[EARLY RATHER THAN IMMEDIATE PCI IN NSTEMI; IS TIME EQUAL TO MUSCLE ONCE AGAIN?]

BACKGROUND: Current guidelines advocate immediate vs. non-immediate percutaneous coronary intervention (PCI) strategy in ST elevation vs. non ST elevation myocardial infarction (STEMI, NSTEMI). There is however increasing concern that "next-day PCI" in NSTEMI may adversely affect LV systolic and/or diastolic function and a more urgent aggressive approach should be taken in NSTEMI, similar to that in STEMI. In the current study we compared echocardiographic data between patients with STEMI and NSTEMI who had either primary or early PCI respectively. METHODS: Prospective data of 165 consecutive patients with an acute MI were analyzed. Patients had primary PCI if they had STEMI and non-emergent PCI if they had NSTEMI. Demographic information, laboratory test results, procedure time and post-PCI echocardiographic assessment were compared between the two groups. RESULTS: Patients with STEMI were younger compared to patients with NSTEMI. Time to intervention was significantly longer in NSTEMI, reflecting guideline derived intervention strategy (1.9±1.7days, (median 1day) vs. 30±15min, for NSTEMI and STEMI, respectively, p<0.00001). Post-interventional LV systolic ejection fraction was better in NSTEMI compared to STEMI (53±14 vs. 48±13, respectively, p<0.05). Left atrial diameter, mitral inflow parameters and pulmonary arterial pressure were similar between the two groups. CONCLUSIONS: Adherence to practice guidelines delaying PCI up to 72 hours in patients with NSTEMI did not adversely affect left ventricular systolic and/or diastolic function compared to immediate PCI in patients with STEMI. Based on current data, we conclude that early PCI intervention rather than an immediate one is appropriate in NSTEMI patients.

Endothelial nitric oxide synthase polymorphism and prognosis in systolic heart failure patients.

BACKGROUND: The endothelial nitric oxide synthase (eNOS) gene single nucleotide polymorphism G894T is associated with thrombotic vascular diseases. However, its functional significance is controversial and data are scarce concerning its influence in heart failure (HF). METHODS: We studied 215 patients with chronic systolic HF. DNA was analyzed for eNOS gene G894T polymorphism using PCR and DNA sequencing. Evaluation of clinical characteristics and analysis of factors associated with 2-year mortality were performed for the homozygous G-allele G894T variant (GG), relative to the TT and GT variants. RESULTS: The genotype distributions of eNOS G894T alleles were: GG 135 patients (63%) and TT/GT 80 (37%). Two-year mortality was significantly higher in the GG variant (48%) than the combined TT/GT group (32%). The usage of nitrates was associated with increased 2-year mortality (HR 2.0, 95% CI 1.28-3.17; p = 0.003), which was most significant in the GG group treated with nitrates (73.5%) in comparison to the TT/GT group not treated with nitrates (34%); HR 2.75, 95% CI 1.57-4.79, P < 0.001. CONCLUSIONS: Homozygosity for the G allele of the eNOS G894T polymorphism was associated with worse survival in systolic HF patients, especially in those treated with nitrates. ENOS polymorphism may result in different mechanistic interactions in HF than in thrombotic vascular diseases, suggesting that overexpression of NO may be associated with deleterious effects in systolic HF.

First experience in ambulatory ultrafiltration therapy for congested heart failure patients in Israel: a feasibility study.

BACKGROUND: The prevalence of heart failure (HF) is increasing rapidly with high readmission rates, mainly due to fluid retention. Ultrafiltration (UF) is a mechanical method for removing fluids. Since UF was introduced only recently in Israel, the skill and experience required for outpatient congested HF patients is scarce. OBJECTIVEs: To evaluate the feasibility and safety of UF therapy in congested HF patients in outpatient clinics under a strict protocol of monitoring and therapy that we developed. METHODS: Between April and September 2013 we applied UF in our outpatient clinic to seven chronically congested HF patients with NYHA III-IV who did not respond adequately to diuretics. We administered a total of 38 courses. RESULTS: On average, 1982 ml fluid per course was removed without significant adverse events and with patients' subjective feeling of improvement. Only two courses were interrupted prematurely due to mechanical problems but were completed without harm to the patients. CONCLUSIONS: Under appropriate professional medical supervision, UF therapy in an outpatient setting is a safe and effective procedure and serves as an additional tool for managing congested HF patients who do not respond adequately to diuretics.

The need for maximal sterile barrier precaution in routine interventional coronary procedures; microbiology analysis.

BACKGROUND: Maximal sterile barrier precautions (MSBP) including head coverings and face masks are advocated for use in invasive procedures, including coronary interventions. The rationale for MSBP assumes it is an obligatory measure for infection prevention. However, in many coronary catheterization laboratories, head coverings/face masks are not used in daily practice. This study prospectively evaluated the potential hazards of not routinely using head coverings/face masks in routine coronary interventions. METHODS: This is a prospective study of ambulatory patients in hospital care. A total of 110 successive elective patients undergoing cardiac catheterizations were recruited. Patients were catheterized by several interventional cardiologists who employed only routine infection control precautions without head coverings or face masks. For each patient, we took blood cultures and cultures from the tips of the coronary catheters and from the sterile saline water flush bowl. Cultures were handled and analyzed at our certified hospital microbiology laboratory. RESULTS: In none of the cultures was a clinically significant bacterial growth isolated. No signs of infection were reported later by any of the study patients and there were no relevant subsequent admissions. CONCLUSION: Operating in the catheterization lab without head coverings/face masks was not associated with any bacterial infection in multiple blood and equipment cultures. Accordingly, we believe that the use of head coverings/face masks should not be an obligatory requirement and may be used at the interventional cardiologist's discretion.

Body surface area as a prognostic marker in chronic heart failure patients: results from the Heart Failure Registry of the Heart Failure Association of the European Society of Cardiology.

AIMS: The 'obesity paradox' is consistently observed in patients with heart failure (HF). We investigated the relationship of body surface area (BSA) to mortality and hospitalizations in patients with chronic HF. METHODS AND RESULTS: Data from the outpatient cohort of the observational, prospective, Heart Failure Long-Term Registry of the Heart Failure Association of the European Society of Cardiology was analysed in order to evaluate the prognostic significance of BSA in chronic HF. A total of 9104 chronic HF patients (age 64.8 ± 13.4 years; 71.6% males) were enrolled. Mortality during 1-year follow-up was observed in 718 of 8875 (8.1%) patients. A progressive, inverse relationship between all-cause mortality and BSA levels was observed; the adjusted hazard ratio (HR) for 1-year mortality was 1.823 [95% confidence interval (CI) 1.398-2.376], P < 0.001 for the lowest quartile of BSA <1.78 m(2) , and 1.255, 95% CI 1.000-1.576, P = 0.05 for the middle two quartiles (1.78 ≤BSA ≤2.07 m(2) ), compared with the highest quartile (BSA >2.07 m(2) ). For each increase of 0.1 m(2) in BSA, an adjusted HR of 0.908 (95% CI 0.870-0.948), P < 0.001 for mortality was calculated. HF hospitalizations were not associated with BSA subgroup distribution. In both genders, subjects within the lowest BSA quartile (males <1.84 m(2) and females <1.64 m(2) ) had significantly higher mortality rates during follow-up (log-rank P < 0.0001). However, the stepwise association with mortality was more distinct in males. CONCLUSIONS: Total and cardiovascular mortality, but not HF hospitalizations was inversely associated with BSA levels in chronic HF patients. BSA may serve as a prognostic indicator for adverse outcome in HF patients.

Comparison of body mass index and body surface area as outcome predictors in patients with systolic heart failure.

BACKGROUND: We investigated whether the 'obesity paradox' in heart failure (HF) is influenced by common confounders, and assessed if body surface area (BSA) may correlate more closely than body mass index (BMI) with prognosis. METHODS: We studied 630 systolic HF patients at their initial visit to the HF clinic. Body size was measured by BMI and BSA. The association between body indices and mortality was assessed by Cox proportional-hazard analyses. RESULTS: There were 248 deaths during mean follow-up of 39 months. A progressive inverse association of BMI and BSA tertiles (T1-T3) with mortality risk was observed (for BSA: T3, reference, T2, hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.01-1.95, p = 0.04 and T1, HR = 1.78, 95% CI 1.29-2.45, p < 0.001; for BMI: T3, reference, T2, HR = 1.29, 95% CI 0.92-1.79, p = 0.13 and T1, HR = 1.66, 95% CI 1.21-2.27, p = 0.002). The obesity paradox was attenuated after multivariate adjustment, and did not persist after adjustment for age alone (for BMI: T3, reference, T2, HR = 1.13, 95% CI 0.81-1.58, p = 0.47; T1, HR = 1.30, 95% CI 0.94-1.80, p = 0.12; for BSA: T3, reference, T2, HR = 0.96, 95% CI 0.68-1.35, p = 0.82; T1, HR = 1.15, 95% CI 0.82-1.63, p = 0.42). CONCLUSIONS: BSA provides prognostic information similar to BMI in systolic HF. However, the obesity paradox of both BMI and BSA in HF may be confounded by the younger age of the obese patients.

Single measurement of serum N-terminal pro-brain natriuretic peptide: the best predictor of long-term mortality in patients with chronic systolic heart failure.

BACKGROUND: Although high serum natriuretic peptide (NP) has long been associated with mortality prediction, it was usually tested under acute heart failure (HF) conditions and periods of analysis were short. This may explain the lack of consensus when its routine measurement for mortality prediction is contemplated. Here we evaluated, at the first clinic visit of chronic systolic HF patients, the usefulness of a single serum NP assessment for long-term mortality prediction. METHODS: In 279 consecutive patients with chronic systolic HF, serum NT-proBNP was routinely measured once during the first clinic visit. We analyzed correlations between recorded mortality and the NT-proBNP finding, along with several known clinical echocardiographic, electrocardiographic and laboratory parameters recorded at that visit. RESULTS: During average follow-up of 34±21months 59 (21%) patients died. Serum NT-proBNP was the strongest of the tested predictors of mortality [hazard ratio 3.76, 95% Cl (1.20-11.80), p=0.008]. Nearly seven years later, mortality was still higher in patients with higher initial serum NT-proBNP (p<0.001). CONCLUSIONS: Compared to many other traditional prognostic parameters tested at the same time, the single serum NT-proBNP finding was the strongest predictor of long-term mortality. These results may justify its routine use for this purpose.