Vasodilator Stress CMR and All-Cause Mortality in Stable Ischemic Heart Disease: A Large Retrospective Registry.

OBJECTIVES: This study explored the association of ischemic burden, as measured by vasodilator stress cardiovascular magnetic resonance (CMR), with all-cause mortality and the effect of revascularization on all-cause mortality in patients with stable ischemic heart disease (SIHD). BACKGROUND: In patients with SIHD, the association of ischemic burden, derived from vasodilator stress CMR, with all-cause mortality and its role for decision-making is unclear. METHODS: The registry consisted of 6,389 consecutive patients (mean age: 65 ± 12 years; 38% women) who underwent vasodilator stress CMR for known or suspected SIHD. The ischemic burden (at stress first-pass perfusion imaging) was computed (17-segment model). The effect of CMR-related revascularization (within the following 3 months) on all-cause mortality was retrospectively explored using the electronic regional health system registry. RESULTS: During a 5.75-year median follow-up, 717 (11%) deaths were documented. In multivariable analyses, more extensive ischemic burden (per 1-segment increase) was independently related to all-cause mortality (hazard ratio: 1.04; 95% confidence interval: 1.02 to 1.07; p < 0.001). In 1,032 1:1 matched patients using a limited number of variables (516 revascularized, 516 non-revascularized), revascularization within the following 3 months was associated with less all-cause mortality only in patients with extensive CMR-related ischemia (>5 segments, n = 432; 10% vs. 24%; p = 0.01). CONCLUSIONS: In a large retrospective registry of unselected patients with known or suspected SIHD who underwent vasodilator stress CMR, extensive ischemic burden was related to a higher risk of long-term, all-cause mortality. Revascularization was associated with a protective effect only in the restricted subset of patients with extensive CMR-related ischemia. Further research will be needed to confirm this hypothesis-generating finding.

Carbohydrate Antigen-125-Guided Therapy in Acute Heart Failure: CHANCE-HF: A Randomized Study.

OBJECTIVES: This study sought to evaluate the prognostic effect of carbohydrate antigen-125 (CA125)-guided therapy (CA125 strategy) versus standard of care (SOC) after a hospitalization for acute heart failure (AHF). BACKGROUND: CA125 has emerged as a surrogate of fluid overload and inflammatory status in AHF. After an episode of AHF admission, elevated values of this marker at baseline as well as its longitudinal profile relate to adverse outcomes, making it a potential tool for treatment guiding. METHODS: In a prospective multicenter randomized trial, 380 patients discharged for AHF and high CA125 were randomly assigned to the CA125 strategy (n = 187) or SOC (n = 193). The aim in the CA125 strategy was to reduce CA125 to ≤35 U/ml by up or down diuretic dose, enforcing the use of statins, and tightening patient monitoring. The primary endpoint was 1-year composite of death or AHF readmission. Treatment strategies were compared as a time to first event and longitudinally. RESULTS: Patients allocated to the CA125 strategy were more frequently visited, and treated with ambulatory intravenous loop diuretics and statins. Likewise, doses of oral loop diuretics and aldosterone receptor blockers were more frequently modified. The CA125 strategy resulted in a significant reduction of the primary endpoint, whether evaluated as time to first event (66 events vs. 84 events; p = 0.017) or as recurrent events (85 events vs. 165 events; incidence rate ratio: 0.49; 95% confidence interval: 0.28 to 0.82; p = 0.008). The effect was driven by significantly reducing rehospitalizations but not mortality. CONCLUSIONS: The CA125 strategy was superior to the SOC in terms of reducing the risk of the composite of 1-year death or AHF readmission. This effect was mainly driven by significantly reducing the rate of rehospitalizations. (Carbohydrate Antigen-125-guided Therapy in Heart Failure [CHANCE-HF]; NCT02008110).

Efecto pronóstico de una estrategia terapéutica guiada por los valores del antígeno carbohidrato 125 (CHANCE-HF). Diseño del estudio / Prognostic effect of carbohydrate antigen 125-guided therapy in patients recently discharged for acute heart failure (CHANCE-HF). Study design

Introducción y objetivos La morbilidad y la mortalidad después de un ingreso por insuficiencia cardiaca aguda siguen siendo extremadamente elevadas. En este contexto, se ha demostrado que las concentraciones plasmáticas del antígeno carbohidrato 125 muestran correlación con la gravedad de la sobrecarga hídrica y el riesgo de muerte y reingreso. Los datos preliminares indican un posible papel del antígeno carbohidrato 125 como guía para el tratamiento. El objetivo de este estudio es evaluar el efecto pronóstico de una estrategia de tratamiento guiada por el antígeno carbohidrato 125 comparada con el tratamiento estándar en pacientes dados de alta recientemente tras un ingreso por insuficiencia cardiaca aguda. Métodos Ensayo clínico multicéntrico, aleatorizado y a ciego simple, de evaluación de la eficacia en pacientes recientemente dados de alta tras una insuficiencia cardiaca aguda (< 180 días), en clase funcional II-IV de la New York Heart Association y con antígeno carbohidrato 125 > 35 U/ml. Se utilizó un esquema de aleatorización para asignar a los participantes (en relación 1:1) a tratamiento guiado por el antígeno carbohidrato 125 (destinado a mantener valores normales) o tratamiento estándar. El tratamiento guiado se centra principalmente en la frecuencia de monitorización y ajuste de dosis de los tratamientos descongestivos y las estatinas. Hasta el 10 de diciembre de 2013, se había incluido en el estudio a 383 pacientes. El objetivo principal era la combinación de mortalidad por cualquier causa o rehospitalización por insuficiencia cardiaca aguda a 1 año. Se planificó el análisis según el criterio de intención de tratar. Conclusiones: El descubrimiento de estrategias terapéuticas novedosas o mejores formas de optimizar los tratamientos establecidos ha pasado a ser una prioridad de la asistencia sanitaria en la insuficiencia cardiaca. Este estudio aporta nuevos conocimientos importantes acerca del potencial del antígeno carbohidrato 125 como instrumento útil para la monitorización y ajuste de la posología de los tratamientos en los casos en que la utilización óptima no está bien definida, como ocurre con los diuréticos y las estatinas

Introduction and objectives Morbidity and mortality after admission for acute heart failure remain prohibitively high. In that setting, plasma levels of antigen carbohydrate 125 have shown to correlate with the severity of fluid overload and the risk of mortality and readmission. Preliminary data suggests a potential role of antigen carbohydrate 125 to guide therapy. The objective of this study is to evaluate the prognostic effect of an antigen carbohydrate 125-guided management strategy vs standard therapy in patients recently discharged for acute heart failure. Methods This is a multicenter, randomized, single-blind, efficacy trial study of patients recently discharged from acute heart failure (< 180 days), New York Heart Association functional class II-IV and antigen carbohydrate 125 > 35 U/ml. A randomization scheme was used to allocate participants (in a 1:1 ratio) to receive therapy guided by antigen carbohydrate 125 (aiming to keep normal values) or standard treatment. Mainly, antigen carbohydrate 125-guided therapy is focused on the frequency of monitoring and titration of decongestive therapies and statins. As of December 10, 2013, there were 383 patients enrolled. The primary outcome was the composite of 1-year all-cause mortality or rehospitalization for acute heart failure. Analysis was planned to be intention-to-treat. Conclusions Discovering novel therapeutic strategies or finding better ways of optimizing established treatments have become a health care priority in heart failure. This study will add important knowledge about the potential of antigen carbohydrate 125 as a management tool for monitoring and titration of therapies where optimal utilization has not been well defined, such as diuretics and statins (AU)

Prognostic effect of carbohydrate antigen 125-guided therapy in patients recently discharged for acute heart failure (CHANCE-HF). Study design.

INTRODUCTION AND OBJECTIVES: Morbidity and mortality after admission for acute heart failure remain prohibitively high. In that setting, plasma levels of antigen carbohydrate 125 have shown to correlate with the severity of fluid overload and the risk of mortality and readmission. Preliminary data suggests a potential role of antigen carbohydrate 125 to guide therapy. The objective of this study is to evaluate the prognostic effect of an antigen carbohydrate 125-guided management strategy vs standard therapy in patients recently discharged for acute heart failure. METHODS: This is a multicenter, randomized, single-blind, efficacy trial study of patients recently discharged from acute heart failure (< 180 days), New York Heart Association functional class II-IV and antigen carbohydrate 125 > 35 U/ml. A randomization scheme was used to allocate participants (in a 1:1 ratio) to receive therapy guided by antigen carbohydrate 125 (aiming to keep normal values) or standard treatment. Mainly, antigen carbohydrate 125-guided therapy is focused on the frequency of monitoring and titration of decongestive therapies and statins. As of December 10, 2013, there were 383 patients enrolled. The primary outcome was the composite of 1-year all-cause mortality or rehospitalization for acute heart failure. Analysis was planned to be intention-to-treat. CONCLUSIONS: Discovering novel therapeutic strategies or finding better ways of optimizing established treatments have become a health care priority in heart failure. This study will add important knowledge about the potential of antigen carbohydrate 125 as a management tool for monitoring and titration of therapies where optimal utilization has not been well defined, such as diuretics and statins. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT02008110.

Red blood cell distribution width is longitudinally associated with mortality and anemia in heart failure patients.

BACKGROUND: Red blood cell distribution width (RDW) has been found to be an independent predictor for adverse outcome in patients with heart failure (HF), but there are no data on the association of longitudinal RDW with all-cause mortality and occurrence of anemia. METHODS AND RESULTS: 1,702 patients discharged from a previous admission for acute HF (AHF) were included. RDW was measured during the available longitudinal history of the patient. Joint modeling and Multistate Markov were used for the analysis. The median RDW at baseline was 15.0% (IQR: 14.0-16.5), and 45.6% of patients had anemia. At a median follow-up of 1.5 years (IQR: 0.45-3.25), 713 patients died. The last RDW-trajectory value and cumulative RDW-trajectory mean were predictive of mortality (HR, 1.18; 95% CI: 1.12-1.24; and HR, 1.12; 95% CI: 1.08-1.16, respectively; P<0.001 for both). This effect, however, varied according the anemia status (P for interaction<0.001), being more pronounced in absence of anemia [HR=1.31 (95% CI: 1.22-1.42) and HR=1.48 (95% CI: 1.33-1.64)] compared to those with anemia [HR=1.08 (95% CI: 1.04-1.13), 1.12 (95% CI: 1.06-1.18)]. Longitudinal RDW (per 1% increasing) was also independently associated with incident anemia [HR=1.10 (95% CI: 1.03-1.18) P=0.002]. CONCLUSIONS: Following an admission for AHF, higher longitudinal RDW values over time were associated to an increased risk for both developing anemia and dying. The effect on mortality was more pronounced among non-anemic patients.

Valor pronóstico a largo plazo del análisis completo de los índices de resonancia magnética cardiaca tras un infarto de miocardio con elevación del segmento ST / Long-term prognostic value of a comprehensive assessment of cardiac magnetic resonance indexes after an ST-segment elevation myocardial infarction

Introducción y objetivos. Se ha demostrado el valor pronóstico de varios índices de resonancia magnética cardiaca a medio plazo tras un infarto agudo de miocardio con elevación del segmento ST. La extensión de la necrosis transmural permite una predicción simple y exacta de viabilidad miocárdica. Sin embargo, se desconoce su valor pronóstico a largo plazo más allá de una completa evaluación clínica y por resonancia. Nuestra hipótesis es que la evaluación semicuantitativa de la extensión de la necrosis transmural es el mejor índice de resonancia para predecir el pronóstico a largo plazo tras un infarto con elevación del segmento ST. Métodos. Se realizó un estudio cuantitativo con resonancia a 206 pacientes consecutivos tras un infarto con elevación del segmento ST. También se evaluó semicuantitativamente (número de segmentos alterados, modelo de 17 segmentos) edema, contractilidad basal y tras dobutamina, perfusión de primer paso, obstrucción microvascular y extensión de la necrosis transmural. Resultados. Durante el seguimiento (mediana, 51 meses), 29 pacientes sufrieron un primer evento cardiaco adverso (8 muertes cardiacas, 11 infartos y 10 reingresos por insuficiencia cardiaca). Estos eventos se asociaron con mayor alteración de los índices de resonancia. Tras un ajuste multivariable, la extensión de la necrosis transmural fue el único índice de resonancia con asociación independiente con los eventos cardiacos adversos (razón de riesgos = 1,34 [1,19-1,51] por cada segmento con necrosis transmural > 50%; p < 0,001). Conclusiones. Un sencillo análisis semicuantitativo de la extensión de la necrosis transmural es el índice de resonancia cardiaca más potente para predecir el pronóstico a largo plazo tras un infarto agudo de miocardio con elevación del segmento ST (AU)

Introduction and objectives: A variety of cardiac magnetic resonance indexes predict mid-term prognosis in ST-segment elevation myocardial infarction patients. The extent of transmural necrosis permits simple and accurate prediction of systolic recovery. However, its long-term prognostic value beyond a comprehensive clinical and cardiac magnetic resonance evaluation is unknown. We hypothesized that a simple semiquantitative assessment of the extent of transmural necrosis is the best resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction. Methods: One week after a first ST-segment elevation myocardial infarction we carried out a comprehensive quantification of several resonance parameters in 206 consecutive patients. A semiquantitative assessment (altered number of segments in the 17-segment model) of edema, baseline and post-dobutamine wall motion abnormalities, first pass perfusion, microvascular obstruction, and the extent of transmural necrosis was also performed. Results: During follow-up (median 51 months), 29 patients suffered a major adverse cardiac event (8 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 readmissions for heart failure). Major cardiac events were associated with more severely altered quantitative and semiquantitative resonance indexes. After a comprehensive multivariate adjustment, the extent of transmural necrosis was the only resonance index independently related to the major cardiac event rate (hazard ratio=1.34 [1.19-1.51] per each additional segment displaying >50% transmural necrosis, P<.001). Conclusions: A simple and non-time consuming semiquantitative analysis of the extent of transmural necrosis is the most powerful cardiac magnetic resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction (AU)

Echocardiographic estimation of pulmonary arterial systolic pressure in acute heart failure. Prognostic implications.

BACKGROUND: Prognostic implications of echocardiographic assessment of pulmonary hypertension (PH) in non-selected patients hospitalized for acute heart failure (AHF) are not clearly defined. The aim of this study was to evaluate the association between echocardiography-derived PH in AHF and 1-year all-cause mortality. METHODS: We prospectively included 1210 consecutive patients admitted for AHF. Patients with significant heart valve disease were excluded. Pulmonary arterial systolic pressure (PASP) was estimated using transthoracic echocardiography during hospitalization (mean time after admission 96±24h). Patients were categorized as follows: non-measurable, normal PASP (PASP≤35mmHg), mild (PASP 36-45mmHg), moderate (PASP 46-60mmHg) and severe PH (PASP >60mmHg). The independent association between PASP and 1-year mortality was assessed with Cox regression analysis. RESULTS: At 1-year follow-up, 232 (19.2%) deaths were registered. PASP was measured in 502 (41.6%) patients with a median of 46 [38-55] mmHg. The distribution of population was: 708 (58.5%), 76 (6.3%), 147 (12.1%), 190 (15.7%) and 89 (7.4%) for non-measurable, normal PASP, mild, moderate and severe PH, respectively. One-year mortality was lower for patients with normal PASP (1.32 per 10 person-years), intermediate for patients with non-measurable, mild and moderate PH (2.48, 2.46 and 2.62 per 10 persons-year, respectively) and higher for those with severe PH (4.89 per 10 person-years). After multivariate adjustment, only patients with PASP >60mmHg displayed significant adjusted increase in the risk of 1-year all-cause mortality, compared to patients with normal PASP (HR=2.56; CI 95%: 1.05-6.22, p=0.038). CONCLUSIONS: In AHF, severe pulmonary hypertension derived by echocardiography is an independent predictor of 1-year-mortality.

Predictors of cardiovascular magnetic resonance-derived microvascular obstruction on patient admission in STEMI.

BACKGROUND: Early stratification of patients according to the risk for developing microvascular obstruction (MVO) after ST-segment elevation myocardial infarction (STEMI) is desirable. We aimed to identify predictors of cardiovascular magnetic resonance (CMR)-derived MVO from clinical+ECG, laboratory and angiographic parameters available on admission. METHODS: Characteristics available on admission were documented in 97 STEMI patients referred for primary angioplasty. MVO was determined using contrast-enhanced CMR. RESULTS: MVO was present in 44 patients (45%). The C-statistic for predicting MVO was: clinical+ECG (.832), laboratory (.743), and angiographic parameters (.669). Adding laboratory to clinical+ECG information did not improve the C-statistic (.873 vs. .832, p=.2). Further addition of angiographic data (.904) improved the C-statistic of clinical+ECG (p=.04) but not of clinical+ECG and laboratory (p=.2). Independent predictors of MVO using clinical and ECG parameters were: Killip class >1 (OR 15.97 95%CI [1.37-186.76], p=.03), diabetes (OR 6.15 95%CI [1.49-25.39], p=.01), age <55years (OR 4.70 95%CI [1.56-14.17], p=.006), sum of ST-segment elevation >10mm (OR 4.5 95%CI [1.58-12.69], p=.005) and delayed presentation >3h (OR 3.80 95%CI [1.19-12.1], p=.02). A score was constructed assigning Killip class >1 2 points and the remaining indexes 1 point. The incidence of MVO increased with the score: 0 point: 8.7%; 1 point: 28.1%; 2 points: 71.4%; and 3+ points: 93% (p<.0001). CONCLUSIONS: MVO can be predicted using parameters already available on patient admission. We developed a clinical-ECG score allowing for early and reliable classification of STEMI patients according to the risk of MVO.

Long-term prognostic value of a comprehensive assessment of cardiac magnetic resonance indexes after an ST-segment elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: A variety of cardiac magnetic resonance indexes predict mid-term prognosis in ST-segment elevation myocardial infarction patients. The extent of transmural necrosis permits simple and accurate prediction of systolic recovery. However, its long-term prognostic value beyond a comprehensive clinical and cardiac magnetic resonance evaluation is unknown. We hypothesized that a simple semiquantitative assessment of the extent of transmural necrosis is the best resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction. METHODS: One week after a first ST-segment elevation myocardial infarction we carried out a comprehensive quantification of several resonance parameters in 206 consecutive patients. A semiquantitative assessment (altered number of segments in the 17-segment model) of edema, baseline and post-dobutamine wall motion abnormalities, first pass perfusion, microvascular obstruction, and the extent of transmural necrosis was also performed. RESULTS: During follow-up (median 51 months), 29 patients suffered a major adverse cardiac event (8 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 readmissions for heart failure). Major cardiac events were associated with more severely altered quantitative and semiquantitative resonance indexes. After a comprehensive multivariate adjustment, the extent of transmural necrosis was the only resonance index independently related to the major cardiac event rate (hazard ratio=1.34 [1.19-1.51] per each additional segment displaying>50% transmural necrosis, P<.001). CONCLUSIONS: A simple and non-time consuming semiquantitative analysis of the extent of transmural necrosis is the most powerful cardiac magnetic resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction.

Outcome of patients with syncope beyond the implantable loop recorder.

AIMS: The implantation of an implantable loop recorder (ILR) leads to the diagnosis in about 35% of patients with syncope of unknown origin. Information on outcome of patients in whom a diagnosis is not reached during the lifetime of the device is scarce. The aim of our study is to determine the outcome of these patients in terms of syncope recurrence and survival. METHODS AND RESULTS: An ILR was implanted to 97 patients with syncope of unknown origin. Patients were classified in groups A and B depending on their high or low risk, respectively, of having arrhythmic syncope. Diagnosis had not been reached in 60 patients (62%) when the ILR battery reached end operational life. Five patients were lost to follow up. During a median follow-up of 48 months after ILR explantation (interquartile range 36-56), 22 patients (40%) had recurrence of syncope (32% in group A vs. 48% in group B, P = 0.3). Syncopes with no neurally mediated profile were more frequent in group A (18 vs. 0%, P = 0.05) and neurally mediated profile syncopes were more frequent in group B (44 vs. 11%, P = 0.007). Five patients died, four of them in group A and 1 in group B (P = 0.4). No sudden or cardiac deaths were detected during follow-up. All deaths were due to non-cardiac causes. CONCLUSION: Recurrent syncope is common in patients in whom a diagnosis is not established after the full battery life of an ILR. The prognosis of these patients seems to be good, without observed sudden or cardiac death.

Diálisis peritoneal ambulatoria continua y evolución clínica de pacientes con insuficiencia cardiaca congestiva refractaria / Continuous ambulatory peritoneal dialysis and clinical outcomes in patients with refractory congestive heart failure

Introducción y objetivos. Se ha propuesto el empleo de la diálisis peritoneal como alternativa para los pacientes con insuficiencia cardiaca congestiva refractaria. El objetivo de este estudio es evaluar su efecto en la evolución clínica a largo plazo de los pacientes con insuficiencia cardiaca avanzada y disfunción renal. Métodos. Se invitó a un total de 62 pacientes, con insuficiencia cardiaca avanzada (clase III/IV), disfunción renal (filtrado glomerular < 60ml/min/1,73 m2), congestión persistente por exceso de líquidos a pesar del tratamiento con diuréticos de asa y al menos dos hospitalizaciones previas por insuficiencia cardiaca, a participar en un programa de diálisis peritoneal ambulatoria continua. De ellos, se excluyó a 34 y se los asignó al grupo control. Las razones de exclusión más importantes fueron la negativa a participar, la incapacidad de aplicar la técnica y la presencia de defectos de la pared abdominal. El objetivo primario fue la mortalidad por cualquier causa y la combinación de mortalidad y reingreso por insuficiencia cardiaca. Para tener en cuenta el desequilibrio existente en la situación basal, se estimó una puntuación de propensión que se utilizó como ponderación en todos los análisis. Resultados. Los grupos de diálisis peritoneal (n = 28) y de control (n = 34) eran similares respecto a todas las covariables basales. Durante una mediana de seguimiento de 16 meses, 39 (62,9%) fallecieron, 21 (33,9%) pacientes fueron rehospitalizados por insuficiencia cardiaca y 42 (67,8%) presentaron el objetivo combinado. En los modelos ajustados según la puntuación de propensión, la diálisis peritoneal, comparada con el grupo control, se asoció a una reducción sustancial del riesgo de mortalidad en el seguimiento completo (razón de riesgos = 0,40; intervalo de confianza del 95%, 0,21-0,75; p = 0,005), la mortalidad evaluada con los días de vida fuera del hospital (razón de riesgos = 0,39; intervalo de confianza del 95%, 0,21-0,74; p = 0,004) y el objetivo combinado (razón de riesgos = 0,32; intervalo de confianza del 95%, 0,17-0,61; p = 0,001). Conclusiones. En la insuficiencia cardiaca congestiva refractaria con disfunción renal concomitante, la diálisis peritoneal se asoció a una mejoría de la evolución clínica a largo plazo (AU)

Introduction and objectives. Peritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction. Methods. A total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60mL/min/1.73 m2), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses. Results. The peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001). Conclusions. In refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes (AU)

Continuous ambulatory peritoneal dialysis and clinical outcomes in patients with refractory congestive heart failure.

INTRODUCTION AND OBJECTIVES: Peritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction. METHODS: A total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60 mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses. RESULTS: The peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001). CONCLUSIONS: In refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes. Full English text available from:www.revespcardiol.org.

Análisis mediante resonancia magnética cardiaca del miocardio salvado tras infarto. Predictores e influencia en el remodelado adverso ventricular / Analysis of post-infarction salvaged myocardium by cardiac magnetic resonance. Predictors and influence on adverse ventricular remodeling

Introducción y objetivos. Analizar mediante resonancia magnética cardiaca los factores que determinan la magnitud del miocardio salvado tras infarto de miocardio y su valor predictivo del remodelado adverso ventricular. Métodos. A 118 pacientes con un primer infarto de miocardio con elevación del ST (angioplastia primaria, 65 pacientes; estrategia farmacoinvasiva, 53 pacientes) se les realizó resonancia magnética (6 [5-8] días y 6 meses; n=83). Se cuantificó el índice de miocardio salvado como el porcentaje de área en riesgo (secuencias ponderadas en T2) que no muestra realce tardío. Resultados. El índice de miocardio salvado > 31% (mediana) se asocia a menor tiempo dolor-reperfusión (153 frente a 258 min), menor frecuencia de diabetes (el 12 frente al 32%), menor retraso hasta la resonancia magnética y mejores parámetros cardiovasculares (p<0,05 para todos ellos). No existen diferencias según el tipo de reperfusión. Mediante regresión logística, los predictores de índice de miocardio salvado > 31% son el retraso hasta la reperfusión (odds ratio = 0,42 [0,29-0,63]; p<0,0001), diabetes (odds ratio=0,32 [0,11-0,99]; p<0,05) y el retraso hasta la resonancia magnética (odds ratio=0,86 [0,76-0,97]; p<0,05). Los predictores de volumen telesistólico dilatado al sexto mes son el número de segmentos con necrosis > 50% (odds ratio=1,51 [1,21-1,90]; p<0,0001) y el volumen telesistólico en la primera semana (odds ratio=1,12 [1,06-1,18]; p<0,0001). Conclusiones. La resonancia magnética permite cuantificar el miocardio salvado tras el infarto. La rapidez en recibir el tratamiento de reperfusión constituye su principal predictor. Se debe confirmar la posible relación entre el retraso en la realización de la resonancia magnética y el miocardio salvado. El miocardio salvado no mejora el valor de la resonancia para predecir remodelado adverso (AU)

Introduction and objectives. To evaluate by cardiovascular magnetic resonance those factors related to the amount of salvaged myocardium after a myocardial infarction and its value in predicting adverse ventricular remodeling. Methods. One hundred eighteen patients admitted for a first ST elevation myocardial infarction (primary angioplasty, 65 patients; a pharmacoinvasive strategy, 53 patients) underwent magnetic resonance (6 [5-8] days and 6 months; n=83). The myocardial salvage index was quantitatively assessed as the percentage of area at risk (T2-weighted sequences) not showing late enhancement. Results. Myocardial salvage index >31% (median) was associated with a shorter time to reperfusion (153min vs 258min), a lower rate of diabetes (12% vs 32%), shorter time to magnetic resonance, and better cardiovascular parameters (P<.05 for all analyses). There were no significant differences depending on the reperfusion method. In a logistic regression analysis, delayed reperfusion (odds ratio=0.42 [0.29-0.63]; P<.0001), diabetes (odds ratio=0.32 [0.11-0.99]; P<.05) and a longer time to the performance of magnetic resonance (odds ratio=0.86 [0.76-0.97]; P<.05) were independently related to a lower probability of a myocardial salvage index >31%. Predictors of increased left ventricular end-systolic volume at 6 months were the number of segments showing an extent of transmural necrosis >50% (odds ratio =1.51 [1.21-1.90]; P<.0001) and left ventricular end-systolic volume at one week (odds ratio=1.12 [1.06-1.18]; P<.0001). Conclusions. Cardiovascular magnetic resonance enables the quantification of the salvaged myocardium after myocardial infarction. The celerity with which reperfusion therapy is administered constitutes its most important predictor. The possible effect of a delay in the performance of magnetic resonance on myocardial salvage needs to be confirmed. Salvaged myocardium does not improve the value of magnetic resonance for predicting adverse remodeling (AU)

Differential mortality association of loop diuretic dosage according to blood urea nitrogen and carbohydrate antigen 125 following a hospitalization for acute heart failure.

AIMS: Recent observations in chronic stable heart failure suggest that high-dose loop diuretics (HDLDs) have detrimental prognostic effects in patients with high blood urea nitrogen (BUN), but recent findings have also indicated that diuretics may improve renal function. Carbohydrate antigen 125 (CA125) has been shown to be a surrogate of systemic congestion. We sought to explore whether BUN and CA125 modulate the mortality risk associated with HDLDs following a hospitalization for acute heart failure (AHF). METHODS AND RESULTS: We analysed 1389 consecutive patients discharged for AHF. CA125 and BUN were measured at a mean of 72 ± 12 h after admission. HDLDs (≥120 mg/day in furosemide equivalent dose) were interacted to a four-level variable according to CA125 (>35 U/mL) and BUN (above the median), and related to all-cause mortality. At a median follow-up of 21 months, 561 (40.4%) patients died. The use of HDLDs was independently associated with increased mortality [hazard ratio (HR) 1.23, 95% confidence interval (CI) 1.01-1.50], but this association was not homogeneous across CA125-BUN categories (P for interaction <0.001). In patients with normal CA125, use of HDLDs was associated with high mortality if BUN was above the median (HR 2.29, 95% 1.51-3.46), but not in those with BUN below the median (HR 1.22, 95% CI 0.73-2.04). Conversely, in patients with high CA125, HDLDs showed an association with increased survival if BUN was above the median (HR 0.73, 95% CI 0.55-0.98) but was associated with increased mortality in those with BUN below the median (HR 1.94, 95% CI 1.36-2.76). CONCLUSION: The risk associated with HDLDs in patients after hospitalization for AHF was dependent on the levels of BUN and CA125. The information provided by these two biomarkers may be helpful in tailoring the dose of loop diuretics at discharge for AHF.

Analysis of post-infarction salvaged myocardium by cardiac magnetic resonance. Predictors and influence on adverse ventricular remodeling.

INTRODUCTION AND OBJECTIVES: To evaluate by cardiovascular magnetic resonance those factors related to the amount of salvaged myocardium after a myocardial infarction and its value in predicting adverse ventricular remodeling. METHODS: One hundred eighteen patients admitted for a first ST elevation myocardial infarction (primary angioplasty, 65 patients; a pharmacoinvasive strategy, 53 patients) underwent magnetic resonance (6 [5-8] days and 6 months; n=83). The myocardial salvage index was quantitatively assessed as the percentage of area at risk (T2-weighted sequences) not showing late enhancement. RESULTS: Myocardial salvage index >31% (median) was associated with a shorter time to reperfusion (153 min vs 258 min), a lower rate of diabetes (12% vs 32%), shorter time to magnetic resonance, and better cardiovascular parameters (P<.05 for all analyses). There were no significant differences depending on the reperfusion method. In a logistic regression analysis, delayed reperfusion (odds ratio=0.42 [0.29-0.63]; P<.0001), diabetes (odds ratio=0.32 [0.11-0.99]; P<.05) and a longer time to the performance of magnetic resonance (odds ratio=0.86 [0.76-0.97]; P<.05) were independently related to a lower probability of a myocardial salvage index >31%. Predictors of increased left ventricular end-systolic volume at 6 months were the number of segments showing an extent of transmural necrosis >50% (odds ratio =1.51 [1.21-1.90]; P<.0001) and left ventricular end-systolic volume at one week (odds ratio=1.12 [1.06-1.18]; P<.0001). CONCLUSIONS: Cardiovascular magnetic resonance enables the quantification of the salvaged myocardium after myocardial infarction. The celerity with which reperfusion therapy is administered constitutes its most important predictor. The possible effect of a delay in the performance of magnetic resonance on myocardial salvage needs to be confirmed. Salvaged myocardium does not improve the value of magnetic resonance for predicting adverse remodeling.

Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure.

AIMS: Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an additional therapeutic resource for patients with advanced congestive heart failure (CHF). The objective of this study was to determine the therapeutic role of CAPD, in terms of surrogate endpoints, in the management of patients with advanced CHF and renal dysfunction. METHODS AND RESULTS: A total of 57 candidates with New York Heart Association (NYHA) class III/IV CHF, renal dysfunction (glomerular filtration rate < 60 mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment, and at least two previous hospitalizations for acute heart failure (AHF) were invited to be included in the CAPD programme; however, 25 patients were finally included. The primary outcome was evaluated by the change at 6 and 24 weeks for the Minnesota Living With Heart Failure Questionnaire (MLWHFQ), the 6 min walk test (6MWT), NYHA class, serum natriuretic peptides [brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)], serum carbohydrate antigen 125 (CA125), and hospitalization rates for AHF. CAPD was associated with a substantial improvement in the MLWHFQ (-21.3, P < 0.001; and -20.4, P < 0.001), the 6MWT (54.0, P < 0.001; and 45.6, P = 0.023), and NYHA class (-1.0, P < 0.001; and -1.4, P < 0.001) at 6 and 24 weeks, respectively. The Ln(CA125) decreased markedly (-0.8, P = 0.003; and -0.98, P = 0.003), with no effect on BNP and NT-proBNP. There was a marked reduction in the number of days hospitalized for AHF (6 month post-CAPD vs. 6 months pre-CAPD: -84%; P < 0.001). CONCLUSIONS: In advanced CHF and renal dysfunction, CAPD was associated with short/mid-term improvement in severity parameters, with an acceptable rate of side effects.

Effectiveness of the relative lymphocyte count to predict one-year mortality in patients with acute heart failure.

Several works have endorsed a significant role of the immune system and inflammation in the pathogenesis of heart failure. As indirect evidence, an association between a low relative lymphocyte count (RLC%) and worse outcomes found in this population has been suggested. Nevertheless, the role of RLC% for risk stratification in a large and nonselected population of patients with acute heart failure (AHF) has not yet been determined. Thus, the aim of this study was to determine the association between low RLC% and 1-year mortality in patients with AHF and consequently to define whether it has any role for early risk stratification. A total of 1,192 consecutive patients admitted for AHF were analyzed. Total white blood cell and differential counts were measured on admission. RLC% (calculated as absolute lymphocyte count/total white blood cell count) was categorized in quintiles and its association with all-cause mortality at 1 year assessed using Cox regression. At 1 year, 286 deaths (24%) were identified. A negative trend was observed between 1-year mortality rates and quintiles of RLC%: 31.5%, 27.2%, 23.1%, 23%, and 15.5% in quintiles 1 to 5, respectively (p for trend <0.001). After thorough covariate adjustment, only patients in the lowest quintile (<9.7%) showed an increased risk for mortality (hazard ratio 1.76, 95% confidence interval 1.17 to 2.65, p = 0.006). When RLC% was modeled with restricted cubic splines, a stepped increase in risk was observed patients in quintile 1: those with RLC% values <7.5% and <5% showed 1.95- and 2.66-fold increased risk for death compared to those in the top quintile. In conclusion, in patients with AHF, RLC% is a simple, widely available, and inexpensive biomarker, with potential for identifying patients at increased risk for 1-year mortality.

Resultados de la estrategia farmacoinvasiva y de la angioplastia primaria en la reperfusión del infarto con elevación del segmento ST. Estudio con resonancia magnética cardiaca en la primera semana y en el sexto mes / One-week and 6-month cardiovascular magnetic resonance outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction

Introducción y objetivos. La estrategia farmacoinvasiva es una alternativa atractiva a la angioplastia primaria. Valoramos mediante resonancia magnética cardiaca la afección del ventrículo izquierdo tras un infarto de miocardio con elevación del segmento ST tratado con estas estrategias de reperfusión. Métodos. Estudiamos con resonancia magnética cardiaca, realizada 1 semana y 6 meses después de un infarto, a dos cohortes consecutivas de pacientes incluidas en un registro prospectivo de infarto de miocardio con elevación del ST en un hospital universitario. Durante el periodo 2004-2006, se trató a 151 pacientes con estrategia farmacoinvasiva (trombolisis seguida de angioplastia sistemática no inmediata). Durante el periodo 2007-2008, se trató con angioplastia primaria a 93 pacientes. Se estudió un subgrupo ajustado mediante propensity score. Resultados. La resonancia magnética cardiaca en la primera semana mostró una extensión de área en riesgo similar para la estrategia farmacoinvasiva y la angioplastia primaria (el 29%±15% frente al 29%±17%; p=0,9). No se observaron diferencias significativas en cuanto a tamaño de infarto, miocardio rescatado, obstrucción microvascular, fracción de eyección e índices de volumen telediastólico y telesistólico entre ambas estrategias en la resonancia magnética cardiaca realizada en la primera semana y en el sexto mes (p>0,2 en todos los casos). La tasa de eventos cardiacos adversos al año (muerte o reinfarto) fue del 6% en la estrategia farmacoinvasiva y del 7% en la angioplastia primaria (p=0,7). Conclusiones. La estrategia farmacoinvasiva es una alternativa ampliamente disponible y logísticamente atractiva con resultados similares a los de la angioplastia primaria en cuanto a afección del ventrículo izquierdo a corto y largo plazo valorado por resonancia magnética cardiaca (AU)

Introduction and objectives: Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. Methods: Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. Results: At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29 +/- 15 vs. 29 +/- 17%, P = .9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and endsystolic volume index (P > .2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P = .7). Conclusions: A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplast (AU)

One-week and 6-month cardiovascular magnetic resonance outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction.

INTRODUCTION AND OBJECTIVES: Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. METHODS: Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. RESULTS: At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29±15 vs. 29±17%, P=.9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index (P>.2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P=.7). CONCLUSIONS: A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.

Usefulness of pain presentation characteristics for predicting outcome in patients presenting to the hospital with chest pain of uncertain origin.

BACKGROUND: Decision making in chest pain of uncertain origin is challenging. OBJECTIVES: To evaluate the predictive value of simple characteristics of pain presentation in patients coming to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin. METHODS: 789 patients were studied. The following categorical pain characteristics were collected: effort related pain, pressing character, radiation, associated symptoms, and ≥ 2 episodes in 24 h. Additionally, a predefined semi-quantitative pain score including seven items (Geleijnse score) was completed. Risk factors and co-morbidities were also recorded. The primary and secondary endpoints were cardiac events at 30 days and at 1 year. RESULTS: After adjusting for risk factors and co-morbidites, the pain characteristics associated with the primary and secondary endpoints were effort related pain (HR=2.1, 95% CI 1.5 to 3.0, p=0.0001; HR=1.8, 95% CI 1.3 to 2.5, p=0.0003) and ≥ 2 episodes in 24 h (HR=2.4, 95% CI 1.7 to 3.5, p=0.0001; HR=2.3, 95% CI 1.7 to 3.2, p=0.0001). Both variables retained their predictive value in women, diabetics and elderly (>70 years) patients. The discriminatory capacity of the predictive models including these two pain characteristics for the primary and secondary endpoints (C-statistic 0.76 and 0.76) was better than using the complex semi-quantitative pain score (C-statistic 0.69 and 0.71). CONCLUSION: In patients presenting to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin, effort related pain and ≥ 2 episodes in 24 h are the main characteristics to be considered for decision making.