Vicent Bodí

Usefulness of the Neutrophil to Lymphocyte Ratio in Predicting Long-Term Mortality in ST Segment Elevation Myocardial Infarction

Neutrophil to lymphocyte ratio (N/L) has been associated with poor outcomes in patients who underwent cardiac angiography. Nevertheless, its role for risk stratification in acute coronary syndromes, specifically in patients with ST-segment elevation myocardial infarction (STEMI), has not been elucidated. We sought to determine the association of N/L maximum value (N/L max) with mortality in the setting of STEMI and to compare its predictive ability with total white blood cell maximum count (WBC max). We analyzed 515 consecutive patients admitted with STEMI to a single university center. White blood cells (WBC) and differential count were measured at admission and daily for the first 96 hours afterward. Patients with cancer, inflammatory diseases, or premature death were excluded, and 470 patients were included in the final analysis. The association between N/L max and WBC max with mortality was assessed by Cox regression analysis. During follow-up, we registered 106 deaths (22.6%). A positive trend between mortality and N/L max quintiles was observed; 6.4%, 12.4%, 11.7%, 34%, and 47.9% of deaths occurred from quintiles 1 to 5 (p <0.001), respectively. In a multivariable setting, after adjusting for standard risk factors, patients in the fourth (Q4 vs Q1) and fifth quintile (Q5 vs Q1) showed the highest mortality risk (hazard ratio 2.58, 95% confidence interal 1.06 to 6.32, p = 0.038 and hazard ratio 4.20, 95% confidence interal 1.73 to 10.21, p = 0.001, respectively). When WBC max and cells subtypes were entered together, N/L max remained as the only WBC parameter; furthermore, the model with N/L max showed the most discriminative ability. In conclusion, N/L max is a useful marker to predict subsequent mortality in patients admitted for STEMI, with a superior discriminative ability than total WBC max.

Improvement in risk stratification with the combination of the tumour marker antigen carbohydrate 125 and brain natriuretic peptide in patients with acute heart failure

AIM Elevated brain natriuretic peptide (BNP) and tumour marker antigen carbohydrate 125 (CA125) levels have shown to be associated with higher risk for adverse outcomes in patients with acute heart failure (AHF). Nevertheless, no attempt has been made to explore the utility of combining these two biomarkers. We sought to assess whether CA125 adds prognostic value to BNP in predicting 6-month all-cause mortality in patients with AHF. METHODS AND RESULTS We analysed 1111 consecutive patients admitted for AHF. Antigen carbohydrate 125 (U/mL) and BNP (pg/mL) were measured at a median of 72 +/- 12 h after instauration of treatment. Antigen carbohydrate 125 and BNP were dichotomized based on proposed prognostic cutpoints, and a variable with four categories was formed (BNP-CA125): C1 = BNP < 350 and CA125 < 60 (n = 394); C2 = BNP > or = 350 and CA125 < 60 (n = 165); C3 = BNP < 350 and CA125 > or = 60 (n = 331); and C4 = BNP > or = 350 and CA125 > or = 60 (n = 221). The independent association between BNP-CA125 and mortality was assessed with the Cox regression analysis, and their added predictive ability tested by the integrated discrimination improvement (IDI) index. At 6 months, 181 deaths (16.3%) were identified. The cumulative rate of mortality was lower for patients in C1 (7.8%), intermediate for C2 and C3 (17.8% and 16.9%, respectively), and higher for C4 (37.2%), and P-value for trend <0.001. After adjusting for established risk factors, the highest risk was observed when both biomarkers were elevated (C4 vs. C1: HR = 4.05, 95% CI = 2.54-6.45; P < 0.001) and intermediate when only one of them was elevated: (C2 vs. C1: HR = 1.71, 95% CI = 1.00-2.93; P = 0.050) and (C3 vs. C1: HR = 2.10, 95% CI = 1.30-3.39; P = 0.002). Moreover, when CA125 was added to the clinical model + BNP, a 10.4% (P < 0.0001) improvement in the IDI (on the relative scale) was found. CONCLUSION In patients admitted with AHF, CA125 added prognostic value beyond the information provided by BNP, and thus, their combination enables better 6-month risk stratification.

Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure

Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an additional therapeutic resource for patients with advanced congestive heart failure (CHF). The objective of this study was to determine the therapeutic role of CAPD, in terms of surrogate endpoints, in the management of patients with advanced CHF and renal dysfunction.

Carbohydrate Antigen 125: An Emerging Prognostic Risk Factor in Acute Heart Failure?

Objective: To assess whether circulating levels of carbohydrate antigen 125 (CA125) predict subsequent 6-month all-cause mortality in patients after the index hospitalisation for acute heart failure (HF). Design and setting: Prospective cohort study at a single teaching centre in Spain. Methods: 529 consecutive patients with acute HF admitted in a single university centre were analysed. In addition to the traditional clinical information, CA125 (U/ml) was measured during the early course of hospitalisation. The independent association between baseline CA125 and mortality was assessed with Cox regression analysis. The follow-up was limited to 6 months. Results: 349 (66%) patients showed serum levels of CA125 >35 U/ml (established cut-off point value). At a 6-month follow-up, 89 (16.8%) deaths were identified. A positive trend between mortality and CA125 quartiles was observed; 3.8%, 15.2%, 22% and 26.5% of deaths occurred from quartile 1 to 4 of CA125 (p<0.001). Likewise, a monotonic, ascending trend in the risk ratios was estimated from the multivariable Cox model. Compared with the first quartile of CA125, the HRs (95% CI) for the second, third and fourth quartiles were 3.25 (1.20 to 8.79), 4.91 (1.88 to 12.85) and 8.41 (3.24 to 21.79), respectively. Conclusions: Serum levels of CA125 obtained in patients admitted with a diagnosis of acute HF was shown to be an independent predictor of mortality up to the 6-month follow-up.

Papel del índice de Charlson en el pronóstico a 30 días y 1 año tras un infarto agudo de miocardio

Introduccion y objetivos.El indice de Charlson (iCh) ha sido utilizado como variable de ajuste en modelos multivariables como indicador de comorbilidad. Debido a que su valor pronostico per se para complicaciones cardiovasculares tras un infarto agudo de miocardio no ha sido ampliamente evaluado, nos propusimos determinar su valor predictivo para muerte de cualquier causa y/o reinfarto, a 30 dias y 1 ano del evento indice. Pacientes y metodo. Se incluyo a 1.035 pacientes con el diagnostico de infarto (508 con elevacion del segmento ST y 527 sin elevacion del segmento ST). La presencia de eventos se determino a 30 dias (13,9%) y a un ano (26,3%). El iCh se calculo junto con otras variables de valor pronostico en el momento del ingreso, y se establecieron 4 grupos: 1, iCh = 0 (control); 2, iCh = 1; 3, iCh = 2, y 4, iCh ≥ 3. Para el analisis multivariable se utilizo la regresion de riesgos proporcionales de Cox; su poder discriminativo se evaluo mediante el indice C. Resultados. Los riesgos relativos (RR) y el intervalo de confianza [IC] del 95% para las categorias del iCh fueron: a los 30 dias, para la categoria 2, RR = 1,69; IC del 95%, 1,10-2,59; para la 3, RR = 1,78; IC del 95%,1,08-2,92, y para la 4, RR = 1,57; IC del 95%, 0,87-2,83; los valores a 1 ano fueron, para la categoria 2, RR = 1,62; IC del 95%, 1,18-2,23; para la 3, RR = 2,00; IC del 95%, 1,39-2,89, y para la 4, RR = 2,24; IC del 95%, 1,50-3,36. La diferencia en el indice C del modelo con y sin la variable iCh fue 0,765 y 0,750 a los 30 dias y 0,751 y 0,735 a 1 ano. Conclusiones. El iCh proporciono informacion pronostica independiente para muerte y/o reinfarto a los 30 dias y a 1 ano tras el infarto indice. Palabras clave: Infarto agudo de miocardio. Comorbilidad. Indice de Charlson.

Valor de la prueba de esfuerzo precoz en un protocolo de unidad de dolor torácico

Early exercise testing (first 24 hours) was evaluated in the stratification of patients seen in the emergency room for chest pain. One hundred and forty-two consecutive patients without ischemia in the ECG or troponin I elevation were included. Ninety-two patients were discharged after the exercise testing (group I, 82 negative and 10 inconclusive test results) and 50 patients were hospitalized (group II, 29 positive and 21 inconclusive test results). In group I, cardiac events (unstable angina and non-fatal infarction) occurred in the next 30 days of follow-up in 2 patients with inconclusive test results; no cardiac events occurred in patients with negative test results. In group II, unstable angina was diagnosed in 30 patients and 3 presented recurrent angina. There were no complications during exercise testing. In conclusion, early exercise testing is safe and useful in the stratification of patients seen in the emergency room for chest pain. Only patients with negative test results should be discharged early.

Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias

Objectives. To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. Patients and method. 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (< 24 h) exercise testing was done for the low-risk subgroup of patients (n = 203). All patients were followed during 3 months for major events (acute myocardial infarction or death). Results. Major events occurred in 71 patients (9.6%). Multivariate analysis (C stadistic = 0.79; 95% CI 0.730.84; p = 0.0001) identified the following predictors: age ≥ 72 years (OR = 1.7; 95% CI, 1.0-2.9; p = 0.05), insulindependent diabetes mellitus (OR = 2.9; 95% CI, 1.5-5.4; p = 0.001), previous ischemic heart disease (OR = 1.9; 95% CI, 1.1-3.2; p = 0.02), ST depression (OR = 2.1; 95% CI, 1.2-3.8; p = 0.01) and troponin I elevation (OR = 2.9; 95% CI, 1.5-5.3; p = 0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and ≥ 8 points (26.2% events); p = 0.0001. No patient with negative findings in the early exercise testing had major events. Conclusions. In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.

Differential prognostic effect of systolic blood pressure on mortality according to left‐ventricular function in patients with acute heart failure

To evaluate the relationship between systolic blood pressure (SBP) and long‐term mortality in patients with acute heart failure (AHF) stratified by ejection fraction (LVEF): reduced (≤40%) vs. preserved (≥50%).

Hyperuricemia in acute heart failure. More than a simple spectator

BACKGROUND Hyperuricemia is a prevalent condition in chronic heart failure (CHF), describing increased oxidative stress and inflammation. Although there is evidence that serum uric acid (UA) predicts mortality in CHF, its role as a prognostic biomarker in acute heart failure (AHF) has not yet been well assessed. The aim of this study was to determine if UA levels predict all-cause mortality. Additionally, as a secondary endpoint we sought the clinical predictors of UA serum level in this population. METHODS We analyzed 560 consecutive patients with AHF admitted in a single university center. UA (mg/dl) was measured during early hospitalization. Patient survival status was followed up after discharge (median follow-up: 330 days). The independent association of UA level with all-cause mortality was analyzed using Cox regression analysis. RESULTS During follow-up 165 (29.5%) deaths were identified. Patients with UA levels above the median value (>or=7.7 mg/dl) exhibited higher mortality rates (21.1 vs. 37.9%; p<0.001). In multivariable analysis, after adjusting for recognized prognostic factors and potential confounders, UA>or=7.7 mg/dl and per change in 1 mg/dl of UA was associated with an increased risk of mortality (HR 1.45, CI 95%=1.03-2.44; p=0.03 and HR 1.08, CI 95%=1.01-1.15; p=0.03, respectively). CONCLUSION UA serum levels is an independent predictor of all-cause mortality in an unselected patients admitted with AHF.

Usefulness of concomitant myoglobin and troponin elevation as a biochemical marker of mortality in non-ST-segment elevation acute coronary syndromes.

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