Fat-Free Mass and Body Fat in Patients with Myocardial Infarction Who Underwent Percutaneous Coronary Intervention.

There are no data on the effects of fat-free mass (FFM) and body fat (BF) on prognosis in patients with myocardial infarction (MI). We investigated the effects of FFM and BF (which were estimated using formulas rather than direct measurements) on 30-day and long-term all-cause mortality in patients with MI who underwent percutaneous coronary intervention. We analyzed data from 6,453 patients with MI. The patients were divided into 2 categories (high/low) according to the fat-free mass index (FFMI) and 2 categories (low/high) according to the BF. The resultant 4 patient groups: HighFFMI-LowBF, HighFFMI-HighBF, LowFFMI-LowBF, and LowFFMI-HighBF, were compared. The lowest crude mortality after 30 days and in the long term was observed in the HighFFMI-LowBF group (3.0%,9.8%, respectively), followed by the HighFFMI-HighBF group (6.6%, 27.0%, respectively), the LowFFMI-LowBF group (10.4%, 36.0%, respectively), and the LowFFMI-HighBF group (14.7%, 56.8%, respectively). The difference was significant (p <0.0001), as was the difference between groups. After adjustment, the FFMI-BF groups independently predicted 30-day mortality (p = 0.003), but the risk was similar in all groups. Compared with the HighFFMI-LowBF group, the long-term mortality risk was similar in the HighFFMI-HighBF group (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.84 to 1.47, p = 0.47), but the LowFFMI-LowBF and LowFFMI-HighBF patients had a higher risk (HR 1.59, 95% CI 1.20 to 2.11, p = 0.001, HR 1.40, 95% CI 1.03 to 1.91, p = 0.033, respectively). Body composition predicted mortality better than body mass index in patients with MI. Mortality appeared to be inversely related to FFM, with patients with low FFM and low BF having a particularly high mortality risk. The body composition groups also confirmed the obesity paradox.

Anemia on admission and long-term mortality risk in patients with acute ischemic stroke.

BACKGROUND: Anemia is associated with adverse outcomes in patients with acute myocardial infarction and congestive heart failure. Additionally, it has been shown that anemia increases the short-term mortality risk in patients with acute stroke. OBJECTIVES: The aim of our study was to determine the importance of anemia as a long-term mortality risk factor by itself or in combination with other risk factors. MATERIAL AND METHODS: We included 390 Caucasian patients with acute ischemic stroke in our study. Their progress was followed from the day of their admission until their death or a max. of 1,669 days. Stroke and anemia were defined according to the World Health Organization (WHO) criteria. RESULTS: Anemia was present in 57 (14.6%) patients. The patients with anemia were older (p < 0.01) and more likely to be female (p < 0.001). They had higher NIHSS scores on admission (p < 0.001) and discharge (p < 0.001), lower estimated glomerular filtration rates (eGFRs) (p < 0.001), lower serum LDL cholesterol (p < 0.01) and lower serum albumin levels (p < 0.001), while their serum C-reactive protein (CRP) levels were higher (p < 0.001). The Kaplan-Meier curves showed that patients with anemia had higher mortality (p < 0.001). Cox's regression analysis revealed that anemia at admission was a predictor of long-term mortality in these patients (hazard ratio (HR) = 2.448, 95% confidence interval (95% CI) = 1.773-3.490; p < 0.001). Anemia remained a strong predictor of mortality after adjusting for other risk factors as well. CONCLUSIONS: Anemia was frequent among our patients and was an independent predictor of long-term mortality even after adjusting for other risk factors.

Newer glomerular filtration rate estimating equations for the full age spectrum based on serum creatinine and cystatin C in predicting mortality in patients with ischemic stroke.

BACKGROUND: Renal dysfunction is associated with increased risk of mortality. The novel Full Age Spectrum (FAS) equations estimating the glomerular filtration rate (GFR) based on serum creatinine (FAScrea) and cystatin C (FAScysC) are validated across the entire age spectrum and are superior markers of renal function compared to other equations. Possible association of these equations with mortality in patients with ischemic stroke is not known. PATIENTS AND METHODS: We included 390 patients (207 men, 183 women) in our observational cohort study who had suffered from an ischemic stroke and followed-up on for 3 years. Serum creatinine and cystatin C were measured at admission; GFR was estimated according to the FAScrea, CKD-EPIcrea, FAScysC and CKD-EPIcysC equations. The values of estimated GFRs were divided into quintiles. RESULTS: During the follow-up period, 173 (44.4%) patients died. The association of hazard ratios for FAScrea and CKD-EPIcrea with all-cause mortality was J-shaped and only significantly higher when comparing the fifth quintile hazard ratio for mortality with the first quintile (P < 0.001). For FAScysC and CKD-EPIcysC, hazard ratios increased from the first to the fifth quintile linearly. In an adjusted analysis, FAScrea and CKD-EPIcrea were not associated with all-cause mortality and the hazard ratios of the fifth quintile of FAScysC (P = 0.008) and CKD-EPIcysC (P = 0.042) were significantly associated with mortality compared to the first quintile. CONCLUSIONS: In patients with an ischemic stroke, estimated GFR based on serum cystatin (FAScysC and CKD-EPIcysC) was a better predictor of all-cause and cardiovascular mortality than estimated GFR based on serum creatinine.

GPIIb-IIIa Receptor Inhibitors in Acute Coronary Syndrome Patients Presenting With Cardiogenic Shock and/or After Cardiopulmonary Resuscitation.

BACKGROUND: Data on the use of GPIIb-IIIa receptor inhibitors (GPI) in acute coronary syndrome (ACS) patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation is sparse. The aim of the study was to establish the possible influence of the adjunctive use of GPI on 30-day and 1-year mortality in these high-risk patients. METHODS: Acute coronary syndrome patients (261), who presented with cardiogenic shock and/or were cardiopulmonary resuscitated on admission, were analysed. Groups receiving (170 patients) and not receiving (91 patients) GPI were compared regarding 30-day and 1-year mortality. RESULTS: The unadjusted all-cause 30-day and 1-year mortality were similar in patients receiving GPI and those not receiving GPI [79 patients (46.5%) vs 50 patients (54.9%) at 30 days; ns, 91 patients (53.5%) vs. 55 (61.1%) at 1 year; ns]. After the adjustment for baseline and clinical characteristics, the adjunctive usage of GPI was identified as an independent prognostic factor in lower 30-day mortality (adjusted OR: 0.41; 95%CI: 0.20 to 0.84; p=0.015) and 1-year mortality (HR 0.62; 95%CI 0.39-0.97; p=0.037). Age, left main PCI and major bleeding, were also identified as independent prognostic factors in worse 30-day and 1-year mortality. In addition, Thrombolysis in Myocardial Infarction (TIMI) flow 0/1 pre-percutaneous coronary intervention (PCI) predicted a worse 1-year outcome. Novel oral P2Y12 receptor antagonists predicted better 30-day and 1-year survival. CONCLUSION: Our study suggests that the adjunctive usage of GPI may be beneficial in this high-risk group of patients in whom a delayed onset of action of oral antiplatelet therapy would be expected.

Deterioration of renal function at stent implantation can predict long-term outcome after stent thrombosis.

OBJECTIVES: The aim of the study was to examine the possible influence of minor deterioration of the renal function after stent implantation not fulfilling the criteria for acute kidney injury on long-term outcomes after stent thrombosis (ST). BACKGROUND: Decreased renal function (DRF) is associated with an increased risk for worse outcome after percutaneous coronary intervention. There is no data if the deterioration of renal function after stent implantation influences the prognosis after ST. If so patients with a higher risk for worse outcome after ST could be identified already at the time of stent implantation. METHODS: Data from 4824 consecutive patients treated with percutaneous coronary intervention in our center was recorded from March 2004 to April 2010. We excluded patients with acute kidney injury at stent implantation and 86 of them with ST without acute kidney injury at stent implantation were involved in the study. They were prospectively followed until December 2012 for 50.2 ± 28.1 months. Only patients with definite ST were included in the study. The Academic Research Consortium definition of ST was used. Data on death, myocardial infarction, and repeated percutaneous or operative revascularization after ST were ascertained from the hospital database, by phone or with clinical examinations. The outcomes after definite ST were compared in patients with and without deterioration of renal function after stent implantation (DRFafterSI). RESULTS: During the observational period patients with DRFafterSI had a higher mortality rate after ST than patients without DRFafterSI (35.1 vs. 10.3 %; p <0.019). The incidence of major adverse cardiac events (major adverse coronary event (MACE)-death, myocardial infarction, repeated revascularization) rate after ST was similar in both groups (66.1 % with DRFafterSI vs. 55.2 % without DRFafterSI). The prevalence of myocardial infarction was also similar in both groups (31.6 vs. 34.5 %) as was the revascularizations rate (43.9 vs. 48.3 %). Death was predicted by DRFafterSI (adjusted hazard ratio (HR) 3.96; 95 % confidence interval (CI) 1.11 to 14.10; p <0.034) and age > 75 years (adjusted HR 2.85: 95 % CI 1.12-7.30; p = 0.029). We could not find any predictor for MACE. CONCLUSIONS: Even more subtle DRFafterSI (not fulfilling the criteria for acute kidney injury) at stent implantation were associated with higher long-term mortality after ST. Especially at risk were patients older than 75 years at stent implantation. DRFafterSI and age more than 75 years pointed out the group of patients with a high risk for death after ST already at the time of stent implantation. The best treatment option for preventing ST in these patients is still to be determined. Until then, we must pay a special attention to proper patients' preparation and hydration to avoid DRFafterSI.

General public awareness of heart failure: results of questionnaire survey during Heart Failure Awareness Day 2011.

INTRODUCTION: General public views about heart failure (HF) alone and in comparison with other chronic conditions are largely unknown; thus we conducted this survey to evaluate general public awareness about HF and HF disease burden relative to common chronic disease. MATERIAL AND METHODS: This was a cross-sectional survey during European Heart Failure Awareness Day 2011. People visiting the stands and other activities in 12 Slovenian cities were invited to complete a 14-item questionnaire. RESULTS: The analysis included 850 subjects (age 56 ±15 years, 44% men, 55% completed secondary education or higher). Overall, 83% reported to have heard about HF, 58% knew someone with HF, and 35% believed that HF is a normal consequence of ageing. When compared to other chronic diseases, HF was perceived as less important than cancer, myocardial infarction, stroke and diabetes with only 6%, 12%, 7%, and 5% of subjects ranking HF as number 1 in terms of prevalence, cost, quality of life, and survival. A typical patient with HF symptoms was recognized by 30%, which was comparable to the description of myocardial ischemia (33%) and stroke (39%). Primary care physicians (53%) or specialists (52%) would be primary sources of information about HF. If experiencing HF, 83% would prefer their care to be focused on quality of life rather than on survival (14%). CONCLUSIONS: Many participants reported to have heard about heart failure but the knowledge was poor and with several misbeliefs. Heart failure was perceived as less important than several other chronic diseases, where cancer appears as a main concern among the general public.

A prospective study about impact of renal dysfunction and morbidity and mortality on cardiovascular events after ischemic stroke.

BACKGROUND: The aim of our prospective study was to define the impact of renal dysfunction on future cardiovascular events and total mortality in 390 patients suffering from ischemic stroke. METHODS: A quantitative measurement of neurologic deficit according to National Institutes of Health Stroke Scale (NIHSS) score was performed. Blood parameters were measured. Diabetes, hypertension and smoking habits were defined. Estimated glomerular filtration rate was calculated. RESULTS: 153 (39.2%) patients had renal dysfunction. In the follow-up period in 36 (9.2%) patients acute coronary syndrome, in 102 (26.2%) recurrent ischemic stroke and in 44 (11.3%) peripheral arterial disease were documented. 191 (49%) patient died, 118 (30.3%) of whom died of cardiovascular events. Patients who died were older, had higher prevalence of renal dysfunction and NIHSS score. The Kaplan-Meier survival analysis showed that total mortality (p < 0.003) and cardiovascular mortality (p < 0.01) were higher in patients with renal dysfunction. According to Cox's regression analysis, renal dysfunction was the predictor of cardiovascular events, cardiovascular and total mortality. CONCLUSIONS: Patients with ischemic stroke and renal dysfunction are at higher risk for long term cardiovascular and total mortality. The patients with ischemic stroke and renal dysfunction are also at higher risk of new cardiovascular morbidity. Renal dysfunction should be added to the other known prognostic factors in patients with ischemic stroke. Our results also emphasize the importance of identification and management of renal dysfunction in stroke patients.

Cystatin C, creatinine, estimated glomerular filtration, and long-term mortality in stroke patients.

Renal dysfunction is associated with mortality in patients after ischemic stroke. Cystatin C is a potentially superior marker of renal function compared to creatinine and estimated glomerular filtration rate (GFR). In our observational cohort study, 390 Caucasian patients suffered from acute ischemic stroke (mean age 70.9 years; 183 women and 207 men) were included and prospectively followed up to maximal 56 months. Serum creatinine and cystatin C were measured at admission to the hospital; GFR was estimated according to CKD-EPI creatinine and CKD-EPI creatinine/cystatin equations. According to values of serum creatinine, estimated GFR and serum cystatin C patients were divided into quintiles. In the follow-up period, 191 (49%) patients died. For serum cystatin C and estimated GFR based on creatinine and cystatin C, the mortality and the hazard ratios for long-term mortality increased from the first to the fifth quintile nearly linearly. The associations of serum creatinine and estimated GFR categories based on creatinine with long-term mortality were J-shaped. As compared with lowest quintile of serum cystatin C, the fifth quintile was associated with long-term mortality significantly also after multivariate adjustment (age, gender, initial stroke severity, known risk factors for stroke mortality). In contrast, in adjusted analysis serum creatinine and estimated GFR (CKD-EPI creatinine and CKD-EPI creatinine/cystatin) were not associated with long-term mortality. In summary, serum cystatin C was independently and better associated with the risk of long-term mortality in patients suffering from ischemic stroke than were creatinine and estimated GFR using both CKD-EPI equations.

Changes in left ventricular filling in patients with persistent atrial fibrillation.

BACKGROUND: Former studies showed possible interrelationship between altered ventricular filling patterns and atrial fibrillation (AF). HYPOTHESIS: Long term persistent AF has a negative impact on left ventricular filling in patients with preserved ejection fraction of left ventricle. METHODS: Our study was designed as a prospective case control study. We included 40 patients with persistent AF and preserved ejection fraction after successful electrical cardioversion and 43 control patients. Persistent AF was defined as AF lasting more than 4 weeks. Cardiac ultrasound was performed in all patients 24 hours after the procedure. Appropriate mitral flow and tissue Doppler velocities as well as standard echocardiographic measurements were obtained. RESULTS: There were no significant differences between both groups' parameters regarding age, sex, commorbidities or drug therapy. Analysis of mitral flow velocities showed significant increase of E value in AF group (0.96±0.27 vs.0.70±0.14; p = 0.001). Tissue Doppler measurements didn't reveal any differences in early diastolic movement, however there was a statistically significant difference in E/Em values of both groups, respectively (12.0±4.0 vs. 9.0±2.1; p= 0.001). CONCLUSION: Our study shows that in patients with preserved systolic function and persistent AF shortly after cardioversion diastolic ventricular filling patterns are altered mainly due to increased left atrial pressure and not due to impaired diastolic relaxation of left ventricle. Further studies are needed in order to define the interplay between diminished atrial function and impaired ventricular filling.

Mortality of patients with renal dysfunction after percutaneous coronary intervention.

AIM: To determine the impact of stages of renal dysfunction on mortality after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). PATIENTS AND METHODS: A total of 449 patients (mean age 63 +/- 11.9 years) with ACS after PCI were included. Serum creatinine was determined and creatinine clearance was calculated using the Modification of Diet in Renal Disease (MDRD) formula. RESULTS: The prevalence of chronic kidney disease (CKD) defined as glomerular filtration rate (GFR) <60 mL/min per 1.73 m(2) was 26.3%. After up to 787 days of follow-up, 40 patients had died. Kaplan-Meier survival analysis showed progressively higher risk for cardiovascular death from stage 1 to stage 4 of renal dysfunction. In an adjusted Cox model, gender (P < .009), age (P < .0001), total cholesterol level (P < .01), and stage of renal dysfunction (P < .04) were predictors of mortality. CONCLUSIONS: In patients with ACS after PCI, a higher stage of renal dysfunction was directly associated with higher mortality of these patients.