[Influence of admission glucose level on long-term prognosis in patients with acute coronary syndrome]. / Influencia de la concentración de glucemia en el momento del ingreso en la evolución a largo plazo de los pacientes con síndrome coronario agudo.

INTRODUCTION AND OBJECTIVES: Hyperglycemia can increase the risk of death or a poor outcome following myocardial infarction. Our objective was to investigate the value of the admission glucose level in predicting long-term outcome in patients with acute coronary syndrome. METHODS: The study population comprised 565 patients admitted with acute coronary syndrome within 24 hours of the start of symptoms. The final diagnosis was myocardial infarction in 56% and unstable angina in 44%. RESULTS: The patients' mean glucose level was 143 (77) mg/dL. During follow-up (42 [6] months), 55 (9.7%) patients died. The area under the receiver operating characteristic curve for the optimum cut point for predicting death from the glucose level was 0.67; the cut point was 128 mg/dL, with a sensitivity of 85% and a specificity of 62%. Patients were divided into 2 groups according to blood glucose level: in group 1 (36.8%), it was > or = 128 mg/dL; in group 2, <128 mg/dL. There were differences between the groups in the incidence of diabetes (47.2% vs 12.6%; P< .001), systolic blood pressure (138 [33] mm Hg vs 133 [33] mm Hg; P< .001), and ejection fraction (48.3 [0.9]% vs 55.2 [12.4]%; P=.004). At 4 years, the survival rates were 40% and 77% in groups 1 and 2, respectively (log rank test P< .001). The following were independent predictors of mortality: admission glucose level > or =128 mg/dL (hazard ratio [HR= 2.41; P=.021), admission systolic blood pressure (HR= 0.97; P< .001), admission troponin-T level (HR=4.88; P< .001), and the development of heart failure (HR=1.04; P=.001). A rise of 10 mg/dL in glucose level was associated with a 2.56-fold increase in the risk of death (P=.012). CONCLUSIONS: In patients with acute coronary syndrome, hyperglycemia at admission (cut point > or =128 mg/dL) was associated with increased long-term risk and, in addition, was a strong independent predictor of mortality.

Influencia de la concentración de glucemia en el momento del ingreso en la evolución a largo plazo de los pacientes con síndrome coronario agudo / Influence of admission glucose level on long-term prognosis in patients with acute coronary syndrome

Introducción y objetivos. La hiperglucemia puede incrementar el riesgo de muerte y evolución adversa después del infarto. Analizamos el valor pronóstico a largo plazo de la concentración de glucemia en el momento del ingreso en pacientes con síndrome coronario agudo (SCA). Métodos. La población estaba constituida por 565 pacientes hospitalizados con SCA dentro de las 24 h siguientes al inicio de los síntomas. El diagnóstico fue infarto agudo de miocardio en el 56% y angina inestable en el 44%. Resultados. La glucemia media fue de 143 ± 77 mg/dl. Durante el seguimiento (42 ± 6 meses) se registraron 55 muertes (9,7%). El área bajo la curva ROC para determinar el mejor punto de corte de glucemia en la predicción de muerte fue 0,67; el punto de corte de 128 mg/dl mostró una sensibilidad del 85% y una especificidad del 62%. Los pacientes fueron clasificados en grupo 1 (glucemia ≥ 128 mg/dl), con un 36,8%, o grupo 2 (glucemia < 128 mg/dl). Ambos grupos difirieron en la diabetes (el 47,2 frente al 12,6%; p < 0,001), la presión arterial sistólica (138,3 ± 33 frente a 133 ± 33 mmHg; p < 0,001) y la fracción de eyección (48,3 ± 0,9 frente a 55,2 ± 12,4%; p = 0,004). La supervivencia a 4 años fue del 40 y el 77% en los grupos 1 y 2, respectivamente (test de rangos logarítmicos; p < 0,001). En el momento del ingreso, un valor de glucemia ≥ 128 mg/dl (hazard ratio [HR] = 2,41; p = 0,021), la presión arterial sistólica (HR = 0,97; p < 0,001), la troponina T (HR = 4,88; p < 0,001) y el desarrollo de insuficiencia cardiaca (HR = 1,04; p = 0,001) fueron predictores independientes de mortalidad. Un incremento de 10 mg en la glucemia supuso un aumento del riesgo de muerte de 2,56 (p = 0,012). Conclusiones. En pacientes con síndrome coronario agudo, la hiperglucemia en el momento del ingreso, con un punto de corte ≥ 128 mg/dl, se asoció con un mayor riesgo a largo plazo y fue, además, un fuerte predictor independiente

Introduction and objectives. Hyperglycemia can increase the risk of death or a poor outcome following myocardial infarction. Our objective was to investigate the value of the admission glucose level in predicting long-term outcome in patients with acute coronary syndrome. Methods. The study population comprised 565 patients admitted with acute coronary syndrome within 24 hours of the start of symptoms. The final diagnosis was myocardial infarction in 56% and unstable angina in 44%. Results. The patients' mean glucose level was 143 (77) mg/dL. During follow-up (42 [6] months), 55 (9.7%) patients died. The area under the receiver operating characteristic curve for the optimum cut point for predicting death from the glucose level was 0.67; the cut point was 128 mg/dL, with a sensitivity of 85% and a specificity of 62%. Patients were divided into 2 groups according to blood glucose level: in group 1 (36.8%), it was ≥ 128 mg/dL; in group 2, <128 mg/dL. There were differences between the groups in the incidence of diabetes (47.2% vs 12.6%; P<.001), systolic blood pressure (138 [33] mm Hg vs 133 [33] mm Hg; P<.001), and ejection fraction (48.3 [0.9]% vs 55.2 [12.4]%; P=.004). At 4 years, the survival rates were 40% and 77% in groups 1 and 2, respectively (log rank test P<.001). The following were independent predictors of mortality: admission glucose level ≥128 mg/dL (hazard ratio [HR= 2.41; P=.021), admission systolic blood pressure (HR= 0.97; P<.001), admission troponin-T level (HR=4.88; P<.001), and the development of heart failure (HR=1.04; P=.001). A rise of 10 mg/dL in glucose level was associated with a 2.56-fold increase in the risk of death (P=.012). Conclusions. In patients with acute coronary syndrome, hyperglycemia at admission (cut point ≥128 mg/dL) was associated with increased long-term risk and, in addition, was a strong independent predictor of mortality

Efecto aditivo de los incrementos de urea y creatinina a la admisión sobre el pronóstico a largo plazo en pacientes con insuficiencia cardíaca descompensada / Additive effect of increased urea and creatinine levels at admission on long-term prognosis in patients with decompensated heart failure

Introducción y objetivos: La elevación de la creatinina es un marcador de riesgo en la insuficiencia cardíaca descompensada (ICD). Nuestro objetivo fue evaluar el rol pronóstico a largo plazo de la detección temprana de deterioro renal (DR), definido por elevación en los niveles de urea y/o creatinina, en pacientes con ICD. Material y métodos: Se incluyeron en forma prospectiva 241 individuos admitidos por ICD. Se seleccionaron los puntos de corte para urea y creatinina al ingreso a través de curva ROC, para la detección de eventos combinados (muerte o rehospitalización por ICD). El seguimiento medio fue de 366 ± 482 días. Resultados: La edad media fue 65,4 ± 11,6 años (63,8% hombres, 42,3% etiología isquémica) y la incidencia de eventos fue de 107. El área bajo curva ROC de urea y creatinina para la predicción de eventos fue de 0,59 y 0,57. Los puntos de corte, sensibilidad y especificidad fueron: urea 55 mg/dL, 57% y 63%; y creatinina 1,17 mg/dL, 58% y 62%, respectivamente. El DR se identificó en 144 (60,4%) sujetos, 82 con ambos marcadores elevados, 29 sólo con creatinina elevada y 33 sólo con urea elevada. En el grupo con DR fue más frecuente el diagnóstico previo de ICD (89 vs 78%, p=0,041) y la hipoperfusión periférica (12,5 y 4,1%, p=0,020), tuvieron menor fracción de eyección del ventrículo izquierdo (FEVI) (36,4±17,2% y 41,1±19,6%, p=0,05) y mayor nivel de pro-BNP (8681±9010 pg/l y 2943±269 pg/l, p<0,001). La supervivencia libre de rehospitalización por ICD a 18 meses en aquellos con y sin DR fue 35 y 60% (p=0,0086), y las variables asociadas con evolución adversa fueron DR (HR=1,8; IC 95% 1,1-2,7) y diagnóstico previo de ICD (HR=1,9; p<0,001; IC 95% 1,1-3,5). Conclusión: El uso combinado de urea y creatinina permite incrementar la detección temprana de DR en pacientes con ICD. Este hallazgo fue un fuerte predictor de eventos a largo plazo.

Background: Increased level of creatinine is a powerful risk marker in decompensated heart failure (DHF). Our objective was to evaluate the long-term prognostic role of early detection of renal dysfunction (RD), defined by abnormal levels of urea and/or creatinine, in patients with DHF. Patients and methods: Two hundred and forty-one patients admitted for DHF were prospectively included. The cut-off of urea and creatinine were selected using ROC curves for predicting combined events (death or rehospitalization for DHF). The mean follow-up was 366±482 days. Results: The mean age were 65.4±11.6 years (64% male, 42.3% ischemic etiology), and 44.4% had events. The area under ROC curves to predicting events for urea and creatinine was 0.59 and 0.57, respectively. The cut-off, sensitivity and specificity were: urea 55 mg/dL, 57% and 63%; creatinine 117 mg/dL, 58% and 62%, respectively. RD was identified in 144 (60.4%) subjects, 82 had elevated both markers, 29 with only increased levels of creatinine, and 33 with only abnormal levels of urea. RD groups had more frequently a previous diagnosis of HF (89 vs 78%, p=0.041) and peripheral hypoperfusion (12.5 vs 4.1%, p=0.020), and they showed lower LVEF (36.4±17.2% vs 41.1±19.6%, p=0.05) and higher pro-BNP (8.681±9010 pg/mL vs 2943±2690 pg/ mL, p<0.001) than those without RD. Eighteen-month free-DHF rehospitalization survival in patients with and without RD was 35% and 60% (p=0.0086). The variables significantly associated with events were RD (1.8, p<0.001; CI 95%=1.1-2.7) and previous diagnosis of HF (HR=1.9, CI 95%=1.1-3.5). Conclusion: The combined use of urea and creatinine improve the early detection of RD in patients with DHF. This finding was a strong long-term prognostic predictor.

Overview of acute decompensated heart failure in Argentina: lessons learned from 5 registries during the last decade.

BACKGROUND: The acute decompensated heart failure (ADHF) is not as well characterized as the chronic phase, particularly in Latin American countries. Thus, the aim of this overview was to describe the clinical profile, treatment, and inhospital course of ADHF during the last decade in Argentina. METHODS: Results obtained from 5 Argentinean prospective and multicenter registries, involving 2974 patients admitted for ADHF, were assessed. These registries were performed and published between 1992 and 2004. RESULTS: The mean age was 65 to 70 years, and nearly 40% were female. Coronary artery disease was the main etiology in nearly 30% of the patients. Between 1992 and 2004, the use of angiotensin-converting enzyme inhibitors increased from 29.9% to 53.4% before admission and from 48.5% to 69.3% before discharge; the use of beta-blockers rose from 4.2% to 33.2% at admission and from 2.5% to 42.4% at predischarge (all P < .0001). Inhospital mortality rates in the first to the fifth registries were 12.1%, 4.6%, 10.5%, 8.9%, and 4.7% (P [trend] = .006). However, there were 98 (7.7%) deaths among 1272 patients before 2002, compared with 129 (7.6%) among 1702 since 2002 (P = .9). CONCLUSIONS: The clinical profile of this largest sample of ADHF reported from a Latin American country is different from that observed in clinical trials and comparable to registries worldwide. Although an improvement in the use of recommended drugs was observed in the last decade, the average mortality has not changed. These findings might have implications in the design of multinational clinical trials.