Pedro Monteiro

Hemoglobina: um mero valor analítico ou um poderoso preditor de risco em doentes com síndromes coronárias agudas?

INTRODUCTION Anemia has been shown to be associated with a worse prognosis, especially higher mortality in various pathological conditions. However, few studies have specifically examined its impact in acute coronary syndrome (ACS) patients. The purpose of our study was to assess the association between different quartiles of hemoglobin on admission and short- and long-term prognosis in patients with ACS. METHODS We performed a retrospective analysis of 1303 consecutive ACS patients admitted to a coronary care unit and analyzed the association between baseline hemoglobin and morbidity and mortality, in-hospital and at 12-month follow-up. The population was divided into groups according to quartiles of hemoglobin concentration (Hb): Q1: <10.8g/dl; Q2: 10.8-12.2g/dl; Q3: 12.3-13.2g/dl; Q4: ≥13.3g/dl. Logistic regression analysis was used to identify independent predictors of short- and long-term mortality. RESULTS Hypertension and diabetes mellitus were more common in the lower Hb quartiles, while the prevalence of smoking and physical inactivity increased with higher Hb. A higher proportion of patients in the lower quartiles had congestive heart failure, peripheral artery disease and previous stroke or transient ischemic attack. Anemic patients tended to be older, with worse renal function and left ventricular systolic function. Patients in Q1 had significantly higher levels of troponin I and blood glucose on admission. Anemic patients showed significantly higher in-hospital mortality (Q1: 9.8%; Q2: 6.3%; Q3: 4.1%; Q4: 3.6%, p<0.001), longer hospital stay (Q1: 6.1±4.4; Q2: 5.2±3.0; Q3: 4.9±2.7; Q4 4.3±2.1 days, p<0.001) and higher 1-year mortality (Q1: 23.6%; Q2: 11.6%; Q3: 10.6%; Q4: 5.5%, p<0.001). In multivariate analysis, the only independent predictor of in-hospital mortality was Killip class >1 at admission. The independent predictors of long-term mortality were age ≥69.5 years, Killip class >1 at admission, diabetes mellitus, ST-segment depression on admission ECG and Hb <10.8g/dl. DISCUSSION AND CONCLUSIONS Low baseline hemoglobin is associated with more comorbidities and can accurately predict 1-year mortality after an acute coronary syndrome.

CYP2C19*2 and prognosis after an acute coronary syndrome, Insights from a Portuguese center

BACKGROUND Clopidogrel requires oxidation dependent on the cytochrome P450 enzyme 2C19 (CYP2C19) to form its active metabolite. The importance of loss-of-function alleles (particularly CYP2C19*2, 681G>A) in poor platelet response to clopidogrel is well recognized. OBJECTIVE To investigate the prevalence and prognostic impact of the CYP2C19*2 allele in a local acute coronary syndrome (ACS) population. METHODS We performed a prospective, longitudinal study of 95 patients admitted for an ACS between March and October 2009 to a single coronary care unit. Patients aged under 75 who survived hospital stay and for whom clopidogrel was prescribed were included. At discharge, CYP2C19 was genotyped using a commercially available kit. Patients were divided into two groups: Group A (non-carriers, normal metabolizers, CYP2C19*1/*1), n=69; and Group B (carriers, slow metabolizers, CYP2C19*2/*1 or *2/*2), n=26. The primary endpoint was a combined outcome of cardiovascular death, non-fatal myocardial infarction or re-admission for unstable angina; median follow-up was 136.0 (79.0-188.0) days. RESULTS The median age of the population was 62.0 (51.0-68.0) years, and 83.2% were male. The CYP2C19*2 (A) allele had a frequency of 14.2%. There were no differences between the groups with respect to demographic data or history of cardiovascular disease. Coronary anatomy, left ventricular ejection fraction and renal function were also similar. The groups were also homogenous with respect to GRACE risk score (118.0 (95.0-136.5) vs. 115.0 (96.0-133.0), p=0.68), medical treatment and percutaneous revascularization during hospital stay. Event-free survival was higher for Group A (94.0% vs. 75.0%, log-rank p=0.010). Three readmissions for MI were documented, all in the slow metabolizers group. CONCLUSION In our ACS population, the CYP2C19*2 allele was a medium-term prognostic marker.

Implicações prognósticas da pressão telediastólica do ventrículo esquerdo nas síndromes coronárias agudas com fracção de ejecção maior ou igual a 40

INTRODUCTION There is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS). OBJECTIVE To assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%. METHODS We performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were excluded (n=489). The population was divided into three groups: A - LVEDP ≤19 mmHg (n=186); B - LVEDP >19 and ≤27 mmHg (n=172); and C - LVEDP >27 mmHg (n=131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission. RESULTS Mean LVEDP was 22.8±7.8 mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p<0.01), higher peak levels of cardiac biomarkers, and lower LVEF (56.5±7.0 vs. 55.3±7.6 vs. 53.0±7.5%, p<0.01). There were no significant differences between the groups in terms of coronary anatomy, medical therapy during hospital stay and at discharge, or in-hospital mortality. With regard to the primary endpoint, cumulative freedom from congestive heart failure was higher in group A patients (99.4 vs. 97.6 vs. 94.4%, log rank p=0.02). In a multivariate Cox regression model, a 5-mmHg increase in LVEDP (HR 1.97, 95% CI 1.10-3.54, p=0.02) remained an independent predictor of the primary endpoint when adjusted for age, systolic function, atrial fibrillation, peak troponin I, renal function, and prescription of diuretics and beta-blockers. CONCLUSION In selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.