coronária significativa foram: 0,605 ng/dL (sensibilidade de 63,4%, especificidade de 67%) no grupo geral, 0,605 ng/dL (sensibilidade de 62,7% e especificidade de 71%) em pacientes sem insuficiência renal e 0,515 ng/dL (sensibilidade de 80,6% e especificidade de 42%) no grupo com insuficiência renal crônica. Conclusão: Na população avaliada de pacientes com dor torácica, a troponina I sensível apresentou boa correlação com lesões coronarianas significativas quando acima de 0,605 ng/dL. Em pacientes com insuficiência renal crônica, observamos uma queda importante de especificidade na correlação dos valores com lesões coronarianas graves.

Why do patients with chagasic cardiomyopathy have worse outcomes than those with non-chagasic cardiomyopathy?

BACKGROUND: Heart failure is a highly prevalent disease, the prognosis of which depends on different predictive factors. OBJECTIVE: Chagas disease is a predictor of poor prognosis in patients with chronic heart failure (HF). The purpose of this study is to investigate whether this condition also predicts poor outcome in acutely decompensated patients. METHODS: Four hundred and seventeen patients admitted for decompensated heart failure were studied. Mean age was 51.8 years, and 291 (69.8%) were male. They were divided into two groups: 133 (31.9%) patients with Chagas heart disease (CH) and 284 patients with heart failure of other etiologies. Cytokine and norepinephrine plasma levels were measured in a subgroup of 63 patients (15.1% with Chagas disease). RESULTS: At admission, 24.6% of the patients needed inotropic support, and one-year mortality was 54.7%. Mortality rates were higher in the CH group (69.2% vs. 47.9%, p < 0.001). When data were compared, patients with Chagas disease were younger (47.6 vs. 53.8 years, p < 0.001) and, on average, showed lower systolic blood pressure (96.7 vs. 111.2 mmHg, p < 0,001), ejection fraction (32.7 vs. 36.4%, p < 0.001), and serum Na (134.6 vs. 136.0, p = 0.026), in addition to higher TNF-alpha levels (33.3 vs. 14.8, p = 0.001). The presence of hypotension requiring inotropic support, left ventricular (LV) diastolic diameter, renal function findings, and interleukin-6 and norepinephrine plasma levels did not differ between both groups. CONCLUSION: Chagas disease patients admitted with decompensated heart failure had worse prognoses than patients with heart failure of other etiologies. This may be owing to a greater degree of cardiac impairment (lower ejection fraction) and hemodynamic instability (lower systolic blood pressure and heart rate), increased activation of the renin-angiotensin system (lower sodium), and increased cytokine levels (TNF-alpha).