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1.
J Card Fail ; 2020 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-33038531

RESUMO

BACKGROUND: Identifying patients at risk of poor diuretic response in acute heart failure (AHF) is critical to make prompt adjustments in therapy. The objective of this study was to investigate whether the circulating levels of soluble ST2 predict the cumulative diuretic efficiency (DE) at 24 and 72 hours in patients with AHF and concomitant renal dysfunction. METHODS AND RESULTS: This is a post hoc analysis of the IMPROVE-HF trial, in which we enrolled 160 patients with AHF and renal dysfunction (estimated glomerular filtrate rate of <60 mL/min/1.73 m2). DE was calculated as the net fluid output produced per 40 mg of furosemide equivalents. The association between sST2 and DE was evaluated by using multivariate linear regression analysis. The median cumulative DE at 24 and 72 hour was 747 mL (interquartile range 490-1167 mL) and 1844 mL (interquartile range 1142-2625 mL), respectively. The median sST2 and mean estimated glomerular filtrate rate were 72 ng/mL (interquartile range 47-117 ng/mL), and 34.0 ± 8.5 mL/min/1.73 m2, respectively. In a multivariable setting, higher sST2 were significant and nonlinearly related to lower DE both at 24 and 72 hours (P = .002 and P = .019, respectively). CONCLUSIONS: In patients with AHF and renal dysfunction at presentation, circulating levels of sST2 were independently and negatively associated with a poor diuretic response, both at 24 and 72 hours.

2.
Cardiorenal Med ; 10(5): 362-372, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32721973

RESUMO

OBJECTIVE: In acute heart failure (AHF), early assessment of spot urinary sodium (UNa) has emerged as a useful biomarker for risk stratification and monitoring. The objective of this study was to investigate (a) whether early spot UNa predicts 24-h diuretic efficiency and (b) the clinical factors associated with early spot UNa in patients with AHF and concomitant renal dysfunction (RD). METHODS: This is a post hoc analysis of the IMPROVE-HF trial, in which 160 patients with AHF and RD (estimated glomerular filtrate rate [eGFR] <60 mL/min/1.73 m2) were included. Diuretic efficiency was calculated as the net fluid output produced per 40 mg of furosemide equivalents in 24 h. The association between early spot UNa and diuretic efficiency and clinical variables associated with UNa were evaluated using multivariate linear regression analysis. The contribution of the exposures in the predictability of the models was assessed with the coefficient of determination (R2). RESULTS: The mean age of the study population was 78 ± 8 years. The median (interquartile range) diuretic efficiency, early spot UNa, aminoterminal pro-brain natriuretic peptide, and eGFR were 747 (490-1,167) mL, 90 mmol/L (65-111), 7,765 pg/mL (3,526-15,369), and 33.7 ± 11.3 mL/min/1.73 m2, respectively. In a multivariate setting, lower UNa was significantly and nonlinearly associated with lower diuretic efficiency (p = 0.001), explaining the 44.4% of the model predictability. Natremia and surrogates of congestion emerged as the main factors related to UNa. CONCLUSIONS: In patients with AHF and RD at presentation, early spot UNa was inversely related to 24-h diuretic efficiency.

3.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32624444

RESUMO

INTRODUCTION AND OBJECTIVES: Urinary sodium (UNa+) has emerged as a useful biomarker of poor clinical outcomes in acute heart failure (AHF). Here, we sought to evaluate: a) the usefulness of a single early determination of UNa+ for predicting adverse outcomes in patients with AHF and renal dysfunction, and b) whether the change in UNa+ at 24hours (ΔUNa24h) adds any additional prognostic information over baseline values. METHODS: This is a post-hoc analysis of a multicenter, open-label, randomized clinical trial (IMPROVE-HF) (ClinicalTrials.gov NCT02643147) that randomized 160 patients with AHF and renal dysfunction on admission to a) the standard diuretic strategy, or b) a carbohydrate antigen 125-guided diuretic strategy. The primary end point was all-cause mortality and total all-cause readmissions. RESULTS: The mean age was 78±8 years, and the mean glomerular filtration rate was 34.0±8.5mL/min/1.73 m2. The median UNa+ was 90 (65-111) mmol/L. At a median follow-up of 1.73 years [interquartile range, 0.48-2.35], 83 deaths (51.9%) were registered, as well as 263 all-cause readmissions in 110 patients. UNa+ was independently associated with mortality (HR, 0.75; 95%CI, 0.65-0.87; P <.001) and all-cause readmissions (HR, 0.92; 95%CI, 0.88-0.96; P <.001). The prognostic usefulness of the ΔUNa24h varied according to UNa+ at admission (P for interaction <.05). The ΔUNa24h was inversely associated with both end points only in the group with UNa+ ≤ 50 mmol/L. Conversely, no effect was found in the group with UNa+> 50 mmol/L. CONCLUSIONS: In patients with AHF and renal dysfunction, a single early determination of UNa+ ≤ 50 mmol/L identifies patients with a higher risk of all-cause mortality and readmission. The ΔUNa24h adds prognostic information over baseline values only when UNa+ at admission is ≤ 50 mmol/L.

4.
JACC Cardiovasc Imaging ; 13(8): 1674-1686, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32682717

RESUMO

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.

5.
Am J Med ; 133(3): 370-380.e4, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31422111

RESUMO

BACKGROUND: The optimal diuretic treatment strategy for patients with acute heart failure and renal dysfunction remains unclear. Plasma carbohydrate antigen 125 (CA125) is a surrogate of fluid overload and a potentially valuable tool for guiding decongestion therapy. The aim of this study was to determine if a CA125-guided diuretic strategy is superior to usual care in terms of short-term renal function in patients with acute heart failure and renal dysfunction at presentation. METHODS: This multicenter, open-label study randomized 160 patients with acute heart failure and renal dysfunction into 2 groups (1:1). Loop diuretics doses were established according to CA125 levels in the CA125-guided group (n = 79) and in clinical evaluation in the usual-care group (n = 81). Changes in estimated glomerular filtration rate (eGFR) at 72 and 24 hours were the co-primary endpoints, respectively. RESULTS: The mean age was 78 ± 8 years, the median amino-terminal pro-brain natriuretic peptide was 7765 pg/mL, and the mean eGFR was 33.7 ± 11.3 mL/min/1.73m2. Over 72 hours, the CA125-guided group received higher furosemide equivalent dose compared to usual care (P = 0.011), which translated into higher urine volume (P = 0.042). Moreover, patients in the active arm with CA125 >35 U/mL received the highest furosemide equivalent dose (P <0.001) and had higher diuresis (P = 0.013). At 72 hours, eGFR (mL/min/1.73m2) significantly improved in the CA125-guided group (37.5 vs 34.8, P = 0.036), with no significant changes at 24 hours (35.8 vs 39.5, P = 0.391). CONCLUSION: A CA125-guided diuretic strategy significantly improved eGFR and other renal function parameters at 72 hours in patients with acute heart failure and renal dysfunction.


Assuntos
Antígeno Ca-125/sangue , Furosemida/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Proteínas de Membrana/sangue , Insuficiência Renal/tratamento farmacológico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/urina , Humanos , Testes de Função Renal , Masculino , Medicina de Precisão , Insuficiência Renal/complicações , Insuficiência Renal/urina , Urina
6.
Rev. esp. cardiol. (Ed. impr.) ; 70(12): 1067-1073, dic. 2017. tab, ilus
Artigo em Espanhol | IBECS | ID: ibc-169305

RESUMO

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)


Assuntos
Humanos , Insuficiência Cardíaca/terapia , Nefropatias/complicações , Biomarcadores , Diuréticos/uso terapêutico , Insuficiência Cardíaca/complicações , Análise Estatística
7.
Rev Esp Cardiol (Engl Ed) ; 70(12): 1067-1073, 2017 Dec.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-28341415

RESUMO

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.


Assuntos
Acetazolamida/uso terapêutico , Antígeno Ca-125/sangue , Síndrome Cardiorrenal/tratamento farmacológico , Clortalidona/uso terapêutico , Diuréticos/uso terapêutico , Furosemida/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Proteínas de Membrana/sangue , Desequilíbrio Hidroeletrolítico/tratamento farmacológico , Doença Aguda , Síndrome Cardiorrenal/sangue , Síndrome Cardiorrenal/complicações , Creatinina/sangue , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/complicações , Humanos , Planejamento de Assistência ao Paciente , Desequilíbrio Hidroeletrolítico/sangue , Desequilíbrio Hidroeletrolítico/etiologia
8.
Eur J Intern Med ; 35: 89-94, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27423981

RESUMO

BACKGROUND: Comorbid elderly patients with non-ST-elevation myocardial infarction (non-STEMI) are underrepresented in randomized trials and undergo fewer cardiac catheterizations according to registries. Our aim was to compare the conservative and invasive strategies in these patients. METHODS: Randomized multicenter study, including 106 patients (January 2012-March 2014) with non-STEMI, over 70years and with comorbidities defined by at least two of the following: peripheral artery disease, cerebral vascular disease, dementia, chronic pulmonary disease, chronic renal failure or anemia. Patients were randomized to invasive (routine coronary angiogram, n=52) or conservative (coronary angiogram only if recurrent ischemia or heart failure, n=54) strategy. Medical treatment was identical. The main endpoint was the composite of all-cause mortality, reinfarction and readmission for cardiac cause (postdischarge revascularization or heart failure), at long-term (2.5-year follow-up). Analysis of cumulative event rate (incidence rate ratio=IRR) and time to first event (hazard ratio=HR), were performed. RESULTS: Cardiac catheterization/revascularization rates were 100%/58% in the invasive versus 20%/9% in the conservative arm. There were no differences between groups in the main endpoint (invasive vs conservative: IRR=0.946, 95% CI 0.466-1.918, p=0.877) at long-term. The invasive strategy, however, tended to improve 3-month outcomes in terms of mortality (HR=0.348, 95% CI 0.122-0.991, p=0.048), and of mortality or ischemic events (reinfarction or postdischarge revascularization) (HR=0.432, 95% CI 0.190-0.984, p=0.046). This benefit declined during follow-up. CONCLUSIONS: Invasive management did not modify long-term outcome in comorbid elderly patients with non-STEMI. The finding of a tendency towards an improvement in the short-term needs confirmation in larger studies (clinicaltrials.govNCT1645943).


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Angiografia Coronária , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão , Cateterismo Cardíaco , Comorbidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Espanha , Resultado do Tratamento
9.
J Cardiovasc Med (Hagerstown) ; 17(4): 283-90, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25333379

RESUMO

AIMS: Fluid overload is a hallmark in acute heart failure (AHF). Bioelectrical impedance vector analysis (BIVA) has emerged as a noninvasive method for quantifying patients' hydration. We aimed to evaluate the effect of BIVA hydration status (BHS) measured before discharge on mortality and rehospitalization for AHF. METHODS: We included 369 consecutive patients discharged from the cardiology department from a third-level hospital with a diagnosis of AHF. On the basis of BHS, patients were grouped into three categories: hyper-hydration (>74.3%), normo-hydration (72.7-74.3%) and dehydration (<72.7%). Appropriate survival techniques were used to evaluate the association between BHS and the risk of death and readmission for AHF. RESULTS: At a median follow-up of 12 months (interquartile range, IQR: 5-19), 80 (21.7%) deaths and 93 (25.2%) readmissions for AHF were registered. The mortality and readmission rates for the BHS categories were hyper-hydration (3.28 and 3.83 per 10 persons-years); normo-hydration (1.43 and 2.68 per 10 persons-years); and dehydration (2.24 and 2.53 per 10 persons-years) (P < 0.05 for all comparisons). In an adjusted analysis, BHS displayed a significant association with mortality (P = 0.004), with a higher mortality risk in those with hyperhydration. Likewise, BHS showed to linearly predict AHF-readmission risk [hazard ratio 1.06 (1.03-1.10); P = 0.001 per increase in 1%]. CONCLUSION: In patients admitted with AHF, BHS assessed before discharge was independently associated with the risk of death and AHF-readmission.


Assuntos
Insuficiência Cardíaca/diagnóstico , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Água Corporal , Impedância Elétrica , Feminino , Seguimentos , Hospitalização , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos , Processamento de Sinais Assistido por Computador
10.
Rev. esp. cardiol. (Ed. impr.) ; 68(10): 852-860, oct. 2015. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-143222

RESUMO

Introducción y objetivos: En los pacientes con insuficiencia cardiaca y diabetes tipo 2, las cifras bajas de glucohemoglobina se han relacionado con un riesgo más elevado de mortalidad, pero la información relativa a la morbilidad es escasa. El objetivo de este estudio fue evaluar la asociación existente entre la glucohemoglobina y el reingreso en un plazo de 30 días en los pacientes con diabetes tipo 2 e insuficiencia cardiaca aguda. Métodos: Se determinó la glucohemoglobina antes del alta en 835 pacientes consecutivos con insuficiencia cardiaca aguda y diabetes tipo 2. Se utilizó un análisis de regresión de Cox adaptado para eventos competitivos. Resultados: La media de edad fue de 72,9 ± 9,6 años y la mediana de la glucohemoglobina fue de 7,2% (6,5-8,0%). Los pacientes tratados con insulina o con insulina/sulfonilurea/meglitinidas constituyeron un 41,1 y un 63,2% de la cohorte, respectivamente. A los 30 días del alta, 109 (13,1%) pacientes habían tenido un reingreso en el hospital. El análisis multivariante reveló que el efecto de la glucohemoglobina sobre el riesgo de reingreso en 30 días se veía afectado de manera diferente según el tipo de tratamiento (p para la interacción < 0,01). La glucohemoglobina (por cada 1% de disminución) presentaba una asociación inversa con un mayor riesgo en los pacientes tratados con insulina (hazard ratio = 1,45; intervalo de confianza del 95%, 1,13-1,86; p = 0,003) o con insulina/sulfonilurea/meglitinidas (hazard ratio= 1,44; intervalo de confianza del 95%, 1,16-1,80; p = 0,001). En cambio, la glucohemoglobina (por cada 1% de aumento) no tenía efecto alguno en la diabetes no insulinodependiente (hazard ratio = 1,01; intervalo de confianza del 95%, 0,87-1,17; p = 0,897) o mostraba incluso un efecto positivo en los pacientes no tratados con insulina/sulfonilurea/meglitinidas (hazard ratio = 1,12; intervalo de confianza del 95%, 1,03-1,22; p = 0,011). Conclusiones: En la insuficiencia cardiaca aguda, la glucohemoglobina mostró una asociación inversa con el riesgo de reingreso en 30 días en los pacientes insulinodependientes o en los tratados con insulina/sulfonilurea/meglitinidas. En el resto de pacientes se observó un efecto marginal. En futuros estudios deberá esclarecerse si esa asociación refleja un efecto relacionado con el tratamiento o bien es un indicador indirecto de una enfermedad más avanzada (AU)


Introduction and objectives: In patients with heart failure and type 2 diabetes, low glycosylated hemoglobin has been related with higher risk of mortality but information regarding morbidity is scarce. We sought to evaluate the association between glycosylated hemoglobin and 30-day readmission in patients with type 2 diabetes and acute heart failure. Methods: Glycosylated hemoglobin was measured before discharge in 835 consecutive patients with acute heart failure and type 2 diabetes. Cox regression analysis adapted for competing events was used. Results: Mean (standard deviation) age was 72.9 (9.6) years and median glycosylated hemoglobin was 7.2% (6.5%-8.0%). Patients treated with insulin or insulin/sulfonylurea/meglitinides were 41.1% and 63.2% of the cohort, respectively. At 30 days post-discharge, 109 (13.1%) patients were readmitted. A multivariate analysis revealed that the effect of glycosylated hemoglobin on the risk of 30-day readmission was differentially affected by the type of treatment (P for interaction < .01). Glycosylated hemoglobin (per 1% decrease) was inversely associated with higher risk in those receiving insulin (hazard ratio = 1.45; 95% confidence interval, 1.13-1.86; P = .003) or insulin/sulfonylurea/ meglitinides (hazard ratio = 1.44; 95% confidence interval, 1.16-1.80; P = .001). Conversely, glycosylated hemoglobin (per 1% increase) had no effect in non-insulin dependent diabetes (hazard ratio = 1.01; 95% confidence interval, 0.87-1.17; P = .897) or even a positive effect in patients not receiving insulin/ sulfonylurea/meglitinides (hazard ratio = 1.12; 95% confidence interval, 1.03-1.22; P = .011). Conclusions: In acute heart failure, glycosylated hemoglobin showed to be inversely associated to higher risk of 30-day readmission in insulin-dependent or those treated with insulin/sulfonylurea/meglitinides. A marginal effect was found in the rest. Whether this association reflects a treatment-related effect or a surrogate of more advanced disease should be clarified in further studies (AU)


Assuntos
Humanos , Insuficiência Cardíaca/fisiopatologia , Hemoglobina A Glicada/análise , Diabetes Mellitus Tipo 2/tratamento farmacológico , Readmissão do Paciente/estatística & dados numéricos , Índice Glicêmico , Diabetes Mellitus Tipo 2/complicações , Fatores de Risco , Hipoglicemiantes/uso terapêutico
11.
Rev Esp Cardiol (Engl Ed) ; 68(10): 852-60, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25792287

RESUMO

INTRODUCTION AND OBJECTIVES: In patients with heart failure and type 2 diabetes, low glycosylated hemoglobin has been related with higher risk of mortality but information regarding morbidity is scarce. We sought to evaluate the association between glycosylated hemoglobin and 30-day readmission in patients with type 2 diabetes and acute heart failure. METHODS: Glycosylated hemoglobin was measured before discharge in 835 consecutive patients with acute heart failure and type 2 diabetes. Cox regression analysis adapted for competing events was used. RESULTS: Mean (standard deviation) age was 72.9 (9.6) years and median glycosylated hemoglobin was 7.2% (6.5%-8.0%). Patients treated with insulin or insulin/sulfonylurea/meglitinides were 41.1% and 63.2% of the cohort, respectively. At 30 days post-discharge, 109 (13.1%) patients were readmitted. A multivariate analysis revealed that the effect of glycosylated hemoglobin on the risk of 30-day readmission was differentially affected by the type of treatment (P for interaction<.01). Glycosylated hemoglobin (per 1% decrease) was inversely associated with higher risk in those receiving insulin (hazard ratio = 1.45; 95% confidence interval, 1.13-1.86; P=.003) or insulin/sulfonylurea/meglitinides (hazard ratio = 1.44; 95% confidence interval, 1.16-1.80; P=.001). Conversely, glycosylated hemoglobin (per 1% increase) had no effect in non-insulin dependent diabetes (hazard ratio = 1.01; 95% confidence interval, 0.87-1.17; P=.897) or even a positive effect in patients not receiving insulin/sulfonylurea/meglitinides (hazard ratio = 1.12; 95% confidence interval, 1.03-1.22; P=.011). CONCLUSIONS: In acute heart failure, glycosylated hemoglobin showed to be inversely associated to higher risk of 30-day readmission in insulin-dependent or those treated with insulin/sulfonylurea/meglitinides. A marginal effect was found in the rest. Whether this association reflects a treatment-related effect or a surrogate of more advanced disease should be clarified in further studies.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hemoglobina A Glicada/metabolismo , Insuficiência Cardíaca/complicações , Alta do Paciente/tendências , Readmissão do Paciente/tendências , Medição de Risco , Doença Aguda , Idoso , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Humanos , Hipoglicemiantes/uso terapêutico , Masculino , Prognóstico , Estudos Retrospectivos , Espanha/epidemiologia , Taxa de Sobrevida/tendências
12.
Am Heart J ; 168(5): 784-91, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25440808

RESUMO

BACKGROUND: Geriatric conditions may predict outcomes beyond age and standard risk factors. Our aim was to investigate a wide spectrum of geriatric conditions in survivors after an acute coronary syndrome. METHODS: A total of 342 patients older than 65 years were included. At hospital discharge, 5 geriatric conditions were evaluated: frailty (Fried and Green scores), physical disability (Barthel index), instrumental disability (Lawton-Brody scale), cognitive impairment (Pfeiffer questionnaire), and comorbidity (Charlson and simple comorbidity indexes). The outcomes were postdischarge mortality and the composite of death/myocardial infarction during a 30-month median follow-up. RESULTS: Seventy-four (22%) patients died and 105 (31%) suffered from the composite end point. Through univariable analysis, all individual geriatric indexes were associated with outcomes, mainly mortality. Of all of them, frailty using the Green score had the strongest discriminative accuracy (area under the receiver operating characteristic curve 0.76 for mortality). After full adjustment including clinical and geriatric data, the Green score was the only independent predictive geriatric condition (per point; mortality: hazard ratio 1.25, 95% CI 1.15-1.36, P = .0001; composite end point: hazard ratio 1.16, 95% CI 1.09-1.24, P = .0001). A Green score ≥ 5 points was the strongest mortality predictor. The addition of the Green score to the clinical model improved discrimination (area under the receiver operating characteristic curve 0.823 vs 0.846) and significantly reclassified mortality risk (net reclassification improvement 26.3, 95% CI 1.4-43.5; integrated discrimination improvement 4.0, 95% CI 0.8-9.0). The incremental predictive information was even greater over the GRACE score. CONCLUSIONS: Frailty captures most of the prognostic information provided by geriatric conditions after acute coronary syndromes. The Green score performed better than the other geriatric indexes.


Assuntos
Atividades Cotidianas , Síndrome Coronariana Aguda/epidemiologia , Transtornos Cognitivos/epidemiologia , Idoso Fragilizado/estatística & dados numéricos , Infarto do Miocárdio/epidemiologia , Medição de Risco , Síndrome Coronariana Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Estudos de Coortes , Comorbidade , Teste de Esforço , Feminino , Avaliação Geriátrica , Força da Mão , Humanos , Masculino , Análise Multivariada , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Curva ROC , Fatores de Risco
13.
Heart ; 100(20): 1591-6, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24947318

RESUMO

OBJECTIVES: High-sensitivity troponin (hs-cTn) is substituting conventional cTn for evaluation of chest pain. Our aim was to assess the impact on patient management and outcome. METHODS: A total of 1372 consecutive patients presenting at the emergency department with non-ST-elevation acute chest pain were divided into two periods according to the cTn assay used, conventional (n=699, March 2008 to July 2010) or hs-cTn (n=673, November 2010 to March 2013). Management policies were similar and according to guidelines. The primary endpoint was major adverse cardiac events (MACE) at 6 months (death, myocardial infarction, readmission by unstable angina or postdischarge revascularisation). RESULTS: There were minor differences in baseline characteristics. In the hs-cTn period, more patients elevated cTn (73% vs 37%, p=0.0001) leading to more coronary angiograms (77% vs 55%, p=0.0001) and revascularisations (45% vs 31%, p=0.0001); conversely, fewer patients were initially assigned to exercise testing (14% vs 36%, p=0.0001) and, therefore, discharged early after a negative result (7% vs 22%, p=0.0001). At 6 months, 135 patients suffered MACE, including 54 deaths. After adjusting for a Propensity Score, hs-cTn use was not significantly associated with MACE (HR=0.99; 95% CI 0.70 to 1.41; p=0.98) or mortality (HR=1.02; 95% CI 0.59 to 1.77; p=0.95), though the risk of longer hospitalisation stay increased at the index episode (OR=1.35, 95% CI 1.07 to 1.71, p=0.02). CONCLUSIONS: hs-cTn simplified chest pain triage on avoiding a more complex evaluation with non-invasive tests in the chest pain unit, but prompted longer hospitalisations and more invasive procedures without impacting on the 6-month outcomes.


Assuntos
Dor no Peito/sangue , Dor no Peito/terapia , Troponina/sangue , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Sensibilidade e Especificidade
14.
Int J Cardiol ; 174(3): 516-23, 2014 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-24801083

RESUMO

BACKGROUND: The use of loop diuretics in acute heart failure (AHF) is largely empirical and has been associated with renal function impairment by reducing renal perfusion but also renal improvement by decreasing renal venous congestion. Antigen carbohydrate 125 (CA125) has emerged as a proxy for fluid overload. We sought to evaluate whether the early changes in creatinine (ΔCr) induced by intravenous furosemide doses (ivFD) differ among clinical groups defined by overload status (CA125) and creatinine on admission (Cr). METHODS AND RESULTS: We included 526 consecutive patients admitted for AHF. All patients received intravenous furosemide for the first 48 hours. CA125 and Cr were dichotomized at 35 U/ml and 1.4 mg/dl, respectively, and grouped as follows: C1 [Cr <1.4, CA125 ≤ 35 (n=151)]; C2 [Cr <1.4, CA125 >35 (n=241)]; C3 [Cr ≥ 1.4, CA125 ≤ 35 (n=45)]; and C4 [Cr ≥ 1.4, CA125 >35 (n=89)]. Clinicians in charge of the management of patients were blind to CA125 values. ΔCr was estimated as the absolute difference in Cr between admission and 48-72 hours. Multivariable linear regression analysis was used for modeling purposes. The adjusted analysis showed a differential effect of ivFD on ΔCr. Per increase in 20mg/day of ivFD, the mean ΔCr was 0.010 mg/dl (p=0.464) in C1, 0.002 mg/dl (p=0.831) in C2, 0.045 mg/dl (p=0.032) in C3, and -0.045 mg/dl (p<0.001) in C4 (omnibus p<0.001). A similar pattern of response was observed in a validation cohort. CONCLUSIONS: In patients with AHF, the magnitude and direction of ΔCr attributable to ivFD were differentially associated with values of CA125 and Cr on admission.


Assuntos
Antígeno Ca-125/sangue , Creatinina/sangue , Insuficiência Cardíaca/sangue , Rim/fisiologia , Admissão do Paciente , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Coortes , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Infusões Intravenosas , Rim/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/tendências , Valor Preditivo dos Testes
15.
Rev. Soc. Boliv. Pediatr ; 52(2): 100-109, 2013. ilus
Artigo em Espanhol | LILACS-Express | LILACS | ID: lil-738270

RESUMO

El cuidado e higiene del cordón umbilical (CU) es motivo de preocupación para los padres. Objetivos. Principal: comparar la efectividad del secado natural del CU, con la práctica habitual (alcohol), en la reducción del tiempo de caída del CU y la incidencia de infecciones en el recién nacido (RN). Secundarios: comparar la colonización bacteriana intrahospitalaria del CU, y el grado de satisfacción de los padres en ambos grupos. Población. RN de término asistidos en el Servicio de Neonatología del Hospital Privado del Sur, cuyos padres consintieron participar. Material y métodos. Estudio clínico prospectivo, controlado, abierto, aleatorizado, en dos grupos: Grupo Estudio (secado natural y baño diario con jabón neutro) y Grupo Control (alcohol 70%). Variables principales: tiempo de caída del CU; presencia de infecciones en piel o conjuntivas en el primer mes de vida; colonización del cordón y satisfacción parental. Análisis por intención de tratamiento. Resultados. Se analizaron 362 RN, 181 en cada grupo. La higiene con baño se asoció con una mayor frecuencia de colonización intrahospitalaria del CU (OR 1,92 [1,22 - 3,12], p <0,01) y caída del cordón más temprana (mediana [rango intercuartílico]= 6,00 [3] vs. 7,00 [4] días en el grupo control; p <0,001). No se observó un mayor riesgo de infecciones. El grado de satisfacción parental fue similar y elevado en ambos grupos. Conclusiones. El secado natural y baño redujo el tiempo de caída del CU; aun cuando la frecuencia de colonización fue mayor en el grupo estudio, no se encontró un riesgo mayor de infecciones en el primer mes.


Background. Umbilical cord (UC) care is a cause of concern for parents from birth until its separation. Standard practice in Argentina includes frequent cleansing of the UC with alcohol and body bath only two days after its separation. The effect of different methods of UC care on its separation time and on colonization with microorganisms has been insufficiently explored. Objectives. Main: To compare the effect on time of UC separation when using body bath with neutral soap followed by natural drying of the UC vs. standard care. Secondary: a) colonization rates during hospitalization; b) incidence of skin infection and conjunctivitis and c) parental comfort with both types of care. Population. Normal term newborns (>37 weeks), born at the HPS, and whose parents provided informed consent. Methods. Open prospective controlled clinical trial, with random allocation to two groups: study group -natural drying of the UC and body bath with neutral soap-and control group -UC hygiene with alcohol 70% at each diaper change until its separation and bath two days later-. UC separation time; UC colonization during hospital stay and skin and conjunctive infections in the first 30 days of life were monitored. Analysis was by intention-to-treat. Results. 362 newborns were included, 181 in each group. The groups were well balanced in baseline characteristics. Being in the study group was associated with a shorter time to UC separation (median [interquartile range]= 6.00 [3] vs. 7.00 [4] days; p <0.001) and an increased frequency in nosocomial UC colonization (adjusted OR= 1.92 [1.22- 3.12], p= 0.007). No difference in the rate of infections was observed between both groups. Parental comfort was high and similar in both groups. Conclusions. Compared to standard practice in Argentina, body bath with neutral soap and natural drying of the UC reduced the time to cord separation. This practice increased the colonization rate, but the risk of skin and conjunctive infections was apparently not modified by it. However, the study has insufficient power for secondary outcomes. Health care providers should continue to develop evidence to support or eliminate historical practices.

16.
Eur J Heart Fail ; 14(9): 974-84, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22700856

RESUMO

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.


Assuntos
Nitrogênio da Ureia Sanguínea , Antígeno Ca-125/sangue , Furosemida/efeitos adversos , Insuficiência Cardíaca/mortalidade , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Coortes , Feminino , Seguimentos , Furosemida/administração & dosagem , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/tratamento farmacológico , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem
17.
Clin Cardiol ; 35(4): 237-43, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22083556

RESUMO

BACKGROUND: Data on the effect of revascularization on outcome in patients with high-risk non-ST-segment elevation acute coronary syndrome (NSTEACS) and significant comorbidities are scarce. Recently, a simple comorbidity index (SCI) including 5 comorbidities (renal failure, dementia, peripheral artery disease, heart failure, and prior myocardial infarction [MI]) has shown to be a useful tool for risk stratification. Nevertheless, therapeutic implications have not been derived. HYPOTHESIS: We sought to evaluate the prognostic effect attributable to revascularization in NSTEACS according the SCI score. METHODS: We included 1017 consecutive patients with NSTEACS. The effect of revascularization on a combined end point of all-cause mortality or nonfatal MI was evaluated by Cox regression according to SCI categories. RESULTS: A total of 560 (55.1%), 236 (23.2%), and 221 (21.7%) patients showed 0, 1, and ≥2 points according to the SCI, respectively. Coronary angiography was performed in 725 patients (71.5%), and 450 patients (44.3%) underwent revascularization. During a median follow-up of 16 months (interquartile range, 12-36 months), 305 (30%) patients experienced the combined end point (202 deaths [19.9%] and 170 MIs [16.7%]). In multivariate analysis, a differential prognostic effect of revascularization was observed comparing SCI ≥2 vs 0 (P for interaction = 0.008). Thus, revascularization was associated with a greater prognostic benefit in patients with SCI ≥2 (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.29-0.89), P = 0.018), whereas no significant benefit was observed in those with 0 and 1 point (HR: 1.31, 95% CI: 0.88-1.94, P = 0.171 and HR: 1.11, 95% CI: 0.70-1.76, P = 0.651, respectively). CONCLUSIONS: In NSTEACS, the SCI score appears to be a useful tool for identifying a subset of patients with a significant long-term death/MI risk reduction attributable to revascularization.


Assuntos
Síndrome Coronariana Aguda/patologia , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/mortalidade , Idoso , Comorbidade , Intervalos de Confiança , Tomada de Decisões , Feminino , Indicadores Básicos de Saúde , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Espanha , Estatística como Assunto , Fatores de Tempo , Troponina/sangue
18.
Rev. esp. cardiol. Supl. (Ed. impresa) ; 12(supl.D): 21d-24d, 2012. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-166450

RESUMO

En el paciente con cardiopatía isquémica crónica y angina estable, los estudios aleatorizados recomiendan un tratamiento médico óptimo en la mayoría de los casos, excepto en algunas circunstancias en que el paciente podría beneficiarse de la revascularización, como la angina recurrente, la isquemia inducible extensa y la complejidad de la anatomía coronaria. Sin embargo, dado que clásicamente los pacientes con comorbilidades han sido excluidos de estos estudios, desconocemos cuál sería la mejor alternativa terapéutica en este contexto. Aunque en la práctica clínica habitual se tiende a un tratamiento conservador para los enfermos con comorbilidades, algunos estudios recientes sobre ancianos plantean la controversia de que tal vez este subgrupo podría beneficiarse de la revascularización (AU)


Randomized controlled trials in patients with chronic ischemic heart disease and stable angina indicate that the majority of cases can be managed by optimum medical treatment. The exceptions are patients with conditions that could benefit from revascularization, such as recurrent angina, extensive inducible ischemia or complex coronary anatomy. However, since studies have traditionally excluded patients with significant comorbidity, it is not clear which treatment approach would be best in these circumstances. Although patients with comorbidities are usually treated conservatively in routine clinical practice, some recent studies in elderly patients have raised the possibility that this subgroup could benefit from revascularization (AU)


Assuntos
Humanos , Isquemia Miocárdica/cirurgia , Revascularização Miocárdica , Angina Estável/cirurgia , Comorbidade , Fatores de Risco
19.
Acta pediátr. hondu ; 2(2): 155-160, oct,-2011. ilus
Artigo em Espanhol | LILACS | ID: biblio-884740

RESUMO

Latiroides lingual es lavariante más común de tiroides ectópica benigna. Suele manifestarse en la infancia con hipotiroidismo o síntomas locales, como tos crónica y disfagia. Se diagnostica durante la niñez tras el comienzo de síntomas obstructivos, como la disfagia y disfonías progres ivas, obst rucción respiratoria intermitente, disnea, estridor laríngeo o sensación de cuerpo extraño. El diagnóstico por imagen ideal es la resonancia magnética. El objetivo de este artículo es presentar el caso de una lactante menor de 46 días, presentando estridor laríngeo, cianosis, disnea, secundaria a una disgenesia de tiroides debido a tiroides lingual, la cual la llevó a un hipotiroidismo secundario...(AU)


Assuntos
Humanos , Lactente , Cianose/congênito , Transtornos de Deglutição/classificação , Hipotireoidismo/complicações , Tireoide Lingual
20.
Arch Argent Pediatr ; 109(4): 305-13, 2011 Aug.
Artigo em Espanhol | MEDLINE | ID: mdl-21829871

RESUMO

BACKGROUND: Umbilical cord (UC) care is a cause of concern for parents right from birth until its separation. Standard practice in Argentina includes frequent cleansing of the UC with alcohol and body bath only two days after its separation. The effect of different methods of UC care on its separation time and on colonization with microorganisms has been insufficiently explored. OBJECTIVES: Main: To compare the effect on time of UC separation when using body bath with neutral soap followed by natural drying of the UC vs. standard care. Secondary: a) colonization rates during hospitalization; b) incidence of skin infection and conjunctivitis and c) parental comfort with both types of care. POPULATION: Normal term newborns (≥37 weeks), born at the HPS, and whose parents provided informed consent. METHODS: Open prospective controlled clinical trial, with random allocation to two groups: study group -natural drying of the UC and body bath with neutral soap- and control group -UC hygiene with alcohol 70% at each diaper change until its separation and bath two days later-. UC separation time; UC colonization during hospital stay and skin and conjunctive infections in the first 30 days of life were monitored. Analysis was by intention-to-treat. RESULTS: 362 newborns were included, 181 in each group. The groups were well balanced in baseline characteristics. Being in the study group was associated with a shorter time to UC separation (median [interquartile range]= 6.00 [3] vs. 7.00 [4] days; p <0.001) and an increased frequency in nosocomial UC colonization (adjusted OR= 1.92 [1.22- 3.12], p= 0.007). No difference in the rate of infections was observed between both groups. Parental comfort was high and similar in both groups. CONCLUSIONS: Compared to standard practice in Argentina, body bath with neutral soap and natural drying of the UC reduced the time to cord separation. This practice increased the colonization rate, but the risk of skin and conjunctive infections was apparently not modified by it. However, the study has insufficient power for secondary outcomes. Health care providers should continue to develop evidence to support or eliminate historical practices.


Assuntos
Banhos , Etanol/administração & dosagem , Cuidado do Lactente/métodos , Cordão Umbilical , Feminino , Humanos , Recém-Nascido , Masculino , Estudos Prospectivos
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