Collaborative registry of pulmonary hypertension in Argentina (RECOPILAR). Final analysis / Registro colaborativo de hipertensión pulmonar en Argentina (RECOPILAR): análisis final

Abstract The epidemiology of pulmonary hypertension (PH), especially pulmonary arterial hypertension (PAH), has not been evaluated in our country, therefore there is no reference parameter to establishing the representativeness of this information in the national order. This registry represents the first collaborative effort to provide a knowledge base of this disease, including 5 scientific societies that represent different specialties (pediatrics, rheumatology, pulmonology and cardiology) with data from 23 Argentine provinces. These efforts involved five societies of various adult (cardiology, rheumatology, and pulmonology) and pediatric (cardiology) specialties. Subjects were grouped (1-5) in accord with the 2013 Nice classification. A total of 627 patients (mean age, 50.8±18 years; women, 69.2%) were recruited. Incident cases accounted for 53%. Functional class III-IV accounted for 69% at time of diagnosis and 33.4% at time of inclusion. Distributions in groups 1-5 were 63.6%, 15.9%, 8.3%, 9.7%, and 2.4%, respectively. Treatment consisted of diuretics (51.2%), mineralocorticoid receptor antagonists (44.7%), digoxin (16.6%), anticoagulants (39.2%), renin-angiotensin antagonists (15.5%), beta blockers (15.6%), and calcium channel blockers (8%). Rates of specific therapies usage in PAH vs. non-PAH group were 80.5% vs. 40.8% (phosphodiesterase-5 inhibitors: 71% vs. 38.6%; endothelin receptor antagonists: 54.4% vs. 14.5%; prostanoids: 14.3 vs. 3.1%; all p < 0.001). Three-year survival in PAH and non-PAH differed significantly (82.8% vs. 73.3%; p = 0.001). In the Argentine RECOPILAR registry, the clinic-epidemiologic profile was that of advanced-stage disease. Diagnostic workups and therapeutics interventions, including use of specific therapy for PAH, were consistent with current recommendations. Despite delays in diagnosis, survival was aligned with other contemporary registries.

Resumen La epidemiología de la hipertensión pulmonar (HP), especialmente la arterial (HAP), no ha sido evaluada en nuestro país, por lo cual no existe un parámetro de referencia para establecer la representatividad de esta información en el orden nacional. El presente registro representa el primer esfuerzo colaborativo para una base de conocimiento de esta enfermedad, incluyendo 5 sociedades científicas que representan a distintas especiali dades médicas (pediatría, reumatología, neumonología y cardiología) con datos de 23 provincias argentinas. Los sujetos se agruparon (1-5) de acuerdo con la clasificación de Niza de 2013. El seguimiento se completó en 583 pacientes (93%) un año después del final de la inscripción. Se incluyeron 627 pacientes (edad media, 50.8 ± 18 años; mujeres, 69.2%). Los casos incidentes representaron el 53%. La clase funcional III-IV representaba 69% en el momento del diagnóstico y 33.4% en el momento de la inclusión. Las manifestaciones clínicas fueron disnea (81.8%), fatiga (54.1%), síncope (10.8%), dolor torácico (14.7%), palpitaciones (20.9%) e insuficiencia cardíaca (20.4%). Las tasas de uso de terapias específicas en la hipertensión arterial pulmonar (HAP) frente al grupo sin HAP fueron del 80.5% frente al 40.8%. La supervivencia a tres años en los subconjuntos de HAP y no HAP difirió significativamente (82.8% vs. 73.3%; p = 0.001). En el registro RECOPILAR argentino, que aborda principalmente la HAP, el perfil clínico-epidemiológico fue el d e una enfermedad en estadios avanzados. El diag nóstico y las intervenciones terapéuticas, incluido el uso de terapia específica para la HAP, fueron consistentes con las recomendaciones actuales.

Collaborative registry of pulmonary hypertension in Argentina (RECOPILAR). Final analysis.

The epidemiology of pulmonary hypertension (PH), especially pulmonary arterial hypertension (PAH), has not been evaluated in our country, therefore there is no reference parameter to establishing the representativeness of this information in the national order. This registry represents the first collaborative effort to provide a knowledge base of this disease, including 5 scientific societies that represent different specialties (pediatrics, rheumatology, pulmonology and cardiology) with data from 23 Argentine provinces. These efforts involved five societies of various adult (cardiology, rheumatology, and pulmonology) and pediatric (cardiology) specialties. Subjects were grouped (1-5) in accord with the 2013 Nice classification. A total of 627 patients (mean age, 50.8 ± 18 years; women, 69.2%) were recruited. Incident cases accounted for 53%. Functional class III-IV accounted for 69% at time of diagnosis and 33.4% at time of inclusion. Distributions in groups 1-5 were 63.6%, 15.9%, 8.3%, 9.7%, and 2.4%, respectively. Treatment consisted of diuretics (51.2%), mineralocorticoid receptor antagonists (44.7%), digoxin (16.6%), anticoagulants (39.2%), renin-angiotensin antagonists (15.5%), beta blockers (15.6%), and calcium channel blockers (8%). Rates of specific therapies usage in PAH vs. non-PAH group were 80.5% vs. 40.8% (phosphodiesterase-5 inhibitors: 71% vs. 38.6%; endothelin receptor antagonists: 54.4% vs. 14.5%; prostanoids: 14.3 vs. 3.1%; all p < 0.001). Three-year survival in PAH and non-PAH differed significantly (82.8% vs. 73.3%; p = 0.001). In the Argentine RECOPILAR registry, the clinic-epidemiologic profile was that of advanced-stage disease. Diagnostic workups and therapeutics interventions, including use of specific therapy for PAH, were consistent with current recommendations. Despite delays in diagnosis, survival was aligned with other contemporary registries.

La epidemiología de la hipertensión pulmonar (HP), especialmente la arterial (HAP), no ha sido evaluada en nuestro país, por lo cual no existe un parámetro de referencia para establecer la representatividad de esta información en el orden nacional. El presente registro representa el primer esfuerzo colaborativo para una base de conocimiento de esta enfermedad, incluyendo 5 sociedades científicas que representan a distintas especialidades médicas (pediatría, reumatología, neumonología y cardiología) con datos de 23 provincias argentinas. Los sujetos se agruparon (1-5) de acuerdo con la clasificación de Niza de 2013. El seguimiento se completó en 583 pacientes (93%) un año después del final de la inscripción. Se incluyeron 627 pacientes (edad media, 50.8 ± 18 años; mujeres, 69.2%). Los casos incidentes representaron el 53%. La clase funcional III-IV representaba 69% en el momento del diagnóstico y 33.4% en el momento de la inclusión. Las manifestaciones clínicas fueron disnea (81.8%), fatiga (54.1%), síncope (10.8%), dolor torácico (14.7%), palpitaciones (20.9%) e insuficiencia cardíaca (20.4%). Las tasas de uso de terapias específicas en la hipertensión arterial pulmonar (HAP) frente al grupo sin HAP fueron del 80.5% frente al 40.8%. La supervivencia a tres años en los subconjuntos de HAP y no HAP difirió significativamente (82.8% vs. 73.3%; p = 0.001). En el registro RECOPILAR argentino, que aborda principalmente la HAP, el perfil clínico-epidemiológico fue el d e una enfermedad en estadios avanzados. El diagnóstico y las intervenciones terapéuticas, incluido el uso de terapia específica para la HAP, fueron consistentes con las recomendaciones actuales.

Lung ultrasound in acute myocardial infarction. Updating Killip & Kimball.

BACKGROUND: Heart failure complicating acute myocardial infarction marks an ominous prognosis. Killip and Kimball's classification of heart failure remains a useful tool in these patients. Lung ultrasound can detect pulmonary congestion but its usefulness in this scenario is unknown. OBJECTIVE: To investigate the diagnostic accuracy of lung ultrasound to predict heart failure in patients with acute myocardial infarction. METHODS: Patients admitted with acute myocardial infarction and without heart failure were evaluated with a lung ultrasound. The presence of B-lines was recorded and counted. The presence of new heart failure (Killip Class B, C, or D) during hospitalization was evaluated by a cardiologist blinded to the results of lung ultrasound. A ROC curve analysis was done to evaluate the diagnostic accuracy of B-lines to predict heart failure. RESULTS: 200 patients were included. Three patients were diagnosed with cardiogenic shock, 5 with acute pulmonary edema, and 17 with mild heart failure. Patients who develop heart failure had a median of 14 B-lines, however, patients who remained in Killip class A had a median of 2 (p = 0,0001). The area under the ROC curve of the sum of B-lines to predict any form of heart failure was 0,91 (CI95% 86-97). The best cut-off value was 5 B-lines, with a sensitivity of 88% (IC95% 68,8-97,5) and specificity of 81% (IC95% 73,9-86,2). CONCLUSION: Lung ultrasound done at admission can help to predict heart failure In patients with acute myocardial infarction.

The predictive value of plasma biomarkers in discharged heart failure patients: role of troponin I/T.

Hospitalization for heart failure (HHF) is a frequent manifestation of chronic heart failure (CHF), and represents the moment of greatest impact on costs and on risk for the patient, in particular after discharge. Contributing factors to this disappointingly high postdischarge event rate include the incomplete relief of fluid overload, insufficient patient education, the lack of implementation of evidence-based therapies, poor follow-up and inadequate risk stratification before leaving hospital. Among available tools, different biomarkers have been tested, including cardiac troponin (cTn). The value of cTn to monitoring and to stratifying risk before discharge has been evaluated by mean of three strategies: a single measurement before discharge, monitoring with serial sampling during hospitalization, and comparing admission and predischarge values to establishing the cTn "delta". Acute heart failure syndrome (AHFS) is an active and continuing process, which starts at admission, but its evolution might be unpredictable, and the prevention of ongoing myocardial damage (OMD) might be one of the important targets to improve prognosis. OMD is also a dynamic process and can be detected in CHF and HHF, at different moments and in diverse magnitudes, justifying the cTn monitoring. The favorable effect of drugs on cTn release and its association with better prognosis have increased our expectation for the role of serial determination in HHF patients.

Valor en la práctica diaria de la troponina T ultrasensible para el diagnóstico de infarto de miocardio / The value in daily practice of high sensitive troponin T for myocardial infarction diagnosi / Valor na prática diária da troponina T ultra-sensível para o diagnóstico de infarto do miocárdio

Introducción. La troponina T ultrasensible (TnTus) es un biomarcador útil para la valoración del dolor precordial. Sin embargo, es frecuente su incremento en pacientes sin diagnóstico de síndrome coronario agudo. El objetivo de este trabajo fue evaluar la utilidad de diferentes estrategias de uso de TnTus para el diagnóstico de infarto agudo de miocardio (IAM). Material y método. Estudio retrospectivo que incluyó 99 pacientes consecutivos con sospecha de IAM ingresados a la unidad coronaria, con al menos una determinación de TnTus dentro de las 4-6 horas del inicio del dolor o admisión. El diagnóstico final de IAM fue realizado por dos médicos expertos que analizaron los datos clínicos, laboratorio e imágenes. Resultados. La edad media fue de 64 años y el 75% fueron varones. De acuerdo al diagnóstico final se clasificaron como IAM: el 58%. La TnTus basal mostró un área bajo la curva COR de 0,86 y el punto de corte de 30 ng/L tuvo sensibilidad del 86% y especificidad del 71% para diagnóstico de IAM, mientras que para el valor >14 ng/L, la sensibilidad y especificidad fueron del 93 y 34%, respectivamente. Las áreas bajo la curva para la variación absoluta y porcentual de TnTus (basal y segunda determinación) fueron 0,69 y 0,68, identificándose puntos de corte de 10 ng/L y 15%, respectivamente (sensibilidad 60 y 63%, especificidad del 74 y 74%). Conclusiones. La medición temprana de TnTus>14ng/L muestra la mejor sensibilidad para el diagnóstico de IAM, mientras que un valor >30ng/L fue más específico. La medición repetida del biomarcador mostró menor utilidad.(AU)

Background. High-sensitive troponin T (hs-TnT) is a useful biomarker in the assessment of chest pain. However, it could be frequently elevated in patients without acute coronary syndrome. We sought to evaluate the usefulness of different strategies using hs-TnT for diagnosis of acute myocardial infarction (AMI). Material and method. Retrospective study including 99 consecutive patients with suspected AMI admitted to the coronary care unit with at least one determination of hs-TnT within 4-6 hours of onset of pain or admission. The final diagnosis of AMI was made by two medical experts who analyzed the clinical, laboratory and imaging. Results. The mean age was 64 years and 75% were male. According to the final diagnosis were classified as AMI 58%. The basal hs-TnT showed an area under the ROC curve of 0.86 and the cut-off of 30 ng/L had a sensitivity of 86% and specificity of 71% for diagnosis of AMI, whereas the value >14 ng/L had a sensitivity and specificity of 93 and 34%, respectively. The areas under the curve for the absolute and percentage changes of hs-TnT (basal and second determination) were 0.69 and 0.68, identifying cut-offs of 10 ng/L and 15%, respectively (sensitivity 60 and 63%, specificity of 74 and 74%). Conclusions. Early measurement hs-TnT>14ng/L shows the best sensitivity for the diagnosis of AMI, while a value >30ng/L was more specific. Repeated measurements of biomarker showed less useful.(AU)

IntroduþÒo. A troponina ultra-sensível (TnTus) é um biomarcador útil na avaliaþÒo de dor de peito. Além disso, seu crescimento é comum em pacientes sem diagnóstico da síndrome coronariana aguda. O objeto desta investigaþÒo foi avaliaþÒo da utilidade de diferentes estratégias de TnTus empregadas para o diagnóstico do infarto agudo do miocárdio (IAM). Material e método. Foi realizado um estudo retrospectivo incluindo 99 pacientes consecutivos com suspeita de IAM admitidos na unidade coronariana com pelo menos uma determinaþÒo TnTus dentro de 4-6 horas após o início da dor ou da admissÒo. O diagnóstico final de IAM foi conferido por dois médicos especialistas que analisaram o quadro clínico, laboratorial e de imagem. Resultados. A idade média foi de 64 anos, e 75% foram de sexo masculino. Cinq³enta e oito porcento dos IAM diagnosticado a traveis da TnTus foram conferidos pelos especialistas. A TnTus basal mostrou área embaixo da curva ROC de 0,86 e o corte de 30 ng/L com uma sensibilidade de 86% e especificidade de 71% para o diagnóstico de IAM, mas também o valor >14ng/L teve uma sensibilidade e especificidade de 93 e 34% respectivamente. As áreas sob a curva para o percentual absoluto e de mudanþa de TnTus (basal e segunda determinaþÒo) foram 0,69 e 0,68 com uma sensibilidade de 60 e 63% e especificidade de 74 e 74% respectivamente. NÒo só, os pontos de inflexÒo foram de 10 ng/L e 15%, respectivamente (sensibilidade de 60 e 63%, especificidade 74 e 74%). Conclus§es. A mediþÒo precoce de TnTus >14ng/L mostrou a melhor sensibilidade para o diagnóstico de IAM, mais também um valor >30 ng/L teve mais especificidade em nossa série. As determinaþ§es repetidas nÒo melhoraram a utilidade do biomarcador.(AU)

Valor en la práctica diaria de la troponina T ultrasensible para el diagnóstico de infarto de miocardio / The value in daily practice of high sensitive troponin T for myocardial infarction diagnosi / Valor na prática diária da troponina T ultra-sensível para o diagnóstico de infarto do miocárdio

Introducción. La troponina T ultrasensible (TnTus) es un biomarcador útil para la valoración del dolor precordial. Sin embargo, es frecuente su incremento en pacientes sin diagnóstico de síndrome coronario agudo. El objetivo de este trabajo fue evaluar la utilidad de diferentes estrategias de uso de TnTus para el diagnóstico de infarto agudo de miocardio (IAM). Material y método. Estudio retrospectivo que incluyó 99 pacientes consecutivos con sospecha de IAM ingresados a la unidad coronaria, con al menos una determinación de TnTus dentro de las 4-6 horas del inicio del dolor o admisión. El diagnóstico final de IAM fue realizado por dos médicos expertos que analizaron los datos clínicos, laboratorio e imágenes. Resultados. La edad media fue de 64 años y el 75% fueron varones. De acuerdo al diagnóstico final se clasificaron como IAM: el 58%. La TnTus basal mostró un área bajo la curva COR de 0,86 y el punto de corte de 30 ng/L tuvo sensibilidad del 86% y especificidad del 71% para diagnóstico de IAM, mientras que para el valor >14 ng/L, la sensibilidad y especificidad fueron del 93 y 34%, respectivamente. Las áreas bajo la curva para la variación absoluta y porcentual de TnTus (basal y segunda determinación) fueron 0,69 y 0,68, identificándose puntos de corte de 10 ng/L y 15%, respectivamente (sensibilidad 60 y 63%, especificidad del 74 y 74%). Conclusiones. La medición temprana de TnTus>14ng/L muestra la mejor sensibilidad para el diagnóstico de IAM, mientras que un valor >30ng/L fue más específico. La medición repetida del biomarcador mostró menor utilidad.

Background. High-sensitive troponin T (hs-TnT) is a useful biomarker in the assessment of chest pain. However, it could be frequently elevated in patients without acute coronary syndrome. We sought to evaluate the usefulness of different strategies using hs-TnT for diagnosis of acute myocardial infarction (AMI). Material and method. Retrospective study including 99 consecutive patients with suspected AMI admitted to the coronary care unit with at least one determination of hs-TnT within 4-6 hours of onset of pain or admission. The final diagnosis of AMI was made by two medical experts who analyzed the clinical, laboratory and imaging. Results. The mean age was 64 years and 75% were male. According to the final diagnosis were classified as AMI 58%. The basal hs-TnT showed an area under the ROC curve of 0.86 and the cut-off of 30 ng/L had a sensitivity of 86% and specificity of 71% for diagnosis of AMI, whereas the value >14 ng/L had a sensitivity and specificity of 93 and 34%, respectively. The areas under the curve for the absolute and percentage changes of hs-TnT (basal and second determination) were 0.69 and 0.68, identifying cut-offs of 10 ng/L and 15%, respectively (sensitivity 60 and 63%, specificity of 74 and 74%). Conclusions. Early measurement hs-TnT>14ng/L shows the best sensitivity for the diagnosis of AMI, while a value >30ng/L was more specific. Repeated measurements of biomarker showed less useful.

Introdução. A troponina ultra-sensível (TnTus) é um biomarcador útil na avaliação de dor de peito. Além disso, seu crescimento é comum em pacientes sem diagnóstico da síndrome coronariana aguda. O objeto desta investigação foi avaliação da utilidade de diferentes estratégias de TnTus empregadas para o diagnóstico do infarto agudo do miocárdio (IAM). Material e método. Foi realizado um estudo retrospectivo incluindo 99 pacientes consecutivos com suspeita de IAM admitidos na unidade coronariana com pelo menos uma determinação TnTus dentro de 4-6 horas após o início da dor ou da admissão. O diagnóstico final de IAM foi conferido por dois médicos especialistas que analisaram o quadro clínico, laboratorial e de imagem. Resultados. A idade média foi de 64 anos, e 75% foram de sexo masculino. Cinqüenta e oito porcento dos IAM diagnosticado a traveis da TnTus foram conferidos pelos especialistas. A TnTus basal mostrou área embaixo da curva ROC de 0,86 e o corte de 30 ng/L com uma sensibilidade de 86% e especificidade de 71% para o diagnóstico de IAM, mas também o valor >14ng/L teve uma sensibilidade e especificidade de 93 e 34% respectivamente. As áreas sob a curva para o percentual absoluto e de mudança de TnTus (basal e segunda determinação) foram 0,69 e 0,68 com uma sensibilidade de 60 e 63% e especificidade de 74 e 74% respectivamente. Não só, os pontos de inflexão foram de 10 ng/L e 15%, respectivamente (sensibilidade de 60 e 63%, especificidade 74 e 74%). Conclusões. A medição precoce de TnTus >14ng/L mostrou a melhor sensibilidade para o diagnóstico de IAM, mais também um valor >30 ng/L teve mais especificidade em nossa série. As determinações repetidas não melhoraram a utilidade do biomarcador.

Advances in brain targeting and drug delivery of anti-HIV therapeutic agents.

INTRODUCTION: Human immunodeficiency virus (HIV) is a neurotropic virus that enters the central nervous system (CNS) early in the course of infection. Although antiretroviral drugs are able to eliminate the majority of the HIV virus in the bloodstream, however, no specific treatment currently exist for CNS infections related to HIV. This is mainly attributed to the poor penetrability of antiretroviral therapy across the blood-brain barrier (BBB), and the protective nature of the BBB. Therefore, in order to increase the efficacy of anti-HIV drugs, novel drug delivery methodologies that can exhibit activity in the CNS are most needed and warranted. AREAS COVERED: In this review article, the authors discussed the challenges with delivering drugs to the brain especially under HIV infection pathophysiology status. Also, they discussed the approaches currently being investigated to enhance brain targeting of anti-HIV drugs. A literature search was performed to cover advances in major approaches used to enhance drug delivery to the brain. EXPERT OPINION: If drugs could reach the CNS in sufficient quantity by the methodologies discussed, mainly through intranasal administration and the utilization of nanotechnology, this could generate interest in previously abandoned therapeutic agents and enable an entirely novel approach to CNS drug delivery.

Science and technology of the emerging nanomedicines in cancer therapy: A primer for physicians and pharmacists.

Nanomedicine, the medical applications of devices based on nanotechnology, promises an endless range of applications from biomedical imaging to drug and gene delivery. The size range of the nanomaterials is strictly defined as 1-100 nm, although many marketed nanomedicines are in the submicron range of 100-1000 nm. The major advantages of using nanomaterials as a carrier for anticancer agents are the possibility of targeted delivery to the tumor; their physical properties such as optical and magnetic properties, which can be exploited for developing contrast agents for tumor imaging; their ability to hold thousands of molecules of a drug and deliver at the required site and also the ability to overcome solubility and stability issues. Currently, there are several nanotechnology-enabled diagnostic and therapeutic agents undergoing clinical trials and a few already approved by Food and Drug Administration. Targeted delivery of anticancer agents is achieved by exploiting a unique characteristic of the rapidly dividing tumor cells called "the enhanced permeability and retention effect." Nanoparticles with mean diameter between 100 and 200 nm or even above 200 nm have also been reported to be taken up by tumor cells via the enhanced permeability and retention effect. In addition to this passive targeting based on size, the nanoparticle surface may be modified with a variety of carefully chosen ligands that would interact with specific receptors on the surface of the tumor cells, thus imparting additional specificity for active targeting. Regional release of a drug contained in a nanoparticulate system by the application of external stimuli such as hyperthermia to a thermosensitive device is another innovative strategy for targeted delivery. Nanoparticles protect the enclosed drug from rapid elimination from the body, keep them in circulation for prolonged periods and often evade expulsion by the efflux pump mechanisms, which also leads to avoidance of development of resistance. This review focuses on the science and technology of Food and Drug Administration-approved cancer nanomedicines such as Abraxane, Doxil, DaunoXome and those drug-delivery systems that have reached an advanced stage of clinical development utilizing liposomes, albumin nanospheres, thermosensitive devices and gold nanoshells.

Minor myocardial damage is a prevalent condition in patients with acute heart failure syndromes and preserved systolic function with long-term prognostic implications: a report from the CIAST-HF (Collaborative Italo-Argentinean Study on cardiac Troponin T in Heart Failure) study.

BACKGROUND: Half of patients with acute heart failure syndromes (AHFS) have preserved left ventricular ejection fraction (PLVEF). In this setting, the role of minor myocardial damage (MMD), as identified by cardiac troponin T (cTnT), remains to be established. AIM: To evaluate the prevalence and long-term prognostic significance of cTnT elevations in patients with AHFS and PLVEF. PATIENTS AND METHODS: This retrospective, multicenter, collaborative study included 500 patients hospitalized for AHFS with PLVEF (ejection fraction ≥40%) between October 2000 and December 2006. Blood samples were collected within 12 hours after admission and were assayed for cTnT. MMD was defined as a cTnT value of ≥0.020 ng/mL. RESULTS: Mean age was 73 ± 12 years, 47% were female, 38% had an ischemic etiology, and New York Heart Association (NYHA) class was 2.2 ± 0.7. Mean cTnT value was 0.149 ± 0.484 ng/mL, and cTnT was directly correlated with serum creatinine (Spearman's Rho = 0.35, P < .001) and NYHA class (0.25, P < .001). MMD was diagnosed in 220 patients (44%). Patients with MMD showed lower left ventricular ejection fraction (P < .05), higher serum creatinine (P < .001), higher prevalence of ischemic etiology and diabetes mellitus, a worse NYHA class (P < .001), and higher natriuretic peptide levels (P < .001) as compared with patients without MMD. At 6-month follow-up, overall event-free survival was 55% and 75% in patients with and without MMD (P < .001), respectively. On multivariate Cox regression analysis, only NYHA class (HR = 1.50; P = .002) and MMD (HR = 1.81; P = .001) were identified as predictors of events. CONCLUSIONS: Increased cTnT levels were detected in approximately 50% of patients with AHFS with preserved systolic function, and were found to correlate with clinical measures of disease severity. The presence of MMD was associated with a worse long-term outcome, lending support to cTnT-based risk stratification in the setting of AHFS.

Valor pronóstico de la respuesta serológica debida a Helicobacter pylori en la evolución a largo plazo del síndrome coronario agudo / Prognostic Value of the Serological Response to Helicobacter pylori in Long-Term Outcomes of Acute Coronary Syndrome

Introducción La respuesta serológica a Helicobacter pylori (HP) se ha reconocido como un factor de riesgo cardiovascular. Sin embargo, su utilidad pronóstica en síndromes coronarios agudos (SCA) fue escasamente evaluada. Objetivos Identificar prevalencia y pronóstico a largo plazo de anormalidades en niveles de anticuerpos IgG contra HP (HP-IgG) en pacientes con SCA. Material y métodos La población estuvo constituida por 67 sujetos consecutivos hospitalizados por SCA (angina inestable [AI]/infarto agudo de miocardio [IAM]) dentro de las 24 horas del inicio de los síntomas, entre abril de 2003 y diciembre de 2003, quienes fueron evaluados mediante un kit inmunoenzimático comercial (Meridian Diagnostics, USA). Resultados Durante el seguimiento (12 ± 3 meses) se registraron 10 (14,6%) eventos (muerte/infarto/ rehospitalización por AI). El área bajo la curva ROC de HP-IgG para predecir eventos fue de 0,85 ± 0,06 (IC 95% 0,74-0,96); el punto de corte de 185 UI mostró una sensibilidad del 70% y una especificidad del 82%. Según el nivel de HP-IgG por encima o por debajo de 185 UI, los pacientes se dividieron en grupo 1 (25,4%) y grupo 2. Ambos fueron comparables. La supervivencia anual libre de eventos fue del 67% versus el 90% en los grupos 1 y 2, respectivamente (prueba de rangos logarítmicos, p = 0,01). Al ingreso, un nivel de HP-IgG > 185 UI (hazard ratio [HR] = 5,588; p = 0,039), la hipotensión arterial (HR = 1,109; p = 0,035) y niveles elevados de creatinina (HR = 1,997; p = 0,019) fueron predictores independientes de eventos. Conclusiones En uno de cada cuatro pacientes con SCA se detectaron tempranamente niveles elevados de HP-IgG. Títulos mayores de 185 UI se asociaron con peor evolución a largo plazo.

Background The serological response to Helicobacter pylori (HP) has been recognized as a cardiovascular risk factor. Yet, its prognostic usefulness in acute coronary syndromes (ACS) has not been extensively evaluated. Objectives To identify the prevalence and long-term prognosis of abnormalities in the level of IgG antibodies against HP (HP-IgG) in patients with ACS. Material and Methods From April 2003 to December 2003, a total of 67 consecutive patients hospitalized due to ACS (unstable angina [UA], acute myocardial infarction [AMI]) within 24 hours from symptoms onset were evaluated using a commercial immunoassay kit (Meridian Diagnostics, USA). Results During follow-up (12±3 months) 10 (14.6%) events were reported (death/AMI/rehospitalization due to UA). The area under the ROC curve using HP-IgG to predict events was 0.85±0.06 (95% CI, 0.74-0.96); the cut-off point of 185 IU had a sensitivity of 70% and a specificity of 82%. Patients were divided into 2 groups: group 1 (HP-IgG >185 IU, 25.4%) and group 2 (HP-IgG <185 IU). Both groups were comparable. Annual survival free from events was 67% versus 90% in groups 1 and 2, respectively (log-rank test, p=0.01). The variables identified at admission as independent predictors of events were HP-IgG >185 UI (hazard ratio [HR]=5.588; p=0.039), hypotension (HR=1.109; p=0.035) and elevated oreatinine levéis (HR=1.997; p=0.019). Conclusions Early elevation of HP-IgG levéis was present in 25% of patients with ACS and levéis > 185 IU were associated with poor long-term outcomes.

[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