Prognostic and diagnostic value of elevated serum concentration of procalcitonin in patients with suspected heart failure. A review and meta-analysis.

PURPOSE: The diagnostic and prognostic significance of procalcitonin remains uncertain in HF patients. We reviewed and performed a meta-analysis of studies that measured PCT in HF patients, with or without infection. MATERIALS AND METHODS: We identified seven studies (9514 patients, 5810 with diagnoses of HF) eligible for our analysis, out of 247 examined. We estimated the serum PCT concentrations in patients with and without HF and/or infection and examined the mortality rates of patients with versus without elevated serum PCT concentrations. RESULTS: The mean age of the study samples ranged between 58 and 81 years, the men proportion between 47% and 66%, the follow-up duration between 22 and 180 days. The median PCT concentration in patients with HF and concomitant infections tended to be higher (0.26 ng/l [0.06, 0.46]) than in patients with HF alone (0.10 ng/l [0.08, 0.12]; p = 0.059). The mortality of patients suffering from HF and whose serum PCT concentrations were elevated was significantly higher than that of patients suffering from HF whose PCT concentrations were normal at 30 (2.66 [1.74, 4.05]), 90 (2.12 [1.59, 2.83]) and 180 days (2.06 [1.13, 3.78]). CONCLUSIONS: In patients with HF, an elevated serum PCT concentration predicted the short-term risk of death.

Small, medium but not large arteries are involved in digital ulcers associated with systemic sclerosis.

OBJECTIVE: Digital ulcers (DU) are a burden in systemic sclerosis (SSc). Microangiopathy is a cardinal feature of SSc that plays a critical role in the development of DU. However, whether injury of medium or large vessels also contributes to DU in SSc remains controversial. METHODS: To measure concomitantly in SSc patients with and without active DU: (i) the Augmentation Index of the reflected wave (Aix_75) by radial applanation tonometry, an index of small and medium arterial function; (II) the aortic pulse wave velocity (PWV), a marker of large vessel injury (aortic stiffness). RESULTS: Sixty-three consecutive SSc patients were included (49 females, aged 60 [49-65] years, disease duration of 8.5 [5-13] years), including 10 (15.9%) with active DU. Patients with active DU versus those without had increased Aix_75 (35% [28-38] versus 28% [20-34], P=0.041) whereas no difference existed in PWV (7.0m/s [6.7-10.1] versus 7.6m/s [6.8-8.7], P=0.887), in systolic, diastolic, as well as aortic pulse pressure (P=0.126, 0.592, and 0.161, respectively). When compared to patients in the low tertile, patients having Aix_75 in the highest tertile had 10-fold more DU (OR=10.23; 95% CI 1.12 to 93.34, P=0.039). CONCLUSION: The presence of DU is associated with increased Aix_75 whereas there is no relation with PWV. These data suggest that small and medium arteries are involved in the occurrence of DU whether large vessel stiffness does not contribute. Whether Aix_75 is predictive of further DU remained to be studied.

Reduced inotropic reserve is predictive of further degradation in left ventricular ejection fraction in patients with Duchenne muscular dystrophy.

AIMS: Duchenne muscular dystrophy (DMD), an inherited X-linked muscular disease, is associated with dilated cardiomyopathy that is responsible for death in 40% of patients. Our objective was to determine whether inotropic reserve is predictive of LV trend over time. METHODS AND RESULTS: A total of 69 DMD patients (age 12.2±2.3 years) were investigated. At baseline, LVEF and the presence of inotropic reserve (defined as an increase in LVEF >10% during dobutamine infusion) were investigated using radionuclide ventriculography. During follow-up (FU), LVEF was remeasured after a mean 29±19 months delay. In the whole population, mean LVEF was 58±8% at baseline and declined to 54±11% during FU (P =0.004). At baseline, 21 patients (30.4%) had LVEF <55% and 38 had no LV inotropic reserve. LVEF declined in the 38 patients (55.1%) without LV inotropic reserve (58±8% to 52±10%, P =0.001), and not in the other patients (58±8% to 57±11%, P =0.516) (P =0.042 for trends in LVEF between groups after adjustment for age, FU duration, and baseline LVEF). Fewer patients with vs. without inotropropic reserve at baseline show a depressed LVEF <55% during follow-up(35.5% vs. 63.2%, respectively, P =0.030). Similar findings were observed in the subgroups of patients with LVEF >45% or 55% at baseline. CONCLUSION: Inotropic reserve assessment allows the distinction of DMD patients who will vs. those who will not show a deterioration in LVEF, thus offering a sensitive approach for delineating the presence and progression of cardiovascular disease in these patients.

[Interpretation of mild elevation of high-sensitivity cardiac troponins]. / Interprétation des concentrations intermédiaires de troponine hyper-sensible.

Measurements of cardiac troponins (cTn) are yet considered the gold standard method in patients with chest pain. Very recently, high-sensitivity (hs)cTn emerged and allow to measure very low concentrations of cTn. The aim of these assays was the better detection of patients with acute myocardial infarction (AMI). The threshold value should be the 99th percentile of the method, which corresponds to the concentration obtained from 99% of a reference population. These assays improve the detection of patients with elevated cTn concentrations. All patients with increased hs-cTn concentration above the 99th percentile should be considered at high risk of future clinical event when compared to patients with lower concentration. However, these elevated concentrations are not necessarily related to AMI due to coronary artery plaque rupture and superimposed thrombus. In order to understand adequately cTn measurement, the physician should base his interpretation on the context, the cTn concentration, variations during serial sampling, and the possible existence of a coexistent disease characterized by increased cTn concentrations.

Prevalence and prognostic significance of 'J waves' in patients experiencing ventricular fibrillation during acute coronary syndrome.

BACKGROUND: 'J waves' have been associated with idiopathic ventricular fibrillation (VF) and have also been described in patients with ischaemic VF. AIMS: Our aim was to determine whether inferior and/or lateral 'J waves' were associated with the occurrence of VF or in hospital mortality during acute coronary syndrome (ACS). METHODS: Fifty-three patients (mean age 52 ± 10 years) experienced cardiac arrest due to VF during the first 48 hours of an ACS. These patients were entered in a retrospective case-control study. The control group was matched for age and sex and included 106 patients who experienced an ACS but without VF. RESULTS: 'J waves' were more frequent in the study group than in the control group (62% vs. 39%; P=0.006). 'J waves' (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.5-7.1; P=0.001) and left ventricular ejection fraction<40% (53% vs. 14%; P<0.001) (OR 7.9, 95% CI 3.5-18.0; P=0.001) were associated with VF. Inhospital mortality was 15.1% in the study group versus 0.9% in the control group (OR 18.7, 95% CI 2.2-157.5; P=0.008). VF (OR 18.3, 95% CI 2.3-835.9; P<0.001) and the presence of 'J waves' (OR 15.9. 95% CI 2.4-∞; P<0.001) were predictive of inhospital mortality. In patients who experienced VF, inhospital mortality was 24% when 'J waves' were observed and 0% when 'J waves' were absent (P=0.02). CONCLUSIONS: Inferior and lateral 'J waves' were observed more frequently in patients who experienced cardiac arrest due to VF associated with ACS than in the absence of cardiac arrest and were associated with higher inhospital mortality.

Use of implantable loop recorders in patients with Brugada syndrome and suspected risk of ventricular arrhythmia.

AIMS: Implantable cardioverter defibrillator (ICD) therapy is recommended in patients with Brugada syndrome (BS) who experienced aborted sudden cardiac death (SCD) or syncope while the risk stratification of ventricular arrhythmias is a difficult step in patients with atypical symptoms. Implantable loop recorder (ILR) use has been proposed to study patients with unexplained recurrent syncopal events, but its usefulness remains to be defined in patients with BS. In this retrospective study we aimed to investigate the effectiveness of ILR as a diagnostic tool in BS patients suspected of low or moderate risk of SCD. METHODS AND RESULTS: We gathered data from 11 ILR recipients with supposed risk of ventricular arrhythmia, issue of Amiens registry of 204 patients with BS. We reported clinical events before and after implant, electrocardiogram (ECG) characteristics, ILR findings, and its limitations as well as tried to specify ILR utility in diagnosis approach and its consequent contribution to guide the optimal therapy. Within the 11 patients (8 men, 3 women), 9 were symptomatic, and 5 had a spontaneous Type 1 ECG pattern. During mean follow-up period of 33 months, 8 patients had a recurrence of symptoms with a mean delay of 9 months after implant. Bradycardia (two atrioventricular blocks and two sinus bradycardia) was detected in four out of eight patients (50%), and there was no ventricular arrhythmia in any patient during symptomatic events which included six vasovagal syncopes and two epileptic seizures. Two initially asymptomatic patients did not experience any symptoms after ILR implant and their ILR recordings did not reveal any arrhythmias. CONCLUSION: The ILR contributed to the exclusion of a ventricular arrhythmia as a mechanism of an atypical syncope in patients with electrocardiographic BS and the suspension of the ICD implant. Episodes of transient symptomatic bradycardia were the most common findings suggesting the vagal mechanism of symptoms. The use of ILR should be considered in selected patients with atypical syncope and spontaneous or transient Type 1 ECG pattern.