Pentraxin 3: a novel and independent prognostic marker in ischemic stroke

ObjectivePentraxin 3 (PTX3) is one of the pattern-recognition receptors related to the initial step of the immune response with C-reactive protein, but the physiologic and pathologic functions are not fully understood. The purpose of the current study was to determine the impact of PTX3 levels on mortality after ischemic stroke.MethodsWe consecutively enrolled 376 patients who had ischemic stroke between September 2004 and September 2006. The patients were divided into tertiles according to PTX3 levels. Cox regression analysis was used to determine hazard ratios (HRs) and 95% confidence intervals (CIs) of the PTX3 tertiles for all-cause mortality with adjustment for traditional risk factors and laboratory variables, including C-reactive protein.ResultsDuring the follow-up, 19.4% of the patients were deceased. The median PTX3 levels were higher in the deceased patients (18.0 vs. 6.4 ng/mL, p < 0.001). Based on Cox regression analysis, compared with the first tertile of PTX3, the adjusted HRs of the second and third tertiles for all-cause mortality were 1.24 (95% CI, 0.52–2.98) and 2.64 (95% CI, 1.19–5.85), respectively. When the log-transformed levels of PTX3 were incorporated as continuous variables, higher levels of PTX3 were also associated with an increased mortality (increase per log unit; HR, 1.60; 95% CI, 1.19–2.16).ConclusionsWe showed that higher levels of PTX3 are independently associated with increased mortality after ischemic stroke. Our results suggest that PTX3 may be used as a new powerful prognostic biomarker in patients with ischemic stroke.     

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.     

Coronary bare metal stent implantation in homozygous LDL receptor deficient swine induces a neointimal formation pattern similar to humans

ObjectiveMethylarginines have been shown to interfere with nitric oxide (NO) formation by inhibiting NO synthase (asymmetric dimethylarginine, ADMA, and monomethylarginine, NMMA) and the cellular l-arginine uptake system (ADMA, NMMA and symmetric dimethylarginine, SDMA), thereby causing endothelial dysfunction. ADMA is a predictor of cardiovascular events and mortality in diverse populations.MethodsWe investigated whether methylarginines are predictors of mortality in 394 patients after acute ischemic stroke during 7.4 years of follow-up.ResultsPatients who died (N = 231) were older and more frequently had one of the traditional risk factors for stroke (previous stroke/TIA, atrial fibrillation, prevalent ischemic heart disease, peripheral vascular disease, each p < 0.05). ADMA (0.52 μmol/l vs. 0.50 μmol/l, p = 0.015) and SDMA (0.56 μmol/l vs. 0.43 μmol/l, p < 0.001) were higher in patients who died. In multivariable-adjusted hazard models, SDMA but not ADMA or NMMA was an independent predictor of all-cause mortality after stroke (SDMA, hazard ratio 2.41 (1.55–3.72), p < 0.001; ADMA, hazard ratio 1.43 (0.99–2.07), p = 0.06). SDMA was significantly associated with atrial fibrillation (0.55 μmol/l vs. 0.50 μmol/l, p = 0.03) but there was no significant interaction between SDMA and AF in relation to mortality (p = 0.81). SDMA remained significantly associated with mortality after adjusting for eGFR and also additionally adjusting for C-reactive protein, albumin, β-thromboglobulin, and von Willebrand factor.ConclusionOur study demonstrates that SDMA is an independent predictor of total mortality after acute stroke irrespective of renal function. SDMA is associated with atrial fibrillation, endothelial and platelet activation, and may therefore play a previously unknown role in the pathophysiology of stroke.     

Carotid endarterectomy during the acute period of ischemic stroke

Objective/backgroundHigh risk of recurrent ischemic stroke within the first 14 days after index event in patients with atherosclerotic stenosis of the carotid arteries gave the impetus for the revision of the term of performing carotid endarterectomy (CEA) in symptomatic patients. Nowadays the advisability of performing urgent CEA within 72 h after stroke onset in neurologically unstable patients is discussed frequently. The paper presents the evaluation of carotid endarterectomy during the acute period of ischemic stroke.MethodsThe results of CEA in 462 patients with symptomatic ICA stenosis performed in two independent Vascular Centers were analyzed. Indication for CEA was stenosis of ICA 50%. In Group I 28.5% of patients underwent CEA within 14 days after stroke onset, and in 71.5% of patients was performed 6 weeks after stroke onset. In Group II 39.5% of patients with unstable neurological symptoms underwent within 3–6 h after stroke onset, and in 60.5% of patients with unstable atherosclerotic plaque, CEA was performed within 24–48 h after stroke onset.ResultsIn Group I (239 people) 7 (2.9%) patients developed stroke. Three (1.3%) patients died. In Group II (223 people) 5 (2.2%) patients developed stroke. One (0.4%) patient died. When comparing complications in the early postoperative period no statistical significance was found.ConclusionsUrgent CEA is indicated in patients with unstable neurological symptoms as well as for those with unstable atherosclerotic plaques. Considering a high risk of stroke recurrence within the first 14 days urgent CEA is effective in the prevention of recurrent stroke. Only 2.2% patients developed postoperatively stroke.     

Stress hyperglycemia and acute ischemic stroke in-hospital outcome

Background and AimsStress hyperglycemia is frequent in patients with acute ischemic stroke. However, it is unclear whether stress hyperglycemia only reflects stroke severity or if it is directly associated with adverse outcome. We aimed to evaluate the prognostic significance of stress hyperglycemia in acute ischemic stroke.MethodsWe prospectively studied 790 consecutive patients who were admitted with acute ischemic stroke (41.0% males, age 79.4 ± 6.8 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Stress hyperglycemia was defined as fasting serum glucose levels at the second day after admission ≥ 126 mg/dl in patients without type 2 diabetes mellitus (T2DM). The outcome was assessed with adverse outcome rates at discharge (modified Rankin scale between 2 and 6) and with in-hospital mortality.ResultsIn the total study population, 8.6% had stress hyperglycemia. Patients with stress hyperglycemia had more severe stroke. Independent predictors of adverse outcome at discharge were age, prior ischemic stroke and NIHSS at admission whereas treatment with statins prior to stroke was associated with favorable outcome. When the NIHSS was removed from the multivariate model, independent predictors of adverse outcome were age, heart rate at admission, prior ischemic stroke, log-triglyceride (TG) levels and stress hyperglycemia, whereas treatment with statins prior to stroke was associated with favorable outcome. Independent predictors of in-hospital mortality were atrial fibrillation (AF), diastolic blood pressure (DBP), serum log-TG levels and NIHSS at admission. When the NIHSS was removed from the multivariate model, independent predictors of in-hospital mortality were age, AF, DBP, log-TG levels and stress hyperglycemia.ConclusionStress hyperglycemia does not appear to be directly associated with the outcome of acute ischemic stroke. However, given that patients with stress hyperglycemia had higher prevalence of cardiovascular risk factors than patients with normoglycemia and that glucose tolerance was not evaluated, more studies are needed to validate our findings.     

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.     

Different impact of aspirin on renal progression in patients with predialysis advanced chronic kidney disease with or without previous stroke

BackgroundThe benefit of reducing the risk of stroke against increasing the risk of renal progression associated with antiplatelet therapy in patients with advanced chronic kidney disease (CKD) is controversial.MethodsWe enrolled 1301 adult patients with advanced CKD treated with erythropoiesis stimulating agents from January 1, 2002 to June 30, 2009 from the 2005 Longitudinal Health Insurance Database in Taiwan. All of the patients were followed until the development of the primary or secondary endpoints, or the end of the study (December 31, 2011). The primary endpoint was the development of ischemic stroke, and the secondary endpoints included hospitalization for bleeding events, cardiovascular mortality, all-cause mortality, and renal failure. The adjusted cumulative probability of events was calculated using multivariate Cox proportional regression analysis.ResultsAdjusted survival curves showed that the usage of aspirin was not associated with ischemic stroke, hospitalization for bleeding events, cardiovascular mortality or all-cause mortality, however, it was significantly associated with renal failure. In subgroup analysis, aspirin use was associated with renal failure in the patients with no history of stroke (HR, 1.41; 95% CI, 1.14–1.73), and there was a borderline interaction between previous stroke and the use of aspirin on renal failure (interaction p = 0.0565).ConclusionsThere was no significant benefit in preventing ischemic stroke in the patients with advanced CKD who received aspirin therapy. Furthermore, the use of aspirin was associated with the risk of renal failure in the patients with advanced CKD without previous stroke.     

Necesidad de una ecocardiografía transtorácica en pacientes con tromboembolia de pulmón de riesgo bajo: revisión sistemática y metanálisis

IntroductionIt is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram.MethodsWe performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I² testing to assess heterogeneity.ResultsThe meta-analysis included a total of 11 studies 1,868 patients with low-risk PE. Ten of the 447 (2.2%; 1.1%-4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1,421 (0.7%; 0.3-1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8-5.1, p = .14; I² = 8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7-16, p < .01; I² = 0%).ConclusionsIn patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.     

The coexistence of heart failure predicts short term mortality, but not disability, in patients with acute ischemic stroke treated with thrombolysis: The Florence area Registry

BackgroundThrombolysis in ischemic stroke reduces disability but not mortality. Our aim was to evaluate the predictivity of heart failure (HF) diagnosis on 90-day mortality and disability in stroke patients undergoing thrombolysis.Material and methodsHospital records of all consecutive stroke patients treated with thrombolysis at our University Hospital were reviewed. Clinical assessment for HF and echocardiogram were available for all patients according to the thrombolysis institutional protocol. History of HF, LVEF < 40%, or BOSTON score ≥ 5 were tested as predictors.ResultsOf 130 patients (age 66 ± 14 years, 64.6% males, baseline NIHSS 15.6 ± 8.8), 17 (13.1%) had a history of HF, 16 (12.7%) a BOSTON score ≥ 5, 13 (10.9%) a LVEF < 40% and 24 (19.0%) met clinical criteria for HF diagnosis. Ninety-day mortality and incidence of disability were 16.1% and 36.1%, respectively. After adjustment for age, sex, baseline stroke severity and pre-stroke disability, LVEF < 40% and clinical diagnosis of HF were predictors of 90-day mortality, (p = 0.007 and p = 0.037, respectively).ConclusionClinical diagnosis of HF predicts mortality, but not disability, in acute stroke patients undergoing thrombolysis. Unlike anamnestic record of HF, clinical evaluation of cardiac function, with estimation of LVEF, predicts mortality.     

Influence of age on perioperative major adverse cardiovascular events and mortality risks in elective non-cardiac surgery

Background and aimsAdvanced age increases the risk of perioperative cardiovascular complications and may pose reluctance to subject elderly patients to surgery. We examined the impact of high age on perioperative major adverse cardiovascular events (MACE) and mortality in a nationwide cohort of patients undergoing elective surgery.MethodsAll Danish patients aged ≥ 20 years undergoing non-cardiac, elective surgery in 2005–2011 were identified from nationwide administrative registers. Risks of 30-day MACE (non-fatal ischemic stroke, non-fatal myocardial infarction, or cardiovascular death) and all-cause mortality were analyzed by multivariable logistic regression models (adjusted for comorbidities, revised cardiac risk index, cardiovascular pharmacotherapy, body mass index, and surgery type).ResultsA total of 386,818 procedures on 302,459 patients were included; mean age was 54.8 years (min–max 20–104), and 44% were men. A total of 1297 (0.34%) had perioperative MACE and 1449 (0.37%) died. Advanced age was associated with increased risks of MACE (odds ratio [OR], 1.87; 95% CI, 1.78–1.98 per 10-year high) and mortality (OR, 1.87; 95% CI, 1.78–1.96 per 10-year high). A total of 21,511 procedures were performed on patients > 80–90 years old, and 1662 on patients > 90 years. The numbers of MACE and crude mortality rates were 331 (1.7%) and 388 (2.0%) among > 80–90 years old, and 50 (3.0%) and 67 (4.0%) for those aged > 90 years.ConclusionThe risk of mortality and major adverse cardiovascular events within 30 days after surgery increased with advanced age. However, despite advanced age, the absolute event rates appeared to be relatively modest and around 4% for people aged above 90 years.     

Cardiovascular outcomes in patients with cancer during a 5-year follow-up: Results from a French administrative database

BackgroundLimited data are available regarding the optimal management and prognosis of patients with cancer who develop an acute myocardial infarction.AimThe objective of this study was to analyse the characteristics and outcomes of patients according to cancer and myocardial infarction occurrence.MethodsBased on the French administrative hospital discharge database, the study collected information for all consecutive patients seen in French hospitals in 2013, excluding those with a history of myocardial infarction. The population was divided into two groups according to their history of cancer. We studied the following outcomes: all-cause and cardiovascular mortality; acute myocardial infarction; and ischaemic stroke. Data were collected after a 5-year follow-up.ResultsBetween 2013 and 2019, 3,381,472 patients were seen in French hospitals; among them, 3,323,757 had no history of myocardial infarction. Patients with a history of cancer (n = 497,593) had higher incidences of all-cause mortality (17.82%/year vs 3.79%/year), cardiovascular mortality (1.61%/year vs 1.17%/year), myocardial infarction (0.82%/year vs 0.61%/year) and ischaemic stroke (0.91%/year vs 0.62%/year) compared with patients without cancer (n = 2,826,164). After performing an adjusted competing-risk analysis, the cumulative incidence of acute myocardial infarction, cardiovascular death and ischaemic stroke incidence was found to be lower in patients with a history of cancer, whereas death of non-cardiac origin was more prevalent in patients with a history of cancer.ConclusionsIn this observational study, we have shown that patients with cancer have a higher incidence of all-cause mortality, cardiovascular mortality and myocardial infarction. However, multivariable analysis showed a lower cumulative incidence of these events.     

Prognostic value of low and high ankle-brachial index in hospitalized medical patients

BackgroundPeripheral arterial disease (PAD) is frequently underdiagnosed in the clinical practice, leading to a lack of opportunity to detect subjects at a high risk for cardiovascular (CV) death. The ankle-brachial pressure index (ABI) represents a noninvasive, objective tool to diagnose PAD and to predict adverse outcome.MethodsABI was determined by means of Doppler velocimetry, in 707 patients, aged 50 years or older, consecutively hospitalized in an internal medicine ward, who were followed-up for at least 12 months in order to assess all-cause and CV mortality.ResultsSymptomatic PAD affected 8% of the population while the prevalence of PAD, defined as ABI < 0.90, was 29%; high ABI (> 1.40) was found in 8% of the patients. After a mean follow-up period of 1.6 years, both low and high ABI were independently associated with CV mortality with a hazard ratio of 1.99 (p = 0.016) for low and 2.13 (p = 0.04) for high ABI, compared with normal ABI (0.90–1.40). High ABI also independently predicted all-cause mortality with a hazard ratio of 1.77 (p = 0.04).DiscussionABI measurement reveals a large number of individuals with asymptomatic PAD among those hospitalized in an internal medicine department. An increased mortality was observed in patients with both low and high ABI. Hospital admission for any reason may serve as an opportunity to detect PAD and start appropriate preventive actions.     

Cardiovascular mortality in Hispanics compared to non-Hispanic whites: A systematic review and meta-analysis of the Hispanic paradox

BackgroundHispanics, the largest minority in the U.S., have a higher prevalence of several cardiovascular (CV) risk factors than non-Hispanic whites (NHW). However, some studies have shown a paradoxical lower rate of CV events among Hispanics than NHW.ObjectiveTo perform a systematic review and a meta-analysis of cohort studies comparing CV mortality and all-cause mortality between Hispanic and NHW populations in the U.S.MethodsWe searched EMBASE, MEDLINE, Web of Science, and Scopus databases from 1950 through May 2013, using terms related to Hispanic ethnicity, CV diseases and cohort studies. We pooled risk estimates using the least and most adjusted models of each publication.ResultsWe found 341 publications of which 17 fulfilled the inclusion criteria; data represent 22,340,554 Hispanics and 88,824,618 NHW, collected from 1950 to 2009. Twelve of the studies stratified the analysis by gender, and one study stratified people by place of birth (e.g. U.S.-born, Mexican-born, and Central/South American-born). There was a statistically significant association between Hispanic ethnicity and lower CV mortality (OR 0.67; 95% CI, 0.57–0.78; p < 0.001), and lower all-cause mortality (0.72; 95% CI, 0.63–0.82; p < 0.001). A subanalysis including only studies that reported prevalence of CV risk factors found similar results. OR for CV mortality among Hispanics was 0.49; 95% CI 0.30–0.80; p-value < 0.01; and OR for all-cause mortality was 0.66; 95% CI 0.43–1.02; p-value 0.06.ConclusionThese results confirm the existence of a Hispanic paradox regarding CV mortality. Further studies are needed to identify the mechanisms mediating this protective CV effect in Hispanics.     

Slow heart rate recovery after exercise is associated with carotid atherosclerosis

ObjectiveSlow heart rate recovery (HRR) after exercise is an estimate of impaired parasympathetic tone and predictor of all-cause and cardiovascular mortality. Carotid atherosclerosis is associated with high risk of developing coronary heart disease (CHD) and stroke. We tested the hypothesis that slow HRR is associated with carotid atherosclerosis in a cross-sectional study of 12,712 middle-aged men (age 49.1 ± 8.9 years).MethodsCarotid atherosclerosis was measured using B-mode ultrasonography and defined as stenosis >25% and/or intima–media thickness >1.2 mm. HRR was calculated as the difference between peak heart rate during a graded exercise treadmill test and heart rate 2 min after cessation of exercise.ResultsThe prevalence of carotid atherosclerosis was 8.4%. The prevalence of atherosclerosis was significantly higher among subjects in the lowest (<44 bpm) versus the highest (>61 bpm) quartile of HRR (14.4% versus 4.1%, p < 0.001). In multivariable logistic regression models adjusted for established CHD risk factors, inflammatory markers, and exercise capacity, subjects in the lowest quartile of HRR (<44 bpm) were 1.50 times (95% CI: 1.13–2.00) more likely to have carotid atherosclerosis than subjects in the highest quartile (HRR >61 bpm).ConclusionsSlow heart rate recovery after exercise, an index of decreased parasympathetic activity, is associated with carotid atherosclerosis independent of established risk factors in middle-age men.     

Hyperuricemia in acute heart failure. More than a simple spectator?

BackgroundHyperuricemia is a prevalent condition in chronic heart failure (CHF), describing increased oxidative stress and inflammation. Although there is evidence that serum uric acid (UA) predicts mortality in CHF, its role as a prognostic biomarker in acute heart failure (AHF) has not yet been well assessed. The aim of this study was to determine if UA levels predict all-cause mortality. Additionally, as a secondary endpoint we sought the clinical predictors of UA serum level in this population.MethodsWe analyzed 560 consecutive patients with AHF admitted in a single university center. UA (mg/dl) was measured during early hospitalization. Patient survival status was followed up after discharge (median follow-up: 330 days). The independent association of UA level with all-cause mortality was analyzed using Cox regression analysis.ResultsDuring follow-up 165 (29.5%) deaths were identified. Patients with UA levels above the median value (≥ 7.7 mg/dl) exhibited higher mortality rates (21.1 vs. 37.9%; p < 0.001). In multivariable analysis, after adjusting for recognized prognostic factors and potential confounders, UA ≥ 7.7 mg/dl and per change in 1 mg/dl of UA was associated with an increased risk of mortality (HR 1.45, CI 95% = 1.03–2.44; p = 0.03 and HR 1.08, CI 95% = 1.01–1.15; p = 0.03, respectively).ConclusionUA serum levels is an independent predictor of all-cause mortality in an unselected patients admitted with AHF.     

Serum albumin as a determinant of cortisol release in patients with acute ischemic stroke

ObjectiveAnimal studies demonstrated that protein malnutrition increases pituitary-adrenorcortical activity and leads to excessive cortisol release. The aim of our study was to determine the association between serum albumin and cortisol level in patients with acute ischemic stroke.MethodsFifty-nine patients with first-ever ischemic stroke were included. Serum albumin level was measured within 36 h after stroke symptoms onset. Serum cortisol was measured between 36 and 72 h after stroke onset at 6 a.m., 10 a.m., 6 p.m. and 10 p.m.ResultsThe patients in upper tertile of serum albumin had significantly lower cortisol level measured at 6 a.m. (median with interquartiles: 549.0 [430.4–667.7] nmol/L vs 590.4 [482.8–918.7] nmol/L, P = 0.047) and 10 a.m. (402.8 [344.9–510.4] nmol/L vs 634.6 [482.8–827.7] nmol/L, P < 0.01) than patients in lower and middle tertiles. On logistic regression analysis adjusted for age and stroke severity, patients in lower and middle tertile of serum albumin had about 7-times higher risk of hypercortisolemia than patients in upper tertile (P < 0.01).ConclusionsLow serum albumin level in patients with ischemic stroke is associated with higher serum cortisol level and predisposes to hypercortisolemia.     

L’apport des explorations cardiovasculaires réalisées de manière systématique lors du bilan étiologique d’un AVC ischémique constitué (À propos de 230 cas)

ObjectivesIschemic stroke are estimated at 80% of all strokes. Embolism of cardiac origin accounts for around 20% of them. The aim of our study is to report the contribution of cardiovascular investigations performed as a routine during the evaluation of patients with ischemic stroke.Patients and methodsThis is a retrospective study of ischemic stroke cases collated in Cardiology department of the military hospital of Marrakech between January 2010 and December 2014. All our patients have systematically ECG, transthoracic echocardiography and Echo-Doppler ultrasound of the neck vessels while the transesophageal (TEE) echocardiography and Holter ECG was performed in some indications.ResultsTwo hundred and thirty patients were collected. The average age of patients was 66.3 ± 12.5 years with a male predominance in 64.2%. Eighty-five percent of patients had at least three cardiovascular risk factors. Hypertension (60.8%), diabetics (41.7%) and tobacco (33.3%). Cardiovascular history was noted in 30% of cases with 10% of dilated cardiomyopathy and 9.2% of ischemic stroke. Cardiovascular explorations led to the diagnosis of heart disease embolism in 32% and atherosclerosis of the neck vessels in 16%. The TEE performed in 8% of cases showed an emboligenic cause in 42% of them.ConclusionCardiovascular explorations remain indispensable in the workup of all ischemic strokes even if their therapeutic effect is modest. The lacunar infarct out first at 34% followed by 32% of cardio embolic causes and atheroma of the neck vessels in approximately 16%.     

Quality of diabetes care predicts the development of cardiovascular events: results of the QuED study

Background and aimIn the context of the QuED Study we assessed whether a quality of care summary score was able to predict the development of cardiovascular (CV) events in patients with type 2 diabetes.Methods and resultsThe score was calculated using process and intermediate outcome indicators (HbA_1c, blood pressure, low-density lipoprotein cholesterol, microalbuminuria) and ranged from 0 to 40. Overall, 3235 patients were enrolled, of whom 492 developed a CV event after a median follow-up of 5 years. The incidence rate (per 1000 person-years) of CV events was 62.4 in patients with a score ≤10, 54.8 in those with a score between 15 and 20, and 39.8 in those with a score >20. In adjusted multilevel regression models, the risk to develop a CV event was 89% greater in patients with a score of ≤10 (rate ratio [RR] = 1.89; 95% confidence interval [CI] 1.43–2.50) and 43% higher in those with a score between 10 and 20 (RR = 1.43; 95% CI 1.14–1.79), as compared to those with a score >20. A difference between centers of 5 points in the mean quality score was associated with a difference of 16% in CV event risk (RR = 0.84; 95% CI 0.72–0.98).ConclusionOur study documented for the first time a close relationship between a score of quality of diabetes care and long-term outcomes.     

Bed-side inferior vena cava diameter and mean arterial pressure predict long-term mortality in hospitalized patients with heart failure: 36 months of follow-up

BackgroundIn discharged patients with heart failure (HF), diverse conditions can intervene to worsen outcome. We would investigate whether such factors present on hospital admission can affect long-term mortality in subjects hospitalized for acute HF.MethodsOne hundred twenty-three consecutive patients hospitalized for acute HF (mean age 74.8 years; 57% female) were recruited and followed for 36 months after hospitalization.ResultsAt multivariate Cox model, only inferior vena cava (IVC) diameter and mean arterial pressure (MAP) registered bed-side on admission, resulted, after correction for all confounders factors, the sole factors significantly associated with a higher risk of all-cause mortality in long-term (HR 1.06, p = 0.0057; HR 0.97, p = 0.0218; respectively). Study population was subdivided according to median values of IVC diameter (23 mm) and MAP (93.3 mm Hg). The Kaplan–Meier curve showed that HF patients with both IVC ≥ 23 mm and MAP < 93.3 mm Hg on admission had reduced probability of survival free from all-cause death (log rank p = 0.0070 and log rank p = 0.0028, respectively).ConclusionsIn patients hospitalized for acute HF, IVC diameter, measured by hand-carried ultrasound (HCU), and MAP detected on admission are strong predictors of long-term all-cause mortality. The data suggest the need for a careful clinical-therapeutic surveillance on these patients during the post-discharge period. IVC diameter and MAP can be utilized as parameters to stratify prognosis on admission and to be supervised during follow-up.     

New Onset Atrial Fibrillation Developing in Medical Inpatients

BackgroundThe outcome of patients who develop new onset atrial fibrillation (AF) after admission to an Internal Medicine service for acute medical illnesses is unknown.MethodsIn a retrospective review, we compared patients in the study group: patients who were admitted to hospital for acute medical illnesses and subsequently developed new onset AF during hospitalization, with a control group 1: patients whose admitting diagnosis was new onset AF and a control group 2: patients who were admitted for acute medical illnesses and never developed AF. We analyzed clinical characteristics and all-cause mortality rate during the first 30 days, 6 months, and 1 year after admission.ResultsThe 1-year mortality rates in study group were significantly higher than control group 1 (62% versus 8%, P < 0.001) and control group 2 (62% versus 29%, P < 0.05). These results suggest that AF and acute medical illness both are risk factors for increased mortality. The odds ratios were 4.05 (P = 0.023) and 18.33 (P = 0.001) for AF and acute medical illnesses, respectively, indicating that acute medical illness is the better predictor for mortality. Troponin I levels were elevated in 46% of patients in study group versus 12% in control group 1 and 42% in control group 2 (P < 0.05).ConclusionsMedical inpatients who develop new onset AF during hospitalization for acute medical illnesses have an increased mortality when compared with patients who were admitted solely for new onset AF. Acute medical illness rather than AF plays a more important role on the increased mortality in this subset of patient population.