Valentina Spini

Levosimendan produces an additional clinical and hemodynamic benefit in patients with decompensated heart failure successfully submitted to a fluid removal treatment.

A pivotal role in treating decompensated heart failure (HF) is played by inotropes and calcium sensitizers such as levosimendan. In this study, the authors evaluated whether levosimendan could determine further clinical and hemodynamic benefits in 31 HF patients (New York Heart Association [NYHA] class III or IV), after successful treatment with diuretics (n=15) or ultrafiltration (n=16). Systolic, diastolic, dicrotic, and mean arterial pressures; systemic vascular resistance (SVR); some classic hemodynamic variables (cardiac output [CO], stroke volume [SV], dP/dt(max) ); and indices of cardiovascular system performance (cardiac cycle efficiency [CCE], cardiac power output) have been assessed by the pressure recording analytical method (PRAM), a minimally invasive monitoring system, before levosimendan infusion, at the end of treatment (EoT), and 36 hours after EoT (post-36). A significant increase in CCE, CO, SV, and dP/dt(max) and a significant decrease in diastolic and dicrotic arterial pressures and in SVR have been observed at EoT and at post-36. After the addition of levosimendan, a further reduction in signs and symptoms of HF and NYHA class was observed. Five patients showed an opposite trend of several hemodynamic parameters without any significant clinical improvement (nonresponders). In conclusion, most HF patients treated with diuretics or ultrafiltration receive additional clinical and hemodynamic benefits from levosimendan. The characterization of nonresponders could help in optimizing its use.

Different NT-proBNP circulating levels for different types of cardiac amyloidosis.

Aim Several studies suggest that the N-terminal fragment of pro-brain natriuretic peptide levels are quite different in wild-type transthyretin (TTR)-related amyloidosis (ATTRwt) and mutated TTR-related amyloidosis (ATTRm) compared with immunoglobulin light-chain cardiac amyloidosis. Our aim was to test this hypothesis in a cohort of patients with different types of cardiac amyloidosis. Patients and methods Seventy patients with ATTRwt, ATTRm, and light-chain cardiac amyloidosis matched for left ventricular (LV) mass index were studied by standard echocardiography, tissue Doppler imaging, and plasmatic cardiac biomarkers. Results Despite similar LV mass and renal function, patients with ATTR cardiac amyloidosis showed lower levels of N-terminal fragment of pro-brain natriuretic peptide than do light-chain amyloidosis ones, especially when expressed as a function of LV mass index. Conclusion Amyloidogenic light-chain-derived fibrils induce more severe myocardial dysfunction in light-chain amyloidosis than in ATTR, despite similar myocardial infiltration. Thus, the degree of cardiac dysfunction may be related not only to the amount of amyloid deposited, but also to qualitative differences among fibrils.

COmparison between COronary THrombus aspiration with Angiojet® or Export® catheter in patients with ST-elevation myocardial infarction submitted to primary angioplasty: The COCOTH Study

AIMS To compare the effects of two thrombus aspiration devices, the manual catheter Export® and the more complex and expensive mechanical Angiojet®, on several indices of reperfusion in acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS Clinical, hemodynamic and procedural characteristics of 185 STEMI patients, randomized to treatment with Export (n=95) or Angiojet (n=90) during primary percutaneous coronary intervention (PPCI) were analyzed. The primary endpoint was ST-segment elevation reduction 90 min after culprit vessel re-opening. Secondary endpoints included variations in some angiographic parameters (TIMI Flow, TIMI Frame Count and Myocardial Blush Grade) and Infarct Size and Severity at myocardial scintigraphy. A significant reduction in ST-elevation was observed in both groups after PPCI without significant differences between the two groups. No significant difference between Angiojet vs. Export was observed in ST-segment resolution >50% and ≥ 70%, in TIMI Flow, TIMI Frame Count and Myocardial Blush Grade before vs. after PPCI and in Infarct Size and Severity. CONCLUSIONS PPCI with thrombus aspiration was effective in both groups of patients, without differences in myocardial reperfusion and necrosis indices. These results could support the routine use of manual devices during PPCI, reserving the more expensive Angiojet in case of manual device failure and persistent or massive intracoronary thrombosis, with favorable implications in terms of cost containment.

Uric acid and mild renal impairment in patients with ST-elevation myocardial infarction.

Abstract Aims. Mild renal impairment (estimated GFR 60–89 ml/min/1.73 m2) is a strong independent risk factor for mortality in ST-elevation myocardial infarction (STEMI), and is submitted to mechanical revascularization. Patients with renal impairment have decreased excretion of uric acid (UA) and they are thus particularly prone to have elevated serum UA concentrations. This study was aimed at assessing the association between increased UA and mortality in STEMI patients with mild renal impairment. Methods. We prospectively assessed, in 578 STEMI patients with mild renal impairment, whether elevated UA levels are associated with increased mortality both in the short term and in the long term. Results. Patients in the highest UA tertile showed a higher incidence of Killip class III–IV (p = 0.003) and lower values of ejection fraction (EF) (p < 0.001). Lower values for estimated glomerular filtration rate (eGFR) at admission, nadir, and discharge were detected in the highest UA tertile, together with the highest values of peak troponin I (Tn I) (p = 0.002), and NT-proBrain Natriuretic Peptide [NT-proBNP] (p < 0.001). No difference was found in mortality rates (both during their stay in the intensive cardiac care unit [ICCU], and at the 1-year post-discharge follow-up) among the UA tertiles. Conclusions. The UA levels seem to serve as markers of the severity of coronary artery disease, since they identify a subset of patients characterized by an advanced age, more hemodynamic derangement, and reduced renal function. However, neither short nor long-term mortality was affected.

Early invasive strategy and outcomes of non-ST-elevation acute coronary syndrome patients: is time really the major determinant?

In non-ST-elevation acute coronary syndromes (ACS), an early invasive strategy is recommended for middle/high-risk patients; however, the optimal timing for coronary angiography is still debated. The aim of this study was to evaluate the prognostic implications of the time of angiography in ACS patients treated in accord with an early invasive strategy. We analyzed the relationship between the time of angiography and outcomes at follow-up in 517 ACS patients, of whom 482 were revascularized with percutaneous coronary intervention (PCI) (86.9%) or coronary artery by-pass graft (13.1%). We also evaluated the influence of clinical, biohumoral and angiographic variables on the patients’ outcomes at follow-up. Among patients submitted to angiography at different time intervals from both hospital admission and symptom onset, significant differences neither in mortality nor in cardiac ischemic events at follow-up were observed. At univariate analysis, complete versus partial revascularization, longer hospital stay, higher TIMI risk score, diabetes mellitus, higher discharge creatinine and admission anemia were associated with mortality and cardiac ischemic events at follow-up; a lower left ventricular ejection fraction was associated with mortality; higher peak troponin I and previous PCI were associated with cardiac ischemic events at follow-up. At multivariate analysis longer hospital stay, higher discharge creatinine levels, and previous PCI were independent predictors of cardiac ischemic events at follow-up. Our evaluation in ACS patients treated with an early invasive strategy does not support the concept that angiography should be performed as soon as possible after symptom onset or hospital admission. Rather, an unfavorable long-term outcome is influenced principally by the clinical complexity of patients.

Admission Glycaemia and Acute Insulin Resistance in Heart Failure Complicating Acute Coronary Syndrome

BACKGROUND Few data are so far available on the relation between increased glucose values and insulin resistance and mortality at short-term in patients with acute heart failure (AHF). METHODS The present investigation, performed in 409 consecutive patients with AHF complicating acute coronary syndrome (ACS), was aimed at assessing the prognostic role of admission glycaemia and acute insulin resistance (as indicated by the Homeostatic Model Assessment - HOMA index) for death during Intensive Cardiac Care (ICCU) stay. Admission glucose tertiles were considered. RESULTS In our series, diabetic patients accounted for the 33%. Patients in the third glucose tertiles exhibited the lowest LVEF (both on admission and at discharge), a higher use of mechanical ventilation, intra-aortic balloon pump and inotropic drugs and the highest in-ICCU mortality rate. In the overall population, hyperglycaemic patients (both diabetic and non diabetic) were 227 (227/409, 55.5%). Admission glycaemia was an independent predictor of in-ICCU mortality, together with admission LVEF and eGFR, while acute insulin resistance (as indicated by HOMA-index) was not associated with early death. The presence of admission hyperglycaemia in non-diabetic patients was independently associated with in-ICCU death while hyperglycaemia in diabetic patients was not. CONCLUSIONS According to our results, hyperglycaemia is a common finding in patients with ACS complicated by AHF and it is an independent predictor of early death. Non-diabetic patients with hyperglycaemia are the subgroup with the highest risk of early death.

Continuous renal replacement therapy: Should the cardiologist be able to manage it out of intensive care units?

Continuous renal replacement therapy (CRRT) has received increasing attention in recent years parallel to the publication of several favourable data regarding the use of this technique in different clinical conditions such as congestive heart failure (CHF) [1,2] and contrast induced nephropathy (CIN) [3,4]. Moreover, the improvement in technology has led to the diffusion of devices easier to use, that can be managed in Cardiology Units also out of the intensive care setting, overcoming logistic and practical problems. CRRT can be performed in cardiac patients with three different main techniques: