Circulating MR-proADM levels, as an indicator of endothelial dysfunction, for early risk stratification of mid-term mortality in COVID-19 patients.

OBJECTIVES: Thromboinflammation, resulting from a complex interaction between thrombocytopathy, coagulopathy, and endotheliopathy, contributes to increased mortality in COVID-19 patients. MR-proADM, as a surrogate of adrenomedullin system disruption, leading to endothelial damage, has been reported as a promising biomarker for short-term prognosis. We evaluated the role of MR-proADM in the mid-term mortality in COVID-19 patients. METHODS: A prospective, observational study enrolling COVID-19 patients from August to October 2020. A blood sample for laboratory test analysis was drawn on arrival in the emergency department. The primary endpoint was 90-day mortality. The area under the curve (AUC) and Cox regression analyses were used to assess discriminatory ability and association with the endpoint. RESULTS: A total of 359 patients were enrolled, and the 90-day mortality rate was 8.9%. ROC AUC for MR-proADM predicting 90-day mortality was 0.832. An optimal cutoff of 0.80 nmol/L showed a sensitivity of 96.9% and a specificity of 58.4%, with a negative predictive value of 99.5%. Circulating MR-proADM levels (inverse transformed), after adjusting by a propensity score including eleven potential confounders, were an independent predictor of 90-day mortality (HR: 0.162 [95% CI: 0.043-0.480]) CONCLUSIONS: Our data confirm that MR-proADM has a role in the mid-term prognosis of COVID-19 patients and might assist physicians with risk stratification.

Association between new-onset right bundle branch block and primary or secondary ventricular fibrillation in ST-segment elevation myocardial infarction.

AIMS: New-onset right bundle branch block (RBBB) in myocardial infarction (MI) is often associated with ventricular fibrillation (VF) but the nature of this relationship has not been determined. METHODS AND RESULTS: Between 1998 and 2014, among other data, incidence and duration of RBBB and VF occurrence were prospectively collected in 5301 patients with ST-segment elevation MI (STEMI) admitted to two University Hospitals in Murcia (Spain). Multinomial adjusted logistic regression analyses were used to examine the association between RBBB, attending to its duration, and VF according to its primary VF (PVF) or secondary VF (SVF) character. Among 284 (5.4%) patients with new-onset RBBB, 158 were transient and 126 permanent. VF occurred in 339 (6.4%) patients, 201 PVF and 138 SVF, documented within the first 2 h of symptoms-onset in 78% and 60%, respectively. New-onset RBBB was more frequent in PVF (11.4%) and SVF (20.3%), than in non-VF (4.7%). Transient RBBB incidence was higher in PVF (9.0%) and SVF (9.4) than in non-VF (2.6%), whereas permanent RBBB was higher in SVF (10.9%) than PVF (2.5%) and non-VF (2.1%). New-onset RBBB 1.83 [95% confidence interval (CI): 1.07-3.11] and new-onset transient RBBB 2.39 (95% CI: 1.32-4.32) were independently associated with PVF. New-onset 3.03 (95% CI: 1.83-5.02), transient 2.40 (95% CI: 1.27-4.55), and permanent 2.99 (95% CI: 1.52-5.86) RBBB were independently associated with SVF. CONCLUSION: New-onset RBBB and VF in STEMI are independently associated and show particularities based on the duration of the conduction disturbance and/or the primary or secondary character of the arrhythmia.

MR-proADM as marker of endotheliitis predicts COVID-19 severity.

BACKGROUND: Early identification of patients at high risk of progression to severe COVID-19 constituted an unsolved challenge. Although growing evidence demonstrates a direct association between endotheliitis and severe COVID-19, the role of endothelial damage biomarkers has been scarcely studied. We investigated the relationship between circulating mid-regional proadrenomedullin (MR-proADM) levels, a biomarker of endothelial dysfunction, and prognosis of SARS-CoV-2-infected patients. METHODS: Prospective observational study enrolling adult patients with confirmed COVID-19. On admission to emergency department, a blood sample was drawn for laboratory test analysis. Primary and secondary endpoints were 28-day all-cause mortality and severe COVID-19 progression. Area under the curve (AUC) and multivariate regression analysis were employed to assess the association of the biomarker with the established endpoints. RESULTS: A total of 99 patients were enrolled. During hospitalization, 25 (25.3%) cases progressed to severe disease and the 28-day mortality rate was of 14.1%. MR-proADM showed the highest AUC to predict 28-day mortality (0.905; [CI] 95%: 0.829-0.955; P < .001) and progression to severe disease (0.829; [CI] 95%: 0.740-0.897; P < .001), respectively. MR-proADM plasma levels above optimal cut-off (1.01 nmol/L) showed the strongest independent association with 28-day mortality risk (hazard ratio [HR]: 10.470, 95% CI: 2.066-53.049; P < .005) and with progression to severe disease (HR: 6.803, 95% CI: 1.458-31.750; P = .015). CONCLUSION: Mid-regional proadrenomedullin was the biomarker with highest performance for prognosis of death and progression to severe disease in COVID-19 patients and represents a promising predictor for both outcomes, which might constitute a potential tool in the assessment of prognosis in early stages of this disease.

Integral Velocidade-Tempo da Insuficiência Aórtica: Um Novo Marcador Ecocardiográfico na Avaliação da Gravidade da Insuficiência Aórtica / Velocity-Time Integral of Aortic Regurgitation: A Novel Echocardiographic Marker in the Evaluation of Aortic Regurgitation Severity

Resumo Fundamento A ecocardiografia é essencial para o diagnóstico e a quantificação da insuficiência aórtica (IA). A integral velocidade-tempo (IVT) do fluxo da IA pode estar relacionada à gravidade da IA. Objetivo Este estudo tem por objetivo avaliar se a IVT é um marcador ecocardiográfico de gravidade da IA. Métodos Foram incluídos todos os pacientes com IA nativa moderada ou grave e ritmo sinusal que visitaram o nosso laboratório de imagem entre janeiro e outubro de 2016. Todos os indivíduos foram submetidos a um ecocardiograma completo com medição da IVT da IA. A associação entre a IVT e a gravidade da IA foi analisada por regressão logística e modelos de regressão multivariada. Valores p<0,05 foram considerados estatisticamente significativos. Resultados Entre os 62 pacientes incluídos (68,5±14,9 anos; 64,5%: IA moderada; 35,5%: IA grave), a IVT foi maior em indivíduos com IA moderada em comparação àqueles com IA grave (2,2±0,5 m versus 1,9±0,5 m, p=0,01). Pacientes com IA grave apresentaram valores maiores de diâmetro diastólico final do ventrículo esquerdo (DDFVE) (56,1±7,1 mm versus 47,3±9,6 mm, p=0,001), volume diastólico final do ventrículo esquerdo (VDFVE) (171±36,5 mL versus 106±46,6 mL, p<0,001), orifício regurgitante efetivo (0,44±0,1 cm2 versus 0,18±0,1 cm2, p=0,002) e volume regurgitante (71,3±25,7 mL versus 42,5±10,9 mL, p=0,05), assim como menor fração de ejeção do ventrículo esquerdo (FEVE) (54,1±11,2% versus 63,2±13,3%, p=0,012). A IVT mostrou ser um marcador de gravidade da IA, independentemente do DDFVE, VDFVE e FEVE ( odds ratio 0,160, p=0,032) e da frequência cardíaca e pressão arterial diastólica (PAD) ( odds ratio 0,232, p=0,044). Conclusões A IVT do fluxo da IA apresentou associação inversa com a gravidade da IA, independentemente do diâmetro e volume do ventrículo esquerdo, frequência cardíaca, PAD e FEVE. A IVT pode ser um marcador de gravidade da IA em pacientes com IA nativa e ritmo sinusal. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background Echocardiography is essential for the diagnosis and quantification of aortic regurgitation (AR). Velocity-time integral (VTI) of AR flow could be related to AR severity. Objective This study aims to assess whether VTI is an echocardiographic marker of AR severity. Methods We included all patients with moderate or severe native AR and sinus rhythm who visited our imaging laboratory from January to October 2016. All individuals underwent a complete echocardiogram with AR VTI measurement. The association between VTI and AR severity was analyzed by logistic regression and multivariate regression models. A p-value<0,05 was considered statistically significant. Results Among the 62 patients included (68.5±14.9 years old; 64.5%: moderate AR; 35.5%: severe AR), VTI was higher in individuals with moderate AR compared to those with severe AR (2.2±0.5 m vs. 1.9±0.5 m, p=0.01). Patients with severe AR presented greater values of left ventricular end-diastolic diameter (LVEDD) (56.1±7.1 mm vs. 47.3±9.6 mm, p=0.001), left ventricular end-diastolic volume (LVEDV) (171±36.5 mL vs. 106±46.6 mL, p<0.001), effective regurgitant orifice (0.44±0.1 cm2vs. 0.18±0.1 cm2, p=0.002), and regurgitant volume (71.3±25.7 mL vs. 42.5±10.9 mL, p=0.05), as well as lower left ventricular ejection fraction (LVEF) (54.1±11.2% vs. 63.2±13.3%, p=0.012). The VTI proved to be a marker of AR severity, irrespective of LVEDD, LVEDV, and LVEF (odds ratio 0.160, p=0.032) and of heart rate and diastolic blood pressure (DBP) (odds ratio 0.232, p=0.044). Conclusions The VTI of AR flow was inversely associated with AR severity regardless of left ventricular diameter and volume, heart rate, DBP, and LVEF. VTI could be a marker of AR severity in patients with native AR and sinus rhythm. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Velocity-Time Integral of Aortic Regurgitation: A Novel Echocardiographic Marker in the Evaluation of Aortic Regurgitation Severity. / Integral Velocidade-Tempo da Insuficiência Aórtica: Um Novo Marcador Ecocardiográfico na Avaliação da Gravidade da Insuficiência Aórtica.

BACKGROUND: Echocardiography is essential for the diagnosis and quantification of aortic regurgitation (AR). Velocity-time integral (VTI) of AR flow could be related to AR severity. OBJECTIVE: This study aims to assess whether VTI is an echocardiographic marker of AR severity. METHODS: We included all patients with moderate or severe native AR and sinus rhythm who visited our imaging laboratory from January to October 2016. All individuals underwent a complete echocardiogram with AR VTI measurement. The association between VTI and AR severity was analyzed by logistic regression and multivariate regression models. A p-value<0,05 was considered statistically significant. RESULTS: Among the 62 patients included (68.5±14.9 years old; 64.5%: moderate AR; 35.5%: severe AR), VTI was higher in individuals with moderate AR compared to those with severe AR (2.2±0.5 m vs. 1.9±0.5 m, p=0.01). Patients with severe AR presented greater values of left ventricular end-diastolic diameter (LVEDD) (56.1±7.1 mm vs. 47.3±9.6 mm, p=0.001), left ventricular end-diastolic volume (LVEDV) (171±36.5 mL vs. 106±46.6 mL, p<0.001), effective regurgitant orifice (0.44±0.1 cm2vs. 0.18±0.1 cm2, p=0.002), and regurgitant volume (71.3±25.7 mL vs. 42.5±10.9 mL, p=0.05), as well as lower left ventricular ejection fraction (LVEF) (54.1±11.2% vs. 63.2±13.3%, p=0.012). The VTI proved to be a marker of AR severity, irrespective of LVEDD, LVEDV, and LVEF (odds ratio 0.160, p=0.032) and of heart rate and diastolic blood pressure (DBP) (odds ratio 0.232, p=0.044). CONCLUSIONS: The VTI of AR flow was inversely associated with AR severity regardless of left ventricular diameter and volume, heart rate, DBP, and LVEF. VTI could be a marker of AR severity in patients with native AR and sinus rhythm. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: A ecocardiografia é essencial para o diagnóstico e a quantificação da insuficiência aórtica (IA). A integral velocidade-tempo (IVT) do fluxo da IA pode estar relacionada à gravidade da IA. OBJETIVO: Este estudo tem por objetivo avaliar se a IVT é um marcador ecocardiográfico de gravidade da IA. MÉTODOS: Foram incluídos todos os pacientes com IA nativa moderada ou grave e ritmo sinusal que visitaram o nosso laboratório de imagem entre janeiro e outubro de 2016. Todos os indivíduos foram submetidos a um ecocardiograma completo com medição da IVT da IA. A associação entre a IVT e a gravidade da IA foi analisada por regressão logística e modelos de regressão multivariada. Valores p<0,05 foram considerados estatisticamente significativos. RESULTADOS: Entre os 62 pacientes incluídos (68,5±14,9 anos; 64,5%: IA moderada; 35,5%: IA grave), a IVT foi maior em indivíduos com IA moderada em comparação àqueles com IA grave (2,2±0,5 m versus 1,9±0,5 m, p=0,01). Pacientes com IA grave apresentaram valores maiores de diâmetro diastólico final do ventrículo esquerdo (DDFVE) (56,1±7,1 mm versus 47,3±9,6 mm, p=0,001), volume diastólico final do ventrículo esquerdo (VDFVE) (171±36,5 mL versus 106±46,6 mL, p<0,001), orifício regurgitante efetivo (0,44±0,1 cm2 versus 0,18±0,1 cm2, p=0,002) e volume regurgitante (71,3±25,7 mL versus 42,5±10,9 mL, p=0,05), assim como menor fração de ejeção do ventrículo esquerdo (FEVE) (54,1±11,2% versus 63,2±13,3%, p=0,012). A IVT mostrou ser um marcador de gravidade da IA, independentemente do DDFVE, VDFVE e FEVE ( odds ratio 0,160, p=0,032) e da frequência cardíaca e pressão arterial diastólica (PAD) ( odds ratio 0,232, p=0,044). CONCLUSÕES: A IVT do fluxo da IA apresentou associação inversa com a gravidade da IA, independentemente do diâmetro e volume do ventrículo esquerdo, frequência cardíaca, PAD e FEVE. A IVT pode ser um marcador de gravidade da IA em pacientes com IA nativa e ritmo sinusal. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Medición de la satisfacción del paciente en un servicio de cardiología mediante mapas asociativos: un nuevo método / Measuring patient satisfaction in a cardiology service using associative maps. A new method

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In vitro stability of B-type natriuretic peptide (BNP) in plasma stored under different conditions when measured with the Lumipulse® assay.

Natriuretic peptides are a laboratory tool with significant implications for the diagnosis and prognosis of heart failure (HF). The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) recommended that assays must be examined for sample stability because there appears to be assay dependent. We aimed to evaluate the in vitro stability of B-type natriuretic peptide (BNP) under different handling conditions and using a BNP assay from Fujirebio Diagnostics (Tokyo, Japan). BNP concentrations were measured in plasma EDTA samples from 11 subjects to evaluate the in vitro stability at room temperature and at 4 °C and in 10 subjects to check the in vitro stability of samples stored at -20 °C during 1 and 3 months. Stability limit was defined according to Spanish Society of Laboratory Medicine (SEQC-ML) recommendations. At room temperature and 4 °C, BNP concentrations decreased progressively in samples collected in both groups, remaining stable within four hours from collection. BNP concentrations also were stable within four hours from collection in whole blood at room temperature. Finally, at -20 °C, BNP concentrations remained stable in both groups at 1 and 3 months, respectively. According to our results, BNP, stored at room temperature or at 4 °C, should be assayed in the first four hours after collection. Besides, BNP was shown to be stable in whole blood for at least four hours at room temperature. If the testing cannot be performed within the first four hours, the plasma should be frozen and kept at -20 °C for up to 3 months.

Impact of exposure of emergency patients with acute heart failure to atmospheric Saharan desert dust. / Impacto de la exposición a la calima del polvo del Sáhara en los pacientes con insuficiencia cardiaca aguda atendidos en un servicio de urgencias.

OBJECTIVES: To explore whether episodes of exposure to atmospheric Saharan dust is a risk factor for hospitalization in patients with acute heart failure (AHF) attended in a hospital emergency department (ED). METHODS: Single-center retrospective study of patients with AHF. The cohort was analyzed in 2 groups: ED patients hospitalized with AHF and patients discharged home from the ED. Air pollution on the 5 days leading to ED admission for AHF was recorded as the average concentration of breathable particulate matter with an aerodynamic diameter of no more than 10 µm (PM10) in the following ranges: fine PM (diameter less than 2.5 µm) or coarse PM (diameters between 2.5 and 10 µm). High Saharan dust pollution exposure was defined by mean daily PM10 concentrations between 50 and 200 µg/m3. Multivariable analysis was used to estimate risk for AHF in relation to PM10 exposure in the 5 days before the ED visit. RESULTS: A total of 1097 patients with AHF were treated in the ED; 318 of them (29%) were hospitalized and 779 (71%) were discharged home. Hospitalized patients were older, had more concomitant illnesses, and more episodes of exposure to Saharan dust (P < .0001). Multivariable analysis confirmed the association between Saharan dust exposure and hospital admission in these patients (odds ratio, 2.36; 95% CI, 1.21-4.58; P = .01). CONCLUSION: In the absence of prospective studies, the results of this series suggest that exposure to high levels of Saharan dust (PM10 concentrations between 50 and 200 µg/m3) may be a precipitating factor for hospitalization in AHF episodes.

OBJETIVO: Evaluar si la exposición a episodios de polvo sahariano predice los ingresos hospitalarios de los pacientes con insuficiencia cardiaca aguda (ICA) atendidos en un servicio de urgencias hospitalario (SUH). METODO: Estudio unicéntrico, de cohorte retrospectiva, de pacientes con ICA atendidos en un SUH. La población de estudio se dividió en 2 grupos: pacientes ingresados por ICA y pacientes con ICA dados de alta directa a domicilio desde el SUH. Se analizaron las concentraciones medias de material partículado (PMx) (respirables, diámetro aerodinámico, da< 10 µm), PM2,5 (finas, da <2,5 µm) y PM2,5-10 (gruesas, da 2,5-10 µm) desde el día de la llegada al SUH hasta 5 días previos. Se definió exposición intensa al polvo sahariano cuando las concentraciones medias diarias de PM10 estaban entre 50 y 200 µg/m3. La relación para estimar el riesgo de ingresar por ICA en función de la exposición de PMx durante los 5 días previos a su llegada a urgencias se analizó mediante análisis multivariable. RESULTADOS: Se incluyeron 1.097 pacientes con ICA, ingresaron 318 pacientes (29%), 779 (71%) se dieron de alta. Los pacientes ingresados por ICA tenían mayor edad, elevada comorbilidad y mayor proporción de pacientes expuestos a episodios intensos de polvo sahariano (p < 0,0001). En el análisis multivariable la exposición a episodios de polvo sahariano intensos se relacionó con el ingreso hospitalario en los pacientes con ICA (OR = 2,36; IC 95% 1,21-4,58; p = 0,01). CONCLUSIONES: En ausencia de estudios prospectivos, los resultados obtenidos de la serie analizada sugieren que la presencia de concentraciones elevadas de polvo sahariano (PM10: 50-200 µg/m3) puede constituir un factor precipitante de ingreso por ICA.

Impacto de la exposición a la calima del polvo del Sáhara en los pacientes con insuficiencia cardiaca aguda atendidos en un servicio de urgencias / Impact of exposure of emergency patients with acute heart failure to atmospheric Saharan desert dust

Objetivo: Evaluar si la exposición a episodios de polvo sahariano predice los ingresos hospitalarios de los pacientes con insuficiencia cardiaca aguda (ICA) atendidos en un servicio de urgencias hospitalario (SUH). Método: Estudio unicéntrico, de cohorte retrospectiva, de pacientes con ICA atendidos en un SUH. La población de estudio se dividió en 2 grupos: pacientes ingresados por ICA y pacientes con ICA dados de alta directa a domicilio desde el SUH. Se analizaron las concentraciones medias de material partículado (PMx) (respirables, diámetro aerodinámico, da < 10 µm), PM2,5 (finas, da < 2,5 µm) y PM2,5-10 (gruesas, da 2,5-10 µm) desde el día de la llegada al SUH hasta 5 días previos. Se definió exposición intensa al polvo sahariano cuando las concentraciones medias diarias de PM10 estaban entre 50 y 200 µg/m3. La relación para estimar el riesgo de ingresar por ICA en función de la exposición de PMx durante los 5 días previos a su llegada a urgencias se analizó mediante análisis multivariable. Resultados: Se incluyeron 1.097 pacientes con ICA, ingresaron 318 pacientes (29%), 779 (71%) se dieron de alta. Los pacientes ingresados por ICA tenían mayor edad, elevada comorbilidad y mayor proporción de pacientes expuestos a episodios intensos de polvo sahariano (p < 0,0001). En el análisis multivariable la exposición a episodios de polvo sahariano intensos se relacionó con el ingreso hospitalario en los pacientes con ICA (OR = 2,36; IC 95% 1,21-4,58; p = 0,01). Conclusiones: En ausencia de estudios prospectivos, los resultados obtenidos de la serie analizada sugieren que la presencia de concentraciones elevadas de polvo sahariano (PM10: 50-200 µg/m3) puede constituir un factor precipitante de ingreso por ICA

Objective: To explore whether episodes of exposure to atmospheric Saharan dust is a risk factor for hospitalization in patients with acute heart failure (AHF) attended in a hospital emergency department (ED). Methods: Single-center retrospective study of patients with AHF. The cohort was analyzed in 2 groups: ED patients hospitalized with AHF and patients discharged home from the ED. Air pollution on the 5 days leading to ED admission for AHF was recorded as the average concentration of breathable particulate matter with an aerodynamic diameter of no more than 10 µm (PM10) in the following ranges: fine PM (diameter less than 2.5 µm) or coarse PM (diameters between 2.5 and 10 µm). High Saharan dust pollution exposure was defined by mean daily PM10 concentrations between 50 and 200 µg/m3. Multivariable analysis was used to estimate risk for AHF in relation to PM10 exposure in the 5 days before the ED visit. Results: A total of 1097 patients with AHF were treated in the ED; 318 of them (29%) were hospitalized and 779 (71%) were discharged home. Hospitalized patients were older, had more concomitant illnesses, and more episodes of exposure to Saharan dust (P < .0001). Multivariable analysis confirmed the association between Saharan dust exposure and hospital admission in these patients (odds ratio, 2.36; 95% CI, 1.21-4.58; P = .01). Conclusions: In the absence of prospective studies, the results of this series suggest that exposure to high levels of Saharan dust (PM10 concentrations between 50 and 200 µg/m3) may be a precipitating factor for hospitalization in AHF episodes

Feasibility of Implanting 50-60 mm-Tapered Drug Eluting Stents in Chronic Total Occlusions.

BACKGROUND: Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) usually involves multiple overlapping stents implantation to cover long coronary segments. A higher rate of restenosis has been described with stent overlapping. Recently, new long tapered stents emerged as a potential tool for treating long coronary lesions. Feasibility of using these new devices for the CTO PCI has not been described. The aim of this work was to describe our initial experience with 50 and 60 mm-long tapered sirolimus-eluting stents (SES) in CTO PCI. METHODS: We included 54 consecutive patients who underwent a CTO PCI and in whom an attempt to implant a 50 or 60 mm-long tapered SES was performed. Baseline clinical, angiographic, and procedural characteristics were recorded. RESULTS: The median (IQR) age was 64 (58-73) years, and 45 (83.3%) patients were male. The tapered SES 50 and 60 mm-long was successfully implanted in 51 (94.4%) patients. In three patients, a 60 mm-long stent could not be implanted, and two or three overlapped shorter drug-eluting stents were deployed instead. An average of 1.4 ±â€¯0.6 stents per patient was implanted. A single stent was deployed in 32 (59.3%) patients. During a median follow-up of 330 (149-551) days, repeat PCI in the target vessel was performed in two patients. CONCLUSIONS: The use of the new BioMime Morph™ tapered SES for the treatment of CTO appears to be feasible in a high proportion of procedures. Further studies confirming the feasibility of this approach and its potential clinical advantages are needed.

Low Performance of a Clinical-Genetic Model in the Estimation of Time in Therapeutic Range in Acenocoumarol-Adherent Patients with Nonvalvular Atrial Fibrillation: The Quality of Anticoagulation Challenge.

BACKGROUND: Anticoagulation with vitamin K antagonists continues to be a challenging task given the difficulty of achieving a correct time in therapeutic range (TTR). The SAMeTT2R2 score has been proposed to identify patients that will be good responders. In this study we aimed to analyse clinical and genetic factors involved in a correct level of anticoagulation in patients with atrial fibrillation and thereby potentially improve the diagnostic performance of SAMeTT2R2 score. METHODS: We prospectively included 212 consecutive patients with nonvalvular atrial fibrillation under treatment with acenocoumarol for at least 6 months that were attended in a cardiology outpatient clinic and were categorized as adherent to medication. We carried out a multivariate regression analysis to detect the independent predictive factors of good control. In all patients VKORC1, CYP2C9⁎2, CYP2C9⁎3, and MIR133A2 genotyping was performed. RESULTS: A total of 128 (60.4%) patients presented TTR <70% (average TTR = 63.2). We identified body mass index (OR 0.94, 95%CI 0.89-0.99, p=0.032) and regular vitamin K intake (OR 0.53, 95%CI 0.28-0.99, p= 0.046) as independent predictors of poor anticoagulation control. The discriminatory power of a clinical-genetic model derived from our cohort was significantly better compared to the SAMeTT2R2 score (C-statistic 0.658 versus 0.524, p<0.001). CONCLUSIONS: In our study the SAMeTT2R2 score revealed a poor ability in the prediction of TTR. Besides SAMeTT2R2, body mass index and possibly vitamin K intake should be taken into account when deciding the optimal anticoagulation strategy. The information provided by the identified genotypes was marginal.

Implicaciones diagnósticas y en el pronóstico de la elevación de troponina en ausencia de dolor torácico en pacientes atendidos en urgencias / Diagnostic and prognostic implications of troponin elevation without chest pain in the emergency department

Objetivos. Analizar la implicación en el pronóstico de la ausencia de dolor torácico en pacientes con troponina elevada atendidos en urgencias. Métodos. Estudio observacional de cohortes retrospectivo realizado en un servicio de urgencias entre enero 2012 y diciembre de 2013, que incluyó a todos los pacientes a los que se les había solicitado al menos una determinación de troponina I. Se recogieron las características clínicas de los pacientes y se realizó un modelo de supervivencia. Resultados. Un total de 3.629 pacientes quedaron distribuidos en 4 grupos: dolor torácico y troponina I no elevada (n = 1.379), ausencia de dolor torácico y troponina I no elevada (n = 1.196), dolor torácico y troponina I elevada (n = 517) y ausencia de dolor torácico y troponina I elevada (n = 537). Los pacientes con ausencia de dolor torácico y troponina I elevada fueron de mayor edad y tuvieron mayor carga de comorbilidad, así como otros diagnósticos alternativos al de síndrome coronario agudo con respecto a los otros grupos estudiados. En el análisis de supervivencia a los 12 meses tuvieron mayor mortalidad (log rank test < 0,001). En el análisis multivariado la ausencia de dolor torá- cico con elevación de troponina I demostró ser factor independiente de exceso de mortalidad con respecto a los otros grupos diagnósticos (hazard ratio con respecto al grupo dolor torácico con troponina no elevada = 5,130; intervalo de confianza del 95% 3,291-7,996; p < 0,001). Conclusiones. La ausencia de dolor torácico y troponina I elevada identifica a un grupo heterogéneo de pacientes con un pronóstico al año adverso (AU)

Objective. To analyze the prognostic implications of the absence of chest pain in emergency department patients with elevated troponin I levels. Methods. Observational retrospective study of patients for whom troponin I level was analyzed at least once between January 2012 and December 2013. Patient characteristics were recorded and survival was modeled. Results. A total of 3629 patients were distributed in 4 groups according to troponin I level and chest pain as follows: chest pain without troponin I elevation (n = 1379), no chest pain and no troponin I elevation (n = 1196), chest pain with troponin I elevation (n = 517), and troponin I elevation but no chest pain (n = 537). The patients with troponin I elevation but no chest pain were older and had more chronic conditions as well as more alternative diagnoses to consider other than acute coronary syndrome. Mortality was also higher at 12 months (log rank test < 0.001) in these patients. Multivariate analysis showed that absence of chest pain accompanying troponin I elevation was an independent predictor of mortality (hazard ratio, 5.130; 95% CI, 3.291-7.996; P <001) vs patients with chest pain but no troponin I elevation. Conclusion. The absence of chest pain in the presence of troponin I elevation identifies a heterogeneous group of patients with a worse 12-month prognosis (AU)

Diagnostic and prognostic implications of troponin elevation without chest pain in the emergency department. / Implicaciones diagnósticas y en el pronóstico de la elevación de troponina en ausencia de dolor torácico en pacientes atendidos en urgencias.

OBJECTIVES: To analyze the prognostic implications of the absence of chest pain in emergency department patients with elevated troponin I levels. MATERIAL AND METHODS: Observational retrospective study of patients for whom troponin I level was analyzed at least once between January 2012 and December 2013. Patient characteristics were recorded and survival was modeled. RESULTS: A total of 3629 patients were distributed in 4 groups according to troponin I level and chest pain as follows: chest pain without troponin I elevation (n = 1379), no chest pain and no troponin I elevation (n = 1196), chest pain with troponin I elevation (n = 517), and troponin I elevation but no chest pain (n = 537). The patients with troponin I elevation but no chest pain were older and had more chronic conditions as well as more alternative diagnoses to consider other than acute coronary syndrome. Mortality was also higher at 12 months (log rank test < 0.001) in these patients. Multivariate analysis showed that absence of chest pain accompanying troponin I elevation was an independent predictor of mortality (hazard ratio, 5.130; 95% CI, 3.291-7.996; P<.001) vs patients with chest pain but no troponin I elevation. CONCLUSION: The absence of chest pain in the presence of troponin I elevation identifies a heterogeneous group of patients with a worse 12-month prognosis.

OBJETIVO: Analizar la implicación en el pronóstico de la ausencia de dolor torácico en pacientes con troponina elevada atendidos en urgencias. METODO: Estudio observacional de cohortes retrospectivo realizado en un servicio de urgencias entre enero 2012 y diciembre de 2013, que incluyó a todos los pacientes a los que se les había solicitado al menos una determinación de troponina I. Se recogieron las características clínicas de los pacientes y se realizó un modelo de supervivencia. RESULTADOS: Un total de 3.629 pacientes quedaron distribuidos en 4 grupos: dolor torácico y troponina I no elevada (n = 1.379), ausencia de dolor torácico y troponina I no elevada (n = 1.196), dolor torácico y troponina I elevada (n = 517) y ausencia de dolor torácico y troponina I elevada (n = 537). Los pacientes con ausencia de dolor torácico y troponina I elevada fueron de mayor edad y tuvieron mayor carga de comorbilidad, así como otros diagnósticos alternativos al de síndrome coronario agudo con respecto a los otros grupos estudiados. En el análisis de supervivencia a los 12 meses tuvieron mayor mortalidad (log rank test < 0,001). En el análisis multivariado la ausencia de dolor torácico con elevación de troponina I demostró ser factor independiente de exceso de mortalidad con respecto a los otros grupos diagnósticos (hazard ratio con respecto al grupo dolor torácico con troponina no elevada = 5,130; intervalo de confianza del 95% 3,291-7,996; p < 0,001). CONCLUSIONES: La ausencia de dolor torácico y troponina I elevada identifica a un grupo heterogéneo de pacientes con un pronóstico al año adverso.