Added Value of Modified Anderson–Wilkins Acuteness Score in Prognostication of Patients with Acute Myocardial Infarction

BACKGROUND: Electrocardiogram (ECG) signs on admission can serve as a prognostic marker in patients treated for myocardial infarction (MI). AIM: The aim of the study was to determine the predictive role of modified Anderson–Wilkins (MAW) ECG score of acuteness on the extent of myocardial injury, left ventricular (LV) remodeling, and clinical outcome in patients with acute MI. METHODS: Prospective, observational cohort study on patients treated for MI at the University Clinic for Cardiology. Subjects were analyzed for their demographic, clinical, ECG, LV functional, angiographic variables, course of treatment, and in-hospital outcome. MAW score was calculated for each patient. Patients were comparatively analyzed divided in two groups (score <3 and ≥3). RESULTS: One hundred fifty patients (70% males and 30% females), aged 60.9 years were included in the study. Sixty-eight patients had MAW score <3 (mean 1.7), and 82 had score ≥3 (mean 3.5), p>0.001. Patients with ST-segment elevation MI had OR 2.1 (p>0.000), and patients with multiple locations (excluding anterior) had OR 2.1 (p > 0.000) of having MAW score ≥3. They received mechanical reperfusion 1.9 (p = 0.032) times more often. High MAW score was associated with stress hyperglycemia (OR 2.1; p = 0.032); low potassium (OR 2.8; p = 0.032), lower creatinine (p = 0.050), and higher NT-proBNP (OR 2.5; p = 0.050). High MAW score was associated with decreased LV function and increased LV dimensions on the follow-up echocardiography (p = 0.050 and 0.012, respectively). CONCLUSION: ECG is an important prognostic tool in MI patients. ECG-derived MAW score demonstrates a strong correlation with stress hyperglycemia, potassium, creatinine, and natriuretic peptides level and can serve as an early marker of LV remodeling after MI

Added Value of Modified Anderson–Wilkins Acuteness Score in Prognostication of Patients with Acute Myocardial Infarction

BACKGROUND: Electrocardiogram (ECG) signs on admission can serve as a prognostic marker in patients treated for myocardial infarction (MI). AIM: The aim of the study was to determine the predictive role of modified Anderson–Wilkins (MAW) ECG score of acuteness on the extent of myocardial injury, left ventricular (LV) remodeling, and clinical outcome in patients with acute MI. METHODS: Prospective, observational cohort study on patients treated for MI at the University Clinic for Cardiology. Subjects were analyzed for their demographic, clinical, ECG, LV functional, angiographic variables, course of treatment, and in-hospital outcome. MAW score was calculated for each patient. Patients were comparatively analyzed divided in two groups (score <3 and ≥3). RESULTS: One hundred fifty patients (70% males and 30% females), aged 60.9 years were included in the study. Sixty-eight patients had MAW score 0.001. Patients with ST-segment elevation MI had OR 2.1 (p>0.000), and patients with multiple locations (excluding anterior) had OR 2.1 (p > 0.000) of having MAW score ≥3. They received mechanical reperfusion 1.9 (p = 0.032) times more often. High MAW score was associated with stress hyperglycemia (OR 2.1; p = 0.032); low potassium (OR 2.8; p = 0.032), lower creatinine (p = 0.050), and higher NT-proBNP (OR 2.5; p = 0.050). High MAW score was associated with decreased LV function and increased LV dimensions on the follow-up echocardiography (p = 0.050 and 0.012, respectively). CONCLUSION: ECG is an important prognostic tool in MI patients. ECG-derived MAW score demonstrates a strong correlation with stress hyperglycemia, potassium, creatinine, and natriuretic peptides level and can serve as an early marker of LV remodeling after M

Thoracic Aortic Disease - Aortic Dissection

The term Thoracic Aortic Disease (TAD), covers a wide range of degenerative, structural, acquired, genetically based and traumatic diseases, conditions and presentations of the thoracic aorta. In 2010 several professional associations published joint Recommendations for diagnosis and treatment of TAD, and last year ESC published new Guidelines for diagnosis and treatment of Aortic Disease. Interesting enough is the fact that, 2010 Guidelines were the first recommendations accompanied by a campaign designed for the general population, with a purpose to increase awareness of the existence and importance of these conditions. It was explained by the fact that dissection of the thoracic aorta, the most distinguished acute clinical manifestation of TAD, is recognized as one of the twenty most common causes of death. This is a condition that is diagnosed mainly based on data obtained by a detailed history and clinical examination, for the existence of high-risk situations, high-risk features of the chest pain and high risk clinical findings. Unfortunately, yet, there isn’t sensitive and specific biomarker that could help in the diagnosis of this acute condition. The definitive confirmation of the disease is made by imaging of the aorta with one of the imaging modalities such as transoesophageal echocardiography (TOE), computed tomography (CT) or magnetic resonance (MRI). And in terms of rapid diagnosis, this condition is still characterized with high mortality. This paper is an attempt to give an overview of the situation with TAD in our country, through a retrospective analysis of the medical database at the University Clinic of Cardiology of all patients hospitalized during the year 2009 with a working diagnosis of AoD

Glicoregulation in diabetic and no diabetic patients and the impact on early clinical outcome in patients with acute coronary syndrome

Aim of the study: The aim of our study was to analyse the impact of glicoregulation before and during the hospital treatment in patients with acute coronary syndrome on early in-hospital clinical outcome (CE). Methods: We included in the analyse ACS patients (STEMI, NSTEMI, APNS) treated with PCI, in whom we analysed: demographics, risk profile, basic biochemical variables (Hgb, BUN, creatinine, Na, K), lipid profile (Tg, HDL, LDL Hol, lpa), HgbA1C, admitting glucose level and levels of glucose during the hospitalisation, and TIMI flow before and after PCI procedure. We divided patients in diabetics and non-diabetics. Than based on the level of HgbA1C measured at admition we subdivided diabetics in good (6.5%) DM, and patients without previously known diabetes in three groups: no diabetics (6.5) HgbA1C. Based on glycaemic levels we divided pts. in groups: good regulation (5-10mmol/L), bed regulation: >10mmol/L epizodes, and <5mmolL aeizodes. We analized influence of glikoregulation on biochemical variables and lipide profile, PCI results (TIMI flow), and cardiac events (heart failure, shock, dysrhythmias, GIT bleeding, CVI and cardiac death). Statistical analyse: descriptive and comparative statistics with t-test, Chi square test, uni and multivariate analyse. Significance determined at 0.05. Results: 80 pts. Were included in the analyse (33.8% females and 66.2% males), at mean age of 60.2±10.8y. Risk profile: 51% had HTA, 6.3% HLP, 36.3% positive family history, 33.8% were diabetics, 61.4% smokers, 5% previous CAD. Mean Hgb 14.6±1.4mg/dl, BUN 5.9±3.2, creatinine 80.5±30.6 micromol/L, Na 137.5±3.4, K 4.2±0.5. No differences in biochemical and lipide profile was found between groups. Among 53 no diabetic patients prior to ACS, we identified 4 (5%) patients with diabetes (>6,5), and 18 (22.5%) with pre-diabetes (5.6-6.5%). Mean TIMI flow was 0.45±0.79 before, and 2.96±0.19 after PCI, r -.221, p 0.000. The single independent predictor in multivariate analyse (included HgbA1C, admitting glycaemic level, glucoregulation and diabetic group) on TIMI flow was admitting glycaemia (beta -.327, p 0.003). 12/80 pts. had CE, and again we included same variables and identified two independent predictors of CE: admitting glycaemic level (beta .386, p 0.007) and HgbA1C (beta .254, p 0.070). Conclusion: Acute coronary syndrome identified patients with previously no diagnosed diabetes. Stress glycaemia (admition glycaemic level) was found to be significant predictor of PCI results, and together with HgbA1C level of CE in ACS patients treated with PCI

Association of biomarkers of oxidative stress, stress glycaemia and glycated haemoglobin with coronary artery disease

Introduction: Reactive oxygen species (ROS) are responsible for generalized oxidation which results in cell dysfunction, necrosis or apoptosis. Assessment of oxidative stress markers could modify course of treatment of patients with coronary artery disease (CAD). The aim of this study was to evaluate association of markers of oxidative stress, stress glycaemia and glycated hemoglobin (HgbA1c) with CAD. Methods: Crosssectional observational study. Variables: demographics, risk factors and comorbidities, lipoprotein and glycemic profile, oxidative stress biomarkers: malondialdehyde (MDA) and hydro peroxide (HP), and antioxidant enzymes: superoxide dismutase (SOD), CATALASE and glutathione peroxidase (GPS). Comparison was performed between CAD patients and healthy controls, patients with acute coronary syndrome (ACS) versus chronic CAD, and between PCI revascularised and stable post MI patients. Results: 300 patients, (64.7% m/36.3% f), mean age 62±11 y. (p=ns between genders). 187 (62.3%) were ACS and 113 (37.7%) chronic CAD patients. There was no statistical significant difference in the risk profile between the CAD groups. Patients with CAD had significantly higher prooxidative and significantly lower antioxidative levels of biomarkers (Table 1), as compared with healthy volunteers. Statistically significant differences were observed for HP and SOD between ACS and HCAD group. In HCAD group, revascularized patients demonstrated higher oxidative stress as compared to stable post MI patients. In ACS patients statistical significant intergroup difference was registered, but not pointing to the single type of ACS. ACS patients had also higher levels of stress glycaemia and HgbA1c. Significant positive correlation were found for HgbA1c and stress glycaemia with MDA (r=,154**, p=0,008; r=,254**, p=0,024 respectively). Conclusion: CAD patients demonstrated pronounced oxidative stress when compared to healthy controls, ACS patients had higher oxidative stress as compared with chronic CAD patients, PCI subgroup performed worse that stable post MI patients. Higher oxidative stress activity was linked to worse glycemic control as measured threw stress glycaemia and HbA1c

Anemia, renal impairment and in-hospital mortality, in acute worsening chronic heart failure patients

Aim of the study: To analyze the impact of anemia and renal impairment on in-hospital mortality(IHD), in patients with acute worsening chronic heart failure. Methods: 232 randomly selected patients with symptoms of HF were retrospectively analyzed. Analyzed variables: gender, age, risk factors and co-morbidities: HTA, HLP, DM, COPD, CAD, PVD, CVD, anemia(defined as Hgb ≤10mg/dl), renal failure. Measured variables: systolic and diastolic BP, Hgb, sodium, BUN, creatinine, length of hospital stay and IHD. Comparative analysis was performed between patients with in-hospital mortality(IHD) and survivors, as a function of anemia and renal impairment. Statistical analysis: descriptive and comparative analysis, t-test, Chi square, univariate (binary logistic and linear regression and multivariate linear regression(stepwise backward). Results: Mean age 69.6±11.4, 102(44%)females and 130(56%) males, with females being significantly older 72.6±12.5 vs. 67.7±10.2(p=0.002), with significantly higher SBP, DBP and sodium level (p=0.003; 0.002 and 0.028 respectively), and males having HTA more often OR 1.3; p=0.017. Mean hospital stay was 6.8±5.8 days, with significant difference between IHD and non IHD group(7.9±4.5 vs. 3.8±7.9; p=0.000), with the highest mortality during the first (37.3%) and second hospital day (44.1%). 44 pts.(19%) had anemia, 31(13.4%) had known Chronic Renal Failure(CRF), and 59(25.4%) had IHD. Anemia was significantly associated with IHD (Chi square 6,36, sig 0.012, Exp B 2.48, sig 0.010), meaning pts. with anemia had 2,5 times greater risk for IHD. CRF per se, was not associated with IHD. Univariate linear regression identified creatinine(R square .032, beta .180, sig 0.006), and BUN(R square .034, beta .184, sig 0.005), as predictors of IHD. Multivariate stepwise regression model(anemia, HRF, Hgb, BUN, creatinine, sodium) at step 3(mean square .799, sig 0.002), identified two independent predictors Hgb(beta -.148, sig 0.028), and BUN(beta .163, sig 0.055). Multivariate model that included other known predictors of IHD(EF%, SBP, DBP, HRF, CAD, anemia, Hgb, BUN, creatinine, sodium) at step 8(mean square 1.537, sig 0.000), identified four independent predictors: EF%(beta -.204, sig 0.002), SBP(beta -.130, sig 0.052) as markers of systolic dysfunction and again anemia(Exp B 2.2.06, sig 0.041), and BUN(beta .200, sig 0.002). Conclusion: Anemia and renal impairment are well known comorbidities associated with HF that have great impact on course of HF. We confirmed that anemia and BUN, are significantly independent predictors of in hospital mortality in acute worsening CHF

Association of biomarkers of oxidative stress, stress glycaemia and glycated haemoglobin with acute coronary syndrome

The aim of our study was to comparatively evaluate association between biomarkers of oxidative stress, stress glycemia and HbA1c in patients with coronary artery disease

Predictors of in-hospital mortality in patients with acute or acute worsening chronic heart failure

Aim of the study: to identify predictors of in-hospital mortality in acute HF patients. Patients and methods: 355 randomly selected patients admitted to ICCU with symptoms of HF were analyzed for: risk factors and co-morbidities (COPD, CAD, PVD, anemia, renal failure), heart rate, systolic and diastolic BP, Hgb, sodium, BUN, creatinine, ejection fraction (based on which patients were divided in PEF-HF and REF-HF); length of stay and GWTG-HF score (Get with the Guidelines-HF risk score), calculated from the seven clinical variables in that score. Comparative analyze was performed between patients with in-hospital mortality (IHM) and survivors. Statistical analyze: univariate and multivariate binary and linear logistic regression, ROC Curve for testing of discriminate function of GWTG-HF score. Results: 355 patients at mean age 70.1±10.9, 150 (42%) females and 205 (58%) males were included. Females were older 72.9±11.4 vs. 67.9±10.0 (p=0.000), had higher DBP (p 0.007) and EF (%): 43.6±11.6 vs 41.1±9.5 (p 0.029), and sodium level (p 0.018), more often had HTA (OR 1.4; p=0.001), while males had PAD (OR 1.7; p 0.020), and prior MI (OR 2.2; p 0.001). No significant differences in death rate, length of hospital stay and GWTG-HF score was observed. 82 (23.1%) events were registered (IHD group). The highest mortality rate was observed during the first 48 hours (40.4%). Mean hospital stay was 6.3±5.3 days, with no differences between the groups (5.6±3.9 vs. 6.7±5.9; p=0.056). We identified several univariate predictors: prior MI (beta -.490; p 0.041), PVD (beta -1.01; p 0.007); anemia (OR 1,89; p 0.044); REF-HF (OR 2.43; CI 1.7-3.6; p 0,000); EF (beta -.258; p=0.000); SBP (beta -.299; p=0.000), DBP (beta .315; p=0.000); Hgb (beta -.142; p=0.007), sodium (beta -.107; p 0.045); creatinine (beta .184; p=0.000), BUN (beta .199; p=0.000), and GWTG-HF score (beta .279; p 0.000). Multivariate logistic regression identified SBP (beta -.014; p 0.020) and anemia (ExpB 3.668; p 0.019); as positive, while prior MI (ExpB -2.753; p 0.050); PVD (ExpB -1.348; p 0.005) and DBP (beta .034; p 0.003) as negative predictors for in-hospital death. Mean GWTG-HF score was 38.9 ±10.1 (37.3 ±9.3; 44.0 ±11.0; p 0.000, non-IHD vs IHD pts). It had excellent discriminate function (ROC Curve: Area under the Curve .694, p< 0.000 (CI .627-.778), in predicting IHD. Conclusion: Low sodium, high BUN and creatinine are predictors of IHD, but only anemia, reduced EF and low systolic BP were identified as independent predictors of IHD. GWTG-HF score is a powerful tool for prediction of IHD in acute or acute worsening CHF patients

Early rehospitalizations in patients treated for acute coronary syndrome - can we identify predictors?

Purpose: To analyze early rehospitalization rate (defined as 90 days after the acute event) in patients with ACS, and to identify predictors of risk for readmission. Methods:463 randomly selected patients with ACS,were retrospectively analyzed.Analyzed variables:type of ACS(STEMI/NSTEMI/APNS),location of MI,gender,age,risk factors:HTA,HLP,DM,COPD,CAD,PVD,CVD,EF,type of treatment(PCI vs. noninvasive),extensiveness of coronary disease,GRACE and TIMI risk score, type of morbidity,and reason for rehospitalization.Comparative analysis was performed between patients with early rehospitalisation and others.Statistical analysis:t-test,Chi square,univariate and multivariate linear regression. Results:463 patients were enrolled:68.9% males mean age 60.4±10.9, and 31.1% females mean age 64.94±12.0(p 0.000).MI type:STEMI 75.8%,NSTEMI 11.2%,APNS 13%; MI location:40.2% anterior,39,7% inferior,3% lateral and 3.7% multiple locations(p 0.000).Risk profile:15.3% HCAD,27% HF,62% HTA,28.1% DM,5.8% PVD,2.6% COPD.Mean BMI was 27±2.9,mean SBP 138.8±28.5mmHg,mean HR 84.3±24.2,mean EF (in 208 pts.) 50.2±10.4%, mean GRACE score(in 72 pts.) was 148.9±60.6,mean TIMI score(in 263 pts.) was 3.9±2.3. 87.5% were treated with PCI procedure, with mean disease’s CA 1.84(range 1-5), median 1(p 0.000). Hospital morbidity was present in 16% of pts.,6.9% minor, 3% major bleeding complications, 2.4% acute HF, 1.9% pericardial effusion, and 1.1% early stent thrombosis.Early rehospitalization rate was 6.3% (29/463):14 ischemic/trombotic events;9 acute heart failures, 3 malignant arrhythmias, and three fatal events. Univariate predictors of RH: HR(R square 0.014, p 0.014, beta .116, r -.217, p 0.002);EF(%) (R square 0.055, p 0.001, beta -.234, r -.231, p 0.001).HTA was significantly associated with reduced hospitalization risk (Chi square 4.28, p 0.039, exp B .405, p 0.054),diabetes(Chi square 10.04, p 0.002, exp B 3.45, p 0.001), PVD (expB 2.85, p 0.070),early in-hospital morbidity(expB 2.12, p 0.084),and NSTEMI pts. had OR 1.3, and APNS pts. OR 1.16 for rehospitalization(higher but not significantly in comparison to STEMI pts.). Multivariate model with variables that were found significantly associated with HR, identified two strong independent predictors of early rehospitalization(mean square.424, sig 0.000),EF(beta -.220, p 0.001),and diabetes(t 2.52, p 0.012) Conclusions:LV systolic dysfunction was again proven to be a strong predictor of clinical outcome in terms of early hospital readmission in ACS patients no matter how they were treated for ACS, and diabetes was the single strong independent predictor-risk factor for this event

Acute heart failure in the context of acute coronary syndrome (a case report)

RVMI is associated with acute STEMI myocardial infarction of the inferior wall of the left ventricle, and occurs in 30 to 50 percent of such cases