Pedro J. Flores-Blanco

Comparison of Risk Prediction With the CKD-EPI and MDRD Equations in Acute Decompensated Heart Failure

BACKGROUND Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations estimate glomerular filtration rate (eGFR) more accurately than the Modification of Diet in Renal Disease (MDRD) equation. The aim of this study was to evaluate whether CKD-EPI equations based on serum creatinine and/or cystatin C (CysC) predict risk for adverse outcomes more accurately than the MDRD equation in a hospitalized cohort of patients with acute decompensated heart failure (ADHF). METHODS AND RESULTS A total of 526 subjects with ADHF were studied. Blood was collected within 48 hours from admission. eGFR was calculated with the use of MDRD and CKD-EPI equations. The occurrences of mortality and heart failure (HF) hospitalization were recorded. Over the study period (median 365 days [interquartile range 238-370]), 305 patients (58%) died or were rehospitalized for HF. Areas under the receiver operator characteristic curves for CKD-EPI CysC and CKD-EPI creatinine-CysC equations were significantly higher than that for the MDRD equation, especially in patients with >60 mL min(-1) 1.73 m(-2). After multivariate adjustment, all eGFR equations were independent predictors of adverse outcomes (P < .001). However, only CKD-EPI CysC and CKD-EPI creatinine-CysC equations were associated with significant improvement in reclassification analyses (net reclassification improvements 10.8% and 12.5%, respectively). CONCLUSIONS In patients with ADHF, CysC-based CKD-EPI equations were superior to the MDRD equation for predicting mortality and/or HF hospitalization especially in patients with >60 mL min(-1) 1.73 m(-2), and both CKD-EPI equations improved clinical risk stratification.

Comparison of 1-Year Outcome in Patients With Severe Aorta Stenosis Treated Conservatively or by Aortic Valve Replacement or by Percutaneous Transcatheter Aortic Valve Implantation (Data from a Multicenter Spanish Registry)

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p <0.001). The 2 main reasons to choose conservative management were the absence of significant symptoms (136% to 29.1%) and the presence of co-morbidity (128% to 27.4%). During 1-year follow-up, 132 patients died (18.2%). The main causes of death were heart failure (60% to 45.5%) and noncardiac diseases (46% to 34.9%). One-year survival for patients treated conservatively, with TAVI, and with AVR was 76.3%, 94.9%, and 92.5%, respectively, p <0.001. One-year survival of patients treated conservatively in the absence of significant symptoms was 97.1%. In conclusion, most patients with severe AS are treated conservatively. The outcome in asymptomatic patients managed conservatively was acceptable. Management in tertiary hospitals is associated with valve intervention. One-year survival was similar with both interventional strategies.

Cystatin C–based CKD-EPI Equations and N-Terminal Pro-B-Type Natriuretic Peptide for Predicting Outcomes in Acutely Decompensated Heart Failure

In patients with acute decompensated heart failure (ADHF), both natriuretic peptides and renal impairment predict adverse outcomes. Our aim was to evaluate the complementary prognosis role of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) and the newly developed Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equations based on cystatin C (CysC) for glomerular filtration rate (GFR) estimation in ADHF patients.

Comparison between type-2 and type-1 myocardial infarction: clinical features, treatment strategies and outcomes.

Objective To assess the differences in incidence, clinical features, current treatment strategies and outcome in patients with type-2 vs. type-1 acute myocardial infarction (AMI). Methods We included 824 consecutive patients with a diagnosis of type-1 or type-2 AMI. During index hospitalization, clinical features and treatment strategies were collected in detail. At 1-year follow-up, mortality, stroke, non-fatal myocardial infarction and major bleeding were recorded. Results Type-1 AMI was present in 707 (86%) of the cases while 117 (14%) were classified as type-2. Patients with type-2 AMI were more frequently female and had higher co-morbidities such as diabetes, previous non-ST segment elevation acute coronary syndromes, impaired renal function, anaemia, atrial fibrillation and malignancy. However, preserved left ventricular ejection fraction and normal coronary arteries were more frequently seen, an invasive treatment was less common, and anti-platelet medications, statins and beta-blockers were less prescribed in patients with type-2 AMI. At 1-year follow-up, type-2 AMI was associated with a higher crude mortality risk (HR: 1.75, 95% CI: 1.14–2.68; P = 0.001), but this association did not remain significant after multivariable adjustment (P = 0.785). Furthermore, we did not find type-2 AMI to be associated with other clinical outcomes. Conclusions In this real-life population, compared with type-1, type-2 AMI were predominantly women and had more co-morbidities. Invasive treatment strategies and cardioprotective medications were less used in type-2, while the 1-year clinical outcomes were similar.

Comparison of Risk Prediction With the CKD-EPI and MDRD Equations in Non–ST-Segment Elevation Acute Coronary Syndrome

Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equations estimate glomerular filtration rate (GFR) more accurately than the Modification of Diet in Renal Disease (MDRD) equation.

Aortic Valve Stenosis Planimetry by Means of Three-Dimensional Transesophageal Echocardiography in the Real Clinical Setting: Feasibility, Reliability and Systematic Deviations

To assess the feasibility and reliability of aortic valve area (AVA) planimetry by means of three‐dimensional transesophageal echocardiography (3DTEE) as compared with the transthoracic echocardiogram (TTE) calculation of AVA, to determine the systematic deviations between measurements, and to describe the distribution of mean systolic in relation with 3DTEE anatomical AVA.

Impact of Variations in Kidney Function on Nonvitamin K Oral Anticoagulant Dosing in Patients With Atrial Fibrillation and Recent Acute Heart Failure.

INTRODUCTION AND OBJECTIVES Renal impairment and fluctuations in renal function are common in patients recently hospitalized for acute heart failure and in those with atrial fibrillation. The aim of the present study was to evaluate the hypothetical need for dosage adjustment (based on fluctuations in kidney function) of dabigatran, rivaroxaban and apixaban during the first 6 months after hospital discharge in patients with concomitant atrial fibrillation and heart failure. METHODS An observational study was conducted in 162 patients with nonvalvular atrial fibrillation after hospitalization for acute decompensated heart failure who underwent creatinine determinations during follow-up. The hypothetical recommended dosage of dabigatran, rivaroxaban and apixaban according to renal function was determined at discharge. Variations in serum creatinine and creatinine clearance and consequent changes in the recommended dosage of these drugs were identified during 6 months of follow-up. RESULTS Among the overall study population, 44% of patients would have needed dabigatran dosage adjustment during follow-up, 35% would have needed rivaroxaban adjustment, and 29% would have needed apixaban dosage adjustment. A higher proportion of patients with creatinine clearance < 60 mL/min or with advanced age (≥ 75 years) would have needed dosage adjustment during follow-up. CONCLUSIONS The need for dosage adjustment of nonvitamin K oral anticoagulants during follow-up is frequent in patients with atrial fibrillation after acute decompensated heart failure, especially among older patients and those with renal impairment. Further studies are needed to clarify the clinical importance of these needs for drug dosing adjustment and the ideal renal function monitoring regime in heart failure and other subgroups of patients with atrial fibrillation.

Major bleeding risk prediction using Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease equations in acute coronary syndrome

Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equations estimate glomerular filtration rate more accurately than the Modification of Diet in Renal Disease (MDRD) Study equation. Our aim was to evaluate whether CKD‐EPI equations based on serum creatinine and/or cystatin C (CysC) predict risk for major bleeding (MB) more accurately than the MDRD Study equation in patients with non‐ST‐segment elevation acute coronary syndromes (ACS).

Red cell distribution width and additive risk prediction for major bleeding in non-ST-segment elevation acute coronary syndrome.

INTRODUCTION AND OBJECTIVES Red cell distribution width has been linked to an increased risk for in-hospital bleeding in patients with non-ST-segment elevation acute coronary syndrome. However, its usefulness for predicting bleeding complications beyond the hospitalization period remains unknown. Our aim was to evaluate the complementary value of red cell distribution width and the CRUSADE scale to predict long-term bleeding risk in these patients. METHODS Red cell distribution width was measured at admission in 293 patients with non-ST-segment elevation acute coronary syndrome. All patients were clinically followed up and major bleeding events were recorded (defined according to Bleeding Academic Research Consortium Definition criteria). RESULTS During a follow-up of 782 days [interquartile range, 510-1112 days], events occurred in 30 (10.2%) patients. Quartile analyses showed an abrupt increase in major bleedings at the fourth red cell distribution width quartile (> 14.9%; P=.001). After multivariate adjustment, red cell distribution width >14.9% was associated with higher risk of events (hazard ratio=2.67; 95% confidence interval, 1.17-6.10; P=.02). Patients with values ≤ 14.9% and a CRUSADE score ≤ 40 had the lowest events rate, while patients with values >14.9% and a CRUSADE score >40 points (high and very high risk) had the highest rate of bleeding (log rank test, P<.001). Further, the addition of red cell distribution width to the CRUSADE score for the prediction of major bleeding had a significant integrated discrimination improvement of 5.2% (P<.001) and a net reclassification improvement of 10% (P=.001). CONCLUSIONS In non-ST-segment elevation acute coronary syndrome patients, elevated red cell distribution width is predictive of increased major bleeding risk and provides additional information to the CRUSADE scale.

Methods of kidney function assessment in non-valvular atrial fibrillation in the era of new oral anticoagulants

We have readwith great interest the letter by Jolobe OM concerning the importance of kidney function assessment for new oral anticoagulant (NOAC) dosing adjustment [1]. However, we think that there is a lack of consensus on which method should be used for this purpose. Given that the use of different equations frequently result in discordances in estimated glomerular filtration rate (GFR), and consequently in NOAC recommended doses [2,3], we consider that the evaluation of methods that are used for renal function assessment before prescribing NOAC in daily practice could be of clinical interest. In this study, we performed a cross-sectional study based on a survey of Spanish physicians from 17 hospitals and 8 primary care centers. The study population consisted of 642 physicians who participated voluntarily and anonymously. Of them, 489 (76.2%) declared to have previously used NOAC. Among these subjects, there was only one (0.2%) who does not estimate renal function before prescribing NOAC. Fig. 1 shows the different methods of renal function assessment used. The Modification of Diet in Renal Disease Study (MDRD) and Cockcroft–Gault (CG) equations were the most frequently used: 46.6% (n = 228) and 39.1% (n = 191) respectively, while the 24-hour urine creatinine excretion and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) were the less used for this purpose: 3.3% (n = 16) and 1.0% (n = 5) respectively. The results of the present study show that there is a high variability in the methods used for renal function assessment before prescribing NOAC. This variability may be explained in part by the lack of consensus onwhat should be themethodused for this purpose. In fact, theU.S. FDA (Food and Drug Administration) and NKDEP (National Kidney Disease Education Program) suggest that both CG and MDRD equations could be used interchangeably for drug dosing adjustment [4,5], while the European Medicines Agency (EMA) recommends the use of CG equation because phase III clinical trials evaluating NOAC have used this equation [6–8]. Compared to randomized clinical trials setting, we found that MDRD is the most frequently method used for NOAC dosing