Paola Attanà

The Impact of Hypertension on Patients with Acute Coronary Syndromes

Arterial chronic hypertension (HTN) is a well-known cardiovascular risk factor for development of atherosclerosis. In order to explain the relation between HTN and acute coronary syndromes the following factors should be considered: (1) risk factors are shared by the diseases, such as genetic risk, insulin resistance, sympathetic hyperactivity, and vasoactive substances (i.e., angiotensin II); (2) hypertension is associated with the development of atherosclerosis (which in turn contributes to progression of myocardial infarction). From all the registries and the data available up to now, hypertensive patients with ACS are more likely to be older, female, of nonwhite ethnicity, and having a higher prevalence of comorbidities. Data on the prognostic role of a preexisting hypertensive state in ACS patients are so far contrasting. The aim of the present paper is to focus on hypertensive patients with ACS, in order to better elucidate whether these patients are at higher risk and deserve a tailored approach for management and followup.

Lactate clearance in cardiogenic shock following ST elevation myocardial infarction: A pilot study

Background: Recent studies documented that serial lactate measurements over time may be clinically more reliable than lactate absolute value for risk stratification. The aim of the present investigation was to assess the role of lactate clearance in predicting early death in cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). Methods: 51 consecutive patients with CS following STEMI were prospectively enrolled. Lactate was measured in Intensive Cardiac Care Unit (ICCU) on admission and on the twelfth hour. Logistic regression analysis was performed to identify the independent predictors for in-ICCU mortality. Receiver operating characteristic (ROC) curve was constructed in order to identify cut-off for admission lactate and for 12-h lactate clearance in relation to in-ICCU mortality. Follow-up survival rate were investigated by Kaplan–Meier curves. Results: At 12 h from admission, lactate clearance was higher in survivors (P = 0.013). A higher in-ICCU mortality was observed in patients with 12 hours lactate clearance < 10% (P = 0.002). At follow up, patients with 12-h lactate clearance < 10% showed a significantly lower survival rate. Conclusions: In patients with CS following STEMI, 12-h lactate clearance < 10% identifies a subset of patients at higher risk for death at short and long-term.

Lactate and lactate clearance in acute cardiac care patients

Hyperlactataemia is commonly used as a diagnostic and prognostic tool in intensive care settings. Recent studies documented that serial lactate measurements over time (or lactate clearance), may be clinically more reliable than lactate absolute value for risk stratification in different pathological conditions. While the negative prognostic role of hyperlactataemia in several critical ill diseases (such as sepsis and trauma) is well established, data in patients with acute cardiac conditions (i.e. acute coronary syndromes) are scarce and controversial. The present paper provides an overview of the current available evidence on the clinical role of lactic acid levels and lactate clearance in acute cardiac settings (acute coronary syndromes, cardiogenic shock, cardiac surgery), focusing on its prognostic role.

Hyperglycemia, acute insulin resistance, and renal dysfunction in the early phase of ST-elevation myocardial infarction without previously known diabetes: impact on long-term prognosis

We evaluated the relationship between admission renal function (as assessed by estimated glomerular filtration rate (eGFR)), hyperglycemia, and acute insulin resistance, indicated by the homeostatic model assessment (HOMA) index, and their impact on long-term prognosis in 825 consecutive patients with ST-elevation myocardial infarction (STEMI) without previously known diabetes who underwent primary percutaneous coronary intervention (PCI). Admission eGFR showed a significant indirect correlation with admission glycemia (Spearman’s ρ −0.23, P < 0.001) and insulin values (Spearman’s ρ −0.11, P = 0.002). The incidence of patients with admission glycemia ≥140 mg/dl was significantly higher in patients with eGFR <60 ml/min/m2 (P < 0.001) as well as the incidence of HOMA positivity (P = 0.002). According to our data, a relationship between renal function and glucose values and acute insulin resistance in the early phase of STEMI was detectable, since a significant, indirect correlation between eGFR, insulin values, and glycemia was observed. Patients with renal dysfunction (eGFR <60 ml/min/1.73 m2) exhibited higher glucose values and a higher incidence of acute insulin resistance (as assessed by HOMA index) than those with normal renal function (eGFR ≥60 ml/min/1.73 m2). The prognostic role of glucose values for 1-year mortality was confined to patients with eGFR ≥60 ml/min/m2, who represent the large part of our population and are thought to be at lower risk. In these patients, an independent relationship between 1-year mortality and glucose values was detectable not only for admission glycemia but also for glucose values measured at discharge.

Echocardiographic and biohumoral characteristics in patients with AL and TTR amyloidosis at diagnosis

Few studies have analyzed the clinical and echocardiographic differences between light‐chain (AL) and transthyretin (TTR) amyloidosis.

The prognostic role of chronic obstructive pulmonary disease in ST-elevation myocardial infarction after primary angioplasty.

Background: Chronic obstructive pulmonary disease (COPD) has been reported as a common finding in patients with acute myocardial infarction but data on its prognostic role are still controversial. Methods: The present investigation was aimed at assessing the impact of COPD at short and long terms in 818 consecutive patients with ST-elevation myocardial infarction all submitted to percutaneous coronary intervention. Results: Patients with COPD were older (p < 0.001) and more frequently smokers (p = 0.019). They showed a reduced estimated glomerular filtration rate (eGFR; p = 0.004) and a higher incidence of a more advanced coronary artery disease (p = 0.004). Patients with COPD showed higher values of N-terminal pro-brain natriuretic peptide (p = 0.004), uric acid (p = 0.005), erythrocyte sedimentation rate (p = 0.002), fibrinogen (p = 0.004), and C-reactive protein positivity (p = 0.017). Kaplan−Meier survival curve documented a significantly worse outcome in COPD patients. When age was taken into account, COPD patients aged <75 years showed a significantly worse outcome at follow up when compared to non-COPD patients aged <75 years. At multivariate analysis, the following variables were independent predictors for death at follow up: age, eGFR, COPD, and discharge left ventricular ejection fraction. Conclusions: In our series, while the presence of COPD was not significantly associated with an increased early mortality, COPD is an independent predictor of long-term mortality. In particular, long-term survival was significantly poorer in COPD patients <75 years in respect to non-COPD patients with the same age. Our data strongly suggest that age should be taken into account in the risk stratification of COPD patients with ST-elevation myocardial infarction.

Kinetics of procalcitonin in cardiogenic shock and in septic shock. Preliminary data

Abstract Background: In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No data are so far available on the dynamics of PCT levels in patients with cardiogenic shock. Aims: to evaluate the serum evolution of PCT during intensive cardiac care unit (ICCU) staying in a group of 24 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) with no laboratory or clinical sign of infection. Furthermore we assessed the kinetics of PCT in a series of 24 patients with septic shock. Results: In septic shock, no significant difference was detectable in PCT kinetics between survivors (R2 = 0.90; P = 0.051) and non-survivors (R2 = 0.63; P = 0.204). In cardiogenic shock, survivors exhibited a significant reduction in PCT values (R2 = 0.94; P = 0.032) while non survivors did not (R2 = 0.68; P = 0.178). Conclusions: differently from septic shock, cardiogenic shock following STEMI was associated with heterogeneous patterns of temporal PCT variations since only patients who survived exhibited a significant PCT reduction during ICCU stay. Our findings support the contention that the ‘dynamic’ approach may be more reliable that the static one especially in cardiogenic shock.

Mechanical ventilation in the early phase of ST elevation myocardial infarction treated with mechanical revascularization

BACKGROUND So far, few data have been available on the incidence and outcome of patients with acute myocardial infarction (MI) requiring mechanical ventilation (MV). The aim of the study was to assess the clinical and prognostic impact of MV at short and long term in 106 patients with ST elevation MI (STEMI) requiring mechanical ventilation. RESULTS The incidence of mechanical ventilation was 7.6%. Reasons for intubation were as follows: cardiogenic shock in 64 (60.4%) patients, ventricular fibrillation in 32 (30.1%) patients and acute pulmonary edema in 10 (9.5%) patients. Patients submitted to MV were older (p = 0.016), more frequently had a previous percutaneous coronary intervention (PCI;p = 0.014) and a previous MI (p = 0.001). A higher in-Intensive Cardiac Care Unit death was observed in MV patients (44.3% vs. 1.5%, p < 0.001), as well as a higher mortality at follow-up (36.7% vs. 14.8%, p < 0.001). MV was associated with higher mortality rates both at short and long term. CONCLUSIONS In a large series of consecutive STEMI patients submitted to MV, the need of MV is a strong prognostic indicator of mortality both at short and long term. Among mechanically ventilated STEMI patients infarct size (as inferred by TnI values) and PCI failure were independent predictors of early death, while the duration of MV was related to death at longterm.

Glycated hemoglobin in ST-elevation myocardial infarction without previously known diabetes: Its short and long term prognostic role

In 518 consecutive STEMI non-diabetic patients, glycated hemoglobin>6.5% was not associated with increased short and long term mortality, but was associated with higher admission glucose values, worse in-hospital glycemic control and a higher incidence of acute insulin resistance (HOMA index).

The prognostic impact of glycated hemoglobin in diabetic ST-elevation myocardial infarction☆

[1] Lavie P, Lavie L. Cardiovascular morbidity and mortality in obstructive sleep apnea. Curr Pharm Des 2008;14:3466–73. [2] Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth Sleepiness Scale Chest 1993;103:30–6. [3] Chica-Urzola HL, Escobar-Cordoba F, Eslava-Schmalbach J. Validating the Epworth sleepiness scale. Rev Salud Publica 2007;9:558–67. [4] Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of sleep medicine task force, 22. Sleep; 1999. p. 667–89.