Anna Mollar

High-sensitivity versus conventional troponin for management and prognosis assessment of patients with acute chest pain

Objectives High-sensitivity troponin (hs-cTn) is substituting conventional cTn for evaluation of chest pain. Our aim was to assess the impact on patient management and outcome. Methods A total of 1372 consecutive patients presenting at the emergency department with non-ST-elevation acute chest pain were divided into two periods according to the cTn assay used, conventional (n=699, March 2008 to July 2010) or hs-cTn (n=673, November 2010 to March 2013). Management policies were similar and according to guidelines. The primary endpoint was major adverse cardiac events (MACE) at 6 months (death, myocardial infarction, readmission by unstable angina or postdischarge revascularisation). Results There were minor differences in baseline characteristics. In the hs-cTn period, more patients elevated cTn (73% vs 37%, p=0.0001) leading to more coronary angiograms (77% vs 55%, p=0.0001) and revascularisations (45% vs 31%, p=0.0001); conversely, fewer patients were initially assigned to exercise testing (14% vs 36%, p=0.0001) and, therefore, discharged early after a negative result (7% vs 22%, p=0.0001). At 6 months, 135 patients suffered MACE, including 54 deaths. After adjusting for a Propensity Score, hs-cTn use was not significantly associated with MACE (HR=0.99; 95% CI 0.70 to 1.41; p=0.98) or mortality (HR=1.02; 95% CI 0.59 to 1.77; p=0.95), though the risk of longer hospitalisation stay increased at the index episode (OR=1.35, 95% CI 1.07 to 1.71, p=0.02). Conclusions hs-cTn simplified chest pain triage on avoiding a more complex evaluation with non-invasive tests in the chest pain unit, but prompted longer hospitalisations and more invasive procedures without impacting on the 6-month outcomes.

Iron deficiency and risk of early readmission following a hospitalization for acute heart failure.

Early rehospitalization after an episode of acute heart failure (AHF) remains excessively high and its prediction a contemporary challenge. Iron deficiency (ID) is a frequent finding in AHF, but its prognostic implications remain unclear. We sought to evaluate the association between ID and risk of 30‐day readmission in an unselected cohort of patients discharged for AHF.

Burden of Recurrent Hospitalizations Following an Admission for Acute Heart Failure: Preserved Versus Reduced Ejection Fraction

INTRODUCTION AND OBJECTIVES Heart failure with preserved ejection fraction and reduced ejection fraction share a high mortality risk. However, differences in the rehospitalization burden over time between these 2 entities remains unclear. METHODS We prospectively included 2013 consecutive patients discharged for acute heart failure. Of these, 1082 (53.7%) had heart failure with preserved ejection fraction and 931 (46.2%) had heart failure with reduced ejection fraction. Cox and negative binomial regression methods were used to evaluate the risks of death and repeat hospitalizations, respectively. RESULTS At a median follow-up of 2.36 years (interquartile range: 0.96-4.65), 1018 patients (50.6%) died, and 3804 readmissions were registered in 1406 patients (69.8%). Overall, there were no differences in mortality between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction (16.7 vs 16.1 per 100 person-years, respectively; P=0794), or all-cause repeat hospitalization rates (62.1 vs 62.2 per 100 person-years, respectively; P=.944). After multivariable adjustment, and compared with patients with heart failure with reduced ejection fraction, patients with heart failure with preserved ejection fraction exhibited a similar risk of all-cause readmissions (incidence rate ratio=1.04; 95%CI, 0.93-1.17; P=.461). Regarding specific causes, heart failure with preserved ejection fraction showed similar risks of cardiovascular and heart failure-related rehospitalizations (incidence rate ratio=0.93; 95%CI, 0.82-1.06; P=.304; incidence rate ratio=0.96; 95% confidence interval, 0.83-1.13; P=.677, respectively), but had a higher risk of noncardiovascular readmissions (incidence rate ratio=1.24; 95%CI, 1.04-1.47; P=.012). CONCLUSIONS Following an admission for acute heart failure, patients with heart failure with preserved ejection fraction have a similar rehospitalization burden to those with heart failure with reduced ejection fraction. However, patients with heart failure with preserved ejection fraction are more likely to be readmitted for noncardiovascular causes.

Left ventricular ejection fraction recovery in patients with heart failure treated with intravenous iron: a pilot study.

In patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency, treatment with intravenous iron has shown a clinical improvement regardless of anaemic status. Cardiac magnetic resonance (CMR) T2* sequence has shown a potential utility for evaluating myocardial iron deficiency. We aimed to evaluate whether T2* sequence significantly changes after ferric carboximaltose (FCM) administration, and if such changes correlate with changes in left ventricle ejection fraction (LVEF).

Procalcitonin and long-term prognosis after an admission for acute heart failure

BACKGROUND Traditionally, procalcitonin (PCT) is considered a diagnostic marker of bacterial infections. However, slightly elevated levels of PCT have also been found in patients with heart failure. In this context, it has been suggested that PCT may serve as a proxy for underrecognized infection, endotoxemia, or heightened proinflammatory activity. Nevertheless, the clinical utility of PCT in this setting is scarce. We aimed to evaluate the association between PCT and the risk of long-term outcomes. METHODS AND RESULTS We measured at admission PCT of 261 consecutive patients admitted for acute heart failure (AHF) after excluding active infection. Cox and negative binomial regression methods were used to evaluate the association between PCT and the risk of death and recurrent rehospitalizations, respectively. At a median follow-up of 2years (IQR: 1.0-2.8), 108 deaths, 170 all-cause rehospitalizations and 96 AHF-rehospitalizations were registered. In an adjusted analysis, including well-established risk factors such as natriuretic peptides and indices of renal function, the logarithm of PCT was associated with a higher risk of death (HR=1.43, CI 95%: 1.12-1.82; p=0.004), all-cause rehospitalizations (IRR=1.22, CI 95% 1.02-1.44; p=0.025) and AHF-rehospitalizations (IRR=1.28, CI 95%: 1.02-1.61; p=0.032). The association with these endpoints persisted after adjustment for other inflammatory biomarkers such as white blood cells, C-reactive protein and interleukins. CONCLUSION In patients with AHF and no evidence of infection, PCT was independently and positively associated with the risk of long-term death and recurrent rehospitalizations.

Prognostic Value of Geriatric Conditions Beyond Age After Acute Coronary Syndrome

Abstract The aim of the present study was to investigate the prognostic value of geriatric conditions beyond age after acute coronary syndrome. This was a prospective cohort design including 342 patients (from October 1, 2010, to February 1, 2012) hospitalized for acute coronary syndrome, older than 65 years, in whom 5 geriatric conditions were evaluated at discharge: frailty (Fried and Green scales), comorbidity (Charlson and simple comorbidity indexes), cognitive impairment (Pfeiffer test), physical disability (Barthel index), and instrumental disability (Lawton‐Brody scale). The primary end point was all‐cause mortality. The median follow‐up for the entire population was 4.7 years (range, 3‐2178 days). A total of 156 patients (46%) died. Among the geriatric conditions, frailty (Green score, per point; hazard ratio, 1.11; 95% CI, 1.02‐1.20; P=.01) and comorbidity (Charlson index, per point; hazard ratio, 1.18; 95% CI, 1.0‐1.40; P=.05) were the independent predictors. The introduction of age in a basic model using well‐established prognostic clinical variables resulted in an increase in discrimination accuracy (C‐statistic=.716‐.744; P=.05), though the addition of frailty and comorbidity provided a nonsignificant further increase (C‐statistic=.759; P=.36). Likewise, the addition of age to the clinical model led to a significant risk reclassification (continuous net reclassification improvement, 0.46; 95% CI, 0.21‐0.67; and integrated discrimination improvement, 0.04; 95% CI, 0.01‐0.09). However, the addition of frailty and comorbidity provided a further significant risk reclassification in comparison to the clinical model with age (continuous net reclassification improvement, 0.40; 95% CI, 0.16‐0.65; and integrated discrimination improvement, 0.04; 95% CI, 0.01‐0.10). In conclusion, frailty and comorbidity are mortality predictors that significantly reclassify risk beyond age after acute coronary syndrome.

Determinants of procalcitonin concentration in acute heart failure.

Age, years 73.1 ± 10.4 Male, n (%) 133 (51.0) Hypertension, n (%) 212 (81.2) Diabetes mellitus, n (%) 126 (49.4) Previous smoker, n (%) 104 (28.2) Ischemic etiology, n (%) 92 (35.3) Peripheral oedema, n (%) 187 (71.7) Previous admission for AHF, n (%) 95 (36.4) Prior use of beta-blockers, n (%) 111 (42.5) Prior use of loop diuretics, n (%) 175 (67.0) Prior use of ACEI/ARB, n (%) 134 (51.3) Heart rate, beats/min 97 ± 28 SBP, mm Hg 148 ± 34 DBP, mm Hg 81 ± 19 Atrial fibrillation, n (%) 119 (45.6) Hemoglobin, g/dl 12.1 ± 2.0 Serum creatinine, mg/dl 1.23 ± 0.57 Urea, mg/dl 60.5 ± 30.1 Sodium, mEq/l 137.8 ± 4.7 NT-proBNP, pg/ml 4813 (6011) Leukocyte count, 10 cells/l 9286 ± 3468 Relative lymphocyte count, % 17.4 ± 10.4 Gamma glutamyl transpeptidase, U/l a 48 (55) TnTHs, pg/ml a 31.3 (39.5) CRP, mg/l 14.3 (24.9) Fibrinogen, g/l 5.1 ± 1.16 Procalcitonin, ng/ml a 0.06 (0.06) Endotoxin, EU/ml a 0.67 (0.46) IL-1b, pg/ml 0.12 (0.25) IL-6, pg/ml 16.8 (45.1) TNF-alfa, pg/ml 12.4 (20.6) Il-10, pg/ml 28.2 (93.8) Total cholesterol, mg/dl 156.8 ± 47.6 LDL, mg/dl 100.8 ± 36.2 HDL, mg/dl 43.9 ± 13.6 LVEF, % 49.3 ± 15.8

Usefulness of delta troponin for diagnosis and prognosis assessment of non-ST-segment elevation acute chest pain

Background: The additional diagnostic and prognostic information provided by delta high-sensitivity troponin T (hs-cTnT) in patients with acute chest pain and hs-cTnT elevation remains unclear. Methods: The study group consisted of 601 patients presenting at the emergency department with non-ST-segment elevation acute chest pain and hs-cTnT elevation after two determinations (admission and within the first six hours). Maximum hs-cTnT and delta hs-cTnT (absolute or percentage change between the two measurements) were considered. Cutoff values were optimized using the quartile distribution for the endpoints. The endpoints were diagnostic (significant stenosis in the coronary angiogram) and prognostic (death or recurrent myocardial infarction at one year). Results: Regarding the diagnostic endpoint, 114 patients showed a normal angiogram. Both maximum hs-cTnT ⩾80 ng/ml (OR 2.5, 95% CI 1.3–4.8, P=0.005) and delta hs-cTnT ⩾20 ng/l (OR 2.1, 95% CI 1.1–4.0, P=0.02) median value cutoffs were related to significant coronary stenosis. Furthermore, the combination of hs-cTn <80 ng/l and delta hs-cTn <20 ng/l showed the lowest probability of significant coronary stenosis (OR 0.3, 95% CI 0.1–0.4, P=0.001). During follow-up, 86 patients experienced the prognostic endpoint. After full adjustment for clinical data, maximum hs-cTnT ⩾30 ng/l, first quartile cutoff, was related to the outcome (HR 1.8, 95% CI 1.0–3.4, P=0.05), while delta hs-cTnT, either absolute or percentage change, lacked prognostic value. Conclusions: Maximum hs-cTnT captures all the prognostic information provided by hs-cTnT in non-ST-segment elevation acute chest pain. Low maximum and low delta hs-cTnT are associated with a normal coronary angiogram, which could make the final diagnosis challenging in some cases.

Sacubitril/valsartan and short-term changes in the 6-minute walk test: A pilot study

BACKGROUND Impaired exercise capacity is the most disabling symptom in patients with heart failure with reduced ejection fraction (HFrEF). Despite sacubitril/valsartan showing reduced long-term morbidity and mortality over enalapril in HFrEF, its effects on short-term functional capacity remain uncertain. We sought to evaluate the effects of sacubitril/valsartan on a 30-day six-minute walk test in eligible patients with HFrEF. METHODS AND RESULTS From November 1, 2016 to February 1, 2017, a total of 58 stable symptomatic patients with HFrEF were eligible for sacubitril/valsartan and underwent 6-MWT before and 30days after initiation of sacubitril/valsartan therapy. A mixed-effects model for repeated-measures was used to analyze the changes. Mean age was 70±11years. 72.4% males, 46.6% with ischemic heart disease, and 51.7% on NYHA functional class III were included. The mean (SD) values of baseline LVEF and 6MWT were 30±7%, and 300±89m, respectively. The median (IQR) of NT-proBNP at baseline was 2701pg/ml (1087-4200). Compared with baseline, the 6-MWT distance increased significantly at 30days by 13.9% (+∆=41.8m (33.4-50.2); p<0.001). CONCLUSIONS In this pilot study, sacubitril/valsartan was associated with an improvement in exercise tolerance in symptomatic patients with HFrEF.

Length of stay and risk of very early readmission in acute heart failure

INTRODUCTION AND OBJECTIVES In patients admitted for acute heart failure (AHF), optimal length of stay (LOS) remains controversial. Longer hospitalizations are associated with worse prognosis, but little is known about short hospitalizations. The aim of this work was to evaluate the relationship between LOS and the risk of short-term readmission in patients discharged after a hospitalization for AHF. METHODS We included 2110 consecutive patients. The independent associations between LOS and unplanned 10, 15 and 30-day readmissions were evaluated by Cox regression analysis adjusted for competing events. LOS was categorized as LOS1: ≤4days, LOS2: 5-7days, LOS3: 8-10days, and LOS4: >10days. RESULTS The mean age was 73±11years and 52.6% exhibited left ventricle ejection fraction≥50%. The median (IQR) LOS was 7 (5-11) days. At 10, 15 and 30-day follow-up, 130 (6.2%), 181 (8.6%), and 282 (13.4%) unplanned readmissions were registered. Rates of 10 and 15-day readmission among LOS categories showed a J-shaped pattern with lower rates for those in LOS2 and higher at the both extremes (p=0.001). At 30-day, only longer stays showed higher rates of readmission (p=0.002). In the multivariate analysis, the U-shaped curve remained significant for 10 and 15-day readmissions (p<0.05). Compared to LOS2, LOS1, LOS3 and LOS4 showed about two-fold increased risk. At 30-day only longer stays showed a borderline and modest increase of risk. CONCLUSIONS Shorter and longer stays are associated with the risk of very early readmissions after an episode of AHF. These associations are marginal for 30-day readmissions.