The prognostic impact of inflammation in patients with decompensated acute heart failure, as assessed using the pan-immune inflammation value (PIV).

There is increasing evidence that composite scores based on blood counts, which are reflectors of uncontrolled inflammation in the development and progression of heart failure, can be used as prognostic biomarkers in heart failure patients. The prognostic effects of pan-immune inflammation (PIV) as an independent predictor of in-hospital mortality in patients with acute heart failure (AHF) were evaluated based on this evidence. The data of 640 consecutive patients hospitalized for New York Heart Association (NYHA) class 2-3-4 AHF with reduced ejection fraction were analyzed and 565 patients were included after exclusion. The primary outcome was in hospital all-cause death. Secondary outcomes were defined as the following in-hospital events: Acute kidney injury (AKI), malignant arrhythmias, acute renal failure (ARF) and stroke. The PIV was computed using hemogram parameters such as lymphocytes, neutrophils, monocytes and platelets. Patients were categorized as low or high PIV group according to the median value, which was 382.8. A total of 81 (14.3%) in-hospital deaths, 31 (5.4%) AKI, 34 (6%) malignant arrhythmias, 60 (10.6%) ARF and 11 (2%) strokes were reported. Patients with high PIV had a higher in-hospital mortality rate than patients with low PIV (OR: 1.51, 95% CI, 1.26-1.80, p < 0.001). Incorporating PIV into the full model significantly improved model performance (odds ratio X2, p < 0.001) compared to the baseline model constructed with other inflammatory markers. PIV is a potent predictor of prognosis with better performance than other well-known inflammatory markers for patients with AHF.

Fibrinogen and D-dimer variances and anticoagulation recommendations in Covid-19: current literature review

SUMMARY INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly described virus responsible for the outbreak of the coronavirus disease 2019 (Covid-19), named by the World Health Organization (WHO) in February/2020. Patients with Covid-19 have an incidence of acute respiratory distress syndrome (ARDS) of 15.9-29% and sepsis is observed in all deceased patients. Moreover, disseminated intravascular coagulation (DIC) is one of the major underlying causes of death among these patients. In patients with DIC, there is a decrease in fibrinogen and an increase in D-dimer levels. Some studies have shown that fibrinogen and one of its end products, D-dimer, might have a predictive value for mortality in patients with non-Covid sepsis secondary to complications of DIC. Therefore, anticoagulation, considering its mortality benefits in cases of non-Covid sepsis, may also have an important role in the treatment of Covid-19. METHODS We reviewed the literature of all studies published by April 2020 on patients infected with Covid-19. Our review was limited to D-dimer and fibrinogen changes and anticoagulation recommendations. RESULTS Anticoagulation therapy can be started following the DIC diagnosis in Covid-19 patients despite the bleeding risks. In addition, the current evidence suggests a routine use of anticoagulation, particularly in patients with higher D-dimer levels (> 3.0 μg/mL). CONCLUSION Covid-19 is a systemic, hypercoagulable disease requiring more studies concerning treatment. Aanticoagulation is still an issue to be studied, but D-dimer rise and disease severity are the indicative factors to start treatment as soon as possible.

RESUMO INTRODUÇÃO O coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2) é o vírus responsável pelo surto recentemente batizado de doença pelo coronavirus 2019 (Covid-19) pela Organização Mundial de Saúde (OMS) em fevereiro/2020. Os doentes com Covid-19 têm uma incidência de síndrome de dificuldade respiratória aguda (SDRA) de 15,9-29% e sepse é observada em todos os pacientes que vêm a óbito. Além disso, a coagulação intravascular disseminada (DIC) é uma das principais causas subjacentes de morte entre esses pacientes. Em pacientes com DIC, ocorre com uma diminuição do fibrinogênio e um aumento dos níveis de dímero D. Alguns estudos mostraram que o fibrinogênio e um dos seus produtos finais, o dímero D, podem ter um valor preditivo para a mortalidade em pacientes com sepse não relacionada à Covid-19 decorrente de complicações da DIC. Portanto, a anticoagulação, considerando seus benefícios quanto à mortalidade na sepse não relacionada à Covid-19, pode também ter um papel importante no tratamento da Covid-19. MÉTODOS Realizamos uma revisão de todos os estudos publicados até abril de 2020 sobre pacientes infectados com Covid-19. A nossa revisão limitou-se a alterações no dímero D, nos fibrinogênios e recomendações de anticoagulantes. RESULTADOS A terapêutica anticoagulante pode ser iniciada após o diagnóstico de DIC em pacientes com Covid-19 apesar dos riscos de hemorragia. Além disso, a evidência atual sugere o uso rotineiro da anticoagulação, principalmente em pacientes com níveis mais elevados de dímero D (> 3, 0 µg/mL). CONCLUSÃO A Covid-19 é uma doença sistêmica e hipercoagulável que requer mais estudos em relação ao tratamento. A anticoagulação ainda é uma questão a ser estudada, mas o aumento de dímeros D e a gravidade da doença são os fatores indicativos para o início do tratamento o mais rápido possível.

The use of monocyte to HDL ratio to predict postoperative atrial fibrillation after aortocoronary bypass graft surgery.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is a frequent and serious complication after aortocoronary bypass graft (ACBG) surgery and one that, unfortunately, increases morbidity and mortality. Postoperative stroke, hemodynamic instability, renal failure, infection, need for inotropic agent and coronary unit are complications caused by POAF. Inflammation and oxidative stress are among several mechanisms that contribute to pathogenesis of POAF. Monocyte to HDL (M/H) ratio is a newly defined parameter of both inflammation and oxidative stress. In this study, M/H ratio was investigated as predictor of POAF after ACBG surgery. METHODS: Total of 311 patients who underwent ACBG surgery were included in the study. Blood samples for analysis of routine biochemistry and lipid panel were obtained from the patients on the morning of ACBG surgery after 12 hours of fasting. Patients were continuously monitored for occurrence of POAF throughout hospitalization. RESULTS: POAF was observed in 71 patients following ACBG operation. M/H ratio was significantly higher in POAF(+) group compared with POAF(-) group (p<0.001). Median age of POAF(+) patients was 62.0±10.1 years, which was significantly higher than mean age of POAF(-) patients. Other atrial fibrillation (AF) risk factors, such as hypertension, diabetes mellitus, smoking, and alcohol consumption, were similar between groups. Potassium level was statistically lower in POAF(+) group compared with POAF(-) group (p=0.01). CONCLUSION: M/H ratio is an indicator of inflammation and oxidative stress, both of which play important role in pathogenesis of AF. M/H ratio was found be statistically significantly higher in POAF(+) patients than in POAF(-) patients.

Off-Hour Primary Percutaneous Coronary Angioplasty Does Not Affect Contrast-Induced Nephropathy in Patients With ST-Segment Elevation Myocardial Infarction.

We evaluated whether primary percutaneous coronary intervention (pPCI) during off-hours is related to an increased incidence of contrast-induced nephropathy (CIN). We retrospectively analyzed the incidence of CIN mortality among 2552 patients with consecutive ST-segment elevation myocardial infarction treated with pPCI during regular hours (weekdays 8:00 am to 5:00 pm) and off-hours (weekdays 5:01 pm to 7:59 am, weekends and holidays). Patients in the off-hour group were more frequently admitted with acute heart failure symptoms (16.4% vs 7.8%, P < .001) and more contrast was injected during the procedure (235.2 ± 82.3 vs 248.9 ± 87.1 mL, P = .002). The frequency of CIN between on-hour and off-hour groups was similar (7.1% vs 6.2%, P = .453), but there was a trend toward higher in-hospital mortality when pPCI was performed during off-hours (1.9% vs 0.7%, P = .081). Off-hour pPCI was not associated with an increased risk of CIN (odds ratio: 1.051, P = .833). The incidence of CIN did not increase during off-hours, and off-hour pPCI is not a risk factor for CIN, despite an apparent increase in contrast media use during off-hour pPCI.

Wolff-Parkinson-White and left ventricular noncompaction in a Fabry patient: A case report.

Fabry disease is the second most common inherited (X-linked recessive) lysosomal storage disease associated with multiple organ involvement. Cardiac involvement of Fabry disease varies. Successful radiofrequency ablation of a Fabry disease patient with Wolff-Parkinson-White syndrome and left ventricular noncompaction is described in the present report.

Incidence, risk factors, and outcomes of perioperative acute kidney injury in noncardiac and nonvascular surgery.

BACKGROUND: The aim of this study was to determine the incidence rate, identify the risk factors, and describe the clinical outcome of perioperative acute kidney injury (AKI) in patients undergoing noncardiac, nonvascular surgery (NCS). METHODS: A total of 1,200 adult consecutive patients undergoing NCS were prospectively evaluated. Patients with pre-existing renal dysfunction were excluded. The primary outcome of this study was perioperative AKI defined by the RIFLE (risk, injury, failure, loss of function, and end-stage kidney disease) criteria. RESULTS: Eighty-one patients (6.7%) met the AKI criteria. Multivariate analysis identified age, diabetes, revised cardiac risk index, and American Society of Anesthesiologists physical status as independent predictors of AKI. Patients with AKI had more cardiovascular (33.3% vs 11.3%, P < .001) complications and a higher in-hospital mortality rate (6.1% vs 0.9%, P = .003) compared with patients without AKI. CONCLUSIONS: Several preoperative predictors are found to be associated with AKI after NCS. Perioperative AKI is an independent risk factor for outcome after NCS.

Outcome of noncardiac and nonvascular surgery in patients with mechanical heart valves.

There is a tendency to avoid noncardiac surgery in patients with mechanical heart valves (MHVs) owing to the increased risk of perioperative thromboembolism, infective endocarditis, and bleeding. We aimed to determine the risk of cardiac and noncardiac complications in patients with MHVs who underwent noncardiothoracic, nonvascular surgery. A total of 140 patients with MHVs (77 aortic, 46 mitral, and 17 double valve) and 1,200 patients with native valves (control group) were prospectively followed up for a minimum of 3 months after noncardiothoracic and nonvascular surgery. Patients with bioprostheses were excluded. Those patients aged >18 years who underwent an elective, non-outpatient, open surgical procedure were enrolled. Subcutaneous enoxaparin 1 mg/kg, twice daily, was used as bridging anticoagulation. The demographics, co-morbidities, and preoperative (medications, echocardiographic findings, laboratory results) and postoperative data were evaluated for their association with the occurrence of perioperative adverse events. The incidence of perioperative adverse cardiovascular (10.8% vs 10.7%, p = 0.985) and noncardiovascular (11.9% vs 11.4%, p = 0.989) events was similar in those patients with and without MHVs. Bleeding (18.6% vs 14.2%, p = 0.989), thromboembolism (3.6% vs 2%, p = 0.989), and mortality at 3 months (1.4% vs 1.3%, p = 0.825) were also similar for the 2 groups. In conclusion, with close follow-up and strict adherence to the guidelines, patients with MHVs and patients with native heart valves undergoing noncardiac and nonvascular surgery have a similar risk of mortality and morbidity.

A novel prognostic marker in acute ischemic stroke: small pericardial effusion.

The study aimed to evaluate the prognostic importance of small pericardial effusion (SPE) found on echocardiography in a cohort of patients hospitalized for acute ischemic stroke. We prospectively followed a series of 408 consecutive first-ever acute ischemic stroke patients aged ≥50 years who were admitted to the hospital within 24 h of the onset of stroke symptoms. All of the patients underwent transthoracic echocardiography within the first 48 h. Exclusion criteria were cardiothoracic surgery or acute myocardial infarction within the previous 6 months, a moderate or greater pericardial effusion (>1 cm if circumferential), and inadequate visualization of the pericardial space. The patients were followed for 1 year or until death, whichever came first. SPE was noted in 64 (15.7 %) of the patients. Mortality at 1 year was greater for patients with a small effusion (n = 21, 32.8 %) compared to those without an effusion (n = 40, 11.6 %, p < 0.001). After adjustment for age, demographics, medical history, and other echocardiographic findings, SPE remained associated with higher mortality (OR 2.515; 95 % CI 1.188-5.477; p = 0.008). This study is the first to demonstrate that the presence of SPE is associated with increased mortality in patients with first-ever acute ischemic stroke.

Adenotonsillar hypertrophy: correlation between obstruction types and cardiopulmonary complications.

OBJECTIVES/HYPOTHESIS: To evaluate the association of upper airway obstruction (UAO) type and cardiopulmonary complications in children. The effect of obstruction type on quality of life and severity of obstructive symptoms were also investigated. STUDY DESIGN: Cross-sectional study. METHODS: A Brodsky scale and adenoid-nasopharynx ratio (ANR) were used to categorize tonsil and adenoid size, respectively. The patients were divided into four groups according to obstruction type: adenoid hypertrophy only (ANR ≥ 0.63, tonsil grade 1 or 2), adenoid and tonsil hypertrophy (ANR ≥ 0.63, tonsil grade 3 or 4), tonsillar hypertrophy only (ANR < 0.63, tonsil grade 3 or 4), and normal (ANR < 0.63, tonsil grade 1 or 2). Mean pulmonary artery pressure (MPAP), tricuspid annular plane systolic excursion (TAPSE), and right ventricle myocardial performance index (RVMPI) were evaluated for each patient. The obstructive sleep apnea questionnaire (OSA-18) and Brouilette symptom score questionnaire were completed by each child's parents. RESULTS: MPAP was higher in patients with adenoid hypertrophy and adenoid and tonsil hypertrophy in comparison with the normal group. The P values were .079 and .055, respectively, when comparing TAPSE and RVMPI measurents in adenoid and tonsil hypertrophy and normal patients. A significant correlation was found between ANR and MPAP, RVMP, and TAPSE. The patients in the adenoid and tonsil hypertrophy group had the highest Brouilette symptom and OSA-18 scores. CONCLUSIONS: Patients with adenoid and tonsil hypertrophy are at a higher risk for cardiopulmonary complications, poorer quality of life, and more severe UAO symptoms and should have priority for surgical treatment to prevent cardiopulmonary complications.

Predictive value of preoperative electrocardiography for perioperative cardiovascular outcomes in patients undergoing noncardiac, nonvascular surgery.

BACKGROUND: The utility of routine preoperative electrocardiography (ECG) for assessing perioperative cardiovascular risk in patients undergoing noncardiac, nonvascular surgery (NCNVS) is unclear. HYPOTHESIS: There would be an association between preoperative ECG and perioperative cardiovascular outcomes in patients undergoing NCNVS. METHODS: A total of 660 patients undergoing NCNVS were prospectively evaluated. Patients age >18 years who underwent an elective, nonday case, open surgical procedure were enrolled. Troponin I concentrations and 12-lead ECG were evaluated the day before surgery, immediately after surgery, and on the first 5 postoperative days. Preoperative ECG showing atrial fibrillation, left or right bundle branch block, left ventricular hypertrophy, frequent premature ventricular complexes, pacemaker rhythm, Q-wave, ST-segment changes, or sinus tachycardia or bradycardia were classified as abnormal. The patients were followed up during hospitalization and were evaluated for the presence of perioperative cardiovascular events (PCE). RESULTS: Eighty patients (12.1%) experienced PCE. Patients with abnormal ECG findings had a greater incidence of PCE than those with normal ECG results (16% vs 6.4%; P < 0.001). Mean QTc interval was significantly longer in the patients who had PCE (436.6 ± 31.4 vs 413.3 ± 16.7 ms; P < 0.001). Univariate analysis showed a significant association between preoperative atrial fibrillation, pacemaker rhythm, ST-segment changes, QTc prolongation, and in-hospital PCE. However, only QTc prolongation (odds ratio: 1.15, 95% confidence interval: 1.06-1.2, P < 0.001) was an independent predictor of PCE according to the multivariate analysis. Every 10-ms increase in QTc interval was related to a 13% increase for PCE. CONCLUSIONS: Prolongation of the QTc interval on the preoperative ECG was related with PCE in patients undergoing NCNVS.