Olimpia Trio

Age, glomerular filtration rate, ejection fraction, and the AGEF score predict contrast-induced nephropathy in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.

In patients undergoing primary percutaneous coronary interventions (PCI) for ST‐segment elevation myocardial infarction (STEMI), the occurrence of Contrast‐Induced Nephropathy (CIN) has a pronounced impact both on morbidity and mortality. We investigated the variables associated with CIN development in 481 consecutive patients with STEMI undergoing primary PCI and evaluated the predictive value of a 3‐variable clinical risk score (the AGEF score) based on age, left ventricular ejection fraction (EF), and estimated glomerular filtration rate (eGFR).

Renal Function–Adjusted Contrast Volume Redefines the Baseline Estimation of Contrast-Induced Acute Kidney Injury Risk in Patients Undergoing Primary Percutaneous Coronary Intervention

Background—Age, estimated glomerular renal function (eGFR), and ejection fraction are preprocedural predictors of contrast-induced acute kidney injury (CI-AKI) after primary percutaneous coronary intervention. The effect of renal function–adjusted contrast volume (CV) remains not totally explored, and a threshold has not yet been established. Methods and Results—Logistic regression and receiver-operating characteristic curve analyses were used to assess whether CV/eGFR was an independent predictor of CI-AKI. The increased discriminative value of CV/eGFR over the preprocedural model based on age, eGFR, and ejection fraction was examined using the net reclassification improvement analysis. Of 470 patients enrolled, we observed 25 (5.3%) cases of CI-AKI. Patients with CI-AKI had received a higher renal function–adjusted CV (CV/eGFR 3.62 versus 1.96; P<0.001), and CI-AKI incidence was higher (15%; P<0.001) in patients in the highest quartile of CV/eGFR, corresponding to the cutoff indicated by the receiver-operating characteristic curve (>2.5; area under the curve, 0.77). At multivariable analysis, CV/eGFR above the cutoff (odds ratio, 5.57; P=0.002) remained an independent predictor of CI-AKI. The model with CV/eGFR demonstrated a statistically significantly net reclassification improvement of 0.23 (P=0.021) over the baseline preprocedural model, largely driven by a correct decrease in risk estimates for patients not experiencing CI-AKI, with a likelihood ratio &khgr;2 of 5.973 (P=0.029). Conclusions—CV remains a key risk factor for CI-AKI after primary percutaneous coronary intervention and our study supports the need for minimizing CV, independently from baseline preprocedural risk. A CV restricted to no more than twice and a half the baseline eGFR might be valuable in reducing the risk of CI-AKI.

The ACEF score as predictor of acute kidney injury in patients undergoing primary percutaneous coronary intervention

Acute kidney injury (AKI) is an important complication of iodinated contrast media administration [1]. It particularly occurs after coronary procedures; the reported incidencemaybe ashigh as50%, dependingon populations, baseline risk factors and definitions [2]. In patients undergoing primary percutaneous coronary interventions (PCI) for ST-segment elevation myocardial infarction (STEMI), AKI is an established predictor of mortality [3]. Apart from increasing mortality, AKI leads to prolonged hospital stay and additional cost [4] and is also associated with late cardiovascular adverse events [5]. The main purpose of this study was to investigate the risk factors associated with AKI development in patients with STEMI undergoing primary PCI and to evaluate the predictive value of the ACEF score [6]. All the patients consecutively referred to the Coronary Care Unit (CCU) of the University Hospital of Messina from January 2008 to June 2011 for primary PCI in the course of STEMI were included. Primary PCI wasperformed fromthe femoral approach according to standard clinical practice and the indication to intra-aortic balloon pump (IABP) support was left to the discretion of the attending cardiologists. Wall motion abnormalities and left ventricular ejection fraction (EF) were rapidly assessedwith echocardiography in all subjects, either in the Emergency Department or in the pre-cath room. The images were digitally stored and evaluated off-line. Blood samples were collected for measurement of serum creatinine (sCr) on admission, 6 h after the procedure, every day for the following 3 days, and at discharge from the CCU. The ACEF score was calculated according to the original study by Ranucci et al. [6]: age/EF(%) + 1 (if sCr ≥2.0 mg/dL). The primary end point of the study was the occurrence of AKI, defined as an absolute increase in sCr ≥0.5 mg/dL or an increase ≥25% from baseline within 72 h after the administration of contrast medium, without any other plausible etiology. Continuous variables are expressed as mean ± standard deviation and comparedwith t test; categorical variables are expressed as absolute counts and/or percentages and compared by Fisher’s exact test and χ test, as appropriate. Those variables associated with AKI development at univariate analysis were entered into a stepwise forward logistic regression model in order to assess their significance as independent predictors of AKI. The odds ratios (OR) and 95% confidence intervals (CI) are presented. Finally, logistic regression analysis, Hosmer–Lemeshow χ statistic and receiver-operating characteristic (ROC) curve analysis were performed to assess accuracy and calibration of ACEF score as predictor of AKI. A two-tailed p b 0.05 was always requested for statistical significance. The calculations were performed by using Statistical Package for Social Sciences, version 20. Four hundred eighty-one patients with STEMI undergoing primary PCI were enrolled. Demographic characteristics and procedural data are summarized in Table 1. We observed 25 (5.2%) cases of AKI. These patients (Table 1) were older, had a more severe impairment of both basal EF and global hemodynamic status, as expressed by the Killip score, and worse basal sCr thanpatientswithoutAKI. In addition, patientswithAKI had ahigher troponin at admission and a higher prevalence of hypertension and diabetes. From the procedural standpoint (Table 1), patients with AKI had not received a higher total contrast volume nor a higher number of stents. Conversely, they had had a poorer post-procedural TIMI flow (grade 3 in 76% Vs 91.5%, p b 0.001; on average 2.6 ± 0.9 Vs 2.9 ±0.4, p = 0.002) andweremore likely to have received an IABP. They had, on average, a 2-

Myocardial dysfunction after subarachnoid haemorrhage and tako-tsubo cardiomyopathy: a differential diagnosis?

The frequent occurrence of a reversible left ventricular dysfunction complicating subarachnoid haemorrhage raises a number of issues about the clinical and pathophysiological similarities with the transient left ventricular apical ballooning syndrome (TLVABS) or tako-tsubo cardiomyopathy (TTC). Given the latest clinical and pathophysiological evidence about neurogenic cardiomyopathies, the diagnosis of TTC should not be ruled out in patients experiencing acute brain injury and cerebrovascular events. Each type of reversible left ventricular dysfunction mediated by the central nervous system and initiated by acute brain injury, both physical, such as intracranial bleeding or head traumas, and psychological, such as sudden emotional stress, could be encompassed in a single definition with larger inclusion criteria, such as ‘acute ballooning cardiomyopathy’ (ABC), that is likely to be more representative of the real needs in the clinical setting.

Transient left ventricular dysfunction in patients with neurovascular events

Abstract Neurogenic cardiomyopathies are raising a growing interest due to their multidisciplinary implications. Despite the body of literature, questions about pathophysiology, risk predictors and prognosis of the various clinical pictures are still open. The frequent observation of a reversible left ventricular dysfunction complicating subarachnoid haemorrhage drops several hints of discussion about the clinical and pathophysiological similarities with the ‘typical’ transient left ventricular apical ballooning syndrome. In the light of the latest clinical and pathophysiological evidences, transient left ventricular apical ballooning syndrome could no longer be considered as an exclusively ‘apical’ wall motion abnormality and this diagnosis had not to be ruled out in patients experiencing acute brain injury and cerebrovascular events. Each kind of reversible left ventricular dysfunction mediated by the central nervous system and initiated by acute brain injury, both physical, like intracranial bleeding or head traumas, and psychical, like sudden emotional stress, could be encompassed in a single definition with wider inclusion criteria, such as ‘acute ballooning cardiomyopathy’ (ABC), that is likely to be more representative of the real needs in the clinical setting.

Systemic embolism in takotsubo syndrome

A 57-year-old woman with acute left leg ischemia due to popliteal artery occlusion and deep T-wave inversion at ECG revealed she had suffered, the day before, from typical chest pain after a confrontational argument; yet, she had not sought medical assistance. Echocardiography showed left ventricular wall motion abnormalities consistent with the diagnosis of emotional stress-induced takotsubo syndrome. Coronary angiography ruled out obstructive atherosclerotic disease and left ventriculography confirmed apical ballooning with evolving thrombosis. Left leg angiography demonstrated diffuse embolisation of the popliteal artery. Ventricular thrombosis is a complication of takotsubo syndrome and has been associated with adverse events supposed to be due to a cardioembolic mechanism, in particular cerebro-vascular accidents. To the best of our knowledge, this is the first direct visualization of systemic cardiogenic embolism in takotsubo syndrome. Physicians should be aware that ventricular thrombosis may be present in the earliest stages of the disease and that emboli dislocation can occur even before wall motion normalization.

Endothelial dysfunction in patients with coronary artery disease: insights from a flow-mediated dilation study.

Background: The use of flow-mediated dilation (FMD) as a surrogate indicator for the extent of coronary artery disease (CAD) remains largely unknown. We assessed FMD at the brachial artery in 89 consecutive patients undergoing coronary angiography. Methods and Results: Patients were classified in groups 0 to 3 according to the number of diseased vessels and the SYNTAX score was calculated. The FMD decreased significantly from groups 0 to 3 (P < .001). There was a significant linear relation between SYNTAX score and FMD (corrected r 2 = .64, P < .001). In multivariate analysis, a reduced FMD was the only significant independent predictor of the presence of CAD (odds ratio [OR] 1.78, P = .032) and of CAD severity (OR 1.85, P = .005). Conclusion: This study confirms that FMD is reduced in patients with CAD and that such reduction in FMD is related to the extent of the disease. Therefore, FMD at the brachial artery is likely to represent a reliable indicator of CAD burden.

Coronary spasm and myocardial bridging: an elusive pathophysiological mechanism leading to apical ballooning syndrome?

Apical ballooning syndrome or Takotsubo-like cardiomyopathy is an acute syndrome characterized by normal or near-normal coronary arteries, regional wall motion abnormalities that extend beyond a single coronary vascular bed and, often, a precipitating stressor. We observed a case of an elderly lady with Takotsubo-like left ventricular dysfunction in whom both left anterior descending artery and diagonal branch coronary artery reversible spasm and myocardial bridging were demonstrated at the time of acute cardiac catheterization. It is a common observation that a combination of multiple pathophysiological mechanisms may produce a clinically similar picture. We believe that reversible, yet extreme, spasticity elicited at the level of myocardial bridging and involving a territory beyond a single coronary branch may explain in this case a functional phenomenon, namely the Takotsubo-shaped dysfunction of the left ventricle, which is more commonly observed in women with totally normal coronary arteries after exaggerated sympathetic stimulation.

Impact of vascular access on acute kidney injury after percutaneous coronary intervention

OBJECTIVES We performed a systematic review of the literature and a meta-analysis to examine the role of access site in affecting the incidence of acute kidney injury (AKI) after percutaneous coronary intervention (PCI). BACKGROUND The vascular access site may play a central role among procedure-related risk factors for AKI after PCI. Transradial access is associated with reduced vascular complications and major bleeding which, in turn, is an emerging risk factor for post-procedural AKI. METHODS Results of six observational studies, three out of six providing propensity matching adjustment, of patients undergoing PCI from the radial and the femoral access were pooled, including overall 26,185 patients. The endpoint was the incidence of study-defined AKI. A meta-regression analysis was performed to further assess the role of study-level covariates. Random-effects models were privileged. RESULTS There was a significant difference in the incidence of AKI after PCI, favoring radial access (odds ratio [OR] 0.51, 95% CI 0.39-0.67, p<0.0001), and the effect size was larger in studies including only patients presenting with ST-elevation myocardial infarction (STEMI) (OR 0.42, 95% CI 0.24-0.72, p=0.001). The meta-regression showed a significant relationship between the benefit of radial access and the proportion of STEMI patients (p=0.031) in each of the included studies. CONCLUSIONS Transradial intervention is associated with a reduction in the incidence of AKI after PCI, as compared to the femoral access, and this benefit is more evident in STEMI patients. These findings warrant further confirmation in randomized controlled trials.

Catecholamine-induced stress cardiomyopathies: More similarities than differences

patients [2]. In light of these data, rivaroxaban initiation should be discouraged in transplanted patients with a creatinine clearance b30 ml/min. Moreover, our study suggests that in transplanted patients with moderate renal failure (30 b creatinine clearance b 60 ml/min), a great caution is needed to use rivaroxaban since renal function is frequently unstable and may rapidly worsen during the follow-up [3]. References