Incidence and Predictors of Hyperkalemia in Patients With Heart Failure: An Analysis of the CHARM Program Akshay S. Desai, Karl Swedberg, John J. V. McMurray, Christopher B. Granger, Salim Yusuf, ...James B. Young, Mark E. Dunlap, Scott D. Solomon, James W. Hainer, Bertil Olofsson, Eric L. Michelson, Marc A. Pfeffer We examined the incidence and predictors of hyperkalemia in a broad population of patients with symptomatic heart failure enrolled in the CHARM (Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity) Program. Independent of assignment to candesartan or placebo, the risk of hyperkalemia increased with advanced age, male gender, baseline hyperkalemia, renal failure, diabetes, and background use of angiotensin-converting enzyme inhibitors or spironolactone. Candesartan increased the observed rate of hyperkalemia in these subgroups but was associated with a consistent reduction in the risk of cardiovascular death or heart failure hospitalization. Although renin-angiotensin-aldosterone antagonists improve clinical outcomes in heart failure patients, careful surveillance of serum potassium and creatinine is essential.
Abstract Objectives To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI). Background Baseline Q-waves are ...useful in predicting clinical outcomes after MI. Methods 3589 STEMI patients were assessed from a multi-centre study. Results 1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p < 0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥ 40 ms for inferior and ≥ 20 ms for lateral/apical MI in all patients (n = 3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54–3.85), p < 0.001) and the composite (HR: 2.32, 95% CI (1.70–3.16), p < 0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p < 0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02–0.29), p = 0.027). Conclusions The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥ 40 ms in inferior and ≥ 20 ms for lateral/apical MI enhances prognostic insight beyond current criteria.
Red Cell Distribution Width as a Novel Prognostic Marker in Heart Failure: Data From the CHARM Program and the Duke Databank G. Michael Felker, Larry A. Allen, Stuart J. Pocock, Linda K. Shaw, John ...J. V. McMurray, Marc A. Pfeffer, Karl Swedberg, Duolao Wang, Salim Yusuf, Eric L. Michelson, Christopher B. Granger, for the CHARM Investigators Among 36 routine laboratory measures in the CHARM (Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity) program, higher red cell distribution width showed the greatest association with cardiovascular death and heart failure hospitalization (adjusted hazard ratio 1.17 per 1 SD increase, p < 0.001). Only age and cardiomegaly showed better independent association with outcome. This finding was replicated in the Duke Databank, in which red cell distribution width continued to be strongly associated with mortality (adjusted hazard ratio 1.29 per 1 SD, p < 0.001). Understanding how and why this marker is associated with outcome may provide novel insights into heart failure pathophysiology.
Background Accurate estimation of coronary epicardial flow in patients with ST-elevation myocardial infarction (STEMI) is crucial to evaluating the effect of therapy and predicting outcome. Whether ...operator bias exists in visual estimation of TIMI flow grade among patients with STEMI undergoing primary percutaneous coronary intervention (PCI) remains uncertain. Hence, we examined this issue in the angiographic substudy of the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. Method TIMI flow grade of the infarct-related artery was assessed before and after PCI by visual estimation of local investigators (LI) and by an independent core laboratory (CL). We evaluated agreement between the CL and LI and the relationship between post-PCI TIMI flow grade and 90-day outcomes (mortality; death/congestive heart failure/shock). Results Of 922 patients with independent CL estimation of TIMI flow grade, there was moderate agreement in the pre-PCI assessment ( κ = 0.56) and poor agreement post-PCI ( κ = 0.36); moreover, these disparities were directionally different before versus after PCI. Disagreement between LI and CL occurred in 167 patients pre-PCI (19%) and in 123 (14%) patients post-PCI. LI TIMI grades consistently underestimated flow pre-PCI in 63% and overestimated flow post-PCI in 78% of patients relative to the CL. Core laboratory estimation of post-PCI TIMI flow grade provided better prediction of 90-day mortality and death/congestive heart failure/shock than that of LI. Conclusion Significant quantitative and directional variation existed in TIMI flow grades assessed by LI versus a CL in nearly a fifth of the patients. Core laboratory interpretation post-PCI provides better prediction of clinical outcomes. These data deserve consideration when interpreting angiographic data from STEMI patients without CL estimation.
Efficacy and Safety of Fondaparinux Versus Enoxaparin in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: Results From the OASIS-5 Trial Shamir R. Mehta, ...Christopher B. Granger, John W. Eikelboom, Jean-Pierre Bassand, Lars Wallentin, David P. Faxon, Ron J. G. Peters, Andrzej Budaj, Rizwan Afzal, Susan Chrolavicius, Keith A. A. Fox, Salim Yusuf We report a prospectively planned analysis of 6,238 patients with acute coronary syndrome who underwent early percutaneous coronary intervention in the OASIS-5 (Fifth Organization to Assess Strategies in Ischemic Syndromes) randomized trial. Fondaparinux compared with enoxaparin reduced major bleeding by more than 50% (2.4% vs. 5.1%, hazard ratio HR 0.46, p < 0.00001), with similar rates of ischemic events, resulting in superior net clinical benefit (death, myocardial infarction, stroke, major bleeding: 8.2% vs. 10.4%, HR 0.78, p = 0.004). Catheter thrombus occurred in <1% in both groups, but was prevented by use of standard unfractionated heparin at the time of percutaneous coronary intervention without compromising the benefits of upstream fondaparinux.
Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Review of Contemporary Management Options William E. Boden, Kim Eagle, Christopher B. Granger Despite ...improvements in care, many patients presenting with ST-segment elevation myocardial infarction (STEMI) within 12 h of symptom onset still receive no reperfusion therapy. Timely reperfusion is central to the optimal treatment of STEMI; although there is much debate over whether mechanical or pharmacologic intervention is superior, speed of reperfusion after infarct onset may be more important than which treatment approach is used. This review highlights reperfusion options in STEMI, with regard to efficacy and safety, as well as temporal and logistical factors that may affect treatment outcomes and thus clinical decision making.
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