Diastolic Dysfunction Following Anthracycline-Based Chemotherapy in Breast Cancer Patients: Incidence and Predictors.

INTRODUCTION: Cardiotoxicity represents a major limitation for the use of anthracyclines or trastuzumab in breast cancer patients. Data from longitudinal studies of diastolic dysfunction (DD) in this group of patients are scarce. The objective of the present study was to assess the incidence, evolution, and predictors of DD in patients with breast cancer treated with anthracyclines. METHODS: This analytical, observational cohort study comprised 100 consecutive patients receiving anthracycline-based chemotherapy (CHT) for breast cancer. All patients underwent clinical evaluation, echocardiogram, and measurement of cardiac biomarkers at baseline, end of anthracycline-based CHT, and at 3 months and 9 months after anthracycline-based CHT was completed. Fifteen patients receiving trastuzumab were followed with two additional visits at 6 and 12 months after the last dose of anthracycline-based CHT. A multivariate analysis was performed to find variables related to the development of DD. Fifteen of the 100 patients had baseline DD and were excluded from this analysis. RESULTS: At the end of follow-up (median: 12 months, interquartile range: 11.1-12.8), 49 patients (57.6%) developed DD. DD was persistent in 36 (73%) but reversible in the remaining 13 patients (27%). Four patients developed cardiotoxicity (three patients had left ventricular systolic dysfunction and one suffered a sudden cardiac death). None of the patients with normal diastolic function developed systolic dysfunction during follow-up. In the logistic regression model, body mass index (BMI) and age were independently related to the development of DD, with the following odds ratio values: BMI: 1.19 (95% confidence interval [CI]: 1.04-1.36), and age: 1.12 (95% CI: 1.03-1.19). Neither cardiac biomarkers nor remaining clinical variables were predictors of DD. CONCLUSION: Development of diastolic dysfunction after treatment with anthracycline or anthracycline- plus trastuzumab chemotherapy is common. BMI and age were independently associated with DD following anthracycline chemotherapy.

Early and late onset cardiotoxicity following anthracycline-based chemotherapy in breast cancer patients: Incidence and predictors.

INTRODUCTION: Cardiotoxicity represents a major limitation for the use of anthracyclines or trastuzumab in breast cancer patients. Data on longitudinal studies about early and late onset cardiotoxicity in this group of patients is scarce. The objective of the present study was to assess predictors of early and late onset cardiotoxicity in patients with breast cancer treated with A. METHODS: 100 consecutive patients receiving anthracycline-based chemotherapy (CHT) to treat breast cancer were included in this prospective study. All patients underwent evaluation at baseline, at the end of CHT, 3 months after the end of CHT and 1 and 4 years after the beginning of CHT. Clinical data, systolic and diastolic echo parameters and cardiac biomarkers including high sensitivity Troponin T (TnT), N-terminal pro-brain natriuretic peptide (NT-proBNP) and Heart-type fatty acid binding protein (H-FABP) were assessed. RESULTS: Mean doxorubicin dose was 243 mg/m2. Mean follow-up was 51.8 ± 8.2 months. At one-year incidence of anthracycline related-cardiotoxicity (AR-CT) was 4% and at the end of follow-up was 18% (15 patients asymptomatic left ventricular systolic dysfunction, 1 patients heart failure and 2 patients a sudden cardiac death). Forty-nine patients developed diastolic dysfunction (DD) during first year. In the univariate analysis DD during first year was the only parameter associated with AR-CT (Table 1). In the logistic regression model DD was independently related with the development of AR-CT, with an odds ratio value of 7.5 (95% CI 1.59-35.3). CONCLUSIONS: Incidence of late-onset cardiotoxicity is high but mostly subclinical. Diastolic dysfunction early after chemotherapy is a strong predictor of anthracycline cardiotoxicity.

Periannular extension of infective endocarditis.

OBJECTIVES: This prospective study was designed to assess the current clinical course, risk factors, microbiologic profile and echocardiographic findings of patients with left-sided endocarditis and perivalvular complications. BACKGROUND: Periannular complications worsen the prognosis of patients with endocarditis. The relation between these complications and the clinical and microbiologic data has not been clearly defined. METHODS: In this clinical cohort study, 211 patients with left-sided endocarditis, according to the Duke criteria, were prospectively recruited. All patients underwent conventional and transesophageal echocardiography. The mean follow-up interval was 151 days. RESULTS: Perivalvular complications were detected in 78 patients (37%). The incidence of periannular extension of infection in native and prosthetic valves was 29% and 55%, respectively. The presence of prosthesis (relative risk [RR] 1.88, 95% confidence interval [CI] 1.35 to 2.64) and previous endocarditis (RR 1.78, 95% CI 1.16 to 2.7) were the only pre-existing heart conditions associated with perivalvular complications. Aortic infection (RR 1.8, 95% CI 1.23 to 2.66) and the development of atrioventricular (AV) block (RR 2.55, 95% CI 1.91 to 3.41) were related with the existence of these complications. Coagulase-negative staphylococci were very common in patients with perivalvular complications (RR 1.77, 95% CI 1.21 to 2.59), and small vegetations were more frequent in these patients (RR l.45, 95% CI 0.95 to 2.22). An operation was more frequently performed in patients with perivalvular complications, but mortality was similar in patients with and without these complications. CONCLUSIONS: Aortic infection, prosthetic endocarditis, new AV block and coagulase-negative staphylococci were independent risk factors of periannular complications. The period between symptom onset and diagnosis, the incidence of pericardial effusion and persistent signs of infection were similar between patients with and without perivalvular complications. Patients with perivalvular complications did not demonstrate a difference in the presence or size of vegetations or the frequency of embolism. An operation was more frequently performed in these patients, but mortality was similar in both groups.

Risk of embolization after institution of antibiotic therapy for infective endocarditis.

OBJECTIVES: This study was designed to assess the risk of systemic embolization in patients with left-sided infective endocarditis, once adequate antibiotic treatment had been initiated, on the basis of prospective clinical follow-up. BACKGROUND: As one of the complications of infective endocarditis, embolization has a great impact on prognosis. Prediction of an individual patient's risk of embolization is very difficult. METHODS: We studied 217 episodes of left-sided endocarditis that were experienced among a cohort of 211 prospectively recruited patients. According to the Duke criteria, 91% of the episodes were definite infective endocarditis. Seventy-two episodes involved infections located on prosthetic valves. All patients were studied by transthoracic and transesophageal echocardiography. Clinical, echocardiographic and microbiologic data were entered in a data base. The mean follow-up interval was 151 days. RESULTS: Twenty-eight episodes (12.9%; group I) of endocarditis had embolic events after the initiation of antibiotic therapy. The remaining 189 episodes did not embolize (group II). Most emboli (52%) affected the central nervous system, and 65% of the embolic events occurred during the first two weeks after initiation of antibiotic therapy. Previous embolism was associated with new embolism (relative risk [RR] 1.73, 95% confidence interval [CI] 1.02 to 2.93; p = 0.05). There was an increase in the risk of embolization with increasing vegetation size (RR 3.77, 95% CI 0.97 to 12.57; p = 0.07). Vegetation size had no impact on the risk of embolization in streptococcal endocarditis or aortic infection. By contrast, large (> or = 10 mm) vegetations had a higher incidence of embolism when the microorganism was staphylococcus (p = 0.04) and the mitral valve was infected (p = 0.03). The increase in vegetation size at follow-up showed a higher risk for embolization (RR 2.64, 95% CI 0.98 to 7.16; p = 0.02). CONCLUSIONS: Embolism before antimicrobial therapy is a risk factor for new emboli. The risk of embolization seems to increase with increasing vegetation size, and this is particularly significant in mitral endocarditis and staphylococcal endocarditis. An increase in vegetation size, despite antimicrobial treatment, may predict later embolism.

Vegetation size at diagnosis in infective endocarditis: influencing factors and prognostic implications.

The role of vegetation as the key feature of infective endocarditis is universally recognized. Nowadays, the wide availability of transesophageal echocardiography has made of it the most employed technique to establish the diagnosis by visualizing vegetations. However, the factors which influence the size of vegetation when first detected are not clearly determined. Furthermore, there is considerable controversy regarding the prognostic implications of the size of vegetation. This is of paramount significance to early identify patients at high risk for complications, which might benefit from aggressive attitudes. We present a study based on TEE. Our results show that the size of vegetation at admission is mostly determined by anatomical and not microbiological factors, and the prognostic influence of vegetations on the risk of embolisms, need of surgery, persistent infection and septic shock.

¿Bivalirudina o heparina asociada a inhibidores de la glucoproteína IIb/IIIa en el síndrome coronario agudo sin elevación del ST? / Bivalirudin or heparin plus glycoprotein-IIb/IIIa inhibitors for non-ST-elevation acute coronary syndrome?

La bivalirudina, análogo sintético de la hirudina que se une reversiblemente a la trombina, pertenece al grupo de anticoagulantes que son inhibidores directos de la trombina con un efecto muy predecible. El objetivo de esta revisión es responder a la pregunta: ¿cuáles son la eficacia y la seguridad del tratamiento con bivalirudina en pacientes con síndrome coronario agudo sin elevación del ST, en comparación con la combinación de heparina (no fraccionada o de bajo peso molecular) e inhibidores de la glucoproteína IIb/ IIIa? Ambas estrategias han sido comparadas en dos estudios (ACUITY y REPLACE-2), de diseño e interpretación difícil, y que han mostrado una eficacia en términos de prevención de eventos cardiacos similar y disminución de las complicaciones hemorrágicas en los grupos asignados a recibir tratamiento con bivalirudina. Se realiza un análisis crítico de las evidencias y de las limitaciones existentes, que pueden servir de base para implantar una u otra estrategia en los protocolos de manejo del síndrome coronario agudo sin elevación del ST (AU)

Bivalirudin is a synthetic analog of hirudin that binds reversibly to thrombin. It belongs to a group of anticoagulants that act as direct thrombin inhibitors and whose effect is highly predictable. The aim of this review was to answer the question: How does the efficacy and safety of bivalirudin in patients with nonST-elevation acute coronary syndrome compare with that of the combination of (unfractionated or lowmolecular-weight) heparin and a glycoprotein-IIb/IIIa inhibitor? The two treatment strategies have been compared in two studies (i.e. ACUITY and REPLACE-2), both of which had a complex design and were difficult to interpret. These studies demonstrated that the two treatment strategies had similar efficacy in terms of preventing cardiac events and that fewer hemorrhagic complications occurred in the groups assigned to bivalirudin. We carried out a thorough analysis of the data available and their limitations, the results of which can serve as a basis for implementing one or other strategy in treatment protocols for nonST-elevation acute coronary síndrome (AU)

Perfil clínico y pronóstico de los pacientes con endocarditis y seudoaneurismas perianulares / Clinical Profile and Prognosis of Patients with Endocarditis and Periannular Pseudoaneurysms

Introducción y objetivos. El propósito de este estudio ha sido conocer el curso clínico y el pronóstico de los pacientes con endocarditis que desarrollan un seudoaneurisma. Métodos. Se describen las características clínicas y evolutivas de un grupo de 18 pacientes (11 varones, edad media 55 ñ 4 años) con endocarditis infecciosa, en quienes la ecografía transesofágica diagnosticó la presencia de seudoaneurisma. Resultados. Catorce seudoaneurismas se localizaron en posición aórtica (6 sobre válvula nativa y 8 sobre prótesis), tres en posición mitral (tres prótesis) y uno en posición tricuspídea. En 6 casos apareció bloqueo aurículoventricular que no existía al ingreso, y en todos ellos el seudoaneurisma estaba en posición aórtica. Los microorganismos más frecuentemente aislados fueron los estafilococos (n = 5) y estreptococos (n = 5). Se encontraron abscesos en 5 pacientes. La presencia de seudoaneurisma no fue considerada per se como criterio de cirugía. De los 11 pacientes operados, 5 fallecieron tras la cirugía (45 por ciento), uno presentó reinfección y otros 5 están asintomáticos. Los restantes 7 pacientes recibieron exclusivamente tratamiento médico: fallecieron dos (28 por ciento), uno presentó reinfección y cuatro están asintomáticos. En el grupo de tratamiento conservador que están asintomáticos (n = 4), el tamaño del seudoaneurisma no se modificó después de 24 meses de seguimiento (diámetro mayor 21 ñ 5 frente a 22 ñ 5 mm en el seguimiento; p = NS). Conclusiones. La presencia de seudoaneurisma identifica a un subgrupo de pacientes con endocarditis que tienen una alta mortalidad. Los seudoaneurismas son más frecuentes en posición aórtica y alrededor de material protésico. El tratamiento médico puede considerarse una alternativa a la cirugía cuando no existan otras indicaciones quirúrgicas. Finalmente, el tamaño del seudoaneurisma en el grupo de pacientes tratados de forma conservadora permanece estable a lo largo del tiempo (AU)