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1.
Int J Cardiol ; 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34600979

RESUMO

INTRODUCTION: We investigated the associations of high-sensitivity cardiac Troponin T (hs-cTnT) and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels with risk of developing clinical peripheral artery disease (PAD) or a low ankle-brachial index (ABI). METHODS: Hs-cTnT and NT-proBNP were measured in 6692 and 5458 participants respectively without baseline PAD between 2000 and 2002 in the Multi-ethnic Study of Atherosclerosis. A significant number also had repeat biomarker measurement between 2004 and 2005. Incident clinical PAD was ascertained through 2017. Incident low ABI, defined as ABI <0.9 and decline of ≥0.15 from baseline, was assessed among 5920 eligible individuals who had an ABI >0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Multivariable Cox proportional hazards and logistic regression modeling were used to determine the association of these biomarkers with clinical PAD and low ABI, respectively. RESULTS: Overall, 121 clinical PAD and 118 low ABI events occurred. Adjusting for demographic and clinical characteristics, each log unit increment in hs-cTnT and NT-proBNP was associated with a 30% (adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI): 1.1, 1.6) and 50% (HR) 1.5, 95% CI: 1.2, 1.8) higher risk of clinical PAD respectively. No significant associations were observed for incident low ABI. Change in these biomarkers was not associated with either of the PAD outcomes. CONCLUSIONS: NT-proBNP and hs-cTnT are independently associated with the development of clinical PAD. Further study should determine whether these biomarkers can help to better identify those at higher risk for PAD.

2.
J Card Fail ; 27(10): 1073-1081, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34625127

RESUMO

BACKGROUND: Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown. METHODS AND RESULTS: We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017-2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th-75th: 5-11) vs acute-on-chronic HF-CS (6; 25th-75th: 4-9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05-1.75, P = 0.02). CONCLUSIONS: Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.

4.
Am J Kidney Dis ; 2021 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-34293394

RESUMO

RATIONALE & OBJECTIVE: The utility of conventional upper reference limits (URL) for N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) in chronic kidney disease (CKD) remains debated. We analyzed the distribution of hsTnT and NT-proBNP in people with CKD in ambulatory settings to examine the diagnostic value of conventional URL in this population. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: We studied participants of the Chronic Renal Insufficiency Cohort (CRIC) with CKD and no self-reported history of cardiovascular disease. EXPOSURE: Estimated glomerular filtration rate (eGFR). OUTCOME: NT-proBNP and hsTnT at baseline. ANALYTICAL APPROACH: We described the proportion of participants above the conventional URL for NT-proBNP (125pg/mL) and hsTnT (14ng/L) overall and by eGFR. We then estimated 99th percentile URL for NT-proBNP and hsTnT. Using quantile regression of the 99th percentile, we modeled the association of eGFR with NT-proBNP and hsTnT. RESULTS: Among 2,312 CKD participants, 40% and 43% had levels of NT-proBNP and hsTnT above the conventional URL, respectively. In those with eGFR <30mL/min/1.73m2, 71% and 68% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, respectively. Among all CKD participants, the 99th percentile for NT-proBNP was 3,592 (95% CI, 2,470-4,849) pg/mL and for hsTnT it was 126 (95% CI, 100-144) ng/L. Each 15mL/min/1.73m2 decrement in eGFR was associated with a ~40% higher threshold for the 99th percentile of NT-proBNP (1.43 [95% CI, 1.21-1.69]) and hsTnT (1.45 [95% CI, 1.31-1.60]). LIMITATIONS: Study included ambulatory patients, and we could not test the accuracy of the URL of NT-proBNP and hsTnT in the acute care setting. CONCLUSIONS: In this ambulatory CKD population with no self-reported history of cardiovascular disease, a range of 40%-88% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, depending on eGFR strata. Developing eGFR-specific thresholds for these commonly used cardiac biomarkers in the setting of CKD may improve their utility for evaluation of suspected heart failure and myocardial infarction.

5.
PLoS One ; 16(7): e0254635, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34264974

RESUMO

BACKGROUND: Statins have anti-inflammatory and immunomodulatory effects that may reduce the severity of coronavirus disease 2019 (COVID-19), in which organ dysfunction is mediated by severe inflammation. Large studies with diverse populations evaluating statin use and outcomes in COVID-19 are lacking. METHODS AND RESULTS: We used data from 10,541 patients hospitalized with COVID-19 through September 2020 at 104 US hospitals enrolled in the American Heart Association's COVID-19 Cardiovascular Disease (CVD) Registry to evaluate the associations between statin use and outcomes. Prior to admission, 42% of subjects (n = 4,449) used statins (7% on statins alone, 35% on statins plus anti-hypertensives). Death (or discharge to hospice) occurred in 2,212 subjects (21%). Outpatient use of statins, either alone or with anti-hypertensives, was associated with a reduced risk of death (adjusted odds ratio [aOR] 0.59, 95% CI 0.50-0.69), adjusting for demographic characteristics, insurance status, hospital site, and concurrent medications by logistic regression. In propensity-matched analyses, use of statins and/or anti-hypertensives was associated with a reduced risk of death among those with a history of CVD and/or hypertension (aOR 0.68, 95% CI 0.58-0.81). An observed 16% reduction in odds of death among those without CVD and/or hypertension was not statistically significant. CONCLUSIONS: Patients taking statins prior to hospitalization for COVID-19 had substantially lower odds of death, primarily among individuals with a history of CVD and/or hypertension. These observations support the continuation and aggressive initiation of statin and anti-hypertensive therapies among patients at risk for COVID-19, if these treatments are indicated based upon underlying medical conditions.


Assuntos
Anti-Hipertensivos/administração & dosagem , COVID-19/epidemiologia , Doenças Cardiovasculares/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Sistema de Registros/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , American Heart Association , Anti-Hipertensivos/uso terapêutico , COVID-19/mortalidade , Doenças Cardiovasculares/tratamento farmacológico , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Grupos Populacionais/estatística & dados numéricos , Estados Unidos
6.
Am J Med ; 134(4): e302, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33888228
7.
Int J Cardiol Heart Vasc ; : 100770, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33778152

RESUMO

Background: Coronavirus Disease-2019 (COVID-19) is associated with cardiovascular injury, but left ventricular (LV) function is largely preserved. We aimed to evaluate for subclinical LV dysfunction in patients with COVID-19 through myocardial strain analysis. Methods: We performed a single-center retrospective cohort study of all patients hospitalized with COVID-19 who underwent echocardiography. Traditional echocardiographic and global longitudinal strain (GLS) values were compared with prior and subsequent echocardiograms. Results: Among 96 patients hospitalized with COVID-19 with complete echocardiograms, 67 (70%) had adequate image quality for strain analysis. The cohort was predominantly male (63%) and 18% had prevalent cardiovascular disease (CVD). Echocardiograms were largely normal with median [IQR] LV ejection fraction (EF) 62% [56%, 68%]. However, median GLS was abnormal in 91% (-13.5% [-15.0%, -10.8%]). When stratified by CVD, both groups had abnormal GLS, but presence of CVD was associated with worse median GLS (-11.6% [-13.4%, -7.2%] vs -13.9% [-15.0%, -11.3%], p=0.03). There was no difference in EF or GLS when stratified by symptoms or need for intensive care. Compared to pre-COVID-19 echocardiograms, EF was unchanged, but median GLS was significantly worse (-15% [-16%, -14%] vs -12% [-14%, -10%], p=0.003). Serial echocardiograms showed no significant changes in GLS or EF overall, however patients who died had stable or worsening GLS, while those who survived to discharge home showed improved GLS. Conclusions: Patients with COVID-19 had evidence of subclinical cardiac dysfunction manifested by reduced GLS despite preserved EF. These findings were observed regardless of history of CVD, presence of COVID-19 symptoms, or severity of illness. Funding Sources: Partially supported by the National Institutes of Health, Grant 5T32HL079891, as part of the UCSD Integrated Cardiovascular Epidemiology Fellowship. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Disclosures: There are no relationships with industry relevant to this manuscript. The authors report no relationships that could be construed as a conflict of interest.

9.
Ann Thorac Surg ; 111(5): 1703-1709, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32896544

RESUMO

BACKGROUND: At the University of California, San Diego, routine coronary angiography has generally been performed in men 40 years of age and older and women 45 years of age and older before pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (CTEPH). The prevalence of significant coronary artery disease (CAD) in this population has not been evaluated, however, and the optimal screening strategy has not been established. This study sought to evaluate whether the current approach may be better optimized on the basis of cardiac risk factors. METHODS: This study included 462 consecutive patients with CTEPH who were undergoing preoperative coronary angiography for pulmonary thromboendarterectomy. Baseline demographic and medical information was recorded. Major cardiac risk factors included: diabetes, hypertension, hyperlipidemia, body mass index 25 kg/m2 or greater, tobacco use, and family history of CAD. Charts were then reviewed for presence of significant CAD and revascularization. RESULTS: Significant CAD was found in 13.4% of patients who underwent routine preoperative coronary angiography; it was present in only 5% of patients younger than 50 years of age, compared with 16% of patients 50 years old and older. No patient younger than 50 years of age without cardiac risk factors was found to have significant CAD. Furthermore, in patients younger than 50 years of age, significant CAD was found only among those with 3 or more major risk factors. CONCLUSIONS: In patients younger than 50 years of age with CTEPH, the prevalence of significant CAD was low. Omitting preoperative coronary angiography in this subset of patients is reasonable when no coronary risk factors are present. Preoperative coronary angiography is warranted in individuals 50 years of age and older, as well as in those younger than 50 years who have significant risk factors for CAD.


Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Endarterectomia , Embolia Pulmonar/complicações , Embolia Pulmonar/cirurgia , Adulto , Doença Crônica , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Prevalência , Estudos Retrospectivos , Fatores de Risco
10.
Sci Immunol ; 5(51)2020 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-32978242

RESUMO

Sterile tissue injury is thought to locally activate innate immune responses via damage-associated molecular patterns (DAMPs). Whether innate immune pathways are remotely activated remains relatively unexplored. Here, by analyzing ~145,000 single-cell transcriptomes at steady state and after myocardial infarction (MI) in mice and humans, we show that the type I interferon (IFN) response, characterized by expression of IFN-stimulated genes (ISGs), begins far from the site of injury, in neutrophil and monocyte progenitors within the bone marrow. In the peripheral blood of patients, we observed defined subsets of ISG-expressing neutrophils and monocytes. In the bone marrow and blood of mice, ISG expression was detected in neutrophils and monocytes and their progenitors, intensified with maturation at steady-state and after MI, and was controlled by Tet2 and Irf3 transcriptional regulators. Within the infarcted heart, ISG-expressing cells were negatively regulated by Nrf2 activation in Ccr2- steady-state cardiac macrophages. Our results show that IFN signaling begins in the bone marrow, implicate multiple transcriptional regulators (Tet2, Irf3, and Nrf2) in governing ISG expression, and provide a clinical biomarker (ISG score) for studying IFN signaling in patients.

11.
Am J Cardiol ; 136: 149-155, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-32946859

RESUMO

The impact of statins, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) on coronavirus disease 2019 (COVID-19) severity and recovery is important given their high prevalence of use among individuals at risk for severe COVID-19. We studied the association between use of statin/angiotensin-converting enzyme inhibitors/ARB in the month before hospital admission, with risk of severe outcome, and with time to severe outcome or disease recovery, among patients hospitalized for COVID-19. We performed a retrospective single-center study of all patients hospitalized at University of California San Diego Health between February 10, 2020 and June 17, 2020 (n = 170 hospitalized for COVID-19, n = 5,281 COVID-negative controls). Logistic regression and competing risks analyses were used to investigate progression to severe disease (death or intensive care unit admission), and time to discharge without severe disease. Severe disease occurred in 53% of COVID-positive inpatients. Median time from hospitalization to severe disease was 2 days; median time to recovery was 7 days. Statin use prior to admission was associated with reduced risk of severe COVID-19 (adjusted OR 0.29, 95%CI 0.11 to 0.71, p < 0.01) and faster time to recovery among those without severe disease (adjusted HR for recovery 2.69, 95%CI 1.36 to 5.33, p < 0.01). The association between statin use and severe disease was smaller in the COVID-negative cohort (p for interaction = 0.07). There was potential evidence of faster time to recovery with ARB use (adjusted HR 1.92, 95%CI 0.81 to 4.56). In conclusion, statin use during the 30 days prior to admission for COVID-19 was associated with a lower risk of developing severe COVID-19, and a faster time to recovery among patients without severe disease.


Assuntos
Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pneumonia Viral/epidemiologia , Adulto , Idoso , COVID-19 , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Cuidados Críticos , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Índice de Gravidade de Doença
12.
Circulation ; 142(16): 1532-1544, 2020 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-32820656

RESUMO

BACKGROUND: The observed incidence of type 2 myocardial infarction (T2MI) is expected to increase with the implementation of increasingly sensitive cTn assays. However, it remains to be determined how to diagnose, risk-stratify, and treat patients with T2MI. We aimed to discriminate and risk-stratify T2MI using biomarkers. METHODS: Patients presenting to the emergency department with chest pain, enrolled in the CHOPIN study (Copeptin Helps in the early detection Of Patients with acute myocardial INfarction), were retrospectively analyzed. Two cardiologists adjudicated type 1 MI (T1MI) and T2MI. The prognostic ability of several biomarkers alone or in combination to discriminate T2MI from T1MI was investigated using receiver operating characteristic curve analysis. The biomarkers analyzed were cTnI, copeptin, MR-proANP (midregional proatrial natriuretic peptide), CT-proET1 (C-terminal proendothelin-1), MR-proADM (midregional proadrenomedullin), and procalcitonin. The prognostic utility of these biomarkers for all-cause mortality and major adverse cardiovascular event (a composite of acute myocardial infarction, unstable angina pectoris, reinfarction, heart failure, and stroke) at 180-day follow-up was also investigated. RESULTS: Among the 2071 patients, T1MI and T2MI were adjudicated in 94 and 176 patients, respectively. Patients with T1MI had higher levels of baseline cTnI, whereas those with T2MI had higher baseline levels of MR-proANP, CT-proET1, MR-proADM, and procalcitonin. The area under the receiver operating characteristic curve for the diagnosis of T2MI was higher for CT-proET1, MR-proADM, and MR-proANP (0.765, 0.750, and 0.733, respectively) than for cTnI (0.631). Combining all biomarkers resulted in a similar accuracy to a model using clinical variables and cTnI (0.854 versus 0.884, P=0.294). Addition of biomarkers to the clinical model yielded the highest area under the receiver operating characteristic curve (0.917). Other biomarkers, but not cTnI, were associated with mortality and major adverse cardiovascular event at 180 days among all patients, with no interaction between the diagnosis of T1MI or T2MI. CONCLUSIONS: Assessment of biomarkers reflecting pathophysiologic processes occurring with T2MI might help differentiate it from T1MI. All biomarkers measured, except cTnI, were significant predictors of prognosis, regardless of the type of myocardial infarction.

13.
J Am Coll Cardiol ; 76(4): 357-370, 2020 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-32703505

RESUMO

BACKGROUND: Low values of high-sensitivity cardiac troponin (hs-cTn) and coronary artery calcium (CAC) scores of zero are associated with a low risk for atherosclerotic cardiovascular disease (ASCVD). OBJECTIVES: The purpose of this study was to evaluate baseline hs-cTnT and CAC in relation to ASCVD. METHODS: Baseline hs-cTnT (limit of detection [LoD] 3 ng/l) and CAC measurements were analyzed across participants age 45 to 84 years without clinical cardiovascular disease from the prospective MESA (Multi-Ethnic Study of Atherosclerosis) in relationship to incident ASCVD. RESULTS: Among 6,749 participants, 1,002 ASCVD events occurred during a median follow-up of 15 years. Participants with detectable CAC (20.1 vs. 5.0 events per 1,000 person-years; adjusted hazard ratio [HR]: 2.35; 95% confidence interval [CI]: 2.0 to 2.76; p < 0.001) and detectable hs-cTnT (15.4 vs. 5.2 per 1,000 person-years; adjusted HR: 1.47; 95% CI: 1.21 to 1.77; p < 0.001) had higher rates of ASCVD than those with undetectable results. Individuals with undetectable hs-cTnT (32%) had similar risk for ASCVD as did those with a CAC of zero (50%) (5.2 vs. 5.0 per 1,000 person-years). Together, hs-cTnT and CAC (discordance 38%) resulted in the following ASCVD event rates: hs-cTnT < LoD/CAC = 0: 2.8 per 1,000 person-years (reference), hs-cTnT ≥ LoD/CAC = 0: 6.8 per 1,000 person-years (HR: 1.59; 95% CI: 1.17 to 2.16; p = 0.003), hs-cTnT < LoD/CAC > 0: 11.1 per 1,000 person-years (HR: 2.74; 95% CI: 1.96 to 3.83; p < 0.00001), and hs-cTnT ≥ LoD/CAC > 0: 22.6 per 1,000 person-years (HR: 3.50; 95% CI: 2.60 to 4.70; p < 0.00001). CONCLUSIONS: An undetectable hs-cTnT identifies patients with a similar, low risk for ASCVD as those with a CAC score of zero. The increased risk among those with discordant results supports their conjoined use for risk prediction.


Assuntos
Cálcio/análise , Doença da Artéria Coronariana , Medição de Risco/métodos , Troponina/análise , Calcificação Vascular , Idoso , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevenção Primária/métodos , Reprodutibilidade dos Testes , Fatores de Risco , Estados Unidos/epidemiologia , Calcificação Vascular/sangue , Calcificação Vascular/diagnóstico
14.
J Gen Intern Med ; 35(9): 2537-2544, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32666493

RESUMO

BACKGROUND: Prior studies have demonstrated the importance of diversity among physicians. Identifying trends in diversity within the most competitive internal medicine (IM) fellowships can guide focused efforts to address barriers to equal representation. OBJECTIVE: To examine the racial and gender composition of resident applicants and accepted fellows to the top five most competitive IM specialties. DESIGN: Survey data from the AAMC, JAMA, and NRMP were obtained. Fisher's exact tests were conducted to compare differences in representation between fellows in the most competitive specialties, resident applicants into those specialties, and categorical IM residents. Linear regression was used to analyze trends within each group. PARTICIPANTS: Categorical IM residents and fellows at ACGME-accredited M.D. programs in the USA. MAIN MEASURES: Proportion of each population by gender and race/ethnicity KEY RESULTS: Women saw an increase in representation among accepted fellows to the most competitive IM fellowships from 2008 to 2013 (+ 4.4%, p < 0.011), but the trend has since plateaued at a level (34%) significantly lower than their representation among IM residents (43%, p < 0.001). Black representation among accepted fellows (4.6%) has been increasing from 2008 to 2018 (+ 1.2%, p = 0.001), but is still significantly lower than their representation among IM residents (5.6%, p < 0.001). Hispanic resident applicant and fellow representation have seen minimal change. CONCLUSION: Despite trends towards better representation among women and underrepresented minorities (URMs) among fellows in the most competitive IM specialties from 2008 to 2013, there has been a stagnation in both gender and racial diversity over the past 5 years. Further efforts must be undertaken to address barriers to entry and advocate for better representation of women and URMs in fellowship programs.


Assuntos
Bolsas de Estudo , Internato e Residência , Grupos Étnicos , Feminino , Hispano-Americanos , Humanos , Medicina Interna , Grupos Minoritários , Estados Unidos
15.
Circ Heart Fail ; 13(7): e006570, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32507024

RESUMO

BACKGROUND: NPs (natriuretic peptides) are cardiac-derived hormones that promote natriuresis, diuresis, and vasodilation. Preclinical evidence suggests that nonhemodynamic triggers for NP release exist, with a few studies implicating inflammatory stimuli. We examined the association between inflammation and NP levels in humans. METHODS: The associations between inflammation and NP levels were examined in 3 independent studies. First, in 5481 MESA (Multi-Ethnic Study of Atherosclerosis) participants, the cross-sectional (exam 1) and longitudinal (exams 1 to 3) associations between circulating IL6 (interleukin-6) and NT-proBNP (N terminal pro B-type natriuretic peptide) levels were examined in multivariable-adjusted models. Second, in a prospective study of 115 healthy individuals, changes in NP levels were quantified following exposure to lipopolysaccharide as an inflammatory stimulus. Third, in 13 435 hospitalized patients, the association between acute inflammatory conditions and circulating NP levels was assessed using multivariable-adjusted models. RESULTS: At the baseline MESA exam, each 1-unit higher natural log IL6 was associated with 16% higher NT-proBNP level ([95% CI, 10%-22%]; P=0.002). Each 1-unit higher baseline natural log IL6 level also associated with 6% higher NT-proBNP level ([95% CI, 1%-11%]; P=0.02) at 4-year follow-up. In the lipopolysaccharide study, median NT-proBNP levels rose from 21 pg/mL pre-lipopolysaccharide to 54 pg/mL post-lipopolysaccharide, P<0.001. In the hospitalized patient study, acute inflammatory conditions were associated with 36% higher NP levels ([95% CI, 17%-60%]; P<0.001). CONCLUSIONS: Inflammation appears to be associated with NP release. Interpretation of NP levels should therefore take into account inflammatory conditions.


Assuntos
Inflamação/sangue , Peptídeos Natriuréticos/sangue , Ensaios Clínicos como Assunto , Humanos , Inflamação/etiologia
16.
Curr Cardiol Rep ; 22(6): 41, 2020 05 19.
Artigo em Inglês | MEDLINE | ID: mdl-32430626

RESUMO

PURPOSE OF REVIEW: Biomarkers of cardiac fibrosis closely track the disease state that gives rise to heart failure. The purpose of this review is to highlight recent data on the use of soluble ST2, galectin-3, and procollagen, three markers of cardiac fibrosis, for aiding with prognostication, and to explore the use of these biomarkers for guiding therapy. RECENT FINDINGS: Soluble ST2, galectin-3, and procollagen are prognostic in both acute and chronic heart failure, and data are emerging as to their potential uses for guiding therapies. Mortality benefit from exercise, cardiac resynchronization therapy, statin use, as well as anti-fibrotic therapies such as aldosterone antagonism may vary based upon levels of these fibrosis markers. Soluble ST2, galectin-3, and procollagen provide independent prognostic information for heart failure morbidity and mortality. Markers of cardiac fibrosis may also help identify the subsets of patients who are most likely to benefit from various therapies. However, further studies are needed prior to formalizing individual patient care algorithms guided by fibrosis biomarkers.


Assuntos
Fibrose/diagnóstico , Galectina 3/sangue , Insuficiência Cardíaca/diagnóstico , Proteína 1 Semelhante a Receptor de Interleucina-1/sangue , Pró-Colágeno/sangue , Biomarcadores/sangue , Fibrose/sangue , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/etiologia , Humanos , Valor Preditivo dos Testes , Prognóstico
17.
J Am Heart Assoc ; 9(10): e015272, 2020 05 18.
Artigo em Inglês | MEDLINE | ID: mdl-32390494

RESUMO

Emergence of various highly sensitive cardiac troponin assays into clinical practice provides a new tool for clinicians diagnosing acute coronary syndrome. These assays also create a challenge for laboratories and clinicians who have yet to familiarize themselves with sex-specific cutoffs. Healthy men and women, studied across various age groups and geographic locations, have notable differences in baseline values of highly sensitive cardiac troponin I and T, leading to establishment of sex-specific upper reference limits and cutoffs. Several differences in cardiac physiology, size, and structure may account for baseline differences in highly sensitive cardiac troponins and outcomes between the sexes. The clinical utility of implementing sex-specific cutoffs for diagnosis and management of acute coronary syndrome remains unclear. Presently, the only prospective study failed to show improved outcomes for men or women with use of sex-specific cutoffs; however, a major limitation is the frequent lack of diagnostic, therapeutic, and preventive interventions prescribed to women with low-level troponin elevations. Based on the current literature, we posit that there may nonetheless be clinical value in the use of sex-specific cutoffs for evaluating suspected acute coronary syndrome, especially in select patient populations such as younger women who tend to have lower baseline values of highly sensitive cardiac troponins. Future studies should prospectively evaluate differences in diagnostic, pharmacologic, and interventional management in men and women using myocardial infarctions classified with sex-specific cutoffs of the highly sensitive cardiac troponin assays.


Assuntos
Infarto do Miocárdio/diagnóstico , Troponina/sangue , Biomarcadores/sangue , Feminino , Disparidades nos Níveis de Saúde , Humanos , Masculino , Infarto do Miocárdio/sangue , Infarto do Miocárdio/terapia , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Fatores Sexuais
18.
Am J Med ; 133(10): 1203-1208, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32234496

RESUMO

BACKGROUND: Despite differing underlying pathophysiology, type 1 and type 2 myocardial infarction share many of the same diagnostic criteria and can be challenging to differentiate in clinical practice. Correctly differentiating type 1 from type 2 myocardial infarction is important because they are managed differently. The aim of this study was to compare the patterns of rise of cardiac troponin (cTn) and creatine kinase MB (CK-MB) in type 1 and type 2 myocardial infarction. METHODS: We analyzed retrospective data on 200 patients with myocardial infarction (97 with type 1, 103 with type 2), excluding patients with ST-segment elevation myocardial infarction. The percentage rise from trough to peak values and the ratio of the peak to the upper limit of normal (RULN) were calculated for both cardiac troponin T (cTnT) and CK-MB. The ratio of peak cTnT to peak CK-MB was also calculated before and after adjusting for sex, glomerular filtration rate (GFR), and infarct size. RESULTS: Type 1 myocardial infarction tended to be larger than type 2 myocardial infarction, with a significantly higher mean percentage rise for both cTnT and CK-MB as well as higher mean RULN (207 vs 86 for cTnT, P = 0.02; 9 vs 4 for CK-MB, P = 0.002). There was a trend toward a higher rise of cTnT than CK-MB in type 2 compared with type 1 myocardial infarction, as demonstrated by the ratio of peak cTnT to peak CK-MB (0.09 in type 2 myocardial infarction vs 0.06 in type 1 myocardial infarction, P = 0.06). This difference persisted after adjusting for sex, GFR, and infarct size (P = 0.05). CONCLUSION: Both cTnT and CK-MB rise higher in type 1 than in type 2 myocardial infarction. Meanwhile, cTnT tends to rise out of proportion to CK-MB in type 2 myocardial infarction. These patterns may have considerable implications for the differentiation and subsequent treatment of patients with type 1 versus type 2 myocardial infarction.


Assuntos
Creatina Quinase Forma MB/sangue , Infarto do Miocárdio/sangue , Troponina T/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/classificação
19.
Am Heart J ; 222: 8-14, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32006910

RESUMO

BACKGROUND: The prevalence of renal disease in cardiac intensive care units (CICUs) is increasing, but little is known about the utilization, concurrent therapies, and outcomes of patients requiring acute renal replacement therapy (RRT) in this specialized environment. METHODS: In the Critical Care Cardiology Trials Network, 16 centers submitted data on CICU admissions including acute RRT (defined as continuous renal replacement therapy and/or acute intermittent dialysis). RESULTS: Among 2,985 admissions, 178 (6.0%; interhospital range 1.0%-16.0%) received acute RRT. Patients receiving RRT, versus not, were more commonly admitted for cardiogenic shock (15.7% vs 4.2%, P < .01), cardiac arrest (9.6% vs 3.7%, P < .01), and acute general medical diagnoses (10.7% vs 5.8%, P < .01), whereas acute coronary syndromes (16.9% vs 32.1%, P < .01) were less frequent. Variables independently associated with acute RRT included diabetes, heart failure, liver disease, severe valvular disease, shock, cardiac arrest, hypertension, and younger age. In patients receiving acute RRT, versus not, advanced therapies including mechanical ventilation (55.6% vs 18.0%), vasoactive support (73.0% vs 35.2%), invasive hemodynamic monitoring (59.6% vs 29.2%), and mechanical circulatory support (27.5% vs 8.4%) were more common. Acute RRT was associated with higher in-hospital mortality (42.1% vs 9.3%, adjusted odds ratio 3.74, 95% CI, 2.52-5.53) and longer median length of stay (10.0 vs 5.3 days, P < .01). In conclusion, acute RRT in contemporary CICUs was associated with the provision of other advanced therapies and lower survival. CONCLUSIONS: These data underscore the risks associated with the provision of renal support in patients with primary cardiovascular problems and the need to develop standardized indications and potential futility measures in this specialized population.


Assuntos
Injúria Renal Aguda/epidemiologia , Doenças Cardiovasculares/complicações , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Cuidados Críticos/métodos , Sistema de Registros , Terapia de Substituição Renal/métodos , Injúria Renal Aguda/complicações , Injúria Renal Aguda/terapia , Idoso , Canadá/epidemiologia , Doenças Cardiovasculares/epidemiologia , Estudos Transversais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
20.
Hypertension ; 75(2): 316-323, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31865797

RESUMO

Cross-sectionally measured NT-proBNP (N-terminal pro-B-type natriuretic peptide) is related to incident dementia. However, data linking changes in NT-proBNP to risk of future dementia are lacking. We aimed to examine the association of change in NT-proBNP over 3.2 years with incident dementia. We included 4563 participants in MESA (Multi-Ethnic Study of Atherosclerosis) prospective cohort who were free of cardiovascular disease at enrollment, had NT-proBNP level measured at MESA exams 1 (baseline, 2000-2002) and 3 (2004-2005), and had no diagnosis of dementia before exam 3. The association of change in NT-proBNP level between MESA exams 1 through 3 and all-cause hospitalized dementia (by International Classification of Diseases, Ninth Revision, codes) after MESA exam 3 (2004-2005) through 2015 was assessed using competing-risks Cox proportional hazard regression analysis. During 45 522 person-years of follow-up, 223 dementia cases were documented. Increase in log-NT-proBNP from MESA exams 1 through 3 was positively associated with incidence of dementia (multivariable hazard ratio, 1.28 [95% CI, 1.001-1.64]; P=0.049). An increase of at least 25% in NT-proBNP level from MESA exam 1 through 3 was associated with a 55% (P=0.02) increase in the risk of dementia in multivariable analysis. Addition of temporal NT-proBNP change to a model including risk factors and baseline NT-proBNP improved the prediction of dementia (Harrell C statistic from 0.85 to 0.87, P=0.049). Increase in NT-proBNP is independently associated with future all-cause hospitalized dementia and offers a moderately better predictive performance for risk of dementia compared with risk factors and baseline NT-proBNP. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00005487.


Assuntos
Aterosclerose , Demência , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Idoso , Aterosclerose/sangue , Aterosclerose/diagnóstico , Aterosclerose/epidemiologia , Aterosclerose/psicologia , Biomarcadores/sangue , Demência/sangue , Demência/diagnóstico , Demência/epidemiologia , Demência/fisiopatologia , Grupos Étnicos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Saúde Pública/métodos , Saúde Pública/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Estados Unidos/epidemiologia
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