Jorge R. Alegria

Elevated cardiac troponin is an independent risk factor for short- and long-term mortality in medical intensive care unit patients

Background:Troponin elevations are common in critically ill patients. Whether they are predictors of mortality independent of the severity of the underlying disease is unclear. Objective:To determine whether troponin elevations predict in-hospital, short-term, and long-term mortality in medical intensive care unit patients independent of the severity of the underlying disease as measured by Acute Physiology and Chronic Health Evaluation III prognostic system. Design:Retrospective study. Setting:We examined the Acute Physiology and Chronic Health Evaluation III database and cardiac troponin T levels of medical intensive care unit patients at Mayo Clinic, Rochester, MN. Patients:In all, 1,657 patients consecutively admitted to medical intensive care units between August 2000 and December 2001. Measurements:In-hospital, short-term (30-day), and long-term all-cause mortality. Results:During hospitalization, 12.5% of patients with a cardiac troponin T < 0.01 &mgr;g/L suffered deaths compared with 29.5% among those with cardiac troponin T ≥0.01 &mgr;g/L (p < .001). At 30 days, mortality was 13.7% without and 34.6% with elevations (p < .001). The expected probability of survival at 1-, 2-, and 3-yr follow-up was 43.7%, 33.8%, and 25.7% among patients with cardiac troponin T ≥0.01 &mgr;g/L and 75.3%, 67.6%, and 62.9% in those with cardiac troponin T < 0.01 &mgr;g/L, respectively (p < .001). After adjustment for the severity of disease and baseline characteristics, cardiac troponin levels were still associated with in-hospital, short-term, and long-term mortality (p = .006, p = .007, and p = .001, respectively). Limitations:This is a single-site retrospective study that included only patients in whom a troponin level was obtained on admission. Conclusions:In medical intensive care unit patients, admission troponin levels are independently associated with short- and long-term mortality, even after adjustment for severity of disease.

Long-term prognostic significance of elevated cardiac troponin levels in critically ill patients with acute gastrointestinal bleeding.

Background:Elevations in troponin level have prognostic importance in critically ill patients, including those with gastrointestinal (GI) bleeding. However, there are no data addressing the independent association of troponin levels and mortality, adjusted for the severity of the underlying disease, in patients with GI bleeding. Objective:This study was designed to determine whether troponin T elevations are independently associated with in-hospital, short-term (30 days), and long-term mortality in medical intensive care unit patients with GI bleeding after adjusting for the severity of disease measured by the Acute Physiology, Age, and Chronic Health Evaluation score prognostic system. Design:Retrospective study. Setting:We examined the Acute Physiology, Age, and Chronic Health Evaluation III database and cardiac troponin T levels from patients consecutively admitted to the medical intensive care unit at Mayo Clinic, Rochester, MN, with acute GI bleeding. Patients:Between August 2000 and July 2005, 1076 patients with acute GI bleeding consecutively admitted to the medical intensive care units. Measurements:In-hospital, short-term (30 days), and long-term all-cause mortality. Results:During hospitalization, 8.0% of deaths occurred in patients with troponin T <0.01% and 11.9% with troponin T ≥0.01 (p = 0.083). At 30 days, mortality was 10.1% and 18.8% in patients without and with elevations of troponins, respectively (p < 0.001). The Kaplan-Meier expected probability of survival at 1-, 2-, and 3-yr follow-up was 54.2%, 40.8%, and 30.4% with troponin T ≥0.01 &mgr;g/L and 78.3%, 69.3%, and 61.5% with troponin T <0.01 &mgr;g/L (p < 0.001). After adjustment for severity of disease and baseline characteristics, cardiac troponin levels were associated only with long-term mortality (p < 0.001). Limitations:This is a retrospective, single-center study which included only patients in whom troponin level was determined upon admission. Conclusions:In patients with GI bleeding severe enough to require admission to the medical intensive care unit, admission troponin T elevations are associated with long-term but not short-term mortality.

Cell therapy for cardiovascular disease: what cells, what diseases and for whom?

Experimental and human data suggesting progenitor cells possess the capacity to regenerate tissue and augment repair in injured organs has generated widespread interest in the basic research and clinical communities. Nowhere have these findings been more tantalizing than in human cardiovascular disease, in which vasculogenesis and myocardial regeneration logically and understandably remain as attractive therapeutic targets. Burgeoning experimental evidence attests to the proangiogenic, vasculogenic and tissue reparative capabilities of a broad range of progenitor cells derived from the bone marrow, circulation and a number of other tissues in vivo. Studies demonstrating the most apparent therapeutic success are those implicated in revascularization and repair of acute or chronically ischemic tissues in the heart and the peripheral vascular system. Numerous small clinical trials have yielded promising preliminary results without clear evidence of a superiority for a specific cell type or clinical disease entity as the most suitable target for cell therapy. This review will evaluate the scientific rationale for use of a specific cell or cells, the cardiovascular disease states most appropriate for targeted cell therapy, and the patient-specific barriers to therapeutic success, including emerging hurdles such as cardiovascular risk factors and comorbidities in eligible subjects.

Nonexercise Activity Thermogenesis in Obesity Management

Obesity is linked to cardiovascular disease. The global increase in sedentary lifestyle is an important factor contributing to the rising prevalence of the obesity epidemic. Traditionally, counseling has focused on moderate- to vigorous-intensity exercise, with disappointing results. Nonexercise activity thermogenesis (NEAT) is an important component of daily energy expenditure. It represents the common daily activities, such as fidgeting, walking, and standing. These high-effect NEAT movements could result in up to an extra 2000 kcal of expenditure per day beyond the basal metabolic rate, depending on body weight and level of activity. Implementing NEAT during leisure-time and occupational activities could be essential to maintaining a negative energy balance. NEAT can be applied by being upright, ambulating, and redesigning workplace and leisure-time environments to promote NEAT. The benefits of NEAT include not only the extra calories expended but also the reduced occurrence of the metabolic syndrome, cardiovascular events, and all-cause mortality. We believe that to overcome the obesity epidemic and its adverse cardiovascular consequences, NEAT should be part of the current medical recommendations. The content of this review is based on a literature search of PubMed and the Google search engine between January 1, 1960, and October 1, 2014, using the search terms physical activity, obesity, energy expenditure, nonexercise activity thermogenesis, and NEAT.

Hypoplasia, pseudocoarctation and coarctation of the aorta - a systematic review.

Aortic arch abnormalities are uncommon and may be seen in association with other congenital cardiac anomalies. Coarctation, pseudocoarctation and hypoplastic aortic arch are known aortic arch abnormalities, with the former being well studied, whilst for the latter two, much less is known. There are similarities and differences that are important to distinguish among these three conditions in order to avoid errors in diagnosis that may result in unnecessary investigations, which may in turn result in physical or emotional harm to the patient. For this reason, we present a systematic review of the published literature providing an evidence-based overview that may be helpful to clinicians when faced with this diagnostic dilemma.

Papillary Fibroelastoma of the Pulmonary Valve – A Systematic Review

The pulmonary valve is the least affected site for valvular papillary fibroelastoma. With increasing use of routine echocardiography and other modalities of imaging, pulmonary valve papillary fibroelastomas (PVPFE) are being recognized more frequently. PVPFE is more often an incidental diagnosis and symptomatic patients usually present with shortness of breath. Embolic phenomena and right ventricular outflow tract obstruction are the most serious complications of PVPFE. Since PVPFE is rare, the purpose of this systematic review is to address demographic characteristics, the clinical presentation, management, and outcome of this benign tumor of the pulmonary valve.

Coronary Artery Ectasia in an Adult Noonan Syndrome Detected on Coronary CT Angiography

Coronary ectasia is rare in patients with Noonan syndrome. When suspected during echocardiography more common causes including Kawasaki disease in children and atherosclerosis coronary artery disease in adults should be ruled out. Coronary CT angiogram, a non-invasive imaging tool may be preferred over conventional coronary angiogram in the initial diagnosis and monitoring the progression of coronary ectasia in such patients. Aspirin may be considered to prevent coronary thrombosis.

Giant Superior Vena-cava Aneurysm after Glenn Surgery: A New Complication of the Glenn Procedure

A 27 year-old male presented with chest tightness, shortness of breath on exertion, and palpitations. He had a history of double outlet right ventricle with transposition of the great vessels, sub pulmonic ventricular septal defect, membranous septal defect, superior vena cava to right pulmonic artery anastomosis (Bidirectional Glenn), atrial septostomy, right pulmonary arterioplasty 13 years earlier (Fig. 1). A pacemaker was placed for high-grade AV block. He had New York Heart Association (NYHA) class III heart failure and was on ACE-inhibitors and beta-blockers. Chest X ray showed an abnormal cardiac silhouette that was initially assumed to be right-sided aortic arch (Fig. 2, Arrow,

Interferon-α and pericardial injury: a case report and literature review

Interferon- α (IFN-α) alone or in combination with other chemotherapeutic agents has been used in the management of many malignant and non-malignant conditions. Pericarditis with or without pericardial effusion has been reported with IFN-α therapy, and available literature is limited to case reports. Pericardial constriction after interferon use has not been described in the published literature to date. We performed a systematic review of literature to address the demographic features, clinical presentation, diagnosis, treatment and outcome of interferon-related pericardial injury.