Rodolfo Pizarro

Independent Prognostic Value of Elevated C-Reactive Protein in Unstable Angina

BACKGROUND There is growing evidence of the prognostic importance of C-reactive protein (CRP) in unstable angina. However, the independent value of CRP relative to other conventional markers at different stages of treatment has not been established. Therefore, we assessed the in-hospital and 90-day prognostic values of serum CRP in unstable angina. We also compared the relation of CRP at admission and discharge with 90-day outcome. METHODS AND RESULTS One hundred ninety-four consecutive patients were included in a derivation (n = 105) and a validation set (n = 89). Serum CRP was measured at admission, at 48 hours, and at hospital discharge. A cutoff point of 1.5 mg/dL for CRP provided optimum sensitivity and specificity for adverse outcome, based on the receiver operator curves. No association was found between CRP on admission and in-hospital outcome. CRP at admission, adjusted for age, ECG findings on admission, silent ischemia, left ventricular wall motion score, and high-risk clinical presentation, was related to the combined end point of refractory angina, myocardial infarction, or death at 90 days (hazard ratio [HR] 1.9, 95% CI 1.2 to 8.3, P = 0.002). CRP at hospital discharge was the strongest independent marker of an adverse outcome (HR 3.16, 95% CI 2.0 to 5.2, P = 0.0001). These results were confirmed in the validation set (CRP at discharge: HR 3. 3, 95% CI 2.0 to 7.69, P = 0.0001). CONCLUSIONS In unstable angina, CRP is a strong independent marker of increased 90-day risk. Compared with CRP at admission, CRP at discharge is better related to later outcome and could be of great utility for risk stratification.

Prospective Validation of the Prognostic Usefulness of Brain Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Mitral Regurgitation

OBJECTIVES The purpose of the study was to determine the independent and additive prognostic value of brain natriuretic peptide (BNP) in patients with severe asymptomatic mitral regurgitation and normal left ventricular function. BACKGROUND Early surgery could be advisable in selected patients with chronic severe mitral regurgitation, but there are no criteria to identify candidates who could benefit from this strategy. Assessment of BNP has not been studied in asymptomatic patients with severe mitral regurgitation; hence, its prognostic value remains unclear. METHODS We prospectively evaluated 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%. The first 167 consecutive patients served as the derivation cohort, and the following 102 patients served as a validation cohort. The combined end point was the occurrence of either symptoms of congestive heart failure, left ventricular dysfunction, or death at follow-up. RESULTS The end point was reached in 35 (21%) patients of the derivation set and in 21 (20.6%) patients of the validation cohort. The receiver-operating characteristics curve yielded an optimal cutoff point of 105 pg/ml of BNP that was able to discriminate patients at higher risk in both cohorts (76% vs. 5.4% and 66% vs. 4.0%, respectively). In both sets, BNP was the strongest independent predictor by multivariate analysis. CONCLUSIONS Among patients with severe asymptomatic organic mitral regurgitation, BNP > or =105 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, BNP assessment should be considered in clinical routine workup for risk stratification.

C-reactive protein and the stress tests for the risk stratification of patients recovering from unstable angina pectoris.

We assessed the 90-day prognostic value of stress tests and C-reactive protein (CRP) after medical stabilization of unstable angina. We included 139 consecutive patients with unstable angina who were free of complications or did not undergo revascularization during hospitalization. Blinded CRP assays and a stress test (95 exercise electrocardiograms, 44 dobutamine echocardiograms) were performed within the first week after discharge. Of 139 participants, 44 (31.6%) had an ischemic stress test response. CRP was elevated (> 1.5 mg/dl) in 40 patients (28.7%). CRP >1.5 mg/dl was more frequently observed among patients who experienced death or myocardial infarction at 90 days (88.2% vs 20.5%, p <0.0001). Compared with the stress tests, CRP showed greater sensitivity (88% vs 47%) and specificity (81% vs 70%) for increased risk, and higher positive (37.5% vs 18.2%) and negative (98% vs 90%) predictive values. The area under the receiver operating curve of the relation with the 90-day outcome increased from 0.58 +/- 0.07 to 0.83 +/- 0.05 when the CRP data were added to the stress tests results (p <0.001). Elevation of CRP differentiated stress tests negative patients with increased risk of major events during follow-up. In patients who respond to medical treatment for unstable angina, CRP elevation may be a better parameter than the stress test in identifying the presence of persistent plaque instability.

Dobutamine-Precipitated Takotsubo Cardiomyopathy Mimicking Acute Myocardial Infarction A Multimodality Image Approach

A 77-year-old woman was referred for a dobutamine stress test. She had a prior history of hypertension. Basal ECG was normal (Figure 1A). At 40 μg · kg−1 · min−1 she developed typical chest pain with ST-segment elevation in DI, DII, and the anterior leads with ventricular bigeminy (Figure 1B and 1C). The echocardiogram showed apical and mid-wall myocardial segment akinesis with basal hyperkinesis and left outflow tract gradient obstruction of 60 mm Hg. The …

Prognostic Value of Left Atrial Volume in Asymptomatic Organic Mitral Regurgitation

BACKGROUND Basal left atrial volume (LAV) indexed to body surface area (LAVI) predicts adverse events in patients with organic mitral regurgitation, but information is lacking regarding change in left atrial volume during follow-up. METHODS One hundred forty-four asymptomatic patients (mean age, 71 ± 12 years; 66% women; mean ejection fraction, 66 ± 4.8%) with moderate to severe mitral regurgitation were prospectively included, with a median follow-up period of 2.76 years (interquartile range, 1.86-3.48 years). RESULTS Fifty-four patients (37.50%) reached the combined end point of dyspnea and/or systolic dysfunction. Both basal and change in LAV were independently associated with the combined end point on multivariate analysis: for basal LAVI ≥ 55 mL/m(2), odds ratio, 2.26 (95% confidence interval, 1.04-4.88; P = .038), and for change in LAV ≥ 14 mL, odds ratio, 7.32 (95% confidence interval, 3.25-16.48; P < .001), adjusted for effective regurgitant orifice area and deceleration time. Combined event-free survival at 1, 2, and 3 years was significantly less in patients with basal LAVI ≥ 55 mL/m(2) (75%, 58%, and 43%) than in those with basal LAVI < 55 mL/m(2) (95%, 89%, and 77%) (log-rank test = 15.38, P = .0001). The incidence of the combined end point was highest (88%) in patients with basal LAVI ≥ 55 mL/m(2) and change in LAV ≥ 14 mL. CONCLUSIONS Measurement of basal LAV and its increase during follow-up predict an adverse course in patients with moderate and severe asymptomatic mitral regurgitation. Hence, its assessment could be incorporated into the currently used algorithm for risk stratification and decision making in this group of patients.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of survival after heart transplantation: NLR and PLR after heart transplantation

The aim of this study was to evaluate whether neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) predict outcome in heart failure (HF) patients undergoing heart transplantation (HTX).

Assessment of fractional excretion of urea for early diagnosis of cardiac surgery associated acute kidney injury

Abstract Background: Acute kidney injury (AKI) is a common complication after cardiac surgery (CS). Recently, neutrophil gelatinase-associated lipocalin (NGAL) was shown to predict AKI development earlier than serum creatinine, but it is not widely used in clinical practice. Fractional excretion of urea (FeU) has been referred to as a useful tool to discriminate between prerenal and established AKI. The aim of our study is to evaluate the sensitivity and specificity of FeU, in the early diagnosis of AKI in patients undergoing CS. Methods: We performed a prospective study on adults undergoing CS. AKI was defined by AKIN criteria. Individuals suffering from CKD, were excluded. Sensitivity and specificity of FeU, fractional excretion of sodium (FeNa) and urine NGAL, measured at 1, 6 and 24 h following CS, were assessed. Results: We included 66 patients (26% female) aging 68 ± 11 years. AKI prevalence was 24% and mortality was 3.28%. Patients with AKI had a significantly lower FeU compared to those without AKI (23.89 ± 0.67% vs. 34.22 ± 0.58%; p < 0.05) 6 h after CS, but not at the 1- and 24-h time points. NGAL was also statistically significant between both groups. FeU showed a 75% sensitivity and 79.5% specificity; the AUC was 0.786. ROC analysis of FeU and NGAL yielded similar values (p = NS). Conclusion: FeU is useful as an early biomarker to predict AKI after CS and it is comparable to the new biomarker NGAL.

Factores determinantes de una baja dosis de hemodiálisis establecida por dialisancia iónica en pacientes críticos con insuficiencia renal aguda

BACKGROUND Estimating the dialysis dose is a requirement commonly used to assess the quality of renal replacement therapy (RRT) in patients with chronic kidney disease (CKD). In patients with acute kidney injury (AKI), this value is not always evaluated and it has been estimated that the prescribed dose is seldom obtained. Reports addressing this issue in AKI individuals are scarce and most have not included an adequate number of patients or treatments, nor were patients treated with extended therapies. Kt values obtained by the ionic dialysance method have been validated for the evaluation of the dialysis dose and it has also been shown that, compared with Kt/V, this is the most sensitive strategy for revealing inadequate dialysis treatment in critically ill AKI individuals. The main aim of this study was to assess the difference between the prescribed and the administered dialysis dose in critically ill AKI patients, and to evaluate what factors determine this gap using Kt values assessed through ionic dialisance. MATERIAL AND METHOD Data from 394 sessions of renal replacement therapy in 105 adult haemodialysis (HD) patients with oliguric acute kidney injury and admitted to ICU were included in this analysis. RRT was carried out with Fresenius 4008E dialysis machines equipped with on-line clearance monitoring (OCM® Fresenius), which use non-invasive techniques to monitor the effective ionic dialysance, equivalent to urea clearance. The baseline characteristics of the study population as well as the prescription and outcome of RRT were analysed. These variables were included in a multivariate model in which the dependent variable was the failure to obtain the threshold dose (TD). RESULTS The main baseline characteristics of the study population/treatments were: age 66 ± 15 years, 37% female, most frequent cause of AKI: sepsis (70%). Low BP and/or vasoactive drug requirement (71%), mechanical ventilation (70%) and average individual severity index: 0.7 ± 0.26. Two hundred and one intermittent HD (IHD) and 193 extended HD (EHD) sessions were performed; the most frequently used temporary vascular access was the femoral vein catheter (79%). Prescribed Kt was 53.5 ± 14L and 21% of prescriptions fell below the TD. Sixty-one percent of treatments did not fulfill the TD (31 ± 8L) compared with 56 ± 12L obtained in the subgroup that achieved the target. Compared to IHD, EHD provided a significantly larger Kt (46 ± 16L vs 33L ± 9L). Univariate analysis showed that inadequate compliance was associated with age (>65y), male gender, intra-dialytic hypotension, low Qb, catheter line reversal, and IHD. The same variables with the exception of age and gender were independently associated in the multivariate analysis. CONCLUSIONS The dialysis dose obtained was significantly lower than that prescribed. EHD achieved values closer to the prescribed KT and significantly higher than in IHD. Ionic Kt measurement facilitates monitoring and allows HD treatments to be extended based upon a previously established TD. Besides the chosen strategy to dispense the dose of dialysis, a well-functioning vascular access allowing for optimal blood flow and other approaches aimed at avoiding hemodynamic instability during RRT are the most important factors to achieve TD, mainly in elderly male patients. The dialysis dose should be prescribed and monitored for all critically ill AKI patients.

Validación de un instrumento para la evaluación de la interpretación de los resultados de estudios de investigación en los residentes de un hospital universitario.

La informacion medica que hoy en dia se publica en revistas de interes cientifico es abundante. En este contexto, la habilidad para interpretar criticamente los estudios de investigacion resulta ser esencial con el objeto de ofrecer a los pacientes una atencion medica de alta calidad [1,2]. Evaluar adecuadamente lo relevante de esta informacion requiere que el medico sea capaz de reconocer los distintos disenos de investigacion, interpretar las pruebas estadisticas mas frecuentemente utilizadas y comprender como se informan los resultados. Un estudio [1] realizado en 11 programas de residencias de Medicina Interna en Connecticut (EE. UU.) y otro en Dinamarca [3], ambos utilizando una prueba de eleccion de opciones multiples, han demostrado que los medicos sin entrenamiento formal en epidemiologia y estadistica presentaban una pobre comprension de las pruebas estadisticas mas utilizadas y una interpretacion limitada de los resultados de las investigaciones. Solo el 21% de los medicos era capaz de analizar correctamente los articulos de investigacion presentados. A partir de estos estudios y de una encuesta realizada a los directores de programa de residencias en EE. UU. [4] surge una fuerte recomendacion de tener en cuenta un entrenamiento mas efectivo en este campo en el diseno de los programas de formacion del medico residente. En este escenario nos hemos propuesto desarrollar y validar un instrumento que permita conoValidacion de un instrumento para la evaluacion de la interpretacion de los resultados de estudios de investigacion en los residentes de un hospital universitario

Hypertrophic Cardiomyopathy, All Phenotypes in one

Hypertrophic cardiomyopathy (HCM) is an intrinsic myocardial disorder characterized by cardiac hypertrophy (wall thickness ≥ 15 mm), that is not explained by conditions of pressure overload (eg, hypertension, severe aortic stenosis).1 HCM is the most common genetic primary cardiomyopathy, with a prevalence estimated to be about one in 500 adults in the general population.2 More than 450 mutations have been identified in the 20 genes that cause different phenotypes. In most cases, HCM is associated with sarcomere protein gene mutations, and exhibits multiple phenotypic expressions. We present a case that combines all phenotypes.3