Repercusión ecocardiográfica del estado de hidratación en los pacientes en diálisis / Echocardiographic impact of hydration status in dialysis patients

Introducción: La enfermedad cardiovascular es la principal causa de muerte en los pacientes con enfermedad renal crónica. La hipertrofia ventricular izquierda (HVI) es la manifestación más frecuente y está relacionada con la hipertensión arterial y la hiperhidratación. El objetivo del presente trabajo es estratificar a los pacientes en diálisis según el estado de hidratación y valorar las posibles alteraciones ecocardiográficas en los distintos grupos. Métodos: Realizamos un estudio transversal de 117 pacientes, 65 en hemodiálisis (HD) y 52 en diálisis peritoneal (DP). Las exploraciones realizadas fueron: bioimpedancia multifrecuencia con el sistema BCM-Body Composition Monitor de Freesenius, ecocardiografía transtorácica y analítica de sangre. Definimos hiperhidratación cuando el cociente volumen extracelular-volumen corporal total (ECW/TBW) normalizado para edad y sexo es > 2,5% de la desviación estándar. Resultados: Los pacientes en HD están pre-HD (67,1%) más hiperhidratados de forma significativa que los de DP (46,1%), presentando casi la mitad de la población hiperhidratada hipertensión arterial; tras la sesión de HD se consigue un mejor control del estado de hidratación (26,1%). Los pacientes en DP presentan con más frecuencia cifras de tensión arterial alta y/o llevan tratamiento antihipertensivo (DP 76,9 vs. HD 49,2%). La HVI es más frecuente en los pacientes en HD e hiperhidratados, siendo la más prevalente la HVI excéntrica. Los pacientes hiperhidratados presentan cifras superiores, de forma significativa, del IVAI (volumen de aurícula izquierda indexada por superficie corporal, la IMVI (masa ventricular izquierda indexada) y el cociente sobrehidratación-agua extracelular. Conclusiones: La bioimpedancia es una técnica que nos permite detectar un gran número de pacientes hiperhidratados. Al estudiar las alteraciones ecocardiográficas en los pacientes en diálisis encontramos una alta correlación entre el estado de hidratación por ECW/TBW normalizado para edad y sexo, y el IVAI e IMVI (AU)

Introduction: Cardiovascular disease is the main cause of death in Chronic Kidney Disease patients. Left ventricular hypertrophy is the most common manifestation and it is linked to arterial hypertension and overhydration. The goal of this paper is to stratify dialyzed patients according to hydration status and to make an evaluation about the possible echocardiography alterations of the different groups. Methods: a transversal study was carried out with 117 patients: 65 were on hemodialysis and 52 on peritoneal dialysis. We performed the following tests: multifrequency bioimpedance with the BCM-Body Composition Freesenius’ Monitor system, transthoracic echocardiography, and blood tests. If ECW/TBW (extracellular water vs total body water) normalization ratio for age and gender was > 2.5% SD, the patient was considered overhydrated. Results: HD patients are significantly overhydrated before HD (67.1%) compared to DP patients (46.1%), and almost half of the overhydrated population presents arterial hypertension. However, after an HD session, a better control of the hydration status is reached (26.1%). DP patients frequently present high arterial pressure and/or are under antihypertensive treatment (DP 76.9% vs HD 49.2%). Left ventricular hypertrophy is much more common in HD overhydrated patients, eccentric LVH being more prevalent. Overhydrated patients present significantly high values of LAVI, ILVM, OH/ECW. Conclusions: Bioimpedance technique allows for the detection of a large number of overhydrated patients. Echocardiographic alterations in dialyzed patients show a high correlation between the hydration stage by ECW/TBW normalized ratio for age and gender and the LAVI and ILVM (AU)

Echocardiographic impact of hydration status in dialysis patients.

INTRODUCTION: Cardiovascular disease is the main cause of death in Chronic Kidney Disease patients. Left ventricular hypertrophy is the most common manifestation and it is linked to arterial hypertension and overhydration. The goal of this paper is to stratify dialyzed patients according to hydration status and to make an evaluation about the possible echocardiography alterations of the different groups. METHODS: A transversal study was carried out with 117 patients: 65 were on hemodialysis and 52 on peritoneal dialysis. We performed the following tests: multifrequency bioimpedance with the BCM-Body Composition Freesenius' Monitor system, transthoracic echocardiography, and blood tests. If ECW/TBW (extracellular water vs total body water) normalization ratio for age and gender was > 2.5% SD, the patient was considered overhydrated. RESULTS: HD patients are significantly overhydrated before HD (67.1%) compared to DP patients (46.1%), and almost half of the overhydrated population presents arterial hypertension. However, after an HD session, a better control of the hydration status is reached (26.1%). DP patients frequently present high arterial pressure and/or are under antihypertensive treatment (DP 76.9% vs HD 49.2%). Left ventricular hypertrophy is much more common in HD overhydrated patients, eccentric LVH being more prevalent. Overhydrated patients present significantly high values of LAVI, ILVM, OH/ECW. CONCLUSIONS: Bioimpedance technique allows for the detection of a large number of overhydrated patients. Echocardiographic alterations in dialyzed patients show a high correlation between the hydration stage by ECW/TBW normalized ratio for age and gender and the LAVI and ILVM.

N-acetylcysteine: short-term clinical benefits after coronary angiography in high-risk renal patients.

INTRODUCTION AND OBJECTIVES: Previous studies on the role of N-acetylcysteine in the prevention of contrast-induced nephropathy after coronary angiography and on the drug's long-term effects have produced contradictory findings. The aim of this study was to clarify the benefits of N-acetylcysteine. METHODS: A prospective, randomized, double-blind study was carried out in patients with chronic renal failure (plasma creatinine= >or=1.4 mg/dL) who underwent coronary angiography. This study concerns the second arm of the main study. Findings on the arm involving patients with normal renal function have been published previously. As before, patients were randomly assigned to receive either N-acetylcysteine, 600 mg every 12 h intravenously, or placebo. The primary end-point was the development of contrast-induced nephropathy. RESULTS: The study included 81 patients (39 on N-acetylcysteine, 42 on placebo) with comparable baseline clinical characteristics. The overall incidence of contrast-induced nephropathy was 14.8% (12 patients): 5.1% (2 patients) in the N-acetylcysteine group and 23.8% (10 patients) in the placebo group (odds ratio [OR]=0.17; 95% confidence interval [CI], 0.03-0.84; P=.027). One patient (1.2%) in the latter group required dialysis while in the coronary unit. Multivariate analysis showed that N-acetylcysteine was an independent protective factor against the composite end-point of contrast-induced nephropathy, need for dialysis and mortality during the coronary unit stay (OR=0.20; 95% CI, 0.04-0.97; P=.04). Nevertheless, no significant difference was observed between the N-acetylcysteine and placebo groups in the rates of in-hospital (10.3% vs. 16.7%, respectively) or 1-year mortality (15.4% vs. 21.4%, respectively). CONCLUSIONS: Prophylactic administration of N-acetylcysteine provided significant short-term clinical benefits in high-risk renal patients who underwent coronary angiography.

N-acetilcisteína: beneficio clínico a corto plazo tras coronariografía en pacientes renales de alto riesgo / N-acetylcysteine: short-term clinical benefits after coronary angiography in high-risk renal patients

Introducción y objetivos. El papel de la N-acetilcisteína en la prevención de la nefropatía por contraste tras coronariografía y sus efectos a largo plazo se presentan con resultados contradictorios en la literatura previa. Este estudio pretende clarificar su beneficio clínico. Métodos. Estudio prospectivo, aleatorizado y a doble ciego de pacientes sometidos a angiografía coronaria con insuficiencia renal crónica (creatinina plasmática ≥ 1,4 mg/dl). Representa así el segundo brazo del diseño del estudio principal, previamente publicado, respecto al brazo de pacientes con función renal normal. Igualmente, se los aleatorizó a recibir N-acetilcisteína intravenosa (600 mg/12 h) o placebo. El objetivo principal es el desarrollo de nefropatía inducida por contraste. Resultados. Se incluyó a 81 pacientes (N-acetilcisteína, 39 pacientes; placebo, 42 pacientes), equiparables respecto a las características clínicas basales. La incidencia total de nefropatía por contraste fue del 14,8% (12 pacientes), el 5,1% (2 pacientes) en el grupo con N-acetilcisteína y el 23,8% (10 pacientes) en el grupo a placebo (odds ratio [OR] = 0,17; intervalo de confianza [IC] del 95%, 0,03-0,84); p = 0,027). Un paciente de este último grupo requirió diálisis mientras se encontraba ingresado en la unidad coronaria (1,2%). En el análisis multivariable, la N-acetilcisteína resultó factor protector independiente de la variable compuesta por nefropatía inducida por contraste, necesidad de diálisis y mortalidad durante la estancia en la unidad coronaria (OR = 0,20; IC del 95%, 0,04-0,97; p = 0,04). Sin embargo, no se observaron diferencias significativas en cuanto a mortalidad hospitalaria y al año de seguimiento (el 10,3 frente al 16,7% y el 15,4 frente al 21,4% en los grupos con N-acetilcisteína y placebo respectivamente). Conclusiones. La administración profiláctica de N-acetilcisteína conlleva importantes beneficios clínicos a corto plazo en los pacientes renales con alto riesgo sometidos a angiografía coronaria (AU)

Introduction and objectives. Previous studies on the role of N-acetylcysteine in the prevention of contrastinduced nephropathy after coronary angiography and on the drug’s long-term effects have produced contradictory findings. The aim of this study was to clarify the benefits of N-acetylcysteine. Methods. A prospective, randomized, double-blind study was carried out in patients with chronic renal failure (plasma creatinine=1.4 mg/dL) who underwent coronary angiography. This study concerns the second arm of the main study. Findings on the arm involving patients with normal renal function have been published previously. As before, patients were randomly assigned to receive either N-acetylcysteine, 600 mg every 12 h intravenously, or placebo. The primary end-point was the development of contrast-induced nephropathy. Results. The study included 81 patients (39 on N-acetylcysteine, 42 on placebo) with comparable baseline clinical characteristics. The overall incidence of contrast-induced nephropathy was 14.8% (12 patients): 5.1% (2 patients) in the N-acetylcysteine group and 23.8% (10 patients) in the placebo group (odds ratio [OR]=0.17; 95% confidence interval [CI], 0.03-0.84; P=.027). One patient (1.2%) in the latter group required dialysis while in the coronary unit. Multivariate analysis showed that N-acetylcysteine was an independent protective factor against the composite end-point of contrast-induced nephropathy, need for dialysis and mortality during the coronary unit stay (OR=0.20; 95% CI, 0.04-0.97; P=.04). Nevertheless, no significant difference was observed between the N-acetylcysteine and placebo groups in the rates of in-hospital (10.3% vs. 16.7%, respectively) or 1-year mortality (15.4% vs. 21.4%, respectively). Conclusions. Prophylactic administration of N-acetylcysteine provided significant short-term clinical benefits in high-risk renal patients who underwent coronary angiography (AU)

Intravenous N-acetylcysteine for preventing contrast-induced nephropathy: a randomised trial.

BACKGROUND: Studies evaluating the role of N-acetylcysteine in patients undergoing coronary angiography have yielded inconsistent data. Less is known about patients with normal renal function at baseline. METHODS: Prospective, double-blind, placebo-controlled trial to determine the benefits of intravenous N-acetylcysteine as an adjunct to hydration in this kind of population. Patients were randomly assigned to receive either N-acetylcysteine (600 mg twice daily) or placebo, in addition to 0.45% intravenous saline. The primary end point was development of contrast-induced nephropathy, defined as an acute increase in the serum creatinine concentration > or = 0.5 mg/dl and/or > 25% increase above baseline level at 48 h after contrast dosing. RESULTS: A total of 216 patients were studied: N-acetylcysteine = 107 and placebo = 109. Treatment groups were similar with respect to baseline clinical characteristics. Overall incidence of contrast-induced nephropathy was 10.2%, 10.3% in the N-acetylcysteine group and 10.1% in the placebo group. Furthermore, no significant differences were observed when considering the non-diabetic population, although there was a trend towards a protective effect of N-acetylcysteine in the subgroup of 47 patients with both hypertension and diabetes. There were no significant changes in serum urea nitrogen concentrations. The incidence of in-hospital adverse clinical events was low: no patient with contrast-induced nephropathy required dialysis, the median Coronary Unit stay was 4.5 vs. 4 days, and the mortality rate was 2.8% vs. 4.6% in the N-acetylcysteine and placebo groups, respectively (p=NS). CONCLUSIONS: The prophylactic administration of intravenous N-acetylcysteine provides no additional benefit to saline hydration in high-risk coronary patients with normal renal function.

Usefulness of C-reactive protein and left ventricular function for risk assessment in survivors of acute myocardial infarction.

The additional prognostic information provided by C-reactive protein (CRP) to parameters of left ventricular function in survivors of acute myocardial infarction (AMI) was investigated in 665 patients (326 with ST elevation and 339 with non-ST elevation). Cox multivariable analysis identified the following predictors of 6-month cardiac death: age (per 5 years hazard ratio [HR] 1.2, 95% confidence interval [CI] 1.1 to 1.4, p = 0.004), Killip class >I at presentation (HR 2.4, 95% CI 1.3 to 4.5, p = 0.0001), a reduced ejection fraction (per 5% HR 1.3, 95% CI 1.2 to 1.4, p = 0.0001), and greater CRP (per 5 mg/L HR 1.02, 95% CI 1.01 to 1.04, p = 0.02); the C-index of the model was 0.77 without and 0.78 with CRP. CRP is associated with mortality in addition to age and parameters of ventricular function (Killip class and ejection fraction) in survivors of AMI, although the relevance of its additive predictive role seems marginal.

Preoperative use of sotalol versus atenolol for atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation is one of the most common complications of cardiac surgery. Beta blockers have been demonstrated to decrease the incidence of postoperative atrial fibrillation. Preliminary investigations reporting sotalol and atenolol to be effective in preventing postoperative atrial fibrillation are encouraging, but no studies have been conducted comparing both drugs. METHODS: A total of 253 consecutive eligible patients (66 +/- 8 years; mean +/- standard deviation) scheduled to undergo cardiac surgery were enrolled in this study. Patients were randomized in a prospective open manner 1.5:1 to atenolol group (50 mg/daily; 153 patients) or sotalol group (80 mg twice daily; 100 patients). RESULTS: Atrial fibrillation occurred in 44/253 patients (17.45%). A significant difference was found in the occurrence of atrial fibrillation in the atenolol group (34 patients, 22%) compared with those receiving sotalol (10 patients, 10%; p = 0.013). Therapeutic efficiency and efficacy was 12% and 54%, respectively. Stepwise logistic regression analysis revealed that age more than 68 years old (odds ratio = 2.72; 95% confidence interval [CI] = 1.37-5.41; p = 0.004), the use of beta-adrenergic agents (odds ratio = 2.74; 95% CI = 1.5-5; p = 0.001), and sotalol (odds ratio = 0.46; 95% CI = 0.23-0.95; p = 0.035) were independently associated with development of atrial fibrillation. CONCLUSIONS: Oral low-dose sotalol provides a considerable reduction in the occurrence of atrial fibrillation. A selective approach based on clinical risk prediction should decrease the occurrence of atrial fibrillation after cardiac surgery.

[Prognostic factors in unstable angina with dynamic electrocardiographic changes. Value of fibrinogen]. / Factores pronósticos en la angina inestable con cambios dinámicos del electrocardiograma. Valor del fibrinógeno.

INTRODUCTION AND OBJECTIVES: The prognosis of unstable angina varies between series depending on the inclusion criteria and management protocol used. The aim of this study was to analyze in-hospital events and their predictors in a homogeneous single-center series of patients with unstable angina. MATERIAL AND METHODS: A total of 246 patients with the following inclusion criteria were studied: 1) resting anginal pain, 2) transient electrocardiographic changes during anginal pain, 3) normal CK-MB levels and 4) exclusion of postinfarction angina. All patients were treated with aspirin and enoxaparin (1 mg/kg/12 h). Coronary angiography was performed in the case of recurrent angina or ischemia in Bruce I-II stage during the predischarge effort stress test. The variables recorded were risk factors, history of ischemic heart disease, history of coronary surgery, ECG upon admission, and fibrinogen. RESULTS: During the hospital stay the following events were recorded: 36% recurrent angina, 58% cardiac catheterization, and 5,7% major events (infarction or death). Multivariate analysis found recurrent angina to be more frequent in patients with a history of coronary bypass surgery (p = 0.004. OR = 22; CI 95%, 3-182), ST-segment changes (p = 0.01. OR = 4.7, CI 95%; 1.4-15.9) and higher fibrinogen (p = 0.002. OR = 1,4, CI 95%; 1.1-1.7). Fibrinogen was the only variable related to cardiac catheterization (p = 0,009. OR = 1.3. CI 95%, 1.1-1.6) and major events (p = 0.001. OR = 2.0. CI 95%, 1.4-3.1). CONCLUSIONS: 1) Unstable angina with electrocardiographic changes was associated to a high rate of in-hospital events. 2) Fibrinogen was related to any event, and previous by-pass surgery and ST changes were related to recurrent angina.

Factores pronósticos en la angina inestable con cambios dinámicos del electrocardiograma. Valor del fibrinógeno / Prognostic factors in unstable angina with dynamic electrocardiographic changes. Value of fibrinogen

Introducción y objetivos. El pronóstico de la angina inestable varía entre diferentes series según los criterios de inclusión. El objetivo ha sido evaluar los episodios hospitalarios y sus predictores en una serie homogénea de angina inestable. Material y métodos. Se incluyó a 246 pacientes consecutivos con los siguientes criterios: a) dolor anginoso en reposo; b) cambios electrocardiográficos dinámicos durante el dolor; c) CK-MB normal, y d) angina postinfarto excluida. Se trataron con aspirina y enoxaparina (1 mg/kg/12 h) y se efectuó coronariografía en caso de angina recurrente o isquemia en el estadio I-II de Bruce en el test de esfuerzo prealta. Se recogieron los factores de riesgo, historia previa de cardiopatía isquémica, historia de cirugía coronaria, electrocardiograma durante el dolor y fibrinógeno. Resultados. Durante el ingreso se presentaron los siguientes episodios: 36 por ciento, angina recurrente; 58 por ciento, cateterismo cardíaco y 5,7 por ciento, episodios mayores (infarto o muerte). Mediante análisis multivariado se observó que la angina recurrente fue más frecuente con antecedentes de cirugía coronaria (p = 0,004; OR = 22; IC del 95 por ciento, 3-182), desviación del segmento ST (p = 0,01; OR: 4,7; IC del 95 por ciento, 1,4-15,9) y mayor fibrinógeno (p = 0,002; OR = 1,4; IC del 95 por ciento, 1,1-1,7). El fibrinógeno fue la única variable relacionada con la necesidad de cateterismo (p = 0,009; OR = 1,3; IC del 95 por ciento, 1,1-1,6) y episodios mayores (p = 0,001; OR = 2,0; IC del 95 por ciento, 1,4-3,1).Conclusiones. a) La angina inestable con cambios electrocardiográficos se acompaña de una alta tasa de episodios hospitalarios, y b) los valores elevados de fibrinógeno se asocian con todos los episodios desfavorables, y los antecedentes de cirugía coronaria y la desviación del ST con angina recurrente (AU)