Abstract: BACKGROUND: Episodes ventricular fibrillation (VF) initiated by ventricular premature complexes (VPCs) of a single morphology have been reported. However, the characteristics of the VPCs over long periods of time are unknown. OBJECTIVES: To compare the morphologies and coupling intervals of VPCs that initiate episodes of VF that occur at different time periods. METHODS: The database of the follow-up of the International Classification of Diseases (ICD) unit was reviewed and patients having at least two spontaneous VF episodes with available recorded EGMs in unipolar and bipolar configuration were included in the study. The coupling interval and morphology of the initiating beat were analyzed. RESULTS: Nine out of 300 patients with ICD had two or more spontaneous VF episodes. The time interval between episodes ranged from seconds (arrhythmic storm) to 3 years. The fibrillatory VPCs presented the same morphology in both recordings in all episodes of each patient. The coupling intervals of VPCs initiating VF were close for the episodes that occurred during a single arrhythmic storm and were more variable when the time intervals between episodes of VF were longer. CONCLUSION: VPCs triggering VF that occur at different times in the same patient have similar morphologies suggesting similar sites of origin for the initial VPC of VF in each patient.
Abstract: Management of ventricular arrhythmias due to Chronic Chagas' Myocardiopathy (CCM) is challenging. We present a case of CCM complicated with ventricular tachycardia (VT), and a brief review focused on VT management in this occidental emergent entity.
Abstract: BACKGROUND: Patients with indications for oral anticoagulation (OAC) undergoing percutaneous coronary artery stenting (PCI-S) represent a high-risk population for major bleeding complications. Chronic kidney disease (CKD) is also associated with poor outcome after PCI-S. Limited data are available regarding the impact of CKD on the frequency of major bleeding and mortality in this population. METHODS: We investigated the influence of CKD on major bleeding and all-cause mortality in patients with indication for OAC who undergo PCI-S. Patients were grouped according to calculated creatinine clearance (CrCl): CrCl > 60 mL/min, (n = 98) and CrCl < or = 60 mL/min, (n = 68). Major bleeding and major adverse vascular events (all-cause mortality, myocardial infarction, repeat revascularization, stent thrombosis, or stroke) were collected during follow-up. RESULTS: We analyzed 166 consecutive patients with indication(s) for OAC (77% men; mean age, 71 years; range, 66 to 76 years) after undergoing PCI-S. CKD was associated with higher risk for major bleeding (hazard ratio [HR], 3.44; 95% confidence interval [CI], 1.50 to 7.93; p = 0.004) and all-cause mortality (HR, 3.50; 95% CI, 1.53 to 7.99; p = 0.003). In multivariate analyses, age > 75 years (HR, 2.75; 95% CI, 1.15 to 6.56; p = 0.023), CKD (HR, 2.59; 95% CI, 1.00 to 6.95; p = 0.049), anemia (HR, 2.36; 95% CI, 1.00 to 5.54; p = 0.049), and triple antithrombotic therapy (HR, 3.29; 95% CI, 1.23 to 8.84; p = 0.018) were independent predictors for major bleeding, whereas age > 75 years (HR, 2.38; 95% CI, 1.03 to 5.59; p = 0.046) and CKD (HR, 2.44; 95% CI, 1.03 to 5.82; p = 0.044) were predictors for all-cause mortality. CONCLUSION: In this high-risk population, CKD is independently associated with increased major bleeding and all-cause mortality following PCI-S.
Abstract: AIMS: Drug-eluting stents (DES) have never been sufficiently studied in patients with atrial fibrillation (AF). The latter are considered as a high-risk population with uncertainty over the optimal antithrombotic therapy strategy to prevent stroke, stent thrombosis, and recurrent cardiac ischaemia, balanced against the high risk of haemorrhage. The aim of this study was to evaluate the safety and efficacy of the use of DES vs. bare-metal stents (BMS) in a cohort of patients with AF. METHODS AND RESULTS: We reviewed 604 patients with AF who had undergone percutaneous coronary intervention with stent over a period of 7 years (January 2001-January 2008). After a propensity score selection, we identified two matched cohorts who received DES (n = 207) or BMS (n = 207). Clinical follow-up was performed, and all bleeding episodes, thrombo-embolism, and major adverse cardiac events (MACE; i.e. death, acute myocardial infarction, target vessel failure) were recorded. Complete follow-up was achieved in 95.9% of the cohort (mean: 693 +/- 427 days, median: 564). The incidence density of MACE as well as the incidence of all-cause mortality in both groups was similar. There was a higher incidence of major bleeding in DES group (2.26 vs. 1.19 per 10 000 days of exposure; P = 0.03). In a multivariate analysis, age, chronic AF, chronic renal failure, and non-use of dicoumarin were predictors of MACE and of all-cause mortality. The use of DES was not a predictor of reduced events. CONCLUSION: On the basis of this study, the routine use of DES in patients with AF does not seem to be justified. A higher risk of major bleeding with DES in comparison with BMS raises the possibility that DES should be limited to lesions or patients with a high risk of restenosis.
Abstract: The aims of this study were to compare the prognostic value of cystatin C over creatinine and the Modification of Diet in Renal Disease (MDRD) equation and to evaluate whether it provides complementary information to cardiac biomarkers in the risk stratification of an unselected cohort of patients with acute heart failure. Consecutive hospitalized patients with established diagnoses of acute heart failure were prospectively studied. Blood samples were collected on hospital arrival to determine cystatin C, cardiac troponin T, and N-terminal-pro-brain natriuretic peptide. Clinical follow-up was obtained, and the occurrence of mortality and/or heart failure readmission was registered. One hundred thirty-eight patients (median age 74 years, interquartile range 67 to 80; 54% men) were studied. During a median follow-up period of 261 days (interquartile range 161 to 449), 60 patients (43.5%) presented with adverse events. After multivariate adjustment, cystatin C, N-terminal-pro-brain natriuretic peptide, cardiac troponin T, New York Heart Association functional class III or IV, and diabetes mellitus were identified as independent predictors of mortality and/or heart failure readmission. In contrast to creatinine and the MDRD equation, the highest cystatin C tertile (>1.50 mg/L) was a significant independent risk factor for adverse events (hazard ratio 3.08, 95% confidence interval 1.54 to 6.14, p = 0.004). A multimarker approach combining cardiac troponin T, N-terminal-pro-brain natriuretic peptide, and cystatin C improved risk stratification further, showing that patients with 2 (hazard ratio 2.37, 95% confidence interval 1.10 to 5.71) or 3 (hazard ratio 3.64, 95% confidence interval 1.55 to 8.56) elevated biomarkers had a higher risk for adverse events than patients with no elevated biomarkers (p for trend = 0.015). In conclusion, in this unselected cohort, cystatin C was a stronger predictor of adverse events than conventional measures of kidney function. In addition, cystatin C offered complementary prognostic information to cardiac biomarkers and could help clinicians perform more accurate risk stratification of patients with acute heart failure.
Abstract: Serum B-type natriuretic peptide (BNP) is increased after heart transplantation (HT), but it has not been well established whether BNP could be used to detect acute rejection in asymptomatic patients after HT. A total of 259 routine endomyocardial biopsy specimens from 50 consecutive patients after HT (83% men; age 50 +/- 15 years) were studied. Serial BNP measurements were performed at the time of each biopsy. BNP was evaluated as an absolute level (picograms per milliliter) and percentage of change from the previous biopsy (BNP - BNP at previous biopsy)/BNP at previous biopsy] x 100). Rejection was defined as grade > or =2R International Society of Heart and Lung Transplantation grading system. BNP correlated independently with time after HT (p <0.001), pulmonary artery systolic pressure (p <0.001), creatinine (p = 0.001), and age (p = 0.0012). Asymptomatic rejection was found in 15 biopsy specimens (6%), for which absolute BNP (106 pg/ml; interquartile range [IQR] 67 to 495) did not differ from nonrejection biopsy specimens (92 pg/ml; IQR 49 to 230; p = 0.286). BNP percentage of change showed a median of +60% (IQR -29 to +154%) in rejection versus -17% (IQR -47 to +19%) in nonrejection biopsy specimens (p = 0.009). After multivariable adjustment, BNP percentage of change was a consistent predictor of rejection (+10%; odds ratio 1.05, 95% confidence interval 1.01 to 1.09, p = 0.021). Receiver-operator characteristic analysis showed an area under the curve of 0.71 (95% confidence interval 0.643 to 0.768) and identified percentage of change <+38% as an optimal cut-off point, with a negative predictive value of 97%. In conclusion, serial monitoring of BNP, evaluated as a percentage of change, may be a useful noninvasive tool in the clinical management of rejection.
Abstract: AIMS: To study the long-term prognostic value of red blood cell distribution width (RDW) in patients hospitalized with acute heart failure (AHF) and to compare the value of this measurement with haemoglobin levels and anaemia status. METHODS AND RESULTS: During a 2-year period, we studied 628 consecutive patients (aged 71 years [interquartile range, IQR: 61-77], 68% male) hospitalized with AHF. Demographic, clinical, echocardiographic, and laboratory characteristics were registered at discharge and patients were closely followed-up for 38.1 months [16.5-49.1]. Median RDW was 14.4% [13.5-15.5] and was higher among decedents (15.0% [13.8-16.1] vs. 14.2 [13.3-15.3], P < 0.001). After adjustment for other prognostic factors in a multivariable Cox proportional-hazards model, RDW remained a significant predictor (P = 0.004, HR 1.072, 95% CI 1.023-1.124); whereas, haemoglobin or anaemia status did not add prognostic information. RDW levels above the median were associated with a significantly lower survival rate on long-term follow-up (log rank <0.001). These levels were predictive of death in anaemic patients (n = 263, P = 0.029) and especially in non-anaemic patients (n = 365) (P < 0.001, HR 1.287, 95% CI 1.147-1.445), even after adjustment in the multivariable model. CONCLUSION: Higher RDW levels at discharge were associated with a worse long-term outcome, regardless of haemoglobin levels and anaemia status.
Abstract: BACKGROUND: The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S. METHODS: We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [< or = 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded. RESULTS: We studied 104 patients (mean age +/- SD, 72 +/- 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53). CONCLUSION: A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.
