Infective Endocarditis in the Elderly: Challenges and Strategies.

The specific management of infective endocarditis (IE) in elderly patients is not specifically addressed in recent guidelines despite its increasing incidence and high mortality in this population. The term "elderly" corresponds to different ages in the literature, but it is defined by considerable comorbidity and heterogeneity. Cancer incidence, specifically colorectal cancer, is increased in older patients with IE and impacts its outcome. Diagnosis of IE in elderly patients is challenging due to the atypical presentation of the disease and the lower performance of imaging studies. Enterococcal etiology is more frequent than in younger patients. Antibiotic treatment should prioritize diminishing adverse effects and drug interactions while maintaining the best efficacy, as surgical treatment is less commonly performed in this population due to the high surgical risk. The global assessment of elderly patients with IE, with particular attention to frailty and geriatric profiles, should be performed by multidisciplinary teams to improve disease management in this population.

Prognostic value of NT-proBNP and CA125 across glomerular filtration rate categories in acute heart failure.

BACKGROUND: This study aimed to evaluate whether glomerular filtration rate (eGFR) during admission modifies the predictive value of plasma amino-terminal pro-brain natriuretic peptide (NT-proBNP) and carbohydrate antigen 125 (CA125) in patients hospitalized for acute heart failure (AHF). METHODS: We retrospectively evaluated 4595 patients consecutively discharged after admission for AHF at three tertiary-care hospitals from January 2008 through October 2019. To investigate the effect of kidney function on the association of NT-proBNP and CA125 with 1-year mortality (all-cause and cardiovascular mortality), we stratified patients according to four eGFR categories: <30 mL•min-1•1.73 m-2, 30-44 mL•min-1•1.73 m-2, 44-59 mL•min-1•1.73 m-2, and ≥60 mL•min-1•1.73 m-2. Biomarkers were assessed within the first 24 hours following admission. RESULTS: At 1-year follow-up, 748 of 4595 (16.3%) patients died after discharge (of all deaths, 575 [12.5%] were cardiovascular). After multivariate adjustment, both NT-proBNP and CA125 remained independently associated with a higher risk of death when modeled as main effects (P<0.001). However, we found a differential prognostic effect of NT-proBNP across eGFR categories for both endpoints (all-cause mortality, P-value for interaction=0.002; CV mortality, P-value for interaction=0.001). Whereas NT-proBNP was positively and linearly associated with mortality in the subset of patients with normal or mildly reduced eGFR, its predictive ability progressively decreased at the lower extreme of eGFR (<45 mL•min-1•1.73 m-2). In contrast, the association between CA125 and survival remained consistent across all eGFR categories (all-cause mortality, P-value for interaction=0.559; CV mortality, P-value for interaction=0.855). CONCLUSIONS: In patients with AHF and severely reduced eGFR, CA125 outperforms NT-proBNP in predicting 1-year mortality.

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.

Prognostic Value of Strain by Tissue Tracking Cardiac Magnetic Resonance After ST-Segment Elevation Myocardial Infarction.

OBJECTIVES: The aim of this study was to evaluate the prognostic value of strain as assessed by tissue tracking (TT) cardiac magnetic resonance (CMR) soon after ST-segment elevation myocardial infarction (STEMI). BACKGROUND: The prognostic value of myocardial strain as assessed post-STEMI by TT-CMR is unknown. METHODS: The authors studied the prognostic value of TT-CMR in 323 patients who underwent CMR 1 week post-STEMI. Global (average of peak segmental values [%]) and segmental (number of altered segments) longitudinal (LS), circumferential, and radial strain were assessed using TT-CMR. Global and segmental strain cutoff values were derived from 32 control patients. CMR-derived left ventricular ejection fraction, microvascular obstruction, and infarct size were determined. Results were validated in an external cohort of 190 STEMI patients. RESULTS: During a median follow-up of 1,085 days, 54 first major adverse cardiac events (MACE), which included 10 cardiac deaths, 25 readmissions for heart failure, and 19 readmissions for reinfarction were documented. MACE was associated with more severe abnormalities in all strain indexes (p < 0.001), although only global LS was an independent predictor (p < 0.001). The MACE rate was higher in patients with a global LS of ≥-11% (22% vs. 9%; p = 0.001). After adjustment for baseline and CMR variables, global LS (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.11 to 1.32; p < 0.001) was associated with MACE. In the external validation cohort, a global LS ≥-11% was seen in a higher proportion of patients with MACE (34% vs. 9%; p < 0.001). Global LS predicted MACE after adjustment for baseline and CMR variables (HR: 1.18; 95% CI: 1.04 to 1.33; p = 0.008). The addition of global LS to the multivariate models, including baseline and CMR variables, did not significantly improve the categorical net reclassification improvement index in either the study group (-0.015; p = 0.7) or in the external validation cohort (-0.019; p = 0.9). CONCLUSIONS: TT-CMR provided prognostic information soon after STEMI. However, it did not substantially improve risk reclassification beyond traditional CMR indexes.

Estrategias diuréticas en insuficiencia cardiaca aguda con disfunción renal: terapia convencional frente a guiada por el antígeno carbohidrato 125. Diseño de ensayo clínico / Diuretic strategies in acute heart failure and renal dysfunction: conventional vs carbohydrate antigen 125-guided strategy. Clinical trial design

Introducción y objetivos: El tratamiento óptimo de pacientes con insuficiencia cardiaca aguda (ICA) y síndrome cardiorrenal tipo 1 (SCR-1) no está bien definido. La hipoperfusión arterial y la congestión venosa tienen un papel fundamental en la fisiopatología del SCR-1. El antígeno carbohidrato 125 (CA125) ha emergido como marcador indirecto de sobrecarga de volumen en la ICA. El objetivo de este estudio es evaluar la utilidad del CA125 para el ajuste del tratamiento diurético de pacientes con SCR-1. Métodos: Ensayo clínico multicéntrico, abierto y paralelo, que incluye a pacientes con ICA y creatinina ≥ 1,4 mg/dl al ingreso, aleatorizados a: a) estrategia convencional: titulación basada en la evaluación clínica y bioquímica habitual, o b) estrategia basada en CA125: dosis altas de diuréticos si CA125 > 35 U/ml y bajas en caso contrario. El objetivo principal es el cambio en la función renal a las 24 y las 72 h tras el comienzo del tratamiento. Como objetivos secundarios: a) cambios clínicos y bioquímicos a las 24 y las 72 h, y b) cambios en la función renal y eventos clínicos mayores a 30 días. Resultados: Los resultados de este estudio aportarán datos relevantes sobre la utilidad del CA125 para guiar el tratamiento diurético en el SCR-1. Además, permitirá ampliar el conocimiento de la fisiopatología de esta compleja entidad clínica. Conclusiones: La hipótesis del presente estudio es que las concentraciones de CA125 aumentadas pueden identificar a una población de pacientes con SCR-1 para quienes una estrategia diurética más intensa puede ser beneficiosa. Por el contrario, las concentraciones bajas de esta glucoproteína seleccionarían a los pacientes para los que serían perjudiciales las dosis altas de diuréticos (AU)

Introduction and objectives: The optimal treatment of patients with acute heart failure (AHF) and cardiorenal syndrome type 1 (CRS-1) is far from being well-defined. Arterial hypoperfusion in concert with venous congestion plays a crucial role in the pathophysiology of CRS-I. Plasma carbohydrate antigen 125 (CA125) has emerged as a surrogate of fluid overload in AHF. The aim of this study was to evaluate the clinical usefulness of CA125 for tailoring the intensity of diuretic therapy in patients with CRS-1. Methods: Multicenter, open-label, parallel clinical trial, in which patients with AHF and serum creatinine ≥ 1.4 mg/dL on admission will be randomized to: a) standard diuretic strategy: titration-based on conventional clinical and biochemical evaluation, or b) diuretic strategy based on CA125: high dose if CA125 > 35 U/mL, and low doses otherwise. The main endpoint will be renal function changes at 24 and 72 hours after therapy initiation. Secondary endpoints will include: a) clinical and biochemical changes at 24 and 72 hours, and b) renal function changes and major clinical events at 30 days. Results: The results of this study will add important knowledge on the usefulness of CA125 for guiding diuretic treatment in CRS-1. In addition, it will pave the way toward a better knowledge of the pathophysiology of this challenging situation. Conclusions: We hypothesize that higher levels of CA125 will identify a patient population with CRS-1 who could benefit from the use of a more intense diuretic strategy. Conversely, low levels of this glycoprotein could select those patients who would be harmed by high diuretic doses (AU)

Length of stay and risk of very early readmission in acute heart failure.

INTRODUCTION AND OBJECTIVES: In patients admitted for acute heart failure (AHF), optimal length of stay (LOS) remains controversial. Longer hospitalizations are associated with worse prognosis, but little is known about short hospitalizations. The aim of this work was to evaluate the relationship between LOS and the risk of short-term readmission in patients discharged after a hospitalization for AHF. METHODS: We included 2110 consecutive patients. The independent associations between LOS and unplanned 10, 15 and 30-day readmissions were evaluated by Cox regression analysis adjusted for competing events. LOS was categorized as LOS1: ≤4days, LOS2: 5-7days, LOS3: 8-10days, and LOS4: >10days. RESULTS: The mean age was 73±11years and 52.6% exhibited left ventricle ejection fraction≥50%. The median (IQR) LOS was 7 (5-11) days. At 10, 15 and 30-day follow-up, 130 (6.2%), 181 (8.6%), and 282 (13.4%) unplanned readmissions were registered. Rates of 10 and 15-day readmission among LOS categories showed a J-shaped pattern with lower rates for those in LOS2 and higher at the both extremes (p=0.001). At 30-day, only longer stays showed higher rates of readmission (p=0.002). In the multivariate analysis, the U-shaped curve remained significant for 10 and 15-day readmissions (p<0.05). Compared to LOS2, LOS1, LOS3 and LOS4 showed about two-fold increased risk. At 30-day only longer stays showed a borderline and modest increase of risk. CONCLUSIONS: Shorter and longer stays are associated with the risk of very early readmissions after an episode of AHF. These associations are marginal for 30-day readmissions.

Diuretic Strategies in Acute Heart Failure and Renal Dysfunction: Conventional vs Carbohydrate Antigen 125-guided Strategy. Clinical Trial Design.

INTRODUCTION AND OBJECTIVES: The optimal treatment of patients with acute heart failure (AHF) and cardiorenal syndrome type 1 (CRS-1) is far from being well-defined. Arterial hypoperfusion in concert with venous congestion plays a crucial role in the pathophysiology of CRS-I. Plasma carbohydrate antigen 125 (CA125) has emerged as a surrogate of fluid overload in AHF. The aim of this study was to evaluate the clinical usefulness of CA125 for tailoring the intensity of diuretic therapy in patients with CRS-1. METHODS: Multicenter, open-label, parallel clinical trial, in which patients with AHF and serum creatinine ≥ 1.4mg/dL on admission will be randomized to: a) standard diuretic strategy: titration-based on conventional clinical and biochemical evaluation, or b) diuretic strategy based on CA125: high dose if CA125 > 35 U/mL, and low doses otherwise. The main endpoint will be renal function changes at 24 and 72hours after therapy initiation. Secondary endpoints will include: a) clinical and biochemical changes at 24 and 72hours, and b) renal function changes and major clinical events at 30 days. RESULTS: The results of this study will add important knowledge on the usefulness of CA125 for guiding diuretic treatment in CRS-1. In addition, it will pave the way toward a better knowledge of the pathophysiology of this challenging situation. CONCLUSIONS: We hypothesize that higher levels of CA125 will identify a patient population with CRS-1 who could benefit from the use of a more intense diuretic strategy. Conversely, low levels of this glycoprotein could select those patients who would be harmed by high diuretic doses.

Incidence, Outcomes, and Predictors of Ventricular Thrombus after Reperfused ST-Segment-Elevation Myocardial Infarction by Using Sequential Cardiac MR Imaging.

Purpose To characterize the incidence, outcomes, and predictors of left ventricular (LV) thrombus by using sequential cardiac magnetic resonance (MR) imaging after ST-segment-elevation myocardial infarction (STEMI). Materials and Methods Written informed consent was obtained from all patients, and the study protocol was approved by the committee on human research. In a cohort of 772 patients with STEMI, 392 (mean age, 58 years; range, 24-89 years) were retrospectively selected who were studied with cardiac MR imaging at 1 week and 6 months. Cardiac MR imaging guided the initiation and withdrawal of anticoagulants. Patients with LV thrombus at 6 months were restudied at 1 year. For predicting the occurrence of LV thrombus, a multiple regression model was applied. Results LV thrombus was detected in 27 of 392 patients (7%): 18 (5%) at 1 week and nine (2%) at 6 months. LV thrombus resolved in 22 of 25 patients (88%) restudied within the first year. During a mean follow-up of 181 weeks ± 168, patients with LV thrombus displayed a very low rate of stroke (0%), peripheral embolism (0%), and severe hemorrhage (n = 1, 3.7%). LV ejection fraction (LVEF) less than 50% (P < .001) and anterior infarction (P = .008) independently helped predict LV thrombus. The incidence of LV thrombus was as follows: (a) nonanterior infarction, LVEF 50% or greater (one of 135, 1%); (b) nonanterior infarction, LVEF less than 50% (one of 50, 2%); (c) anterior infarction, LVEF 50% or greater (two of 92, 2%); and (d) anterior infarction, LVEF less than 50% (23 of 115, 20%) (P < .001 for the trend). Conclusion Cardiac MR imaging contributes information for the diagnosis and therapy of LV thrombus after STEMI. Patients with simultaneous anterior infarction and LVEF less than 50% are at highest risk. © RSNA, 2017 Online supplemental material is available for this article.

Cardiac Involvement in Von Hippel-Lindau Disease.

OBJECTIVE: The aim of this case report was to highlight the importance of ruling out pheochromocytoma in a patient with Von Hippel-Lindau disease (VHL) and cardiovascular manifestations. CLINICAL PRESENTATION AND INTERVENTION: A 22-year-old woman with type IIb VHL presented with signs and symptoms of acute decompensated heart failure. Transthoracic echocardiography showed a dilated left ventricle with severely depressed ejection fraction, confirmed by MRI. Urinary catecholamine and metanephrine tests had elevated levels and an abdominal MRI showed the presence of two cystic masses at the left hypochondrium. Surgical resection of both masses was performed, confirming the diagnosis of pheochromocytoma and clear cell renal carcinoma on histology. Six-month echocardiography showed a left ventricle with normal diameters and preserved ejection fraction. Genetic analysis revealed a germline mutation (exon 3 deletion of VHL). As there was no family history of VHL, it was determined to be a de novo mutation. CONCLUSION: This case report showed an atypical manifestation in a patient with VHL and underlines the importance of screening for pheochromocytoma in such patients.

Identification of very low risk chest pain using clinical data in the emergency department.

BACKGROUND: Evaluation of chest pain of uncertain origin in the emergency department is a challenge. Chest pain units, involving non-invasive stress testing, have logistic constraints. Our aim was to identify very low risk patients for early discharge using clinical data. METHODS: A total of 772 patients were studied. Ischemia in the electrocardiogram, troponin elevation or history of ischemic heart disease, were exclusion criteria. The primary end point was 30 day cardiac events (death, myocardial infarction or revascularization). The secondary end point was 1 year major events (death or myocardial infarction). RESULTS: The primary and secondary end point rates were 123 (18%) and 31 (4%). Predictive variables for the primary end point were typical chest pain (OR=1.8, p=0.007), ≥ 2 pain episodes in last 24h (OR=3.4, p=0.0001), age ≥ 55 years (OR=1.8, p=0.03), male (OR=2.2, p=0.001), diabetes (OR=1.8, p=0.01) and family history of ischemic heart disease (OR=2.0, p=0.02). A very low risk category could be distinguished (<2 predictors, n=114) that showed only 3 (2.6%) events at 30 days (all 3 revascularizations), compared with 120 (18%) in the remaining patients (p=0.0001). The very low risk criteria had 97% negative predictive for 30 day cardiac events. No very low risk patient presented major events at 1 year compared with 31 (4.7%) in the remaining patients (p=0.009). CONCLUSION: In patients presenting to the emergency department with chest pain of uncertain origin and without prior ischemic heart disease, very low risk patients can be identified using clinical data. These patients could be quickly discharged without further non-invasive stress testing.

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.

Prevalence and prognostic implications of active cytomegalovirus infection in patients with acute heart failure.

AHF (acute heart failure) causes significant morbidity and mortality. Recent studies have postulated that the expression of inflammatory mediators, such as cytokines and chemokines, plays an important role in the development and progression of heart failure. A pro-inflammatory state has been postulated as a key factor in triggering CMV (cytomegalovirus) reactivation. Therefore we sought to determine the prevalence of active CMV infection in immunocompetent patients admitted for AHF and to quantify the association with the risk of the combined end point of death or AHF readmission. A total of 132 consecutive patients admitted for AHF were enrolled in the present study. Plasma CMV DNAaemia was assessed by qRT-PCR (quantitative real-time PCR), and cytokine measurements in plasma were performed by ELISA. Clinical data were evaluated by personnel blinded to CMV results. The independent association between active CMV infection and the end point was determined by Cox regression analysis. During a median follow-up of 120 [IQR (interquartile range), 60-240] days, 23 (17.4%) deaths, 34 (24.2%) readmissions for AHF and 45 (34.1%) deaths/readmissions for AHF were identified. Plasma CMV DNAaemia occurred in 11 (8.3%) patients, albeit at a low level (<100 copies/ml). The cumulative rate of the composite end point was higher in patients with CMV DNAaemia (81.8 compared with 29.8%; P<0.001). After adjusting for established risk factors, the occurrence of CMV DNAaemia was strongly associated with the clinical end point [hazard ratio = 4.39 (95% confidence interval, 2.02-9.52); P<0.001]. In conclusion, active CMV infection occurs, although uncommonly, in patients with AHF, and may be a marker of disease severity.

Non-ST-elevation acute myocardial infarction with normal coronary arteries: predictors and prognosis.

INTRODUCTION AND OBJECTIVES: Occasionally, coronary arteries without significant stenosis are observed during invasive treatment of acute non-ST-elevation myocardial infarction (NSTEMI). The aim was to investigate predictive factors and prognosis in these patients. METHODS: The study involved 504 patients admitted for NSTEMI who underwent cardiac catheterization. The primary end-point was the observation of coronary arteries without significant stenosis, and the secondary end-point was death or myocardial infarction within a median of 3 years. In evaluating the secondary end-point, a control group of 160 patients with a normal troponin level and no significant coronary artery stenosis who were admitted for chest pain during the same period was included. RESULTS: Overall, 64 patients (13%) had coronary arteries without significant lesions. The predictors were: female sex (odds ratio [OR]=6.6; P=.0001), age <55 years (OR=3.0; P=.001), and the absence of diabetes (OR=2.4, P=.02), previous antiplatelet treatment (OR=3.9, P=.007) or ST-segment depression (OR=2.4, P=.008). The composite variable of female sex plus at least two additional predictive factors had a specificity of 85% and a sensitivity of 53% for coronary angiography showing no significant stenosis. The absence of coronary artery stenosis decreased the probability of death or myocardial infarction during follow-up (hazard ratio=0.3, 95% confidence interval, 0.2-0.9; P=.03). Among all patients without significant stenosis (n=224), there was no difference in the event rate between those with elevated and normal troponin levels. CONCLUSIONS: In NSTEMI, female sex, age <55 years and the absence of diabetes, previous antiplatelet treatment or ST-segment depression were all associated with coronary angiography showing no significant stenosis. The long-term prognosis in these patients was good.

Infarto de miocardio sin elevación del ST con coronarias normales: predictores y pronóstico / Non-ST-elevation acute myocardial infarction with normal coronary arteries: predictors and prognosis

Introducción y objetivos. El manejo invasivo del infarto agudo de miocardio sin elevación del ST (IAMSEST) detecta en ocasiones arterias coronarias sin estenosis significativas. Nuestro objetivo fue evaluar los factores asociados y el pronóstico de esta población. Métodos. Estudiamos a 504 pacientes ingresados por IAMSEST y sometidos a cateterismo cardiaco. El objetivo primario fue el hallazgo de coronarias sin estenosis significativas y el secundario, la mortalidad o el infarto a una mediana de 3 años. Para evaluar el objetivo secundario, se utilizó un grupo control de 160 pacientes ingresados por dolor torácico durante el mismo periodo con troponina normal y coronarias sin estenosis significativas. Resultados. Encontramos coronarias sin lesiones significativas en 64 (13%) pacientes. Los predictores fueron: ser mujer (odds ratio [OR] = 6,6; p = 0,0001), edad < 55 años (OR = 3,0; p = 0,001) y ausencia de diabetes (OR = 2,4; p = 0,02), tratamiento antiagregante previo (OR = 3,9; p = 0,007) o descenso del ST (OR = 2,4; p = 0,008). La variable ser mujer con al menos dos variables adicionales identificó una coronariografía sin estenosis significativas con especificidad del 85% y sensibilidad del 53%. La ausencia de estenosis coronarias significativas disminuyó la probabilidad de muerte o infarto durante el seguimiento (hazard ratio = 0,3; intervalo de confianza del 95%, 0,2-0,9; p = 0,03). En el total de pacientes sin estenosis coronarias significativas (n = 224), no hubo diferencias en la tasa de sucesos entre los pacientes con troponina elevada y normal. Conclusiones. El sexo femenino, la edad < 55 años y la ausencia de diabetes, tratamiento antiagregante previo o descenso del ST se asociaron a una coronariografía sin estenosis significativas en el IAMSEST. El pronóstico a largo plazo de esta población fue bueno (AU)

Introduction and objectives. Occasionally, coronary arteries without significant stenosis are observed during invasive treatment of acute non-ST-elevation myocardial infarction (NSTEMI). The aim was to investigate predictive factors and prognosis in these patients. Methods. The study involved 504 patients admitted for NSTEMI who underwent cardiac catheterization. The primary end-point was the observation of coronary arteries without significant stenosis, and the secondary end-point was death or myocardial infarction within a median of 3 years. In evaluating the secondary end-point, a control group of 160 patients with a normal troponin level and no significant coronary artery stenosis who were admitted for chest pain during the same period was included. Results. Overall, 64 patients (13%) had coronary arteries without significant lesions. The predictors were: female sex (odds ratio [OR]=6.6; P=.0001), age <55 years or p=".03)." and the absence of diabetes previous antiplatelet treatment st-segment depression composite variable female sex plus at least two additional predictive factors had a specificity 85 sensitivity 53 for coronary angiography showing no significant stenosis artery decreased probability death myocardial infarction during follow-up hazard ratio="0.3," 95 confidence interval 0 2-0 9 among all patients without n="224)," there was difference in event rate between those with elevated normal troponin levels conclusions nstemi age <55 years and the absence of diabetes previous antiplatelet treatment or st-segment depression were all associated with coronary angiography showing no significant stenosis long-term prognosis in these patients was good (AU)

Relationship between low lymphocyte count and major cardiac events in patients with acute chest pain, a non-diagnostic electrocardiogram and normal troponin levels.

OBJECTIVE: Risk stratification of patients with acute chest pain, non-diagnostic electrocardiogram and normal troponin (ACPneg) remains a challenge, partly because no standardized set of biomarkers with prognostic ability has been identified in this population. Lymphopenia has been associated with atherosclerosis progression and adverse outcomes in cardiovascular diseases; although its prognostic value in ACPneg is unknown. We sought to determine the relationship between the lymphocyte count obtained in the Emergency Department (ED) and the risk of the long-term all-cause mortality or myocardial infarction (MI) in patients with ACPneg. METHODS: We analyzed 1030 consecutive patients admitted with ACPneg in our institution. Lymphocyte count was determined in the ED as a part of a routine diagnostic workup to rule out an acute coronary syndrome. Patients with inflammatory, infectious diseases, or active malignancy were excluded (final sample=975). The independent association between lymphocyte count and the composite endpoint (death/MI) was assessed by survival analysis for competing risk events (revascularization procedures). RESULTS: During a median follow-up of 36 months, 139 (14.3%) patients achieved the combined endpoint, with rates increasing monotonically across lymphocyte quartiles (6.2%, 10%, 20.6% and 24.1% for Q4, Q3, Q2 and Q1 (p<0.001), respectively). In a multivariable analysis, patients in lymphocytes' Q1 and Q2 as compared with those in Q4 had an increased risk for the combined endpoint: HR=2.45 (CI 95% 1.25-4.79, p=0.008) and HR=2.56 (CI 95% 1.30-5.07, p=0.007), respectively. CONCLUSION: In patients with ACPneg, low lymphocytes count was associated with an increased risk for developing the combined endpoint of death or MI.

Evolution of 5 cardiovascular magnetic resonance-derived viability indexes after reperfused myocardial infarction.

BACKGROUND: The objective of this study was to evaluate the simultaneous evolution of 5 cardiovascular magnetic resonance-derived myocardial viability indexes. METHODS: We studied 72 patients with a first ST-elevation myocardial infarction and sustained TIMI 3 flow. In the first week and in the sixth month of the study, using cardiovascular magnetic resonance imaging, we determined wall thickening (WT) and the following viability indexes: wall thickness, WT with low-dose dobutamine, microvascular perfusion in first-pass imaging, microvascular obstruction in late-enhancement imaging, and transmural extent of necrosis. RESULTS: In 250 dysfunctional segments, the evolution outcomes for the viability indexes were as follows: (1) wall thickness thinned (8.6 +/- 2.9 versus 7.7 +/- 3 mm, P < .001), (2) WT with low-dose dobutamine improved (1.5 +/- 1.9 versus 2.6 +/- 3 mm, P < .001), (3) the number of segments showing abnormal microvascular perfusion in first-pass imaging decreased (22% versus 7%, P < .001), (4) the number of segments showing microvascular obstruction in late-enhancement imaging decreased (14% versus 2%, P < .001), and (5) the transmural extent of necrosis remained stable throughout follow-up (56% +/- 40% versus 54% +/- 39%, P = .3). CONCLUSIONS: After reperfused myocardial infarction, dynamic changes in wall thickness, contractile reserve, microvascular perfusion, and microvascular obstruction take place. These changes may affect their accuracy as viability indexes early after myocardial infarction. The transmural extent of necrosis does not vary, however.

[Prognostic value of serum creatinine in non-ST-elevation acute coronary syndrome]. / Valor pronóstico de la creatinina sérica en el síndrome coronario agudo sin elevación del segmento ST.

INTRODUCTION AND OBJECTIVES: Cardiovascular disease is the main cause of death in patients with kidney failure. Moreover, the presence of impaired renal function is an important prognostic factor in patients with heart disease, and is a determinant of outcome during follow-up. The main aim was to investigate the relationship between kidney failure at admission and one-year mortality in patients with non-ST-elevation acute coronary syndrome. PATIENTS AND METHOD: We studied 1029 consecutive patients admitted to our institution. The serum creatinine level and glomerular filtration rate were determined at admission, and classical risk factors and biochemical markers were assessed. The primary endpoint was all-cause mortality at one year. RESULTS: Patients who died were older, more frequently had a history of diabetes or coronary artery disease, were more likely to have heart failure at admission, had higher troponin-I, myoglobin and creatinine levels, and were less likely to have dyslipidemia or to be a smoker. Multivariate analysis showed that the independent predictors of all-cause mortality at one year were age, diabetes, troponin-I level, Killip class > 1, male gender, creatinine level, and glomerular filtration rate. There was a linear correlation between increased risk and creatinine level. CONCLUSIONS: Creatinine level at admission is one of the most important covariates in early prognostic stratification in these patients. A high serum creatinine level (or a low glomerular filtration rate) increases the probability of death due to all causes. The serum creatinine level is, moreover, an inexpensive, easy-to-use, and widely available prognostic marker.

Valor pronóstico de la creatinina sérica en el síndrome coronario agudo sin elevación del segmento ST / Prognostic value of serum creatinine in non-ST-elevation acute coronary syndrome

Introducción y objetivos. Las enfermedades cardiovasculares son la principal causa de muerte en los pacientes con insuficiencia renal. La presencia de fallo renal es un factor pronóstico muy importante en los pacientes cardiópatas, y es determinante en el seguimiento. El objetivo es determinar la asociación entre la presencia de insuficiencia renal en el momento del ingreso y la mortalidad a 1 año en los pacientes con síndrome coronario agudo sin elevación del segmento ST. Pacientes y método. Estudiamos a 1.029 pacientes consecutivos, en los que se determinaron la creatinina y el filtrado glomerular en el momento del ingreso, junto con los factores de riesgo clásicos y los marcadores bioquímicos. El criterio de evaluación principal fue la muerte por todas las causas a 1 año. Resultados. Los pacientes fallecidos eran mayores, con más antecedentes de diabetes y cardiopatía isquémica, y con un mayor porcentaje de insuficiencia cardiaca en el momento del ingreso, junto con unas concentraciones más altas de troponina I, mioglobina y creatinina, y un menor porcentaje de dislipémicos y fumadores. En el análisis multivariable, los predictores independientes de muerte a 1 año fueron: edad, diabetes, troponina, clase Killip > 1, sexo masculino, creatinina y filtrado glomerular. El incremento de riesgo con respecto a las concentraciones de creatinina fue lineal. Conclusiones. La determinación de la creatinina en el momento del ingreso es una de las variables importantes en la estratificación pronóstica inicial de estos pacientes. Las concentraciones de creatinina más elevadas (o un filtrado glomerular menor) aumentan la probabilidad de muerte por todas las causas. Se trata, por tanto, de un marcador de obtención inmediata, fácil y disponible en todos los centros

Introduction and objectives. Cardiovascular disease is the main cause of death in patients with kidney failure. Moreover, the presence of impaired renal function is an important prognostic factor in patients with heart disease, and is a determinant of outcome during follow-up. The main aim was to investigate the relationship between kidney failure at admission and one-year mortality in patients with non-ST-elevation acute coronary syndrome. Patients and method. We studied 1029 consecutive patients admitted to our institution. The serum creatinine level and glomerular filtration rate were determined at admission, and classical risk factors and biochemical markers were assessed. The primary endpoint was all-cause mortality at one year. Results. Patients who died were older, more frequently had a history of diabetes or coronary artery disease, were more likely to have heart failure at admission, had higher troponin-I, myoglobin and creatinine levels, and were less likely to have dyslipidemia or to be a smoker. Multivariate analysis showed that the independent predictors of all-cause mortality at one year were age, diabetes, troponin-I level, Killip class > 1, male gender, creatinine level, and glomerular filtration rate. There was a linear correlation between increased risk and creatinine level. Conclusions. Creatinine level at admission is one of the most important covariates in early prognostic stratification in these patients. A high serum creatinine level (or a low glomerular filtration rate) increases the probability of death due to all causes. The serum creatinine level is, moreover, an inexpensive, easy-to-use, and widely available prognostic marker

Prognostic effect of renal dysfunction after ST-segment elevation myocardial infarction with and without heart failure.

PURPOSE: The present study was designed to assess, 1) the independent prognostic effect of renal dysfunction on all-cause mortality in the setting of acute myocardial infarction with ST-segment elevation (STEMI), and 2) to determine if such effect varies based upon the presence of heart failure (HF) on admission. METHODS: 549 consecutive patients admitted with the diagnosis of STEMI were prospectively recruited in a teaching hospital in Spain. Serum creatinine (sCr) and glomerular filtration rate (GFR) were obtained on admission, together with other relevant information used for risk stratification. The independent effect of sCr and GFR on long-term mortality was determined by Cox regression analysis. Main outcome was all-cause mortality, with a median follow-up of 1 year. RESULTS: In a multivariate analysis the degree of renal impairment was a strong predictor of mortality in patients without clinical evidence of HF at admission (HR=1.15; 95% CI 1.10 to 1.19 and HR=1.58; 95% CI 1.30 to 1.81) for sCr (per 0.1 mg/dl) and GFR (per decreasing 10 ml/min/1.73 m2), respectively. In the group with HF, the effect was less pronounced (HR=1.03; 95% CI 1.01 to 1.04 and HR=1.17; 95% CI 1.02 to 1.37) for sCr and GFR, respectively. CONCLUSIONS: In the setting of STEMI, renal dysfunction estimates showed a differential prognostic effect depending on HF status, with a greater impact seen in patients without clinical evidence of HF.