Performance of prognostic risk scores in chronic heart failure patients enrolled in the European Society of Cardiology Heart Failure long-term registry

[Abstract] Objectives. This study compared the performance of major heart failure (HF) risk models in predicting mortality and examined their utilization using data from a contemporary multinational registry. Background. Several prognostic risk scores have been developed for ambulatory HF patients, but their precision is still inadequate and their use limited. Methods. This registry enrolled patients with HF seen in participating European centers between May 2011 and April 2013. The following scores designed to estimate 1- to 2-year all-cause mortality were calculated in each participant: CHARM (Candesartan in Heart Failure-Assessment of Reduction in Mortality), GISSI-HF (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico-Heart Failure), MAGGIC (Meta-analysis Global Group in Chronic Heart Failure), and SHFM (Seattle Heart Failure Model). Patients with hospitalized HF (n = 6,920) and ambulatory HF patients missing any variable needed to estimate each score (n = 3,267) were excluded, leaving a final sample of 6,161 patients. Results. At 1-year follow-up, 5,653 of 6,161 patients (91.8%) were alive. The observed-to-predicted survival ratios (CHARM: 1.10, GISSI-HF: 1.08, MAGGIC: 1.03, and SHFM: 0.98) suggested some overestimation of mortality by all scores except the SHFM. Overprediction occurred steadily across levels of risk using both the CHARM and the GISSI-HF, whereas the SHFM underpredicted mortality in all risk groups except the highest. The MAGGIC showed the best overall accuracy (area under the curve [AUC] = 0.743), similar to the GISSI-HF (AUC = 0.739; p = 0.419) but better than the CHARM (AUC = 0.729; p = 0.068) and particularly better than the SHFM (AUC = 0.714; p = 0.018). Less than 1% of patients received a prognostic estimate from their enrolling physician. Conclusions. Performance of prognostic risk scores is still limited and physicians are reluctant to use them in daily practice. The need for contemporary, more precise prognostic tools should be considered

Early evaluation of global, regional and intramyocardial left ventricular function after acute myocardial infarction with a new ultrasonic software

Lo studio valuta la funzione ventricolare sinistra in corso di STEMI, mediante una nuova tecnica ultrasonica computerizzata. E’ stato eseguito un ecocardiogramma convenzionale all’ingresso in UTIC (t0), in 3° (t1) ed in 6° giornata (t2) post-IMA, con l’acquisizione di immagini bidimensionali, per l’analisi quantitativa. Le immagini ecocardiografiche sono state sottoposte ad analisi mediante il programma “Diogene”. Sono stati arruolati 39 pazienti suddivisi in due gruppi; gruppo 0 (20 pz) nel quale si realizza un miglioramento dell’EF% da t0 a t2 (p= 0.01) e gruppo 1 (19 pz) nel quale l’EF% si mantiene stabile o peggiora (p=0.04). Con il programma Diogene è stata calcolato il valore della frazione di eiezione (EFc); i risultati documentano come vi sia, in analogia con quanto rilevato dall’operatore, un significativo aumento dell’EFc da t0 a t2 nel gruppo 0 (p=0.03) ed una riduzione nel gruppo 1 (p=0.05). La correlazione dei dati relativi all’EF% valutata dall’operatore e calcolata da Diogene, è risultata statisticamente significativa (p<0.001). Lo studio della funzione intramiocardica, ha evidenziato come il picco di strain, a t0, sia un parametro predittivo della tendenza del ventricolo sinistro al rimodellamento già a sei giorni di distanza dall’evento acuto; infatti il gruppo 1 presenta nella regione infartuata una riduzione statisticamente significativa del picco di strain (p=0.05)

Debate: Should the elderly receive thrombolytic therapy or primary angioplasty?

Thrombolysis and primary angioplasty are both recommended reperfusion strategies for elderly patients presenting with myocardial infarction (MI). Primary angioplasty is most beneficial in high-risk patients. While the elderly have a high absolute risk of dying or developing complications after MI, they also have an increased risk of intracranial haemorrhage if they are given thrombolytic therapy. It could therefore be reasonably argued that primary angioplasty is the reperfusion strategy of choice in the elderly. However, primary angioplasty has not been shown to have a greater relative benefit than thrombolytic therapy in the elderly. Recent data from the Fibrinolytic Therapy Trialists' (FTT) Collaborative Group show that thrombolytic therapy significantly reduces mortality compared with control treatment in patients over 75 years of age presenting within 12 h of symptom onset, with ST-segment elevation or bundle branch block. Future advances in adjunctive therapies may improve myocyte perfusion and hence the outcomes achieved by both invasive and noninvasive reperfusion strategies. Better thrombolytic regimens incorporating adjunctive agents such as bivalirudin may reduce the risk of intracranial haemorrhage. Few hospitals can provide a 24-h primary angioplasty service with door-to-balloon times consistently less than 90 min, and thrombolytic therapy is therefore a far more practical option in most instances

Angiotensin-Converting Enzyme Inhibitor Therapy Affects Left Ventricular Mass in Patients With Ejection Fraction >40% After Acute Myocardial Infarction

AbstractObjectives. We tested the hypothesis that angiotensin-converting enzyme (ACE) inhibitor therapy decreases left ventricular (LV) mass in patients with a left ventricular ejection fraction (LVEF) >40% and no evidence of heart failure after their first acute Q wave myocardial infarction (MI).Background. Recently, ACE inhibitor therapy has been shown to have an early mortality benefit in unselected patients with acute MI, including patients without heart failure and a LVEF >35%. However, the effects on LV mass and volume in this patient population have not been studied.Methods. Thirty-five patients with a LVEF >40% after their first acute Q wave MI were randomized to titrated oral ramipril (n = 20) or conventional therapy (control, n = 15). Magnetic resonance imaging (MRI) performed an average of 7 days and 3 months after MI provided LV volumes and mass from summated serial short-axis slices.Results. Left ventricular end-diastolic volume index did not change in ramipril-treated patients (62 ± 16 [SD] to 66 ± 17 ml/m2) or in control patients (62 ± 16 to 68 ± 17 ml/m2), and stroke volume index increased significantly in both groups. However, LV mass index decreased in ramipril-treated patients (82 ± 18 to 73 ± 19 g/m2, p = 0.0002) but not in the control patients (77 ± 15 to 79 ± 23 g/m2). Systolic arterial pressure did not change in either group at 3-month follow-up.Conclusions. In patients with a LVEF >40% after acute MI, ramipril decreased LV mass, and blood pressure and LV function were unchanged after 3 months of therapy. Whether the decrease in mass represents a sustained effect that is associated with a decrease in morbid events requires further investigation.(J Am Coll Cardiol 1997;29:49–54)

Drug therapy for acute myocardial infarction at Hospital de Clínicas de Porto Alegre

OBJETIVO: Determinar a taxa de prescrição de trombolíticos, aspirina, betabloqueadores e inibidores da enzima conversora da angiotensina na fase aguda do infarto e, no caso dos três últimos fármacos citados, na profilaxia secundária do infarto agudo do miocárdio. MATERIAIS E MÉTODOS: As taxas de prescrição foram determinadas mediante revisão de prontuários de todos os pacientes que estiveram internados com o diagnóstico de infarto agudo do miocárdio no Hospital de Clínicas de Porto Alegre entre janeiro de 1996 e fevereiro de 1997. RESULTADOS: Foram identificados 100 pacientes, com uma idade média de 63 ± 13 anos, 58% homens e 89% brancos. As taxas de prescrição dos fármacos na fase aguda foram: 41% para trombolíticos, 97% para aspirina, 81% para betabloqueadores e 38% para inibidores da enzima conversora. As taxas de prescrição na profilaxia secundária foram: 71% para aspirina, 68% para beta-bloqueadores e 45% para inibidores da enzima conversora. CONCLUSÃO: As taxas de prescrição dos fármacos acima citados ainda encontramse abaixo dos valores ideais, apesar de serem comparáveis às taxas relatadas na literatura.OBJECTIVE: To determine the prescription rates of thrombolytics, aspirin, betaadrenergic antagonists and angiotensin-converting-enzyme inhibitors during the acute phase of the infarction, and to determine the prescription rates of aspirin, betaadrenergic antagonists, and angiotensin-converting-enzyme inhibitors for secondary prophylaxis. MATERIALS AND METHODS: The prescription rates were determined by reviewing the medical records of all patients whose diagnosis of acute myocardial infarction was made at Hospital de Clínicas de Porto Alegre from January 1996 to February 1997. RESULTS: We identified 100 patients, with a mean age of 63 ± 13 years, 58% men and 89% white. The drug prescription rates in the acute phase were: 41% for thrombolytics, 97% for aspirin, 81% for beta-adrenergic antagonists and 38% for angiotensin-converting-enzyme inhibitors. The secondary prophylaxis prescription rates were: 71% for aspirin, 68% for beta-adrenergic antagonists and 45% for angiotensin-converting-enzyme inhibitors. CONCLUSION: The prescripition rates forthe drugs listed above are still bellow the ideal ranges, although they are comparable to the rates reported in the medical literature

Effects Of Attenuation And Thrombus Age On The Success Of Ultrasound And Microbubble-Mediated Thrombus Dissolution

The purpose of this study was to examine the effects of applied mechanical index, incident angle, attenuation and thrombus age on the ability of 2-D vs. 3-D diagnostic ultrasound and microbubbles to dissolve thrombi. A total of 180 occlusive porcine arterial thrombi of varying age (3 or 6 h) were examined in a flow system. A tissue-mimicking phantom of varying thickness (5 to 10 cm) was placed over the thrombosed vessel and the 2-D or 3-D diagnostic transducer aligned with the thrombosed vessel using a positioning system. Diluted lipid-encapsulated microbubbles were infused during ultrasound application. Percent thrombus dissolution (%TD) was calculated by comparison of clot mass before and after treatment. Both 2-D and 3-D-guided ultrasound increased %TD compared with microbubbles alone, but %TD achieved with 6-h-old thrombi was significantly less than 3-h-old thrombi. Thrombus dissolution was achieved at 10 cm tissue-mimicking depths, even without inertial cavitation. In conclusion, diagnostic 2-D or 3-D ultrasound can dissolve thrombi with intravenous nontargeted microbubbles, even at tissue attenuation distances of up to 10 cm. This treatment modality is less effective, however, for older aged thrombi. (E-mail: [email protected]) (C) 2011 World Federation for Ultrasound in Medicine & Biology

Stroke in Patients With Acute Coronary Syndromes: Incidence and Outcomes in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial

BACKGROUND: The incidence of stroke in patients with acute coronary syndromes has not been clearly defined because few trials in this patient population have been large enough to provide stable estimates of stroke rates. METHODS AND RESULTS: We studied the 10 948 patients with acute coronary syndromes without persistent ST-segment elevation who were randomly assigned to placebo or the platelet glycoprotein IIb/IIIa receptor inhibitor eptifibatide in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial to determine stroke rates, stroke types, clinical outcomes in patients with stroke, and independent baseline clinical predictors for nonhemorrhagic stroke. Stroke occurred in 79 (0.7%) patients, with 66 (0.6%) nonhemorrhagic, 6 intracranial hemorrhages, 3 cerebral infarctions with hemorrhagic conversion, and 4 of uncertain cause. There were no differences in stroke rates between patients who received placebo and those assigned high-dose eptifibatide (odds ratios and 95% confidence intervals 0.82 [0.59, 1.14] and 0.70 [0.49, 0.99], respectively). Of the 79 patients with stroke, 17 (22%) died within 30 days, and another 26 (32%) were disabled by hospital discharge or 30 days, whichever came first. Higher heart rate was the most important baseline clinical predictor of nonhemorrhagic stroke, followed by older age, prior anterior myocardial infarction, prior stroke or transient ischemic attack, and diabetes mellitus. These factors were used to develop a simple scoring nomogram that can predict the risk of nonhemorrhagic stroke. CONCLUSIONS: Stro

The Impact of Hypertension on Patients with Acute Coronary Syndromes

Arterial chronic hypertension (HTN) is a well-known cardiovascular risk factor for development of atherosclerosis. In order to explain the relation between HTN and acute coronary syndromes the following factors should be considered: (1) risk factors are shared by the diseases, such as genetic risk, insulin resistance, sympathetic hyperactivity, and vasoactive substances (i.e., angiotensin II); (2) hypertension is associated with the development of atherosclerosis (which in turn contributes to progression of myocardial infarction). From all the registries and the data available up to now, hypertensive patients with ACS are more likely to be older, female, of nonwhite ethnicity, and having a higher prevalence of comorbidities. Data on the prognostic role of a preexisting hypertensive state in ACS patients are so far contrasting. The aim of the present paper is to focus on hypertensive patients with ACS, in order to better elucidate whether these patients are at higher risk and deserve a tailored approach for management and followup