Eva Rumiz

Usefulness of the Neutrophil to Lymphocyte Ratio in Predicting Long-Term Mortality in ST Segment Elevation Myocardial Infarction

Neutrophil to lymphocyte ratio (N/L) has been associated with poor outcomes in patients who underwent cardiac angiography. Nevertheless, its role for risk stratification in acute coronary syndromes, specifically in patients with ST-segment elevation myocardial infarction (STEMI), has not been elucidated. We sought to determine the association of N/L maximum value (N/L max) with mortality in the setting of STEMI and to compare its predictive ability with total white blood cell maximum count (WBC max). We analyzed 515 consecutive patients admitted with STEMI to a single university center. White blood cells (WBC) and differential count were measured at admission and daily for the first 96 hours afterward. Patients with cancer, inflammatory diseases, or premature death were excluded, and 470 patients were included in the final analysis. The association between N/L max and WBC max with mortality was assessed by Cox regression analysis. During follow-up, we registered 106 deaths (22.6%). A positive trend between mortality and N/L max quintiles was observed; 6.4%, 12.4%, 11.7%, 34%, and 47.9% of deaths occurred from quintiles 1 to 5 (p <0.001), respectively. In a multivariable setting, after adjusting for standard risk factors, patients in the fourth (Q4 vs Q1) and fifth quintile (Q5 vs Q1) showed the highest mortality risk (hazard ratio 2.58, 95% confidence interal 1.06 to 6.32, p = 0.038 and hazard ratio 4.20, 95% confidence interal 1.73 to 10.21, p = 0.001, respectively). When WBC max and cells subtypes were entered together, N/L max remained as the only WBC parameter; furthermore, the model with N/L max showed the most discriminative ability. In conclusion, N/L max is a useful marker to predict subsequent mortality in patients admitted for STEMI, with a superior discriminative ability than total WBC max.

Prognostic value of a comprehensive cardiac magnetic resonance assessment soon after a first ST-segment elevation myocardial infarction.

OBJECTIVES To evaluate the prognostic value of a comprehensive cardiac magnetic resonance (CMR) assessment soon after a first ST-segment elevation myocardial infarction (STEMI). BACKGROUND CMR allows for a simultaneous assessment of wall motion abnormalities (WMA), WMA with low-dose dobutamine (WMA-dobutamine), microvascular obstruction, and transmural necrosis. This approach has been proven to be useful to predict late systolic recovery soon after STEMI. Its prognostic value and the relative prognostic weight of these indexes are not well-defined. METHODS We studied 214 consecutive patients with a first STEMI treated with thrombolytic therapy or primary angioplasty discharged from hospital. In the first week (7 +/- 1 day after infarction), with CMR we determined the extent (number of segments) of WMA, WMA-dobutamine, microvascular obstruction, and transmural necrosis. RESULTS During a median follow-up of 553 days, 21 major adverse cardiac events (MACE) including 4 cardiac deaths, 6 nonfatal myocardial infarctions, and 11 readmissions for heart failure were documented. The MACE was associated with a larger extent of WMA (8 +/- 4 segments vs. 5 +/- 3 segments, p < 0.001), WMA-dobutamine (6 +/- 4 segments vs. 4 +/- 3 segments, p = 0.004), microvascular obstruction (3 +/- 3 segments vs. 1 +/- 2 segments p <0.001), and transmural necrosis (7 +/- 3 segments vs. 3 +/- 3 segments, p < 0.001). In a complete multivariate analysis that included baseline characteristics, electrocardiogram, biomarkers, angiography, ejection fraction, left ventricular volumes, and all CMR indexes, WMA/segment (hazard ratio: 1.29 [95% confidence interval: 1.11 to 1.49], p = 0.001) and the extent of transmural necrosis/segment (hazard ratio: 1.30 [95% confidence interval: 1.12 to 1.51], p < 0.001) were the only independent prognostic variables. CONCLUSIONS A comprehensive CMR assessment is useful for stratifying risk soon after STEMI, but only the extent of systolic dysfunction and of transmural necrosis provide independent prognostic information.

Prognostic and therapeutic implications of dipyridamole stress cardiovascular magnetic resonance on the basis of the ischaemic cascade

Objective: To determine the prognostic and therapeutic implications of stress perfusion cardiovascular magnetic resonance (CMR) on the basis of the ischaemic cascade. Setting: Single centre study in a teaching hospital in Spain. Patients: Dipyridamole stress CMR was performed on 601 patients with ischaemic chest pain and known or suspected coronary artery disease. On the basis of the ischaemic cascade, patients were categorised in C1 (no evidence of ischaemia, n = 354), C2 (isolated perfusion deficit at stress first-pass perfusion imaging, n = 181) and C3 (simultaneous perfusion deficit and inducible wall motion abnormalities, n = 66). CMR-related revascularisation (n = 102, 17%) was defined as the procedure prompted by the CMR results and carried out within the next three months. Results: During a median follow-up of 553 days, 69 major adverse cardiac events (MACE), including 21 cardiac deaths, 14 non-fatal myocardial infarctions and 34 admissions for unstable angina with documented abnormal angiography were detected. In non-revascularised patients (n = 499), the MACE rate was 4% (14/340) in C1, 20% (26/128) in C2 and 39% (12/31) in C3 (adjusted p value = 0.004 vs C2 and <0.001 vs C1). CMR-related revascularisation had neutral effects in C2 (20% vs 19%, 1.1 (0.5 to 2.4), p = 0.7) but independently reduced the risk of MACE in C3 (39% vs 11%, 0.2 (0.1 to 0.7), p = 0.01). Conclusions: Dypiridamole stress CMR is able to stratify risk on the basis of the ischaemic cascade. A small group of patients with severe ischaemia—simultaneous perfusion deficit and inducible wall motion abnormalities—are at the highest risk and benefit most from MACE reduction due to revascularisation.

Prognostic implications of dipyridamole cardiac MR imaging: a prospective multicenter registry.

PURPOSE To evaluate dipyridamole cardiac magnetic resonance (MR) imaging in the prediction of major events (MEs) in patients with ischemic chest pain in a large multicenter registry. MATERIALS AND METHODS Institutional ethics committee approval and written informed consent were obtained. A total of 1722 patients who were undergoing cardiac MR imaging for chest pain were included. Wall motion abnormalities (WMAs) at rest, hyperemia perfusion defect (PD), late gadolinium enhancement (LGE), and inducible WMA were analyzed (abnormal if more than one abnormal segment was seen) with the 17-segment model. A cardiac MR categorization was created: category 1, no PD, LGE, or inducible WMA; category 2, PD without LGE and inducible WMA; category 3, LGE without inducible WMA; and category 4, inducible WMA. The association with ME was analyzed by using Cox proportional hazard regression multivariate models. RESULTS During a median follow-up period of 308 days, 61 MEs (4%) occurred (36 cardiac deaths, 25 nonfatal myocardial infarctions). MEs were associated with a greater extent of WMA, PD, LGE, and inducible WMA (P ≤ .001 for all analyses). In multivariable analyses, PD (P = .002) and inducible WMA (P = .0001) were the only cardiac MR predictors. ME rate in categories 1, 2, 3, and 4 was 2% (14 of 901 patients), 3% (six of 219 patients), 4% (15 of 409 patients), and 14% (26 of 193 patients), respectively (category 4 vs category 1, adjusted P < .001). Cardiac MR-directed revascularization was performed in 242 patients (14%) and reduced the risk of ME in only category 4 (7% [six of 92 patients] vs 26% [26 of 101 patients], P = .0004). CONCLUSION Dipyridamole cardiac MR imaging can be used to predict MEs in patients with ischemic chest pain. Patients with inducible WMA are at the highest risk for MEs and benefit the most from revascularization.

Resultados de la estrategia farmacoinvasiva y de la angioplastia primaria en la reperfusión del infarto con elevación del segmento ST. Estudio con resonancia magnética cardiaca en la primera semana y en el sexto mes

INTRODUCTION AND OBJECTIVES Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction. METHODS Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated. RESULTS At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29±15 vs. 29±17%, P=.9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index (P>.2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P=.7). CONCLUSIONS A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.

Cardiac magnetic resonance evaluation of edema after ST-elevation acute myocardial infarction.

INTRODUCTION AND OBJECTIVES The aims of the study were to characterize myocardial edema after ST-elevation acute myocardial infarction using cardiac magnetic resonance imaging and to investigate its impact on ventricular function and its subsequent evolution. METHODS In total, 134 patients admitted to hospital for a first ST-elevation myocardial infarction who had a patent infarct-related artery underwent cardiac magnetic resonance imaging. Cine images (at rest and with low-dose dobutamine) and edema, perfusion and viability images were acquired. Imaging was repeated after 6 months. RESULTS In the first week after infarction, edema was detected in at least one segment in 96.6% of patients (4+/-2.1 segments per patient). Extensive edema (> or = 4 segments) was associated with large ventricular end-diastolic and end-systolic volumes (P< .0001), a small left ventricular ejection fraction at rest (P=.001) and with low-dose dobutamine (P=.006), a large number of segments showing hypoperfusion (P=.001) or microvascular obstruction (P=.009), a more extensive infarct (P=.017) and greater transmural extent of the infarct (P=.003). The association between the presence and extent of edema during the first week and functional, perfusion and viability variables was still observable after 6 months. No patient exhibited edema at 6 months. CONCLUSIONS Cardiac magnetic resonance imaging was useful for characterizing the myocardial edema that occurred after ST-elevation acute myocardial infarction. Extensive edema was associated with poor left ventricular characteristics. Edema was a transitory phenomenon that vanished within 6 months.

Effectiveness of the relative lymphocyte count to predict one-year mortality in patients with acute heart failure.

Several works have endorsed a significant role of the immune system and inflammation in the pathogenesis of heart failure. As indirect evidence, an association between a low relative lymphocyte count (RLC%) and worse outcomes found in this population has been suggested. Nevertheless, the role of RLC% for risk stratification in a large and nonselected population of patients with acute heart failure (AHF) has not yet been determined. Thus, the aim of this study was to determine the association between low RLC% and 1-year mortality in patients with AHF and consequently to define whether it has any role for early risk stratification. A total of 1,192 consecutive patients admitted for AHF were analyzed. Total white blood cell and differential counts were measured on admission. RLC% (calculated as absolute lymphocyte count/total white blood cell count) was categorized in quintiles and its association with all-cause mortality at 1 year assessed using Cox regression. At 1 year, 286 deaths (24%) were identified. A negative trend was observed between 1-year mortality rates and quintiles of RLC%: 31.5%, 27.2%, 23.1%, 23%, and 15.5% in quintiles 1 to 5, respectively (p for trend <0.001). After thorough covariate adjustment, only patients in the lowest quintile (<9.7%) showed an increased risk for mortality (hazard ratio 1.76, 95% confidence interval 1.17 to 2.65, p = 0.006). When RLC% was modeled with restricted cubic splines, a stepped increase in risk was observed patients in quintile 1: those with RLC% values <7.5% and <5% showed 1.95- and 2.66-fold increased risk for death compared to those in the top quintile. In conclusion, in patients with AHF, RLC% is a simple, widely available, and inexpensive biomarker, with potential for identifying patients at increased risk for 1-year mortality.

La suma de la elevación del segmento ST predice mejor la obstrucción microvascular en pacientes tratados con éxito con una intervención coronaria percutánea primaria. Un estudio de resonancia magnética cardiovascular

Introduccion y objetivos La utilidad de la resolucion del segmento ST (RST) para la prediccion de la reperfusion epicardica esta bien establecida. La asociacion de los cambios del segmento ST con la obstruccion microvascular (OMV) observada en la resonancia magnetica cardiovascular (RMC) tras una intervencion coronaria percutanea primaria (ICPp) en el infarto de miocardio con elevacion del ST (IMEST) no se ha aclarado todavia. Metodos Estudiamos a 85 pacientes consecutivos ingresados por un primer IMEST y tratados con una ICPp que tenian una arteria relacionada con el infarto permeable. Se registro un ECG al ingreso, tras 90 min y tras 6, 24, 48 y 96 h de la ICPp. Se calculo la RST y la suma de la elevacion del ST (sumEST) en todas las derivaciones. Resultados La RMC revelo una OMV en 37 pacientes. En los infartos con OMV, el valor de la sumEST antes y despues de la revascularizacion fue mayor que en los infartos sin OMV (p ≤ 0,001 en todos los casos). En cambio, no hubo diferencias significativas en la cantidad de RST entre los infartos con y sin OMV a los 90 min de la revascularizacion (p = 0,1), sino solo a partir de las 6 h (p 3 mm a los 90 min de la ICPp, pero no una RST ≥ 70%, predijo de manera independiente la OMV observada en la RMC ( odds ratio = 3,1; intervalo de confianza del 95%, 1,2-8,4; p = 0,02). Conclusiones La OMV se asocio a un valor significativamente superior de la sumEST en todos los momentos de valoracion tras la revascularizacion. La diferencia en la cantidad de RST entre los infartos con OMV y sin OMV solo fue significativa a partir de las 6 h tras la revascularizacion. La OMV se predijo mejor con una sumEST > 3 mm a los 90 min de la ICPp.

Impacto pronóstico de una estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST según la presencia o no de disfunción sistólica

Introduccion y objetivos Escasa evidencia respalda la implantacion de una estrategia invasiva (EI) en pacientes con sindrome coronario agudo sin elevacion del segmento ST (SCASEST) y disfuncion sistolica (DS). El objetivo de este trabajo es evaluar el impacto pronostico atribuible a una EI en sujetos con SCASEST segun tengan DS o no. Metodos Se incluyo a 972 pacientes consecutivos ingresados por SCASEST (descenso del segmento ST y/o elevacion de troponina I). Se definio la DS como fraccion de eyeccion Resultados El 23,4% presento DS. Un total de 303 (31%) pacientes alcanzaron el objetivo primario, hecho que fue mas frecuente en los pacientes con DS (el 49,8 frente al 25,5%; p Conclusiones La presencia de DS permite la identificacion de los SCASEST que mas se benefician de aplicar una EI.

Effect of Invasive Treatment on Prognosis in Non-ST-Segment Elevation Acute Coronary Syndrome With or Without Systolic Dysfunction

INTRODUCTION AND OBJECTIVES Few data are available on the use of invasive treatment in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) and systolic dysfunction. The aim of this study was to determine the effect of invasive treatment on the prognosis of patients with NSTEACS, with or without systolic dysfunction. METHODS The study included 972 consecutive patients admitted for NSTEACS (i.e. ST-segment depression or an elevated troponin-I level). Systolic dysfunction was defined as an ejection fraction <50% on transthoracic echocardiography. The primary long-term endpoint was death or myocardial infarction. The effect of invasive treatment on prognosis was evaluated by Cox regression analysis. RESULTS Overall, 23.4% of patients had systolic dysfunction, and 303 (31.2%) reached the primary endpoint, which was more frequent in those with systolic dysfunction (49.8% vs. 25.5%; P< .001). Usage of coronary angiography and revascularization procedures were similar in patients with systolic dysfunction and those with an ejection fraction >/=50% (59% vs. 63.4%; P=.239; and 38.3% vs. 38.8%; P=.9; respectively). Detailed adjusted multivariate analysis, including the use of a propensity score, demonstrated that coronary angiography had a differential effect on prognosis depending on the presence or absence of systolic dysfunction (interaction, P=.01). Catheterization was clearly beneficial in patients with systolic dysfunction (hazard ratio [HR]=0.47; 95% confidence interval [CI], 0.3-0.75; P=.001) but not in those with an ejection fraction >/=50% (HR=0.9; 95% CI, 0.63-1.29; P=.567). CONCLUSIONS The presence of systolic dysfunction identifies those patients with NSTEACS who will benefit most from invasive treatment.