The aim of this study was to describe differences in the characteristics and short- and long-term prognoses of patients with first acute myocardial infarction (MI) according to the presence of ...ST-segment elevation or non–ST-segment elevation. From 2001 and 2003, 2,048 patients with first MI were consecutively admitted to 6 participating Spanish hospitals and categorized as having ST-segment elevation MI (STEMI), non–ST-segment elevation MI (NSTEMI), or unclassified MI (pacemaker or left bundle branch block) according to electrocardiographic results at admission. The proportions of female gender, hypercholesterolemia, hypertension, and diabetes were higher among NSTEMI patients than in the STEMI group. NSTEMI 28-day case fatality was lower (2.99% vs 5.26%, p = 0.02). On multivariate analysis, the odds ratio of 28-day case fatality was 2.23 for STEMI patients compared to NSTEMI patients (95% confidence interval 1.29 to 3.83, p = 0.004). The multivariate adjusted 7-year mortality for 28-day survivors was higher in NSTEMI than in STEMI patients (hazard ratio 1.31, 95% confidence interval 1.02 to 1.68, p = 0.035). However, patients with unclassified MI presented the highest short- and long-term mortality (11.8% and 35.4%, respectively). The excess of short-term mortality in unclassified and STEMI patients was mainly observed in those patients not treated with revascularization procedures. In conclusion, patients with first NSTEMI were older and showed a higher proportion of previous coronary risk factors than STEMI patients. NSTEMI patients had lower 28-day case fatality but a worse 7-year mortality rate than STEMI patients. Unclassified MI presented the worst short- and long-term prognosis. These results support the invasive management of patients with acute coronary syndromes to reduce short-term case fatality.
Preoperative anemia is a risk factor for postoperative morbidity and in-hospital mortality in cardiac surgery. However, it is not known whether treatment of anemia before cardiac surgery by ...administering recombinant human erythropoietin (rhEPO) plus iron improves postoperative outcomes and decreases red blood cell transfusions in these patients. In 1998 a collection of consecutive data for patients who underwent valve replacement was initiated and the inclusion criterion was anemia. Treatment with rhEPO was given at a dose of 500 IU/kg/day every week for 4 weeks and the fifth dose 48 hours before valve replacement. During each rhEPO session, patients received intravenous iron sucrose supplementation. The intervention cohort (2006 to 2011) included 75 patients and the observation cohort was composed of 59 patients who did not receive any treatment (1998 to 2005). Multivariable logistic regression analysis showed that administration of combined therapy was independently associated with decreased postoperative morbidity (odds ratio OR 0.13, 95% confidence interval CI 0.03 to 0.59 p = 0.008) and in-hospital mortality (OR 0.16, 95% CI 0.28 to 0.95 p = 0.04) after adjusting for logistic European System for Cardiac Operative Risk Evaluation score, type of intervention, time of cardiopulmonary bypass, and year of surgery. Individually, this treatment also decreased postoperative renal failure (OR 0.23, 95% CI 0.06 to 0.88, p = 0.03). Rate of red blood cell transfusion decreased from 93% in the observation cohort to 67% in the intervention cohort as did days of hospitalization (median, 15 days, 10 to 27, versus 10 days, 8 to 14, respectively, p = 0.01 for all comparisons). In conclusion, administration of intravenous rhEPO plus iron in anemic patients before valve replacement improves postoperative survival, decreases blood transfusions, and shortens hospitalization.
Pulmonary vein isolation has evolved over the past years as an alternative for the treatment of symptomatic recurrences of atrial fibrillation refractory to antiarrhythmic drug treatment. Both ...radiofrequency energy and cryoballoon ablation have proven useful in this setting. We present the case of a 55-year-old male patient undergoing cryoballoon ablation complicated with pulmonary hemorrhage. The cause of this rare complication may be found in the damage of vascular venous structures near the ablation zone or, alternatively, in hemorrhagic damage of the pulmonary vein surrounding tissue (or less probably to direct injury of the lingular bronchus). The extremely low temperatures achieved in this case (which are often associated with deep balloon position inside the veins) are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the cryoablation balloon.
The objective of the study is to investigate the impact of anemia (defined as hemoglobin concentration of <12 g/dl in women and 13 g/dl in men) on prognosis and to study the effect of recovery from ...anemia on echocardiographic and clinical parameters in patients with aortic stenosis (AS). This was a prospective study in 315 patients with moderate or severe AS. Patients with anemia received oral iron (ferrous sulfate with mucoproteose, 160 mg iron/day) and erythropoietin, if needed, or intravenous iron, if necessary. The following tests were performed before and after normalization of hemoglobin values: echocardiogram, 6-minute walk test, N-terminal B-type natriuretic peptide, and measures of depression, cognitive impairment, and dependence. Patient mean age was 74 years (SD 9). Mean follow-up was 25 months (SD 8). Anemia prevalence in the overall group was 22% (n = 70). Patients who are anemic had a higher rate of complications at follow-up (mortality, hospital admission, or need for valve procedure; 80% vs 62%, p = 0.009). In total, 89% of patients recovered from anemia, with a mean time to recovery of 4.6 weeks (SD 1.4). Improvements were observed on echocardiographic parameters of peak velocity (4.1 to 3.7 m/s, p = 0.02) and mean gradient (44 to 35 mm Hg, p = 0.02). Performance on the 6-minute walk test improved from 235 to 303 m (p <0.001). Median N-terminal B-type natriuretic peptide value decreased from 612 to 189 pg/dl (p <0.001). In conclusion, patients with AS and anemia have a worse prognosis than those without anemia. Resolution of anemia is associated with improvements in echocardiographic parameters and functional status, suggesting that treatment of iron deficiency is a relevant option in the management of patients with AS, particularly in nonoperable cases.
Abstract Background The prognosis in elderly patients with advanced chronic heart failure (CHF) and cardio-renal anemia syndrome (CRAS) is ominous, and treatment alternatives in this subset of ...patients are scarce. Methods and Results To assess the long-term influence of combined therapy with intravenous (IV) iron and erythropoietin (rHuEPO) on hemoglobin (Hb), natriuretic peptides (NT-proBNP), and clinical outcomes in elderly patients with advanced CHF and mild-to-moderate renal dysfunction and anemia (CRAS) who are not candidates for other treatment alternatives, 487 consecutive patients were evaluated. Of them, 65 fulfilling criteria for entering the study were divided into 2 groups and treated in an open-label, nonrandomized fashion: intervention group (27, combined anemia therapy) and control group (38, no treatment for anemia). At baseline, mean age was 74 ± 8 years, left ventricular ejection fraction was 34.5 ± 14.1, Hb was 10.9 ± 0.9 g/dL, creatinine was 1.5 ± 0.5 mg/dL, NT-proBNP was 4256 ± 4952 pg/mL, and 100% were in persistent New York Heart Association (NYHA) Class III or IV. At follow-up (15.3 ± 8.6 months), patients in the intervention group had higher levels of hemoglobin (13.5 ± 1.5 vs. 11.3 ± 1.1; P < .0001), lower levels of natural log of NT-proBNP (7.3 ± 0.8 vs. 8.0 ± 1.3, P = .016), better NYHA functional class (2.0 ± 0.6 vs. 3.3 ± 0.5; P < .001), and lower readmission rate (25.9% vs. 76.3%; P < .001). In the multivariate Cox proportional hazards model, combined therapy was associated with a reduction of the combined end point all-cause mortality or cardiovascular hospitalization (HR 95%CI 0.2 0.1-0.6; P < .001). Conclusion Long-term combined therapy with IV iron and rHuEPO may increase Hb, reduce NT-proBNP, and improve functional capacity and cardiovascular hospitalization in elderly patients with advanced CHF and CRAS with mild to moderate renal dysfunction.
The 12-lead electrocardiogram helps to define the arrhythmic mechanism in patients with palpitations. However, in the setting of nondocumented palpitations the value of the electrophysiologic study ...(EPS) needs additional investigation. We investigated the utility of the EPS in patients with nondocumented palpitations. A total of 172 patients with normal electrocardiographic findings and nondocumented palpitations underwent an EPS. The clinical and electrophysiologic characteristics were assessed. The symptoms were long-lasting (>5 minutes) in 56%. Sudden onset was present in 99%, and termination was rapid in 65%. Neck palpitations were reported in 36%. The EPS findings were normal in 86 patients (50%); atrioventricular nodal reentrant tachycardia was induced in 43, orthodromic reentrant tachycardia in 9, and nonsustained atrial tachycardia/fibrillation (AT/AF) in 34. Long-lasting episodes, sudden termination, and neck palpitations predicted positive EPS findings and were associated with reentrant supraventricular tachycardia (p <0.001). The induction of AT/AF was associated with age >50 years and structural heart disease (p <0.001). After 53 ± 36 months of follow-up, 92% of patients with negative EPS findings were symptom free. Only 32% of patients with induced AT/AF remained free of symptoms (p <0.001). The recurrence of palpitations was more prevalent among patients with structural heart disease and aged >50 years (p <0.001). In conclusion, 50% of patients with nondocumented palpitations had positive EPS findings. A long duration, sudden termination, and neck palpitations, together with structural heart disease and age >50 years, predicted tachycardia inducibility and recurrence and could help in selecting patients suitable for EPS and ablation.
Aim Right ventricular (RV) pump function is of essential clinical and prognostic importance in a variety of heart and lung diseases. While the evaluation of RV performance at rest has been ...implemented in the clinical setting, it is unknown whether this assessment during exercise may provide additional benefit. With this aim, we evaluated the exercise-induced pulmonary arterial systolic pressure (PASP) increase during exercise in patients with severe chronic obstructive pulmonary disease (COPD) as an expression of RV contractile reserve. Method Cardiopulmonary exercise testing (CPET) with synchronic echocardiography was performed in 81 patients. Patients were classified into two groups according to an exercise-induced PASP increase above 30 mmHg (High PSAP) or below 30 mmHg (Low PSAP) during maximal exercise. Patients were then followed for three years. Results Sixteen patients (20%) had low PSAP and 65 (80%) showed high PSAP. These were not significant clinical and functional differences. Low PSAP was associated with a significantly lower peak VO2 (mean (SD), 35 (2) % predicted) compared to high PSAP response (peak VO2 45 (3) % predicted), p=0.045. Factors associated with mortality were age and exercise-induced PASP. Seventeen patients died during the three years of follow-up (7 (39%) in the low PSAP group and only 10 (1%) in the high PSAP group, p=0.041). Conclusion Cardiopulmonary exercise testing with a synchronic echocardiography may be a useful tool for the assessment of RV contractile reserve in severe COPD patients. Exercise-induced PSAP emerges as a possible prognostic factor in these patients.
Background The clinical yield of cavotricuspid isthmus (CTI) radiofrequency ablation of atrial flutter (AF) is limited by a high incidence of atrial fibrillation (AFib) in the long term. Among other ...acknowledged variables, the association of obstructive sleep apnea (OSA) could favor incomplete arrhythmia control in this setting. We assessed the impact of CPAP in reducing the occurrence of AFib after CTI ablation. Methods Consecutive patients with AF who were undergoing CTI ablation were screened for OSA. Relationship of the following variables with the occurrence of AFib during follow-up (12 months) was investigated: CPAP initiation, hypertension, BMI, underlying structural heart disease, left atrial diameter, and AFib documentation prior to ablation. Results We prospectively included 56 patients (mean age: 66 (± 11) years; 12 female patients), of whom 46 (82%) had OSA and 25 (45%) had severe OSA. Twenty-one patients (38%) had AFib during follow-up after CTI ablation. Both freedom from AFib prior to ablation and CPAP initiation in those patients without previously documented AFib at inclusion were associated with a reduction of AFib episodes during follow-up ( P = .019 and P = .025, respectively). Inversely, CPAP was not protective from AFib recurrence when this arrhythmia was documented prior to ablation ( P = .25). Conclusions OSA is a prevalent condition in patients with AF. Treatment with CPAP is associated with a lower incidence of newly diagnosed AFib after CTI ablation. Screening for OSA in patients with AF appears to be a reasonable clinical strategy.
The Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II has broadened the indications for cardioverter defibrillator implantation. We present a retrospective study designed to estimate ...the number of patients in Spain eligible for an implantable defibrillator according to the MADIT-II criteria. From January 1999 to October 2002, 758 consecutive patients were admitted to our center with the diagnosis of acute myocardial infarction. Sixty-seven had a left ventricular ejection fraction ≤30% (mean, 235) and were not eligible for revascularization. Excluding patients older than 80 years and patients with marked co-morbidity, 47 patients met the MADIT-II criteria for an implantable defibrillator. After a mean follow-up of 18 months, there were 20 deaths, 6 of which were considered sudden. In conclusion, application of the MADIT-II criteria for defibrillator implantation may benefit 6% of the patients with myocardial infarction in Spain. This proportion translates as 4110 defibrillator implantations.
El Multicenter Automatic Defibrillator Implantation Trial (MADIT) II amplía las indicaciones de los desfibriladores automáticos implantables. Presentamos un estudio retrospectivo que tiene como objetivo conocer el número de pacientes con criterios MADIT-II en nuestro entorno. Entre enero de 1999 y octubre de 2002, 758 pacientes fueron ingresados en nuestro servicio por un infarto agudo de miocardio. En 67 pacientes, la fracción de eyección fue ≤ 30% y no eran revascularizables. La fracción de eyección media de este grupo fue del 23 ± 5%. Si excluimos a los pacientes de más de 80 años y a los que presentaban una marcada morbilidad asociada, 47 pacientes hubieran cumplido los criterios MADIT-II (6%). En un seguimiento medio de 18 meses hubo 20 muertes, 6 de ellas de forma súbita. Si extrapolamos estos datos a nuestro país, el número anual de implantes se incrementaría hasta unos 4.110.
