RESUMEN
AIM: To examine the effects of sinus rhythm (SR) restoration on N-Terminal pro-BNP (NTP-BNP) in patients with atrial fibrillation (AF). METHODS: Subjects with paroxysmal and persistent AF and absence of organic heart disease were prospectively studied. Chemical or electrical restoration of SR was attempted within 48 hours (n = 37) or >3 weeks (n = 73). Clinical and laboratory (NTP-BNP, 72-hour Holter monitor, and electrocardiogram) assessment were obtained at baseline and at 1, 30, and 180 days after SR restoration. Patients were divided into three predefined "outcome groups": (a) maintenance of SR for 1 month, (b) SR with recurrent paroxysmal AF (PaAF), and (c) early (<30 days) recurrence persistent AF (RAF). RESULTS: Of the 110 patients enrolled, 89 had initial successful SR restoration. Baseline NTP-BNP was 936 pg/mL (interquartile range (IQR) 333-2,026); ratio between baseline and 30-day NTP-BNP was 10.2 (IQR 6.42-22.0) for SR group, 3.3 (IQR 2.45-7.34) for PaAF, and 1.07 (IQR 0.87-1.22) for RAF (P < 0.001). Patients with ratio
Asunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/terapia , Péptido Natriurético Encefálico/sangre , Evaluación de Resultado en la Atención de Salud/métodos , Fragmentos de Péptidos/sangre , Medición de Riesgo/métodos , Anciano , Fibrilación Atrial/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Recuperación de la Función , Reproducibilidad de los Resultados , Factores de Riesgo , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
Telomeres serve as a mitotic clock and biological marker of senescence. Diabetes mellitus (DM) is associated with damage to target organs and premature aging. We assessed the effect of glycemic control on telomere dynamics in arterial cells of 58 patients undergoing coronary artery bypass and in mononuclear blood cells of other diabetic (32 type I and 47 type II) patients comparing well controlled to uncontrolled patients. All were compared to age-dependent curve of healthy controls. Telomeres were significantly shorter in the arteries of diabetic versus non-diabetic patients (p=0.049) and in mononuclear cells of both type I and type II diabetes. In all study groups good glycemic control attenuated shortening of the telomeres. In arterial cells good glycemic control attenuated, but not abolished, the telomere shortening. In type II DM the mononuclear telomere attrition was completely prevented by adequate glycemic control. Telomere shortening in mononuclear cells of type I diabetic patients was attenuated but not prevented by good glycemic control. Results of this study suggest that diabetes is associated with premature cellular senescence which can be prevented by good glycemic control in type II DM and reduced in type I DM.
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Glucemia/metabolismo , Diabetes Mellitus/genética , Leucocitos Mononucleares/ultraestructura , Telómero/ultraestructura , Adulto , Anciano , Anciano de 80 o más Años , Senescencia Celular/genética , Puente de Arteria Coronaria , Diabetes Mellitus/sangre , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/genética , Femenino , Humanos , Masculino , Arterias Mamarias/ultraestructura , Persona de Mediana EdadRESUMEN
BACKGROUND: Treatment of unprotected left main coronary disease by percutaneous interventions, even in the urgent setting, is still not an approved indication. However, the evolution of transcatheter technology and supporting devices, along with greater skill in high-volume centers, led the interventional community to deal with these cases. This study aimed to investigate whether the percutaneous approach in this cohort could be a viable alternative to coronary artery bypass graft (CABG) surgery in the urgent setting. METHODS: We enrolled 51 acute myocardial infarction patients with left main disease as the culprit lesion and treated them by percutaneous coronary intervention. This cohort was followed for major adverse cardiac and cerebrovascular events (MACCE) in-hospital and at 30 days, 6 months and 1 year, and was compared with a population of 35 CABG patients matched for clinical and angiographic characteristics. RESULTS: The estimated MACCE-free survival at 6 months and 1 year was 90% and 88%, respectively. The overall MACCE was 6%. Analysis of the surgical cohort showed an overall MACCE of 17%. In the final Cox model, significant predictors of MACCE were Parsonnet score for surgical risk (HR 1.93, 95% CI 1.15-7.3; p = 0.04) and diabetes mellitus (HR 1.73, 95% CI 1.03-3.8; p = 0.038). CONCLUSIONS: Angioplasty for unprotected left main coronary disease in the urgent clinical setting is feasible, showing a relatively low short- and long-term rate of MACCE.
Asunto(s)
Angioplastia Coronaria con Balón/mortalidad , Puente de Arteria Coronaria/mortalidad , Estenosis Coronaria/mortalidad , Estenosis Coronaria/terapia , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Angioplastia Coronaria con Balón/métodos , Estudios de Casos y Controles , Estudios de Cohortes , Angiografía Coronaria , Puente de Arteria Coronaria/métodos , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/patología , Tratamiento de Urgencia , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Spontaneous coronary reperfusion occurs in 7-27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome. OBJECTIVES: To determine the optimal PCI time for patients admitted to the hospital due to STEMI with SCR. METHODS: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR. RESULTS: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2-3 was seen in > 95% in both groups. PCI was performed more frequently in the "early" group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the "late catheterization" group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 +/- 245 days). CONCLUSIONS: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive antiplatelet therapy, seems to result in an excess of early MACE without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.
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Toma de Decisiones , Infarto del Miocardio/fisiopatología , Revascularización Miocárdica , Angiografía Coronaria , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/cirugía , Pronóstico , Remisión Espontánea , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: External counterpulsation is a safe and effective method of alleviating angina pectoris, but the mechanism of benefit is not understood. OBJECTIVES: To evaluate the safety and efficacy of external counterpulsation therapy in heart failure patients. METHODS: Fifteen symptomatic heart failure patients (subsequent to optimal medical and device therapy) underwent 35 hourly sessions of ECPT over a 7 week period. Before and after each ECPT session we performed pro-B-type natriuretic peptide and brachial artery function studies, administered a quality of life questionnaire, and assessed exercise tolerance and functional class. RESULTS: Baseline left ventricular ejection fraction was 28.1+/-5.8%. ECPT was safe and well tolerated and resulted in a reduction in pro-BNP levels (from 2,245+/- 2,149 pcg/ml to 1,558+/-1206 pcg/ml, P= 0.022). Exercise duration (Naughton protocol) improved (from 720+/-389 to 893+/-436 seconds, P= 0.0001), along with functional class (2.63+/-0.6 vs. 1.93+/-0.7, P= 0.023) and quality of life scores (54+/-22 vs. 67+/-23, P= 0.001). Nitroglycerine-mediated brachial vasodilatation increased (11.5+/-7.3% vs. 15.6+/-5.2%, P=0.049), as did brachial flow-mediated dilation (8.35+/-6.0% vs. 11.37+/-4.9%, P= 0.09). CONCLUSIONS: ECPT is safe for symptomatic heart failure patients and is associated with functional and neurohormonal improvement. Larger long-term randomized studies with a control arm are needed to confirm these initial encouraging observations.
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Contrapulsación/efectos adversos , Contrapulsación/métodos , Insuficiencia Cardíaca/terapia , Adulto , Anciano , Arteria Braquial/fisiología , Prueba de Esfuerzo , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/terapia , Función Ventricular IzquierdaRESUMEN
BACKGROUND: There are few data regarding the impact of prior heart failure (P-HF) on the presentation, course and outcomes of acute coronary syndromes (ACS). METHODS AND RESULTS: We prospectively analyzed all ACS patients admitted in all cardiology wards in Israel during February and March, 2004. Of the 2098 patients, 156(7.4%) had P-HF. These patients were older (75 [66.5-81] versus 63 [53-74] years, (P<0.001)) and more often female (38.5% versus 25.0%, P<0.001)), with a higher prevalence of coronary artery disease risk factors, prior cardiac disease and procedures, and other co-morbidities. They more often presented with atypical angina and heart failure and less with ST-elevation (18.6% versus 51.3%, p<0.0001). In-hospital heart failure developed more frequently (15.4% versus 6.1%, p = 0.00001), including cardiogenic shock (7.1% versus 2.9%, p = 0.005), as did persistent atrial fibrillation (6.4% versus 0.7%, p<0.001), but not ischemic complications. After adjustment for differences, P-HF was not independently associated with 30 day or six-month mortality, but at one-year follow-up, it was (OR 1.16, 95% CI 1.0-2.5). P-HF was also independently associated with increased incidence of heart failure upon admission or thereafter in-hospital (OR = 4.3, 95% CI 2.8-6.6). CONCLUSIONS: P-HF ACS patients had high-risk features, lower incidence of ST-elevation, and higher one-year adjusted mortality. P-HF was also independently associated with in-hospital heart failure, suggesting they should be monitored vigilantly.
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Enfermedad Coronaria/mortalidad , Insuficiencia Cardíaca/mortalidad , Factores de Edad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/diagnóstico por imagen , Ecocardiografía , Femenino , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/diagnóstico por imagen , Hospitalización/estadística & datos numéricos , Humanos , Incidencia , Israel/epidemiología , Masculino , Persona de Mediana Edad , Mortalidad , Prevalencia , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Factores Sexuales , SíndromeRESUMEN
BACKGROUND: Increased left ventricular mass index (LVMI) is associated with a greater incidence of acute myocardial infarction (AMI), but there are no data regarding its impact on infarct size. OBJECTIVES: The objective of this study was to determine whether LVMI impacts on infarct size. METHODS: We analyzed consecutive patients with a first ST-elevation AMI and successful reperfusion of the culprit artery who underwent an echocardiographic assessment of LVMI and regional wall motion score index (RWMSI) <72 hours post AMI. RESULTS: Of the 165 patients (76.4% men) with a mean age of 61.0 +/- 13.9 years, 53.9% had anterior wall involvement and 59.3% had increased LVMI. There were no significant differences in baseline characteristics between patients with and without increased LVMI, except for a greater prevalence of hypertension among patients with increased LVMI (44.0% vs 22.4%, P < .001). The distributions of anterior wall AMI location and culprit artery involvement were similar between the groups. Patients with increased LVMI were more likely to present with single-vessel coronary artery disease (P = .04) and heart failure upon presentation (P = .03). There was no significant difference between patients with and without increased LVMI in peak creatine kinase (2106.8 +/- 1642.7 vs 2551.2 +/- 2357.4 U/L, P = .16) or RWMSI (1.62 +/- 0.44 vs 1.61 +/- 0.38, P = .91). In addition, no correlation was observed between LVMI as a continuous variable and RWMSI (r = 0.11, P = .18) or peak creatine kinase values (r = 0.02, P = .81). CONCLUSIONS: Among patients with a first ST-elevation AMI and successful reperfusion, antecedent increased LVMI was fairly common and did not impact on infarct size.
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Ventrículos Cardíacos/patología , Infarto del Miocardio/patología , Anciano , Creatina Quinasa/sangre , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Cardiovasculares , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/terapia , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , UltrasonografíaRESUMEN
Recent studies highlighted the 'obesity paradox' after revascularization, suggesting a 'cardioprotective' effect of obesity. We assessed the association of BMI and regional wall motion score (RWMS) and peak CK and cTnI values (markers of infarct size) and 30-day survival among consecutive first ST-segment-elevation myocardial infarction patients who underwent successful primary PCI. Of the 164 patients, we found no difference in infarct size among the different groups, BMI < or = 25 kg/m2, 25 < BMI < or = 30 kg/m2, and BMI > 30 kg/m2, and no association between BMI as continuous variable and these variables. Thirty-day death rates were not statistically different among the three groups (10, 5, 2%, respectively, P = 0.83). Increased BMI does not confer any protective effect on the heart during acute ischemia.
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Índice de Masa Corporal , Electrocardiografía , Infarto del Miocardio/patología , Obesidad/complicaciones , Angioplastia Coronaria con Balón , Biomarcadores/sangre , Creatina Quinasa/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/terapia , Troponina I/sangreRESUMEN
E-wave velocity in mitral flow has previously been shown to discriminate between severe and nonsevere mitral regurgitation. In this study, we sought to explore this association in the tricuspid position. The peak velocity of the tricuspid inflow E wave was measured in 118 patients (mean age 62 +/- 16.6 years; 48% women). Patients with tricuspid stenosis, transvenous pacemakers, and tricuspid prostheses were excluded. E-wave measurements were taken during shallow breathing. Tricuspid regurgitation (TR) was quantified as none or mild (group 1), moderate (group 2), or severe (group 3), according to American Society of Echocardiography guidelines. Forty-three patients had mild TR, 43 had moderate TR, and 33 had severe TR. Peak E-wave velocity was 48.6 +/- 13.8, 48.6 +/- 11.7, and 78.3 +/- 26.1 cm/s in groups 1, 2, and 3, respectively (p > 0.0001). Mean E-wave velocity was similar in groups 1 and 2 but greater in group 3 (p < 0.0001). A peak E-wave velocity of > or = 65 cm/s had a sensitivity of 73% and specificity of 88% for the detection of severe TR. In conclusion, increased peak tricuspid E-wave velocity is associated with severe TR and thus can be used as a simple measure of TR grade.