Lorenzo Fácila

Carbohydrate Antigen 125: An Emerging Prognostic Risk Factor in Acute Heart Failure?

Objective: To assess whether circulating levels of carbohydrate antigen 125 (CA125) predict subsequent 6-month all-cause mortality in patients after the index hospitalisation for acute heart failure (HF). Design and setting: Prospective cohort study at a single teaching centre in Spain. Methods: 529 consecutive patients with acute HF admitted in a single university centre were analysed. In addition to the traditional clinical information, CA125 (U/ml) was measured during the early course of hospitalisation. The independent association between baseline CA125 and mortality was assessed with Cox regression analysis. The follow-up was limited to 6 months. Results: 349 (66%) patients showed serum levels of CA125 >35 U/ml (established cut-off point value). At a 6-month follow-up, 89 (16.8%) deaths were identified. A positive trend between mortality and CA125 quartiles was observed; 3.8%, 15.2%, 22% and 26.5% of deaths occurred from quartile 1 to 4 of CA125 (p<0.001). Likewise, a monotonic, ascending trend in the risk ratios was estimated from the multivariable Cox model. Compared with the first quartile of CA125, the HRs (95% CI) for the second, third and fourth quartiles were 3.25 (1.20 to 8.79), 4.91 (1.88 to 12.85) and 8.41 (3.24 to 21.79), respectively. Conclusions: Serum levels of CA125 obtained in patients admitted with a diagnosis of acute HF was shown to be an independent predictor of mortality up to the 6-month follow-up.

Erectile Dysfunction in High-Risk Hypertensive Patients Treated with Beta-Blockade Agents

BACKGROUND Erectile dysfunction (ED) is a multifactorial disease related to age, vascular disease, psychological disorders, or medical treatments. Beta-blockade agents are the recommended treatment for hypertensive patients with some specific organ damage but have been outlined as one of leading causes of drug-related ED, although differences between beta-blockade agents have not been assessed. METHODS Cross-sectional and observational study of hypertensive male subjects treated with any beta-blockade agent for at least 6 months. ED dysfunction was assessed by the International Index of Erectile Dysfunction (IIEF). RESULTS 1.007 patients, mean age 57.9 (10.59) years, were included. The prevalence of any category of ED was 71.0% (38.1% mild ED; 16.8% moderate ED; 16.1% severe ED). Patients with ED had longer time since the diagnosis of hypertension and higher prevalence of risk factors and comorbidities. The prevalence of ED increased linearly with age. ED patients received more medications and were more frequently treated with carvedilol and less frequently with nebivolol. Patients treated with nebivolol obtained higher scores in every parameter of the IIEF questionnaire. The multivariate analysis identified independent associations between ED and coronary heart disease (OR: 1.57), depression (OR: 2.25), diabetes (OR: 2.27), atrial fibrillation (OR: 2.59), and dyhidopiridines calcium channel blockers (OR: 1.76); treatment with nebivolol was associated to lower prevalence of ED (OR: 0.27). CONCLUSION ED is highly prevalent in hypertensive patients treated with beta-blockade agents. The presence of ED is associated with more extended organ damage and not to cardiovascular treatments, except for the lower prevalence in nebivolol-treated patients.

Papel del índice de Charlson en el pronóstico a 30 días y 1 año tras un infarto agudo de miocardio

Introduccion y objetivos.El indice de Charlson (iCh) ha sido utilizado como variable de ajuste en modelos multivariables como indicador de comorbilidad. Debido a que su valor pronostico per se para complicaciones cardiovasculares tras un infarto agudo de miocardio no ha sido ampliamente evaluado, nos propusimos determinar su valor predictivo para muerte de cualquier causa y/o reinfarto, a 30 dias y 1 ano del evento indice. Pacientes y metodo. Se incluyo a 1.035 pacientes con el diagnostico de infarto (508 con elevacion del segmento ST y 527 sin elevacion del segmento ST). La presencia de eventos se determino a 30 dias (13,9%) y a un ano (26,3%). El iCh se calculo junto con otras variables de valor pronostico en el momento del ingreso, y se establecieron 4 grupos: 1, iCh = 0 (control); 2, iCh = 1; 3, iCh = 2, y 4, iCh ≥ 3. Para el analisis multivariable se utilizo la regresion de riesgos proporcionales de Cox; su poder discriminativo se evaluo mediante el indice C. Resultados. Los riesgos relativos (RR) y el intervalo de confianza [IC] del 95% para las categorias del iCh fueron: a los 30 dias, para la categoria 2, RR = 1,69; IC del 95%, 1,10-2,59; para la 3, RR = 1,78; IC del 95%,1,08-2,92, y para la 4, RR = 1,57; IC del 95%, 0,87-2,83; los valores a 1 ano fueron, para la categoria 2, RR = 1,62; IC del 95%, 1,18-2,23; para la 3, RR = 2,00; IC del 95%, 1,39-2,89, y para la 4, RR = 2,24; IC del 95%, 1,50-3,36. La diferencia en el indice C del modelo con y sin la variable iCh fue 0,765 y 0,750 a los 30 dias y 0,751 y 0,735 a 1 ano. Conclusiones. El iCh proporciono informacion pronostica independiente para muerte y/o reinfarto a los 30 dias y a 1 ano tras el infarto indice. Palabras clave: Infarto agudo de miocardio. Comorbilidad. Indice de Charlson.

Prevalencia de fibrilación auricular y uso de fármacos antitrombóticos en el paciente hipertenso ≥ 65 años. El registro FAPRES

INTRODUCTION AND OBJECTIVES Age and arterial hypertension are two of the main factors associated with atrial fibrillation and an increased risk of embolism. The objective of this study was to determine the prevalence of atrial fibrillation and the extent of antithrombotic use in hypertensive patients aged ≥65 years in the Spanish region of Valencia. METHODS Each study investigator enrolled the first three hypertensive patients aged ≥65 years who came for a consultation on the first day of each week for 5 weeks. Each patients risk factors, history of cardiovascular disease, CHADS(2) score and medical treatment were noted and an ECG was recorded. Data were analyzed centrally. A patient was regarded as having atrial fibrillation if it was observable on the ECG or reported in medical records. RESULTS The study included 1,028 hypertensive patients with a mean age of 72.8 years. Overall, 10.3% had atrial fibrillation: in 6.7%, it was observable on the ECG while 3.6% were in sinus rhythm but had a history of the condition. Factors associated with atrial fibrillation were age, alcohol intake, structural heart disease and glomerular filtration rate. In total, 76.2% of patients with ECG evidence of atrial fibrillation and a CHADS(2) score >1 were taking anticoagulants compared with 41.7% of those who had a history of the condition but were currently in sinus rhythm. CONCLUSIONS The prevalence of atrial fibrillation in our group of hypertensives was 10.3%; in 1.7%, it was previously undiagnosed. Antithrombotic use was high in patients with current atrial fibrillation, but lower in those who had experienced an episode previously.

Factores asociados a la falta de control de la hipertensión arterial en pacientes con y sin enfermedad cardiovascular

INTRODUCTION AND OBJECTIVES Hypertension is one of the most prevalent and poorly controlled risk factors, especially in patients with established cardiovascular disease (CVD). The aim of this study was to describe the rate of blood pressure (BP) control and related risk factors. METHODS Multicenter, cross-sectional and observational registry of patients with hypertension recruited from cardiology and primary care outpatient clinics. Controlled BP defined as <140/90 mmHg. RESULTS 55.4% of the 10 743 patients included had controlled BP and these had a slightly higher mean age. Patients with uncontrolled BP were more frequently male, with a higher prevalence of active smokers, obese patients, and patients with diabetes. The rate of controlled BP was similar in patients with or without CVD. Patients with uncontrolled BP had higher levels of blood glucose, total cholesterol, low density lipoproteins and uric acid. Patients with uncontrolled BP were receiving a slightly higher mean number of antihypertensive drugs compared to patients with controlled BP. Patients with CVD were more frequently receiving a renin-angiotensin-aldosterone axis inhibitor: 83.5% vs. 73.2% (P<.01). Multivariate analysis identified obesity and current smoking as independently associated with uncontrolled BP, both in patients with or without CVD, as well as relevant differences between the two groups on other factors. CONCLUSIONS Regardless of the presence of CVD, 55% of hypertensive patients had controlled BP. Lifestyle and diet, especially smoking and obesity, are independently associated with lack of BP control. Full English text available from: www.revespcardiol.org.

Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias

Objectives. To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. Patients and method. 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (< 24 h) exercise testing was done for the low-risk subgroup of patients (n = 203). All patients were followed during 3 months for major events (acute myocardial infarction or death). Results. Major events occurred in 71 patients (9.6%). Multivariate analysis (C stadistic = 0.79; 95% CI 0.730.84; p = 0.0001) identified the following predictors: age ≥ 72 years (OR = 1.7; 95% CI, 1.0-2.9; p = 0.05), insulindependent diabetes mellitus (OR = 2.9; 95% CI, 1.5-5.4; p = 0.001), previous ischemic heart disease (OR = 1.9; 95% CI, 1.1-3.2; p = 0.02), ST depression (OR = 2.1; 95% CI, 1.2-3.8; p = 0.01) and troponin I elevation (OR = 2.9; 95% CI, 1.5-5.3; p = 0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and ≥ 8 points (26.2% events); p = 0.0001. No patient with negative findings in the early exercise testing had major events. Conclusions. In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.

Usefulness of concomitant myoglobin and troponin elevation as a biochemical marker of mortality in non-ST-segment elevation acute coronary syndromes.

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Pronóstico a corto plazo de los pacientes ingresados por probable síndrome coronario agudo sin elevación del segmento ST. Papel de los nuevos marcadores de daño miocárdico y de los reactantes de fase aguda

Objectives. The relative value of classic markers, myocardial damage variables, and levels of acute-phase reactants in establishing the pre-discharge prognosis of acute coronary syndrome without ST-segment elevation was analyzed. Method. We prospectively studied 385 consecutive patients admitted from our chest pain unit with a highprobability diagnosis of acute coronary syndrome without ST-segment elevation. The clinical and electrocardiographic data, myocardial damage markers (troponin I, CK-Mb mass, myoglobin), and acute-phase reactants (high-sensitivity C-reactive protein, fibrinogen) were recorded. Results. During admission, 15 deaths (3.9%) and 16 complicative infarctions (4.2%) occurred, for a total of 31 major events (death and/or infarction: 8.1%). Age (p = 0.03), insulin-dependent diabetes (p = 0.009), and C-reactive protein (p = 0.05) were independently related to death. Fibrinogen was related to infarction (p = 0.01); by fibrinogen quartiles: 1.4%; 1.4%; 2.9%, and 11.7% (p = 0.02). Age (p = 0.01), insulin-dependent diabetes (p = 0.02), and C-reactive protein (p = 0.04) were independent predictors of major events; by C-reactive protein quartiles: 1.4%; 5.5%; 5.4%, and 16.7% (p = 0.004). Troponin I was related to major events (p = 0.03), but it was not an independent predictor. Conclusions. Acute-phase reactants add independent information to clinical variables in the short-term risk stratification of patients with an acute coronary syndrome. The predictive power of troponins is lower than that of

Prognostic Value of Charlson Comorbidity Index at 30 Days and 1 Year After Acute Myocardial Infarction

INTRODUCTION AND OBJECTIVES The Charlson comorbidity index (CCI), an indicator of comorbidity, has been used as an adjusting variable in multivariate models. Because of its prognostic value per se for cardiovascular complications after acute myocardial infarction (AMI), we sought to determine the predictive value of the CCI for all-cause mortality and recurrent AMI 30 days and 1 year after the index event. PATIENTS AND METHOD We analyzed 1035 consecutive patients admitted with the diagnosis of AMI (ST elevation=508 and non-ST elevation=527). The composite endpoint was determined after 30 days (13.9%) and 1 year (26.3%) of follow-up. The CCI was calculated on admission, and other variables with prognostic value were also recorded. CCI was stratified in 4 categories: 1: CCI=0 (control), 2: CCI=1, 3: CCI=2,4: CCI> or =3. Cox proportional risks analysis was used for the multivariate analysis, and the C-statistic was calculated to assess the discriminative power of the models. RESULTS Hazard ratios (95% CI) estimated for each category of CCI were: 2=1.69 (1.10-2.59), 3=1.78 (1.08-2.92) and 4=1.57 (0.87-2.83) at 30 days; 2=1.62 (1.18-2.23), 3=2.00 (1.39-2.89) and 4=2.24 (1.50-3.36) at 1 year. Comparisons with the C-statistic between the nested multivariate models (with and without CCI) yielded values of 0.765 vs 0.750 after 30 days, and 0.751 vs 0.735 after 1 year. CONCLUSIONS Our data indicate that CCI is an independent predictor of mortality or recurrent AMI 30 days and 1 year after the index AMI.

Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST. De los grandes estudios al mundo real

Rev Esp Cardiol 2004;57(12):1143-5