Prognostische Bedeutung von Serumcholesterinwerten bei Patienten mit dilatativer Kardiomyopathie

ZIELE: Frühere Studien deuten darauf hin, daß Patienten mit chronischer Herzinsuffizienz und niedrigen Serumcholesterinwerten eine schlechte Prognose haben. Es wird vermutet, daß erhöhte Lipoproteinwerte bakterielle Endotoxine neutralisieren können, die über eine gestaute Darmwand in das Blutsystem eindringen. METHODEN UND ERGEBNISSE: Wir untersuchten bei 422 Patienten mit dilatativer Kardiomyopathie (DCM) [50 ± 12 Jahre, 342 Frauen, 80 Männer, linksventrikuläre Ejektionsfraktion (LV-EF): 32 ± 11%] die prognostische Bedeutung von Lipidwerten. Während einer mittleren Nachbeobachtungszeit von 42 Monaten verstarben 86 Patienten (20%) oder erhielten eine Herztransplantation. In der univariaten Cox Regressionsanalyse waren eine niedrige LV-EF, ein hohes NYHA-Stadium, und ein erhöhter linksventrikulärer enddiastolischer Diameter (LVEDD) starke Risikofaktoren für diesen Endpunkt, während niedriges Gesamtcholesterin, HDL-Cholesterin und Apolipoprotein AI nur schwache Prädiktoren waren. In der multivariaten Analyse zeigte sich, daß ausschließlich der LVEDD, das NYHA-Stadium und die LV-EF Parameter waren, die einen unabhängigen Beitrag zur Vorhersage des transplantatfreien Überlebens hatten (P<0,05). Die Cholesterinspiegel waren positiv mit der LV-EF und negativ mit dem LVEDD assoziiert (P<0,05). Zirkulierende sCD14-Spiegel, die als Marker für die Endotoxinbelastung beschrieben werden, zeigten einen signifikanten Zusammenhang mit den Cholesterinspiegeln (P<0,05) und der LV-EF (P<0,05). SCHLUSSFOLGERUNG: Niedriges Cholesterin ist kein unabhängiger Risikoprädiktor für die Prognose von Patienten mit dilatativer Kardiomyopathie. Unsere Ergebnisse deuten darauf hin, daß niedrige Cholesterinspiegel vom Schweregrad der Herzinsuffizienz abhängig sind

Prognostische Bedeutung von Serumcholesterinwerten bei Patienten mit dilatativer Kardiomyopathie

ZIELE: Frühere Studien deuten darauf hin, daß Patienten mit chronischer Herzinsuffizienz und niedrigen Serumcholesterinwerten eine schlechte Prognose haben. Es wird vermutet, daß erhöhte Lipoproteinwerte bakterielle Endotoxine neutralisieren können, die über eine gestaute Darmwand in das Blutsystem eindringen. METHODEN UND ERGEBNISSE: Wir untersuchten bei 422 Patienten mit dilatativer Kardiomyopathie (DCM) [50 ± 12 Jahre, 342 Frauen, 80 Männer, linksventrikuläre Ejektionsfraktion (LV-EF): 32 ± 11%] die prognostische Bedeutung von Lipidwerten. Während einer mittleren Nachbeobachtungszeit von 42 Monaten verstarben 86 Patienten (20%) oder erhielten eine Herztransplantation. In der univariaten Cox Regressionsanalyse waren eine niedrige LV-EF, ein hohes NYHA-Stadium, und ein erhöhter linksventrikulärer enddiastolischer Diameter (LVEDD) starke Risikofaktoren für diesen Endpunkt, während niedriges Gesamtcholesterin, HDL-Cholesterin und Apolipoprotein AI nur schwache Prädiktoren waren. In der multivariaten Analyse zeigte sich, daß ausschließlich der LVEDD, das NYHA-Stadium und die LV-EF Parameter waren, die einen unabhängigen Beitrag zur Vorhersage des transplantatfreien Überlebens hatten (P<0,05). Die Cholesterinspiegel waren positiv mit der LV-EF und negativ mit dem LVEDD assoziiert (P<0,05). Zirkulierende sCD14-Spiegel, die als Marker für die Endotoxinbelastung beschrieben werden, zeigten einen signifikanten Zusammenhang mit den Cholesterinspiegeln (P<0,05) und der LV-EF (P<0,05). SCHLUSSFOLGERUNG: Niedriges Cholesterin ist kein unabhängiger Risikoprädiktor für die Prognose von Patienten mit dilatativer Kardiomyopathie. Unsere Ergebnisse deuten darauf hin, daß niedrige Cholesterinspiegel vom Schweregrad der Herzinsuffizienz abhängig sind

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective: To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors. Design: Retrospective cohort study. Setting: Medical ICU of an academic tertiary care hospital. Patients: Atotal of 273 consecutive overdose admissions. Measurements and results: Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in apatient with alocalised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with ahigher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1-3) vs 1 (1-2), p = 0.025; and median 2 (1-7) vs 1 (1-3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7-0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7-11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 109/l 1.05; 95% CI 1.0-1.19; p = 0.049) were identified as independent risk factors. Conclusions: Clinically relevant aspiration pneumonitis is afrequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with ahigher incidence of cardiac arrest and increased ICU and total in-hospital sta

Sodium chloride vs. sodium bicarbonate for the prevention of contrast medium-induced nephropathy: a randomized controlled trial

Aims The most effective regimen for the prevention of contrast-induced nephropathy (CIN) remains uncertain. Our purpose was to compare two regimens of sodium bicarbonate with 24 h sodium chloride 0.9% infusion in the prevention of CIN. Methods and results We performed a prospective, randomized trial between March 2005 and December 2009, including 258 consecutive patients with renal insufficiency undergoing intravascular contrast procedures. Patients were randomized to receive intravenous volume supplementation with either (A) sodium chloride 0.9% 1 mL/kg/h for at least 12h prior and after the procedure or (B) sodium bicarbonate (166 mEq/L) 3 mL/kg for 1h before and 1 mL/kg/h for 6h after the procedure or (C) sodium bicarbonate (166 mEq/L) 3 mL/kg over 20min before the procedure plus sodium bicarbonate orally (500 mg per 10 kg). The primary endpoint was the change in estimated glomerular filtration rate (eGFR) within 48h after contrast. Secondary endpoints included the development of CIN. The maximum change in eGFR was significantly greater in Group B compared with Group A {mean difference −3.9 [95% confidence interval (CI), −6.8 to −1] mL/min/1.73 m2, P = 0.009} and similar between Groups C and B [mean difference 1.3 (95% CI, −1.7-4.3) mL/min/1.73 m2, P = 0.39]. The incidence of CIN was significantly lower in Group A (1%) vs. Group B (9%, P = 0.02) and similar between Groups B and C (10%, P = 0.9). Conclusion Volume supplementation with 24 h sodium chloride 0.9% is superior to sodium bicarbonate for the prevention of CIN. A short-term regimen with sodium bicarbonate is non-inferior to a 7 h regimen. ClinicalTrials.gov Identifier: NCT0013059

Multimarker strategy for risk prediction in patients presenting with acute dyspnea to the emergency department

BACKGROUND: Multimarker approaches improve risk prediction in patients presenting with acute coronary syndrome. We hypothesized that simultaneous assessment of B-type natriuretic peptide (BNP), cardiac troponin I (cTNI) and C-reactive protein (CRP) enables clinicians to better predict risk among patients with acute dyspnea presenting to the emergency department. METHODS AND RESULTS: In this post-hoc analysis of the B-Type natriuretic peptide for Acute Shortness of Breath Evaluation (BASEL) study, above biomarkers were available in 305 patients. Death occurred in 123 (40%) patients within 24 months of follow-up. Using prospectively defined cut-off points (BNP0.001 for trend). Elevated biomarkers significantly predicted increased risk of death at 24 months of follow-up in univariate Cox models (BNP: RR 4.78, 95%CI: 2.51-9.14; p>0.001; cTNI: RR: 2.29, 95%CI: 1.61-3.26, p>0.001; CRP: RR 1.98, 95%CI: 1.28-3.08; p=0.002). Multivariable Cox regression analysis revealed that elevated levels of BNP (p>0.001) and TNI levels (p>0.002) indicated increased risk of death during long-term follow-up, while only a statistical trend was seen for elevated CRP (p=0.09). Comparably, risk of death or rehospitalization significantly increased with the number of elevated biomarkers. CONCLUSIONS: Our findings suggest that a simple multimarker approach with simultaneous assessment of BNP, and cTNI demonstrates potential to assist clinicians in predicting risk of death and/or rehospitalization in patients presenting with acute dyspnea in the emergency department

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors.; Retrospective cohort study.; Medical ICU of an academic tertiary care hospital.; A total of 273 consecutive overdose admissions.; Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1-3) vs 1 (1-2), p = 0.025; and median 2 (1-7) vs 1 (1-3), p > 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7-0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7-11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10(9)/l 1.05; 95% CI 1.0-1.19; p = 0.049) were identified as independent risk factors.; Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay

Diagnostic and prognostic value of uric acid in patients with acute dyspnea

Uric acid was shown to predict outcome in patients with stable chronic heart failure. Its impact in patients admitted in the Emergency Department with acute dyspnea, however, remains unknown.; We prospectively investigated the diagnostic and prognostic value of uric acid in 743 unselected patients presenting to the Emergency Department with acute dyspnea.; Uric acid at admission was higher in patients with acute decompensated heart failure (51% of the cohort) as compared with patients with noncardiac causes of dyspnea (median, 447 micromol/L vs 340 micromol/L, P >.001). The area under the receiver operating characteristic curve for the accuracy to detect acute decompensated heart failure was inferior for uric acid (0.70) than for B-type natriuretic peptide (area under the receiver operating characteristic curve 0.91, P >.001). Patients in the highest uric acid tertile more often required admission to the hospital (92% vs 74% in the first tertile, P >.001) and had higher in-hospital mortality (13% vs 4% in the first tertile, P >.001). Cumulative 24-month mortality rates were 28% in the first, 31% in the second, and 50% in the third tertile (P >.001). After adjustment in multivariable Cox proportional hazard analysis, uric acid predicted 24-month mortality independently of B-type natriuretic peptide (P=.003).; Our study first shows that uric acid, measured at Emergency Department admission or hospital discharge, is a powerful predictor of long-term outcome in dyspneic patients