Supervivencia a largo plazo de una población española con cardiopatía isquémica estable: el registro CICCOR

Introduction and objectivesData are lacking on the long-term prognosis of stable ischemic heart disease (SIHD). Our aim was to analyze long-term survival in patients with SIHD and to identify predictors of mortality.MethodsA total of 1268 outpatients with SIHD were recruited in this single-center prospective cohort study from January 2000 to February 2004. Cardiovascular and all-cause death during follow-up were registered. All-cause and cardiovascular mortality rates were compared with those in the Spanish population adjusted by age, sex, and year. Predictors of these events were investigated.ResultsThe mean age was 68 ± 10 years and 73% of the patients were male. After a follow-up lasting up to 17 years (median 11 years), 629 (50%) patients died. Independent predictors of all-cause mortality were age (HR, 1.08; 95%CI, 1.07-1.11; P < .001), diabetes (HR, 1.36; 95%CI, 1.14-1.63; P < .001), resting heart rate (HR, 1.01; 95%CI, 1.00-1.02; P < .001), atrial fibrillation (HR, 1.61; 95%CI, 1.22-2.14; P = .001), electrocardiographic changes (HR, 1.23; 95%CI, 1.02-1.49; P = .02) and active smoking (HR, 1.85; 95%CI, 1.31-2.80; P = .001). All-cause mortality and cardiovascular mortality rates were significantly higher in the sample than in the general Spanish population (47.81/1000 patients/y vs 36.29/1000 patients/y (standardized mortality rate, 1.31; 95%CI, 1.21-1.41) and 15.25/1000 patients/y vs 6.94/1000 patients/y (standardized mortality rate, 2.19; 95%CI, 1.88-2.50, respectively).ConclusionsThe mortality rate was higher in this sample of patients with SIHD than in the general population. Several clinical variables can identify patients at higher risk of death during follow-up.Full English text available from:www.revespcardiol.org/en     

The impact of angiotensin converting enzyme insertion/deletion gene polymorphism on diabetic kidney disease: A debatable issue

ObjectiveThe objective of this study was to evaluate the influence of ACE I/D gene polymorphisms on diabetic kidney disease (DKD) risk.MethodsAll eligible investigations were identified, the number of various genotype in the case and control group were reviewed. The pooled analysis was performed using Stata software.ResultsIn overall subjects, 24,321 participants with 12,961 cases and 11,360 controls were included. the pooled analysis showed a significant link between D allele, DD or II genotype and DKD risk (D versus I: OR = 1.316, 95% CI: 1.213–1.427, P = 0.000; DD versus ID + II: OR = 1.414, 95% CI: 1.253–1.595, P = 0.000; II versus DD + ID: OR = 0.750, 95% CI: 0.647–0.869, P = 0.000). The subgroup pooled analysis showed that ACE I/D gene polymorphism was correlated with DKD both in Asian and in Chinese population. In addition, ACE I/D gene polymorphism was correlated with type 2 DKD (D versus I: OR = 1.361, 95% CI: 1.243–1.490, P = 0.000; DD versus ID + II: OR = 1.503, 95% CI: 1.310–1.726, P = 0.000; II versus DD + ID: OR = 0.738, 95% CI: 0.626 –0.870, P = 0.000). However, there was no obvious correlation in Caucasian subjects and type 1 diabetic patients.ConclusionACE I/D polymorphisms were correlated with DKD in Asian and type 2 diabetic populations. ACE D allele/DD genotype might be a risk factor, while ACE II genotype might be a protective factor for DKD.     

Serum Ferritin Levels Predict All-Cause and Infection-Cause 1-Year Mortality in Diabetic Patients on Maintenance Hemodialysis

BackgroundThe aim of this study was to assess the relationship between the serum ferritin level and the 1-year outcome in diabetic maintenance hemodialysis (MHD) patients.MethodsThe prospective clinical study enrolled 187 diabetic MHD patients from a university hospital in Taiwan. All the patients were divided into 3 groups according to their serum ferritin levels: group I (<200 ng/mL; n = 71), group II (200–700 ng/mL; n = 97), and group III (>700 ng/mL; n = 19). A total of 26 demographic, clinical, and laboratory variables were analyzed as predictors of the 1-year mortality.ResultsThere were no significant differences between these 3 groups except in their erythropoietin usage, hemoglobin, transferrin saturation, and high-sensitive C-reactive protein levels. The 1-year mortality rates were 9.2%, 11.4%, and 46.2% in groups I, II, and III, respectively. Group I and group II patients had a lower 1-year mortality rate than group III patients (log-rank test; χ² = 8.807; P = 0.0112).ConclusionThe study suggested that serum ferritin levels predict both all-cause and infection-cause 1-year mortality in diabetic patients on MHD. In such patients, the serum ferritin levels are associated with both iron stores and the inflammation status.     

Cardiothoracic Ratio,Inflammation, Malnutrition,and Mortality in Diabetes Patients on Maintenance Hemodialysis

BackgroundThis study investigates diabetic patients on maintenance hemodialysis (HD), and examines whether cardiothoracic ratio (CTR), malnutrition, and inflammation are closely interrelated, and whether CTR predicts short-term mortality in this population.MethodsA 2-year longitudinal study that enrolls 179 patients—73 without cardiomegaly (CTR < 50%), 81 with mild cardiomegaly (CTR 50%–60%), and 25 with moderate-to-severe cardiomegaly (CTR > 60%).ResultsSpearman analysis established that CTR was positively correlated with age (P < 0.001) and high sensitivity C reactive protein (HsCRP) (P < 0.05), but negatively correlated with albumin (P < 0.05) and creatinine (P < 0.001). Multivariate logistic analyses identified age (P = 0.0027), creatinine (P = 0.0484), intact-PTH (P = 0.0197) and HsCRP (P = 0.0247) were independent determinants of cardiomegaly. After 2 years, 31 of 179 (17.32%) patients died including 9 of 25 (36%) with CTR > 60%, 14 of 81 (17.28%) with CTR 50%–60%, and 8 of 73 (10.96%) with CTR < 50%. The primary causes of death were infection (61.29%) and cardiovascular disease (CVD) (32.26%). Cox multivariable regression analysis revealed CTR > 50% was the only independent variable for the development of all-cause and infection-cause mortality in 2 years. Kaplan-Meier analysis confirmed that patients with CTR > 60% suffered higher cumulative mortality than patients with CTR < 50% (P = 0.0003).ConclusionsCTR does not only correlate with inflammation and nutritional status in diabetic patients on maintenance HD, but also predict the all-cause and infection-cause 2-year mortality.     

Presence of coronary artery disease in diabetic and non diabetic South Asian immigrants

IntroductionSouth Asian Immigrants (SAIs) are the second fastest growing Asian immigrant population in the US, and at a higher risk of type 2 diabetes (diabetes) and coronary artery disease (CAD) than the general US population. Objectives: We sought to determine in SAIs the; 1) the prevalence of CAD risk factors in diabetics and non-diabetics; and b) the high possibility of CAD in diabetic SAIs. We also assessed the prevalence of sub-clinical CAD in both diabetics and non-diabetics SAIs using common carotid artery Intima-media thickness (CIMT) as a surrogate marker for atherosclerosis.MethodsIn a cross-sectional study design, 213 first generation SAIs were recruited and based on the history, and fasting glucose levels were divided into two subgroups; 35 diabetics and 178 non-diabetics. 12-hour fasting blood samples were collected for glucose and total cholesterol levels. Exercise Tolerance Test (ETT) was performed to determine the possibility of CAD.ResultsBoth diabetics and non-diabetics SAIs in general, share a significant burden of CAD risk factors. The prevalence of hypertension (p = 0.003), total cholesterol ≥ 200 mg/dl (p < 0.0001) and family history of diabetes (p < 0.0001) was significantly was significantly higher in diabetics compared to non-diabetics. Of the 22/29 diabetic participants without known history of CAD, 45% had positive ETT (p < 0.001). Similarly, 63.1% of diabetics and 51.8 % of non-diabetics were positive for sub-clinical CAD using CIMT as a marker.ConclusionThe susceptibility to diabetes amongst SAIs promotes an adverse CAD risk, as evident by this small study. Further research, including larger longitudinal prospective studies, is required to validate the current small study findings with investigation of the temporal association.     

Interacción cardiorrenal y evolución de la insuficiencia cardiaca. ¿Tiene un papel la proteína de unión del factor de crecimiento de tipo insulina 2?

Introduction and objectivesPreliminary results suggest that high circulating insulin-like growth factor binding protein 2 (IGFBP2) levels are associated with mortality risk in heart failure (HF) patients. As IGFBP2 levels are increased in patients with chronic kidney disease (CKD), which is associated with a higher mortality risk in HF patients, we examined whether IGFBP2 is associated with CKD in HF patients, and whether CKD modifies the prognostic value of this protein in HF patients.MethodsHF patients (n = 686, mean age 66.6 years, 32.7% women) were enrolled and followed up for a median of 3.5 (min-max range: 0.1-6) years. Patients were classified as having CKD with decreased estimated glomerular filtration rate (eGFR < 60 mL/min/1.73 m²) or as having CKD with nondecreased eGFR (≥ 60 mL/min/1.73 m²). Serum IGFBP2 was detected by ELISA.ResultsIGFBP2 was increased (P < .001) in CKD patients with decreased eGFR (n = 290, 42.3%) compared with patients with nondecreased eGFR. IGFBP2 was directly associated with NT-proBNP (P < .001) and inversely associated with eGFR (P < .001), with both associations being independent of confounding factors. IGFBP2 was directly and independently associated with cardiovascular and all-cause death (P < .001) in the whole group of patients, but showed a stronger association with cardiovascular death in CKD patients with decreased eGFR (P for interaction < .05), improving risk prediction in these patients over clinically relevant risk factors.ConclusionsSerum IGFBP2 is associated with impaired renal function and prognosticates cardiovascular death in patients with HF and CKD with decreased eGFR. Thus, there is an effect modification of CKD on circulating IGFBP2 and on its association with cardiovascular mortality in HF patients.     

Valor pronóstico de la ecografía de pulmón en pacientes ambulatorios con insuficiencia cardiaca crónica estable

Introduction and objectivesThe role of lung ultrasound (LUS) in acute heart failure (HF) has been widely studied, but little is known about its usefulness in chronic HF. This study assessed the prognostic value of LUS in a cohort of chronic HF stable ambulatory patients.MethodsWe included consecutive outpatients who attended a scheduled follow-up visit in a HF clinic. LUS was performed in situ. The operators were blinded to clinical data and examined 8 thoracic areas. The sum of B-lines across all lung zones and the quartiles of this addition were used for the analyses. Linear regression and Cox regression analyses were performed. The main clinical outcomes were a composite of all-cause death or hospitalization for HF and mortality from any cause.ResultsA total of 577 individuals were included (72% men; 69 ± 12 years). The mean number of B-lines was 5 ± 6. During a mean follow-up of 31 ± 7 months, 157 patients experienced the main clinical outcome and 111 died. Having ≥ 8 B-lines (Q4) doubled the risk of experiencing the composite primary event (P < .001) and increased the risk of death from any cause by 2.6-fold (P < .001). On multivariate analysis, the total sum of B-lines remained independent predictive factor of the composite endpoint (HR, 1.04; 95%CI, 1.02-1.06; P = .002) and of all-cause death (HR, 1.04; 95%CI, 1.02-1.07; P = .001), independently of whether or not N-terminal pro-B-type natriuretic peptide (NT-proBNP) was included in the model (P = .01 and P = .008, respectively), with a 3% to 4% increased risk for each 1-line addition.ConclusionsLUS identified patients with stable chronic HF at high risk of death or HF hospitalization.     

Efecto pronóstico diferencial de la diabetes mellitus tipo 2 en mujeres y varones con insuficiencia cardiaca y fracción de eyección conservada

Introduction and objectivesType 2 diabetes mellitus (DM2) is a common comorbidity in patients with heart failure (HF) with preserved ejection fraction (HFpEF). Previous studies have shown that diabetic women are at higher risk of developing HF than men. However, the long-term prognosis of diabetic HFpEF patients by sex has not been extensively explored. In this study, we aimed to evaluate the differential impact of DM2 on all-cause mortality in men vs women with HFpEF after admission for acute HF.MethodsWe prospectively included 1019 consecutive HFpEF patients discharged after admission for acute HF in a single tertiary referral hospital. Multivariate Cox regression analysis was used to evaluate the interaction between sex and DM2 regarding the risk of long-term all-cause mortality. Risk estimates were calculated as hazard ratios (HR).ResultsThe mean age of the cohort was 75.6 ± 9.5 years and 609 (59.8%) were women. The proportion of DM2 was similar between sexes (45.1% vs 49.1%, P = .211). At a median (interquartile range) follow-up of 3.6 (1-4-6.8) years, 646 (63.4%) patients died. After adjustment for risk factors, comorbidities, biomarkers, echo parameters and treatment at discharge, multivariate analysis showed a differential prognostic effect of DM2 (P value for interaction = .007). DM2 was associated with a higher risk of all-cause mortality in women (HR, 1.77; 95%CI, 1.41-2.21; P < .001) but not in men (HR, 1.23; 95%CI, 0.94-1.61; P = .127).ConclusionsAfter an episode of acute HF in HFpEF patients, DM2 confers a higher risk of mortality in women. Further studies evaluating the impact of DM2 in women with HFpEF are warranted.Full English text available from:www.revespcardiol.org/en     

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups.ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.     

Comparative Effects of Benidipine and Amlodipine on Proteinuria,Urinary 8-OHdG,Urinary L-FABP,and Inflammatory and Atherosclerosis Markers in Early-Stage Chronic Kidney Disease

IntroductionWe examined the effects of 2 calcium channel blockers, benidipine (T-, L-, and N-type) and amlodipine (L- and N-type), on renal, inflammatory, oxidative, and atherosclerosis markers in hypertensive patients with mild chronic kidney disease (CKD).MethodsForty hypertensive patients with CKD were assigned randomly to either of the 2 treatments: 8 mg benidipine once daily (n = 20, group A) or 5 mg amlodipine once daily (n = 20, group B). Treatment was continued for 12 months. Blood pressure, serum creatinine, estimated glomerular filtration rate, urinary protein excretion, urinary liver-type fatty acid-binding protein, interleukin-6, high mobility group box-1 protein, urinary 8-hydroxy-2′- deoxyguanosine, pulse wave velocity, intima-media thickness, and blood asymmetric dimethylarginine were monitored.ResultsBlood pressure decreased equally in both groups (P < 0.001, at 6 and 12 months versus before treatment). Serum creatinine and estimated glomerular filtration rate changed little during the experimental period in each group. However, urinary protein excretion (P < 0.001), urinary liver-type fatty acid-binding protein (P < 0.001), urinary 8-hydroxy-2'-deoxyguanosine (P < 0.001), blood interleukin-6 (P < 0.001), blood high mobility group box-1 (P < 0.5), and pulse wave velocity (P < 0.01) decreased more in group A than in group B with 12 months of treatment. The percent reductions in intima-media thickness and blood asymmetric dimethylarginine were significantly greater in group A than in group B (P < 0.001).ConclusionsBenidipine is more effective than amlodipine for protecting renal function and potentially for ameliorating atherosclerosis in hypertensive patients with mild CKD. T-type calcium channel blockers may be effective in patients with CKD.     

Effect of cilostazol on arteriovenous fistula in hemodialysis patients

BackgroundThe maturation and patency of permanent vascular access are critical in patients requiring hemodialysis. Although numerus trials have been attempted to achieve permanently patent vascular access, little have been noticeable. Cilostazol, a phosphodiesterase-3 inhibitor, has been shown to be effective in peripheral arterial disease including vascular injury-induced intimal hyperplasia. We therefore aimed to determine the effect of cilostazol on the patency and maturation of permanent vascular access.MethodsThis single-center, retrospective study included 194 patients who underwent arteriovenous fistula surgery to compare vascular complications between the cilostazol (n = 107) and control (n = 87) groups.ResultsThe rate of vascular complications was lower in the cilostazol group than in the control group (36.4% vs. 51.7%; p = 0.033), including maturation failure (2.8% vs. 11.5%; p = 0.016). The rate of reoperation due to vascular injury after hemodialysis initiation following fistula maturation was also significantly lower in the cilostazol group than in the control group (7.5% vs. 28.7%; p < 0.001). However, there were no significant differences in the requirement for percutaneous transluminal angioplasty (PTA), rate of PTA, and the interval from arteriovenous fistula surgery to PTA between the cilostazol and control groups.ConclusionCilostazol might be beneficial for the maturation of permanent vascular access in patients requiring hemodialysis.     

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study

BackgroundPulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions.MethodsThirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed.ResultsMild pulmonary congestion caused a 26.1% decline in DM (R² = .261; P = .004) and 20% reduction in walking time (R² = .200; P = .01), indicating decreases of 2.23 mm and 1.54 min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P = .002), walking (P = .034) and active time (P = .002), and number of steps taken (P = .01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P = .037) and lungs (P = .02), attenuation of exploratory behavior (P = .01) and significant decrease in traveled distance (P = .034). Thoracic ultrasonography of CKD mice showed presence of B-lines.ConclusionThe mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.     

Cambio en la causa de muerte e influencia de la mejora terapéutica con el tiempo en pacientes con insuficiencia cardiaca y fracción de eyección reducida

Introduction and objectivesIn patients with heart failure and reduced ejection fraction (HFrEF), several therapies have been proven to reduce mortality in clinical trials. However, there are few data on the effect of the use of evidence-based therapies on causes of death in clinical practice.MethodsThis study included 2351 outpatients with HFrEF (< 40%) from 2 multicenter prospective registries: MUSIC (n = 641, period: 2003-2004) and REDINSCOR I (n = 1710, period: 2007-2011). Variables were recorded at inclusion and all patients were followed-up for 4 years. Causes of death were validated by an independent committee.ResultsPatients in REDINSCOR I more frequently received beta-blockers (85% vs 71%; P < .001), mineralocorticoid antagonists (64% vs 44%; P < .001), implantable cardioverter-defibrillators (19% vs 2%; P < .001), and resynchronization therapy (7.2% vs 4.8%; P = .04). In these patients, sudden cardiac death was less frequent than in those in MUSIC (6.8% vs 11.4%; P < .001). After propensity score matching, we obtained 2 comparable populations differing only in treatments (575 vs 575 patients). In patients in REDINSCOR I, we found a lower risk of total mortality (HR, 0.70; 95%CI, 0.57-0.87; P = .001) and sudden cardiac death (sHR, 0.46; 95%CI, 0.30-0.70; P < .001), and a trend toward lower mortality due to end-stage HF (sHR, 0.73; 95%CI, 0.53-1.01; P = .059), without differences in other causes of death (sHR, 1.17; 95%CI, 0.78-1.75; P = .445), regardless of functional class.ConclusionsIn ambulatory patients with HFrEF, implementation of evidence-based therapies was associated with a lower risk of death, mainly due to a significant reduction in sudden cardiac death.     

Valor de la puntuación SYNTAX II para la predicción de eventos clínicos en pacientes sometidos a implante percutáneo de válvula aórtica

Introduction and objectives

The predictive value of the SYNTAX score (SS) for clinical outcomes after transcatheter aortic valve implantation (TAVI) is very limited and could potentially be improved by the combination of anatomic and clinical variables, the SS-II. We aimed to evaluate the value of the SS-II in predicting outcomes in patients undergoing TAVI.

Association between neutrophil-to-lymphocyte ratio in the first seven days of sepsis and mortality

IntroductionThe neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of sepsis has been found to be higher in non-survivors than in survivors, and that is associated with mortality. A higher NLR in non-survivors than in survivors has been reported in two studies during patient follow-up; however, NLR was not controlled for sepsis severity. Thus, the objective of this study was to determine whether there is an association between NLR in the first seven days and mortality controlling for sepsis severity.MethodsThis observational study, which included septic patients, was conducted in the Intensive Care Units of 3 Spanish hospitals. NLR was recorded on the first, fourth, and eighth day of sepsis. Multiple logistic regression analyses were carried out to determine the association between NLR during the first 7 days of sepsis diagnosis and mortality controlling for sepsis severity.ResultsThirty-day non-surviving patients (n = 68) compared to surviving patients (n = 135) showed higher NLR on the first (p < 0.001), fourth (p < 0.001), and eighth (p < 0.001) day of sepsis diagnosis. Multiple logistic regression analysis found an association between NLR at days first (p < 0.001), fourth (p = 0.004), and eighth (p = 0.01) of sepsis diagnosis and mortality controlling for SOFA and lactic acid in those days.ConclusionsThe new finding of our study was the association between NLR in the first seven days of sepsis and mortality controlling for sepsis severity.     

Differences in symptoms and presentation delay times in myocardial infarction patients with and without diabetes: A cross-sectional study in Pakistan

ObjectiveA short pre-hospital delay, from the onset of symptoms to rapid initiation of reperfusion therapy, is a crucial factor in determining prognosis of myocardial infarction (MI). The purpose of this study was to evaluate symptoms and presentation delay times in MI patients with and without diabetes.MethodsThis cross-sectional study was conducted in 3 tertiary care hospitals of Pakistan over a period of 6 months. The study sample consisted of 280 consenting individuals diagnosed with ST-elevation MI (STEMI) or Non-ST elevation MI (NSTEMI), out of which 130 were diabetic and 150 were non-diabetic. Data was collected using a standardized questionnaire, investigating MI symptoms along with causes and duration of pre-hospital delay within 72 hours of admission.ResultsNo significant difference was found in the intensity of chest pain between diabetics and non-diabetics. Atypical symptoms of MI such as anxiety (p < 0.001), cold sweats (p = 0.034) and epigastric pain (p = 0.017) were more frequently reported in diabetics. MI patients with diabetes had a significantly longer presentation delay time with 75% of the patients presenting after elapse of 3 h. Only a few patients reported to the hospital within an hour of onset of symptoms (n = 23, 8.2%), out of which majority were non-diabetics (n = 18). A majority of patients (n = 146, 52%) in both groups did not use emergency medical services.ConclusionThis study provides an incentive for further research, aiming to reduce pre hospital delay along with investigating the effectiveness of emergency medical services.     

ACOD frente a AVK en pacientes con fibrilación auricular y bioprótesis: revisión sistemática y metanálisis

Introduction and objectivesDirect oral anticoagulant (DOAC) therapy has been shown to be safe and effective in patients with atrial fibrillation (AF). However, outcomes in AF patients with bioprosthetic valves are unclear, as this population has been underrepresented in clinical trials. The aim of this study was to assess the safety and efficacy of DOACs in this population based on the existing published literature.MethodsA systematic search and review were conducted to identify randomized clinical trials and comparative observational studies published from 2017 to January 2022 that compared DOACs and vitamin K antagonists (VKAs) in AF patients with bioprosthetic valves. Hazard ratios (HR) were collected to compare the 2 treatments in terms of cardiovascular and all-cause mortality, stroke/systemic embolism, and major bleeding. A meta-analysis combining the results was performed.ResultsWe included 12 studies (30 283 patients). DOACs and VKAs were compared based on HRs at the 95% confidence interval. DOAC therapy was associated with a significant 9% reduction in all-cause mortality (HR, 0.91; 95%CI, 0.85-0.97; P = .0068; I² = 8%), with no significant differences in the risk of stroke/systemic embolism (HR, 0.87; 95%CI, 0.67-1.14; P = .29; I² = 45%) or major bleeding (HR, 0.82; 95%CI, 0.67-1.00; P = .054; I² = 48.7%).ConclusionsDOAC therapy in AF patients with bioprosthetic valves may be associated with a significant reduction in all-cause mortality, with no reduction in the efficacy of stroke/systemic embolism prevention or increase in major bleeding risk.     

Eficacia de la tromboaspiración en pacientes con shock cardiogénico secundario a infarto agudo de miocardio y alta carga trombótica

Introduction and objectivesCurrent guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI.MethodsWe included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V).ResultsNo significant difference was found in in-hospital death (28.9% vs 33.5%; P = .28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HR_adj: 0.80; 95%CI, 0.59-1.09; P = .16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HR_adj: 0.59; 95%CI, 0.41-0.85; P = .004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted P_int = .03).ConclusionsRoutine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).     

L’hypo-albuminémie contribue-t-elle à l’aggravation de l’insuffisance cardiaque ?

BackgroundHypoalbuminemia has now emerged as a powerful prognosticator in heart failure regardless of age, clinical presentation, left ventricular ejection fraction and usual prognostic markers. Growing evidence is that this prognostic value persists after adjusting for causative factors for hypoalbuminemia such as malnutrition, inflammation and liver dysfunction.ObjectiveTo address the prognostic relevance of hypoalbuminemia in frail elderly patients with well-characterized cardiogenic pulmonary edema at high risk for adverse outcome, beyond causative factors for low serum albumin levels. Serum albumin was measured after clinical stabilization to avoid hypervolemia.ResultsIn all, 67 patients with a mean age of 86 years were included. Hospital mortality was 30%. Patients who died and who survived were similar in age, ejection fraction, BNP concentration, serum creatinine, serum hemoglobin, total bilirubin and prealbumin. Patients who died had lower serum albumin levels (P < 0.001), higher blood urea nitrogen (P = 0.03) and higher C-reactive protein (P = 0.02). In multivariate analysis, serum albumin was the sole independent predictor of hospital death (P < 0.01), after adjusting for malnutrition (prealbumin P = ns), inflammation (C-reactive protein P = ns) and liver dysfunction (total bilirubin P = ns).ConclusionSerum albumin is a powerful prognosticator in frail elderly patients with acute cardiogenic pulmonary edema even after adjusting for main causative factors. These results suggest that hypoalbuminemia may contribute to the worsening of heart failure given the physiological properties of serum albumin that includes antioxidant activity and plasma colloid osmotic pressure action. Further studies are critically needed to address the relevance of prevention and correction of hypoalbuminemia in heart failure.     

Acute kidney injury and chronic kidney disease after liver transplant: A retrospective observational study

Background and rationaleChronic kidney disease remains an important risk factor for morbidity and mortality among LT recipients, but its exact incidence and risk factors are still unclear.Material and methodsWe carried out a retrospective cohort study of consecutive adults who underwent liver transplant (January 2009–December 2018) and were followed (at least 6 months) at our institution. CKD was defined following the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guidelines. Long-term kidney function was classified into 4 groups: no CKD (eGFR, ≥60 mL/min/1.73 m²), mild CKD (eGFR, 30–59 mL/min/1.73 m²), severe CKD (eGFR, 15–29 mL/min/1.73 m²), and end-stage renal disease (ESRD).ResultsWe enrolled 410 patients followed for 53.2 ± 32.6 months. 39 had CKD at baseline, and 95 developed de novo CKD over the observation period. There were 184 (44.9%) anti-HCV positive, 47 (11.5%) HBsAg positive, and 33 (8.1%) HBV/HDV positive recipients. Recipient risk factors for baseline CKD were advanced age (P = 0.044), raised levels of serum uric acid (P < 0.0001), and insulin dependent DM (P = 0.0034). Early post-transplant AKI was common (n = 95); logistic regression analysis found that baseline serum creatinine was an independent predictor of early post-LT AKI (P = 0.0154). According to our Cox proportional hazards model, recipient risk factors for de novo CKD included aging (P < 0.0001), early post-transplant AKI (P = 0.007), and baseline serum creatinine (P = 0.0002). At the end of follow-up, there were 116 LT recipients with CKD – 109 (93.9%) and 7 (6.1%) had stage 3 and advanced CKD, respectively. Only two of them are undergoing long-term dialysis.ConclusionThe incidence of CKD was high in our cohort of LT recipients, but only a slight decline in kidney function over time was recorded. Prevention of post-transplant AKI will improve kidney function in the long run. We need more studies to analyze the function of kidneys among LT recipients over extended follow-ups and their impact on mortality.