Prognostic Significance of Risk Factors and Biomarkers in Patients Hospitalized for Cardiorenal Syndromes: A Pilot Study.

BACKGROUND: Cardiorenal syndromes (CRS), involving the heart-kidney cross-talk and the activation of neurohumoral and inflammatory pathways, are an entity characterized by high morbidity and mortality. OBJECTIVE: To evaluate the prognostic role of risk factors and biomarkers in patients hospitalized for CRS. METHODS: In this observational cohort study, 100 consecutive patients hospitalized for CRS were enrolled. Socio-demographic characteristics, personal medical history, and prior medication use were recorded upon admission, and echocardiography was performed. Moreover, an array of blood markers were measured. The endpoint of interest was a composite of death or dialysis dependence at discharge. RESULTS: Patients were classified into two groups; Group 1 (N= 52): discharged being dialysis-independent, Group 2 (N=48): death/dialysis dependence at discharge. No significant differences were detected in baseline characteristics between the two groups. Group 2 patients used renin-angiotensin-aldosterone system blockers (RAASb) less often and more frequently presented with oliguria/anuria. Group 2 patients had significantly lower hemoglobin, serum albumin, and 25-hydroxy-vitamin D (25(OH)D). At the same time, serum phosphate, potassium, and parathyroid hormone (PTH) were significantly higher in Group 2 patients. In a multivariate regression analysis, lack of prior RAASb and lower 25(OH)D levels were independently associated with an increased risk of death or dialysis dependence at discharge. 25(OH)D/PTH ratio was the most accurate predictor of the composite endpoint (Sensitivity: 79.4%, Specificity: 70.4%). CONCLUSION: Lack of prior RAASb use, high PTH, low 25(OH)D levels, and low 25(OH) D/PTH ratio are associated with a poor prognosis in patients hospitalized for CRS.

Ranolazine: safe and effective in a patient with hypertensive cardiomyopathy and multiple episodes of electrical storm.

Among implantable cardioverter-defibrillator (ICD) recipients, there are patients with recurrent episodes of electrical storm (ES), retractable to the optimal antiarrhythmic drug therapy or invasive ablation procedures. A relatively novel anti-ischemic drug with also antiarrhythmic properties, ranolazine, may effectively suppress ventricular arrhythmias in such patients for a long period of time.

Microalbuminuria: a strong predictor of 3-year adverse prognosis in nondiabetic patients with acute myocardial infarction.

BACKGROUND: The aim of this study is to evaluate the significance of microalbuminuria (MA) as a 3-year prognostic index in nondiabetic patients with acute myocardial infarction (AMI). METHODS: One hundred seventy-five patients with AMI were followed prospectively for 3 years. The study end point was cardiac death or rehospitalization for an acute coronary event. RESULTS: Forty-two patients (24%) developed a new cardiac event during the follow-up. Microalbuminuria (P < .001), pulmonary edema during initial hospitalization (P < .001) and postinfarction angina (P = .0364), advanced age (P = .001), severe atherosclerosis (high Gensini score) (P = .036), ejection fraction <50% (P = .0013), history of bypass surgery (P = .0265), and early conservative management (P = .0214) were all associated with adverse prognosis. Cox proportional hazards regression analysis showed that MA was an independent predictor of 3-year adverse prognosis in all the models tested, with an adjusted relative risk for the development of a cardiac event ranging from 2.1 to 4.3. CONCLUSIONS: In nondiabetic patients with AMI, MA is a strong and independent predictor of an adverse cardiac event within the next 3 years.

Erythropoietin in heart failure and other cardiovascular diseases: hematopoietic and pleiotropic effects.

Erythropoietin is a hypoxia-induced hormone that is a major regulator of normal erythropoiesis. Over the last decade, the production of recombinant human erythropoietin has revolutionized the treatment of anemia associated with chronic renal failure, and has led to a greater understanding of anemia pathophysiology and to the elucidation of the interactions of erythropoietin, iron, and erythropoiesis. Anemia has been shown to be independently associated with increased mortality and disease progression. Potential survival benefits associated with correction of anemia have expanded considerably the indications of erythropoietin use in various patient populations and are leading to consideration of earlier, more aggressive treatment of mild to moderate anemia. The results of such treatment are promising in a variety of new clinical settings, including anemia associated with congestive heart failure. Furthermore, the erythropoietin receptor is widely distributed in the cardiovascular system, including endothelial cells, smooth muscle cells and cardiomyocytes and preclinical studies have established erythropoietin to be a pleiotropic cytokine with anti-apoptotic activity and tissue-protective actions in the cardiovascular system, beyond correction of hemoglobin levels. Despite some potential adverse effects, such as hypertension, and the occurrence of erythropoietin resistance, early studies in heart failure patients with anemia suggest that erythropoietin therapy is safe and effective in reducing left ventricular hypertrophy, enhancing exercise performance and increasing ejection fraction. Anemia is found in about one-third of all cases of congestive heart failure (CHF). The most likely common cause is chronic renal insufficiency, which is present in about half of all CHF cases. However, anemia can occur in CHF without renal insufficiency and is likely to be due to excessive cytokine production. The anemia itself can worsen cardiac function, both because it causes cardiac stress through tachycardia and increased stroke volume, and because it can cause a reduced renal blood flow and fluid retention, adding further stress to the heart. Long-standing anemia of any cause can cause left ventricular hypertrophy, which can lead to cardiac cell death through apoptosis and worsen CHF. Therefore, a vicious circle, cardio-renal anemia syndrome, is set up wherein CHF causes anemia, and the anemia causes more CHF and both damage the kidneys worsening the anemia and the CHF further and increasing mortality. There is now evidence that early correction of the CHF anemia with subcutaneous erythropoietin and intravenous iron improves shortness of breath and fatigue, cardiac function, renal function and exercise capacity, reducing the need for hospitalization and improving quality of life. In the present review we discuss the data on current clinical use of erythropoietin in cardiovascular disease, with the main focus on the treatment of congestive heart failure, and summarize the advances and progress made in the understanding of the hematopoietic and pleiotropic effects of erythropoietin in the cardiovascular system.

Factors associated with non-bacterial thrombotic endocarditis: case report and literature review.

The case is reported of non-bacterial thrombotic endocarditis (NBTE) in a patient with giant cell arteritis and prostate cancer, and the relevant literature reviewed. To the present authors' knowledge, this is the first case to be reported where NBTE coexists with both arteritis and cancer. NBTE is difficult to diagnose if the underlying disease is accompanied by fever. If a diagnosis of probable infective endocarditis is established, the cultures and serology are negative, and there is no response to antibiotic treatment, then NBTE should be considered.

Impaired systolic dysfunction of left ventricular longitudinal fibers: a sign of early hypertensive cardiomyopathy.

BACKGROUND: Atrioventricular plane displacement (AVPD) study by M-mode echocardiography can supply useful clinical information about left ventricular (LV) long-axis function. HYPOTHESIS: We assessed the hypothesis that AVPD estimation could be used to detect early hypertensive cardiomyopathy. METHODS: The study population included 81 hypertensive patients with normal LV ejection fraction and fractional shortening, and 50 age- and gender-matched healthy controls. By utilizing M-mode and apical views, the following parameters were estimated: early mitral flow peak velocity (E) and deceleration time (DT), peak velocity of late mitral flow (A), A/E ratio, isovolumic relaxation time (IVRT), total AVPD, AVPD motion during atrial systole (At), systolic AVPD (total AVPD-At), and At/total AVPD ratio. RESULTS: Of 81 hypertensive patients, 16 (19.7%) had a normal (Group 1) and 65 (80.3%) an impaired LV relaxation filling pattern (Group 2). Mean total AVPD-At was significantly lower in Group 2 than in Group 1 (7.1 +/- 2 vs. 10.3 +/- 3 mm, p<0.001) and in Group 1 compared with healthy subjects (10.3 +/- 3 vs. 13.1 +/- 1 mm, p<0.001). Mean At and At/total AVPD were significantly higher in Group 2 than in Group 1 (46.9 +/- 8.6 vs. 37.7 +/- 8.7%, p<0.001), but not in Group 1 compared with healthy subjects (37.7 +/- 8.7 vs. 36 +/- 6%, p>0.05). CONCLUSIONS: Hypertensive patients without overt systolic dysfunction demonstrate LV long-axis systolic dysfunction, while long-axis diastolic dysfunction always coexists with abnormal diastolic filling patterns. This suggests that long-axis systolic dysfunction precedes diastolic dysfunction at the same axis in hypertensive patients.

Comparison of the extent and severity of coronary artery disease in patients with acute myocardial infarction with and without microalbuminuria.

The extent and severity of coronary atherosclerosis were compared between 43 microalbuminuric and 87 normoalbuminuric nondiabetic patients with acute myocardial infarction. Patients with microalbuminuria had significantly greater scores of the severity (Gensini score) and extent (Hamsten score) of coronary artery disease (p <0.001).

The Contribution of the Left Atrioventricular Plane Displacement During Low Dose Dobutamine Stress Echocardiography in Predicting Recovery of Left Ventricular Dyssynergies.

The aim of this study was to assess the significance of the left systolic atrioventricular (AV) plane displacement during low dose dobutamine stress echocardiography (DSE), in predicting the recovery of left ventricular dyssynergies after revascularization. In 30 infarctiers with left ventricular dysfunction scheduled for RE (14 percutaneous transluminal coronary angioplasty and 16 coronary artery bypass graft) and in 25 age- and sex-matched healthy subjects, a DSE, using a 16 ventricular segment model and a four-grade scoring system for the assessment of regional wall motion of the left ventricle was performed. Prior and during DSE, the left systolic AV plane displacement was recorded from the apical four- and two-chamber views, by M-mode echo, at four left ventricular sites, corresponding to the septal, lateral, anterior, and inferior walls, both in patients and controls. The study was repeated in all patients 101 +/- 14 days after successful revascularization. Healthy subjects showed a significant increase of left systolic AV plane displacement at all left ventricular sites during dobutamine infusion (DI) (P < 0.001). Patients also exhibited a significant maximum increase of left systolic AV plane displacement during DSE only in the dyssynergic sites with functional improvement in the postrevascularization echocardiogram (P < 0.001). In the remaining dyssynergic sites, without functional improvement after revascularization, the left systolic AV plane displacement did not change (P > 0.05). Selecting a maximum LAVPD increase of >2 mm at any site of the left ventricule to predict recovery of the regional ventricular dyssynergies, results in a sensitivity of 91%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 87%. When two-dimensional DSE was used for the detection of reversible dysfunction, sensitivity and specificity were found to be 81.5% and 87.5%, respectively, while the positive and negative predictive values were 90% and 78%, respectively. When the two methods were in agreement the sensitivity was 90%, the specificity 100%, and the positive and negative predictive values were 100% and 84.2%, respectively. The assessment of left systolic AV plane displacement during DI constitutes a new, simple, and accurate method in the prediction of left ventricular dyssynergy recovery after revascularization. The combination of this method and two-dimensional DSE are basic predictor markers of viability of dysfunctional myocardium. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Epidemiological characteristics and in-hospital management of acute coronary syndrome patients in Greece: results from the TARGET study.

INTRODUCTION: Conduction of national surveys is needed to depict temporal trends in the risk profile, type of implemented treatment strategy and outcome of patients with acute coronary syndromes (ACS). The TARGET study is a multicenter, observational study that aimed to evaluate the epidemiological characteristics, management pattern and outcome of ACS patients in Greece. METHODS: A total of 418 consecutive patients with ACS (44.7% STEMI, 34.2% NSTEMI, 21.1% unstable angina) from 17 centers (52.9% with catheterization facilities) were enrolled in the study (78.0% males, 63.9 ± 12.9 years). RESULTS: Overall, 67.9% of the patients had hypertension, 27.5% were diabetics and 57.4% had dyslipidemia. Thrombolytic therapy (60.7% tenecteplase, 38.2% reteplase) was administered in 22.7% of the study population, while invasive management was performed in 40.2% of patients (27.0% PCI and 1.0% CABG) during the index hospitalization. In-hospital all-cause mortality was 1.9%, with 12.2% of patients experiencing adverse clinical events. Evidence-based medications were prescribed to the majority of enrolled patients during hospitalization and upon discharge (97% and 94% received aspirin, 93% and 84% clopidogrel, 87% and 86% beta-blockers, 96% and 93% statins, respectively). CONCLUSION: The prevalence of modifiable risk factors exhibits an increasing trend among ACS patients in Greece. The prescription pattern of evidence-based medications has improved considerably, while there remains considerable room for improvement in expanding the implementation of invasive management in realworld clinical practice.

Inadequate heart rate control is associated with worse quality of life in patients with coronary artery disease and chronic obstructive pulmonary disease. The RYTHMOS study.

INTRODUCTION: Significant evidence shows that elevated heart rate (HR) is an independent risk factor in patients with coronary artery disease (CAD) and influences their prognosis. In addition, patients with chronic obstructive pulmonary disease (COPD) have more frequent episodes of angina and their compliance with heart rate agents, such as beta blockers, is poor. The purpose of the multicenter observational RYTHMOS study was to evaluate the role of heart rate management in the prognosis and quality of life in patients with CAD and COPD. METHODS: Baseline data from 280 patients, enrolled in 22 hospitals representing all types of hospital and all geographical areas of the country, were analyzed. All patients had either a prior myocardial infarction or angiographically documented CAD, and COPD verified either after spirometry or from a clinical evaluation by pulmonologists. RESULTS: The mean age of the enrolled patients was 71.8 ± 9.3 years, 76% were males, mean body mass index was 28.6 ± 7.9 kg/m2, 76.3% had hypertension, 31% had diabetes mellitus, and 53.5% of them suffered from heart failure. About 31% of the patients had an angina episode the week before the enrollment and the Canadian Cardiovascular Society (CSS) classification was class I, II, III and IV in 55%, 30%, 14% and 1%, respectively. The mean resting HR was 72.5 bpm; 51% of the patients had resting HR>70 bpm and 22% of them had HR80 bpm. Only 52.8% of the study patients were receiving beta-blockade (BB) therapy; they were more likely to have resting HR70 bpm (57.4% vs. 42.7%, p<0.001). 16.4% of the patients were receiving ivabradine and they had a higher initial HR compared to the others (78.5 vs. 71.3, p<0.001). Multivariate analysis showed that diabetes mellitus was independently associated with HR>70 bpm. Patients with resting HR>70 bpm had significantly more frequent angina episodes (p<0.001), were less satisfied with treatment (p<0.001), and had a lower quality of life (p<0.001). CONCLUSION: The baseline data of this study showed that patients with CAD and COPD present inadequate HR control and frequent angina episodes. Apart from the special characteristics of these patients related to COPD management, underuse of BB therapy largely contributes to the inadequate control of HR. Patients with HR>70 bpm had significantly worse quality of life.

Neutrophil count on admission predicts major in-hospital events in patients with a non-ST-segment elevation acute coronary syndrome.

BACKGROUND: Inflammation plays a key role in the pathogenesis of acute coronary syndromes (ACS). In this context we assessed neutrophil count as a predictor of major in-hospital events in patients admitted for a non-ST-segment elevation (NSTE) ACS. METHODS: We measured neutrophils on admission in 160 patients with a NSTE ACS and we correlated their count with the incidence of a combined in-hospital end point including: cardiac death, acute heart failure, ST-segment elevation myocardial infarction, and recurrent myocardial ischemia. RESULTS: Patients who had a major in-hospital event also had a higher neutrophil count (P = 0.02) and higher serum levels of troponin I (P = 0.04). In the univariate logistic regression analysis, in-hospital major events could be predicted by troponin I > 0.07 ng/mL (odds ratio [OR]: 5.65, 95% confidence interval [CI]: 1.26-25.32, P = 0.02), white blood cell count > 8650 cells/microL (OR: 2.68, 95% CI: 1.03-6.95, P = 0.04), neutrophil count > 6700 cells/microL (OR: 7.74, 95% CI: 2.79-21.47, P < 0.001), and C-reactive protein > 0.97 mg/dL (OR: 3.56, 95% CI: 1.13-11.19, P = 0.02). However, in multivariate regression, neutrophil count > 6700 cells/microL (OR: 6.52, 95% CI: 1.56-27.22, P = 0.01) was the only independent in-hospital prognostic factor. CONCLUSIONS: In patients with a NSTE ACS of moderate or high risk, neutrophil count on admission may identify those who are at risk of having an adverse in-hospital outcome.

Clinical implications of the echocardiographic assessment of left ventricular long axis function.

The assessment of the left and right ventricular long axis function by Doppler echocardiography was started many years ago with the use of M-mode. Two-dimensional echocardiography was subsequently used to study the longitudinal function of the left ventricle. The studies of that era led to useful conclusions. However, tissue Doppler imaging, a relatively new echocardiographic technique, recently became the first choice for such an assessment. Moreover, the advances of tissue tracking and strain rate also have an important contribution. New studies were conducted and new data derived for left and right ventricular function in various cardiac diseases. The aim of this review was to present the accumulated knowledge of the Doppler echocardiography study of the left ventricular long axis function and the relevant clinical implications.

Prevalence and potential mechanisms of sustained ventricular arrhythmias during dobutamine stress echocardiography: a literature review.

Sustained ventricular tachycardia during dobutamine stress echocardiography is a rare complication of dobutamine stress echocardiography. It may be related to reduced left ventricular function and prior myocardial infarction but cannot be used as a sensitive or specific sign for myocardial ischemia. The clinical significance of dobutamine stress echocardiography-induced sustained ventricular tachycardia is uncertain, and this condition probably does not represent an adverse prognostic sign.

Intracardiac echocardiography-facilitated ablation of a left-lateral bypass tract in a patient with atrial septal aneurysm.

Intracardiac echocardiography (ICE) has been used as an adjunctive tool during electrophysiological procedures, mainly to increase the safety of transseptal puncture. We present the case of a young patient with a left-lateral bypass tract and atrial septal aneurysm, in whom ICE delineated the underlying anatomy, excluded the presence of thrombus and facilitated access to the left atrium through a small atrial septal defect, avoiding the risk of needle puncture for interatrial septal crossing.