A multimarker risk stratification approach to non-ST elevation acute coronary syndrome: implications of troponin T, CRP, NT pro-BNP and fibrin D-dimer levels.

INTRODUCTION: Biomarkers have emerged as interesting predictors of risk in non-ST elevation acute coronary syndromes (non-ST ACS). The aim of this study was to define the utility of the combined measurement of troponin T (TnT), C-reactive protein (CRP), NT pro-brain natriuretic peptide (NT pro-BNP) and D-dimer as biomarkers to predict adverse events. METHODS: We included 358 consecutive patients admitted in two hospitals for non-ST ACS. Baseline measurements of TnT (associated with myocardial injury, positive, if > or =0.1 ng mL(-1)), CRP (a marker of inflammation), NT-proBNP (associated with left ventricular (dys)function) and fibrin D-dimer (and index of thrombogenesis) were performed. A positive CRP, NT-proBNP and D-dimer test was considered upper than the 75th percentile of our population. The risk for major events (death, new ACS, revascularization and heart failure) at 6 months' follow-up was analysed. RESULTS: Troponin T, NT pro-BNP and CRP were predictors of adverse events in the multivariate analysis [hazards ratio (HR): 2.00 (1.30-3.07), P = 0.0016; HR: 2.27 (1.47-3.50), P = 0.0002; HR: 1.90 (1.24-2.92), P = 0.0034 respectively], but not D-dimer levels [HR: 1.26 (0.79-2.02), P = 0.337). After adjusting for baseline characteristics and electrocardiographic changes, multimarker risk approach was associated with adverse events at 6 months, especially with the presence of three positive biomarkers [HR 2.80 (95%CI 1.68-4.68), P < 0.001]. When we divided patients by risk groups [Thrombolysis in Myocardial Infarction (TIMI) risk score], patients with two or three elevated biomarkers had higher event rates [HR 2.59 (95% CI 1.37-4.91), P = 0.004]. CONCLUSION: A multimarker approach based on TnT, CRP and NT-proBNP provides added information to the TIMI risk score in terms of ACS prognosis at 6 months, with a worse outcome for those with two or three elevated biomarkers.

Prothrombotic state and elevated levels of plasminogen activator inhibitor-1 in mitral stenosis with and without atrial fibrillation.

Patients with mitral stenosis in sinus rhythm are in a prothrombotic state and have fibrinolytic dysfunction, shown by an increase in levels of the inhibitor of tissue plasminogen activator, D-dimer, and modified antithrombin III. This state may be observed even in patients without dilated left atria (diameter < or =45 mm).

Tissue factor/tissue factor pathway inhibitor system and long-term prognosis after acute myocardial infarction.

UNLABELLED: The tissue factor and tissue factor pathway inhibitor (TFPI) system has been studied in the acute phase of coronary disease but its prognostic importance has been less well assessed. We evaluated its association with recurrent coronary events during long-term follow-up after a myocardial infarction. METHODS: We studied 55 consecutive patients with the following criteria for inclusion: (1) first myocardial infarct; (2) aged < 70 years; (3) non-complicated infarct; (4) low risk effort-test. Blood samples were taken 60-80 days after infarction. Tissue factor, total and free-TFPI were measured. A 4-year follow-up was carried out. Death, unstable angina and new myocardial infarction were considered as poor prognosis. RESULTS: There were no statistical differences in tissue factor/TFPI levels between patients and controls. Total-TFPI showed statistical correlation with total cholesterol (r = 0.59), triglycerides (r = 0.34), LDL-cholesterol (r = 40) and Lipoprotein(a) (r = 0.48). Patients with high levels of cholesterol, LDL-cholesterol and triglycerides showed elevated levels of total-TFPI with no differences in free-TFPI. During follow-up, 8 patients showed poor prognosis. There were no statistical associations between tissue factor/TFPI levels and prognosis. CONCLUSIONS: After acute myocardial infarction, we did not find any differences in the tissue factor/TFPI system between controls and patients. The tissue factor/TFPI system showed little value as a prognostic factor.

[Chylopericardium after acute pericarditis]. / Quilopericardio tras pericarditis aguda.

We present an 18 year-old man with chylopericardium after acute pericarditis with severe pericardial effusion and cardiac tamponade secondary to Mycoplasma pneumoniae infection. We review the etiology, diagnostic procedures and therapeutic possibilities for chylopericardium.

[Pulmonary valvular agenesis treated with cryopreserved pulmonary homograft]. / Agenesia valvular pulmonar tratada con homoinjerto pulmonar crioconservado.

We report successful treatment of pulmonary valve agenesia with pulmonary stenosis and ventricular septal defect by infundibular resection, patch-closure of the VSD and implantation of a cryopreserved pulmonary homograft. Cases with mild to moderate hypoplasia of the pulmonary annulus are particularly well suited for direct pulmonary homograft implantation, while cases with severe hypoplasia and high right ventricular pressure after correction may be better treated with aortic homografts. Some technical aspects of homograft implantation (doing first the proximal suture, preserving the normal configuration of the valvular sinuses and using the subvalvular homograft tissue to enlarge the right ventricular outflow tract) may prevent significant valvular incompetence.

[The characteristics, management and prognosis of the acute myocardial infarct patient in the Valencian Community in 1995: the results of the PRIMVAC Registry (The Registry Project of Acute Myocardial Infarct in Valencia, Alicante and Castellón). As representatives of the PRIMVAC investigators]. / Características, manejo y pronóstico del paciente con infarto agudo de miocardio en la Comunidad Valenciana en 1995: resultados del registro PRIMVAC (Proyecto de Registro de Infarto Agudo de Miocardio de Valencia, Alicante y Castellón). En represntación de los investigadores del PRIMVAC.

BACKGROUND AND OBJECTIVES: Regional registers of patients with acute myocardial infarction are scarce in Spain. The PRIMVAC register (Proyecto de Registro de Infarto agudo de Miocardio de Valencia, Alicante y Castellón) was initiated to obtain updated information on the management of these patients in the Valencia Autonomous Community. Data of the first twelve months of the register are presented. METHODS: The 17 participating hospitals cover 2,833,938 inhabitants. Demographic, clinical, procedural and outcome data as well as predictive variables of mortality were analysed in the patients with acute myocardial infarction during their stay in the coronary care units from 1 December 1994 to 30 November 1995. RESULTS: During 12 months, 2,377 patients were included. Mean age was 65.3 years (SD 11.9) and 23.2% were female. Left ventricular failure was present in 39.8%. Thrombolytic therapy was applied in 42.1% with a median time delay of 195 min from chest pain onset. This time was longer in the women (250 min) and in the elderly (210 min). The in-coronary-care-unit-mortality rate was 13.9%. Age, female gender, diabetes, previous myocardial infarction, Q wave and right ventricular infarction independently predicted increased early mortality. CONCLUSION: Present data show the feasibility of an acute myocardial infarction register in the Valencia Autonomous Community. Although an acceptable level of thrombolysis has been reached, the mortality rate is still high. The long delay in initiating thrombolysis, particularly in female and elderly patients is remarkable.

[Heart disease in acromegaly. Study of 27 patients]. / Alteraciones cardiológicas en la acromegalia. Estudio de 27 pacientes.

BACKGROUND: The patients with acromegaly have an increased propensity to develop cardiovascular complications. The aim of this study was to evaluate the most relevant clinic, echocardiographic and Holter recording findings in acromegaly and its correlation with the growth hormone (GH) levels and duration of the disease. PATIENTS AND METHODS: 27 patients with acromegaly were evaluated. The basal levels of GH and insulin-like growth factor 1 (IGF-1) were measured at the time of cardiological study and compared with the spontaneous GH secretion during 12-24 hours previously studied. Echocardiogram was made using complete M-mode, two dimensional and spectral Doppler ultrasound mechanical system. Additionally an standard EKG and a Holter recording were performed during 24 hours. RESULTS: There was a strong correlation between basal levels of GH and integrated concentration of GH during the study of spontaneous secretion (r = 0.92; p < 0.01). The prevalence of symptomatic cardiovascular complications in this study was 49%, including 3 patients who died for cardiovascular events. The echocardiographic study showed a high prevalence of left ventricular hypertrophy (66.7%), diastolic dysfunction (63%) and impaired systolic function (18.5%). There was no correlation between GH and IGF-1 levels and echocardiographic findings. Conversely the degree of hypertrophy was related to the duration of the disease and the presence of arterial hypertension. The diastolic function only was related with the presence of hypertension. We found supraventricular arrhythmic events and malignant premature ventricular complexes in 6 and 6 patients, respectively. The EKG showed a high fiability to detect ventricular hypertrophy but no rhythm events. CONCLUSIONS: The high prevalence of cardiovascular complications in acromegaly, most of them asymptomatic, and its clinical relevance, advise the necessity to perform systematic cardiovascular evaluation in these patients.

Canine hepatitis virus infections in dogs of São Paulo city, Brazil.

Infectious Canine Hepatitis virus was isolated from 10 of 51 tested dogs caught in São Paulo and neighbouring Districts. The viruses were isolated in dog kidney cell cultures from fecal specimens and, in two instances, from the non-inoculated cell cultures themselves. All the isolated virus strains presented biological and physicochemical characteristics proper to the adenovirus and were immunologically identified as ICH virus. Specific neutralizing antibodies to the ICH virus were found in 50% of the dogs with negative virus isolations in titers from 1/500 to 1/25,000. These results point to a very high frequency of infection by the ICH virus in the sample studied.

Hypofibrinolysis in atrial fibrillation.

BACKGROUND: There is a high incidence of systemic embolism in patients with chronic atrial fibrillation. A hypercoagulable state has been demonstrated, but the fibrinolytic system is rarely studied. METHODS: Plasma levels of modified antithrombin III (ATM), tissue plasminogen activator (TPA), its inhibitor (PAI-1), TPA-PAI-1 complexes and plasmin-antiplasmin complexes (PAP), d -dimer, and fibrinogen were measured in plasma from 36 patients with chronic atrial fibrillation. Fifteen patients had rheumatic mitral stenosis and 21 had nonrheumatic atrial fibrillation. Levels were compared with those found in the plasma of 20 healthy subjects. Transthoracic echocardiographic studies were done. RESULTS: Patients with atrial fibrillation had higher plasma levels of ATM, d -dimer, PAI-1, and TPA-PAI-1 complexes than controls (P <.001). The rheumatic atrial fibrillation group also showed elevated levels of fibrinogen (P <. 05). No significant differences were found in TPA and PAP. There were no differences between rheumatic and nonrheumatic atrial fibrillation. CONCLUSIONS: Atrial fibrillation shows a hypofibrinolytic state caused by elevated PAI-1 levels with no increase in PAP complex concentration. Elevated plasma d -dimer levels suggest increased intravascular thrombogenesis. This may contribute to increased risk of thrombosis.

[The fibrinolytic system in patients with dilated myocardiopathy]. / Estudio del sistema fibrinolítico en pacientes con miocardiopatía dilatada.

OBJECTIVES: To study the fibrinolytic system in dilated cardiomyopathy (DCM) patients, and the relationship between the degree of severity (NYHA degree), and the presence of complications (atrial fibrillation, intracavity thrombus, and peripheral embolism). We also analyzed the influence of the antithrombotic therapy on the fibrinolysis's proteins. PATIENTS AND METHODS: We included 18 patients, stratified in two etiologic groups: 9 with idiopathic and 9 with ethyl DCM. The fibrinolytic system was investigated through the plasma levels of antigenic and functional t-PA and PAI-1. We also carried out a venous occlusion test to investigate the fibrinolytic the fibrinolytic activity in t-PA secretion. The clinical aspects were recorded. We included 30 healthy individuals matched for age and sex, as controls. RESULTS: The antigenic levels of t-PA and PAI-1, were significantly higher in the DCM group than in the control group (p < 0.01). The venous occlusion test responses were normal. No relationship between the fibrinolytic parameters and clinical data were observed. DISCUSSION: The high levels of antigenic t-PA found in DCM patients were considered as a vascular injury marker, and a atherothrombotic risk factor. Furthermore, there is a hypofibrinolytic condition shown by a PAI-1 augmentation. In conclusion, we are prone to consider long term oral anticoagulation in the management of DCM patients.

[Septic pulmonary embolism, bacterial endocarditis and endocavitary pacemaker]. / Embolismo pulmonar séptico, endocarditis bacteriana y marcapaso endocavitario.

The number of patients carrying an endocavitary pacemaker is increasing every day. The presence of a foreign body in right cavities predisposes to the formation of thrombi that can be over infected from distal septic focci usually silent. When a pulmonary embolism is diagnosed in these patients, the initial study must include an echocardiographic exam in order to rule out the presence of an intracardiac thrombosis as the origin of the emboli. We present the case of a patient with and endocardiac pacemaker who was admitted with fever and repeated episodes of pulmonary embolism. Hemocultures were positive for proteus mirabilis and a electrocatheter thrombosis was demonstrated in bidimensional echocardiography. Proteus mirabilis was positive in cultures from the material obtained by cardiothomy and clinical evolution after surgery was satisfactory.

Plasma von Willebrand factor, soluble thrombomodulin, and fibrin D-dimer concentrations in acute onset non-rheumatic atrial fibrillation.

OBJECTIVE: To investigate whether new onset acute atrial fibrillation (AF) of < 48 hours' duration creates a prothrombotic state in the absence of anticoagulation and to assess the evolution in research indices after spontaneous or pharmacological cardioversion. METHODS: 24 patients were recruited with first onset acute non-rheumatic AF, in whom sinus rhythm was restored within 48 hours of arrhythmia onset, without anticoagulant treatment. Atrial mechanical function was assessed by transmitral inflow. Soluble thrombomodulin and von Willebrand factor concentrations (both as indices of endothelial damage or dysfunction) and fibrin D-dimer concentrations (as an index of thrombogenesis) were measured. Blood samples were drawn and echocardiographic studies were performed at days 1, 3, 7, and 30 after cardioversion. Research indices were compared with those of 24 healthy participants, 24 patients with chronic AF, and 24 patients with ischaemic heart disease in sinus rhythm. RESULTS: Patients with AF had higher concentrations of soluble thrombomodulin (acute AF 12.1 (4.1) ng/ml; chronic AF 11.8 (4.6) ng/ml), von Willebrand factor (acute AF 137.2 (36.9) ng/ml; chronic AF 133.1 (25.0) ng/ml), and fibrin D-dimer concentrations (acute AF 2.35 (2.68) microg/ml; chronic AF 1.12 (0.65) microg/ml) than did healthy controls (5.9 (2.7) ng/ml, 86.7 (33.2) ng/ml, and 0.39 (0.28) microg/ml, respectively) and patients with ischaemic heart disease (7.4 (3.7) ng/ml, 110.0 (29.0) ng/ml, and 0.99 (0.73) microg/ml, respectively) (all p < 0.05). Day 30 concentrations of fibrin D-dimer were higher in patients with acute AF than in patients with chronic AF (p = 0.038) but sTM and von Willebrand factor concentrations were not different (both not significant). There were no significant changes in research indices or echocardiographic parameters after cardioversion (all p > 0.05). CONCLUSIONS: There was evidence among patients with acute onset AF of endothelial damage or dysfunction and increased thrombogenesis, which persisted up to 30 days after cardioversion.