Cystatin C-based CKD-EPI equations and N-terminal pro-B-type natriuretic peptide for predicting outcomes in acutely decompensated heart failure.

BACKGROUND: In patients with acute decompensated heart failure (ADHF), both natriuretic peptides and renal impairment predict adverse outcomes. Our aim was to evaluate the complementary prognosis role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and the newly developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on cystatin C (CysC) for glomerular filtration rate (GFR) estimation in ADHF patients. HYPOTHESIS: Renal impairment assessed by CysC-based CKD-EPI equations and natriuretic peptides have complementary prognostic value in ADHF patients. METHODS: The study included 613 consecutive patients presenting with ADHF. At admission, plasma levels of NT-proBNP and CysC were determined. The GFR was estimated using CysC-based CKD-EPI equations. The primary endpoint was death from any cause and heart failure readmission. RESULTS: During the median follow-up of 365 days (interquartile range, 227-441 days), 323 patients (0.65 %patient-year) died or were readmitted for heart failure. After multivariate adjustment, estimated GFR <60 mL/min/1.73 m(2) and NT-proBNP >3251 pg/mL were independent predictors of adverse outcomes (P < 0.01). The combination of GFR <60 mL/min/1.73 m(2) and NT-proBNP >3251 pg/mL was associated with the highest risk of adverse outcomes. Furthermore, reclassification analyses demonstrated that use of both NT-proBNP and CysC-based CKD-EPI equations resulted in improving the accuracy for adverse outcomes prediction. CONCLUSIONS: In patients with ADHF, the combination of NT-proBNP with estimated GFR using CysC-based CKD-EPI equations better predicts outcomes than either parameter alone and adds valuable complementary prognosis information to other established risk factors.

Comparison of risk prediction with the CKD-EPI and MDRD equations in acute decompensated heart failure.

BACKGROUND: Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations estimate glomerular filtration rate (eGFR) more accurately than the Modification of Diet in Renal Disease (MDRD) equation. The aim of this study was to evaluate whether CKD-EPI equations based on serum creatinine and/or cystatin C (CysC) predict risk for adverse outcomes more accurately than the MDRD equation in a hospitalized cohort of patients with acute decompensated heart failure (ADHF). METHODS AND RESULTS: A total of 526 subjects with ADHF were studied. Blood was collected within 48 hours from admission. eGFR was calculated with the use of MDRD and CKD-EPI equations. The occurrences of mortality and heart failure (HF) hospitalization were recorded. Over the study period (median 365 days [interquartile range 238-370]), 305 patients (58%) died or were rehospitalized for HF. Areas under the receiver operator characteristic curves for CKD-EPI CysC and CKD-EPI creatinine-CysC equations were significantly higher than that for the MDRD equation, especially in patients with >60 mL min(-1) 1.73 m(-2). After multivariate adjustment, all eGFR equations were independent predictors of adverse outcomes (P < .001). However, only CKD-EPI CysC and CKD-EPI creatinine-CysC equations were associated with significant improvement in reclassification analyses (net reclassification improvements 10.8% and 12.5%, respectively). CONCLUSIONS: In patients with ADHF, CysC-based CKD-EPI equations were superior to the MDRD equation for predicting mortality and/or HF hospitalization especially in patients with >60 mL min(-1) 1.73 m(-2), and both CKD-EPI equations improved clinical risk stratification.

Propeptide of procollagen type I (PIP) and outcomes in decompensated heart failure.

BACKGROUND: Changes in extracellular matrix are recognized as a contributing factor in the cardiac remodeling process. Several studies have addressed the value of turnover markers of collagen as predictors of death or new heart failure episodes. The aim of the present study was to evaluate the relationship between peripheral serum concentration of propeptide of procollagen type I (PIP) and outcomes in patients with decompensated heart failure. METHODS: A total of 111 patients admitted to our Unit between September 2000 and May 2003 for decompensated heart failure were analyzed. Death from any cause or due to heart failure and readmission were considered primary endpoints. RESULTS: The mean PIP concentration was 80.84+/-36.40 ng/mL. The PIP serum level was significantly higher among those patients who suffered some endpoint during follow-up (88.12+/-37.31 ng/mL vs 73.13+/-34.06 ng/mL; p=0.029). Twenty-five (22.52%) of the 111 patients died during the 21 months of follow-up, and 54 (48.6%) were readmitted with new bouts of heart failure. Using Cox proportional hazards regression analyses, serum PIP levels, systolic dysfunction, and diabetes mellitus were identified as independent predictors of death. Serum PIP levels, age, and sex were independent predictors of new heart failure episodes and readmission. CONCLUSION: A single serum measurement of PIP seems to have prognostic value in patients with decompensated heart failure. Accordingly, patients with higher values of PIP at decompensation are at a higher risk of death or readmission during follow-up.

Actualización sobre el tratamiento quirúrgico de la estenosis aórtica asintomática / Update on surgical treatment of asymptomatic aortic stenosis

Aortic stenosis is becoming one of the most common diagnoses in cardiology in Western countries. A high percentage of patients with severe aortic stenosis remains asymptomatic, and management is not clearly established. In this article, we review the natural history of such patients and those factors with prognostic meaning identified in previous studies. Among them, positive exercise test, moderate to severe calcification in aortic valve, peak jet velocity > 4 m/s, left ventricular hypertrophy, left ventricular dysfunction and high values of natriuretic peptides (BNP) have been described as markers of poor prognosis in asymptomatic patients. These tests predict symptom-free survival and cardiovascular death. Sudden death is a fatal complication of aortic stenosis and congenital aortic stenosis is a cause of sudden death in young athletes. Its incidence is estimated in, approximately, 0.12-1% per year. Due to its low incidence, there are not studies for identifying patients at risk in this particular subset of patients. Medical and surgical treatment in asymptomatic patients remains controversial. Because degenerative stenosis has been described as "atheroscleroticlike" process, statins had been proposed to halt its progression, although its usefulness is not clearly established. In this article we review current practice guidelines for surgical treatment in asymptomatic patients with severe aortic stenosis

La estenosis aórtica es una de las enfermedades cardíacas más frecuentes en los países occidentales. Un elevado porcentaje de pacientes que presentan estenosis grave permanecen asintomáticos. Sin embargo, la valoración de los pacientes asintomáticos no ha sido bien establecida. En este artículo revisamos la evolución natural de estos pacientes y los estudios que evaluaron diferentes factores de riesgo en su evolución. Una ergometría positiva, calcificaciones valvulares, pico flujo aórtico > 4 m/s, hipertrofia del ventrículo izquierdo, disfunción del ventrículo izquierdo y valores elevados de péptidos natriuréticos (BNP) han sido descritos como marcadores de mal pronóstico en pacientes asintomáticos. Estas pruebas predicen supervivencia libre de síntomas y muerte por causa cardiovascular. La muerte súbita es una complicación fatal de la estenosis aórtica y la estenosis aórtica congénita es causa de muerte súbita en deportistas jóvenes. Su incidencia se estima en 0.12% a 1% por año. Debido a su baja incidencia no existen estudios que permitan identificar factores de riesgo en estos pacientes. El tratamiento médico y quirúrgico en pacientes asintomáticos es controvertido. Debido a la relación de la estenosis degenerativa con la aterosclerosis, se propuso el tratamiento con estatinas, si bien en estos momentos su indicación es dudosa. Revisamos las guías de practica clínica para el tratamiento quirúrgico de pacientes asintomáticos con estenosis grave

[Cardiac injury after indirect lightning strike]. / Alteraciones cardíacas en la fulguración por impacto indirecto.

Lightning strike is one of the most frequent causes of death due to natural phenomena. In such cases, cardiac injury is the main cause of death, with type of lesion varying by type of impact. We report the case of a 29-year-old woman who was struck indirectly by lightning. Upon hospital admission, she showed both the echocardiographic disturbances characteristic of direct impact and electrocardiographic disturbances. Both types of change resolved spontaneously. After describing the case, we briefly review the literature on echo and electrocardiographic disturbances after lightning strike.