Diastolic dysfunction grade in acute coronary syndromes: Application of 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations.

BACKGROUND: Diagnosis and grading of diastolic dysfunction (DD) is challenging, with different studies using heterogeneous criteria and guidelines not routinely applied in clinical practice. Our aim was to apply the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging classification of DD among a contemporary population of patients with acute coronary syndromes (ACS) by analyzing its correlation with N-terminal pro b-type natriuretic peptide (NT-proBNP) and impact on clinical outcomes. METHODS: Independent investigators blinded to each other and to the clinical history reviewed digitally stored images to apply 2016 and 2009 DD definitions to 380 patients (mean age 66 ± 13 years, 75% men) with ACS admitted to the coronary care unit between January 2016 and March 2018. RESULTS: DD was frequent with both definitions, yet the concordance was weak (kappa =0.21, p < 0.01). Inter-observer reliability was greater by applying the 2016 algorithm (kappa = 0.89, p < 0.001). There was a significant correlation between NT-proBNP and worsening DD (Spearman's rho r = 0.54 for 2016 and r = 0.24 for 2009 algorithms, both p < 0.001). Worse DD was associated with worse clinical presentation and increased risk of events (HR for the cumulative incidence of heart failure and death during follow-up 2.15 [95% CI 1.66-2.78, p < 0.001] and 1.82 [95% CI 1.39-2.40, p < 0.001] for 2016 and 2009 classifications, respectively, all p < 0.001). CONCLUSIONS: The agreement between 2016 and 2009 DD definitions was poor, with newer guidelines having grater interobserver reliability. The positive graded association between 2016 DD classification and NT-proBNP and its association with clinical outcomes provide a validation of the latest guideline algorithm in ACS patients.

Prevention of contrast-induced nephropathy: a single center randomized study.

BACKGROUND: Contrast-induced nephropathy (CIN) is the third cause of acute deterioration of renal function in hospitalized patients. HYPOTHESIS: The purpose of the study was to compare the efficacy of saline infusion, saline infusion plus N-acetylcysteine (NAC), and sodium bicarbonate (SB) infusion to prevent CIN in patients undergoing coronary angiography and/or percutaneous coronary intervention. METHODS: We prospectively studied 156 patients with a baseline creatinine level > or = 1.2 mg/dL. The primary endpoint was the development of CIN, defined as an increase in serum creatinine concentration > or = 25% over the baseline value within 5 days from contrast exposure. RESULTS: Contrast-induced nephropathy developed in 23 patients (14.7%). Incidence of the primary endpoint was similar in the 3 groups of treatment, occurring in 7 patients (14%) in the saline infusion group, in 9 (17%) in the saline infusion plus NAC group, and in 7 (14%) in the SB infusion group. CONCLUSIONS: Our findings suggest that neither the addition of NAC nor the administration of SB add further benefit in CIN prevention, compared to standard hydration with isotonic saline infusion.

Doppler echocardiographic assessment of the effects of inhaled long-acting beta2-agonists on pulmonary artery pressure in COPD patients.

Increase in pulmonary artery pressure (PAP), which is common in severe chronic obstructive pulmonary disease (COPD), is a predictor of mortality independent of airflow limitation. beta-agonists might slightly attenuate this increase because they exert a vasodilating effect on pulmonary circulation when systematically administered. We have investigated the acute effects of salmeterol and formoterol on echocardiographic systolic pulmonary artery pressure (sPAP) in 20 patients with COPD and a sPAP greater than 20mmHg at rest. Acute haemodynamic responses to inhaled formoterol or salmeterol were assessed in all patients, in a randomized, double-blind double-dummy fashion. On two consecutive days, patients received, in a randomized order, formoterol 12microg via Turbuhaler plus placebo via Diskus or salmeterol 50microg via Diskus plus placebo via Turbuhaler. Transthoracic Doppler echocardiography measurements of sPAP were made before and 15, 30, 60 and 180min after bronchodilator inhalation. Lung function, pulse oximetry and heart rate were also monitored at the same times. Mean sPAP significantly (p<0.05) decreased in comparison with baseline at 15, 30, and 60min post inhalation but returned towards control levels at 180min after both salmeterol and formoterol. There was no correlation between the maximum increase in FEV(1) and maximum decrease in sPAP either after inhalation of salmeterol (r(2)=0.071) or after that of formoterol (r(2)=0.0006). The increases in FEV(1) in comparison with baseline were always significant (p<0.05) from 15 to 180min post inhalation after either salmeterol or formoterol. Neither pulse oximetry nor heart rate changed in a significant manner (p>0.05). This study demonstrated that salmeterol and formoterol were equally beneficial for pulmonary haemodynamics in patients with COPD. A direct vasodilatation due to the activation of beta-adrenoceptors that are present in pulmonary vessels is a likely mechanism of their action in inducing the decrease in sPAP.