Predictive value of admission blood glucose level on short-term mortality in acute cerebral ischemia

BackgroundAdmission hyperglycemia increases the risk of death in patients with acute stroke. However, the most appropriate cut-off of glucose level indicating an increased risk of short-term mortality remains unknown.Purpose and methodsWe aimed at establishing the optimum cut-offs of several variables (including admission blood glucose levels) predicting case-fatality (72 hours, 7 days) and unfavorable outcome [modified Rankin Scale (mRS) score 5–6 at 7 days] in consecutive first-ever acute ischemic stroke. Receiver operating characteristic (ROC) curves were constructed.ResultsEight hundred eleven consecutive patients were included [median age of 77 (69–83) years; 418 (52%) male; 239 (30%) diabetics; median admission National Institutes of Health Stroke Scale (NIHSS) 7 (4–12), 32 (4%) dead within 72 hours; 64 (8%) dead within day 7; 155 (19%) with unfavorable outcome]. Median admission glucose levels were 113 (97–155) mg/dL. Diabetics had significantly higher median glucose levels than non-diabetics [163 (133–214) vs. 107 (92–123) mg/dL, p < 0.001]. According to ROC analysis, the only significant predictive value of glycemia was ≥ 143 mg/dL for 72-hour fatality (sensitivity 88% and specificity 70%) especially in non-diabetics (sensitivity 88% and sensitivity 62%). This cut-off point was an independent predictor for 72-hour fatality (overall: OR = 4.0, CI = 1.6–9.9, p = 0.003; non-diabetics: OR = 4.9, CI = 1.7–14.5, p = 0.004). The cut-offs of fasting total cholesterol levels and admission leukocytes had poor predictive values for each outcome, while those of admission NIHSS had good discrimination in predicting short-term outcome measures.ConclusionsAdmission hyperglycemia (≥ 143 mg/dL) is a strong and an independent predictor for 72-hour fatality, especially in patients with no prior history of diabetes mellitus.     

Effects of Different Classes of Antihypertensive Agents on the Outcome of Acute Ischemic Stroke

It is unclear whether antihypertensive treatment before stroke affects acute ischemic stroke severity and outcome. To evaluate this association, the authors studied 482 consecutive patients (age 78.8±6.7 years) admitted with acute ischemic stroke. Stroke severity was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). The outcome was assessed with rates of adverse outcome (modified Rankin scale at discharge ≥2). Independent predictors of severe stroke (NIHSS ≥16) were female sex and atrial fibrillation. Treatment with diuretics before stroke was associated with nonsevere stroke. At discharge, patients with adverse outcome were less likely to be treated before stroke with β‐blockers or with diuretics. Independent predictors of adverse outcome were older age, higher NIHSS at admission, and history of ischemic stroke. Treatment with diuretics before stroke appears to be associated with less severe neurologic deficit in patients with acute ischemic stroke.     

Different prognostic value of white blood cell subtypes in patients with acute cerebral infarction

ObjectiveWe aimed to investigate the relationship of each white blood cells (WBC) subtype with neurologic severity and outcome in acute stroke.MethodsWe included 779 patients with first-ever acute cerebral infarction within 72 h after symptom onset. We investigated the association between counts for WBC subtypes in peripheral blood at admission and (1) initial stroke severity; (2) early change in stroke severity within one week; and (3) functional outcome at three months.ResultsHigher total WBC and neutrophil counts were associated with more severe stroke at admission (p < 0.001). In contrast, lower lymphocyte counts were associated with a lesser improvement during the first week after admission (p < 0.05) and with poor functional outcome at three months (OR = 0.706 per 1000 lymphocyte counts/mm³, p = 0.020).ConclusionsOur study merits further investigation on the role of each WBC subtype in ischemic injury and different prognostic value of WBC subtypes measured at admission in acute stroke.     

Sex differences in clinical presentation,severity and outcome of stroke: Results from a hospital-based registry

Background and purposeSex related differences in cardiovascular disease and stroke are issues of increasing interest. The aim of this study was to evaluate for sex differences in clinical presentation, severity of stroke and outcome in a population of patients admitted to 4 public and 1 private hospitals in three different regions of Italy.MethodsAll hospital admissions for ischemic and haemorrhagic stroke (ICD-IX code 434 and 431 respectively) between January 1st and December 31st, 2011 at five different hospitals located in three different regions of Italy: Milan (North), Rome and Perugia (Center), and Palermo (South) have been recorded and sex-differences have been evaluated.ResultsA total of 1272 stroke patients were included in the analysis: 1152 ischemic and 120 haemorrhagic strokes, 567 women and 705 men. Compared to men, women were significantly older (mean age 75.2 SD 13.7 vs 71.5 SD 12.5 years, P < 0.001) and their stroke severities at onset, measured by NIHSS, were also compared to men (10 SD 8 vs 8 SD 7, P < 0.001).Female sex was associated with a worse functional prognosis measured by modified Rankin Scale score (mRS ≥ 3), as well as in-hospital mortality, without reaching statistical significance.There were no observed significant differences between sexes regarding the number of patients treated with thrombolytic therapy. Analysis of the distribution of risk factors between sexes showed a prevalence of atrial fibrillation in women (29% vs 21%, P = 0.003).ConclusionsBoth stroke severity and functional outcome were worse in women.     

Hyponatremia is an independent predictor of adverse clinical outcomes in hospitalized patients due to worsening heart failure

Background and purposeHyponatremia is common and is associated with poor in-hospital outcomes in patients hospitalized with heart failure (HF). However, it is unknown whether hyponatremia is associated with long-term adverse outcomes. The purpose of this study was to clarify the characteristics, clinical status on admission, and management during hospitalization according to the serum sodium concentration on admission, and determine whether hyponatremia was associated with in-hospital as well as long-term outcomes in 1677 patients hospitalized with worsening HF on index hospitalization registered in the database of the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).Methods and subjectsWe studied the characteristics and in-hospital treatment in 1659 patients hospitalized with worsening HF by using the JCARE-CARD database. Patients were divided into 2 groups according to serum sodium concentration on admission <135 mEq/mL (n = 176; 10.6%) or ≥135 mEq/mL (n = 1483; 89.4%).ResultsThe mean age was 70.7 years and 59.2% were male. Etiology was ischemic in 33.9% and mean left ventricular ejection fraction was 42.4%. After adjustment for covariates, hyponatremia was independently associated with in-hospital death [adjusted odds ratio (OR) 2.453, 95% confidence interval (CI) 1.265–4.755, p = 0.008]. It was significantly associated also with adverse long-term (mean 2.1 ± 0.8 years) outcomes including all-cause death (OR 1.952, 95% CI 1.433–2.657), cardiac death (OR 2.053, 95% CI 1.413–2.983), and rehospitalization due to worsening HF (OR 1.488, 95% CI 1.134–1.953).ConclusionsHyponatremia was independently associated with not only in-hospital but also long-term adverse outcomes in patients hospitalized with worsening HF.     

Evaluation of transient hyperglycemia in non-diabetic patients with febrile neutropenia

BackgroundWe aimed to examine the effect of transient hyperglycemia in non-diabetic patients with febrile neutropenia.MethodsA total of 86 patients with febrile neutropenia were evaluated between June 2006 and December 2009. After measuring random blood glucose level at admission, cases with stress hyperglycemia were included in the study. Stress hyperglycemia was defined as documented random blood glucose level of 140 mg/dl and above without known diabetes mellitus, impaired glucose tolerance and impaired fasting glucose. A Multinational Association for Supportive Care in Cancer (MASCC) scoring system was used for the prediction of low and high risk patients according to medical complications at the onset of the febrile episode.ResultsThere were more patients with stress hyperglycemia than the patients with normoglycemia in the high risk group (p = 0.001). The growth of gram negative bacteria and fungi was higher in patients with stress hyperglycemia than with normoglycemia (p = 0.001). The patients receiving antifungal therapy had a higher rate of stress hyperglycemia than the patients without receiving antifungal therapy (p = 0.009). The patients with stress hyperglycemia had higher mortality rates than the patients with normoglycemia (p = 0.007). According to the MASCC risk-index, stress hyperglycemia increased 3.35 fold in the high risk patients compared to the low risk patients (p = 0.046) and 4.14 fold in the patients treated with antibacterial and antifungal agents compared to the patients treated with only antibacterial agents (p = 0.038).ConclusionPatients with stress hyperglycemia had more adverse clinical outcomes than patients with normoglycemia. We think further studies are needed to evaluate the relationship between stress hyperglycemia and febrile neutropenia.     

Prognostic Significance of Acute Kidney Injury After Reperfused ST-Elevation Myocardial Infarction: Synergistic Acceleration of Renal Dysfunction and Left Ventricular Remodeling

BackgroundAcute kidney injury (AKI) after myocardial infarction is associated with poor clinical outcome. However, mechanisms of the adverse effect of AKI on clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) have not been fully elucidated.Methods and ResultsWe examined 141 consecutive patients with reperfused first anterior STEMI. AKI was defined as an increase in serum creatinine of ≥0.3 mg/dL within 48 hours after admission. Patients with AKI had higher incidence of in-hospital cardiac death (P = .0004) and major adverse cardiac events (MACE, P = .020) during a mean of 39 ± 40 (range, 1 to 96) months than those without, in association with adverse left ventricular (LV) remodeling. White blood cell count on admission and peak C-reactive protein were higher in patients with than those without AKI. Plasma norepinephrine on admission, interleukin-6, brain natriuretic peptide, and malondialdehyde-modified low-density lipoprotein 2 weeks after STEMI were higher in patients with AKI than those without AKI. Cox proportional hazards model analysis revealed AKI was an independent predictor of MACE (hazard ratio = 2.38, P = .019).ConclusionsAKI was a strong predictor of MACE in association with adverse LV remodeling. Enhanced inflammatory response, oxidative stress, and neurohormonal activation may synergistically accelerate renal dysfunction and LV remodeling after STEMI.     

Prediction of cerebrovascular event risk following myocardial infarction

IntroductionPatients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI).MethodsWe analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]).ResultsDuring follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60 ml/min/m² (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42 ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7 mmol/l (OR 4.09; p=0.017) that fi tted the data well (Hosmer-Lemeshow: p=0.916).Discussion/conclusionsIn patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.     

Long-term survival following acute heart failure: The Acute Heart Failure Database Main registry (AHEAD Main)

BackgroundThe in-hospital mortality of patients with acute heart failure (AHF) is reported to be 12.7% and mortality on day 30 after admission 17.2%. Less information is known about the long-term prognosis of those patients discharged after hospitalization. As such, the aim of this study was to investigate long-term survival in a cohort of patients who had been hospitalized for AHF and then discharged.MethodsThe AHEAD Main registry includes 4153 patients hospitalized for AHF in 7 different medical centers, each with its own cathlab, in the Czech Republic. Patient survival rates were evaluated in 3438 patients who had survived to day 30 after admission, and were used as a measurement of long-term survival.ResultsThe most common etiologies were acute coronary syndrome (32.3%) and chronic ischemic heart disease (20.1%). The survival rate after day 30 following admission was 79.7% after 1 year and 64.5% after 3 years. No statistically significant difference in syndromes was found in survival after day 30. Independent predictors of a worse prognosis were defined as follows: age > 70 years, comorbidities, severe left ventricular systolic dysfunction, valvular disease or ACS as an etiology of AHF. A better prognosis was defined for de-novo AHF patients, and those who were taking ACE inhibitors at the time of discharge. In a sub-analysis, high levels of natriuretic peptides were the most powerful predictors of high-risk, long-term mortality.ConclusionThe AHEAD Main registry provides up-to-date information on the long-term prognosis of patients hospitalized with AHF. The 3-year survival of patients following day 30 of admission was 64.5%. Higher age, LV dysfunction, comorbidities and high levels of natriuretic peptides were the most powerful predictors of worse prognosis in long-term survival.     

Clinical outcomes of acute ischemic stroke patients treated by direct catheter-based trombectomy depending on their baseline characteristics

BackgroundDirect catheter-based thrombectomy (d-CBT) was proven to be an effective treatment for proximal occlusions of the major intracranial arteries in acute stroke patients. The aim of this study was to compare clinical outcomes of patients treated by d-CBT depending on their baseline characteristics.MethodsA single center, prospective, observational registry of consecutive patients (pts) treated by d-CBT for an acute ischemic stroke. The degree of dependence after a stroke was measured by the modified Rankin scale (mRS) at 3 months follow-up and pts were divided into 2 subgroups based on functional independence/dependence (mRS 0–2 vs. 3–6).ResultsA total of 111 consecutive patients (mean age 65.9 ys, men 55%) have been enrolled. A favorable outcome (mRS ≤ 2 at 3 months) was reached in 39.8% (44 pts). The pts with favorable outcome (mRS ≤ 2) compared to pts with poor outcome (mRS 3–6) were younger (61 ys vs. 70 ys, p < 0.01), had higher prevalence of cigarette smoking (45.5% vs. 25.4%, p < 0.002) and had lower prevalence of known atrial fibrilation (25% vs. 53.7%, p < 0.001). There were no significant differences between the subgroups in: sex (men 50% vs. 58%, p = 0.27), body mass index (27.8 vs. 29.2, p = 0.21), arterial hypertension (70.5% vs. 77.6%, p = 0.26), diabetes mellitus (15.9% vs. 25.4%, p = 0.15), chronic kidney disease (11.4% vs. 22.4%, p = 0.08) and NIHSS on admission (15 vs. 18, p = 0.69).ConclusionsMechanical thrombectomy achieved better clinical results in younger patients, in smokers and in patients with stroke not caused by atrial fibrillation.     

Pulmonary embolism,acute coronary syndrome and ischemic stroke in the Spanish National Discharge Database

BackgroundVenous and arterial thrombosis share a number of pathogenic mechanisms, but the burden of pulmonary embolism (PE) has not been consistently compared with that in other arterial diseases.MethodsWe used the Spanish National Discharge Database to compare the frequency, clinical characteristics and mortality rate of all patients with PE, acute coronary syndrome (ACS) or ischemic stroke admitted from 2001 to 2010. Patients were classified as having primary diagnosis (the process leading to hospital admission) or secondary diagnosis (it appeared during hospital stay for other reasons)ResultsDuring the study period, 31,949,739 patients were discharged. Of these, 165,229 (0.52%) were diagnosed with PE, 562,837 (1.76%) with ACS and 495,427 (1.55%) with ischemic stroke. Overall, 31% of patients with PE, 8.4% with ACS and 13% with ischemic stroke had secondary diagnoses. The most common reasons for admission in patients with secondary PE were: cancer (21%), acute respiratory failure (11%), acute heart failure (6.4%) and stroke (5.5%). Mean hospital stay was: 14 ± 13 days in PE patients, 9.7 ± 9.7 in those with ACS and 13 ± 14 days in those with stroke. In-hospital mortality rate was: 10.5%, 10.1% and 12.3% respectively in patients with primary diagnosis, and 36%, 34% and 29% in those with secondary diagnosis.ConclusionsPatients hospitalized with PE were 3–4 times less frequent than those with ACS or stroke, but had a higher mortality. One in every 3 patients with PE (but only one in every 10 with ACS or stroke) had secondary diagnosis, and these patients had the highest mortality.     

Prognostic value of hyperglycemia on-admission in diabetic versus non-diabetic patients presenting with ST-elevation myocardial infarction in Tunisia

BackgroundHyperglycemia on-admission is a powerful predictor of adverse events in patients presenting for ST-elevation myocardial infarction (STEMI).AimIn this study, we sought to determine the prognostic value of hyperglycemia on-admission in Tunisian patients presenting with STEMI according to their diabetic status.MethodsPatients presenting to our center between January 1998 and September 2014 were enrolled. Hyperglycemia was defined as a glucose level ≥11 mmol/L. In-hospital prognosis was studied in diabetic and non-diabetic patients. The predictive value for mortality of glycemia level on-admission was assessed by mean of the area under receiver operating characteristic (ROC) curve calculation.ResultsA total of 1289 patients were included. Mean age was 60.39 ± 12.8 years and 977 (77.3%) patients were male. Prevalence of diabetes mellitus was 70.2% and 15.2% in patients presenting with and without hyperglycemia, respectively (p < 0.001). In univariate analysis, hyperglycemia was associated to in-hospital death in diabetic (OR: 8.85, 95% CI: 2.11–37.12, p < 0.001) and non-diabetic patients (OR: 2.57, 95% CI: 1.39–4.74, p = 0.002). In multivariate analysis, hyperglycemia was independently predictive of in-hospital death in diabetic patients (OR: 9.6, 95% CI: 2.18–42.22, p = 0.003) but not in non-diabetic patients (OR: 1.93, 95% CI: 0.97–3.86, p = 0.06). Area under ROC curve of glycemia as a predictor of in-hospital death was 0.792 in diabetic and 0.676 in non-diabetic patients.ConclusionIn patients presenting with STEMI, hyperglycemia was associated to hospital death in diabetic and non-diabetic patients in univariate analysis. In multivariate analysis, hyperglycemia was independently associated to in-hospital death in diabetic but not in non-diabetic patients.     

Prognostic importance of admission versus persistent glycemia in acute coronary syndrome

BackgroundWhether persistent hyperglycemia (PG) during hospitalisation has a greater impact on adverse outcomes in acute myocardial infarction (AMI) than a single random glucose measurement is not well defined.AimsTo find out the association of admission glycemia (AG) VS PG on outcomes in patients of ACS.Study design and methodsProspective, cohort, hospital-based. We evaluated 200 patients of ACS for admission and in-hospital glycemia and their impacts on outcomes. AG was defined as a plasma glucose >198 mg/dl and PG as a random glucose >140 mg/dl at any point during hospitalisation. Demographic and biochemistry including risk factors recorded. A multiple regression was done to evaluate association of various parameters with worse prognosis.ResultsOf the 200 patients evaluated, 35 (17.5%) presented with AG. 31 (15.5%) had PG. Males were predominant and 47 (23%) previously known diabetic patients. 62 (31%) had unstable angina, 52 (26%) NSTEMI and 86 (43%) STEMI, between PG and LEF, higher troponin levels and in-hospital mortality and between LEF and age (p < 0.001), serum creatinine (p 0.023) and mean in-hospital glucose (p 0.005). F-indices were compared with AG for their ability to discriminate hospitalization survivors from non-survivors. All average glucose metrics performed better than AG. The ability of these models improved as the time window increased (F-indices for admission, mean 24 h, 48 h and 72 h were 2.51, 12.05, 8.3 and 5.72, respectively).ConclusionThe present study demonstrates that PG is a better discriminator of prognosis than AG in patients of ACS.     

Diabetic and non-diabetic subjects with ischemic stroke: differences, subtype distribution and outcome

Background and aimDiabetes mellitus increases the risk of stroke, and pathophysiological changes of diabetic cerebral vessels may differ in comparison with non-diabetic ones; nonetheless, the clinical and prognostic profile of stroke in diabetic patients is not yet fully understood. On this basis, the aim of our study was to evaluate cerebrovascular risk factor prevalence in diabetic stroke patients in comparison with non-diabetics, to analyze whether diabetics have a different prevalence of stroke subtypes as classified by the TOAST classification, and determine whether diabetics and non-diabetics have a different prognosis.Methods and resultsWe enrolled 102 diabetics and 204 non-diabetic subjects with acute ischemic stroke, matched by sex and age (± 3 years). We used as outcome indicators the Scandinavian Stroke Scale (SSS) score at admission and the modified Rankin disability scale at discharge and at a 6-month follow-up. We classified ischemic stroke according to the TOAST classification.Diabetes was associated with lacunar ischemic stroke subtype, with a record of hypertension, and with a better SSS score at admission. The association of diabetes with lacunar stroke remained significant even after adjustment for hypertension or for large artery atherosclerotic and cardioembolic stroke subtypes.ConclusionOur study shows some significant differences in acute ischemic stroke among diabetics in comparison with non-diabetics (higher frequency of hypertension, higher prevalence of lacunar stroke subtype, lower neurological deficit at admission in diabetics).     

Clinical predictors of outcome in survivors of out-of-hospital cardiac arrest treated with hypothermia

BackgroundOut-of-hospital cardiac arrest (OHCA) is a leading cause of death and severe neurological disability. The objective of this study was to identify clinical predictors of early neurological outcome in survivors of OHCA managed according to recent recommendations for OHCA care.MethodsData from survivors of OHCA, admitted to a tertiary cardiac intensive care unit and treated with hypothermia in a 22 months period (n=46, age 60±13 years, 74% males) were retrospectively evaluated. At 1-month follow-up, patients were classified according to the best achieved Glasgow–Pittsburgh cerebral performance categories (CPC 1–5) and factors affecting the outcome were analysed.ResultsAt 1-month follow-up, 23 patients (50%) had favourable outcome (CPC 1–2), while 23 patients (50%) had poor outcome (CPC 3–5), including 19 with in-hospital death (41% of total). Patients with good outcome were younger (55±13 years vs. 66±10 years; P=0.003), had more often myocardial infarction as the cause of arrest (63% vs. 30%; P=0.018) and ventricular fibrillation/tachycardia as an initial rhythm (78% vs. 39%; P=0.007). Both groups differed by lactate level on admission (4.0±4.6 vs. 7.3±4.1 mmol/l, P=0.02), after 12 h (2.5±1.1 vs. 4.3±3.2 mmol/l, P=0.04) and after 24 h (1.9±1.2 vs. 3.2±1.9 mmol/l, P=0.04). Logistic regression revealed the following independent outcome predictors: age, acute myocardial infarction and admission lactate level.ConclusionFavourable outcome was observed in a half of OHCA survivors. Young age, acute myocardial infarction as underlying aetiology of cardiac arrest, and low lactate level on admission were the best predictors of favourable outcome.     

Fate of individuals with ischemic amputations in the REACH Registry: three-year cardiovascular and limb-related outcomes

ObjectiveTo evaluate systemic and limb ischemic event rates of PAD patients with prior leg amputation and determine predictors of adverse outcomes.MethodsThe REduction of Atherothrombosis for Continued Health (REACH) Registry provided a prospective multinational cohort of 7996 outpatients with PAD enrolled from primary medical clinics in 44 countries in 2003–2004. 1160 patients (14.5%) had a prior leg amputation at any level. Systemic (myocardial infarction [MI], stroke, cardiovascular death) and limb (angioplasty, surgery, amputation) ischemic event rates were determined in a 3-year follow-up.ResultsPAD patients with leg amputations on entry had a 5-fold higher rate of a subsequent amputation (12.4% vs. 2.4%, P < .001), lower rate of peripheral angioplasty (8.3% vs. 10.7%, P = .005), and similar rates of surgical revascularization procedures compared with PAD patients without amputation. A nearly 2-fold increase in rates of cardiovascular death (14.5% vs. 7.7%, P < .001) and all-cause mortality (21.8% vs. 12.6%, P < .001) and an increase in the composite outcome of MI, stroke, cardiovascular death, or hospitalization (48.7% vs. 40.0%, P < .001) were noted. Recent (≤1 year) amputation was associated with higher rates of worsening PAD, subsequent lower extremity surgical revascularization procedures, re-amputation, non-fatal MI, and the composite outcome, including hospitalization. Adverse systemic and limb ischemic outcomes were similar regardless of amputation level.ConclusionsIndividuals with a history of leg amputations have markedly elevated rates of systemic and limb-related outcomes. PAD patients with recent ischemic amputation have the highest risk of adverse events. A history of “minor” ischemic amputation may confer an identical systemic risk as “major” leg amputation.     

Hemoglobina: um mero valor analítico ou um poderoso preditor de risco em doentes com síndromes coronárias agudas?

IntroductionAnemia has been shown to be associated with a worse prognosis, especially higher mortality in various pathological conditions. However, few studies have specifically examined its impact in acute coronary syndrome (ACS) patients. The purpose of our study was to assess the association between different quartiles of hemoglobin on admission and short- and long-term prognosis in patients with ACS.MethodsWe performed a retrospective analysis of 1303 consecutive ACS patients admitted to a coronary care unit and analyzed the association between baseline hemoglobin and morbidity and mortality, in-hospital and at 12-month follow-up. The population was divided into groups according to quartiles of hemoglobin concentration (Hb): Q1: <10.8 g/dl; Q2: 10.8-12.2 g/dl; Q3: 12.3-13.2 g/dl; Q4: ≥13.3 g/dl. Logistic regression analysis was used to identify independent predictors of short- and long-term mortality.ResultsHypertension and diabetes mellitus were more common in the lower Hb quartiles, while the prevalence of smoking and physical inactivity increased with higher Hb. A higher proportion of patients in the lower quartiles had congestive heart failure, peripheral artery disease and previous stroke or transient ischemic attack. Anemic patients tended to be older, with worse renal function and left ventricular systolic function. Patients in Q1 had significantly higher levels of troponin I and blood glucose on admission. Anemic patients showed significantly higher in-hospital mortality (Q1: 9.8%; Q2: 6.3%; Q3: 4.1%; Q4: 3.6%, p<0.001), longer hospital stay (Q1: 6.1±4.4; Q2: 5.2±3.0; Q3: 4.9±2.7; Q4 4.3±2.1 days, p<0.001) and higher 1-year mortality (Q1: 23.6%; Q2: 11.6%; Q3: 10.6%; Q4: 5.5%, p<0.001). In multivariate analysis, the only independent predictor of in-hospital mortality was Killip class >1 at admission. The independent predictors of long-term mortality were age ≥69.5 years, Killip class >1 at admission, diabetes mellitus, ST-segment depression on admission ECG and Hb <10.8 g/dl.Discussion and conclusionsLow baseline hemoglobin is associated with more comorbidities and can accurately predict 1-year mortality after an acute coronary syndrome.     

Serum ferritin at admission in hospitalized COVID-19 patients as a predictor of mortality

IntroductionSome COVID-19 patients have higher mortality and the responsible factors for this unfavorable outcome is still not well understood.ObjectiveTo study the association between ferritin levels at admission, representing an inflammatory state, and hospital mortality in COVID-19 patients.MethodsFrom May through July 2020, SARS-CoV-2 positive patients with moderate to severe clinical symptoms were evaluated at admission, regarding clinical and laboratory data on renal and hepatic function, hematologic parameters, cytomegalovirus co-infection, and acute phase proteins.ResultsA total of 97 patients were included; mean age = 59.9 ± 16.3 years, 58.8% male, 57.7% non-white, in-hospital mortality = 45.4%. Age, ferritin, C-reactive protein, serum albumin and creatinine were significantly associated with mortality. Ferritin showed area under the curve (AUC) of 0.79 (p < 0.001) for the cut-off of 1873.0 ng/mL, sensitivity of 68.4% and specificity of 79.3% in predicting in-hospital mortality. Age ≥60 years had an odds ratio (OR) of 10.5 (95% CI = 1.8–59.5; p = 0.008) and ferritin ≥1873.0 ng/mL had an OR of 6.0 (95% CI = 1.4–26.2; p = 0.016), both independently associated with mortality based on logistic regression analysis.ConclusionThe magnitude of inflammation present at admission of COVID-19 patients, represented by high ferritin levels, is independently predictive of in-hospital mortality.     

Low plasma testosterone and elevated carotid intima-media thickness: importance of low-grade inflammation in elderly men

ObjectiveCXCL16 is a chemokine involved in atherosclerosis by promoting inflammation, lipid accumulation and matrix degradation. The level of circulating CXCL16 has been proposed as a predictor of long-term mortality in acute coronary syndromes. We studied plasma CXCL16 in acute ischemic stroke and examined associations with long-term mortality following the acute event.MethodsCXCL16 samples were obtained from 244 patients with acute ischemic stroke (age: 69 ± 13 years) daily from presentation to day 5 and at half a year after the stroke. Patients with overt ischemic heart disease and atrial fibrillation were excluded. The patients were followed for 47 months, with all-cause and cardiovascular (CV) mortality as end-points.ResultsAt follow-up, 72 patients had died with 43 due to CV causes. Plasma CXCL16 was stably elevated in the first days after the acute event followed by a marked decrease after 6 months. In patients who subsequently suffered an adverse outcome, CXCL16 levels at 4 days after the initial event were elevated and were moderately associated with mortality. The increase in CXCL16 from day 1 to 4 was a predictor for all-cause and, in particular, CV mortality even after adjustment in the multivariate analysis for established risk factors such as age, the presence of heart/renal failure, troponin, C-reactive protein and stroke severity.ConclusionsAn increase in plasma CXCL16 during the first days after the initial event is associated with an adverse outcome in patients with acute ischemic stroke, supporting the potential pathogenic role of CXCL16 in atherosclerosis and vascular remodelling as well as their major clinical consequences.     

Clinical profile and 30-day outcome of women with acute coronary syndrome as a first manifestation of ischemic heart disease: A single-center observational study

BackgroundGender disparity, with respect to women receiving less medical therapy, undergoing fewer invasive procedures, and experiencing worse outcome than men, has been noted in various observational and randomized trials, though guidelines on acute coronary syndrome (ACS) are gender-neutral. Indian data with focus on women with ACS are lacking.AimThis study was undertaken to give us an insight on the clinical presentation, risk factors, and in-hospital outcome of ACS in women and at 30 days.Materials and methods133 successive cases of women presenting with ACS, who met the inclusion criteria between 2012 and 2014, were included. Cases were grouped into ST elevation myocardial infarction (STEMI), non ST elevation myocardial infarction (NSTEMI), and unstable angina (UA).Results and conclusionThe mean age was 64.4 ± 11 years. The mean BMI was 23.64 ± 3.23 kg/m². Diabetes was present in 58.3% in NSTEMI, 65.1% in STEMI, and 57.1% in UA group. Hypertension was found in 75% of NSTEMI, 60.2% of STEMI, and 71.4% of UA group. Severe MR was found in 11.1% of NSTEMI and 3.6% of STEMI patients. 8.3% of NSTEMI and 15.7% of STEMI patients presented in Killips class IV. Single vessel disease was most commonly found across the spectrum of ACS. 68.7% patients in STEMI group underwent primary angioplasty. 5.6% of NSTEMI and 7.2% in STEMI group had contrast-induced nephropathy (CIN). All deaths were noted in STEMI group with eight in-hospital deaths and three during 30-day follow-up period. Killips class III and IV and higher grace score (>150) were predictors of in-hospital mortality. Chronic kidney disease, ischemic mitral regurgitation, LV clot, and in-hospital cardiac arrest were associated with higher risk.