Plasma B-type natriuretic peptide levels are poorly related to the occurrence of ischemia or ventricular arrhythmias during symptom-limited exercise in low-risk patients

The usefulness of B-type natriuretic peptide (BNP) as a marker of ischemia is controversial. BNP levels have predicted arrhythmias in various settings, but it is unknown whether they are related to exercise-induced ischemic ventricular arrhythmias. We analyzed in 63 patients (64 ±14 years, 65% male, 62% with known coronary disease) undergoing exercise stress single-photon emission computed tomography (SPECT) the association between plasma BNP values (before and 15 min after exercise) and the occurrence of ischemia or ventricular arrhythmias during the test. Exercise test (8.1 ±2.7 min, 7.4 ±8.1 metabolic equivalents, 82 ±12% of maximal predicted heart rate) induced reversible perfusion defects in 23 (36%) patients. Eight (13%) patients presented significant arrhythmias (≥ 7 ventricular premature complexes/min, couplets, or non-sustained ventricular tachycardia during exercise or in the first minute of recovery). Median baseline BNP levels were 17.5 (12.4-66.4) pg/ml in patients developing scintigraphic ischemia and 45.6 (13.2-107.4) pg/ml in those without ischemia (p = 0.137). The BNP levels increased after exercise (34.4 (15.3-65.4)% increment over baseline, p < 0.001), but the magnitude of this increase was not related to SPECT positivity (35.7 (18.8-65.4)% vs. 27.9 (5.6-64.0)% in patients with and without ischemia, respectively, p = 0.304). No significant association was found between BNP values (at baseline or their change during the test) and ventricular arrhythmias. Plasma BNP values - at baseline or after exercise - were not associated with myocardial ischemia or with ventricular arrhythmia during exercise SPECT. These results highlight the limited usefulness of this biomarker to assess acute ischemia

Hospital and 4-year mortality predictors in patients with acute pulmonary edema with and without coronary artery disease

Long-term prognosis of acute pulmonary edema () remains ill defined. We evaluated demographic, echocardiographic, and angiographic data of 806 consecutive patients with with () and without coronary artery disease (non-) admitted from 2000 to 2010. Differences between hospital and long-term mortality and its predictors were also assessed. patients (n=638) were older and had higher incidence of diabetes and peripheral vascular disease than non- (n=168), and lower ejection fraction. Hospital mortality was similar in both groups (26.5% vs 31.5%; P =0.169) but recurrence was higher in patients (17.3% vs 6.5%; P <0.001). Age, admission systolic blood pressure, recurrence of , and need for inotropics or endotracheal intubation were the main independent predictors of hospital mortality. In contrast, overall mortality (70.0% vs 57.1%; P =0.002) and readmission for nonfatal heart failure after a 45-month follow-up (10-140; 17.3% vs 7.6%; P =0.009) were higher in than in non- patients. Age, peripheral vascular disease, and peak creatine kinase during index hospitalization, but not ejection fraction, were the main independent predictors of overall mortality, whereas coronary revascularization or valvular surgery were protective. These interventions were mostly performed during hospitalization index (294 of 307; 96%) and not intervened patients showed a higher risk profile. Long-term mortality in is high and higher in than in non- patients. Considering the different in-hospital and long-term mortality predictors herein described, which do not necessarily involve systolic function, it is conceivable that a more aggressive interventional program might improve survival in high-risk patients

Prothrombotic profile in patients with vasospastic or non vasospastic angina and non significant coronary stenosis

Background: Patients with vasospastic (VA) or non vasospastic angina (NVA) without significant coronary stenosis have a reduced risk of infarction but is unclear whether or not this may be attributable to a lack of prothrombotic profile - similar to that present in patients with stable coronary artery disease (CAD). Methods: Plasma levels of von Willebrand factor, total and free tissue factor pathway inhibitor, plasminogen activator inhibitor-1, and fibrinogen were analyzed in 15 patients with stable VA and 23 with NVA, all with vasoconstrictive response to acetylcholine although with different severity. Results were compared with those of 20 age-matched controls and 10 patients with CAD. Results: Plasma levels of von Willebrand factor in patients with VA or NVA were higher than in controls (207 ± 62 and 203 ± 69% vs 121 ± 38%, p < 0.001) and tended to be lower than in CAD patients (264 ± 65, p = 0.145). They also presented higher total tissue factor pathway inhibitor (123 ± 18 and 111 ± 25 vs 88 ± 14, ng/ml p < 0.001) and plasminogen activator inhibitor-1 levels than controls (51 ± 30 and 52 ± 31% vs 19 ± 9 ng/ml, p < 0.001) and similar to CAD patients (134 ± 23 and 62 ± 31, respectively, ns). Moreover, free tissue factor pathway inhibitor plasma levels were lower than controls (18 ± 5 and 17 ± 5 vs 23 ± 8 ng/ml, p = 0.002) and similar to CAD patients (14 ± 5, ns). Despite this prothrombotic condition none of VA or NVA patients presented a myocardial infarction during a 9 year follow-up, an observation also reported in larger series. Conclusions: During a stable phase of their disease, patients with VA or NVA present a prothrombotic profile that might eventually contribute to occurrence of myocardial infarction. The rarity of these events, however, may suggests that ill defined factors would protect these patients from coronary plaque rupture/fissure

Hospital and 4-year mortality predictors in patients with acute pulmonary edema with and without coronary artery disease

Long-term prognosis of acute pulmonary edema () remains ill defined. We evaluated demographic, echocardiographic, and angiographic data of 806 consecutive patients with with () and without coronary artery disease (non-) admitted from 2000 to 2010. Differences between hospital and long-term mortality and its predictors were also assessed. patients (n=638) were older and had higher incidence of diabetes and peripheral vascular disease than non- (n=168), and lower ejection fraction. Hospital mortality was similar in both groups (26.5% vs 31.5%; P =0.169) but recurrence was higher in patients (17.3% vs 6.5%; P <0.001). Age, admission systolic blood pressure, recurrence of , and need for inotropics or endotracheal intubation were the main independent predictors of hospital mortality. In contrast, overall mortality (70.0% vs 57.1%; P =0.002) and readmission for nonfatal heart failure after a 45-month follow-up (10-140; 17.3% vs 7.6%; P =0.009) were higher in than in non- patients. Age, peripheral vascular disease, and peak creatine kinase during index hospitalization, but not ejection fraction, were the main independent predictors of overall mortality, whereas coronary revascularization or valvular surgery were protective. These interventions were mostly performed during hospitalization index (294 of 307; 96%) and not intervened patients showed a higher risk profile. Long-term mortality in is high and higher in than in non- patients. Considering the different in-hospital and long-term mortality predictors herein described, which do not necessarily involve systolic function, it is conceivable that a more aggressive interventional program might improve survival in high-risk patients