Marco Chiostri

Uric acid in the acute phase of ST elevation myocardial infarction submitted to primary PCI: Its prognostic role and relation with inflammatory markers: A single center experience

BACKGROUND AND METHODS Scarce data are available on the prognostic role of uric acid (UA ) in patients with ST elevation myocardial infarction (STEMI). We aimed at assessing the relation between uric acid, measured on Intensive Cardiac Care Unit (ICCU) admission, and mortality at short term follow-up in 466 consecutive STEMI patients submitted to percutaneous coronary intervention (PCI), as well as its relation with inflammatory markers (C-reactive protein, CRP-fibrinogen, erythrocyte sedimentation rate ESR). RESULTS Higher UA were detectable in the 21.5%.. In-hospital mortality was higher in patients with elevated UA (p<0.01 O.R. (95% C.I.): 3.9 (1.5-10.2)). At backward stepwise regression analysis UA resulted an independent predictor for in-hospital mortality (OR 1.82, 95%CI 1.15-2.86; p=0.01). CONCLUSION Our data strongly suggest that in the acute phase of STEMI patients submitted to PCI, uric acid holds a prognostic role for in-hospital mortality.

Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study

To evaluate the clinical, biohumoral, and haemodynamic effects of ultrafiltration vs. intravenous diuretics in patients with decompensated heart failure (HF). Signs and symptoms of volume overload are often present in these patients and standard therapy consists primarily of intravenous diuretics. Increasing evidence suggests that ultrafiltration can be an effective alternative treatment.

Prognostic role of insulin resistance as assessed by homeostatic model assessment index in the acute phase of myocardial infarction in nondiabetic patients submitted to percutaneous coronary intervention

Background and objectives Little information is available on the relation between insulin resistance and acute myocardial infarction. Methods In 253 consecutive nondiabetic patients with ST elevation myocardial infarction (STEMI) submitted to percutaneous coronary intervention, we assessed the prevalence of insulin resistance by homeostatic model assessment (HOMA) index and its prognostic role in early and late mortality. Results Insulin resistance was detectable in 52.9% of patients. Anterior STEMI was more frequent in insulin-resistant patients (P = 0.040), who showed higher values of probrain natriuretic peptide (P = 0.010), creatinine (P < 0.001), creatinine phosphokinase and creatinine phosphokinase-MB (MB, isoenzyme present in the myocardium; P = 0.016 and P = 0.003, respectively). At backward stepwise logistic regression analysis, the following variables were independent predictors for intra-intensive cardiac care unit mortality: HOMA index [hazard ratio 1.40; 95% confidence interval (CI) 1.02–1.95; P = 0.049]; C-peptide (hazard ratio 3.14; 95% CI 1.40–24.80; P = 0.001) and lactic acid (hazard ratio 2.50; 95% CI 1.41–4.44; P = 0.002). At long-term follow-up (Cox regression analysis), neither fasting glycaemia nor HOMA index resulted in predictors for mortality. Conclusion In nondiabetic STEMI patients submitted to percutaneous coronary intervention, insulin resistance, as assessed by HOMA index, is quite common and helps in the early prognostic stratification, as it represents an independent predictor of in-hospital mortality.

NT-proBNP on admission for early risk stratification in STEMI patients submitted to PCI. Relation with extension of STEMI and inflammatory markers

The prognostic implications of NT-proBNP measured on admission in patients with the ST-elevation myocardial infarction (STEMI) are not so far well elucidated. The present investigation, performed in 198 STEMI patients submitted to percutaneous coronary intervention (PCI), was aimed at assessing the prognostic value of NT-proBNP measured on admission to Intensive Cardiac Care Unit (ICCU) and its relation with the extension of myocardial infarction (indicated by cardiac biomarkers and ejection fraction) and inflammatory markers (C-reactive protein - CRP, erythrocyte sedimentation rate - ESR, leucocytes, fibrinogen). All patients who died during ICCU stay had increased values of NT-proBNP. Each quartile of NT-proBNP resulted directly correlated with age, heart rate, peak Tn I, admission creatinine serum levels, ESR, fibrinogen, and inversely correlated with ejection fraction. At backward logistic regression analysis, NT-proBNP values showed a significative correlation with peak Tn I (OR 1.013; 95% CI 1.001-1.025; p=0.036), and CRP positive (OR 6.450; 95% CI 1.714-24.272; p=0.006); age was close to reaching statistical significance (OR 1.043; 95% CI 0.999-1.089; p=0.055). At long term-follow-up NT-proBNP lacks any prognostic role in predicting adverse events such as hospitalization for rePCI, re-infarction and heart failure. Kaplan-Meier curves showed that all patients dead at follow-up were in the highest NT-proBNP quartiles.

Gender-related difference in ST-elevation myocardial infarction treated with primary angioplasty: a single-centre 6-year registry

Objective: Still contrasting are data on the impact of sex on outcome in patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). Design: We sought sex-related differences in management and early outcomes in 1127 STEMI patients submitted to PCI consecutively admitted to our intensive cardiac care unit (ICCU) in Florence from 1 January 2004 to 31 December 2009. Results: Females were significantly older, leaner (p < 0.001, respectively), more hypertensive (p < 0.001), and diabetic (p = 0.016); they showed a higher incidence of neurological impairment (p = 0.002) and chronic obstructive pulmonary disease (p = 0.048). Higher Killip classes were more frequent in females (p = 0.015). Door-to-balloon time was higher in females (p < 0.001) who showed a higher incidence of major bleeding (p < 0.001) and a higher in-ICCU mortality rate (p = 0.037). The use of IIbIIIa glycoprotein inhibitors was lower in females (p < 0.001) who exhibited higher values of admission glycaemia and peak glycaemia (p < 0.001 and p < 0.001, respectively), higher values of fibrinogen (p < 0.001) and erythrocyte sedimentation rate (p < 0.001), and lower eGFR and haemoglobin values (p < 0.001). Conclusions: According to our data, STEMI women show not only a different risk profile (older age, comorbidities, lower haemoglobin values), but also a different gender-related metabolic and inflammatory responses to acute myocardial ischaemia in respect to men. All these factors can account for the higher in-ICCU mortality in women and strongly suggest that STEMI women deserve more intensive care due to a more severe haemodynamic derangement (as indicated by the higher use of inotropes, diuretics, and non-invasive ventilation) and to a more serious metabolic impairment (as inferred by higher glucose values).

Rotational mechanics of the left ventricle in AL amyloidosis.

Aims: The aim of this study was to investigate whether alterations in left ventricular (LV) twisting and untwisting motion could be induced by cardiac involvement in patients with immunoglobulin light‐chain (AL) systemic amyloidosis. Methods and Results: Forty‐five patients with AL amyloidosis and 26 control subjects were evaluated. After standard echocardiographic measurement and two‐dimensional (2D) speckle tracking echocardiography, LV rotation at both basal and apical planes, twisting, twisting rate, and longitudinal strain were measured. Tissue Doppler imaging (TDI) derived early diastolic peak velocity at septal mitral annulus (E′) was also evaluated. Twenty‐six of 45 patients with systemic amyloidosis were classified as having cardiac amyloidosis (CA) if the mean value of the LV wall thickness was ≥ 12 mm or not (NCA) if this value was not reached. In NCA patients, both LV twist and untwisting rate were increased while they were decreased in CA patients making them similar to the control group. Longitudinal strain was reduced only in CA patients. Impaired relaxation as indicated by E′ values was progressively reduced in the course of the disease. Conclusions: Both twisting and untwisting motions are increased in patients with AL systemic amyloidosis with no evidence of cardiac involvement while they are reduced in patients with evident amyloidosis cardiac involvement. This finding suggests that impaired LV relaxation induces a compensatory mechanism in the early phase of the disease, which fails in more advanced stage when both twisting and untwisting rates are reduced. The increase in LV rotational mechanics could be a marker of subclinical cardiac involvement. (Echocardiography 2010;27:1061‐1068)

In-hospital peak glycemia and prognosis in STEMI patients without earlier known diabetes

Background Acute myocardial infarction is known as an acute metabolic stress, but clinicians currently have limited guidance regarding the evaluation and management of hyperglycemia after revascularization. Methods and results We assessed the prognostic role of three different ranges of in-hospital peak glycemia ([ 140, 140180, and > 180 mg/dl) in 252 acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to percutaneous coronary intervention consecutively admitted to our intensive cardiac care unit (ICCU). Patients with highest peak glycemia showed the highest intra-ICCU mortality (7/44, 15.9%), which was significantly higher with respect to the other two subgroups (P = 0.001 and 0.034, respectively). At backward stepwise logistic regression analysis, peak glycemia (odds ratio: 3.14; 95% confidence interval: 1.019.74, P =0.047) was an independent predictor of intra-ICCU mortality. Conclusion In acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to mechanical revascularization, the poorer in-hospital glucose control was associated with higher mortality; peak glycemia greater than 180 mg/dl was associated with the highest mortality, whereas patients with peak glycemia comprised between 140 and 180 mg/dl exhibited intermediate mortality rates. According to our data during hospitalization intensivists should achieve glucose control values less than 140 mg/dl, as peak glycemia resulted in the independent predictor of intra-ICCU mortality.

Acute glucose dysmetabolism in the early phase of ST-elevation myocardial infarction: the age response

In elderly patients with AMI, hyperglycaemia is associated with increased mortality. Recently it has been observed that insulin resistance, as assessed by the HOMA index, proved an independent predictor of in-hospital mortality. The interaction between age and glucose metabolism response in the acute phase of patients with STEMI without previously known diabetes has not yet been explored. We aimed to assess this relationship in 346 consecutive patients with STEMI admitted to our ICCU after primary PCI. When compared with the other age subgroups, the very oldest patients (aged > 79 years) showed the lowest LVEF (p=0.011), the highest incidence of 2- and 3-vessel coronary artery disease (p=0.002), and, finally, the highest mortality (p=0.037). Advancing age was associated with increased values of fibrinogen (p=0.022) and ESR (p=0.001), as well as of NT-pro-BNP (p<0.001). The very oldest patients (aged > 79 years) exhibited the highest values of glycaemia and peak glycaemia, while the incidence of insulin resistance (as inferred by HOMA index) remained unchanged across the age subgroups. This glycaemic pattern was confirmed after exclusion of patients with HbA1c > 6.5%, that is patients with a poor glycaemic control in the previous 2—3 months. In the acute phase of STEMI acute glucose metabolism is affected by age, since older patients showed the highest glucose levels and the poorest glycaemic control during ICCU stay despite the lack of differences in insulin resistance incidence.

Correlates of acute insulin resistance in the early phase of non-diabetic ST-elevation myocardial infarction

The relationship between insulin secretion and acute insulin resistance (as assessed by Homeostatic Model Assessment [HOMA] index) and clinical and biochemical parameters in the early phase of non-diabetic ST-elevation myocardial infarction (STEMI) is so far unexplored. We aimed at assessing this relation in 286 consecutive STEMI patients without previously known diabetes submitted to primary percutaneous coronary intervention (PCI). Insulin resistance (as indicated by HOMA) was detectable in 67.1%. Non-parametric correlation showed that HOMA index was significantly correlated with BMI (r = 0.242; p < 0.0001) and HbA1c (r = 0.189; p < 0.001). At multivariable backward linear regression analysis, glycaemia was directly related to leukocyte count (p = 0.0003), age (p = 0.0001), creatine kinase isoform MB (CK-MB) (p = 0.00278) and lactate (p < 0.0001). Insulin was directly and significantly related to glycaemia (p = 0.0006), body mass index (BMI) (p = 0.00028) and lactate (p = 0.0096) In the early phase of STEMI without previously known diabetes the acute glucose dysmetabolism is quite complex, comprising increased glucose values and the development of acute insulin resistance. While insulin secretion is strictly related to BMI, apart from glucose levels, increased glucose values can be mainly related to the acute inflammatory response (as indicated to leukocyte count and C-RP), to age and to the degree of myocardial damage (as inferred by CK-MB)

Postprocedural hyperglycemia in ST elevation myocardial infarction submitted to percutaneous coronary intervention: a prognostic indicator and a marker of metabolic derangement.

Background Hyperglycemia in acute coronary syndrome is associated with an increased risk of death in patients without previously known diabetes but the prognostic role of postrevascularization hyperglycemia in these patients is so far incompletely elucidated. Materials and methods In 175 consecutive patients without previously known diabetes and with ST elevation myocardial infarction treated with primary angioplasty, we evaluated the relation between acute and chronic glucose dysmetabolism and early and late mortality and the relation between hyperglycemia and extension of myocardial damage [creatine phosphokinase-MB (CPK-MB), troponin I levels, ejection fraction], inflammation (leukocyte count, erythrocyte sedimentation rate, C-reactive protein) and prognostic biohumoral markers [N-terminal brain natriuretic peptide (NT-proBNP) and lactic acid]. Results Highest glucose levels were associated with higher Killip class, lower ejection fraction and increased values of CPK, CPK-MB, troponin I, proBNP, lactic acid, leukocytes and insulin. At multivariate logistic regression analysis, the following variables were independent predictors of intraintensive cardiac care unit mortality: postprocedural glycemia [odds ratio (OR) 8.79; 95% confidence interval (CI) 1.41–54.94; P = 0.020] and troponin I (OR 1.003; 95% CI 1.0004–1.006; P = 0.023) when adjusted for insulinemia [OR 0.98; 95% CI 0.92–1.06; P = not significant (NS)], HbA1c (OR 0.51; 95% CI 0.11–2.37; P = NS), ST elevation myocardial infarction location (OR 1.27; 95% CI 0.44–3.66; P = NS) and creatininemia (OR 1.48; 95% CI 0.90–2.45; P = NS). Conclusion In ST elevation myocardial infarction patients without previously known diabetes submitted to percutaneous coronary intervention, glucose serum levels measured after mechanical revascularization were independent predictors of in-hospital mortality.