The sodium-chloride difference: A marker of prognosis in patients with acute myocardial infarction.

BACKGROUND: The difference between serum sodium and chloride ion concentrations (SCD) may be considered as a surrogate of a strong ion difference and may help to identify patients with a worse prognosis. We aimed to assess SCD as an early prognostic marker among patients with myocardial infarction. METHODS: Data of 594 consecutive patients with acute myocardial infarction treated with PCI (44.9% STEMI patients; 70.7% males) was analysed for SCD in relation to their 30-day mortality. A restricted cubic spline regression model was used to study the relationship between mortality and SCD. Cox regression models were used to assess the association between SCD and the mortality risk. RESULTS: Patients with Killip class ≥3 had lower SCD values in comparison to patients with Killip class ≤2: (32.0 [30.0-34.0] vs. 33.0 [31.0-36.0], p = .006). The overall 30-day mortality was 7.7% (n = 46). There was a significant difference in SCD values between survivors and non-survivors groups of patients (median (IQR): (33.0 [31.0-36.0] vs. 31.5 [28.0-34.0] (mmol/L), p = .002). The restricted cubic splines model confirmed a non-linear association between SCD and mortality. Patients with SCD <30 mmol/L (in comparison to SCD ≥30 mmol/L) had an increased mortality risk (unadjusted HR 2.92, 95% CI 1.59-5.36, p = .001; and an adjusted HR 2.30, 95% CI 1.02-5.19, p = .04). CONCLUSIONS: Low SCD on admission is associated with an increased risk of 30-day mortality in patients with acute myocardial infarction treated with PCI and may serve as a useful prognostic marker for these patients.

The role of stress hyperglycemia and hyperlactatemia in non-diabetic patients with myocardial infarction treated with percutaneous coronary intervention.

BACKGROUND: Stress hyperglycemia and lactates have been used separately as markers of a severe clinical condition and poor outcomes in patients with myocardial infarction (MI). However, the interplay between glucose and lactate metabolism in patients with MI have not been sufficiently studied. The aim in the present study was to examine the relationship of glycemia on admission (AG) and lactate levels and their impact on the outcome in non-diabetic MI patients treated with percutaneous coronary intervention (PCI). METHODS: A total of 405 consecutive, non-diabetic, MI patients were enrolled in this retrospective, observational, single-center study. Clinical characteristic including glucose and lactate levels on admission and at 30-day mortality were assessed. RESULTS: Patients with stress hyperglycemia (AG ≥ 7.8 mmol/L, n = 103) had higher GRACE score (median [interquartile range]: 143.4 (115.4-178.9) vs. 129.4 (105.7-154.5), p = 0.002) than normoglycemic patients (AG level < 7.8 mmol/L, n = 302). A positive correlation of AG with lactate level (R = 0.520, p < 0.001) was observed. The coexistence of both hyperglycemia and hyperlactatemia (lactate level ≥ 2.0 mmol/L) was associated with lower survival rate in the Kaplan-Meier estimates (p < 0.001). In multivariable analysis both hyperglycemia and hyperlactatemia were related to a higher risk of death at 30-day follow-up (hazard ratio [HR] 3.21, 95%, confidence interval [CI] 1.04-9.93; p = 0.043 and HR 7.08; 95% CI 1.44-34.93; p = 0.016, respectively) CONCLUSIONS: There is a relationship between hyperglycemia and hyperlactatemia in non-diabetic MI patients treated with PCI. The coexistence of both hyperglycemia and hyperlactatemia is associated with lower survival rate and are independent predictors of 30-day mortality in MI patients and these markers should be evaluated simultaneously.

Prevalence and clinical implications of atrial fibrillation in patients hospitalized due to COVID-19: Data from a registry in Poland.

Background: Atrial fibrillation (AF) is a common arrhythmia with increasing prevalence with respect to age and comorbidities. AF may influence the prognosis in patients hospitalized with Coronavirus disease 2019 (COVID-19). We aimed to assess the prevalence of AF among patients hospitalized due to COVID-19 and the association of AF and in-hospital anticoagulation treatment with prognosis. Methods and results: We assessed the prevalence of AF among patients hospitalized due to COVID-19 and the association of AF and in-hospital anticoagulation treatment with prognosis. Data of all COVID-19 patients hospitalized in the University Hospital in Krakow, Poland, between March 2020 and April 2021, were analyzed. The following outcomes: short-term (30-days since hospital admission) and long-term (180-days after hospital discharge) mortality, major cardiovascular events (MACEs), pulmonary embolism, and need for red blood cells (RBCs) transfusion, as a surrogate for major bleeding events during hospital stay were assessed. Out of 4,998 hospitalized patients, 609 had AF (535 pre-existing and 74 de novo). Compared to those without AF, patients with AF were older and had more cardiovascular disorders. In adjusted analysis, AF was independently associated with an increased risk of short-term {p = 0.019, Hazard Ratio [(HR)] 1.236; 95% CI: 1.035-1.476} and long-term mortality (Log-rank p < 0.001) as compared to patients without AF. The use of novel oral anticoagulants (NOAC) in AF patients was associated with reduced short-term mortality (HR 0.14; 95% CI: 0.06-0.33, p < 0.001). Moreover, in AF patients, NOAC use was associated with a lower probability of MACEs (Odds Ratio 0.3; 95% CI: 0.10-0.89, p = 0.030) without increase of RBCs transfusion. Conclusions: AF increases short- and long-term risk of death in patients hospitalized due to COVID-19. However, the use of NOACs in this group may profoundly improve prognosis.

Impact of concomitant COVID-19 on the outcome of patients with acute myocardial infarction undergoing coronary artery angiography.

Background: The impact of COVID-19 on the outcome of patients with MI has not been studied widely. We aimed to evaluate the relationship between concomitant COVID-19 and the clinical course of patients admitted due to acute myocardial infarction (MI). Methods: There was a comparison of retrospective data between patients with MI who were qualified for coronary angiography with concomitant COVID-19 and control group of patients treated for MI in the preceding year before the onset of the pandemic. In-hospital clinical data and the incidence of death from any cause on 30 days were obtained. Results: Data of 39 MI patients with concomitant COVID-19 (COVID-19 MI) and 196 MI patients without COVID-19 in pre-pandemic era (non-COVID-19 MI) were assessed. Compared with non-COVID-19 MI, COVID-19 MI was in a more severe clinical state on admission (lower systolic blood pressure: 128.51 ± 19.76 vs. 141.11 ± 32.47 mmHg, p = 0.024), higher: respiratory rate [median (interquartile range), 16 (14-18) vs. 12 (12-14)/min, p < 0.001], GRACE score (178.50 ± 46.46 vs. 161.23 ± 49.74, p = 0.041), percentage of prolonged (>24 h) time since MI symptoms onset to coronary intervention (35.9 vs. 15.3%; p = 0.004), and cardiovascular drugs were prescribed less frequently (beta-blockers: 64.1 vs. 92.8%, p = 0.009), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers: 61.5 vs. 81.1%, p < 0.001, statins: 71.8 vs. 94.4%, p < 0.001). Concomitant COVID-19 was associated with seven-fold increased risk of 30-day mortality (HR 7.117; 95% CI: 2.79-18.14; p < 0.001). Conclusion: Patients admitted due to MI with COVID-19 have an increased 30-day mortality. Efforts should be focused on infection prevention and implementation of optimal management to improve the outcomes in those patients.

Cardiac biomarkers on admission and in­hospital mortality in COVID-19 patients with or without concomitant heart failure.

INTRODUCTION: High­sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B type natriuretic peptide (NT­ proBNP) are known markers of cardiac injury. However, their role in predicting the severity of COVID­19 remains to be investigated. OBJECTIVES: We aimed to analyze the association between hs­cTnT and NT-proBNP levels and in hospital mortality in patients with COVID­19, with emphasis on those with concomitant chronic heart failure (CHF). PATIENTS AND METHODS: A total of 1729 consecutive patients with COVID­19 were enrolled. Demographic data, laboratory parameters, and clinical outcomes (discharge or death) were analyzed. Receiver operating characteristic (ROC) and logistic regression analyses were performed to evaluate the association between hs­cTnT and NT-proBNP values and the risk of death. RESULTS: Evaluation of hs­cTnT was performed in 1041 patients, while NT-proBNP was assessed in 715 individuals. CHF was present in 179 cases (10.4% of the cohort). Median values of hs­cTnT and NT-proBNP and in­hospital mortality were higher in CHF patients than in those without CHF. Among patients without CHF, mortality was the highest in those with hs­cTnT or NT-proBNP values in the fourth quartile. In ROC analysis, hs­cTnT equal to or above 142 ng/l and NT-proBNP equal to or above 969 pg/ml predicted in­hospital death. In patients without CHF, each 10-ng/l increase in hs-cTnT or 100-pg/ml increase in NT­proBNP was associated with a higher risk of death (odds ratio [OR], 1.01 and OR, 1.02, respectively; P <0.01 for both). CONCLUSION: The level of hs­cTnT or NT-proBNP predicts in hospital mortality in COVID-19 patients. Both hs­cTnT and NT-proBNP should be routinely measured on admission in all patients hospitalized due to COVID­19 for early detection of individuals with an increased risk of in hospital death, even if they do not have concomitant heart failure.

Prognostic value of acid­base balance parameters assessed on admission in peripheral venous blood of patients with myocardial infarction treated with percutaneous coronary intervention.

INTRODUCTION: Peripheral venous blood sample may be used to obtain acid­ base balance parameters (PVA­BP) measured in rapid point­of­care test (POCT) analyzers on admission to an emergency department (ED). Thus, lactates, anion gap (AG), and base excess (BE) may be early prognostic markers in patients with myocardial infarction (MI). OBJECTIVES: We aimed to confirm the relationship between PVA­BP on admission and the outcome in patients with MI treated with percutaneous coronary intervention (PCI). PATIENTS AND METHODS: This was a retrospective, observational analysis of MI patients admitted primarily to an ED and secondly transferred to PCI department. RESULTS: A total of 336 patients (41.1% ST­elevated MI, 58.9% non-ST­elevated MI) were divided according to their lactate level, that is, G1 group with lactate below or equal to 2.0 mmol/l (n = 207) and G2 group with lactate above >2.0 mmol/l (n = 129). G2 patients had higher values of AG (mean, [SD], 9.6 [4.3] vs 6.8 [3.2] mEq/l; P <0.001) and lower BE (median [interquartile range], -0.7 [-3.9 to 0.8] vs 1.0 [-0.2 to 2.4] mEq/l; P <0.001). In­hospital nonsurvivors had higher values of lactates (4.0 [2.0-8.7] vs 1.7 [1.3-2.4] mmol/l; P <0.001), AG (10.5 [4.6] vs 7.7 [3.8] mEq/l; P <0.001), and lower BE (-4.8 [-10.6 to -1.8] vs 1.5 [-0.8 to 2.3] mEq/l; P <0.001) than the survivors. Lactates, AG, and BE correlated with Global Registry of Acute Coronary Events score (r = 0.361, P <0.001; r = 0.158, P = 0.004; r = -0.383, P <0.001, respectively). Only BE independently predicted both 30- and 365­day mortality in the whole group (hazard ratio [HR], 0.79; 95% CI, 0.65-0.95; P = 0.01 and HR, 0.89; 95% CI, 0.76-0.99; P = 0.04, respectively) as well as in­hospital mortality among patients without infarct­related out­of­hospital cardiac arrest (odds ratio, 0.74; 95% CI, 0.57-0.97; P = 0.03). CONCLUSIONS: In the patients admitted to the ED with MI treated with PCI the evaluation of PVA­BP in POCT analyzers may be a reliable tool for early risk stratification.

CHADS2 and CHA2DS2-VASc scores as tools for long-term mortality prognosis in patients with typical atrial flutter after catheter ablation.

BACKGROUND: The CHADS2 and CHA2DS2-VASc scores were shown to predict mortality in patients with atrial fibrillation. However, pathophysiology and treatment outcomes of atrial fibrillation and typical atrial flutter (AFL) differ. Consequently, the prognosis of patients with AFL can also be different. AIMS: The aim of the study was to assess CHADS2 and CHA2DS2­VASc scores as mortality predictors in patients with typical AFL. METHODS: Large cohort of consecutive patients with typical AFL who underwent catheter ablation was retrospectively analyzed. The CHADS2 and CHA2DS2­VASc were calculated using hospital record data. All-cause mortality data was obtained from the registry of national personal identification numbers. The Kaplan-Meier method and multivariable Cox proportional hazard models were applied for survival and hazard ratio analyses, respectively. RESULTS: A total of 469 patients hospitalized for typical AFL ablation were enrolled (mean [SD] age, 63.7 [12.2] years; male sex, 69.1%). Patients were followed from 2 to 12 years resulting in 2974 patient­years of follow­up. The Kaplan-Meier survival analysis revealed a negative impact of each component of the CHADS2 and CHA2DS2­VASc scores on survival with the exception of stroke (not significant) and female sex (related to abetter survival). Consequently, higher scores were predictive of higher all­cause mortality rates (2.7%-54% at 10 years); the CHA2DS2­VASc score was equally predictive as the CHADS2 score. CONCLUSIONS: In patients referred for typical AFL ablation, the CHADS2 score can be applied for prognostic assessment. A successful AFL ablation procedure should not divert the attention from recognizing and addressing other medical issues that have an impact on long­term mortality, which remains very high in this population of patients.

True left bundle branch block and long-term mortality in cardiac resynchronisation therapy patients.

BACKGROUND: Left bundle branch block (LBBB) is an important qualification criterion and determinant of prognosis in cardiac resynchronisation therapy (CRT) patients. AIM: Our goal was to investigate the long-term mortality and morbidity in a sizable cohort of patients with CRT with regard to the new strict LBBB definition proposed by Perrin. METHODS: We performed a longitudinal cohort study that included consecutive CRT patients. Primary endpoint (all-cause death) and secondary endpoint (all-cause death and hospitalisation for heart failure) were analysed. All preimplantation elec- trocardiograms were categorised as LBBB or non-LBBB according to the new definitions/criteria analysed. RESULTS: The survival analysis comprised 552 patients with CRT. The Perrin criteria, CRT guidelines class I indication criteria, and Strauss criteria were fulfilled in 38.9%, 79.4%, and 62.3% of all LBBB patients, respectively. During the nine-year study period, 232 patients died and the combined endpoint was met by 292 patients. The Perrin "true LBBB" definition criteria were inferior to the Strauss "complete" LBBB definition criteria in predicting survival as reflected by Kaplan-Meier survival curves (C-statistics). Multivariate Cox regression models showed that both LBBB definitions predicted mortality, however, the Perrin definition had a higher hazard ratio (HR 0.67) compared to the Strauss definition (HR 0.51). CONCLUSIONS: It seems that the Perrin "true LBBB" criteria are not well-suited for the selection of CRT candidates. Perhaps they do not reflect the presence of a true/complete LBBB or exclude too many patients who, despite some residual conduction in the left bundle branch, responded well to CRT.

Risk stratification in patients with cardiac resynchronisation therapy: the AL-FINE CRT risk score.

BACKGROUND: Mortality and morbidity in patients with cardiac resynchronisation therapy (CRT) remain very high. Prognostic evaluation of CRT candidates might be useful for the assessment of CRT indications, directing further therapy, counselling, etc. AIM: Our goal was to assess the prognostic value of various parameters in order to construct a risk score that could predict long-term mortality and morbidity during the initial evaluation of CRT candidates. METHODS: This was a retrospective, single-centre, large cohort study involving consecutive heart failure patients who underwent CRT device implantation. In order to build a prediction model, 28 parameters were analysed using uni- and multivariate Cox models and Kaplan-Meier survival curves. RESULTS: Data from 552 patients were used for the long-term outcome assessment. During nine years of follow-up, 232 patients met the primary endpoint of death and 128 patients were hospitalised for heart failure. The strongest and clinically most relevant predictors were selected as the final model. AL-FINE is the acronym for these six predictors: Age ( > 75 years), non-Left bundle branch block morphology (according to Strauss criteria), Furosemide dose ( > 80 mg), Ischaemic aetiology, New York Heart Association class ( > III), and left ventricular Ejection fraction ( < 20%). Depending on the number of AL-FINE score points, overall mortality at seven years was in the range of 28% (0-1 points) to 74% (3-6 points). CONCLUSIONS: A novel, multiparametric CRT risk score was constructed on the basis of simple and recognised clinical, electrocardiographic, and echocardiographic parameters that show a significant add-on effect on mortality in this specific population.

Developmental effects of neonatal isoflurane and sevoflurane exposure in rats.

BACKGROUND: The general anesthetics, isoflurane and sevoflurane, cause developmental abnormalities in neonatal animal models via incompletely understood mechanisms. Despite many common molecular targets, isoflurane and sevoflurane exhibit substantial differences in their actions. The authors sought to determine whether these differences can also be detected at the level of neurodevelopmental effects. METHODS: Postnatal rats, 4-6 days old, were exposed to 1.2% isoflurane or 2.1% sevoflurane for 1-6 h and studied for immediate and delayed effects. RESULTS: Isoflurane exposure was associated with weaker seizure-like electroencephalogram patterns than sevoflurane exposure. Confronted with a new environment at a juvenile age, the sevoflurane-exposed rats spent significantly more time in an "immobile" state than unexposed rats. Electroencephalographic (mean ± SE, 55.5 ± 12.80 s vs. 14.86 ± 7.03 s; P = 0.014; n = 6-7) and spontaneous behavior (F(2,39) = 4.43; P = 0.018) effects of sevoflurane were significantly diminished by pretreatment with the Na-K-2Cl cotransporter inhibitor bumetanide, whereas those of isoflurane were not. Pretreatment with bumetanide, however, diminished isoflurane-induced activation of caspase-3 in the cerebral cortex (F(2,8) = 22.869; P = 0.002) and prevented impairment in sensorimotor gating function (F(2,36) = 5.978; P = 0.006). CONCLUSIONS: These findings in combination with results previously reported by the authors suggest that isoflurane and sevoflurane produce developmental effects acting via similar mechanisms that involve an anesthetic-induced increase in neuronal activity. At the same time, differences in their effects suggest differences in the mediating mechanisms and in their relative safety profile for neonatal anesthesia.

Roles of aldosterone and oxytocin in abnormalities caused by sevoflurane anesthesia in neonatal rats.

BACKGROUND: The authors sought to determine whether subjects with pathophysiological conditions that are characterized by increased concentrations of aldosterone have increased susceptibility to the side effects of neonatal anesthesia with sevoflurane. METHODS: Postnatal day 4-20 (P4-P20) rats were exposed to sevoflurane, 6% and 2.1%, for 3 min and 60-360 min, respectively. Exogenous aldosterone was administered to imitate pathophysiological conditions with increased concentrations of aldosterone. RESULTS: Six hours of anesthesia with sevoflurane on P4-P5 rats resulted in a more than 30-fold increase in serum concentrations of aldosterone (7.02 ± 1.61 ng/dl vs. 263.75 ± 22.31 ng/dl, mean ± SE, n = 5-6) and reduced prepulse inhibition of the acoustic startle response (F(2,37) = 5.66, P < 0.001). Administration of exogenous aldosterone during anesthesia with sevoflurane enhanced seizure-like electroencephalogram patterns in neonatal rats (48.25 ± 15.91 s vs. 222.00 ± 53.87 s, mean ± SE, n = 4) but did not affect electroencephalographic activity in older rats. Exogenous aldosterone increased activation of caspase-3 (F(3,28) = 11.02, P < 0.001) and disruption of prepulse inhibition of startle (F(3,46) = 6.36; P = 0.001) caused by sevoflurane. Intracerebral administration of oxytocin receptor agonists resulted in depressed seizure-like electroencephalogram patterns (F(2,17) = 6.37, P = 0.009), reduced activation of caspase-3 (t(11) = 2.83, P = 0.016), and disruption of prepulse inhibition of startle (t(7) = -2.9; P = 0.023) caused by sevoflurane. CONCLUSIONS: These results suggest that adverse developmental effects of neonatal anesthesia with sevoflurane may involve both central and peripheral actions of the anesthetic. Subjects with increased concentrations of aldosterone may be more vulnerable, whereas intracerebral oxytocin receptor agonists may be neuroprotective.