Incremental value of B-type natriuretic peptide for early risk prediction of infective endocarditis

SummaryBackgroundEarly and accurate risk prediction is an unmet clinical need in patients with infective endocarditis (IE). The aim of this study was to determine the value of B-type natriuretic peptide (BNP) levels obtained on admission for the prediction of in-hospital death in IE patients.MethodsBetween 2009 and 2011, consecutive patients with IE diagnosed using the revised Duke criteria and admitted to the emergency department were evaluated prospectively. BNP levels were measured on admission. Death during hospitalization was the primary endpoint.ResultsAmong 104 consecutive patients with IE and with available BNP levels, 34 (32.7%) died in hospital. BNP levels were significantly higher in patients who died as compared to survivors (709.0 pg/ml vs. 177.5 pg/ml, p<0.001). The accuracy of BNP to predict death as quantified by the area under the receiver operating characteristics curve was 0.826 (95% confidence interval (CI) 0.747–0.905). The value of BNP was additive to that provided by clinical, microbiological, and echocardiography assessment. On multivariate analysis, new heart failure (hazard ratio (HR) 2.02, 95% CI 1.15–3.57, p=0.015), sepsis (HR 2.10, 95% CI 1.25–3.55, p=0.005), Staphylococcus aureus endocarditis (HR 2.67, 95% CI 1.60–4.45, p<0.001), left ventricular ejection fraction ≤55% (HR 1.63, 95% CI 1.00–2.65, p=0.047), and BNP (HR 1.04, 95% CI 1.02–1.06, p<0.001) were independent predictors of in-hospital mortality.ConclusionAmong patients with IE, BNP levels obtained on admission provide incremental value for early and accurate risk prediction

Bone metabolism impairment in heart transplant: results from a prospective cohort study

Introdução: Dados na prevenção de fraturas após transplante cardíaco são controversos na literatura. Há questionamentos a respeito da segurança e eficácia dos bisfosfonatos nesta população. Um melhor conhecimento dos efeitos do transplante cardíaco no osso pode orientar o tratamento adequado. O objetivo do estudo foi avaliar metabolismo ósseo, densidade mineral óssea (DMO), microarquitetura e a frequência de fraturas vertebrais após transplante cardíaco. Métodos: Setenta adultos submetidos a transplante cardíaco foram seguidos prospectivamente por 12 meses. Dados clínicos, laboratoriais, DMO, microarquitetura (por HR-pQCT) e fraturas vertebrais foram avaliados no momento inicial (após alta da UTI), após 6 e 12 meses. DMO, composição corporal e fraturas vertebrais foram avaliadas pela densitometria. Todos os pacientes receberam orientações dietéticas para ingesta adequada de cálcio e suplementação oral de vitamina D após o transplante (50.000UI/semana por 3 meses, seguido de 7.000UI/semana). Resultados: Na avaliação inicial, 27% dos pacientes tinham osteoporose, associada ao tempo de hospitalização antes do transplante (p=0,001). A DMO reduziu nos primeiros 6 meses, com recuperação parcial após. Houve deterioração de microarquitetura óssea, principalmente de osso trabecular nos primeiros 6 meses e osso cortical nos 6 meses subsequentes. Na avaliação inicial, 92,9% dos pacientes tinham vitamina D < 30 ng/mL e 20,0% < 10ng/mL. Pacientes também apresentavam cálcio sérico no limite inferior da normalidade, fosfatase alcalina elevada e marcador de reabsorção óssea elevado. Estas alterações eram sugestivas de defeito de mineralização óssea e normalizaram em 6 meses com a correção da deficiência de cálcio e de vitamina D. A maioria das fraturas vertebrais foi identificada já na avaliação inicial (23% dos pacientes). Após análise multivariada, apenas massa gorda reduzida permaneceu como fator de risco para fratura vertebral (p=0,012). Conclusão: Altas frequências de osteoporose densitométrica, deficiência de vitamina D, anormalidades de marcadores ósseos e fraturas vertebrais foram observadas logo após o transplante cardíaco. A correção da deficiência de cálcio e de vitamina D deveria ser o primeiro passo para a correção do defeito de mineralização óssea, antes de outras terapias específicas para osteoporose serem iniciadas. Atenção especial deve ser dada aos pacientes com hospitalização prolongada antes do transplante e com baixa massa gordaBackground: Data on the prevention of fractures after heart transplant are controversial in the literature. There are doubts about the safety and efficacy of the use of bisphosphonates in this population. Understanding the effects of heart transplant on bone may guide appropriate treatment. The aim of the study was to evaluate bone metabolism, bone mineral density (BMD), microarchitecture and frequency of vertebral fractures after heart transplant. Methods: Seventy adult heart transplant patients were prospectively followed for 12 months. Clinical and laboratory parameters, BMD, microarchitecture (by HR-pQCT) and vertebral fractures were assessed at baseline (after intensive care unit discharge) and at 6 and 12 months. BMD, body composition and vertebral fractures were evaluated by DXA. Patients received recommendations regarding calcium intake and vitamin D supplementation after heart transplant (50,000IU/week for 3 months followed by 7,000IU/week). Results: At baseline, 27% of patients had osteoporosis, associated with the length of hospitalization before transplant (p=0.001). BMD decreased in the first 6 months, with partial recovery later. Bone microarchitecture deteriorated, mainly in the trabecular bone in the first 6 months and cortical bone in the subsequent 6 months. At baseline, 92.9% of patients had vitamin D levels < 30 ng/mL and 20.0% < 10 ng/mL. Patients also had calcium at the lower limit of normal, high alkaline phosphatase, and high bone resorption biomarker. These abnormalities were suggestive of impaired bone mineralization and normalized at 6 months with correction of calcium and vitamin D deficiency. The majority of vertebral fractures were identified at baseline (23% of patients). After multivariate analyses, only a lower fat mass persisted as a risk factor for vertebral fractures (p=0.012). Conclusions: High frequencies of densitometric osteoporosis, vitamin D deficiency, bone markers abnormalities and vertebral fractures were observed shortly after heart transplant. Correction of calcium and vitamin D deficiency should be the first step in correcting bone mineralization impairment before specific osteoporosis treatment. Special attention should be given to patients with a long hospitalization duration before heart transplant and a low fat mas