B-type natriuretic peptide as a predictor of anterior wall location in patients with non-ST-elevation myocardial infarction

OBJECTIVE: Involvement of the left ventricular anterior wall in ST-elevation myocardial infarction has a worse prognosis compared with other regions. In non-ST-elevation myocardial infarction, noninvasive methods of locating the ischemic myocardial territory have been limited. The objective of this report is therefore to determine what factors are predictive of the anterior location of the ischemic myocardial territory. METHODS: This study included 170 patients with non-ST-elevation myocardial infarction. Clinical, echocardiographic, and laboratory characteristics, including B-type natriuretic peptide measured within 24 hours of hospitalization, and coronary angiographic features were analyzed. RESULTS: The mean age was 64.5 ± 12.3 years, and 112 of the patients were male (66%). The median follow-up was 23 months. The territory involved, as determined from the angiogram, was divided into anterior [n = 80 (47%)] regions and inferior and lateral [n = 90 (53%)] regions. Multivariate analysis showed that B-type natriuretic peptide was the only independent predictor of an anterior wall infarct [OR = 3.70 (95% CI: 1.61 - 8.53); P = 0.002] in non-STelevation myocardial infarction patients. Multivariate analysis also showed that B-type natriuretic peptide was an independent predictor of in-hospital cardiac events during index admission [OR = 5.05 (95% CI: 1.49 - 17.12); P = 0.009] and of cardiac events occurring during follow-up [HR = 1.79 (95% CI: 1.05 - 3.04); P = 0.032]. CONCLUSIONS: B-type natriuretic peptide was the only factor independently associated with anterior wall involvement in non-ST-elevation myocardial infarction, and the peptide levels upon admission predicted in-hospital and subsequent cardiac events

In-hospital death in acute coronary syndrome was related to admission glucose in men but not in women

<p>Abstract</p> <p>Background</p> <p>Admission hyperglycaemia is associated with mortality in patients with acute coronary syndrome (ACS), but controversy exists whether hyperglycaemia uniformly affects both genders. We evaluated coronary risk factors, gender, hyperglycaemia and their effect on hospital mortality.</p> <p>Methods</p> <p>959 ACS patients (363 women and 596 men) were grouped based on glycaemia ≥ or < 200 mg/dL and gender: men with glucose < 200 mg/dL (menG-); women with glucose < 200 mg/dL (womenG-); men with glucose ≥ 200 mg/dL (menG+); and women with glucose ≥ 200 mg/dL (womenG+). A logistic regression analysis compared the relation between gender and glycaemia groups and death, adjusted for coronary risk factors and laboratory data.</p> <p>Results group</p> <p>menG- had lower mortality than menG + (OR = 0.172, IC95% 0.062-0.478), and womenG + (OR = 0.275, IC95% 0.090-0.841); womenG- mortality was lower than menG + (OR = 0.230, IC95% 0.074-0.717). No difference was found between menG + vs womenG + (p = 0.461), or womenG- vs womenG + (p = 0.110). Age (OR = 1.067, IC95% 1.031–1.104), EF (OR = 0.942, IC95% 0.915-0.968), and serum creatinine (OR = 1.329, IC95% 1.128-1.566) were other independent factors related to in-hospital death.</p> <p>Conclusions</p> <p>Death was greater in hyperglycemic men compared to lower blood glucose men and women groups, but there was no differences between women groups in respect to glycaemia after adjustment for coronary risk factors.</p

BNP and Admission Glucose as In-Hospital Mortality Predictors in Non-ST Elevation Myocardial Infarction

Objectives. Admission hyperglycemia and B-type natriuretic peptide (BNP) are associated with mortality in acute coronary syndromes, but no study compares their prediction in-hospital death. Methods. Patients with non-ST-elevation myocardial infarction (NSTEMI), in-hospital mortality and two-year mortality or readmission were compared for area under the curve (AUC), sensitivity (SEN), specificity (SPE), positive predictive value (PPV), negative predictive value (NPV), and accuracy (ACC) of glycemia and BNP. Results. Respectively, AUC, SEN, SPE, PPV, NPV, and ACC for prediction of in-hospital mortality were 0.815, 71.4%, 84.3%, 26.3%, 97.4%, and 83.3% for glycemia = 200 mg/dL and 0.748, 71.4%, 68.5%, 15.2%, 96.8% and 68.7% for BNP = 300 pg/mL. AUC of glycemia was similar to BNP (P = 0.411). In multivariate analysis we found glycemia ≥200mg/dL related to in-hospital death (P = 0.004). No difference was found in two-year mortality or readmission in BNP or hyperglycemic subgroups. Conclusion. Hyperglycemia was an independent risk factor for in-hospital mortality in NSTEMI and had a good ROC curve level. Hyperglycemia and BNP, although poor in-hospital predictors of unfavorable events, were independent risk factors for death or length of stay >10 days. No relation was found between hyperglycemia or BNP and long-term events

Value of B-type natriuretic peptide and other variables as predictors of location of the territory of acute myocardial ischemia and for the prognostic evaluation in non-ST-elevation myocardial infarction

INTRODUÇÃO: No infarto agudo do miocárdio sem supradesnivelamento do segmento de ST (IAMSS) ocorre limitação dos métodos diagnósticos atuais para localizar o território do ventrículo esquerdo em risco e realizar avaliação prognóstica. O objetivo deste estudo prospectivo foi determinar no IAMSS, quais fatores apresentam capacidade de predizer a localização do território miocárdico isquêmico e possuem capacidade prognóstica independente para a ocorrência de mortalidade, eventos durante internação hospitalar e evento combinado durante seguimento de longo prazo. MÉTODOS: No período de janeiro de 2005 a abril de 2006 foram incluídos 204 pacientes com IAMSS na Unidade Clínica de Emergência do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A mediana do tempo de internação foi de 3 dias com mínimo de 1 e máximo de 125 dias. A mediana do tempo de seguimento foi de 23 meses com mínimo de 1 dia e máximo de 32 meses. O território envolvido foi determinado a partir da identificação da artéria acometida na cineangiocoronariografia e agrupado em: território anterior [n=80 (44,4%)] e inferior e lateral [n=90 (50%)]. RESULTADOS: A média de idade foi de 64,5±12,3 anos; sexo masculino 126 (61,8%). A mediana do peptídeo natriurético tipo B (BNP) foi de 214,5 pg/mL e variou de 7 a 2291 pg/mL. A análise multivariada por regressão logística da capacidade preditiva do território envolvido anterior vs inferior e lateral mostrou o BNP como preditor independente [BNP > 210 pg/mL, OR = 3,44 (IC 95%:1,46 - 8,06); p = 0,005]. A análise multivariada por regressão logística mostrou que o valor de BNP foi preditor independente para a ocorrência de eventos intra-hospitalares [BNP > 240 pg/mL, n = 78, OR = 5,05 (IC 95%: 1,49 - 17.12); p = 0,009] e a análise multivariada pelo modelo de regressão de Cox, mostrou que o BNP também foi preditor independente para evento combinado durante o seguimento de longo prazo [BNP > 156 pg/mL, n = 148, HR = 1,79 (IC 95%: 1,05 - 3,04); p = 0,032], mas não foi preditor independente para óbito geral [BNP > 238 pg/mL, n = 44, HR = 1,45 (IC 95%: 0,67 - 3,13); p = 0,343] . CONCLUSÕES: O BNP foi a única variável com capacidade preditiva independente para identificar o território miocárdico isquêmico da parede anterior no IAMSS. O BNP na admissão foi fator prognóstico independente para eventos intrahospitalares e para evento combinado durante seguimento no IAMSS.INTRODUCTION: In non-ST-elevation myocardial infarction (NSTEMI) there is a limitation of the current diagnostic methods with respect to locating the left ventricular territory at risk as well as to carrying out a prognostic assessment. The objective of this prospective study was to determine, in the context of NSTEMI, which factors are predictive of the location of the ischemic myocardial territory and are independent predictors of the occurrence of mortality, in-hospital events, and composite events during a long-term follow-up. METHODS: In the period from January 2005 to April 2006, 204 patients with NSTEMI seen in the Emergency Department of the Heart Institute (InCor), University of Sao Paulo Medical School were included in the study. The median length of hospital stay was three days, ranging from one to 125 days. The median follow-up period was 23 months, ranging from one day to 32 months. The territory involved was determined from the identification of the culprit artery in coronary angiography and was divided into anterior [n=80 (44.4%)], and inferior and lateral [n=90 (50%)]. RESULTS: The mean age was 64.5±12.3 years; 126 patients were male (61.8%). The median B-type natriuretic peptide (BNP) level was 214.5 pg/mL, ranging from seven to 2291 pg/mL. Multivariate logistic regression analysis of the ability to predict the involvement of the anterior territory vs. inferior and lateral territory showed that BNP was an independent predictor [BNP> 210 pg/mL, OR = 3.44 (95% CI: 1.46 - 8.06); p = 0.005]. Multivariate logistic regression analysis showed that BNP value was an independent predictor of the occurrence of in-hospital events [BNP > 240 pg/mL, n = 78, OR = 5.05 (95% CI: 1.49 - 17.12); p = 0.009], and multivariate Cox regression analysis showed that BNP was also an independent predictor of composite event during the long-term follow-up [BNP > 156 pg/mL, n = 148, HR = 1.79 (95% CI: 1.05 - 3.04); p = 0.032], but not of overall death [BNP > 238 pg/mL, n = 44, HR = 1.45 (95% CI: 0.67 - 3.13); p = 0.343]. CONCLUSIONS: BNP was the only variable with an independent predictive ability to identify the ischemic myocardial territory in the anterior wall in NSTEMI. Baseline BNP in NSTEMI was an independent prognostic factor for in-hospital events and for composite events during follow-up

Hora da admissão na unidade de emergência e mortalidade hospitalar na síndrome coronária aguda

FUNDAMENTO: Há controvérsias sobre a hora da admissão e os desfechos hospitalares da síndrome coronária aguda (SCA). A admissão em horários não regulares seria associada ao pior prognóstico dos pacientes. OBJETIVO: Analisar a influência da hora da admissão na internação prolongada e na mortalidade de pacientes com SCA, segundo os períodos diurno (das 7h às 19h) e noturno (das 19h às 7h). MÉTODOS: Foram avaliados, prospectivamente, 1.104 pacientes consecutivos com SCA. O óbito intra-hospitalar e a internação igual ou superior a cinco dias foram os desfechos analisados. RESULTADOS: A admissão no período diurno foi maior em comparação ao noturno (63% vs. 37%; p < 0,001). A angina instável foi mais prevalente no período diurno (43% vs. 32%; p < 0,001) e o infarto sem supradesnivelamento do segmento ST (IAMssST) no noturno (33% vs. 43%; p = 0,001). Não se observaram diferenças na mortalidade e no tempo de internação nos períodos estudados. Os fatores de predição de internação igual ou superior a cinco dias foram: idade [OR 1,042 (IC 95% 1,025 - 1,058), p < 0,001]; fração de ejeção (FE) [OR 0,977 (IC 95% 0,966 - 0,988), p < 0,001]; IAMssST [OR 1,699 (IC 95% 1,221 - 2,366), p = 0,001]; e tabagismo [OR 1,723 (IC 95% 1,113 - 2,668), p = 0,014]. Para o óbito intra-hospitalar, foram: idade [OR 1,090 (IC 95% 1,047 - 1,134), p < 0,001]; FE [OR 0,936 (IC 95% 0,909 - 0,964), p < 0,001]; e tratamento cirúrgico [OR 3,781 (IC 95% 1,374 - 10,409), p = 0,01]. CONCLUSÃO: A internação prolongada e óbito intra-hospitalar em pacientes com SCA independem do horário de admissão

Coronary revascularization with the left internal thoracic artery and radial artery: comparison of short-term clinical evolution between elective and emergency surgery

BACKGROUND: Left internal thoracic artery-to left anterior descending artery grafting has become a fundamental part of coronary artery bypass grafting. This grafting has led to increased use of other arterial conduits, of which the radial artery is most popular. Whether radial grafting can be used in the emergency patient is not known. This study compares the short-term clinical evolution between elective vs emergency coronary artery bypass grafting surgery with left internal thoracic artery and radial artery. METHODS: A retrospective study of 47 patients who underwent elective or emergency coronary artery bypass grafting from 1996 to 2003. All patients had coronary stenosis >70% in all target vessels. Only the left internal thoracic artery and radial artery were used as grafts. Patients were divided into elective group (23 patients) and emergency group (24 patients). Emergency criteria were unstable angina and/or critical coronary stenosis with high risk for acute myocardial infarction. Groups were similar for age and number of diseased vessels. RESULTS: The mean number of left internal thoracic artery grafts per patient in the elective and emergency groups were respectively 1.17 and 1.38 (P = .17). The mean number of radial artery grafts per patient in the elective and emergency groups was respectively 2.26 and 2.08 (P = .48). The 30-day mortality was 0. There was no postoperative cardiogenic shock. The elective group had 1 acute myocardial infarction (4.4%) postoperatively, and emergency group had 5 (20.8%). A nonsignificant trend towards acute myocardial infarction was noted in the emergency group (P = .18). Intensive care unit and postoperative stay were similar in both groups. CONCLUSION: Coronary artery bypass grafting using left internal thoracic artery and radial artery accomplishing complete revascularization can be performed in emergency patients with results similar to those for elective patients