S-100B protein: An early prognostic marker after cardiac arrest

The identification of a good prognostic factor of neurological outcome after cardiac arrest is needed. S-100B protein seems to be a promising early predictor of brain damage. Yet it is necessary to reach a consensus on cut-off values, time of blood sampling and the predictive accuracy of S-100B protein. The present review summarizes the data about the clinical implications of S-100B protein after brain injury, especially in patients after cardiac arrest. (Cardiol J 2010; 17, 5: 532-536

Białko sST2 w krótkoterminowym rokowaniu po hospitalizacji u chorych z przewlekłą skurczową niewydolnością serca

Background: The prognosis in patients with chronic heart failure (CHF) is poor. ST2 protein is a promising prognostic biomarker for CHF. ST2 belongs to the cardioprotective signalling pathway involving interleukin-33 and its concentration in the serum depends on the biomechanical stress of cardiomyocytes (biomechanical strain). Aim: To determine the prognostic value of ST2 in short term follow-up after hospitalisation among patients with CHF. Methods: The study included 167 patients (mean age 62 years, 83% men) in stable NYHA class I–III with left ventricular ejection fraction (LVEF) of ≤ 45% (average 29.65%, ranges 13–45%). We analysed 58 variables including: demographics, co-morbidities, resting ECG, echocardiographic and coronary arteriography data, basic laboratory tests including N-terminal prohormone B-type natriuretic peptide (NT-proBNP), serum concentration of soluble form of ST2 (sST2) using quantitative ELISA test ST2 Kit (Medical and Biological Laboratories; Japan) and adverse cardiovascular events during a one year observation. In the study, the primary endpoint (death) and the composite endpoint (hospitalisation for HF worsening, worsening in NYHA functional class, the need to increase the dose of diuretics, and/or death in a one year observation) were determined. Results: Patients who died (n = 24; 14.55%) were in more advanced NYHA class, had prolonged QRS duration, higher levels of sST2, NT-proBNP, and lower estimated glomerular filtration rate. From multivariate analysis, the independent variable for the primary endpoint was NT-proBNP (OR = 1.00012; 95% CI 1.00002–1.00022; p = 0.018). 93 (56%) patients reached the composite endpoint. Multivariate analysis revealed that fasting glucose (OR = 1.343; 95% CI 1.041–1.732; p = 0.023) and sST2 (OR = 3.593; 95% CI 1.427–9.05; p = 0.007) independently enhanced the risk of composite endpoint occurrence in a one year observation. Conclusions: In patients with CHF with LVEF ≤ 45%, the prognostic value of sST2 protein in a short-term observation of one year was confirmed. sST2 protein was an independent variable for the composite endpoint, which consisted of worsening NYHA functional class, hospitalisation for worsening of HF, the need to increase the dose of diuretics, and/or death. Wstęp: Rokowanie u pacjentów z przewlekłą niewydolnością serca (CHF) jest niepomyślne. Białko sST2 należące razem z interleukiną 33 do szlaku kardioprotekcyjnego jest obiecującym markerem w CHF. Stężenie białka sST2 w surowicy wzrasta w przypadku mechanicznego odkształcenia kardiomiocytów. Cel: Celem pracy było określenie wartości prognostycznej sST2 w krótkoterminowej obserwacji po hospitalizacji wśród pacjentów z CHF. Metody: Do badania włączono 167 osób (średnia wieku 62 lata, 83% mężczyzn) w I–III klasie wg NYHA, z frakcją wyrzutową lewej komory ≤ 45% (średnio 30%, 13–45%). Przeanalizowano 58 zmiennych, m.in.: dane demograficzne, elektrokardiograficzne, echokardiograficzne, choroby współistniejące, wyniki koronarografii, podstawowe badania laboratoryjne, w tym N-końcowy propeptyd natriuretyczny typu B (NT-proBNP), stężenie sST2 (ilościowy test ELISA ST2 Kit), wystąpienie niekorzystnych zdarzeń sercowo-naczyniowych w ciągu rocznej obserwacji. W badaniu wyznaczono pierwszorzędowy punkt końcowy (zgon w obserwacji rocznej) oraz złożony punkt końcowy (łącznie hospitalizacja z powodu pogorszenia HF, nasilenie klasy NYHA, konieczność zwiększenia dawki leków moczopędnych lub zgon w obserwacji rocznej). Wyniki: U chorych, którzy zmarli (n = 24; 14,55%), występowała bardziej zaawansowana klasa NYHA, wydłużony czas trwania zespołu QRS, wyższe stężenie sST2, NT-proBNP i niższa wartość estymowanego wskaźnika filtracji kłębuszkowej. Z analizy wielowymiarowej jedyną zmienną niezależną dla pierwszorzędowego punktu końcowego było NT-proBNP (OR = 1,00012; 95% CI 1,00002–1,00022; p = 0,018). Złożony punkt końcowy wystąpił u 93 (56%) pacjentów. Analiza wieloczynnikowa wykazała, że stężenie glukozy (OR = 1,343; 95% CI 1,041–1,732; p = 0,023) i sST2 (OR = 3,593; 95% CI 1,427–9,05; p = 0,007) są niezależnymi czynnikami związanymi z ryzykiem wystąpienia złożonego punktu końcowego w rocznej obserwacji. Wnioski: U chorych z CHF z frakcją wyrzutową lewej komory ≤ 45% potwierdzono wartość prognostyczną białka sST2 w obserwacji krótkoterminowej. Białko sST2 było niezależną zmienną dla złożonego punktu końcowego, na który składały się: pogorszenie w zakresie klasy wg NYHA, hospitalizacja z powodu pogorszenia HF, konieczność zwiększenia dawki leków moczopędnych i zgon w obserwacji rocznej.

Cardiac rehabilitation after cardiac surgery is limited by gender and length of hospitalisation

Background: Cardiac rehabilitation (CR) is recommended after cardiac surgery. Secondary prevention through exercise training is one of the best scientifically-proven ways of decreasing mortality and enhancing quality of life in cardiovascular disorders. Studies into the use of CR in different groups of patients after cardiac surgery are limited. Aim: To find the factors determining the reasons for the lack of CR in cardiac surgery patients. Methods: The study group consisted of 82 patients (mean age 58.6 years, 80.7% male) in stable II/III NYHA class, who had undergone coronary artery bypass graft surgery, valvular surgery, or both. The following were analysed: age, gender, body mass index, basic laboratory results such as serum lipids level, cholesterol ratio LDL/HDL, creatinine and glucose levels, results of electrocardiography, echocardiography and coronary arteriography, presence of hypertension, diabetes, coronary artery disease, renal failure, previous stroke, obliteration of peripheral arteries, EuroSCORE and length of hospitalisation. Patients were divided into two groups: those referred for CR (n = 46, the CR group) and those referred for CR but who did not receive it (n = 36, non-CR group). Results: From multiple logistic regression analysis with backward stepwise, only female gender (p = 0.0208, OR = 0.07) and length of hospitalisation (p = 0.0198, OR = 1.17) were significant for non-CR patients. Conclusions: We found a lower rate of use of CR after cardiac surgery in those patients hospitalised for longer periods, and in women. Kardiol Pol 2011; 69, 1: 42-46Wstęp: Rehabilitacja kardiologiczna (CR) stanowi standard postępowania po leczeniu kardiochirurgicznym. Korzyści z wysiłku fizycznego w ramach wtórnej prewencji kardiologicznej są dobrze udokumentowane zarówno w zakresie zmniejszenia śmiertelności, jak i poprawy jakości życia, a postępowanie rehabilitacyjne jest uznane za ważny element decydujący o wczesnych i odległych efektach leczenia kardiochirurgicznego. Niewiele jest jednak badań z wykorzystaniem CR w okresie wczesnym po różnych procedurach kardiochirurgicznych. Cel: Celem pracy było określenie czynników determinujących zaniechanie odbycia wczesnej CR wśród chorych po operacjach kardiochirurgicznych. Metody: Do badania włączono 82 chorych (średni wiek 58,6 roku; 80,7% mężczyzn) po pomostowaniu tętnic wieńcowych, operacjach zastawkowych lub obu procedurach wykonanych łącznie. Wszyscy pacjenci byli w II/III klasie czynnościowej wg NYHA. U pacjentów wykonano spoczynkowe badanie EKG, podstawowe badania laboratoryjne, badanie echokardiograficzne i koronarografię. Analizie poddano: wiek, płeć, wskaźnik masy ciała, stężenia frakcji lipidowych w surowicy, wskaźnik aterogenności LDL/HDL, stężenie kreatyniny i glukozy w surowicy, parametry echokardiograficzne oraz wyniki koronarografii, jak również obciążenie chorobami współistniejącymi, takimi jak nadciśnienie tętnicze, cukrzyca, choroba wieńcowa, niewydolność nerek, przebyty udar mózgu, miażdżyca tętnic obwodowych i dodatkowo ryzyko operacyjne wg skal EuroSCORE i logistic EuroSCORE oraz czas hospitalizacji. W celu identyfikacji czynników determinujących niezgłoszenie się chorych na CR przeprowadzono analizę jedno- i wieloczynnikową. Do modelu wieloczynnikowego włączono te zmienne, dla których znamienność w porównaniach jednoczynnikowych osiągnęła p < 0,15. Chorych analizowano w dwóch grupach: skierowanych na wczesną pooperacyjną CR (n = 46) i skierowanych, ale nieuczestniczących w rehabilitacji (n = 36). Wyniki: Analiza wieloczynnikowa regresji logistycznej wykazała, że płeć żeńska (p = 0,0208; OR = 0,07) oraz czas pobytu w szpitalu związany z operacją (p = 0,0198; OR = 1,17) były istotnie związane z zaniechaniem rehabilitacji. Wnioski: Wczesną CR po operacjach kardiochirurgicznych rzadziej odbywali chorzy dłużej hospitalizowani oraz kobiety. Kardiol Pol 2011; 69, 1: 42-4

Health status after invasive or conservative care in coronary and advanced kidney disease

BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of &lt;30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, 120.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, 122.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, 121.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, 122.2 to 3.4). CONCLUSIONS Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy

Management of coronary disease in patients with advanced kidney disease

BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline