Baseline white blood cell count is an independent predictor of long-term cardiovascular mortality in patients with non-ST-segment elevation acute coronary syndrome, but it does not improve the risk classification of the GRACE score.

OBJECTIVES: To investigate the prognostic significance of baseline white blood cell count (WBCc) in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and its additive predictive value beyond the Global Registry of Acute Coronary Events (GRACE) score. METHODS: We included 1,315 consecutive NSTE-ACS patients. Patients were divided in quartiles according to the WBCc (cells per 1 mm(3)) i.e. Q1 <6,850, Q2 = 6,850-8,539, Q3 = 8,540-10,857 and Q4 ≥10,858. The study end point was 3-year cardiovascular death (CVD). RESULTS: The median age of the study population was 76 years. Overall, 335 patients (25.5%) died with 211 of these (16%) suffering from CVD. Patients in Q4 showed a higher cumulative probability of CVD compared to patients in Q1-Q3. On multivariable analysis, patients in Q4 were at higher risk of CVD [hazard ratio (HR) = 1.47, 95% confidence interval (CI) 1.09-1.98, p = 0.011]. WBCc as a continuous variable was also independently associated with the study end point (HR = 1.043; 95% CI 1.02-1.07; p = 0.001). However, the incorporation of WBCc into the GRACE score did not improve either prediction of risk (C-index = 0.796 for GRACE score with or without WBCc) or classification of risk [relative integrated discrimination improvement = 0.0154, 95% CI) -0.029 to 0.0618; continuous net reclassification improvement = -0.0676, 95% CI -0.2149-0.0738). CONCLUSIONS: WBCc was an independent predictor of 3-year CVD in patients with NSTE-ACS. However, it did not add prognostic information beyond the GRACE score.

Cognitive functions: evaluation and changes after transcatheter aortic valve implantation in elderly patients.

AIM: To assess the prevalence and postprocedural evolution of cognitive impairment (CI) in patients undergoing transcatheter aortic valve implantation. METHODS: 62 patients were enrolled. Mini Mental state examination (MMSE), verbal memory test (VMT), visual search test (VST) and phonemic verbal fluency (PVF) were used to evaluate the cognitive status. CI was considered when a pathological result of MMSE was confirmed by VMT, VST and PVF. RESULTS: A total of 26.2% patients had CI at baseline. MMSE, VMT, VST and PVF were pathologic in 39, 16.1, 8.1 and 22.6% of the patients, respectively. Overall, no significant differences in cognitive function in any dimension were observed from baseline up to 1-year follow-up. CONCLUSION: CI is frequent in patients undergoing transcatheter aortic valve implantation, though the procedure does not forge cognitive status.

[Prevalence of degenerative aortic valve stenosis in the elderly: results of a large community-based epidemiological study]. / Prevalenza della stenosi aortica degenerativa negli anziani: risultati di uno studio epidemiologico di comunità

BACKGROUND: There is a paucity of epidemiological data on the prevalence of degenerative aortic stenosis (AS) after the recent demographic changes and in the present therapeutic era. We sought to assess the prevalence of AS in an elderly population of an Italian urban area and to derive an epidemiological estimate of AS prevalence on a larger scale. METHODS: Elderly people (aged 75-95 years) of a 26 000 inhabitants town were clinically screened by general practitioners and classified into four groups: (1) no signs of AS; (2) known AS; (3) suspected AS (on the basis of the presence of a systolic murmur); (4) prior aortic valve replacement (AVR). Group 2 and 3 patients underwent physical examination and transthoracic echocardiography to confirm or rule out the diagnosis of AS, and to assess main comorbidities. RESULTS: Among the eligible patients, 2203 (93.7%) had no sign of AS; 49 (2.1%) had known AS; in 74 (3.1%) there was a systolic murmur suggesting AS, and 26 (1.1%) had previous AVR because of AS. Ten patients refused further screening, therefore 113 patients underwent transthoracic echocardiography. Among them, degenerative aortic disease without stenosis was observed in 22, and 63 had confirmed AS (severe in 21). Important comorbidities were frequently diagnosed in these patients. Including patients with previous AVR, AS was confirmed in 89/2350 patients (3.8%). On a regional scale, based on the demographics of this area, we estimated a prevalence of severe AS of 2248 cases per million inhabitants. CONCLUSIONS: The prevalence of AS in a population aged 75-95 years was 3.8%, and it was not previously diagnosed in a sizable proportion. More attention for early diagnosis of AS in the elderly is warranted.

Predictors of complicated athero-thrombotic lesions in non-ST segment acute coronary syndrome.

AIMS: Non-ST segment elevation acute coronary syndrome (NSTE-ACS) is a heterogeneous syndrome in terms of patho-physiological mechanisms and prognosis. We sought to investigate the clinical features associated with complicated athero-thrombotic (CAT) coronary lesions and their prognostic relevance in NSTE-ACS. METHODS: We enrolled 701 consecutive NSTE-ACS patients without previous coronary bypass undergoing coronary angiography. The study population was divided into two groups according to the presence/absence of angiographic signs of endoluminal thrombi and/or plaque rupture, defined as CAT lesions. Multivariable analyses were used to identify predictors of CAT lesions. Their relation to composite endpoint of death, re-myocardial infarction, and re-unstable angina was investigated with the use of multivariable logistic regression. RESULTS: Patients with CAT lesions (n = 279, 40%) had a higher incidence of the combined endpoint (11.5 vs. 4.3%; P < 0.001). On multivariable analysis male sex [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.17-2.30, P = 0.004], previous percutaneous coronary intervention (PCI) (OR 0.48, 95% CI 0.32-0.72, P < 0.001), severe angina (OR 1.72, 95% CI 1.18-2.52, P = 0.005) and anterior (i.e. V1-V4) ST segment depression (STD) were independently associated with CAT lesions (OR 1.71, 95% CI 1.14-2.57, P = 0.01). After adjustment for the Global Registry of Acute Coronary Events (GRACE) score only the presence of anterior STD emerged as an independent predictor of the clinical endpoint (OR 2.68, 95% CI 1.38-5.20, P = 0.003). The incorporation of anterior STD into the GRACE risk score showed an important trend toward improving prediction of endpoint as assessed by c-statistic (0.72 vs. 0.67; P = 0.08). CONCLUSION: In patients with NSTE-ACS male sex, severe angina and anterior STD were associated with an increased risk of CAT lesions. Patients with anterior STD were also at increased risk of in-hospital clinical events.