Relationship between low Ankle-Brachial Index and rapid renal function decline in patients with atrial fibrillation: A prospective multicentre cohort study

OBJECTIVE: To investigate the relationship between Ankle-Brachial Index (ABI) and renal function progression in patients with atrial fibrillation (AF). DESIGN: Observational prospective multicentre cohort study. SETTING:Atherothrombosis Center of I Clinica Medica of 'Sapienza' University of Rome; Department of Medical and Surgical Sciences of University Magna Græcia of Catanzaro; Atrial Fibrillation Registry for Ankle-Brachial Index Prevalence Assessment-Collaborative Italian Study. PARTICIPANTS: 897 AF patients on treatment with vitamin K antagonists. MAIN OUTCOME MEASURES: The relationship between basal ABI and renal function progression, assessed by the estimated Glomerular Filtration Rate (eGFR) calculated with the CKD-EPI formula at baseline and after 2 years of follow-up. The rapid decline in eGFR, defined as a decline in eGFR >5 mL/min/1.73 m(2)/year, and incident eGFR<60 mL/min/1.73 m(2) were primary and secondary end points, respectively. RESULTS: Mean age was 71.8±9.0 years and 41.8% were women. Low ABI (ie, ≤0.90) was present in 194 (21.6%) patients. Baseline median eGFR was 72.7 mL/min/1.73 m(2), and 28.7% patients had an eGFR60 mL/min/1.73 m(2), 153 (23.9%) had a reduction of the eGFR <60 mL/min/1.73 m(2). ABI ≤0.90 was also an independent predictor for incident eGFR<60 mL/min/1.73 m(2) (HR 1.851, 95% CI 1.205 to 2.845, p=0.005). CONCLUSIONS: In patients with AF, an ABI ≤0.90 is independently associated with a rapid decline in renal function and incident eGFR<60 mL/min/1.73 m(2). ABI measurement may help identify patients with AF at risk of renal function deterioration

Frequency of left ventricular hypertrophy in non-valvular atrial fibrillation

Left ventricular hypertrophy (LVH) is significantly related to adverse clinical outcomes in patients at high risk of cardiovascular events. In patients with atrial fibrillation (AF), data on LVH, that is, prevalence and determinants, are inconsistent mainly because of different definitions and heterogeneity of study populations. We determined echocardiographic-based LVH prevalence and clinical factors independently associated with its development in a prospective cohort of patients with non-valvular (NV) AF. From the "Atrial Fibrillation Registry for Ankle-brachial Index Prevalence Assessment: Collaborative Italian Study" (ARAPACIS) population, 1,184 patients with NVAF (mean age 72 \ub1 11 years; 56% men) with complete data to define LVH were selected. ARAPACIS is a multicenter, observational, prospective, longitudinal on-going study designed to estimate prevalence of peripheral artery disease in patients with NVAF. We found a high prevalence of LVH (52%) in patients with NVAF. Compared to those without LVH, patients with AF with LVH were older and had a higher prevalence of hypertension, diabetes, and previous myocardial infarction (MI). A higher prevalence of ankle-brachial index 640.90 was seen in patients with LVH (22 vs 17%, p = 0.0392). Patients with LVH were at significantly higher thromboembolic risk, with CHA2DS2-VASc 652 seen in 93% of LVH and in 73% of patients without LVH (p &lt;0.05). Women with LVH had a higher prevalence of concentric hypertrophy than men (46% vs 29%, p = 0.0003). Logistic regression analysis demonstrated that female gender (odds ratio [OR] 2.80, p &lt;0.0001), age (OR 1.03 per year, p &lt;0.001), hypertension (OR 2.30, p &lt;0.001), diabetes (OR 1.62, p = 0.004), and previous MI (OR 1.96, p = 0.001) were independently associated with LVH. In conclusion, patients with NVAF have a high prevalence of LVH, which is related to female gender, older age, hypertension, and previous MI. These patients are at high thromboembolic risk and deserve a holistic approach to cardiovascular prevention

Take back the \u2018\u2018ultrasonographic stethoscope\u2019\u2019

Background: Cardiovascular pathology represents one of the most prevalent disease in Internal Medicine departments; echocardiography represents an essential method for its diagnosis and follow-up. Moreover, it is necessary for an internist to master ultrasonography in most of its various applications, being Internal Medicine departments in the center of the diagnostic process of most of the medical pathologies. Methods: For this reason our department programmed in the formative package of ASUR7, an echocardiography course; internists of different hospitals received yearly 92 h of theoretical-practical training. A certificate of attendance was released after overcoming a final examination. The course was done mainly bedside, focusing on the pathologies of the patients admitted to the Internal Medicine Department of the Osimo Hospital. Every session was guided by 3 expert tutors (one for patient) and 4 trainees for each tutor. Results: In two years 30 internists of our region (specialists coming from different hospitals or post graduate from the internal medicine school of the Marche Polytechnic University) got the \u2018\u2018stethoscope of the third millennium\u2019\u2019 back in their hands. Conclusions: this experience can well represent not only the skill acquisition, but facilitates the Internist to holistic vision of patient and strengthens his diagnostic capacity

BNP levels are related to days of hospitalization independently to the pathology in critical care settings

Background: Increased brain natriuretic peptide (BNP) levels have been related to several conditions, such as acute heart failure (AHF), pulmonary embolism (PE) and acute coronary syndromes (ACS). Particularly among elderly patients, a longer hospitalization is related to higher morbidity and mortality. The usefulness of BNP as a prognostic factor is amply demonstrated in different subpopulations of both medical and surgical patients. Aims: To evaluate the relationship between BNP levels and length of in-hospital stay in patients with PE, ACS, AHF, septic and cardiogenic shock admitted to our internal medicine department (IMD). Methods: We retrospectively evaluated 500 consecutive patients admitted to our IMD. BNP was evaluated at the admission in all the patients. Each patient underwent a complete diagnostic workup. We evaluated the curve-fit correlation between BNP levels and days of hospitalization using SPSS 13.0 for windows systems. Results: Mean age was 80 \ub1 9.85 years, males representing 58 % of the sample. AHF represented 74.9 %, ACS 13.5 %, PE 11.6 % of the sample. We found that BNP levels and days of hospitalization were better described by a logarithmic regression model (R2: 0.674, p\0.0001) (Figure 1). Conclusions: Among elderly patients admitted in an IMDs, higher BNP levels are associated to longer hospitalizations independently to the pathology. This relationship is better described by a logarithmic regression model. However, larger cohorts are required to validate this observation

A different use of the CHA2DS2-VASc: Risk stratification of early recurrence of atrial fibrillation

Background: Cardioembolic pathology is themain cause ofmortality and morbidity in hemodynamically stable patients affected with atrial fibrillation (AF). The risk of embolic events is significantly increased from recurrences after cardioversion (CV). No difference has been described in the survival rate and incidence of embolic events in patient undergoing rhythm or rate control combined with an appropriate anticoagulant therapy. CHA2DS2-VASc is a score that allows clinicians to stratify embolic risk in patients affected by non-valvular AF. Each itemcan be involved in triggering and maintaining AF. CHA2DS2-VASc score may help to predict early recurrences of AF after CV. Methods: 298 consecutive patients, admitted to our Emergency Department (ED) for hemodynamically stable persistent AF, were enrolled and treated with electrical or pharmacological sinus rhythm (SR) restoration. Patients with acute heart failure, acute pulmonary embolism, acute coronary syndrome (ACS), hyperthyroidism, valvular AF, and left atrium diameter above 50 mm, were excluded from further analyses for the higher risk of AF relapse after cardioversion. Oral anticoagulants and amiodarone were started three weeks before cardioversion. Patients with suboptimal control of oral anticoagulant levels and unsuccessful cardioversion procedure were also excluded. Outcome was defined as stability of SR within 24 h from procedure. Predicted probability of SR stability was assessed with an ordinal regression model using CHA2DS2-VASc as independent variable. Results: 213 patients were suitable for the final analysis. 140 patients underwent to electrical, 73 to pharmacologic cardioversion. The ordinal regression model resulted statistically significant (p b 0.05), showing a progressive decrease in the predicted probability of SR stability after electrical or pharmacological CV along with the increase in the CHA2DS2- VASc score. A logarithmic relationship was found to be the best-fit trend among CHA2DS2-VASc ranks and the predicted probability of SR stability both in patients undergoing electrical and pharmacological CV (r2=0.98, p b 0.05 for electric cardioversion; r2=0.91, p b 0.05 for pharmacological CV). CHA2DS2-VASc was related to an increased likelihood of SR stability for scores ranging between 0 and 2 for electric procedures while pharmacologic sinus rhythm restoration seemed to be more stable even in higher CHA2DS2-VASc ranks. Conclusions: Our preliminary results suggest that CHA2DS2-VASc score could be useful in evaluating the risk of early recurrence of AF after cardioversion. According to our findings, CHA2DS2-VASc could be suggested as a useful stratification tool for themanagement of hemodynamically stable elderly patient with AF. This information may have implications for disease monitoring and treatment strategies in clinical practice

Usefulness of echocardiography and tissue Doppler imaging (tDI) in the management of the acute patient: a clinical case report

ase Presentation Male, 64 years old,overweight,hypertensive,current smoker. Arrived to our emergency department(ED)for epigastric pain, swe-ating, nausea, bradicardia (45 bpm) and hypotension. At physical exami-nation, pain at palpation in epigastric region. At admission ECG,sinus bradicardia, negative T-waves in inferior leads without ST-segment altera-tions. Blood chemistry showed troponin I 2.18 ng/ml, d-Dimers 1290 ng/ml. Echocardiography showed hypokinesis of left ventricle inferior wall associated to diffuse hypokinesis and systodiastolic dysfunction of right ventricle RV), as diagnosed with TDI (TAPSE not evaluated for suboptimal window). Right chambers didn\u2019t result dilated,with normal PAPs.Inferior vena cava was dilated (25 mm) and non-collapsing.Our first diagnosis was RV NSTEMI-ACS, and the patients was treated and then admitted in our Internal Medicine Department (critical care area). At arrival, a new ECG showed 1 mm ST-elevation in DII,DIII and aVF leads,associated with epi-gastric pain. Patient was then taken to our Hub hospital for urgent corona-rographic examination, which showed an occlusion of 100% in proximal right coronary artery with a large endoluminal thrombotic occlusion. After PTCA and stenting,the patient was admitted again in our department in good clinical conditions.conclusion Echocardiography and ultrasound examination,integrated with TDI examination can be useful to the Internist working in ED and in critical care area for a correct and fast diagnosis. In this case,it is important to enlighten how echocardiography allowed a correct bedside differential diagnosis

Serum Uric Acid, Kidney Function and Acute Ischemic Stroke Outcomes in Elderly Patients: A Single-Cohort, Perspective Study.

Chronic kidney disease and hyperuricemia have been associated to an increased risk and a worse prognosis in acute ischemic stroke. Several mechanisms, including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and an increased risk of atrial fibrillation could be implicated. The role of serum uric acid in this setting is still object of debate. We enrolled all the consecutive patients admitted to our department for acute ischemic stroke. Cox regression analysis was used to evaluate the risk of in-hospital death considering serum uric acid levels and all the comorbidities. In the overall sample, hyperuricemia was independently associated to an increased risk of in-hospital mortality. This effect was stronger in patients with chronic kidney disease while, in the group of patients with normal renal function, the relationship between hyperuricemia and increased stroke mortality was not confirmed. Hyperuricemia could be associated to higher in-hospital mortality for ischemic stroke among elderly patients when affected by kidney disease. Survival does not seem to be affected by hyperuricemia in patients with normal kidney function

It is time for a SOFA-T score ?

Introduction:SOFA score predicts prognosis and in-hospital mortalityin septic patients, with a known AUC of 0.90. Troponin I (TnI) is amarker of myocardial injury and can be related to MOF and septic car-diomyopathy. We evaluated if adding TnI to SOFA score resulted in abetter prognostic performance in sepsis.Methods:49 septic patients were enrolled and prospectively followed-up. Outcome was in-hospital mortality, coded as binary. All the chroniccomorbidities and TnI were synthesized in different binary variables.SOFA score was coded as an ordinal variable: PaO2, FiO2, plateletcount, GCS, bilirubin, blood pressure and serum creatinine were thesingle items of the scale. SOFA-T was calculated adding 1 point to SSif TnI level was >0.05ng/ml. ROC curve analysis was performed withSPSS 13.0 for Windows.Results:Mean age was 75,83years(\ub113,14 years), males were54,8%. 35,7% of the patients died during the hospitalization. Of thesample, 45,4% were affected by diabetes, 73,7% by chronic cardio-vascular disease, 36,8% by cancer, 21,1% by hepatic disease, 52,6%by CKD, 36,8% by COPD, 26,3% by chronic neurologic disorders,15,8% by chronic haematologic pathologies, 31,6% by chronic gas-troenterologic disorders. SOFA had an AUC of 0.904(95%CI:0.718-1.089) in predicting in-hospital mortality. SOFA-T had an AUC of0.923(95%CI:0.768-1.078) for the same outcome. The difference be-tween the two ROC curves was statistically significant(p<0.05).Discussion:TnI increase could be associated to a worse prognosis insepsis. When included in SOFA, it enhances the AUC and the predictive value of this index

Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients

- Background: e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies. - Objectives: The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients. - Methods: A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed. - Results: a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral. - Conclusions: MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems. - Abbreviations: GP, General practitioner; ICT, Information and communication technologies; MEV, Medical error vulnerability; MT, Medical teleconsultation; WHO, World Health Organization; ITU, International Technology Uni