Andrea Sori

Uric acid in the acute phase of ST elevation myocardial infarction submitted to primary PCI: Its prognostic role and relation with inflammatory markers: A single center experience

BACKGROUND AND METHODS Scarce data are available on the prognostic role of uric acid (UA ) in patients with ST elevation myocardial infarction (STEMI). We aimed at assessing the relation between uric acid, measured on Intensive Cardiac Care Unit (ICCU) admission, and mortality at short term follow-up in 466 consecutive STEMI patients submitted to percutaneous coronary intervention (PCI), as well as its relation with inflammatory markers (C-reactive protein, CRP-fibrinogen, erythrocyte sedimentation rate ESR). RESULTS Higher UA were detectable in the 21.5%.. In-hospital mortality was higher in patients with elevated UA (p<0.01 O.R. (95% C.I.): 3.9 (1.5-10.2)). At backward stepwise regression analysis UA resulted an independent predictor for in-hospital mortality (OR 1.82, 95%CI 1.15-2.86; p=0.01). CONCLUSION Our data strongly suggest that in the acute phase of STEMI patients submitted to PCI, uric acid holds a prognostic role for in-hospital mortality.

Prognostic role of insulin resistance as assessed by homeostatic model assessment index in the acute phase of myocardial infarction in nondiabetic patients submitted to percutaneous coronary intervention

Background and objectives Little information is available on the relation between insulin resistance and acute myocardial infarction. Methods In 253 consecutive nondiabetic patients with ST elevation myocardial infarction (STEMI) submitted to percutaneous coronary intervention, we assessed the prevalence of insulin resistance by homeostatic model assessment (HOMA) index and its prognostic role in early and late mortality. Results Insulin resistance was detectable in 52.9% of patients. Anterior STEMI was more frequent in insulin-resistant patients (P = 0.040), who showed higher values of probrain natriuretic peptide (P = 0.010), creatinine (P < 0.001), creatinine phosphokinase and creatinine phosphokinase-MB (MB, isoenzyme present in the myocardium; P = 0.016 and P = 0.003, respectively). At backward stepwise logistic regression analysis, the following variables were independent predictors for intra-intensive cardiac care unit mortality: HOMA index [hazard ratio 1.40; 95% confidence interval (CI) 1.02–1.95; P = 0.049]; C-peptide (hazard ratio 3.14; 95% CI 1.40–24.80; P = 0.001) and lactic acid (hazard ratio 2.50; 95% CI 1.41–4.44; P = 0.002). At long-term follow-up (Cox regression analysis), neither fasting glycaemia nor HOMA index resulted in predictors for mortality. Conclusion In nondiabetic STEMI patients submitted to percutaneous coronary intervention, insulin resistance, as assessed by HOMA index, is quite common and helps in the early prognostic stratification, as it represents an independent predictor of in-hospital mortality.

NT-proBNP on admission for early risk stratification in STEMI patients submitted to PCI. Relation with extension of STEMI and inflammatory markers

The prognostic implications of NT-proBNP measured on admission in patients with the ST-elevation myocardial infarction (STEMI) are not so far well elucidated. The present investigation, performed in 198 STEMI patients submitted to percutaneous coronary intervention (PCI), was aimed at assessing the prognostic value of NT-proBNP measured on admission to Intensive Cardiac Care Unit (ICCU) and its relation with the extension of myocardial infarction (indicated by cardiac biomarkers and ejection fraction) and inflammatory markers (C-reactive protein - CRP, erythrocyte sedimentation rate - ESR, leucocytes, fibrinogen). All patients who died during ICCU stay had increased values of NT-proBNP. Each quartile of NT-proBNP resulted directly correlated with age, heart rate, peak Tn I, admission creatinine serum levels, ESR, fibrinogen, and inversely correlated with ejection fraction. At backward logistic regression analysis, NT-proBNP values showed a significative correlation with peak Tn I (OR 1.013; 95% CI 1.001-1.025; p=0.036), and CRP positive (OR 6.450; 95% CI 1.714-24.272; p=0.006); age was close to reaching statistical significance (OR 1.043; 95% CI 0.999-1.089; p=0.055). At long term-follow-up NT-proBNP lacks any prognostic role in predicting adverse events such as hospitalization for rePCI, re-infarction and heart failure. Kaplan-Meier curves showed that all patients dead at follow-up were in the highest NT-proBNP quartiles.

Venous-arterial extracorporeal membrane oxygenation for refractory cardiac arrest: a clinical challenge:

Guidelines stated that extracorporeal membrane oxygenation (ECMO) may improve outcomes after refractory cardiac arrest (CA) in cases of cardiogenic shock and witnessed arrest, where there is an underlying circulatory disease amenable to immediate corrective intervention. Due to the lack of randomized trials, available data are supported by small series and observational studies, being therefore characterized by heterogeneity and controversial results. In clinical practice, using ECMO involves quite a challenging medical decision in a setting where the patient is extremely vulnerable and completely dependent on the medical team’s judgment. The present review focuses on examining existing evidence concerning inclusion and exclusion criteria, and outcomes (in-hospital and long-term mortality rates and neurological recovery) in studies performed in patients with refractory CA treated with ECMO. Discrepancies can be related to heterogeneity in study population, to differences in local health system organization in respect of the management of patients with CA, as well as to the fact that most investigations are retrospective. In the real world, patient selection occurs individually within each center based on their previous experience and expertise with a specific patient population and disease spectrum. Available evidence strongly suggests that in CA patients, ECMO is a highly costly intervention and optimal utilization requires a dedicated local health-care organization and expertise in the field (both for the technical implementation of the device and for the intensive care management of these patients). A careful selection of patients guarantees optimal utilization of resources and a better outcome.

Postprocedural hyperglycemia in ST elevation myocardial infarction submitted to percutaneous coronary intervention: a prognostic indicator and a marker of metabolic derangement.

Background Hyperglycemia in acute coronary syndrome is associated with an increased risk of death in patients without previously known diabetes but the prognostic role of postrevascularization hyperglycemia in these patients is so far incompletely elucidated. Materials and methods In 175 consecutive patients without previously known diabetes and with ST elevation myocardial infarction treated with primary angioplasty, we evaluated the relation between acute and chronic glucose dysmetabolism and early and late mortality and the relation between hyperglycemia and extension of myocardial damage [creatine phosphokinase-MB (CPK-MB), troponin I levels, ejection fraction], inflammation (leukocyte count, erythrocyte sedimentation rate, C-reactive protein) and prognostic biohumoral markers [N-terminal brain natriuretic peptide (NT-proBNP) and lactic acid]. Results Highest glucose levels were associated with higher Killip class, lower ejection fraction and increased values of CPK, CPK-MB, troponin I, proBNP, lactic acid, leukocytes and insulin. At multivariate logistic regression analysis, the following variables were independent predictors of intraintensive cardiac care unit mortality: postprocedural glycemia [odds ratio (OR) 8.79; 95% confidence interval (CI) 1.41–54.94; P = 0.020] and troponin I (OR 1.003; 95% CI 1.0004–1.006; P = 0.023) when adjusted for insulinemia [OR 0.98; 95% CI 0.92–1.06; P = not significant (NS)], HbA1c (OR 0.51; 95% CI 0.11–2.37; P = NS), ST elevation myocardial infarction location (OR 1.27; 95% CI 0.44–3.66; P = NS) and creatininemia (OR 1.48; 95% CI 0.90–2.45; P = NS). Conclusion In ST elevation myocardial infarction patients without previously known diabetes submitted to percutaneous coronary intervention, glucose serum levels measured after mechanical revascularization were independent predictors of in-hospital mortality.

In-hospital refractory cardiac arrest treated with extracorporeal membrane oxygenation: a tertiary single center experience.

Abstract We retrospectively assessed the experience of our tertiary care center on the use of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in 16 adult patients with refractory cardiac arrest. Cardiac arrest was due to acute coronary syndrome in 10 patients (62.5%), Takotsubo Syndrome in 1 patient (6.25%), dilated cardiomyopathy in 4 (25%) patients and massive pulmonary embolism in 1 patient (6.25%). The device was implanted in the catheterization laboratory in 14 patients (87.5%), in the operating room in 1 patient (6.25%) and in the emergency department in 1 patient (6.25%). During support, 7 patients were submitted to percutaneous coronary intervention, while coronary artery bypass grafting was performed in 1 patient, and cardiac surgery for repair of left ventricular wall rupture was performed in 1 patient. The device was successfully weaned in 6 patients (37.5%), among whom 2 patients died and 4 patients (25%) were discharged alive. In our institution 2/16 (12.5%) patients treated with VA-ECMO for refractory cardiac arrest survived to hospital discharge neurologically intact, and a good neurological function was observed in 3/16 (18.8%) at six-month follow-up.

Nonthyroidal illness syndrome in ST-elevation myocardial infarction treated with mechanical revascularization

Low T3 syndrome, also known as nonthyroidal illness syndrome and euthyroid sick syndrome, is believed to be a beneficial adaptive mechanism under conditions of stress. In1047 Italian subjectswith suspectedCAD, fT3 levelswere inversely correlated to the presence of CAD and low T3 syndrome conferred an adverse prognosis, even after adjusting for traditional coronary risk factors [1]. While in chronic, systolic heart failure, the presence of low T3 syndromeemergedas a strongprognostic determinant [2,3], data on the clinical role of low T3 syndrome in patients with acute myocardial infarction are so far scarce and controversial. We therefore aimed at assessing the prognostic role (both at short and long terms) of low T3 syndrome in the early phase of 641 consecutive patients with ST elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) [4–13]. Exclusion criteria included patients using corticosteroids, or thyroid disease drugs regularly and patients with established diseases, such as neoplasias, liver cirrhosis, and active infection, conditions that are known to affect thyroid function tests [8]. The study protocol was in accordance with the Declaration of Helsinki and approved by the local Ethics Committee. Informed consent was obtained in all patients before enrollment. Datawere reportedas frequencies (percentages) andmedians(25th– 75th percentile [interquartile range, IR]). Comparisons were made by means of chi-square test (categorical data) and Mann–Whitney U test (continuous data). Two logistic regression analyses were conducted in order to investigate: a) in a univariable manner, the relationship between fT3 levels and in-ICCU death and b) in a multivariable manner, adjusted predictors of normal-high levels of fT3 (Hosmer– Lemeshow goodness-of-fit test and Nagelkerke pseudo-R are reported). After assessment of hazard proportionality, a multivariable Cox regression analysis was performed in order to assess the adjusted predictive value of normal-high fT3 levelswith respect to all cause death at follow-up. Inmultivariable analyses, candidate variableswere chosen as those known to be associated to the considered outcome. Kaplan– Meier survival curveswere calculated in thewhole population aswell as inpatientswith b75 years and N/=75 years (log rank test is reported). A two-tailed p-valueb0.05 was considered statistically significant (SPSS Inc, Chicago, IL). In our series, low fT3 was observed in 114 patients (18.6%, G1). In comparisonwith patientswith normal fT3 values, patients in G1were older (pb0.001), leaner (p=0.001), more frequently females (pb0.001), smokers (pb0.001) and diabetic (p=0.029). No difference was observed in AMI location, CAD severity and Killip class between the two subgroups. A higher incidence of PCI failure was observed in patients with low fT3. Higher mortality rates were observed both during ICCU stay and at follow-up in patients with low fT3. Patients in G1 showed lower values of hemoglobin and eGFR, and higher serum levels of insulin (p=0.007), NT-pro BNP (pb0.001), fibrinogen (pb0.001) together with a higher percentage of CRP positivity (pb0.001). The following variables were independently related to normal fT3 levels (adjusted for gender, Killip class, smoking status, fibrinogen, admission eGFR, peak TnI): age (1 year step) (OR 0.95, 95%CI 0.95–0.99, p=0.013), CRP positivity (OR 0.46, 95%CI 0.28–0.77, p=0.003), and admission Hb (1 g/dl step) (OR 1.24, 95%CI 1.08–1.43, p=0.002). Hosmer–Lemeshow chi-square 3.32, p=0.913; Nagelkerke pseudo-R: 0.18. Free T3 was unadjusted predictor of ICCU death [OR 0.26 (95% CI 0.08–0.78), p=0.016]. At long term follow-up (31.2 (12.0–44.9)months), patientswith low fT3 showed a survival rate comparable to that of patients with normal fT3 (Fig. 1). Among patientsb75 years, those with low fT3 exhibited a significantly lower survival rate, while among patientsN/=75 years, no differencewas observed in long term survival rate betweenpatientswith low fT3 and those with normal ft3 (Fig. 1). At Cox regression analysis, the following variables were independently associated with mortality at follow-up (when adjusted for eGFR, normal fT3 and gender): age (1 year step) (HR 1.07, 95%CI 1.04–1.10, pb0.001); CRP positivity (HR 1.98, 95%CI 1.07–3.68, p=0.030), and discharge LVEF (1% step) (HR 0.95, 95%CI 0.92–0.98, p=0.001). The main findings of the present investigation, performed in consecutive STEMI patients submitted to mechanical revascularization, are as follows: a) low fT3 is not a rare finding, being detectable in about the 20% of the whole population; b) patients with low fT3 exhibit a higher inflammatory activation (as indicated by higher

Decreased usage and increased effectiveness of percutaneous coronary intervention in complex older patients with acute coronary syndromes

Background Application of percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) is suboptimal in older frail individuals. This study was conducted to verify if background risk is a risk factor for underuse and diminished effectiveness of PCI in older patients. Methods An observational cohort study was conducted using data from the Acute Myocardial Infarction in Florence 2 registry, including all ACS hospitalised in 1 year in the area of Florence, Italy. Patients aged 75+ years were selected, whose background risk was stratified with the Silver Code (SC), a validated tool predicting mortality based upon administrative data. Multivariable OR for PCI application and HR for 1-year mortality by PCI usage were calculated. Results In 698 patients (358 women, mean age 83 years), of whom 176 had ST-segment elevation myocardial infarction (STEMI), for each point increase in SC score the odds for application of PCI decreased by 11%, whereas the hazard of 1-year mortality increased by 10%, adjusting for positive and negative predictors. PCI reduced 1-year mortality progressively more with increasing SC, with HR (95% CI) of 0.8 (0.19 to 1.21), 0.41 (0.18 to 0.45), 0.41 (0.23 to 0.74) and 0.26 (0.14 to 0.48) for SC of 0–3, 4–6, 7–10 and 11+. Conclusions Application of PCI in older ACS patients decreased with increasing background risk. This therapeutic attitude could not be justified by decreasing effectiveness of PCI in more compromised patients: conversely, application of PCI was associated with a long-term survival advantage that increased progressively with background risk, as expressed by SC.

The recent evolution of coronary care units into intensive cardiac care units: the experience of a tertiary center in Florence.

Objectives To evaluate the evolution of intensive cardiac care units (ICCUs) in the third millenium by assessing the activity and the workload of our ICCU which is a Hub center, from 1 January 2004 to 30 June 2005. Methods Among the 1397 patients consecutively admitted to our ICCU, 40.5% came from Spokes. Patients with ST elevation myocardial infarction comprised 29.5% of the entire population: all of them were admitted to ICCU after mechanical reperfusion. Results The incidences of ventricular fibrillation (1%) and complete AV block (0.6%) are low in our patients. The most frequent complications were acute renal failure requiring renal replacement therapy (4.4%) and vascular and hemorrhagic complications (4.3%). Conclusions Our ICCU is a post-reperfusion unit for treating complications of therapy and older and more complex patients who require more intensive care. This is why the cardiac intensivists also need to be skilled in general intensive care. In the Integrated Cardiac Network (Hub-and-Spoke model), ICCUs play a crucial role in the management of all cardiac emergencies, and in maintaining a continuous and strict interplay with Spokes, they have a prominent and unique role in the selection and early treatment of acute cardiac patients and their follow-up.

Dynamic behaviour of lactate values during mild hypothermia in patients with cardiac arrest

Background and Methods: The present investigation was aimed at assessing the dynamic behaviour of lactate values during hypothermia in 33 patients with cardiac arrest. Results: Fifteen patients died during intensive care stay (15/33, 45.5%). When compared to survivors, they were older (survivors 50.7±14.7 vs. non-survivors 70.1±10.4 years, p<0.001) and exhibited a significantly higher APACHE score (survivors 21.9±3.9 vs. non-survivors 27.5±4.6, p<0.001). A higher incidence of non-shockable rhythms was observed in non-survivors (p=0.026) who showed a longer collapse–recovery of spontaneous circulation time (p=0.01). During hypothermia, lactate values showed a progressive and significant decrease despite no significant change in mean arterial pressure and central venous pressure (i.e. independently of blood pressure values and volaemia). Lactate values when measured during hypothermia were related to in-intensive cardiac care unit (in-ICCU) death. Conclusion: In our series, lactate values measured during hypothermia hold a prognostic role in these patients since they are related to in-ICCU death.