Epidemiology and Risk Factors of Mycotic Aneurysm in Patients With Infective Endocarditis and the Impact of its Rupture in Outcomes. Analysis of a National Prospective Cohort.

Background: Several aspects of the occurrence and management of mycotic aneurysm (MA) in patients with infective endocarditis (IE) have not been studied. Objectives: To determine the incidence and factors associated with MA presence and rupture and to assess the evolution of those initially unruptured MA. Methods: Prospective multicenter cohort including all patients with definite IE between January 2008 and December 2020. Results: Of 4548 IE cases, 85 (1.9%) developed MA. Forty-six (54.1%) had intracranial MA and 39 (45.9%) extracranial MA. Rupture of MA occurred in 39 patients (45.9%). Patients with ruptured MA had higher 1-year mortality (hazard ratio, 2.33; 95% confidence interval, 1.49-3.67). Of the 55 patients with initially unruptured MA, 9 (16.4%) presented rupture after a median of 3 days (interquartile range, 1-7) after diagnosis, being more frequent in intracranial MA (32% vs 3.3%, P = .004). Of patients with initially unruptured MA, there was a trend toward better outcomes among those who received early specific intervention, including lower follow-up rupture (7.1% vs 25.0%, P = .170), higher rate of aneurysm resolution in control imaging (66.7% vs 31.3%, P = .087), lower MA-related mortality (7.1% vs 16.7%, P = .232), and lower MA-related sequalae (0% vs 27.8%, P = .045). Conclusions: MA occurred in 2% of the patients with IE. Half of the Mas occurred in an intracranial location. Their rupture is frequent and associated with poor prognosis. A significant proportion of initially unruptured aneurysms result from rupture during the first several days, being more common in intracranial aneurysms. Early specific treatment could potentially lead to better outcomes.

Incidence and clinical impact of infective endocarditis after transcatheter aortic valve implantation.

AIMS: To describe the characteristics of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: This study was performed using the GAMES database, a national prospective registry of consecutive patients with IE in 26 Spanish hospitals. Of the 739 cases of IE diagnosed during the study, 1.3% were post-TAVI IE, and these 10 cases, contributed by five centres, represented 1.1% of the 952 TAVIs performed. Mean age was 80 years. All valves were implanted transfemorally. IE appeared a median of 139 days after implantation. The mean age-adjusted Charlson comorbidity index was 5.45. Chronic kidney disease was frequent (five patients), as were atrial fibrillation (five patients), chronic obstructive pulmonary disease (four patients), and ischaemic heart disease (four patients). Six patients presented aortic valve involvement, and four only mitral valve involvement; the latter group had a higher percentage of prosthetic mitral valves (0% vs. 50%). Vegetations were found in seven cases, and four presented embolism. One patient underwent surgery. Five patients died during follow-up: two of these patients died during the admission in which the valve was implanted. CONCLUSIONS: IE is a rare but severe complication after TAVI which affects about 1% of patients and entails a relatively high mortality rate. IE occurred during the first year in nine of the 10 patients.

Endocarditis in patients with ascending aortic prosthetic graft: a case series from a national multicentre registry.

OBJECTIVES: Endocarditis in patients with ascending aortic prosthetic graft (AAPG) is a life-threatening complication. The purpose of this study was to examine the clinical presentation and prognosis of patients with AAPG endocarditis included in a large prospective infectious endocarditis multicentre study. METHODS: From January 2008 to April 2015, 3200 consecutive patients with infectious endocarditis according to the modified Duke criteria, were prospectively included in the 'Spanish Collaboration on Endocarditis Registry (GAMES)' registry. Twenty-seven definite episodes of endocarditis (0.8%) occurred in patients with AAPG. RESULTS: During the study period, 27 cases of endocarditis were detected in patients with AAPG. The median age of patients was 61 years [interquartile range (IQR) 51-68 years] and 23 (85.2%) patients were male. The median time from AAPG surgery to the episode of AAPG infection was 24 months (IQR 6-108 months). The most frequently isolated micro-organisms were coagulase-negative staphylococci and S. aureus (11 patients, 40.7%). Four patients (14.8%) underwent medical treatment, whereas surgery was performed in 21 (77.7%). Two patients (7.4%) died before surgery could be performed. The median hospital stay prior to surgery was 7 days (IQR 4-21 days). Surgery consisted of replacing previous grafts with a composite aortic graft (10 cases) or aortic homograft (2 patients), and removal of a large vegetation attached to the valve of a composite tube (1 case). Nine patients had an infected aortic valve prosthesis without evidence of involvement of the AAPG. Isolated redo-aortic valve replacement was performed in 8 (88.9%) of these patients. Reinfection occurring during 1 year of follow-up was not detected in any patient. Two patients (7.4%) died while awaiting surgery and 6 did so after surgery (22.2%). A New York Heart Association (NYHA) Class IV was associated with mortality in patients undergoing surgery (P < 0.019). CONCLUSIONS: Most cases of endocarditis in patients with AAPG occur late after initial surgery. Mortality rate of patients with AAPG endocarditis who undergo surgery is acceptable. NYHA Class IV before surgery is associated with an increased postoperative mortality.

Inflammatory activation and left ventricular mass in essential hypertension.

BACKGROUND: Inflammation is an independent risk factor for high blood pressure, and as a consequence inflammatory cytokines could be related with left ventricular hypertrophy (LVH). We sought to assess the association and predictive role of different cytokine levels with LVH in a group of patients with essential hypertension (HT). METHODS: We studied 251 asymptomatic hypertensive patients (142 with LVH and 109 without LVH), referred from 11 hospitals. A routine physical examination, laboratory analyses, and echo-Doppler study were performed. Plasma soluble tumor necrosis factor (TNF) receptors (sTNF-R1 and sTNF-R2), interleukin-6 (IL-6), and interleukin-1 receptor antagonist (IL-1ra) were centrally determined. RESULTS: Hypertensive patients with LVH had higher inflammatory cytokine levels than the group without hypertrophy (P < 0.001). Multivariate linear regression reported that sTNF-R1 (P < 0.01) was an independent predictor of left ventricular mass index (LVMI). All cytokines had significant area under the curves for detection of LVH, but sTNF-R1 has the highest area, 0.71 +/- 0.03 (P < 0.001). Finally, prevalence of LVH was increased in the group of patients with higher cytokine levels, and logistic regression analysis showed that sTNF-R1 (odds ratio = 2.59, 95% CI of 1.14-5.87) was an independent predictor of LVH. CONCLUSIONS: Cytokine levels were significantly correlated with LVMI in hypertensive patients. The sTNF-R1 was an independent predictor of LVMI. Plasma sTNF-R1 concentrations could be a predictive factor of LVH in patients with essential HT.

[Evaluation of patients with acute chest pain of uncertain origin by means of serial measurement of high-sensitivity C-reactive protein]. / Evaluación de los pacientes con dolor torácico agudo de origen incierto mediante la determinación seriada de los valores de proteína C reactiva de alta sensibilidad.

INTRODUCTION AND OBJECTIVES: We investigated the usefulness of taking two serial measurements of the high-sensitivity C-reactive protein (hs-CRP) level for evaluating acute chest pain in patients with non-diagnostic ECG findings and normal levels of markers of myocardial cell injury (i.e., an inconclusive diagnosis). We hypothesized that the C-reactive protein concentration would be raised if symptoms were due to coronary endothelial damage or arteriosclerotic plaque rupture. METHODS: The study involved 468 consecutive patients who presented to the emergency department with acute chest pain, 191 of whom had an inconclusive diagnosis. In this patient group, we determined the hs-CRP level on emergency admission and at 24 hours. Standard guidelines on managing acute chest pain of suspected coronary origin were followed. Any increase in hs-CRP level between baseline and 24 hours was regarded as a positive result. RESULTS: In total, 38 (20%) patients were diagnosed with chest pain due to coronary disease. Measurement of the hs-CRP level differential (i.e., the hs-CRP level at 24 hours minus the baseline level at emergency admission) had a sensitivity of 95% (95% confidence interval [CI] 81-98%), a specificity of 40% (95% CI, 32-47%), a positive likelihood ratio of 1.57 (95% CI, 1.33-1.83), a negative likelihood ratio of 0.13 (95% CI, 0.04-0.44), and an area under the receiver operating characteristic curve of 0.77 (95% CI, 0.69-0.85). By 30-day follow-up, no cardiac event had occurred in patients with a negative hs-CRP level differential. CONCLUSIONS: Measurement of the hs-CRP level differential is diagnostically useful in patients with acute chest pain of likely coronary origin. A negative result is associated with a low risk of ischemic heart disease and would allow patients to be discharged safely from the emergency department.

Evaluación de los pacientes con dolor torácico agudo de origen incierto mediante la determinación seriada de los valores de proteína C reactiva de alta sensibilidad / Evaluation of patients with acute chest pain of uncertain origin by means of serial measurement of high-sensitivity C-reactive protein

Introducción y objetivos. Investigamos la utilidad de 2 medidas seriadas de proteína C reactiva de alta sensibilidad (PCR-as) para evaluar el dolor torácico en pacientes con electrocardiograma no diagnóstico y marcadores de daño miocárdico normales. Partimos de la hipótesis de que la concentración de PCR-as se incrementaría si los síntomas fueran causados por daño endotelial coronario o rotura de placa arteriosclerótica. Métodos. Estudiamos a 468 pacientes consecutivos atendidos en urgencias con dolor torácico, 191 con diagnóstico no concluyente. En esta población determinamos la PCR-as en el momento del ingreso en urgencias y a las 24 h. Seguimos el protocolo de tratamiento del dolor torácico con sospecha de origen coronario. Cualquier incremento de la PCR-as a las 24 h en relación con la basal se consideró un resultado positivo Resultados. En total, 38 (20%) pacientes fueron diagnosticados de dolor torácico coronario. La diferencia de PCR-as (PCR-as a las 24 h menos PCR-as basal en urgencias) mostró una sensibilidad del 95% (intervalo de confianza [IC] del 95%, 81-98%), una especificidad del 40% (IC del 95%, 32-47%), una razón de probabilidad positiva de 1,57 (IC del 95%, 1,33-1,83), una razón de probabilidad negativa de 0,13 (IC del 95%, 0,04-0,44) y área bajo la curva receptor-operador de 0,77 (IC del 95%, 0,69-0,85). A los 30 días no hubo eventos cardiacos en los pacientes con diferencia negativa del valor de PCR-as. Conclusiones. La diferencia de PCR-as resulta útil como herramienta diagnóstica en los pacientes con dolor torácico agudo de probable origen isquémico. Los resultados negativos se asocian con un bajo riesgo de isquemia coronaria significativa y permitirían dar de alta de forma segura a los pacientes desde el servicio de urgencias (AU)

Introduction and objectives. We investigated the usefulness of taking two serial measurements of the high-sensitivity C-reactive protein (hs-CRP) level for evaluating acute chest pain in patients with non-diagnostic ECG findings and normal levels of markers of myocardial cell injury (i.e., an inconclusive diagnosis). We hypothesized that the C-reactive protein concentration would be raised if symptoms were due to coronary endothelial damage or arteriosclerotic plaque rupture. Methods. The study involved 468 consecutive patients who presented to the emergency department with acute chest pain, 191 of whom had an inconclusive diagnosis. In this patient group, we determined the hs-CRP level on emergency admission and at 24 hours. Standard guidelines on managing acute chest pain of suspected coronary origin were followed. Any increase in hs-CRP level between baseline and 24 hours was regarded as a positive result. Results. In total, 38 (20%) patients were diagnosed with chest pain due to coronary disease. Measurement of the hs-CRP level differential (i.e., the hs-CRP level at 24 hours minus the baseline level at emergency admission) had a sensitivity of 95% (95% confidence interval [CI] 81-98%), a specificity of 40% (95% CI, 32-47%), a positive likelihood ratio of 1.57 (95% CI, 1.33-1.83), a negative likelihood ratio of 0.13 (95% CI, 0.04-0.44), and an area under the receiver operating characteristic curve of 0.77 (95% CI, 0.69-0.85). By 30-day follow-up, no cardiac event had occurred in patients with a negative hs-CRP level differential. Conclusions. Measurement of the hs-CRP level differential is diagnostically useful in patients with acute chest pain of likely coronary origin. A negative result is associated with a low risk of ischemic heart disease and would allow patients to be discharged safely from the emergency department (AU)

Infarto agudo de miocardio en el seno de hemoglobinuria paroxística nocturna / Acute Myocardial Infarction with Paroxysmal Nocturnal Hemoglobinuria

Se presenta el caso de un paciente varón de 62 años de edad diabético y fumador que, como otros antecedentes de interés, seguía estudio en otro centro hospitalario por presentar anemia, trombopenia y hematuria de varios meses de evolución. Ingresó en la unidad coronaria en el contexto de un infarto agudo de miocardio transmural extenso que se trató con activador tisular del plasminógeno. A las pocas horas presentó 'orinas hematúricas', disminución de las cifras de hemoglobina y plaquetas, así como insuficiencia renal aguda. Se realizó estudio hematológico que confirmó el diagnóstico de hemoglobinuria paroxística nocturna. El paciente evolucionó de forma desfavorable pese a tratamiento médico intensivo y en su evolución precisó hemodiálisis. Finalmente presentó un taponamiento cardíaco y falleció. Se comenta el papel que tiene la enfermedad hematológica en el infarto agudo de miocardio así como el tratamiento y la evolución del síndrome coronario en el contexto de la enfermedad (AU)

Tratamiento hormonal sustitutivo en la prevención de la cardiopatía isquémica en la mujer. Argumentos en contra / Hormone Replacement Therapy in Ischemic Heart Disease Prevention in Women. Arguments Against

El tratamiento hormonal sustitutivo es una de las cuestiones más difíciles a las que se enfrentan las mujeres y sus médicos. Los estudios epidemiológicos demuestran de manera consistente que las mujeres que toman tratamiento hormonal sustitutivo tienen un riesgo de padecer enfermedad coronaria sustancialmente inferior. Los datos observacionales se sustentan en hallazgos que demuestran que el tratamiento hormonal sustitutivo mejora varios factores de riesgo coronario, en especial los cambios en el perfil lipídico. Sin embargo, no se ha demostrado de forma absoluta que las hormonas ayuden a la prevención de la enfermedad cardiovascular. En mujeres sin enfermedad coronaria, el beneficio del tratamiento hormonal sustitutivo no está claro. Lo que sí han demostrado estudios clínicos recientes es que no se debe recomendar este tratamiento a mujeres con enfermedad coronaria establecida con el objetivo de obtener un beneficio cardiovascular (AU)