"A Double Twist" Presentation - A Case Report of Purulent Cardiac Tamponade following a Rare Complication of Small-Cell Lung Cancer Radiotherapy.

Background: Small cell lung cancer is an aggressive tumor with a poor prognosis that requires prompt treatment. While radiotherapy may enhance survival when superior vena cava syndrome is present, radiation therapy-induced pericardial disease can be a potential complication. Case Report: A 55-year-old man, who recently underwent radiotherapy for stage IV small-cell lung cancer complicated by superior vena cava syndrome, presented with chest pain and dyspnea. In the emergency room, he was dyspneic, hypotensive, and tachycardic. Pulmonary auscultation revealed the absence of lung sounds on the right. The initial electrocardiogram showed ST-segment elevation in lateral leads and in lead DII, with reciprocal changes in lead DIII. A bedside transthoracic echocardiogram revealed cardiac tamponade and emergent pericardiocentesis was performed, removing 500 ml of purulent fluid, resulting in an immediate clinical improvement. Thoracentesis was also performed, showing no empyema. Large spectrum empirical antibiotic therapy was started. Cultures from the pericardial fluid and peripheral blood grew multi-sensitive Streptococcus pneumoniae. Cytological analysis of the pericardial fluid was consistent with infection. The patient improved after 2 weeks of targeted antibiotic therapy and underwent the first cycle of chemotherapy. He was discharged with an early scheduled pulmonology appointment. Conclusions: Although the most common causes of pericardial effusion in lung cancer are malignant, non-malignant etiologies should also be considered. This patient had an infectious pericardial effusion most probably due to a pericardial-mediastinal mass fistula caused by radiotherapy. This was a diagnostic challenge, both in the emergency room as well in the inpatient setting. LEARNING POINTS: Small cell lung cancer is a fast-growing cancer that exhibits aggressive behavior.In patients with lung cancer, malignant pericardial effusions are more common than non-malignant ones.Purulent pericardial effusions, especially those due to lung cancer, are rare in developed countries with very few reports in the literature.

Do We Have a Culprit? An Association of Giant Cell Arteritis with Pulmonary Embolism.

Giant cell arteritis is the most common type of systemic vasculitis. An increased risk of venous thromboembolism has been described in these patients. We report the case of a 79-year-old woman with a history of polymyalgia rheumatica, who presented with left thoracic pain radiating to the neck and scapula plus temporal headache. She had no changes on physical examination, but work-up tests showed increased D-dimer levels and computed tomography pulmonary angiography revealed signs of a chronic/subacute embolism in the right inferior lobe. Anticoagulation with edoxaban was started after 5-day bridging with enoxaparin. Three weeks after the initial diagnosis the headache still persisted and she developed scalp tenderness. Giant cell arteritis was diagnosed and treated with prednisolone, with complete resolution of symptoms. Extensive diagnostic work-up was performed to identify an alternative cause of pulmonary thromboembolism; however, the investigations were negative. This case supports the hypothesis that this type of vasculitis could be related to the occurrence of pulmonary embolism. LEARNING POINTS: An increased risk of thromboembolism has been associated with giant cell arteritis.Early diagnosis is crucial; however, the role of antiplatelets or anticoagulants is not yet established.

Non-ST Elevation Myocardial Infarction With Occluded Culprit Artery: A Continuum of Mortality Risk Across the Spectrum of Acute Myocardial Infarction.

BACKGROUND: Non-ST segment elevation myocardial infarction (NSTEMI) patients presenting with occluded culprit artery (OCA) may be at higher risk for worse outcomes. We sought to compare in-hospital (IH) mortality between patients presenting with NSTEMI with and without OCA, and ST-segment elevation myocardial infarction (STEMI). METHODS: This retrospective analysis studied 14,037 patients enrolled in the Portuguese National Registry of Acute Coronary Syndromes. Three groups were defined: (A) STEMI (n = 8616); (B) OCA-NSTEMI (n = 1309); and (C) non-OCA NSTEMI (n = 4112). Baseline characteristics, therapeutic strategies, and outcomes were compared. Multivariate analysis was performed to assess the risk of IH all-cause mortality across the prespecified groups. RESULTS: Twenty-four percent of NSTEMI patients presented with OCA. The left circumflex artery was more frequently the culprit artery in group B (12.4% A vs 34.5% B vs 26.0% C; P<.001) and this group was also less likely to receive percutaneous revascularization (95.2% A vs 69.7% B vs 83.2% C; P<.001). The incidence of left ventricular systolic dysfunction was higher in group A and lower in group C (19.9% A vs 12.2% B vs 8.1% C; P<.001). The adjusted risk of IH mortality was significantly higher in group A when compared with group B (3.9% A vs 1.8% B; odds ratio, 2.34; 95% confidence interval, 1.34-4.07; P<.01) and in group B when compared with group C (1.8% B vs 0.9% C; odds ratio, 2.25; 95% confidence interval, 1.17-4.35; P=.02). CONCLUSION: OCA-NSTEMI patients had worse IH outcomes than non-OCA NSTEMI patients and better IH outcomes than STEMI patients, suggesting the existence of a continuum of increased risk of IH mortality across these groups.

Myocardial infarction with nonobstructive coronary arteries: a single-center retrospective study.

BACKGROUND: Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is a heterogeneous entity often overlooked in contemporary medicine. We aim to determine MINOCA differential characteristics, the main etiologies, and prognostic outcomes. PATIENTS AND METHODS: We carried out a retrospective longitudinal analysis including 1047 patients with MI, from 1 January 2011 to 1 January 2016, subjected to coronary angiography and classified according to the presence [MI and obstructive coronary artery disease (MICAD)] or absence (MINOCA) of any coronary stenosis of at least 50%. Studied data included clinical, demographic, laboratorial, and angiographic features. The median follow-up duration was 35 (interquartile range: 25) months. Mortality was the primary endpoint. To identify MINOCA underlying etiologies, only the final diagnosis obtained according to the European Society of Cardiology proposed algorithm was accepted. To determine MINOCA predictors, multivariate analysis with logistic regression was carried out. RESULTS: The mean age of the patients was 66.3±13.4 years; 319 (30.5%) patients were women. The MINOCA group included 114 (10.8%) patients. The underlying final diagnosis in the MINOCA group was obtained in 78 (68.4%) patients. The total mortality rate was 8.8% (n=10) in the MINOCA group versus 17.7% (n=165) in the MICAD group, P=0.018. After multivariate analysis, age [odds ratio (OR)=1.05, 95% confidence interval (CI): 1.03-1.07, P<0.001], female sex (OR=3.91, 95% CI: 2.53-6.06, P<0.001), no previous tobacco use (OR=3.41, 95% CI: 1.68-3.90, P=0.001), atrial fibrillation (OR=3.62, 95% CI: 1.56-8.40, P=0.003), no previous AMI (OR=6.85, 95% CI: 1.65-28.5, P=0.008), and non-ST-segment elevation myocardial infarction diagnosis (OR=5.36, 95% CI: 2.62-10.96, P<0.001) remained independent predictors of MINOCA. CONCLUSION: MINOCA represents a challenging group of heterogeneous patients whose clinical characteristics contrast with classical cardiovascular risk factors. Despite lower mortality than MICAD, the commonly attributed low-risk classification for MINOCA may be erroneous.

Gerbode defect and multivalvular dysfunction: Complex complications in adult congenital heart disease.

We report a clinical case of a 40-year-old male with surgically corrected congenital heart disease (CHD) 10 years earlier: closure of ostium primum, mitral annuloplasty, and aortic valve and root surgery. The patient was admitted with acute heart failure. Transesophageal echocardiography (TEE) revealed a dysmorphic and severely incompetent aortic valve, a partial tear of the mitral valve cleft repair and annuloplasty ring dehiscence. A true left ventricular-to-right atrial shunt confirmed a direct Gerbode defect. The authors aim to discuss the diagnostic challenge of adult CHD, namely the key role of TEE on septal defects and valve regurgitations description.

Digoxin in advanced heart failure patients: a question of rhythm.

BACKGROUND: The impact of digoxin on outcomes of patients with advanced heart failure (HF) remains uncertain and its effect may be different for patients in atrial fibrillation (AF) or sinus rhythm (SR). OBJECTIVES: To determine the impact of digoxin on outcomes of advanced HF patients and to assess whether prognosis differs in patients in AF and SR. METHODS: A total of 268 consecutive patients admitted to an intensive care unit with decompensated HF were evaluated. Patients were divided into two groups: A - patients with AF (n=89), and B - patients in SR (n=179). For each group we compared patients medicated and not medicated with digoxin. A mean follow-up of 3.3 years was performed. RESULTS: Addition of digoxin to contemporary standard HF therapy showed no impact on mortality of patients in group B (all-cause mortality in follow-up: 19.1% vs. 22.5%, p=0.788). Regarding group A, we observed significantly lower medium-term mortality for patients on digoxin therapy (18.6% vs. 46.6%, p=0.048). Digoxin therapy did not influence readmissions for decompensated HF. Among AF patients, no differences were found regarding demographic, clinical, echocardiographic and laboratory variables between patients medicated and not medicated with digoxin. CONCLUSIONS: Digoxin therapy may improve the prognosis of advanced HF patients with AF under optimal medical therapy. However, no benefit of digoxin was demonstrated for patients in SR. These results may help to improve patient selection for digoxin therapy.

[Acute onset pulmonary toxicity associated to amiodarone]. / Toxicidade pulmonar aguda precoce associada à amiodarona.

Amiodarone is a potent anti-arrhythmic drug with a well-known potential chronic pulmonary toxicity. We describe a case of acute pulmonary toxicity (APT) induced by amiodarone in a 57 year old patient submitted to a perfusion of 900 mg in just 6 hours, to control an auricular flutter with rapid ventricular response. During the administration, the patient developed hemodynamic instability and oxygen dessaturation that led to an electrical cardioversion with return of sinus rhythm. Still, the patient continued in progressive respiratory deterioration with acute bilateral infiltrates on chest x-ray and apparent normal cardiac filling pressures confirmed by echocardiography. Anon-cardiogenic pulmonar edema progressing to clinico-physiological ARDS criteria was diagnosed. Expeditive therapeutic measures were undertaken, namely by initiation of non-invasive positive airway pressure support, that attained a good result.Albeit rare, amiodarone-induced APT might have severe consequences, namely progression to ALI/ARDS with a high mortality index.As it is a frequently prescribed drug, there should be a high clinical suspicion towards this phenomenon, allowing precocious therapeutic measures to be taken in a timely fashion to prevent the associated unfavorable outcome.

[Emery-Dreifuss muscular dystrophy: case report]. / Distrofia muscular de Emery-Dreifuss: a propósito de um caso clínico.

Emery-Dreifuss muscular dystrophy type 1 (EDMD1) is a familial disease with X-Linked recessive transmission, caused by a mutation in a nuclear envelope protein, emerin. Clinical manifestations usually occur in adolescence and include contractures, muscle atrophy and weakness, and cardiac conduction disturbances. We describe the case of a young male, aged 16, with first-degree atrioventricular (AV) block and limited extension of both forearms. He had elevated CK, and cardiac monitoring showed severe conduction tissue disease, with significant sinus pauses, chronotropic incompetence and periods of AV dissociation during exercise. Immunohistochemical staining using an emerin antibody showed absence of the protein in a fragment of muscle tissue and genetic study identified a mutation associated with EDMD1. Study of his brother, aged 21, also established a diagnosis of EDMD1. Both individuals received a permanent pacemaker but musculoskeletal manifestations at that time did not warrant any other intervention: Screening for certain genetic diseases, including muscular dystrophies, is mandatory following identification of conduction abnormalities in young people.

Cardiac angiosarcoma in a pregnant woman: a case report and review of the literature.

Cardiac angiosarcomas, although very rare, are the most common primary malignant tumours. They are characterized by no specific clinical findings, rapid growth with frequent metastasis at the time of diagnosis and a reduced response to treatment. We describe the case of a 34-year-old pregnant woman who began to complain of dyspnoea and palpitations at 32 weeks of gestation. The echocardiogram showed a mass in the right atrial cavity and the CT scan showed extensive local invasion and hepatic metastasis. After 4 weeks, because of progressive heart failure due to obstruction of the tricuspid valve by the mass, the patient was submitted to an urgent caesarean section followed, two days later, by palliative cardiac surgery in order to alleviate the symptoms. Adjuvant chemotherapy was performed.

[Prognostic implications of left ventricular end-diastolic pressure in acute coronary syndromes with left ventricular ejection fraction of 40% or over]. / Implicações prognósticas da pressão telediastólica do ventrículo esquerdo nas síndromes coronárias agudas com fracção de ejecção maior ou igual a 40%.

INTRODUCTION: There is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS). OBJECTIVE: To assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%. METHODS: We performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were excluded (n=489). The population was divided into three groups: A - LVEDP ≤19 mmHg (n=186); B - LVEDP >19 and ≤27 mmHg (n=172); and C - LVEDP >27 mmHg (n=131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission. RESULTS: Mean LVEDP was 22.8±7.8 mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p<0.01), higher peak levels of cardiac biomarkers, and lower LVEF (56.5±7.0 vs. 55.3±7.6 vs. 53.0±7.5%, p<0.01). There were no significant differences between the groups in terms of coronary anatomy, medical therapy during hospital stay and at discharge, or in-hospital mortality. With regard to the primary endpoint, cumulative freedom from congestive heart failure was higher in group A patients (99.4 vs. 97.6 vs. 94.4%, log rank p=0.02). In a multivariate Cox regression model, a 5-mmHg increase in LVEDP (HR 1.97, 95% CI 1.10-3.54, p=0.02) remained an independent predictor of the primary endpoint when adjusted for age, systolic function, atrial fibrillation, peak troponin I, renal function, and prescription of diuretics and beta-blockers. CONCLUSION: In selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.

Anemia: only a marker or an independent predictor of mortality in advanced heart failure?

INTRODUCTION AND OBJECTIVES: Advanced heart failure (HF) remains a major cause of mortality. Identification of new prognostic risk factors is therefore a priority. Anemia, a frequent comorbidity in HF patients and a recognized trigger of symptoms, has recently received considerable attention in this context. Several studies have demonstrated an association between anemia and increased mortality in stable chronic HF patients. However, the prognostic impact of this comorbidity on the survival of advanced HF patients remains unclear. Our aim was to assess whether anemia is not only a marker of advanced HF, but also an independent predictor of mortality. METHODS: We performed a retrospective study of 391 consecutive patients admitted to a single advanced HF care unit and divided into two groups according to the presence or absence of anemia at admission. Demographic, clinical, laboratory and therapeutic data were compared between the groups. Anemia was defined as hemoglobin at admission of <12 g/dl for women and <13 g/dl for men. Appropriate statistical tests and multivariate analysis were used to identify independent predictors of one-year and overall mortality. Median follow-up was 3.2 years. RESULTS: Group A, anemic patients (n=169, 43.2%), were older (61.7 +/- 14.7 vs. 58.0 +/- 14.5 years, p = 0.01) and included a higher number of patients with ischemic cardiomyopathy (40.7% vs. 28.6%, p = 0.01), but fewer with dilated cardiomyopathy (41.0% vs. 55.8%, p = 0.004). At admission, group A had lower systolic blood pressure (110.1 +/- 24.8 mmHg vs. 115.2 +/- 22.0 mmHg, p = 0.03) and higher mean C-reactive protein (1.90 +/- 3.6 mg/dl vs. 1.19 +/- 2.6 mg/dl, p = 0.004) and creatinine (1.50 +/- 0.9 mg/dl vs. 1.20 +/- 0.5 mg/dl, p < 0.001). Gender, prevalence of cardiovascular risk factors, previous medication and left ventricular ejection fraction were not statistically different between the groups. At discharge, fewer anemic patients received digoxin (71.1% vs. 81.8%, p = 0.03). Mortality rates at 3 months (13.6% vs. 6.7%, p = 0.05), one year (22.9% vs. 11%, p = 0.006) and during follow-up (39.8 % vs. 23.8%, p = 0.002) were significantly higher in Group A. Multivariate analysis demonstrated that anemia was an independent predictor of mortality at one year (p = 0.035) and during median follow-up: (p = 0.014). In the anemic group a linear relationship between hemoglobin levels and mortality was also detected. CONCLUSIONS: In our population, anemia was a frequent comorbidity and had an independent and negative impact on long-term mortality. Its correction could improve outcomes in advanced HF patients.

Acute coronary embolism in a patient with a mechanical aortic prosthesis: case report.

Embolic myocardial infarction is a rare entity, which is often difficult to diagnose, and there is little agreement on its treatment. Patients with prosthetic valves are considered an important risk group. A 71-year-old woman with a mechanical aortic prosthesis was admitted with anterior ST segment elevation myocardial infarction after two hours of symptoms. Emergency angiography revealed an image suggestive of a large thrombus at the level of the proximal left anterior descending artery. After several attempts to perform thrombus aspiration and balloon dilatation, TIMI 2 flow was obtained. Effective anticoagulation was immediately started and the clinical outcome was favorable. Angiographically normal coronary arteries one year previously, the patient's discontinuation of warfarin and the present angiographic appearance of the culprit lesion suggested an embolic etiology. This cause is often underdiagnosed and associated with ineffective anticoagulation. Its treatment therefore requires educational intervention.

Pressão diastólica final do ventrículo esquerdo e síndromes coronarianas agudas / Left ventricular end diastolic pressure and acute coronary syndromes / Presión diastólica final del ventrículo izquierdo y síndromes coronarios agudos

FUNDAMENTO: Há falta de dados sobre o impacto prognóstico da pressão diastólica final do ventrículo esquerdo (PDFVE) sobre as síndromes coronarianas agudas (SCA). OBJETIVO: Avaliar a PDFVE e suas implicações prognósticas em pacientes com SCA. MÉTODOS: Estudo prospectivo, longitudinal e contínuo de 1.329 pacientes com SCA de um único centro, realizado entre 2004 e 2006. A função diastólica foi determinada através da PDFVE. A população foi dividida em dois grupos: Grupo A - PDFVE < 26,5 mmHg (n = 449); Grupo B - PDFVE > 26,5 mmHg (n = 226). RESULTADOS: Não houve diferenças significantes entre os grupos em relação aos fatores de risco para doença cardiovascular, histórico médico e terapia médica durante a admissão. Nos pacientes do grupo A, a SCA sem elevação do segmento ST foi mais frequente, bem como angiogramas coronários normais. A mortalidade hospitalar foi similar entre os grupos, mas a sobrevida de um ano foi maior entre os pacientes do grupo A (96,9 vs 91,2 por cento, log rank p = 0,002). Em um modelo multivariado de regressão de Cox, uma PDFVE > 26,5 mmHg (RR 2,45, IC95 por cento 1,05 - 5,74) permaneceu um preditor independente para mortalidade de um ano, quando ajustado para idade, fração de ejeção sistólica do VE, SCA com elevação do segmento ST, pico da troponina, glicemia na admissão hospitalar e diuréticos após 24 horas. Além disso, uma PDFVE > 26,5 mmHg foi um preditor independente de uma futura rehospitalização por IC congestiva (RR 6,65 IC95 por cento 1,74 - 25,5). CONCLUSÃO: Em nossa população selecionada, a PDFVE apresentou uma influência prognóstica significante.

BACKGROUND: Data is lacking in the literature regarding the prognostic impact of left ventricular-end diastolic pressure (LVEDP) across acute coronary syndromes (ACS). OBJECTIVE: To assess LVEDP and its prognostic implications in ACS patients. METHODS: Prospective, longitudinal and continuous study of 1329 ACS patients from a single center between 2004 and 2006. Diastolic function was determined by LVEDP. Population was divided in two groups: A - LVEDP < 26.5 mmHg (n = 449); group B - LVEDP > 26.5 mmHg (n = 226). RESULTS: There were no significant differences between groups with respect to risk factors for cardiovascular disease, medical history and medical therapy during admission. In group A, patients with non-ST elevation ACS were more frequent, as well as normal coronary angiograms. In-hospital mortality was similar between groups, but one-year survival was higher in group A patients (96.9 vs 91.2 percent, log rank p = 0.002). On a multivariate Cox regression model, a LVEDP > 26.5 mmHg (HR 2.45, 95 percentCI 1.05 - 5.74) remained an independent predictor for one-year mortality, when adjusted for age, LV systolic ejection fraction, ST elevation ACS, peak troponin, admission glycemia, and diuretics at 24 hours. Also, a LVEDP > 26.5 mmHg was an independent predictor for a future readmission due to congestive HF (HR 6.65 95 percentCI 1.74 - 25.5). CONCLUSION: In our selected population, LVEDP had a significant prognostic influence.

FUNDAMENTO: Hay falta de datos sobre el impacto pronóstico de la presión diastólica final del ventrículo izquierdo (PDFVI) sobre los síndromes coronarios agudos (SCA). OBJETIVO: Evaluar la PDFVI y sus implicaciones pronósticas en pacientes con SCA. MÉTODOS: Estudio prospectivo, longitudinal y continuo de 1.329 pacientes con SCA de un único centro, realizado entre 2004 y 2006. La función diastólica fue determinada a través de la PDFVI. La población fue dividida en dos grupos: Grupo A - PDFVI < 26,5 mmHg (n = 449); Grupo B - PDFVI > 26,5 mmHg (n = 226). RESULTADOS: No hubo diferencias significativas entre los grupos en relación a los factores de riesgo para enfermedad cardiovascular, historia médica y terapia médica durante la admisión. En los pacientes del grupo A, la SCA sin elevación del segmento ST fue más frecuente, así como angiogramas coronarios normales. La mortalidad hospitalaria fue similar entre los grupos, pero la sobrevida de un año fue mayor entre los pacientes del grupo A (96,9 vs 91,2 por ciento, log rank p = 0,002). En un modelo multivariado de regresión de Cox, una PDFVI > 26,5 mmHg (RR 2,45, IC95 por ciento 1,05 -5,74) permaneció un predictor independiente para mortalidad de un año, cuando fue ajustado para edad, fracción de eyección sistólica del VI, SCA con elevación del segmento ST, pico de la troponina, glicemia en la admisión hospitalaria y diuréticos después de 24 horas. Además de eso, una PDFVI > 26,5 mmHg fue un predictor independiente de una futura rehospitalización por IC congestiva (RR 6,65 IC95 por ciento 1,74 - 25,5). CONCLUSIÓN: En nuestra población seleccionada, la PDFVI presentó una influencia pronóstica significativa.

Left ventricular end diastolic pressure and acute coronary syndromes.

BACKGROUND: Data is lacking in the literature regarding the prognostic impact of left ventricular-end diastolic pressure (LVEDP) across acute coronary syndromes (ACS). OBJECTIVE: To assess LVEDP and its prognostic implications in ACS patients. METHODS: Prospective, longitudinal and continuous study of 1329 ACS patients from a single center between 2004 and 2006. Diastolic function was determined by LVEDP. Population was divided in two groups: A - LVEDP < 26.5 mmHg (n = 449); group B - LVEDP ≥ 26.5 mmHg (n = 226). RESULTS: There were no significant differences between groups with respect to risk factors for cardiovascular disease, medical history and medical therapy during admission. In group A, patients with non-ST elevation ACS were more frequent, as well as normal coronary angiograms. In-hospital mortality was similar between groups, but one-year survival was higher in group A patients (96.9 vs 91.2%, log rank p = 0.002). On a multivariate Cox regression model, a LVEDP ≥ 26.5 mmHg (HR 2.45, 95%CI 1.05 - 5.74) remained an independent predictor for one-year mortality, when adjusted for age, LV systolic ejection fraction, ST elevation ACS, peak troponin, admission glycemia, and diuretics at 24 hours. Also, a LVEDP ≥ 26.5 mmHg was an independent predictor for a future readmission due to congestive HF (HR 6.65 95%CI 1.74 - 25.5). CONCLUSION: In our selected population, LVEDP had a significant prognostic influence.

Predictors of adverse outcome in a diabetic population following acute coronary syndromes.

INTRODUCTION: People with diabetes are at increased risk for heart failure (HF), major adverse cardiovascular events (MACE) and death following acute coronary syndromes (ACS). It is important to recognize the most powerful predictors of these events after an ACS as early as possible, in order to address them more aggressively. This is particularly important considering that various studies have shown that this population is undertreated in the setting of ACS. OBJECTIVES: To characterize a diabetic population presenting with ACS and to determine independent predictors of HF, MACE and mortality on follow-up. METHODS: This was a longitudinal, observational, retrospective study including 471 consecutive diabetic patients, both previously known and newly diagnosed, hospitalized for ACS in a single center between May 2004 and December 2006. A mean 12-month follow-up was conducted. Cox regression analysis was used to determine the independent predictors of HF, MACE and mortality on follow-up, divided into different periods--1 month, 6 months and 1 year. RESULTS: Of the overall diabetic population, 67.3% were male and mean age was 69 +/- 11 years. Mean glomerular filtration rate (GFR) was 62 +/- 22 ml/min and mean left ventricular ejection traction (LVEF) was 50%. diagnosis on admission was ST-elevation myocardial infarction (STEMI) in 31.3%, non-ST elevation myocardial infarction (NSTEMI) in 50.1%, unstable angina (UA) in 14.3% and ACS with left bundle branch block or pacemaker in 4.2%. Cardiac catheterization was performed in 55.6% of the patients during the index hospitalization. Mortality during hospitalization and at 1 year was 6.4% and 10.4%, respectively. The one-year MACE rate was 20.4% and hospitalization for HF occurred in 10.1% of the patients. The independent predictors of HF at 1 year were blood glucose on admission > 184.5 mg/dl, GFR < 63.8 ml/min, LVEF < 46.5% and NSTEMI, while predictors of mortality were LVEF < 40.5% and Killip class on admission > I. Blood glucose on admission > 130.5 mg/dl and LVEF < 49.5% were independent predictors of MACE, whereas cardiac catheterization was a protective factor. CONCLUSION: Following ACS diabetic patients have high rates of mortality, HF and MACE. The low rate of invasive strategy may contribute to this situation. HF during hospitalization, whether by low LVEF or Killip class > I, and higher blood glucose on admission were powerful predictors of poorer outcome. Moreover, the use of recommended cardiovascular agents and procedures were protective factors. These findings suggest that diabetic patients should not be excluded from recommended cardiovascular interventions. Efforts should be made to identify these high-risk patients as early as possible in order to manage them carefully and aggressively to improve their poor prognosis.

Ischemic versus non-ischemic cardiomyopathy--are there differences in prognosis? Experience of an advanced heart failure center.

INTRODUCTION: Previous studies have associated heart failure (HF) of ischemic etiology with worse prognosis compared to HF from non-ischemic cardiomyopathy. HF treatment has evolved significantly in recent years. Has this evolution had an impact on this prognostic gap? OBJECTIVE: The aim of our study was to compare patients with advanced HF--nonischemic versus ischemic etiology--in terms of baseline characteristics, treatment, and in-hospital and long-term prognosis (including death, heart transplantation and hospital readmission). METHODS: We performed a retrospective study including 286 consecutive patients with systolic HF admitted to an HF unit between January 2003 and June 2006. We compared two groups according to HF etiology: Group A--ischemic cardiomyopathy (n = 109); Group B--non-ischemic cardiomyopathy (n = 177). Mean follow-up was 41 months. RESULTS: Group A were older (62.2 +/- 10.4 vs. 55.9 +/- 15.2 years, p < 0.001), with a higher proportion of males (80.7 vs. 67.8%, p = 0.017), diabetes, anemia, dyslipidemia and smokers; they required more prolonged treatment with inotropic drugs and more frequent treatment with statins, antiplatelet agents and nitrates. On admission, Group B patients presented with lower serum sodium and higher aminotransferase levels. There were no differences in the occurrence of cardiogenic shock or dysrhythmias, baseline ECG rhythm, frequency of left bundle branch block, renal function, BNP, left ventricular ejection fraction, heart rate or implantation of intracardiac devices. Group A had higher in-hospital mortality (11.0 vs. 4.0%, p = 0.020). Multivariate analysis showed that the only predictor of in-hospital mortality was serum sodium < 133 mmol/l and also showed that HF etiology was not a predictor of this endpoint; previous medication with angiotensin-converting enzyme inhibitors was a protective factor. On Kaplan-Meier analysis, it was observed that, in the long-term, there were no significant differences in either survival rates (70.0 vs. 76.8%, p = 0.258), or the combined endpoints of survival free of death or heart transplantation (55.7 vs. 54.5%, p = 0.899) and survival free of death, heart transplantation or hospital readmission (38.0 vs. 32.8%, p = 0.386). CONCLUSIONS: Although in-hospital mortality was higher in ischemic cardiomyopathy, this variable was not an independent predictor of mortality and the difference appears to fade in the long-term, in contrast to what had been reported in older studies, but in agreement with more recent data.

Impact of previous insulin therapy on the prognosis of diabetic patients with acute coronary syndromes.

OBJECTIVE: To determine whether previous insulin treatment independently influences subsequent outcomes in diabetic patients with ACS (acute coronary syndromes). SUBJECTS AND METHODS: 375 diabetic patients with ACS, divided in 2 groups: Group A (n = 69)--previous insulin and Group B (n = 306)--without previous insulin. Predictors of 1-year mortality and major adverse cardiac events (MACE) were analyzed by Cox regression analysis. RESULTS: Group A had more previous stroke (17.4% vs. 9.2%, p = 0.047) and peripheral artery disease (13.0% vs. 3.6%, p = 0.005). They had significantly higher admission glycemia and lower LDL cholesterol. There were no significant differences in the type of ACS, in 1-year mortality (18.2% vs. 10.4%, p = 0.103) or MACE (32.1% vs. 23.0%, p = 0.146) between groups. In multivariate analysis, insulin treatment was neither an independent predictor of 1-year mortality nor of MACE. CONCLUSION: Despite the more advanced atherosclerotic disease, diabetics under insulin had similar outcomes to those without insulin. Insulin may protect diabetics from the expected poor adverse outcome of an advanced atherosclerotic disease.

Heart rate and prognosis in acute coronary syndromes.

INTRODUCTION AND OBJECTIVE: Resting heart rate (RHR) is inversely correlated with the average life span of living beings. In coronary patients, increased RHR has been associated with rapid progression of atherosclerosis. The aim of this study was to compare in-hospital and long-term outcome of acute coronary syndromes according to patients' RHR. METHODS: We prospectively studied 1720 consecutive patients, divided into two groups according to RHR at admission: group A--RHR > or =82 bpm (n=543), and group B--RHR < 82 bpm (n=1177). Epidemiological, clinical, laboratory and therapeutic data were analyzed for both groups. Appropriate statistical tests and multivariate analysis were used to identify independent predictors of in-hospital and one-year mortality. RESULTS: Group A included more women (35.9% vs. 27.0%, p < 0.001), older (68.36 +/- 12.74 vs. 66.39 +/- 12.43 years, p = 0.002), and diabetic patients (30.9% vs. 25.1%, p = 0.014) and non-smokers (85.8% vs. 81.4%, p = 0.024). They were admitted more often with ST-segment elevation myocardial infarction (31.5% vs. 21.5%, p < 0.001), presented higher Killip class at admission and had worse left ventricular ejection fraction (47.99 +/- 11.87% vs. 52.45 +/- 10.32%, p < 0.001). Peak myocardial markers, creatinine and blood glucose at admission were significantly higher in this group. Discharge medication was not statistically different. In-hospital mortality (7.7% vs. 3.3%, p < 0.001) and morbidity (10.4% vs. 4.9%, p < 0.001) and one-year mortality (21.3% vs. 9.6%, p < 0.001) and morbidity (43.9% vs. 36.4%, p = 0.009) were higher in the group with RHR > or =82 bpm. The independent predictors of in-hospital mortality were age > or =70.5 years (p = 0.001), RHR > or =82 bpm at admission (p = 0.035) and previous type 2 diabetes (p = 0.004). Age > or =69.5 years (p < 0.001) and RHR > or =82 bpm (p = 0.008) were also independent predictors of one-year mortality, together with Killip class >I (p < 0.001) and ejection fraction < or =49.5% (p < 0.001). CONCLUSION: In our population of acute coronary syndrome patients, RHR > or =82 bpm was associated with worse short- and long-term outcome.

Impact of previous insulin therapy on the prognosis of diabetic patients with acute coronary syndromes / Impacto da insulinoterapia prévia no prognóstico dos pacientes diabéticos com síndromes coronárias agudas

OBJECTIVE: To determine whether previous insulin treatment independently influences subsequent outcomes in diabetic patients with ACS (acute coronary syndromes). SUBJECTS AND METHODS: 375 diabetic patients with ACS, divided in 2 groups: Group A (n = 69) - previous insulin and Group B (n = 306) - without previous insulin. Predictors of 1-year mortality and major adverse cardiac events (MACE) were analyzed by Cox regression analysis. RESULTS: Group A had more previous stroke (17.4 percent vs. 9.2 percent, p = 0.047) and peripheral artery disease (13.0 percent vs. 3.6 percent, p = 0.005). They had significantly higher admission glycemia and lower LDL cholesterol. There were no significant differences in the type of ACS, in 1-year mortality (18.2 percent vs. 10.4 percent, p = 0.103) or MACE (32.1 percent vs. 23.0 percent, p = 0.146) between groups. In multivariate analysis, insulin treatment was neither an independent predictor of 1-year mortality nor of MACE. CONCLUSION: Despite the more advanced atherosclerotic disease, diabetics under insulin had similar outcomes to those without insulin. Insulin may protect diabetics from the expected poor adverse outcome of an advanced atherosclerotic disease.

OBJECTIVO: Avaliar se a insulinoterapia prévia influencia de forma independente o prognóstico de diabéticos após uma síndrome coronária aguda (SCA). SUJEITOS E MÉTODOS: 375 doentes diabéticos com SCA, divididos em 2 grupos: Grupo A (n = 69) - sob insulinoterapia prévia e Grupo B (n = 306) - sem insulinoterapia prévia. Os preditores de mortalidade a um ano e de eventos cardíacos adversos maiores (MACE) foram determinados pela regressão de Cox. RESULTADOS: Verificou-se maior proporção de acidente vascular cerebral prévio (17,4 por cento vs. 9,2 por cento, p = 0,047) e doença arterial periférica (13,0 por cento vs. 3,6 por cento, p = 0,005) no Grupo A. Esses doentes apresentaram glicemia na admissão significativamente mais elevada e LDL inferior. Não houve diferenças estatisticamente significativas no tipo de SCA, na mortalidade (18,2 por cento vs. 10,4 por cento, p = 0,103) e MACE (32,1 por cento vs. 23,0 por cento, p = 0,146) em um ano entre os 2 grupos. Na análise multivariada, a insulinoterapia prévia não foi preditor independente nem de mortalidade, nem de MACE em 1 ano. CONCLUSÃO: Apesar da doença aterosclerótica mais avançada, os diabéticos previamente insulino-tratados têm um prognóstico semelhante aos não insulino-tratados. A insulinoterapia crônica poderá proteger os diabéticos da evolução desfavorável própria da doença aterosclerótica avançada.