Brain natriuretic peptide: a potential marker for mortality in septic shock

SummaryBrain natriuretic peptide (BNP) is a diagnostic marker for left ventricular dysfunction. Sepsis and septic shock are increasing in incidence and mortality. Myocardial dysfunction frequently accompanies severe sepsis and septic shock. Although previously described as a preterminal event, ventricular dysfunction with reduced ejection fraction and biventricular dilatation is present in most patients with severe sepsis and septic shock. In survivors, this depression in cardiac function is reversible over the course of seven to ten days. Even though some prognostic factors have been identified in patients with sepsis-induced myocardial dysfunction, their measurement often includes costly and cumbersome techniques. Thus, there is a need for an inexpensive, simple, rapid and readily available marker to predict mortality in septic shock. At present, a relationship between BNP with myocardial dysfunction in septic shock has not been evaluated. However, growing evidence supports the hypothesis that BNP could be an early predictor of mortality in septic shock. If proven, the hypothesis would have important clinical and public health implications

Late Intervention on an Occluded Infarct-Related Artery: A Meta-analysis of the Randomized Controlled Trials

Context Late intervention to open an occluded infarct-related artery (IRA) after initial acute myocardial infarction was postulated to lead to clinical benefit. Objective To conduct a meta-analysis of the randomized trials. Study Selection Eligibility criteria were: 1) randomized trials comparing percutaneous coronary intervention (PCI) in a totally occluded artery (TIMI flow 0-1) versus medical therapy, 2) in stable post myocardial infarction (MI) patients without spontaneous or low level exercise induced ischemia, 3) trials with a time from the onset of symptoms to randomization >24 hours, but <6 weeks, and 4) trials reporting mortality and recurrent MI as an endpoint. Of 961 citations reviewed, 3 disagreements were easily resolved by discussion and 6 trials were selected for inclusion. Data Synthesis The primary endpoint was the composite of recurrent MI or death. The secondary endpoints were the development of heart failure or recurrent myocardial infarction. In a meta-analysis of the 6 trials, which included 2642 patients, late intervention of an IRA had a RR of death or recurrent MI of 1.12 (95% CI 0.91-1.38). Data regarding the development of heart failure was available for 4 trials. In a meta-analysis of these 4 trials, which included 2527 patients, late intervention of an IRA had a RR of 0.79 (95% CI 0.58-1.08). Data regarding the occurrence of recurrent MI was available for 5 trials. In a meta-analysis of these 5 trials, which included 2598 patients, late intervention of an IRA had a RR of 1.28 (95% CI 0.91-1.79). Conclusions Our meta-analysis of the currently available randomized data addressing late intervention of an occluded IRA failed to reveal clinical benefit with regard to the clinical endpoints of death, heart failure or reinfarction. The trend towards an increase in reinfarction among the PCI treated patients suggested by the Open Artery Trial (OAT) investigators persisted, but did not achieve statistical significance