Hyperuricaemia and long-term outcome after hospital discharge in acute heart failure patients.

BACKGROUND: Uric acid (UA) may be involved in chronic heart failure (HF) pathogenesis, entailing a worse outcome. The purpose of this study was to examine the role of hyperuricaemia as a prognostic marker after hospital discharge in acute HF patients. METHODS: We studied 212 patients consecutively discharged after an episode of acute HF with LVEF<40%. Blood samples for UA measurement were extracted in the morning prior to discharge. The evaluated endpoints were death and new HF hospitalization. RESULTS: Mean UA levels were 7.4+/-2.4 mg/dl (range 1.6 to 16 mg/dl), with 127 (60%) of patients being within the range of hyperuricaemia. Hyperuricaemia was associated with a higher risk of death (n=48) (HR 2.0, 95% CI 1.1-3.9, p=0.028), new HF readmission (n=67) (HR 1.8, 95% CI 1.1-3.1, p=0.023) and the combined event (n=100) (HR 1.9, 95% CI 1.2-2.9, p=0.004). At 24 months, cumulative event-free survival was lower in the two higher UA quartiles (36.9% and 40.7% vs. 63.5% and 59.5%, log rank=0.006). After adjustment for potential confounders, hyperuricaemia remains an independent risk factor for adverse outcomes (HR 1.6, 95% CI 1.1-2.6, p=0.02). CONCLUSIONS: In hospitalized patients with acute HF and LV systolic dysfunction, hyperuricaemia is a long-term prognostic marker for death and/or new HF readmission.

[Use of a coronary risk score (the TIMI Risk Score) in a non-selected patient population assessed for chest pain at an emergency department]. / Aplicación de una puntuación de riesgo coronario (TIMI Risk Score) en una población no seleccionada de pacientes que consultan por dolor torácico en un servicio de urgencias.

INTRODUCTION AND OBJECTIVES: Stratification algorithms for acute coronary syndrome enable the identification of high-risk patients who will benefit from more aggressive treatment. The TIMI Risk Score (TRS) has been shown to be useful in intermediate- and high-risk patients. However, little is known about its value in non-selected patients. Our aim was to assess the efficacy of the TRS for risk stratification in a non-selected population with chest pain. PATIENTS AND METHOD: We evaluated 1254 consecutive patients (age, 54 [19] years; 57% male) attending an emergency department for chest pain. Overall, 343 (27%) were admitted and 911 (73%) were discharged. All cardiac events during 6-month follow-up were recorded. RESULTS: Of the 911 discharged patients, 45 (5.3%) were admitted during follow-up: 9 (1.1%) underwent revascularization, 5 (0.6%) had a myocardial infarction (MI), and 2 (0.2%) died from cardiovascular disease. Patients with a high TRS had a significantly higher risk of reaching the composite endpoint of death, MI, or revascularization (relative risk per unit of TRS increase, 3.63; 95% CI, 2.20-6.00; P < .001). Of the patients who were initially admitted, 22 (6.4%) underwent revascularization, 4 (1.2%) had an MI, and 14 died (4.1%) from cardiovascular disease during follow-up. The relative risk of the composite endpoint per unit of TRS increase was 1.72 (95% CI, 1.32-2.24; P < .001). CONCLUSIONS: The TIMI risk score is useful for stratifying cardiovascular event risk in non-selected patients with chest pain. The score can identify high-risk patients who will benefit from hospital admission and early aggressive treatment.

[Implementation of the new diagnostic criteria for myocardial infarction]. / Utilización de los nuevos criterios diagnósticos de infarto de miocardio.

The extent of implementation in daily clinical practice of the new definition of myocardial infarction is unknown. The purpose of the present study was to describe the use of the new definition in patients discharged from a cardiology department. We analyzed the clinical records of 277 patients admitted because of acute coronary syndromes and discharged from the cardiology department between 1 March 2001 and 31 August 2001. The final clinical diagnosis based on the presence of classical or only new diagnostic criteria was studied. 127 patients (46%) satisfied the new definition (61% classical criteria and 39% only new criteria). Only 98 (77%) of the patients with myocardial infarction according to the new definition were discharged with this diagnosis (96% of the group that satisfied classical criteria and 48% of the group that satisfied only new criteria). The diagnosis of myocardial infarction is still based predominantly on classical criteria; the new criteria have been only partially implemented.

B-type natriuretic peptide release in the coronary effluent after acute transient ischaemia in humans.

BACKGROUND: The association between B-type natriuretic peptide (BNP) and coronary artery disease is not fully understood. OBJECTIVE: To assess whether ischaemia per se is a stimulus for BNP secretion. SETTING: University tertiary hospital, Spain (Virgen de la Arrixaca). DESIGN: Prospective interventional study. PATIENTS: 11 patients (55 (9) years, left ventricular ejection fraction (LVEF) 45% (7%) with a non-complicated anterior myocardial infarction (MI) and isolated stenosis of the left anterior descending (LAD) coronary artery, successfully treated by primary angioplasty. INTERVENTIONS: 11.0 (0.9) days after MI, the LAD was occluded (20 min) for intracoronary infusion of progenitor cells. Blood samples were obtained from the femoral artery (peripheral circulation (PC)) and the coronary sinus (coronary circulation (CC)) immediately before and after coronary occlusion. MAIN OUTCOME MEASURES: BNP (pg/ml) was measured and ischaemia biomarkers were monitored. RESULTS: During coronary occlusion, all patients experienced transitory chest pain and ST-segment dynamic changes. After coronary occlusion, lactic acid levels rose in CC (1.42 (0.63) -1.78 (0.68) ng/ml, p = 0.003). Myoglobin and cardiac troponin T did not differ in CC or PC at 24 h. No differences were found in LVEF (+0.18% (2.4)%, p = 0.86) and motion score index (-0.02 (0.06), p = 0.37). Before occlusion, BNP levels did not differ significantly in CC versus PC (253 (56) vs 179 (34), p = 0.093). After occlusion, BNP showed a significant increase in CC (vs 332 (61), p = 0.004), but no change occurred in PC (vs 177 (23), p = 0.93), and circulating BNP levels were higher in CC versus PC (p = 0.008). CONCLUSIONS: In response to acute ischaemia, BNP levels immediately increase in coronary sinus but not at the peripheral level. BNP release in the coronary effluent may exert local beneficial effects.

Aplicación de una puntuación de riesgo coronario (TIMI Risk Score) en una población no seleccionada de pacientes que consultan por dolor torácico en un servicio de urgencias / Use of a coronary risk score (the TIMI risk score) in a non-selected patient population assessed for chest pain at an emergency department

Introducción y objetivos. Diferentes algoritmos de estratificación del síndrome coronario agudo (SCA) permiten identificar a los individuos con un mayor riesgo que pueden beneficiarse de tratamientos más agresivos. Se ha demostrado que el TIMI Risk Score (TRS) es útil en pacientes con un riesgo intermedio y alto, pero faltan evidencias acerca de su aplicabilidad clínica en pacientes no seleccionados. El objetivo es comprobar la eficacia del TRS en la estratificación del riesgo en una población con dolor torácico no seleccionada. Pacientes y método. Se incluyó a 1.254 pacientes consecutivos que acudieron a urgencias por dolor torácico no traumático sin ascenso del segmento ST (edad 54 ± 19 años, 57% varones). Se ingresó a 343 (27%) y se dio de alta a 911 (73%). Se registró la aparición de eventos cardíacos a los 6 meses. Resultados. En el grupo dado de alta desde urgencias, 45 (5,3%) pacientes fueron ingresados durante el seguimiento, 9 (1,1%) recibieron tratamiento de revascularización, 5 (0,6%) presentaron un infarto agudo miocárdico (IAM) y 2 (0,2%) fallecieron por causa cardiovascular. Los que obtuvieron una mayor puntuación en el TRS presentaron más riesgo de presentar el evento combinado muerte, infarto o revascularización (riesgo relativo por incremento de unidad = 3,63; intervalo de confianza [IC] del 95%, 2,20-6,00; p < 0,001). En el grupo de ingresados hubo 22 revascularizaciones (6,4%), 4 IAM (1,2%) y 14 muertes de causa cardiovascular (4,1%) durante el seguimiento. El riesgo relativo de evento combinado por cada incremento del TRS fue 1,72 (IC del 95%, 1,32-2,24; p < 0,001). Conclusiones. El TRS es una herramienta eficaz para la estratificación pronóstica de pacientes no seleccionados que consultan por dolor torácico. Permite identificar a los individuos de alto riesgo que se beneficiarían de ingreso hospitalario y tratamiento agresivo precoz

Introduction and objectives. Stratification algorithms for acute coronary syndrome enable the identification of high-risk patients who will benefit from more aggressive treatment. The TIMI Risk Score (TRS) has been shown to be useful in intermediate- and high-risk patients. However, little is known about its value in non-selected patients. Our aim was to assess the efficacy of the TRS for risk stratification in a non-selected population with chest pain. Patients and method. We evaluated 1254 consecutive patients (age, 54 [19] years; 57% male) attending an emergency department for chest pain. Overall, 343 (27%) were admitted and 911 (73%) were discharged. All cardiac events during 6-month follow-up were recorded. Results. Of the 911 discharged patients, 45 (5.3%) were admitted during follow-up: 9 (1.1%) underwent revascularization, 5 (0.6%) had a myocardial infarction (MI), and 2 (0.2%) died from cardiovascular disease. Patients with a high TRS had a significantly higher risk of reaching the composite endpoint of death, MI, or revascularization (relative risk per unit of TRS increase, 3.63; 95% CI, 2.20-6.00; P<.001). Of the patients who were initially admitted, 22 (6.4%) underwent revascularization, 4 (1.2%) had an MI, and 14 died (4.1%) from cardiovascular disease during follow-up. The relative risk of the composite endpoint per unit of TRS increase was 1.72 (95% CI, 1.32-2.24; P<.001). Conclusions. The TIMI risk score is useful for stratifying cardiovascular event risk in non-selected patients with chest pain. The score can identify high-risk patients who will benefit from hospital admission and early aggressive treatment

Utilización de los nuevos criterios diagnósticos de infarto de miocardio / Implementation of the new diagnostic criteria for myocardial infarction

La nueva definición del infarto de miocardio tiene implicaciones en múltiples campos de la cardiología. Su grado real de aplicación es actualmente desconocido. Este trabajo se propone conocer la utilización de la nueva definición en los pacientes dados de alta de un servicio de cardiología. Analizamos el historial clínico de los 277 pacientes dados de alta de un servicio de cardiología entre el 1 de marzo y el 31 de agosto de 2001 tras ingresar por un síndrome coronario agudo. Estudiamos el juicio diagnóstico final atendiendo al cumplimiento de los criterios clásicos o actuales de infarto. Cumplieron la nueva definición 127 pacientes (46 por ciento), 61 por ciento con criterios clásicos y 39 por ciento sin ellos. Sólo 98 (77 por ciento) de los pacientes con infarto según la nueva definición recibieron este diagnóstico en el momento del alta hospitalaria (el 48 por ciento si no existían criterios clásicos de infarto). Los criterios clásicos siguen siendo determinantes para el diagnóstico del infarto de miocardio. Los nuevos criterios se aplican sólo parcialmente (AU)