Luciano Consuegra

Improvement in risk stratification with the combination of the tumour marker antigen carbohydrate 125 and brain natriuretic peptide in patients with acute heart failure

AIM Elevated brain natriuretic peptide (BNP) and tumour marker antigen carbohydrate 125 (CA125) levels have shown to be associated with higher risk for adverse outcomes in patients with acute heart failure (AHF). Nevertheless, no attempt has been made to explore the utility of combining these two biomarkers. We sought to assess whether CA125 adds prognostic value to BNP in predicting 6-month all-cause mortality in patients with AHF. METHODS AND RESULTS We analysed 1111 consecutive patients admitted for AHF. Antigen carbohydrate 125 (U/mL) and BNP (pg/mL) were measured at a median of 72 +/- 12 h after instauration of treatment. Antigen carbohydrate 125 and BNP were dichotomized based on proposed prognostic cutpoints, and a variable with four categories was formed (BNP-CA125): C1 = BNP < 350 and CA125 < 60 (n = 394); C2 = BNP > or = 350 and CA125 < 60 (n = 165); C3 = BNP < 350 and CA125 > or = 60 (n = 331); and C4 = BNP > or = 350 and CA125 > or = 60 (n = 221). The independent association between BNP-CA125 and mortality was assessed with the Cox regression analysis, and their added predictive ability tested by the integrated discrimination improvement (IDI) index. At 6 months, 181 deaths (16.3%) were identified. The cumulative rate of mortality was lower for patients in C1 (7.8%), intermediate for C2 and C3 (17.8% and 16.9%, respectively), and higher for C4 (37.2%), and P-value for trend <0.001. After adjusting for established risk factors, the highest risk was observed when both biomarkers were elevated (C4 vs. C1: HR = 4.05, 95% CI = 2.54-6.45; P < 0.001) and intermediate when only one of them was elevated: (C2 vs. C1: HR = 1.71, 95% CI = 1.00-2.93; P = 0.050) and (C3 vs. C1: HR = 2.10, 95% CI = 1.30-3.39; P = 0.002). Moreover, when CA125 was added to the clinical model + BNP, a 10.4% (P < 0.0001) improvement in the IDI (on the relative scale) was found. CONCLUSION In patients admitted with AHF, CA125 added prognostic value beyond the information provided by BNP, and thus, their combination enables better 6-month risk stratification.

Risk stratification of patients with acute chest pain and normal troponin concentrations

Objective: To investigate the outcome of patients with acute chest pain and normal troponin concentrations. Design: Prospective cohort design. Setting: Single centre study in a teaching hospital in Spain. Patients: 609 consecutive patients with chest pain evaluated in the emergency department by clinical history (risk factors and a chest pain score according to pain characteristics), ECG, and early (< 24 hours) exercise testing for low risk patients with physical capacity (n  =  283, 46%). All had normal troponin concentrations after serial determination. Main outcome measures: Myocardial infarction or cardiac death during six months of follow up. Results: 29 events were detected (4.8%). No patient with a negative early exercise test (n  =  161) had events versus the 6.9% event rate in the remaining patients (p  =  0.0001). Four independent predictors were found: chest pain score ⩾ 11 points (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1 to 5.5, p  =  0.04), diabetes mellitus (OR 2.3, 95% CI 1.1 to 4.7, p  =  0.03), previous coronary surgery (OR 3.1, 95% CI 1.3 to 7.6, p  =  0.01), and ST segment depression (OR 2.8, 95% CI 1.3 to 6.3, p  =  0.003). A risk score proved useful for patient stratification according to the presence of 0–1 (2.7% event rate), 2 (10.2%, p  =  0.008), and 3–4 predictors (29.2%, p  =  0.0001). Conclusions: A negative troponin result does not assure a good prognosis for patients coming to the emergency room with chest pain. Early exercise testing and clinical data should be carefully evaluated for risk stratification.

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.

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.

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

Valor pronóstico del recuento leucocitario en el infarto agudo de miocardio: mortalidad a largo plazo

Introduccion y objetivos. Publicaciones recientes respaldan el papel pronostico del recuento leucocitario (RL) en pacientes con infarto agudo de miocardio (IAM). El objetivo de este trabajo fue determinar el valor predictivo atribuible al RL, con independencia de otras variables de contrastado valor pronostico, para predecir mortalidad a largo plazo en pacientes con IAM sin elevacion del segmento ST (IAMSEST) y con elevacion del segmento ST (IAMEST). Pacientes y metodo. Analizamos a 1.118 pacientes admitidos de forma consecutiva con el diagnostico de IAM (IAMSEST = 569; IAMEST = 549). El RL se obtuvo en la primera determinacion analitica. Se utilizaron modelos de regresion de Cox para determinar el grado de asociacion entre el RL y la mortalidad total para ambos tipos de IAM. La mediana de seguimiento fue de 10 ± 2 meses. El RL se incluyo en ambos modelos categorizado en los siguientes puntos de corte (x 10³ celulas/ml): < 10 (RL1); 10-14,9 (RL2) y = 15 (RL3). Resultados. Durante el seguimiento se registraron 105 muertes (18,5%) en pacientes con IAMSEST y 109 (19,9%) con IAMEST. Las hazard ratio ajustadas para las categorias RL2 y RL3 frente a RL1 en el grupo con IAMSEST fueron: 1,61 (1,03-2,51; p = 0,036) y 2,07 (1,08-3,94; p = 0,027), y en el IAMEST: 2,22 (1,35-3,63; p = 0,002) y 2,07 (1,13-3,76; p = 0,017), respectivamente. Conclusiones. El RL determinado en las primeras horas de un IAM demostro ser un predictor independiente de otras variables de contrastado valor pronostico para predecir la mortalidad total a largo plazo en el IAMSEST y el IAMEST.

Prognostic Value of Serum Creatinine in Non-ST-Elevation Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES Cardiovascular disease is the main cause of death in patients with kidney failure. Moreover, the presence of impaired renal function is an important prognostic factor in patients with heart disease, and is a determinant of outcome during follow-up. The main aim was to investigate the relationship between kidney failure at admission and one-year mortality in patients with non-ST-elevation acute coronary syndrome. PATIENTS AND METHOD We studied 1029 consecutive patients admitted to our institution. The serum creatinine level and glomerular filtration rate were determined at admission, and classical risk factors and biochemical markers were assessed. The primary endpoint was all-cause mortality at one year. RESULTS Patients who died were older, more frequently had a history of diabetes or coronary artery disease, were more likely to have heart failure at admission, had higher troponin-I, myoglobin and creatinine levels, and were less likely to have dyslipidemia or to be a smoker. Multivariate analysis showed that the independent predictors of all-cause mortality at one year were age, diabetes, troponin-I level, Killip class > 1, male gender, creatinine level, and glomerular filtration rate. There was a linear correlation between increased risk and creatinine level. CONCLUSIONS Creatinine level at admission is one of the most important covariates in early prognostic stratification in these patients. A high serum creatinine level (or a low glomerular filtration rate) increases the probability of death due to all causes. The serum creatinine level is, moreover, an inexpensive, easy-to-use, and widely available prognostic marker.

Prognostic Value of White Blood Cell Count in Acute Myocardial Infarction: Long-Term Mortality

INTRODUCTION AND OBJECTIVES Although traditionally an elevated white blood cell count (WBC), an indicator of systemic inflammation, has been accepted as part of the healing response following acute myocardial infarction (AMI), it has frequently been shown to be a predictor of adverse cardiovascular events. The present study was designed to assess the association between WBC and long-term mortality in AMI patients either with ST-segment elevation (STEMI) or without ST-segment elevation (non-STEMI). Patients and method. The study included 1118 consecutive patients who were admitted with the diagnosis of AMI: 569 non-STEMI and 549 STEMI. The WBC was measured in the 24 hours following admission. Patients were divided into 3 groups: WBC1 (count, <10 x 103 cells/mL), WBC2 (count, 10-14.9 x 10(3) cells/mL), and WBC3 (count, > or =15x10(3) cells/mL). All-cause mortality was recorded during a median follow-up period of 10+/-2 months. The relationship between WBC and mortality was assessed by Cox regression analysis for both types of AMI. RESULTS Long-term mortality during follow-up was 18.5% in non-STEMI patients and 19.9% in STEMI patients. In non-STEMI patients, the adjusted hazard ratios for those in the WBC3 and WBC2 groups compared with those in the WBC1 group were 2.07 (1.08-3.94; P=.027) and 1.61 (1.03-2.51; P=.036), respectively. The corresponding figures in STEMI patients were 2.07 (1.13-3.76; P=.017) and 2.22 (1.35-3.63; P=.002), respectively. CONCLUSIONS WBC on admission was an independent predictor of long-term mortality in both non-STEMI and STEMI patients.

Influencia del antecedente de hipertensión arterial en los pacientes ingresados por síndrome coronario agudo sin elevación del segmento ST

BACKGROUND AND OBJECTIVE: There are few studies evaluating the effect of a previous history of hypertension on long term prognosis after an acute coronary syndrome, using the new definitions and incorporating new risk markers in the analysis. The aim of our study was to determinate if hypertensive patients differ from non-hypertensives in the epidemiological profile, clinical presentation, treatment prescribed at discharge and prognosis after admission with non ST segment elevation acute coronary syndrome. PATIENTS AND METHOD: A total of 1,029 consecutive patients admitted with high suspicion of non ST segment elevation acute coronary syndrome were evaluated. Prognostic variables were determined during admission (epidemiological and biochemical), as it was the discharge treatment. The primary endpoint was defined as all cause mortality at one year follow up. RESULTS: 65.8% (n = 677) of patients had hypertension. Hypertensive patients displayed a worst epidemiological and biochemical profile, and different discharge treatment. There were 139 (13.5%) deaths at one year follow up. The all cause mortality for non-hypertensive patients was 12.5% and for hypertensives 14.6% (p = NS). In the multivariate analysis (Cox regression) there were no differences in mortality between these groups. CONCLUSIONS: A previous history of hypertension is an important factor to explain differences in the presence of other risk factors or the treatment, but is not a mortality predictor.