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.     

Single measurement of serum N-terminal Pro-Brain Natriuretic Peptide: The best predictor of long-term mortality in patients with chronic systolic heart failure

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

Admission NT-proBNP levels,renal insufficiency and age as predictors of mortality in elderly patients hospitalized for acute dyspnea

BackgroundAssay of baseline B-type peptide (BNP and NT-proBNP) is useful for heart failure (HF) prognostication. In contrast, the prognostic value of NT-proBNP assay performed on admission of elderly subjects for acute dyspnea is uncertain. The aim of this study was to determine the vital prognostic value of NT-proBNP assay and other relevant variables available on admission in elderly patients hospitalized for acute dyspnea.Methods254 patients over 70 years of age who were initially hospitalized with acute dyspnea were prospectively studied. The log-rank test and Cox proportional-hazards regression models were used to determine the prognostic value of NT-proBNP and creatinine clearance, measured within 24 h of initial admission, as well as age, gender, vascular risk factors and other clinical variables.ResultsMean age was 81 ± 7 years, and 52% of the patients were women. During a median follow-up of 34 months, 134 patients (55%) died and 9 patients (4%) were lost to follow-up. The median survival time was 25 months, and almost half the deaths occurred during the first 6 months. In multivariate analysis the following three variables were independently associated with mortality (shown with their accompanying hazard ratios (HR)): NT-proBNP > 2856 pg/mL (median), HR = 1.6[95%CI:1.3–5.2]; creatinine clearance < 30 mL/min, HR = 1.7[95%CI:1.2–2.5]; and age > 80 years, HR = 1.7[95%CI:1.1–2.6]. The median survival time among patients with an admission NT-proBNP level of > 2856 pg/mL (median) was 14 months, compared to > 36 months in the rest of the population.ConclusionThe admission NT-proBNP level, age, and creatinine clearance are predictive of vital outcome in elderly patients hospitalized for acute dyspnea.     

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     

Prognostic value of B-type natriuretic peptide and its amino-terminal proBNP fragment for cardiovascular events with stratification by renal function

BackgroundBrain natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) are useful biomarkers for diagnosis and prediction of prognosis. Both of these peptides are elevated in patients with chronic kidney disease (CKD), but there is no evidence as to which peptide is the more suitable biomarker in patients with severe renal dysfunction.Methods and resultsThis retrospective cohort study evaluated patients with cardiovascular diseases (64.9 ± 11.7 years, mean ± SD). The end points were all-cause death and a composite end point of all-cause death, nonfatal myocardial infarction, nonfatal stroke, hospitalization for severe heart failure, and initiation of hemodialysis. Baseline plasma BNP and NT-proBNP levels, expressed as log-transformed data, were closely correlated in patients with CKD stages 1–3 (n = 998) (r² = 0.870, p < 0.001), whereas for CKD stages 4–5 (n = 85) there was a significant but weaker correlation (r² = 0.209, p < 0.001). During follow-up periods (51.3 ± 0.4 months), 132 patients died and 202 patients reached the composite end point. The area under the receiver operating characteristic curve (AUROC) for BNP and NT-proBNP were similar for CKD stages 1–3. However, for CKD stages 4–5, the AUC for mortality for BNP was 0.713 and that for NT-proBNP was 0.760, while the AUC for the composite end point for BNP was 0.666 and that for NT-proBNP was 0.720.ConclusionsBoth BNP and NT-proBNP are useful biomarkers for mortality and cardiovascular events, but NT-proBNP may be superior to BNP for CKD stages 4–5.     

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.     

V-shaped relationship between HbA1c and all-cause mortality in the elderly with type 2 diabetes

PurposeThe optimal glycemic target for elderly patients with diabetes has not been established. The purpose of this study was to elucidate relationship between HbA1c and mortality in elderly patients with diabetes.SubjectsThree hundred consecutive elderly (≥ 65 yrs) patients with type 2 diabetes mellitus admitted for control of hyperglycemia between 2002 and 2010 were registered. Upon mortality survey at the end of 2012, 201 (70%) of them were traceable (men/women 121/80, mean age 71 yrs, duration of diabetes 11 yrs and HbA1c 9.9%). The analysis took account of the following baseline information: gender, age, duration of diabetes, HbA1c, body mass index, systolic blood pressure, eGFR, urinary albumin excretion, serum lipid levels and use of insulin and oral hypoglycemic agents. The follow-up HbA1c was also recorded.ResultsThe mean follow-up period was 5.7 yrs and 45 of the patients have died. The mortality hazard as a function of the baseline HbA1c quartile was significantly V-shaped with the nadir in quartile 2 (HbA1c 8.5–9.4%) (P = 0.02), and this relationship remained significant after adjustment for the confounders such as estimated glomerular filtration rate and insulin use. The follow-up HbA1c was 7.7 ± 1.6% and not significantly related to mortality.Discussion/ConclusionThere was a V-shaped relationship between baseline HbA1c and all-cause mortality in elderly patients with insufficiently controlled glycemia. The nadir was in Q2 in which the HbA1c value was 8.5–9.4%. No significant relationship was found between the follow-up HbA1c and mortality. Further studies are needed to clarify the relationship between HbA1c and mortality in the elderly.     

Short- and Long-Term Outcomes in Patients With New-Onset Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Replacement

BackgroundThe impact of new-onset persistent left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) on all-cause mortality has been controversial.MethodsWe conducted a systematic review and meta-analysis of eleven studies (7398 patients) comparing the short- and long- outcomes in patients who had new-onset LBBB after TAVR vs. those who did not.ResultsDuring a mean follow-up of 20.5 ± 14 months, patients who had new-onset persistent LBBB after TAVR had a higher incidence of all-cause mortality (29.7% vs. 23.6%; OR 1.28 (1.04–1.58), p = 0.02), rehospitalization for heart failure (HF) (19.5% vs. 17.3%; OR 1.4 (1.13–1.73), p = 0.002), and permanent pacemaker implantation (PPMi) (19.7% vs. 7.1%; OR 2.4 (1.64–3.52), p < 0.001) compared with those who did not. Five studies (4180 patients) reported adjusted hazard ratios (HR) for all-cause mortality; new LBBB remained associated with a higher risk of mortality (adjusted HR 1.43 (1.08–1.9), p < 0.01, I² = 81%).ConclusionPost-TAVR persistent LBBB is associated with higher PPMi, HF hospitalizations, and all-cause mortality. While efforts to identify patients who need post-procedural PPMi are warranted, more studies are required to evaluate the best follow-up and treatment strategies, including the type of pacing device if required, to improve long-term outcomes in these patients.     

Prognostic value of serum cystatin C and N-terminal pro b-type natriuretic peptide in patients with acute heart failure

BackgroundCystatin C (CysC) is a good prognostic marker in heart failure. However, there is not much information of CysC combined with other biomarkers in acute heart failure (AHF).AimTo assess prognostic value of CysC and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients hospitalized for AHF with no apparent deterioration of renal function.DesignProspective, multicenter, observational study.MethodsCysC and NTpro-BNP were measured in patients consecutively admitted with a diagnosis of AHF. Patients with, NTpro-BNP concentration above 900 pg/mL and serum creatinine below 1.3 mg/dL, were included for statistical analysis. End-point of the study was all-cause mortality during a 12-month follow-up.Results526 patients with AHF and NTpro-BNP concentration above 900 pg/mL were included in the study. From this group, 367 patients (69.8%) had serum creatinine below 1.3 mg/dL. Receiver operating characteristic (ROC) curves were used to determine the best cut-off value for CysC. Patients with a concentration of CsyC above 1.25 mg/dL had a 37.8% mortality rate, vs. 13.6% for those below cut-off (p < 0.001). After Cox proportional hazard model, age, CysC, low total cholesterol and HF with preserved ejection fraction remained significantly associated with all-cause mortality during one-year follow-up.ConclusionsIn AHF and normal or slightly impaired renal function, performance of CysC may be superior to NT-proBNP. Hence, CysC may be the preferred biomarker in the assessment of patients with AHF and slightly impaired renal function.     

Impact of prealbumin on mortality and hospital readmission in patients with acute heart failure

BackgroundPrealbumin is a maker of nutritional status and inflammation of potential prognostic value in acute heart failure (HF). The aim of this study is to evaluate if low prealbumin levels on admission predict mortality and readmissions in patients with acute HF.MethodWe conducted a prospective observational cohort study including 442 patients hospitalized for acute HF. Patients were classified in two groups according to prealbumin levels: “normal” prealbumin (> 15 mg) and “low” prealbumin (≤ 15 mg/dL). End-points were mortality and readmissions (all-cause and HF-related) and the combined end-point of mortality/readmission at 180 days.ResultsOut of 442 patients, 159 (36%) had low and 283 (64%) had normal prealbumin levels Mean age was 79.6 (73.9–84.2, p = 0,405) years and 183 (41%, p = 0,482) were males. After a median 180 days of follow-up, 108 (24%, p = 0,021) patients died and 170 (38%, p = 0,067) were readmitted. Mortality was higher in the low prealbumin group. The combined end-point was more frequent in the low prealbumin group (57% vs. 50%, p = 0.199). In the multivariate analysis the following variables were associated with mortality or readmission: older age, exacerbated chronic HF, higher comorbidity, low systolic blood pressure and hemoglobin values and higher pro brain natriuretic peptide levels.ConclusionsLow prealbumin is common (36%) in patients with acute heart failure and it is associated with a higher short-term mortality.     

Relation Between Red Cell Distribution Width With Echocardiographic Parameters in Patients With Acute Heart Failure

BackgroundRed cell distribution width (RDW) has recently been discovered to be a novel prognostic marker in patients with heart failure. However, the relation between RDW and echocardiographic parameters in acute heart failure (AHF) has not been studied.Methods and ResultsWe analyzed laboratory findings including RDW, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiographic parameters in 100 patients with AHF. The mean RDW was 14.2 ± 2.0% and median NT-proBNP was 5183 pg/mL. The mean left ventricular ejection fraction was 33.1 ± 14.5% and early mitral inflow velocity to early diastolic mitral annular velocity (E/E′), was 21.2 ± 9.4. When the RDW was considered in tertile categories, the highest tertile group (>14.5%) had higher E/E′ (P < .001) and higher NT-proBNP (P = .02) than the lowest tertile group (<13.2%). In multiple linear regression analysis, RDW was independently correlated with E/E′ even after adjustment of other risk factors (β-coefficient 0.431, P = .001). The optimal cutoff value of RDW for predicting E/E′ >15, suggesting elevated left ventricular filling pressure (LVFP) was 13.45% (area under the curve 0.633, P < .05). An additive power of RDW with NT-proBNP for predicting E/E′ >15 was found in logistic regression analysis (P = .038).ConclusionsWe found a novel relation between higher levels of RDW and elevated E/E′ in patients with AHF. This novel finding raises the possibility that a simple marker, RDW may be associated with elevated LVFP in patients with AHF.     

A cross sectional study comparing traditional risk factors with N-terminal pro-BNP in high risk groups for cardiovascular disease in Trinidad,West Indies

ObjectiveCardiovascular disease is a leading cause of morbidity and mortality worldwide and traditional risk factors for cardiovascular disease have been well-elaborated. In recent years, the use of biomarkers has emerged for identifying individuals at high risk with the aim of earlier identification and risk mitigation. Among the most promising non-traditional markers are BNP and NT-proBNP. This study aims to compare whether serum NT-proBNP co-segregates with traditional cardiovascular risk factors in elderly type 2 diabetic and non diabetic in a population with high prevalence of CVD.MethodsThis study utilized a cross sectional design. Blood samples collected were analyzed for hs-CRP, total serum cholesterol, triglyceride, LDL cholesterol, HDL cholesterol, fasting glucose, insulin, and NT-proBNP.ResultsMean serum NT-proBNP levels were significantly elevated in diabetics (X = 125.5 ± 49.7) compared to non diabetics (X = 64.3 ± 34.6). In diabetics, NT-proBNP demonstrated statistically significant spearman's coefficients with respect to systolic blood pressure, triglyceride, hs-CRP, fasting glucose and insulin. Among non diabetics there was no relationship between NT-proBNP, blood pressure and insulin. Multivariate logistic regression revealed relation between diabetics; elevated NT-proBNP, blood pressure, triglyceride, CRP, fasting glucose and plasma insulin compared with non diabetics where NT-proBNP showed significant relation only to diastolic blood pressure. Diabetics showed significant correlation with elevated NT-proBNP and traditional risk factors (hypertension, diabetes, dyslipidemia and elevated hs-CRP) as compared with non diabetics.ConclusionsNT-proBNP co-segregates with traditional risk factors for CVD among elderly diabetics and may be a useful additional screening test for those at risk for CVD.     

Prognostic Value of Combined Measurement of Brain Natriuretic Peptide and Triiodothyronine in Heart Failure

BackgroundBoth low free triiodothyronine (fT3) and high brain natriuretic peptide (BNP) have been separately described as prognostic predictors for mortality in heart failure (HF). We investigated whether their prognostic value is independent.Methods and ResultsFrom January of 2001 to December of 2006, we prospectively evaluated 442 consecutive patients with systolic HF and no thyroid disease or treatment with drugs affecting thyroid function (age 65 ± 12 years, mean ± standard deviation, 75% were male, left ventricular ejection fraction 33% ± 10%, New York Heart Association (NYHA) class I and II: 63%, NYHA class III and IV: 37%). All patients underwent full clinical and echocardiographic evaluation and assessment of BNP and thyroid function. Both cardiac and all-cause mortality (cumulative) were considered as end points. During a median 36-month follow-up (range 1–86 months), 110 patients (24.8%) died, 64 (14.4%) of cardiac causes. Univariate Cox model predictors of all-cause mortality and cardiac death were age, body mass index, creatinine, hemoglobin, ejection fraction, NYHA class, BNP, fT3, and thyroxine level. Multivariate analysis selected age, NYHA class, hemoglobin, BNP, and fT3 as independent predictors for all-cause mortality and NYHA class, BNP, and fT3 as independent predictors for cardiac mortality. Patients with low fT3 and higher BNP showed the highest risk of all-cause and cardiac death (odds ratio 11.6, confidence interval, 5.8–22.9; odds ratio 13.8, confidence interval, 5.4–35.2, respectively, compared with patients with normal fT3 and low BNP).ConclusionfT3 and BNP hold an independent and additive prognostic value in HF.     

Fragilidad y pronóstico de los pacientes mayores con insuficiencia cardiaca

Introduction and objectivesHeart failure (HF) is prevalent in advanced ages. Our objective was to assess the impact of frailty on 1-year mortality in older patients with ambulatory HF.MethodsOur data come from the FRAGIC study (Spanish acronym for “Study of the impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly outpatients with heart failure”), a multicenter prospective registry conducted in 16 Spanish hospitals including outpatients ≥ 75 years with HF followed up by cardiology services in Spain.ResultsWe included 499 patients with a mean age of 81.4 ± 4.3 years, of whom 193 (38%) were women. A total of 268 (54%) had left ventricular ejection fraction < 40%, and 84.6% was in NYHA II functional class. The FRAIL scale identified 244 (49%) pre-frail and 111 (22%) frail patients. Frail patients were significantly older, were more frequently female (both, P < .001), and had higher comorbidity according to the Charlson index (P = .017) and a higher prevalence of geriatric syndromes (P < .001). During a median follow-up of 371 [361-387] days, 58 patients (11.6%) died. On multivariate analysis (Cox regression model), frailty detected with the FRAIL scale was marginally associated with mortality (HR = 2.35; 95%CI, 0.96-5.71; P = .059), while frailty identified by the visual mobility scale was an independent predictor of mortality (HR = 2.26; 95%CI, 1.16-4.38; P = .015); this association was maintained after adjustment for confounding variables (HR = 2.13; 95%CI, 1.08-4.20; P = .02).ConclusionsIn elderly outpatients with HF, frailty is independently associated with mortality at 1 year of follow-up. It is essential to identify frailty as part of the comprehensive approach to elderly patients with HF.     

Prognostic value of cystatin C in relation to other markers of renal function in early prediction of hospital mortality and major cardiac adverse events in patients with ST elevation myocardial infarction treated by primary percutaneous coronary intervention

IntroductionCystatin C has been implicated as a prognostic marker in cardiovascular diseases. The aim of prospective study was to evaluate the benefits of measuring cystatin C for prognostic stratification to predict hospital mortality and the rates of major cardiac adverse events (MACE) in ST elevation myocardial infarction (STEMI) patients and to compare cystatin C to other markers of renal function and Global Registry of Acute Coronary Events (GRACE) score.MethodsA total of 659 consecutive patients (479 men, mean age 65 years) from a prospective study on acute STEMI treated by primary percutaneous coronary intervention (PCI) were evaluated. Standard laboratory tests including cystatin C, troponin T, NT-terminal fragment of brain natriuretic peptide (NT-proBNP), markers of renal function were assessed on admission in all patients. Using c-statistic, the ability of cystatin C, other biomarkers and GRACE score to predict hospital mortality and MACE (acute coronary syndrome recurrence, stroke event, definite in-stent thrombosis and mortality) rate was evaluated.ResultsAll-cause hospital mortality and MACE occurrence were 4% (n = 26) resp. 6.8% (n = 45). Cystatin C, creatinine, urea, glomerular filtration rate, troponin T, NT-proBNP and GRACE on admission were identified as significant prognostic risk markers.Serum cystatin C level and GRACE score were significantly higher in non-survivors (1.65 ± 0.91 vs. 0.97 ± 0.41 mg/mL; P < 0.001 resp. 138 ± 43 vs. 99 ± 31; P < 0.001). The area under the curve (AUC) values for mortality and MACE rate prediction for cystatin C and GRACE score were 0.83 and 0.88, respectively 0.66 and 0.72 (all P < 0.001) with optimal cut-off values of 1.3 mg/mL for cystatin C and 136 for GRACE score.Cystatin C above cut-off >1.30 mg/L was associated with the highest adjusted odds ratio (OR) 3.85 (95% confidence interval 2.36–6.38; P < 0.001), and predicted in-hospital mortality with 77% sensitivity and 86% specificity. The addition of cystatin C to the GRACE score (OR 1.05, 95% confidence interval 1.04–1.07; P < 0.001) was not significantly associated with improved risk stratification.ConclusionsCystatin C is a predictor of early outcome comparable with the GRACE score in patients with STEMI.     

Valor pronóstico de la fibrosis hepática valorada por el índice FIB4 en pacientes ingresados por síndrome coronario agudo

Introduction and objectivesLiver fibrosis is present in nonalcoholic liver disease (NAFLD) and both precede liver failure. Subclinical forms of liver fibrosis might increase the risk of cardiovascular events. The objective of this study was to describe the prognostic value of the FIB-4 index on in-hospital mortality and postdischarge outcomes in patients with acute coronary syndrome (ACS).MethodsRetrospective study including all consecutive patients admitted for ACS between 2009 and 2019. According to the FIB-4 index, patients were categorized as < 1.30, 1.30-2.67 or > 2.67. Heart failure (HF) and major bleeding (MB) were assessed taking all-cause mortality as a competing event and subhazard ratios (sHR) are presented. Recurrent events were evaluated by the incidence rate ratio (IRR).ResultsWe included 3106 patients and 6.66% had a FIB-4 index ≥ 1.3. A multivariate analysis verified a higher risk of in-hospital mortality associated with the FIB-4 index (OR, 1.24; P = .016). Patients with a FIB-4 index > 2.67 had a 2-fold higher in-hospital mortality risk (OR, 2.35; P = .038). After discharge (median follow-up 1112 days), the FIB-4 index had no prognostic value for mortality. In contrast, patients with FIB-4 index ≥ 1.3 had a higher risk of first (sHR, 1.61; P = .04) or recurrent (IRR, 1.70; P = .001) HF readmission. Similarly, FIB-4 index ≥ 1.30 was associated with a higher MB risk (sHR, 1.62; P = .030).ConclusionsThe assessment of liver fibrosis by the FIB-4 index identifies ACS patients not only at higher risk of in-hospital mortality but also at higher risk of HF and MB after discharge.Full English text available from:www.revespcardiol.org/en     

Cardiometabolic determinants of mortality in a geriatric population: Is there a “reverse metabolic syndrome”?

AimsDiabetes or insulin resistance, overweight, arterial hypertension, and dyslipidaemia are recognized risk factors for cardiovascular (CV) disease. However, their predictive value and hierarchy in elderly subjects remain uncertain.MethodsWe investigated the impact of cardiometabolic risk factors on mortality in a prospective cohort study of 331 elderly high-risk subjects (mean age ± SD: 85 ± 7 years).ResultsTwo-year total mortality was predicted by age, diabetes, low BMI, low diastolic blood pressure (DBP), low total and HDL cholesterol, and previous CV events. The effect of diabetes was explained by previous CV events. In non-diabetic subjects, mortality was predicted by high insulin sensitivity, determined by HOMA-IR and QUICKI indices. In multivariate analyses, the strongest mortality predictors were low BMI, low HDL cholesterol and previous myocardial infarction. Albumin, a marker of malnutrition, was associated with blood pressure, total and HDL cholesterol, and HOMA-IR. The inflammation marker CRP was associated with low total and HDL cholesterol, and high HOMA-IR.ConclusionIn very old patients, low BMI, low DBP, low total and HDL cholesterol, and high insulin sensitivity predict total mortality, indicating a “reverse metabolic syndrome” that is probably attributable to malnutrition and/or chronic disorders. These inverse associations limit the relevance of conventional risk factors. Previous CV events and HDL cholesterol remain strong predictors of mortality. Future studies should determine if and when the prevention and treatment of malnutrition in the elderly should be incorporated into conventional CV prevention.