José Luis Navarro Estrada

N-Terminal B-Type Natriuretic Peptide Assessment Provides Incremental Prognostic Information in Patients With Acute Coronary Syndromes and Normal Troponin T Values Upon Admission

OBJECTIVES The purpose of this study was to determine the prognostic value of N-terminal B-type natriuretic peptide (NT-proBNP) in two independent samples of patients presenting with acute coronary syndromes (ACS) and normal troponin T (TnT) values. BACKGROUND Recently assessment of NT-proBNP has been studied in patients with ACS. However, the clinical relevance in patients who present without troponin elevation is unclear. METHODS We included 2,614 patients from two independent registries, one serving as a derivation cohort comprising patients with evident ACS (Bad Nauheim ACS registry, n = 1,131) and the other serving as a validation cohort including chest pain patients (PACS [Prognosis in Acute Coronary Syndromes] registry, n = 1,483). NT-proBNP and TnT were measured upon admission. Clinical outcome has been assessed over a 6-month period. RESULTS In both cohorts, the mortality rate was significantly lower among TnT negative patients: 3.8% versus 8.2% (p = 0.009) in the Bad Nauheim ACS registry, and 2.8% versus 8.6% (p = 0.009) in the PACS registry. Among TnT negative patients, receiver-operating characteristics curve analysis yielded an optimal cutoff value of 474 pg/ml for NT-proBNP that was able to discriminate patients at higher risk in the Bad Nauheim ACS and PACS registries (mortality rate 12.3% vs. 1.3%, p < 0.001 and 8.5% vs. 1.5%, p < 0.001, respectively). By Kaplan-Meier analysis, patients with NT-proBNP values over 474 pg/ml were at higher risk for death in the Bad Nauheim ACS registry (log-rank 19.01, p < 0.001, adjusted hazard ratio [HR] 9.56 [95% confidence interval (CI) 2.42 to 37.7], p = 0.001) and in the PACS registry (log-rank 23.16, p < 0.001, adjusted HR 5.02 [95% CI 2.04 to 12.33], p < 0.001). CONCLUSIONS Among patients with suspected ACS considered to be at low risk because of normal troponin values, NT-proBNP above 474 pg/ml is able to discriminate individuals at higher risk. Because of its incremental prognostic value, NT-proBNP assessment should be considered in clinical routine for risk stratification of patients with normal troponin.

Anticoagulation With Otamixaban and Ischemic Events in Non–ST-Segment Elevation Acute Coronary Syndromes: The TAO Randomized Clinical Trial

IMPORTANCE The optimal anticoagulant for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) managed with an invasive strategy remains controversial. OBJECTIVE To compare the clinical efficacy and safety of otamixaban, a novel intravenous direct factor Xa inhibitor, with that of unfractionated heparin plus downstream eptifibatide in patients with NSTE-ACS undergoing a planned early invasive strategy. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, active-controlled superiority trial that enrolled 13,229 patients with NSTE-ACS and a planned early invasive strategy, at 568 active sites in 55 countries and conducted between April 2010 and February 2013. A planned interim analysis was conducted for otamixaban dose selection. INTERVENTIONS Eligible participants were randomized to otamixaban (bolus and infusion, at 1 of 2 doses) or unfractionated heparin plus, at the time of percutaneous coronary intervention, eptifibatide. The otamixaban dose selected at interim analysis was an intravenous bolus of 0.080 mg/kg followed by an infusion of 0.140 mg/kg per hour. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was the composite of all-cause death or new myocardial infarction through day 7. RESULTS Rates of the primary efficacy outcome were 5.5% (279 of 5105 patients) randomized to receive otamixaban and 5.7% (310 of 5466 patients) randomized to receive unfractionated heparin plus eptifibatide (adjusted relative risk, 0.99 [95% CI, 0.85-1.16]; P = .93). There were no differences for the secondary end points, including procedural thrombotic complications. The primary safety outcome of Thrombosis in Myocardial Infarction major or minor bleeding through day 7 was increased by otamixaban (3.1% vs 1.5%; relative risk, 2.13 [95% CI, 1.63-2.78]; P < .001). Results were consistent across prespecified subgroups. CONCLUSIONS AND RELEVANCE Otamixaban did not reduce the rate of ischemic events relative to unfractionated heparin plus eptifibatide but did increase bleeding. These findings do not support the use of otamixaban for patients with NSTE-ACS undergoing planned early percutaneous coronary intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01076764.

Antiischemic properties of amlodipine, a new calcium antagonist, in patients with severe coronary artery disease: A prospective trial

investigators demonstrated definite improvement compared with placebo. Analysis of the difference showed statistical significance despite the high incidence of spontaneous remissions on placebo, a pattern well known in the natural history of patients with vasospastic angina.4 The decrease in the number of attacks of angina in patients receiving amlodipine from 2.1 +0.6 to 0.7 4 0.2 per day is clinically significant and compares well with results of currently approved* calcium antagonists for the therapy of vasospastic angina. 5, 6 However, amlodipine has the advantage of once-daily dosage, securing an improved compliance during long-term use.

Early treatment with low-dose enalapril after acute myocardial infarction: An Equilibrium radionuclide angiographic study☆

BackgroundTo further elucidate the mechanisms involved in the treatment of acute myocardial infarction (AMI) with angiotensin-converting enzyme inhibitors, we compared the effects on left ventricular volumes of early (<48 hours) versus late (45 days) administration of a fixed low dose of enalapril (10 mg) in patients with AMI. We also analyzed the changes of left ventricular volumes after withdrawal of the study drug. Reduced dilation of the left ventricle is one of the beneficial effects of angiotensin-converting enzyme inhibition after AMI. However, the nature of this effect is not completely understood.Methods and ResultsWe included 89 patients within 48 hours after onset of a first AMI and radionuclide left ventricular ejection fraction less than 45%. The study was double-blind and compared enalapril and placebo with a crossover design. All patients were randomly assigned to a sequence A (enalapril, 45 days; placebo, 45 days) or B (placebo, 45 days; enalapril, 45 days). The end point was the change of left ventricular volume at 45 and 90 days. Thrombolysis was administered to 26 patients (70%) in group A and 25 (75%) in group B. All pretreatment clinical variables were similar in both groups. Median and 95% confidence intervals (CIs) of left ventricular diastolic volumes were 46.8 ml/m2 (39 to 61 ml/m2) and 46.6 ml/m2 (39 to 60 ml/m2) for groups A and B, respectively. Baseline end systolic volumes were 28.5 ml/m2 (20 to 36 ml/m2) and 28.9 ml/m2 (23 to 28 ml/m2) in the same groups. Placebo treatment during the initial 45 days was associated with an increase of left ventricular diastolic volume of 8.75 ml/m2 (95% CI, 3.25 to 17.1 ml/m2; p<0.01) and end-systolic volume of 4.20 ml/m2 (95% CI, 0.00 to 10.1 ml/m2; p<0.05). No significant changes during other phases of the study were observed. At 45 days left ventricular diastolic volume was 11.1 ml/m2 (95% CI, 0.5 to 2.2 ml/m2), greater in placebotreated patients compared with patients receiving enalapril.ConclusionsIn patients with a first Q wave AMI and left ventricular ejection fraction less than 45%, treatment with enalapril can prevent left ventricular dilation. This protective effect involves at least partially a structural modification of the left ventricle. Hence, maximal benefit can be obtained only with early initiation of treatment.

Consensus Statement for the Management of Patients with Chest Pain

According to mortality statistics, cardiovascular disease continues to be the major cause of death in Argentina,followed by tumors and infections.The analysis of cardiovascular mortality, shows that coronary heart disease (CHD), together with heart failure(HF) are the most frequent causes of death in our country.Chest pain is the most common form of presentation of patients with CHD and its proper assessment dependson the diagnosis of acute coronary syndrome (ACS) that without hospitalization and appropriate treatmentis associated with high mortality. On the other hand, the unnecessary hospitalization of a patient withnoncardiac chest pain is risky for the patient and generates high costs to the health system.We consider a Consensus statement is necessary because:- Chest pain is the second most common cause of care in emergency departments.- The prompt classification of patients with chest pain aims mainly to differentiate an ACS from othercauses.- Although 50% of these patients present with a clinical condition suggestive of ACS, this diagnosis is reachedonly in half of the cases.- It represents a medical challenge and an important issue for health systems from an economic point of view.

Precisión diagnóstica del espesor íntima-media carotídeo para la detección de aterosclerosis coronaria. Utilidad en la práctica clínica

Introduccion El espesor intima-media carotideo (EIMC) es un marcador independiente de riesgo cardiovascular. El puntaje de calcio coronario (PCC) es un predictor superior al EIMC, pero de costo elevado y en nuestro pais pocos pacientes pueden acceder a su medicion. Objetivos 1) Evaluar la precision diagnostica del EIMC para la deteccion de un PCC > 0. 2) Determinar el punto de corte optimo del EIMC para discriminar entre la presencia o la ausencia de calcio coronario. Material y metodos Estudio descriptivo transversal de muestras consecutivas obtenidas en los consultorios de prevencion cardiovascular. Se midio el EIMC medio y maximo mediante un eco-Doppler carotideo. Se efectuo una tomografia computarizada de 64 pistas para la evaluacion del PCC. Se determino la precision diagnostica del EIMC para la deteccion de un PCC > 0 mediante un analisis ROC. Resultados Se incluyeron 202 sujetos consecutivos que participan de un programa de prevencion primaria. Caracteristicas de la poblacion (media } desviacion estandar): edad 57 } 13 anos, sexo femenino: 49%, tabaquismo: 13%, estatinas: 37%, diabetes mellitus: 13%, puntaje de Framingham en no diabeticos: 9% } 7%, EIMC medio: 0,953 } 0,342 mm, EIMC maximo: 1,383 } 0,679 mm, prevalencia de placa aterosclerotica carotidea: 37% y de PCC > 0: 62%. Las correlaciones entre el EIMC medio y maximo y el PCC fueron moderadas (r = 0,56 y r = 0,55, respectivamente). El area bajo la curva ROC del EIMC maximo fue de 0,822 (IC 95% 0,763-0,880) y la del EIMC medio fue de 0,829 (IC 95% 0,771-0,888). El punto de corte optimo del EIMC maximo para discriminar entre PCC > 0 o PCC = 0 fue de . 1,01 mm y la sensibilidad, la especificidad, el valor predictivo positivo (VPP) y el valor predictivo negativo (VPN) fueron del 78%, 75%, 83% y 67%, respectivamente. El punto de corte optimo del EIMC medio para discriminar entre PCC > 0 o PCC = 0 fue . 0,82 mm y la sensibilidad, la especificidad, el VPP y el VPN fueron del 77%, 78%, 85% y 67%, respectivamente. Conclusiones En esta poblacion predominantemente de riesgo bajo, la precision diagnostica del EIMC para detectar PCC > 0 fue moderada. Una ecografia Doppler carotidea gnormal no excluyo la presencia de aterosclerosis subclinica coronaria. Estos resultados podrian mejorar la seleccion de pacientes que requieran la medicion del PCC para estratificar el riesgo cardiovascular.