Rafael Vázquez

The MUSIC Risk score: a simple method for predicting mortality in ambulatory patients with chronic heart failure.

AIMS The prognosis of chronic heart failure (CHF) is extremely variable, although generally poor. The purpose of this study was to develop prognostic models for CHF patients. METHODS AND RESULTS A cohort of 992 consecutive ambulatory CHF patients was prospectively followed for a median of 44 months. Multivariable Cox models were developed to predict all-cause mortality (n = 267), cardiac mortality (primary end-point, n = 213), pump-failure death (n = 123), and sudden death (n = 90). The four final models included several combinations of the same 10 independent predictors: prior atherosclerotic vascular event, left atrial size >26 mm/m(2), ejection fraction < or =35%, atrial fibrillation, left bundle-branch block or intraventricular conduction delay, non-sustained ventricular tachycardia and frequent ventricular premature beats, estimated glomerular filtration rate <60 mL/min/1.73 m(2), hyponatremia < or =138 mEq/L, NT-proBNP >1.000 ng/L, and troponin-positive. On the basis of Cox models, the MUSIC Risk scores were calculated. A cardiac mortality score >20 points identified a high-risk subgroup with a four-fold cardiac mortality risk. CONCLUSION A simple score with a limited number of non-invasive variables successfully predicted cardiac mortality in a real-life cohort of CHF patients. The use of this model in clinical practice identifies a subgroup of high-risk patients that should be closely managed.

Soluble ST2 for Predicting Sudden Cardiac Death in Patients With Chronic Heart Failure and Left Ventricular Systolic Dysfunction

OBJECTIVES We studied whether the measurement of the soluble form of ST2 (sST2), an interleukin-1 receptor family member, could identify heart failure (HF) patients at risk of sudden cardiac death (SCD). BACKGROUND The prediction of SCD remains an important challenge in patients with mild-to-moderate chronic HF. Concentrations of sST2 have been found increased and related to worse long-term outcomes in patients with acute HF. Whether sST2 has a prognostic role in SCD is unknown. METHODS A nested case-control study was performed on 36 cases of SCD and 63 control patients (matched for age, sex, and left ventricular ejection fraction) obtained from the MUSIC (MUerte Súbita en Insuficiencia Cardíaca) registry, a 3-year multicenter registry of ambulatory HF patients (New York Heart Association functional class II to III, left ventricular ejection fraction < or =45%). Demographic, clinical, echocardiographic, electrical, and biochemical data were collected at enrollment. RESULTS Concentrations of sST2 were greater among decedents (0.23 ng/ml [interquartile range 0.16 to 0.43 ng/ml] vs. 0.12 ng/ml [interquartile range 0.06 to 0.23 ng/ml], p = 0.001) and were predictive of experiencing SCD (+0.1 ng/ml, odds ratio: 1.39, 95% confidence interval: 1.09 to 1.78, p = 0.006). On the basis of a combined biomarker status, only 4% of patients experienced SCD for neither sST2 nor N-terminal pro-B-type natriuretic peptide (NT-proBNP) above receiver-operator characteristic-derived cut-off points (0.15 ng/ml and 2,000 ng/l, respectively), 34% for either biomarker above, and 71% for both biomarkers above (p < 0.001 for trend). This combined variable added incremental prognostic value to the multivariable regression model (p < 0.001). CONCLUSIONS Elevated sST2 concentrations are predictive of SCD in patients with chronic HF and provide complementary information to NT-proBNP levels. A combined biomarker approach may have an impact on clinical decision-making.

Cocaine-related sudden death: a prospective investigation in south-west Spain

AIMS With an estimated 12 million consumers in Europe, cocaine (COC) is the illicit drug leading to the most emergency department visits. The aim of this study was to examine a consecutive series of sudden deaths (SDs) to focus on the prevalence, the toxicological characteristics, and the causes of death in COC-related fatalities. METHODS AND RESULTS Prospective case-control study of forensic autopsies was carried out in the time interval November 2003 to June 2006 at the Institute of Legal Medicine, Seville, south-west Spain, with a reference population of 1 875 462 inhabitants. Toxicology included blood ethanol analysis and blood and urine investigation for drugs of abuse and medical drugs. Autopsy was performed according to the European standardized protocol. Ten age- and sex-matched patients who died of violent causes with no antecedents of COC consumption and negative toxicology served as controls. During the study period, 2477 forensic autopsies were performed, including 1114 natural deaths. Among the latter, 668 fulfilled the criteria of SD and 21 (all males, mean age 34.6 +/- 7.3 years) resulted to be COC-related (3.1%). Cocaine was detected in 67.1% of the blood (median 0.17 mg/L, interquartile range 0.08-0.42) and in 83.0% of the urine samples (median 1.15 mg/L, interquartile range 0.37-17.34). A concomitant use of ethanol was found in 76.0% and cigarette smoking in 81.0%. Causes of SD were cardiovascular in 62.0%, cerebrovascular in 14.0%, excited delirium in 14.0%, respiratory and metabolic in 5.0% each. Left ventricular hypertrophy was observed in 57.0%, small vessels disease in 42.9%, severe atherosclerotic coronary artery disease in 28.6%, and coronary thrombosis in 14.3%. CONCLUSION Systematic toxicology investigation indicates that 3.1% of SDs are COC-related and are mainly due to cardio-cerebrovascular causes. Left ventricular hypertrophy, small vessel disease, and premature coronary artery atherosclerosis, with or without lumen thrombosis, are frequent findings that may account for myocardial ischaemia at risk of cardiac arrest in COC addicts.

Radial compression guided by mean artery pressure versus standard compression with a pneumatic device (RACOMAP).

Background: Transradial access is the approach of choice in many laboratories for diagnostic coronariography or percutaneous coronary interventions (PCI) because of its lower vascular complication rate than the femoral approach. However, this approach has a higher rate (5–10%) of asymptomatic radial artery (RA) occlusion. Methods: We conducted a prospective, controlled, single‐centre trial study. We investigated whether the pneumatic compression (using “TR Band of Terumo®”) of the radial artery guided by the mean artery pressure (MAP) after the procedure (group A) is efficient in reducing radial occlusion in patients under a coronary angiography by transradial access for diagnostic coronariography or PCI compared to use of standard procedure (group B, 15 cm3 of air in the device). Results: The study was suspended after analyzing the results of 50% of the scheduled patients. An analysis of the results of 351 consecutive random patients in Group A showed significantly (P = 0.0001) lower rate (1.1%) of occlusion than Group B (12.0%) without significant differences in the rate of other complications. Other variables associated with RA occlusion in univariate analysis were previous or active smoker (P < 0.04), absence of anti‐aggregant treatment (P < 0.04), and the presence of RA flow postprocedure (PFP, P < 0.001). Independent predictors with logistic regression analysis were PFP (HR = 0.06, 95% CI 0.01–0.2), presence of hematoma (HR = 3.7, 95% CI 1.2–11.0), and standard pneumatic compression in group B patients (HR = 18.8, 95% CI 3.8–92.2). Conclusions: Use of pneumatic compression guided by MAP is safe and efficient, and it can significantly lower the incidence of radial artery occlusion.

Heart rate turbulence predicts all-cause mortality and sudden death in congestive heart failure patients

BACKGROUND Abnormal heart rate turbulence (HRT) has been documented as a strong predictor of total mortality and sudden death in postinfarction patients, but data in patients with congestive heart failure (CHF) are limited. OBJECTIVE The aim of this study was to evaluate the prognostic significance of HRT for predicting mortality in CHF patients in New York Heart Association (NYHA) class II-III. METHODS In 651 CHF patients with sinus rhythm enrolled into the MUSIC (Muerte Subita en Insuficiencia Cardiaca) study, the standard HRT parameters turbulence onset (TO) and slope (TS), as well as HRT categories, were assessed for predicting total mortality and sudden death. RESULTS HRT was analyzable in 607 patients, mean age 63 years (434 male), 50% of ischemic etiology. During a median follow up of 44 months, 129 patients died, 52 from sudden death. Abnormal TS and HRT category 2 (HRT2) were independently associated with increased all-cause mortality (HR: 2.10, CI: 1.41 to 3.12, P <.001 and HR: 2.52, CI: 1.56 to 4.05, P <.001; respectively), sudden death (HR: 2.25, CI: 1.13 to 4.46, P = .021 for HRT2), and death due to heart failure progression (HR: 4.11, CI: 1.84 to 9.19, P <.001 for HRT2) after adjustment for clinical covariates in multivariate analysis. The prognostic value of TS for predicting total mortality was similar in various groups dichotomized by age, gender, NYHA class, left ventricular ejection fraction, and CHF etiology. TS was found to be predictive for total mortality only in patients with QRS > 120 ms. CONCLUSION HRT is a potent risk predictor for both heart failure and arrhythmic death in patients with class II and III CHF.

Specific Characteristics of Sudden Death in a Mediterranean Spanish Population

Most of the data reported on sudden cardiac death has been from studies of Anglo-Saxon patients. We conducted a study to ascertain the relation between sudden death (SD) and some epidemiologic, clinical, and biochemical parameters and to assess the coronary histopathologic aspects of subjects in a Spanish population who had died suddenly. A total of 204 subjects (86% men), aged 12 to 80 years (mean 54 ± 15), who had died from out-of-hospital natural SD were evaluated. Only 15% of subjects had been previously diagnosed with heart disease. Pathologic evidence of underlying cardiovascular disease was found in 90% of cases, with coronary heart disease (CHD) the most frequent (58%). The CHD was acute coronary thrombosis in 41% and a stable plaque with luminal narrowing of ≥75% in 59%. An old myocardial infarction was found in 31% of the SD victims. Cardiac hypertrophy was found in 48%, with no relation between the presence of cardiac hypertrophy and CHD. Patients with stable plaques had a greater heart weight than did those with acute coronary thrombosis (p = 0.02). Male gender, older age, smoking, and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio of ≥3 were associated with CHD. A greater percentage of patients with an eroded and/or ruptured plaque than patients with a stable plaque were smokers. Only smoking and a low-density lipoprotein/high-density lipoprotein cholesterol ratio of ≥3 were associated with an eroded and/or ruptured plaque. In conclusion, compared with the findings from studies of Anglo-Saxon patients, a lower incidence of CHD and acute coronary thrombosis and a greater incidence of cardiac hypertrophy were found in SD victims of a Mediterranean Spanish population.

Left atrial enlargement and NT-proBNP as predictors of sudden cardiac death in patients with heart failure.

The identification of valuable markers of sudden cardiac death (SCD) in patients with established HF remains a challenge. We sought to assess the value of clinical, echocardiographic and biochemical variables to predict SCD in a consecutive cohort of patients with heart failure (HF) due to systolic dysfunction.

Risk Stratification of Mortality in Patients With Heart Failure and Left Ventricular Ejection Fraction >35%

The population of patients with heart failure (HF) and mild to moderate left ventricular (LV) dysfunction is growing, and mortality remains high. There is a need for better risk stratification of patients who might benefit from primary prevention of mortality. This study aimed to evaluate the prognostic value of Holter-based parameters for predicting mortality in patients with HF with LV ejection fraction (EF) >35%. The study involved 294 patients (199 men, mean age 66 years) with HF of ischemic and nonischemic causes, New York Heart Association classes II to III, and LVEF >35%. Surface electrocardiogram and 24-hour Holter monitoring were performed at enrollment to assess traditional electrocardiographic variables, as well as heart rate variability, heart rate turbulence, and repolarization dynamics (QT/RR). Total mortality and sudden death were the primary and secondary end points. During a median 44-month follow-up, there were 43 deaths (15%). None of the traditional electrocardiographic risk parameters significantly predicted mortality. A standard deviation of all normal-to-normal RR intervals < or =86 ms, turbulence slope < or =2.5 ms/RR, and QT end/RR >0.21 at daytime were found to be independent risk predictors of mortality in multivariate analyses. The predictive score based on these 3 variables showed that patients with > or =2 abnormal risk markers were at risk of death (30% 3-year mortality rate) and sudden death (12%), similar to death rates observed in patients with LVEF < or =35%. In conclusion, increased risk of mortality and sudden death could be predicted in patients with HF with LVEF >35% by evaluating the combination of standard deviation of all normal-to-normal RR intervals, turbulence slope, and QT/RR, parameters reflecting autonomic control of the heart, baroreflex sensitivity, and repolarization dynamics.

Prognostic Value of QT/RR Slope in Predicting Mortality in Patients with Congestive Heart Failure

Introduction: Repolarization dynamics, reflecting adaptation of QT to changing heart rate, is considered a marker of unfavorable prognosis in patients with heart diseases. We aimed to evaluate the prognostic value of QT/RR slope in predicting total mortality (TM) and sudden death (SD) in patients with congestive heart failure (CHF).

Predictive Value of Beat-to-Beat QT Variability Index Across the Continuum of Left Ventricular Dysfunction Competing Risks of Noncardiac or Cardiovascular Death and Sudden or Nonsudden Cardiac Death

Background— The goal of the present study was to determine the predictive value of beat-to-beat QT variability in heart failure patients across the continuum of left ventricular dysfunction. Methods and Results— Beat-to-beat QT variability index (QTVI), log-transformed heart rate variance, normalized QT variance, and coherence between heart rate variability and QT variability have been measured at rest during sinus rhythm in 533 participants of the Muerte Subita en Insuficiencia Cardiaca heart failure study (mean age, 63.1±11.7; men, 70.6%; left ventricular ejection fraction >35% in 254 [48%]) and in 181 healthy participants from the Intercity Digital Electrocardiogram Alliance database. During a median of 3.7 years of follow-up, 116 patients died, 52 from sudden cardiac death (SCD). In multivariate competing risk analyses, the highest QTVI quartile was associated with cardiovascular death (subhazard ratio, 1.67 [95% CI, 1.14–2.47]; P=0.009) and, in particular, with non-SCD (subhazard ratio, 2.91 [1.69–5.01]; P<0.001). Elevated QTVI separated 97.5% of healthy individuals from subjects at risk for cardiovascular (subhazard ratio, 1.57 [1.04–2.35]; P=0.031) and non-SCD in multivariate competing risk model (subhazard ratio, 2.58 [1.13–3.78]; P=0.001). No interaction between QTVI and left ventricular ejection fraction was found. QTVI predicted neither noncardiac death (P=0.546) nor SCD (P=0.945). Decreased heart rate variability rather than increased QT variability was the reason for increased QTVI in the present study. Conclusions— Increased QTVI because of depressed heart rate variability predicts cardiovascular mortality and non-SCD but neither SCD nor extracardiac mortality in heart failure across the continuum of left ventricular dysfunction. Abnormally augmented QTVI separates 97.5% of healthy individuals from heart failure patients at risk.