RESUMEN
Increased red blood cell distribution width (RDW) has been associated with adverse outcomes in heart failure and stable coronary disease. We studied the association between baseline RDW and changes in RDW during hospital course with clinical outcomes in patients with acute myocardial infarction (AMI). Baseline RDW and RDW change during hospital course were determined in 1,709 patients with AMI who were followed for a median of 27 months (range 6 to 48). The relation between RDW and clinical outcomes after hospital discharge were tested using Cox regression models, adjusting for clinical variables, baseline hemoglobin, mean corpuscular volume, and left ventricular ejection fraction. Compared to patients in the first RDW quintile, the adjusted hazard ratios for death progressively increased with higher quintiles of RDW (second quintile 1.1, 95% confidence interval [CI] 0.6 to 2.1; third quintile 1.8, 95% CI 1.0 to 3.2; fourth quintile 2.0, 95% CI 1.1 to 3.4; fifth quintile 2.8, 95% CI 1.6 to 4.7, p for trend <0.0001). An increase in RDW during hospital course was also associated with subsequent mortality (adjusted hazard ratio 1.13 for 1-SD increase in RDW, 95% CI 1.02 to 1.25). Similar results were obtained for the end point of heart failure. The association between increased RDW and worse outcome was evident in patients with and without anemia. In conclusion, there is a graded, independent association between increased RDW and mortality after AMI. An increase in RDW during hospitalization also portends adverse clinical outcome.
Asunto(s)
Índices de Eritrocitos , Eritrocitos , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Adulto , Anciano , Intervalos de Confianza , Eritrocitos/citología , Femenino , Estudios de Seguimiento , Humanos , Pacientes Internos/estadística & datos numéricos , Israel/epidemiología , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Stress hyperglycemia is a complex phenomenon that incorporates the cumulative effects of multiple factors. Rapid changes in blood glucose may reflect neurohormonal and homodynamic events that affect patient outcome. We prospectively studied the relation between changes in fasting glucose (FG) during a hospital course and long-term mortality in 1,467 nondiabetic patients with acute myocardial infarction. FG was obtained at admission and later during the hospital course and classified at each time point as normal (<100 mg/dl), impaired (100 to 125 mg/dl), or diabetic range (>or=126 mg/dl). The relation between measurements of FG and mortality (median follow-up 30 months) was assessed using Cox models. FG classification improved in 426 (29.0%) and worsened in 248 patients (16.9%) during hospitalization. Mean FG was a better predictor of mortality than baseline or final FG levels alone (C-index 0.670, 0.656, and 0.645, respectively). Changes in FG during hospitalization were strongly associated with changes in mortality risk. Compared to patients with persistent normal FG, the adjusted hazard ratio (HR) for mortality was 2.6 (95% confidence interval [CI] 1.0 to 7.2) for patients in whom FG increased to the diabetic range; the HR was 6.3 (95% CI 4.0 to 10.4) in patients with persistent FG in the diabetic range but decreased substantially when FG normalized during hospitalization (HR 2.7, 95% CI 1.3 to 5.1). In conclusion, persistent increase of FG during hospitalization for acute myocardial infarction has greater prognostic effect than baseline FG. Changes in FG during hospitalization are simple and sensitive indicators of dynamic changes in risk.
Asunto(s)
Glucemia/metabolismo , Ayuno/sangre , Hospitalización , Hiperglucemia/sangre , Infarto del Miocardio/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Hiperglucemia/etiología , Israel/epidemiología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
Acute kidney injury is a common complication of acute myocardial infarction and is generally associated with adverse outcomes. We studied the incidence and clinical significance of transient versus persistent acute kidney injury in 1957 patients who survived an ST-elevation acute myocardial infarction. We divided the patients into 5 groups based on changes in serum creatinine level during hospitalization. Mild acute kidney injury (creatinine 0.3-0.49 mg/dl above baseline) occurred in 156 patients and was transient (resolved during their hospital stay) in 61. Moderate/severe acute kidney injury (creatinine more than or 0.5 mg/dl above baseline) was found in 138 patients and was transient in 60. Compared to patients without acute kidney injury, the adjusted hazard ratio for mortality was 1.2 in patients with mild, transient acute kidney injury and 1.8 in patients with mild, persistent injury where the creatinine remained elevated. Patients with persistent moderate/severe acute kidney injury had the highest mortality (hazard ratio 2.4), whereas patients with transient moderate/severe injury had an intermediate risk (hazard ratio of 1.7). A similar relationship was present between acute kidney injury and admissions for heart failure. Our study shows that dynamic changes in renal function during acute myocardial infarction are strongly related to long-term mortality and heart failure.
Asunto(s)
Insuficiencia Cardíaca/etiología , Enfermedades Renales/etiología , Infarto del Miocardio/complicaciones , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Creatinina/sangre , Femenino , Tasa de Filtración Glomerular , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Estimación de Kaplan-Meier , Enfermedades Renales/sangre , Enfermedades Renales/mortalidad , Enfermedades Renales/fisiopatología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/terapia , Oportunidad Relativa , Readmisión del Paciente , Modelos de Riesgos Proporcionales , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
Anemia is an independent indicator of mortality in patients with acute myocardial infarctions (AMIs). Although anemia may be a transient phenomenon, secondary to acute blood loss, the prevalence and clinical significance of anemia after recovery from AMI are not known. In this study, 1,065 patients with AMIs for whom postdischarge hemoglobin levels were available were assessed. Patients were categorized into 4 groups according to their anemia status at hospital discharge and at follow-up (no anemia, resolved anemia, persistent anemia, and new-onset anemia). The association between anemia and the primary end point of mortality and hospitalization for heart failure was evaluated using Cox models, using patients without anemia at the 2 time points as the reference group. At hospital discharge, anemia was present in 370 patients (34.7%). At follow-up, anemia had resolved in 162 patients (15.2%), 208 (19.5%) had persistent anemia, and 55 (5.2%) had new-onset anemia. During the follow-up period (median 27 months) 110 patients (10.3%) died, and 89 (8.4%) developed heart failure. The outcomes of patients with resolving anemia were similar to those of patients without anemia (hazard ratio 0.8, 95% confidence interval 0.5 to 1.3). In contrast, there was a marked increase in mortality and heart failure in patients with persistent (hazard ratio 1.8, 95% confidence interval 1.2 to 2.5) and new-onset (hazard ratio 1.9, 95% confidence interval 1.1 to 3.3) anemia. In conclusion, persistent or new-onset anemia occurs in a significant proportion of patients after AMI. Whereas the resolution of anemia after AMI is associated with better outcomes, persistent or new-onset anemia portends increased risk for heart failure and death.
Asunto(s)
Anemia/epidemiología , Infarto del Miocardio/sangre , Anciano , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Hemoglobinas/metabolismo , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Alta del Paciente , Prevalencia , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
Recent studies suggest that statin therapy reduces hospitalizations for heart failure (HF). However, few data exist regarding the role of statins in preventing HF after acute myocardial infarction (AMI). In addition, the potential impact of left ventricular (LV) ejection fraction (EF) and coexisting functional mitral regurgitation (MR) on the efficacy of statin therapy was not considered. We prospectively studied 1,563 patients with AMI. The primary endpoint was readmission for the treatment of HF. The effect of statin therapy initiated before hospital discharge was evaluated using a Cox model, adjusting for clinical variables, a propensity score for statin therapy, LVEF, and MR grade. Patients with recurrent infarctions were censored. Statins were prescribed in 1,048 patients (67.1%) before hospital discharge. During a median follow-up of 17 months, admissions for HF were lower in patients receiving statins (6.5% vs 14.8%; unadjusted hazard ratio 0.45, 95% confidence interval 0.32 to 0.63, p <0.0001). In a multivariable Cox model, statin therapy was associated with a significant reduction of hospitalization for HF (HR 0.62, 95% confidence interval 0.43 to 0.89, p = 0.009). There was a significant interaction between MR and statin therapy (p = 0.039), such that the beneficial effect of statins on HF hospitalizations was most pronounced in patients without concomitant MR and absent in patients with hemodynamically significant MR. In conclusion, in patients with AMI statin therapy initiated before hospital discharge significantly reduces subsequent hospitalizations for HF. The effect of statins is driven largely by the reduction in events in patients without concomitant hemodynamically significant MR.
Asunto(s)
Insuficiencia Cardíaca/prevención & control , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Anciano , Ecocardiografía Doppler en Color , Femenino , Insuficiencia Cardíaca/etiología , Hospitalización/estadística & datos numéricos , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Modelos de Riesgos Proporcionales , Estudios ProspectivosRESUMEN
Divergent views remain regarding the safety of treating anemia with red blood cell (RBC) transfusion in patients with acute coronary syndrome (ACS). We used a prospective database to study effect of RBC transfusion in patients with acute myocardial infarction (MI; n = 2,358). Cox regression models were used to determine the association between RBC transfusion and 6-month outcomes, incorporating transfusion as a time-dependent variable. The models adjusted for baseline variables, propensity for transfusion, and nadir hemoglobin previous to the transfusion. One hundred ninety-two patients (8.1%) received RBC transfusion. Six-month mortality rates were higher in patients receiving transfusion (28.1% vs 11.7%, p <0.0001). The adjusted hazard ratio (HR) for mortality was 1.9 in transfused patients (95% confidence interval [CI] 1.3 to 2.9). Interaction between RBC transfusion and nadir hemoglobin with respect to mortality (p = 0.004) was significant. Stratified analyses showed a protective effect of transfusion in patients with nadir hemoglobin < or=8 g/dL (adjusted HR 0.13, 95% CI 0.03 to 0.65, p = 0.013). By contrast, transfusion was associated with increased mortality in patients with nadir hemoglobin >8 g/dL (adjusted HR 2.2, 95% CI 1.5 to 3.3; p <0.0001). Similar results were obtained for the composite end point of death/MI/heart failure (p for interaction = 0.04). In conclusion, RBC transfusion in patients with acute MI and hemoglobin < or =8 g/dL may be appropriate. The increased mortality observed in transfused patients with nadir hemoglobin above 8 g/dL underscores the clinical difficulty of balancing risks and benefits of RBC transfusion in the setting of ACS.
Asunto(s)
Transfusión de Eritrocitos , Infarto del Miocardio/terapia , Anciano , Bases de Datos como Asunto , Femenino , Hemoglobinas/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Increase of cardiac troponins occurs in a variety of clinical situations in the absence of an acute coronary syndrome (ACS). Few data exist regarding the incidence, clinical characteristics, and predictive value of various cardiac diagnostic tests and outcome of patients with a non-ACS-related troponin increase. We studied 883 consecutive hospitalized patients with increased cardiac troponin I levels. The discharge diagnosis was reclassified and troponin increase attributed to ACS or another process. Clinical data and results of cardiac diagnostic tests were collected. Patients were followed for a median of 30 months. Three hundred eleven patients were classified as having a non-ACS-related troponin increase (35.2%). An alternative explanation for troponin increase was found in 99% of these patients. Troponin level had poor accuracy in discriminating patients with and without ACS (area under the receiver operating characteristics curve 0.63). Coronary angiography was frequently unhelpful in excluding a non-ACS-related troponin increase because 77% of patients in the non-ACS group had significant flow-limiting coronary artery disease. Patients with non-ACS-related troponin increase had significantly higher in-hospital (hazard ratio 2.8, 95% confidence interval 2.0 to 3.8) and long-term (hazard ratio 2.0, 95% confidence interval 1.6 to 2.5) mortalities compared with patients with ACS. In conclusion, cardiac troponin level is frequently increased in hospitalized patients in the absence of an ACS and portends poor short- and long-term outcomes. Most of these patients have an alternative explanation for cardiac troponin increase. Cardiac diagnostic procedures are frequently unhelpful in excluding a non-ACS-related troponin increase.
Asunto(s)
Enfermedad Coronaria/sangre , Pacientes Internos , Troponina I/sangre , Enfermedad Aguda , Anciano , Biomarcadores/sangre , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/mortalidad , Electrocardiografía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Israel/epidemiología , Masculino , Persona de Mediana Edad , Pronóstico , Modelos de Riesgos Proporcionales , Curva ROC , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tasa de Supervivencia/tendencias , SíndromeRESUMEN
BACKGROUND: Chronic subclinical inflammation, manifesting as elevated levels of inflammatory markers such as C-reactive protein (CRP), predicts future atherothrombotic events. The pathophysiology of low-grade inflammation is complex, and multiple intercorrelated conditions have been associated with elevated CRP. METHODS: Principal factor analysis was used to investigate clustering of variables associated with elevated CRP using data from 1435 subjects without known coronary disease. Components of the metabolic syndrome, uric acid, liver enzymes, pulmonary function tests, smoking status, cardiorespiratory fitness (measured by maximal treadmill test), and high-sensitivity C-reactive protein were determined in each subject. RESULTS: Factor analysis identified three factors, which explained 51.0% of the total variance in the dataset (24.4% factor 1, 17.3% factor 2, and 9.3% factor 3). Based on factor loadings of >or=0.5, these factors were interpreted as (1) "metabolic factor" including BMI, fasting glucose, HDL cholesterol, triglycerides, systolic blood pressure, and uric acid; (2) a cardiorespiratory factor that included fitness level, forced expiratory volume in 1s and sex; and (3) "smoking" factor that included cigarette smoking and age. Each of these factors was significantly associated with the presence of high-risk CRP (>or=3mg/L) in the study population. The ability of a multivariate model that included these three factors to predict high-risk CRP was comparable to a model containing the original 10 variables (area under the receiver-operator characteristics curve 0.7 vs. 0.72, respectively). CONCLUSION: Metabolic perturbations, cardiorespiratory fitness, and smoking are separate and largely independent factors in the pathophysiology of chronic, low-grade inflammation.
Asunto(s)
Proteína C-Reactiva/inmunología , Inflamación/inmunología , Síndrome Metabólico/inmunología , Biomarcadores/sangre , Índice de Masa Corporal , Prueba de Esfuerzo , Análisis Factorial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas de Función Respiratoria , Fumar/inmunologíaRESUMEN
BACKGROUND: Transient hyperglycemia is common during acute myocardial infarction in non-diabetic patients and is associated with a worse outcome. There is limited data on the outcome of patients who undergo primary percutaneous coronary intervention and have transient hyperglycemia. METHODS: Fasting plasma glucose was measured in 431 consecutive acute myocardial infarction patients who underwent primary percutaneous coronary interventions. Patients were classified into three groups: non-diabetics/non-hyperglycemic (NDNH, glucose < 126 mg/dL; n=224); non-diabetics/hyperglycemic (NDH, glucose > or = 126 mg/dL; n=119); and diabetics (n=88). Data were analyzed according to the different groups and according to exact glucose levels. RESULTS: In-hospital mortality was significantly lower in NDNH (1%) compared to NDH (8%) and diabetic (5%) patients (p=0.01). One-year cumulative mortality was highest (10%) in patients with NDH (p<0.001). One year target lesion revascularization rates were identical in NDNH and NDH patients (6% vs. 8%) and higher in diabetic patients (19%, p=0.001). In a multivariate model, a striking increase in the risk of death (0.6%, p=0.05) and target lesion revascularization (2%, p<0.0001) was found for every increment of 1 mg/dL in glucose level. CONCLUSIONS: Transient hyperglycemia in non-diabetic acute myocardial infarction patients who undergo primary percutaneous coronary interventions is associated with high one-year mortality. One year target lesion revascularization rates were significantly higher in diabetics compared to non-diabetics with normoglycemia or transient hyperglycemia.
Asunto(s)
Angioplastia Coronaria con Balón , Hiperglucemia/complicaciones , Infarto del Miocardio/mortalidad , Infarto del Miocardio/cirugía , Glucemia/análisis , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Pronóstico , Estudios Prospectivos , Factores de TiempoRESUMEN
INTRODUCTION: Renal dysfunction is associated with increased mortality in acute coronary syndromes and other cardiovascular diseases. The prognostic value of kidney dysfunction has been investigated using creatinine-based measures of renal function. Few data are available on the prognostic significance of blood urea nitrogen (BUN), a sensitive marker of hemodynamic alterations and renal perfusion. METHODS: The relationship between estimated glomerular filtration rate (eGFR), BUN on admission and changes in BUN during hospital course and long-term mortality was evaluated in 1507 patients with acute ST-elevation myocardial infarction (STEMI). RESULTS: During a median follow-up of 27 months (range, 12 to 44 months), 281 patients (18.6%) died. In multivariable Cox regression models, elevated BUN (>or=25 mg/dL) at admission was an independent predictor of mortality after adjustments for clinical variables and eGFR (adjusted hazard ratio [HR] 1.7; 95% confidence interval [CI] 1.2-2.3, P=0.0015). Similar results were obtained for elevated BUN/creatinine ratio (>or=25) at admission (adjusted HR 2.0; 95% CI 1.4-2.8; P<0.0001). An increase in BUN 50% above admission value occurred in 260 of patients (17.3%) during hospital course, and was associated with increased risk of mortality after adjustments of clinical variables, eGFR and BUN on admission (HR, 1.7 95% CI 1.3-2.2; P<0.0001). DISCUSSION: Elevated BUN and BUN/creatinine ratio on admission are independent predictors of long-term mortality in patients with STEMI. An increase in BUN level during hospital course portends adverse outcome independent of eGFR and BUN on admission.
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Nitrógeno de la Urea Sanguínea , Mortalidad Hospitalaria/tendencias , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
INTRODUCTION: Elevation of total white blood cells (WBC) count is associated with higher mortality in patients with acute coronary syndromes. However, it is unknown which specific subset of leukocytes best correlates with increased risk of adverse outcome. METHODS AND RESULTS: We prospectively studied the predictive value of WBC subtypes for long-term outcome in 1037 patients with acute myocardial infarction (AMI). Total WBC, neutrophil, monocyte and lymphocyte counts, and high-sensitivity C-reactive protein (CRP) were obtained in each patient. The median duration of follow up was 23 months (range, 6-42 months). Analyzed separately, baseline total WBC (HR 2.2, 95% CI 1.5-3.3; P<0.0001), neutrophil (HR 2.7, 95% CI 1.8-4.1; P<0.0001) and monocyte (HR 1.9, 95% CI 1.3-2.8; P=0.001) counts in the upper quartile, and lymphocyte count in the lower quartile (HR 1.5, 95% CI 1.1-2.3; P=0.03), were all independent predictors of mortality. Comparing nested models, adding other WBC data failed to improve model based on neutrophil count. In contrast, adding neutrophil count to the models based on total WBC (P=0.01), on monocyte count (P<0.0001) or on lymphocyte count (P<0.0001) improved the prediction of the models. Neutrophil count in the upper quartile (>or=9800 microL(-1)) remained a strong independent predictor of mortality after adjustment for left ventricular systolic function and for CRP (HR 2.2, 95% CI 1.6-3.0; P<0.0001). CONCLUSION: Of all WBC subtypes, elevated neutrophil count best correlates with mortality in patients with AMI. Neutrophil count provides additive prognostic information when combined with CRP.
Asunto(s)
Recuento de Leucocitos , Leucocitos Mononucleares/fisiología , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Neutrófilos/fisiología , Anciano , Proteína C-Reactiva/análisis , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios ProspectivosRESUMEN
BACKGROUND: A diagnosis of unstable angina pectoris (UAP) often carries with it a decision to catheterize the patient promptly. However, UAP remains a clinical diagnosis, based mostly on a patient's clinical history and electrocardiogram (ECG) findings. OBJECTIVE: To evaluate whether the diagnosis of UAP is overused in patients referred for coronary arteriography. METHODS: Ninety-six patients with a diagnosis of UAP who were referred for invasive studies were re-examined clinically before catheterization. Coronarography was independently reviewed for correlation with clinical findings. RESULTS: Based on the patient's history and ECG changes, UAP was classified by two independent cardiologists as 'very likely' in 58% and 49%, 'possible' in 19% and 30%, and of 'low probability' in 23% and 21%, respectively. Patients with 'very likely' UAP had a high incidence of significant coronary lesions (87% and 96% for each cardiologist) and complex lesions by angiography (41% and 49%, respectively). Patients with a diagnosis of 'low probability' UAP had a low incidence of significant coronary lesions (55% for each cardiologist) and a very low incidence of complex angiographic lesions (5% for each cardiologist). Patients with 'possible' UAP had intermediate results. CONCLUSION: Because of a presumptive diagnosis of UAP, approximately 22% of all patients referred for coronarography have no clinical and/or ECG evidence for this diagnosis. The incidence of complex coronary lesions in this group is very low.
RESUMEN
Recent studies have implicated systemic inflammation in the genesis and maintenance of atrial fibrillation (AF). A robust inflammatory response is an integral component of the response to tissue injury during acute myocardial infarction (AMI). However, there is no information concerning the association between inflammation and AF in patients with AMI. We studied 1,209 patients admitted for AMI. C-reactive protein (CRP) was measured by a high-sensitivity assay within 12 to 24 hours after symptom onset. The relation between CRP and new-onset AF occurring during the hospital course and at 1 year was analyzed using multivariable logistic regression and Cox models, respectively. New-onset AF during hospitalization occurred in 6.5%, 10.4%, and 17.1% of patients in the first, second and third CRP tertiles, respectively (p trend <0.0001). In a multivariable logistic regression, adjusting for clinical variables and ejection fraction, compared with patients in the first CRP tertile, the odds ratios for AF were 1.5 (95% confidence interval 0.9 to 2.5, p = 0.15) and 2.0 (95% confidence interval 1.2 to 3.3, p = 0.008) in patients in the second and third CRP tertiles, respectively (p for trend = 0.007). In a Cox multivariate analysis, CRP remained an independent predictor of new-onset AF at 1 year. In conclusion, in a large cohort of patients with AMI, there was a graded positive association between increased CRP and new-onset AF. Inflammation may contribute to the development of AF in the setting of AMI.
Asunto(s)
Fibrilación Atrial/etiología , Proteína C-Reactiva/análisis , Infarto del Miocardio/complicaciones , Factores de Edad , Anciano , Fibrilación Atrial/sangre , Estudios de Cohortes , Creatinina/sangre , Femenino , Estudios de Seguimiento , Predicción , Hospitalización , Humanos , Hipertensión/complicaciones , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Readmisión del Paciente , Estudios Prospectivos , Factores Sexuales , Volumen Sistólico/fisiología , Factores de TiempoRESUMEN
BACKGROUND: The decision to perform primary percutaneous coronary intervention in unconscious patients resuscitated after out-of-hospital cardiac arrest is challenging because of uncertainty regarding the prognosis of recovery of anoxic brain damage and difficulties in interpreting ST segment deviations. In ST elevation myocardial infarction patients after OHCA, primary PCI is generally considered the only option for reperfusion. There are few published studies and no randomized trial has yet been performed in this specific group of patients. OBJECTIVES: To define the demographic, clinical and angiographic characteristics, and the prognosis of STEMI patients undergoing primary PCI after out-of-hospital cardiac arrest. METHODS: We performed a retrospective analysis of medical records and used the prospectively acquired information from the Rambam Primary Angioplasty Registry (PARR) and the Rambam Intensive Cardiac Care (RICCa) databases. RESULTS: During the period March 1998 to June 2006, 25 STEMI patients (21 men and 4 women, mean age 56 +/- 11years) after OHCA were treated with primary PCI. The location of myocardial infarction was anterior in 13 patients (52%) and non-anterior in 12 (48%). Cardiac arrest was witnessed in 23 patients (92%), but bystander resuscitation was performed in only 2 patients (8%). Eighteen patients (72%) were unconscious on admission, and Glasgow Coma Scale > 5 was noted in 2 patients (8%). Cardiogenic shock on admission was diagnosed in 4 patients (16%). PCI procedure was successful in 22 patients (88%). In-hospital, 30 day, 6 month and 1 year survival was 76%, 76%, 76% and 72%, respectively. In-hospital, 30 day, 6 month and 1 year survival without severe neurological disability was 68%, 68%, 68% and 64%, respectively. CONCLUSIONS: In a selected group of STEMI patients after out-of-hospital cardiac arrest, primary PCI can be performed with a high success rate and provides reasonably good results in terms of short and longer term survival.
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Angioplastia Coronaria con Balón/métodos , Paro Cardíaco/terapia , Infarto del Miocardio/complicaciones , Pacientes Ambulatorios , Adulto , Anciano , Angiografía Coronaria , Femenino , Estudios de Seguimiento , Paro Cardíaco/etiología , Paro Cardíaco/fisiopatología , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/terapia , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: Elevation of blood glucose is a common metabolic disorder among patients with acute myocardial infarction (AMI) and is associated with adverse prognosis. However, few data are available concerning the long-term prognostic value of elevated fasting glucose during the acute phase of infarction. RESEARCH DESIGN AND METHODS: We prospectively studied the relationship between fasting glucose and long-term mortality in patients with AMI. Fasting glucose was determined after an >/=8 h fast within 24 h of admission. The median duration of follow-up was 24 months (range 6-48). All multivariable Cox models were adjusted for the Global Registry of Acute Coronary Events (GRACE) risk score. RESULTS: In nondiabetic patients (n = 1,101), compared with patients with normal fasting glucose (<100 mg/dl), the adjusted hazard ratio for mortality progressively increased with higher tertiles of elevated fasting glucose (first tertile 1.5 [95% CI 0.8-2.9], P = 0.19; second tertile 3.2 [1.9-5.5], P < 0.0001; third tertile 5.7 [3.5-9.3], P < 0.0001). The c statistic of the model containing the GRACE risk score increased when fasting glucose data were added (0.8 +/- 0.02-0.85 +/- 0.02, P = 0.004). Fasting glucose remained an independent predictor of mortality after further adjustment for ejection fraction. Elevated fasting glucose did not predict mortality in patients with diabetes (n = 462). CONCLUSIONS: Fasting glucose is a simple robust tool for predicting long-term mortality in nondiabetic patients with AMI. Fasting glucose provides incremental prognostic information when added to the GRACE risk score and left ventricular ejection fraction. Fasting glucose is not a useful prognostic marker in patients with diabetes.
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Glucemia/análisis , Angiopatías Diabéticas/sangre , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Disfunción Ventricular Izquierda/sangre , Función Ventricular Izquierda , Adulto , Anciano , Angiopatías Diabéticas/mortalidad , Ayuno , Femenino , Estudios de Seguimiento , Humanos , Israel , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Estudios Retrospectivos , Análisis de Supervivencia , Sístole , Factores de TiempoRESUMEN
AIMS: To study the prevalence and long-term prognostic significance of changes in haemoglobin levels during hospital course in survivors of acute myocardial infarction (AMI). METHODS AND RESULTS: A prospective study involving 1390 patients who were admitted with AMI. Median follow-up was 24 months. Multivariable Cox models were used to evaluate the relationship between nadir and discharge haemoglobin and mortality after hospital discharge. Anaemia was present in 248 patients on admission (17.8%) and in 502 patients at discharge (36.1%). Nadir haemoglobin during hospital course was 1.3 g/dL lower (IQR 0.6-2.2) when compared with baseline haemoglobin (P < 0.0001). Low nadir haemoglobin and discharge haemoglobin were strongly associated with increased mortality. After adjusting for clinical variables and ejection fraction, the hazard ratios for a 1 g/dL decrease in nadir haemoglobin and discharge haemoglobin were 1.36 (95% CI 1.19-1.55; P < 0.0001) and 1.27 (95% CI 1.16-1.40; P < 0.0001), respectively. CONCLUSION: The development of anaemia during hospitalization for AMI is frequent and is associated with an increased long-term mortality.
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Hemoglobinas/metabolismo , Infarto del Miocardio/sangre , Anciano , Anemia/sangre , Anemia/etiología , Anemia/mortalidad , Femenino , Hemorragia/sangre , Hemorragia/etiología , Hemorragia/mortalidad , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Pronóstico , Estudios Prospectivos , Volumen Sistólico , Análisis de SupervivenciaRESUMEN
The heterogeneity in the degree of collateralization among patients with coronary artery disease (CAD) is poorly understood. We sought to determine whether chronic subclinical inflammation is related to coronary collateral development in patients with chronic stable angina pectoris and obstructive CAD. High-sensitivity C-reactive protein (CRP) levels were measured in 177 patients with stable angina pectoris before coronary angiography. Multivariable logistic regression revealed an inverse graded association between CRP and the presence of coronary collaterals (Rentrop grade 1 to 3). Compared with patients in the first CRP tertile, the adjusted odds ratio for the presence of coronary collaterals was 0.70 (95% confidence interval, 0.33 to 1.52; p = 0.45) for patients in the second CRP tertile and 0.33 (95% confidence interval, 0.15 to 0.75; p = 0.008) for patients in the third CRP tertile (p for trend = 0.008). In conclusion, an inverse graded association exists between CRP and the presence of coronary collaterals in patients with stable angina pectoris.
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Angina de Pecho/sangre , Proteína C-Reactiva/metabolismo , Circulación Colateral/fisiología , Enfermedad de la Arteria Coronaria/sangre , Distribución de Chi-Cuadrado , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estadísticas no ParamétricasRESUMEN
BACKGROUND: The development of ischemic mitral regurgitation (MR) after myocardial infarction may impose hemodynamic load during a period of active left ventricular remodeling and promote heart failure (HF). However, few data are available on the relationship between ischemic MR and the long-term risk for HF. METHODS: We prospectively studied 1190 patients admitted for acute myocardial infarction. Mitral regurgitation was assessed by echocardiography and was considered mild, moderate, and severe when the regurgitant jet area occupied less than 20%, 20% to 40%, and greater than 40% of the left atrial area, respectively. The median duration of follow-up was 24 months (range, 6-48 months). RESULTS: Mild and moderate or severe ischemic MR was present in 39.7% and 6.3% of patients, respectively. After adjusting for ejection fraction and clinical variables (age, sex, Killip class, previous infarction, hypertension, diabetes mellitus, anterior infarction, ST-elevation infarction, and coronary revascularization), compared with patients without MR, the hazard ratios for HF were 2.8 (95% confidence interval [CI], 1.8-4.2; P<.001) and 3.6 (95% CI, 2.0-6.4; P<.001) in patients with mild and moderate or severe ischemic MR, respectively. The adjusted hazard ratios for death were 1.2 (95% CI, 0.8-1.8; P = .43) and 2.0 (95% CI, 1.2-3.4; P = .02) in patients with mild and moderate or severe MR, respectively. CONCLUSIONS: There is a graded independent association between the severity of ischemic MR and the development of HF after myocardial infarction. Even mild ischemic MR is associated with an increase in the risk of HF.
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Insuficiencia Cardíaca/etiología , Insuficiencia de la Válvula Mitral/etiología , Infarto del Miocardio/complicaciones , Anciano , Ecocardiografía Doppler en Color , Femenino , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/mortalidad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Oportunidad Relativa , Estudios Prospectivos , Proyectos de Investigación , Índice de Severidad de la EnfermedadRESUMEN
Intracoronary radiation therapy (IRT), utilizing both gamma- and beta-emitting radiation sources, is considered to be a safe and effective treatment for in-stent restenosis (ISR). Although no longer in clinical use, a significant number of patients were treated in the past with IRT, and their long-term outcomes have not been well documented. The aim of the present analysis was to document the long-term outcomes of all patients who underwent IRT at our institution for the prevention of recurrence of ISR. Data were collected from 132 patients (148 irradiated lesions) treated with IRT at our institution between March 1999 and January 2004. Clinical and angiographic data were collected over a 5-year period. Patients were divided into 2 groups: those with failed IRT (n = 65), defined as a procedure that resulted in a major adverse cardiac event: death, myocardial infarction, target lesion revascularization, target vessel revascularization or coronary artery bypass graft surgery at any time during the follow-up period, and patients with successful IRT (n = 67). Both groups were identical regarding baseline clinical and angiographic characteristics, with the exception of a higher percentage of multivessel disease and diffuse restenosis in patients who failed IRT (p = 0.01). At 1-year follow up, slightly less than half (43%) of those patients in the failure group experienced a major adverse cardiac event. During the long-term follow up period, half of all patients who underwent IRT at our institution experienced a major adverse cardiac event, 61 patients (46%) either died or underwent a revascularization procedure, 16 patients (24%) had a myocardial infarction or died, and 55 patients (42%) required repeat coronary revascularization. The average time to develop a major adverse cardiac event was 14.6 +/- 15 months. Therefore, during long-term follow up following IRT for the prevention of ISR, half of all patients developed a major cardiovascular event, mainly due to the need for repeat revascularization procedures.
Asunto(s)
Braquiterapia , Reestenosis Coronaria/prevención & control , Estenosis Coronaria/terapia , Stents , Anciano , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/mortalidad , Reestenosis Coronaria/epidemiología , Reestenosis Coronaria/terapia , Estenosis Coronaria/radioterapia , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Sistema de Registros , Retratamiento/efectos adversos , Stents/efectos adversosRESUMEN
RATIONALE: Increased levels of systemic markers of inflammation have been reported in patients with impaired lung function due to obstructive or restrictive lung disease. OBJECTIVE: We tested the hypothesis that a decline in lung function within the normal range may be associated with a systemic subclinical inflammation. METHODS: Pulmonary function tests, cardiorespiratory fitness, components of the metabolic syndrome, and high-sensitivity C-reactive protein (CRP) were determined in 1,131 subjects without known pulmonary disease. MEASUREMENTS AND MAIN RESULTS: Ninety-six of the study participants (8.5%) had FEV(1) of less than 80% of predicted values. There was a strong inverse association between CRP levels and quartiles of FEV(1). The median CRP levels in nonsmoking participants were 2.5, 1.8, 1.7, and 1.3 mg/L in the first, second, third, and forth FEV(1) quartiles, respectively (p < 0.0001). A similar inverse association was present in smoking subjects (median CRP levels were 3.8, 2.3, 2.0, and 1.9 mg/L in the first, second, third, and fourth FEV(1) quartiles, respectively; p < 0.0001). These associations remained highly significant after adjustment for age, sex, components of the metabolic syndrome, and fitness level (p = 0.0005). CONCLUSIONS: An inverse linear relationship exists between CRP concentrations and measures of pulmonary function in subjects without pulmonary disease and in never-smokers. These results indicate that systemic inflammation may be linked to early perturbations of pulmonary function.