Pablo Peñafiel

Utilidad de la prueba de troponina T de alta sensibilidad en la detección de rechazo agudo en trasplante cardiaco

INTRODUCTION AND OBJECTIVES Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. METHODS We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). RESULTS In all samples, highly sensitive troponin T was detectable, with a median of 0.068 ng/L (IQR, 0.030-0.300 ng/L). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=-0.81; P<.001). The highly sensitive troponin T concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). CONCLUSIONS Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period.

An atypical presentation of Tako-Tsubo cardiomyopathy

We present the case of a patient with Tako-Tsubo cardiomyopathy whose initial diagnosis, based on the location of shoulder and chest pain and electrocardiographic (ECG) changes, suggested that she was suffering from pericarditis. However, 24 h after admission, evolutionary changes of ECG and the echocardiogram performed suggested a Tako-Tsubo cardiomyopathy. In this context, we review the literature to discuss the clinical presentation and evolutionary ECG changes associated with Tako-Tsubo cardiomyopathy.

The Frequency of Systolic Aortic Regurgitation and Its Relationship to Heart Failure in a Consecutive Series of Patients

Although aortic regurgitation is a diastolic phenomenon, it has been observed during systole in a few cases. Our aims were to determine the incidence of systolic aortic regurgitation in routine clinical practice and to investigate the clinical profiles of patients with the condition. An exhaustive prospective study of all investigations performed by a hospital echocardiographic unit over one month was carried out. Systolic aortic regurgitation was detected in five out of a total of 216 investigations (2.3%). In all cases, the patient had some degree of heart failure. Overall, the condition was present in 5.9% of patients with heart failure. In one patient with atrial fibrillation, systolic aortic regurgitation disappeared and the patients clinical status improved after atrioventricular node modulation using a cryoablation catheter. Systolic aortic regurgitation was not an exceptional occurrence in hospitalized patients. Moreover, it tended to be specifically associated with heart failure.

Comparative determination and monitoring of biomarkers of necrosis and myocardial remodeling between radiofrequency ablation and cryoablation.

Biomarkers of necrosis and inflammation have been found raised after radiofrequency ablation (RF). There is scarce information on biomarkers’ behavior after cryoablation. Our aim was to study biomarkers of necrosis, inflammation, and interstitial remodeling after two different approaches: RF versus cryoablation.

Frecuencia de la insuficiencia aórtica sistólica y su relación con la insuficiencia cardiaca en una serie consecutiva de pacientes

La insuficiencia aortica es un fenomeno diastolico, aunque ha sido descrita durante la sistole en casos aislados. Nos propusimos evaluar la incidencia en la practica habitual del fenomeno de insuficiencia aortica sistolica y el tipo de pacientes en que se presenta. Inclusion exhaustiva y prospectiva de todos los estudios realizados durante 1 mes en una agenda de ecocardiografia hospitalaria. Detectamos 5 casos de insuficiencia aortica sistolica en un total de 216 estudios (2,3%). En todos los casos los pacientes tenian insuficiencia cardiaca de algun grado. El fenomeno estaba presente en el 5,9% de los pacientes ingresados con insuficiencia cardiaca. En un paciente con fibrilacion auricular la insuficiencia aortica sistolica desaparecio y el estado clinico mejoro tras la modulacion del nodo auriculoventricular con cateter de crioablacion. La insuficiencia aortica sistolica no se presenta de forma excepcional en los pacientes ingresados y muestra cierta especificidad para la insuficiencia cardiaca.

Valor pronóstico del BNP y la prueba de esfuerzo cardiopulmonar en la insuficiencia cardiaca sistólica en tratamiento con bloqueadores beta

Introduccion y objetivos En pacientes con insuficiencia cardiaca y tratamiento con bloqueadores beta, el valor pronostico a largo plazo del peptido natriuretico tipo B (BNP) y la prueba de esfuerzo cardiopulmonar no esta bien establecido. Metodos Se estudio a 80 pacientes ambulatorios con insuficiencia cardiaca estable (el 78% varones; media de edad, 50 ± 11 anos), disfuncion ventricular severa (FEVI, 25% ± 9%), deterioro funcional intermedio (NYHA, 2,4 ± 0,6) y tratamiento optimizado que incluyera bloqueadores beta. Se midio el BNP (pg/ml) y se realizo una prueba de esfuerzo cardiopulmonar, en la que se midio el consumo maximo de oxigeno (VO2max) y la ineficiencia ventilatoria (pendiente VE/VCO2). El seguimiento fue de 2,7 ± 0,8 anos y se estudio la muerte cardiovascular, el trasplante y el ingreso hospitalario por insuficiencia cardiaca. Resultados La concentracion de BNP y la pendiente VE/VCO2 fueron mayores en los pacientes que fallecieron (n = 7) (211 [51-266] contra 46 [16-105], p = 0,017; 39 ± 3 contra 33,8 ± 5,5, p = 0,018) o presentaron cualquier evento adverso (n = 19) (139 [88-286] contra 40 [13-81], p 102 pg/ml (p = 0,002; hazard ratio [HR] = 5,2; intervalo de confianza [IC] del 95%, 1,8-14,8) y la pendiente VE/VCO2>35 (p = 0,012; HR = 4,3; IC del 95%, 1,4-13,2) fueron los mejores predictores de complicaciones. En presencia de ninguno, alguno o ambos predictores, la incidencia acumulada de eventos a 36 meses fue del 2, el 25 y el 63% respectivamente (log rank Conclusiones En pacientes con insuficiencia cardiaca, deterioro funcional intermedio y tratamiento optimizado con bloqueadores beta, la persistencia de un BNP elevado (> 102 pg/ml) y la ineficiencia ventilatoria (pendiente VE/VCO2 > 35) identifican a los pacientes con peor pronostico a largo plazo.

Prognostic Value of BNP and Cardiopulmonary Exercise Testing in Patients With Systolic Heart Failure on Beta-Blocker Therapy

INTRODUCTION AND OBJECTIVES The long-term prognostic value of the B-type natriuretic peptide (BNP) level and cardiopulmonary exercise testing in patients with heart failure (HF) who are receiving beta-blocker therapy is not well established. METHODS The study involved 80 outpatients (78% male, age 50 [11] years) with stable HF, severe systolic dysfunction (left ventricular ejection fraction 25 [9]%), and intermediate functional impairment (New York Heart Association functional class 2.4 [0.6]) who were receiving optimum therapy, including beta-blockers. Their BNP levels (pg/mL) were measured and cardiopulmonary exercise testing was carried out to determine maximal oxygen uptake (VO2max) and ventilatory efficiency (VE/VCO2 slope). Patients were followed up for 2.7 (0.8) years. The study endpoints were cardiovascular death, heart transplantation, and HF hospitalization. RESULTS The BNP level and VE/VCO2 slope were greater in patients who died (n=7), at 211 pg/mL (51-266 pg/mL) vs. 46 pg/mL (16-105 pg/mL) (P=.017) and 39 (3) vs. 33.8 (5.5) (P=.018), respectively, or who had an adverse event (n=19), at 139 pg/mL (88-286 pg/mL) vs. 40 pg/mL (13-81 pg/mL) (P< .001) and 38.7 (4.3) vs. 32.9 (5.2) (P< .001), respectively. Only the combined endpoint was associated with a significant difference in VO2max (19.7 [5.4] vs. 16.8 [3.9] mL/kg per min, P=.016). On multivariate analysis, BNP >102 pg/mL (P=.002; hazard ratio [HR]=5.2; 95% confidence interval [CI], 1.8-14.8) and VE/VCO2 slope >35 (P=.012; HR =4.3; 95% CI, 1.4-13.2) were the best predictors of an adverse event. In patients who satisfied neither, one or both criteria, 36-month cumulative adverse event rates were 2%, 25% and 63%, respectively (log rank, P< .001). CONCLUSIONS In ambulatory HF patients with intermediate functional impairment who are receiving optimum beta-blocker therapy, the persistence of a high BNP level (>102 pg/mL) combined with poor ventilatory efficiency (VE/VCO2 slope >35) identify those with a poor long-term prognosis.