Abstract: OBJECTIVE: We sought to determine the relationship between the lowest lymphocyte count (lymphocyte(min))obtained within the first 96 h of symptoms onset and the risk of postdischarge recurrent spontaneous myocardial infarction (re-MI) in patients admitted with ST-segment elevation MI (STEMI). METHODS: We analyzed 549 consecutive patients admitted with STEMI from a single academic hospital. Lymphocyte counts were determined at admission and routinely during the first 96 h. Lymphocyte(min) was selected as the main exposure. Patients with inflammatory or infectious diseases, in-hospital death, or reinfarction were excluded from the analysis (final sample= 426 patients). Lymphocyte(min) was divided into quartiles (Q) and their association with re-MI was assessed by competing risk analysis. Postdischarge death and coronary revascularization were considered competing events. RESULTS: During a median follow-up of 36 months, 53 re-MI (12.4%) were registered. The re-MI crude rate was significantly higher in patients in the lowest lymphocyte(min) quartile (Q1r1045 cells/ml) compared with Q2-Q4: 22.4, 9.4, 8.4, 9.4%, respectively; P =0.005. In a multivariate setting, Q1 was also associated with a significant increased risk of re-MI compared with Q2-Q4 (hazard ratio: 2.04, 95% confidence interval: 1.11-3.76; P = 0.021). CONCLUSION: Low lymphocyte count obtained within the first 96 h of a STEMI predicts the risk of re-MI.
Abstract: AIMS: 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 (< or =40%) vs. preserved (> or =50%). METHODS AND RESULTS: We studied 1049 consecutive patients admitted with AHF. Systolic blood pressure was determined in the emergency department. Left-ventricular ejection fraction was categorized as < or =40% (n = 288), 41-49% (n = 174), or > or =50% (n = 587). Cox regression analysis was used for multivariable analysis. Mean age and SBP were 73 +/- 11 years and 150 +/- 36 mmHg, respectively. During a median follow-up of 18 months, 290 deaths (33.1%) were identified. Higher SBP was associated with lower mortality. In multivariable analysis, a differential effect of SBP across LVEF status was documented (P-value for interaction = 0.036). In linear models, SBP was shown to be inversely related with mortality in both groups (per 10 mmHg decrease): HR((LVEF > or = 50%)): 1.06, CI 95% = 1.01-1.11; P = 0.016, and HR((LVEF < or = 40%)): 1.16, 95% CI = 1.08-1.25; P < 0.001). When SBP was modelled with restrictive cubic splines, an inverse and almost linear relationship with mortality was shown in patients with LVEF < or =40% (P < 0.001), whereas in patients with LVEF > or =50%, SBP followed a J-shape curve. CONCLUSION: In patients with AHF, SBP showed a differential prognostic effect on mortality according to LVEF status; when LVEF was < or =40%, SBP was linearly and inversely associated with mortality. Conversely, in patients with LVEF > or =50% this relationship showed a J-shape pattern.
Abstract: 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.
Abstract: OBJECTIVE: Risk stratification of patients with acute chest pain, non-diagnostic electrocardiogram and normal troponin (ACPneg) remains a challenge, partly because no standardized set of biomarkers with prognostic ability has been identified in this population. Lymphopenia has been associated with atherosclerosis progression and adverse outcomes in cardiovascular diseases; although its prognostic value in ACPneg is unknown. We sought to determine the relationship between the lymphocyte count obtained in the Emergency Department (ED) and the risk of the long-term all-cause mortality or myocardial infarction (MI) in patients with ACPneg. METHODS: We analyzed 1030 consecutive patients admitted with ACPneg in our institution. Lymphocyte count was determined in the ED as a part of a routine diagnostic workup to rule out an acute coronary syndrome. Patients with inflammatory, infectious diseases, or active malignancy were excluded (final sample=975). The independent association between lymphocyte count and the composite endpoint (death/MI) was assessed by survival analysis for competing risk events (revascularization procedures). RESULTS: During a median follow-up of 36 months, 139 (14.3%) patients achieved the combined endpoint, with rates increasing monotonically across lymphocyte quartiles (6.2%, 10%, 20.6% and 24.1% for Q4, Q3, Q2 and Q1 (p<0.001), respectively). In a multivariable analysis, patients in lymphocytes' Q1 and Q2 as compared with those in Q4 had an increased risk for the combined endpoint: HR=2.45 (CI 95% 1.25-4.79, p=0.008) and HR=2.56 (CI 95% 1.30-5.07, p=0.007), respectively. CONCLUSION: In patients with ACPneg, low lymphocytes count was associated with an increased risk for developing the combined endpoint of death or MI.
Abstract: OBJECTIVE: To investigate the safety of discharge of patients deemed at low risk of cardiac events after evaluation in a chest pain unit and to determine the prognostic effect of revascularization of patients deemed at high risk. PATIENTS AND METHODS: The study population consisted of 1088 patients presenting at the emergency department from January 15, 2001, to September 1, 2006, with chest pain but without ischemia on electrocardiography or troponin elevation. Patients were managed by a chest pain unit protocol that included early exercise testing. Three groups of patients were distinguished: (1) those discharged after exercise testing (424 [39%]); (2) those in whom unstable angina was ruled out after in-hospital evaluation (208 [19%]); and (3) those in whom unstable angina was confirmed or not ruled out (456 [42%]). Of the 456 patients in group 3, 183 (40%) were revascularized at the index episode. The primary end point was the occurrence of myocardial infarction or death within 1 year. Adjustments were made for patient characteristics and a propensity score for revascularization (c statistic [0.83]). RESULTS: Groups 1 and 2 showed lower rates of the primary end point than group 3 (group 1: 7 [1.7%]; group 2: 1 [0.5%]; group 3: 62 [13.6%]; P=.001). In group 3, revascularization at the index episode did not reduce the primary end point in the univariate (22 [12%] vs 29 [11%]; P=.80) and multivariate (hazard ratio, 1.4; 95% confidence interval, 0.7-2.5; P=.40) analyses. In-hospital revascularization decreased the need for postdischarge revascularization (hazard ratio, 0.3; 95% confidence interval, 0.1-0.7; P=.01). CONCLUSION: Chest pain unit protocols are associated with safe patient discharge. Although early revascularizations may decrease the need for postdischarge revascularizations, they may not improve 1-year outcomes by reducing the number of myocardial infarctions or deaths.
Abstract: INTRODUCTION AND OBJECTIVES: The right radial (RR) approach has been incorporated into daily clinical practice as a valid alternative to the femoral (F) approach. The left radial (LR) approach is seldom used and few data are available from randomized studies comparing this approach with F and RR approaches. METHODS: We randomized 1005 consecutive patients referred to a tertiary-care hospital for cardiac catheterization to different approaches. Procedures were performed by three interventional cardiologists experienced in transradial catheterization. There were no exclusion criteria. The primary end-point was the percentage of procedures completed using the assigned approach. Secondary endpoints were the percentage completed in the absence of contraindications to any approach, the duration of the procedure, and the incidence of vascular complications. RESULTS: More procedures were completed with the F approach (LR, 71%; F, 92%; RR, 68%; P< .001). The success rate in the absence of contraindications to any approach (n=907) was greater with the F approach, with no difference between LR and RR approaches (LR, 80%; F, 96%; RR, 82%; P< .001). The canalization time was greater with the LR approach (P< .001), the time required for diagnosis was shorter with the F approach (P< .001) and compression was faster with the radial approach (P< .001). There was no difference in the total duration of diagnostic procedures (P=.22) or interventions (P=.9). The incidence of vascular complications was lower with the radial approach (P=.03). CONCLUSIONS: The left radial approach is as valid an alternative to the femoral approach as the right radial approach.
Abstract: INTRODUCTION AND OBJECTIVES: Occasionally, coronary arteries without significant stenosis are observed during invasive treatment of acute non-ST-elevation myocardial infarction (NSTEMI). The aim was to investigate predictive factors and prognosis in these patients. METHODS: The study involved 504 patients admitted for NSTEMI who underwent cardiac catheterization. The primary end-point was the observation of coronary arteries without significant stenosis, and the secondary end-point was death or myocardial infarction within a median of 3 years. In evaluating the secondary end-point, a control group of 160 patients with a normal troponin level and no significant coronary artery stenosis who were admitted for chest pain during the same period was included. RESULTS: Overall, 64 patients (13%) had coronary arteries without significant lesions. The predictors were: female sex (odds ratio [OR]=6.6; P=.0001), age <55 years (OR=3.0; P=.001), and the absence of diabetes (OR=2.4, P=.02), previous antiplatelet treatment (OR=3.9, P=.007) or ST-segment depression (OR=2.4, P=.008). The composite variable of female sex plus at least two additional predictive factors had a specificity of 85% and a sensitivity of 53% for coronary angiography showing no significant stenosis. The absence of coronary artery stenosis decreased the probability of death or myocardial infarction during follow-up (hazard ratio=0.3, 95% confidence interval, 0.2-0.9; P=.03). Among all patients without significant stenosis (n=224), there was no difference in the event rate between those with elevated and normal troponin levels. CONCLUSIONS: In NSTEMI, female sex, age <55 years and the absence of diabetes, previous antiplatelet treatment or ST-segment depression were all associated with coronary angiography showing no significant stenosis. The long-term prognosis in these patients was good.
Abstract: BACKGROUND: Low lymphocyte count (LLC), a surrogate for inflammation, has emerged as a potential risk factor for cardiovascular outcomes, especially new ischemic events. To identify patients with non-ST segment elevation acute coronary syndromes (NSTEACS) who benefit from an invasive revascularization strategy remains a challenge. We sought to determine if patients with high-risk NSTEACS who exhibited LLC have a greater reduction in long-term post-discharge myocardial infarction (MI) when managed under a revascularization invasive strategy (RIS) as compared with conservative strategy (CS). METHODS: Nine hundred seventy two consecutive patients with high-risk NSTEACS were treated under two revascularization strategies (RS): 1) CS, from January 2001 to October 2002 (345 patients; 35.5%) and 2) RIS, from November 2002 to May 2005 (627 patients; 64.5%). LLC was defined as lymphocytes count < or =1200 cells/ml (1 vs. 2-4 quartiles). The association between the type of RS and MI was stratified by lymphocyte count status and assessed by Cox regression adapted for competing events. RESULTS: At 3-year follow-up, 145 deaths (14.9%), 135 MI (13.9%) and 76 revascularization procedures (7.8%) were registered. In a multivariable setting, LLC patients exhibited a greater MI risk reduction when managed under RIS (HR: 0.40; 95% CI=0.22-0.72, p=0.003). Conversely, when LLC was not present, no difference in the rate of MI was detected between the two RS. CONCLUSIONS: LLC identifies a subgroup of patients with greater reduction in the risk of postdischarge MI when a RIS is applied.
Abstract: BACKGROUND AND OBJECTIVE: The relation between left ventricular ejection fraction (LVEF) and prognosis in patients with heart failure is controversial. The aim of this study was to determine the relation of LVEF in long-term mortality and readmissions for acute heart failure in a non-selected population of patients admitted with acute heart failure (AHF). PATIENTS AND METHOD: We included 507 patients admitted consecutively for AHF in a cardiology department of a single-centre. LVEF was assessed with transthoracic echocardiography during hospitalization. All-cause mortality and readmission for AHF were selected as primary and secondary endpoints, respectively. The independent association between LVEF and endpoints was assessed with traditional Cox regression analysis for all-cause mortality and Cox regression for competing risks for readmission for AHF. RESULTS: 47% of patients exhibited LVEF > or = 50%. During a median follow-up of one year, 151 (30%) deaths and 139 (27%) readmissions for AHF were observed. Mortality rates were higher in patients with LVEF < 50% (34 vs 25%; p = 0.028) and no differences were observed for readmissions for AHF (26 vs 29%, p = 0.510). In multivariate analysis, after adjustment for traditional risk factors, patients with LVEF < 50% did not show higher risk of mortality (hazard ratio [HR] = 1.08; 95% confidence interval [CI], 0.76-1.57; p = 0.645) or readmissions for AHF (HR = 1.00; 95% CI, 0.68-1.47; p = 1). CONCLUSIONS: Patients with preserved LVEF constitute a substantial proportion of patients with AHF, exhibiting similar mortality and readmissions risks compared with patients with depressed LVEF.
Abstract: Recently, the theory that hyperinflammation is the body's primary response to potent stimulus has been challenged. Indeed, a deregulation of the immune system could be the cause of multiple organ failure. So far, clinicians have focused on the last steps of the inflammatory cascade. However, little attention has been paid to lymphocytes, which play an important role as strategists of the inflammatory response. Experimental evidence suggests a crucial role of T lymphocytes in the pathophysiology of atherosclerosis and acute myocardial infarction (AMI). In summary, from the bottom of an imaginary inverted pyramid, a few regulatory T-cells control the upper parts represented by the wide spectrum of the inflammatory cascade. In AMI, a loss of regulation of the inflammatory system occurs in patients with a decreased activity of regulatory T-cells. As a consequence, aggressive T-cells boost and anti-inflammatory T-cells drop. A pleiotropic proinflammatory imbalance with damaging effects in terms of left ventricular performance and patient outcome is the result of this uncontrolled immune response. It is needed to unravel the thread of the inflammatory cells to better understand the pathophysiology as well as to open innovative therapeutic options in AMI.
