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The prognostic benefit of statins in patients with heart failure is a topic of controversy. Under the hypothesis that statins may provide greater benefit in a subgroup of patients with heightened inflammatory activity, we sought to explore whether statins are associated with a decreased risk of long-term mortality in patients with acute heart failure based on elevated levels of carbohydrate antigen 125, a biomarker related to systemic congestion and proinflammatory status.We analysed 1222 consecutive patients admitted with acute heart failure in a single teaching center during a median follow-up of 20 months. carbohydrate antigen 125 was measured during index hospitalization and dichotomized according to the established reference cut-off (35 U/mL).Increased levels of carbohydrate antigen 125 (35 U/mL) were observed in 793 (64.9%) and prescription of statins registered in 455 (37.2%) patients. In patients with carbohydrate antigen 12535 U/mL, mortality was lower in statin-treated patients (1.89 vs 2.80 per 10 patient-years of follow-up, P.001). Conversely, in those with carbohydrate antigen 125 in normal range, mortality did not differ (1.76 vs 1.63 per 10 patient-years of follow-up, P = .862). After covariate adjustment, this differential effect persisted (P for interaction = .024) and statin use was associated with a significant mortality reduction in patients with elevated values of carbohydrate antigen 125 (hazard ratio=0.65, 95% confidence interval: 0.51-0.82; P.001), but not in those with values equal to or below 35 U/mL (hazard ratio=1.02, 95% confidence interval: 0.74-1.41; P = .907).Elevation of carbohydrate antigen 125 (35 U/mL) identified a subset of patients with acute heart failure who could benefit from statin treatment in regard to total mortality.

Introduction and objectives The usefulness of ST-segment elevation resolution (STR) for predicting epicardial reperfusion is well established. However, it is still not clear how ST-segment changes are related to microvascular obstruction (MVO) observed by cardiovascular magnetic resonance (CMR) after primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). Methods The study involved 85 consecutive patients admitted for a first STEMI and treated by pPCI who had a patent infarct-related artery. An ECG was recorded on admission and 90 min and 6, 24, 48 and 96 h after pPCI. Thereafter, STR and the sum of ST-segment elevation (sumSTE) in all leads were determined. Results Overall, CMR revealed MVO in 37 patients. In infarcts with MVO, sumSTE was greater both before and after revascularization than in infarcts without MVO ( P ≤.001 at all times). In contrast, there was no significant difference in the magnitude of STR between infarcts with and without MVO 90 min after revascularization ( P =.1), though there was after 6 h ( P P 3 mm 90 min after pPCI was an independent predictor of MVO on CMR, while an STR ≥70% was not (odds ratio=3.1; 95% confidence interval, 1.2–8.4; P =.02). Conclusions MVO was associated with a significantly increased sumSTE at all times after revascularization. The difference in the magnitude of STR between infarcts with and without MVO was significant only >6 h after revascularization. The best predictor of MVO was a sumSTE >3 mm 90 min after pPCI.

The presence of microvascular obstruction after ST-segment elevation acute myocardial infarction is associated with a poor outcome. The pathophysiology of this process has not been fully defined. The aim of this study was to investigate the relationship between post-reperfusion lymphopenia and microvascular obstruction.This prospective study involved 212 patients with a first ST-segment elevation acute myocardial infarction who underwent reperfusion with thrombolytic agents or primary angioplasty and who had an open infarct-related artery. Serial measurements of lymphocyte, neutrophil and monocyte counts were taken. Cardiac magnetic resonance was used to detect microvascular obstruction during the first week after the infarction. Imaging was repeated 6 months after infarction.Microvascular obstruction was observed in 67 patients (32%). A post-reperfusion lymphocyte count1800 cells/ml was associated with a higher risk of microvascular obstruction (44% versus 20%; P.001) as well as with a low left ventricular ejection fraction and large left ventricular volumes (P.05). After adjustment for baseline characteristics, ECG findings, necrosis marker levels and angiographic variables, multivariate analysis showed that a post-reperfusion lymphocyte count1800 cells/ml was independently associated with an increased risk of microvascular obstruction (odds ratio=3.2; 95% confidence interval 1.6-6.3; P.001).In ST-segment elevation myocardial infarction, post-reperfusion lymphopenia is an early and powerful predictor of the presence of microvascular obstruction. The pathophysiological and therapeutic implications of this association require further study.

Introduction and objectives. The aims of the study were to characterize myocardial edema after ST-elevation acute myocardial infarction using cardiac magnetic resonance imaging and to investigate its impact on ventricular function and its subsequent evolution. Methods. In total, 134 patients admitted to hospital for a first ST-elevation myocardial infarction who had a patent infarct-related artery underwent cardiac magnetic resonance imaging. Cine images (at rest and with low-dose dobutamine) and edema, perfusion and viability images were acquired. Imaging was repeated after 6 months. Results. In the first week after infarction, edema was detected in at least one segment in 96.6% of patients (4±2.1 segments per patient). Extensive edema (≥4 segments) was associated with large ventricular enddiastolic and end-systolic volumes (P

The right radial (RR) approach has been incorporated into daily clinical practice as a valid alternative to the femoral (F) approach. The left radial (LR) approach is seldom used and few data are available from randomized studies comparing this approach with F and RR approaches.We randomized 1005 consecutive patients referred to a tertiary-care hospital for cardiac catheterization to different approaches. Procedures were performed by three interventional cardiologists experienced in transradial catheterization. There were no exclusion criteria. The primary end-point was the percentage of procedures completed using the assigned approach. Secondary endpoints were the percentage completed in the absence of contraindications to any approach, the duration of the procedure, and the incidence of vascular complications.More procedures were completed with the F approach (LR, 71%; F, 92%; RR, 68%; P.001). The success rate in the absence of contraindications to any approach (n=907) was greater with the F approach, with no difference between LR and RR approaches (LR, 80%; F, 96%; RR, 82%; P.001). The canalization time was greater with the LR approach (P.001), the time required for diagnosis was shorter with the F approach (P.001) and compression was faster with the radial approach (P.001). There was no difference in the total duration of diagnostic procedures (P=.22) or interventions (P=.9). The incidence of vascular complications was lower with the radial approach (P=.03).The left radial approach is as valid an alternative to the femoral approach as the right radial approach.

The prognostic value of brain natriuretic peptide (BNP) measurement in patients with acute heart failure is not well understood. The aim of this study was to investigate the relationship between the BNP level and mortality and readmission for acute heart failure. We studied 569 consecutive patients who were admitted with a diagnosis of acute heart failure. The BNP level was measured after the patient became clinically stable. The relationship between the BNP level and mortality was assessed by Cox regression analysis, and the relationship with readmission, by competing risks regression analysis. During a median follow-up period of 9 (range, 3-18) months, 156 deaths (27.4%) and 140 readmissions (24.6%) occurred. Multivariate analysis demonstrated a positive linear association between the risk of death and the BNP quintile. In contrast, the BNP level did not predict readmission for acute heart failure, mainly because of the effect of death as a competing outcome.

Introduction and objectives It has been suggested that abnormal perfusion as derived from cardiovascular magnetic resonance imaging (CMR) is a transient dysfunction of microcirculation after myocardial infarction (MI) with TIMI 3 flow. We hypothesized that defects of myocardial perfusion may persist during the following months. Methods Forty-seven patients with MI and sustained TIMI 3 flow underwent intracoronary myocardial contrast echocardiography (MCE) 1 week and 6 months after infarction. Abnormal perfusion by MCE was regarded as >1 hypoperfused segment. Results At one week, 20 patients showed abnormal perfusion as derived from MCE. At six months 10 patients displayed chronic abnormal perfusion. These patients had greater left ventricular volumes and lower ejection fraction at the sixth month by CMR ( P Conclusions MCE detects perfusion defects which can persist in chronic phase–this relates to more severe systolic dysfunction and increased left ventricular volumes.

Introduction and objectives An analysis was made of variability in the measurement of the angiographic index blush between a university hospital and an independent core laboratory, as well as its correlation with perfusion analised by intracoronary myocardial contrast echocardigraphy (MCE) and the ventricular function at the sixth month. Methods The study comprised 40 patients with a first ST-segment elevation myocardial infarction, single-vessel disease and open infarct-related artery. Perfusion was quantified by angiography (median fifth day, range 3-7) with blush in our laboratory and in an independent core laboratory. MCE was performed. Ejection fraction at the sixth month was determined with magnetic resonance imaging. Results We found a weak correlation (r=0.38) between both laboratories. In the comparison of blush measurements concordance was 80%, kappa=0.43 if normality was defined by blush 2-3; and concordance 55%, kappa=0.1 for blush 3. Neither perfusion analised by MCE (r= 0.23, P=.2) nor ejection fraction by resonance (r=0.20, P=.3) did correlate to blush. Conclusions After infarction in patients with TIMI 3, variability is observed in blush measurements between a university hospital and an independent core laboratory, therefore it seems advisable to centralize blush measures in highly specialized core laboratories. A weak correlation was detected with perfusion analised by MCE and with late systolic function.

Introduction and objectives Advanced diabetes can be associated with diffuse coronary artery disease that is difficult to treat by revascularization. We studied angiographic findings and disease progression in patients with advanced diabetes (either insulin-dependent or taking antidiabetic drugs for >5 years) and non-ST-elevation acute coronary syndrome who were being treated using an invasive strategy. Methods The study included 141 patients. The extent of the coronary artery disease was quantified using a score derived from a 29-segment coronary angiogram. The composite endpoint was death, myocardial infarction, or readmission for unstable angina within one year of follow-up. Results The extent of coronary disease was associated with Killip class >1 at admission ( P =.02), previous coronary surgery ( P =.003), ST-segment depression ( P =.01), and a poor ejection fraction ( P =.0001). The more of these factors present (i.e., 0, 1, 2, or 3 factors), the greater the extent of the coronary disease (i.e., 12 [7], 15 [7], 21 [6], and 23 [7] points, respectively; P =.0001). There was a significant difference between patients with 2 factors and those with P =.02), even after adjustment using a revascularization propensity score (C-index, 0.80). Conclusions In patients with non-ST-elevation acute coronary syndrome and advanced diabetes being managed using an invasive strategy, a history of coronary surgery, ST-segment depression and poor left ventricular function were all associated with the presence of diffuse coronary artery disease. Clinical follow-up indicated that revascularization during hospital admission improved prognosis.

Introduction and objectives. Cardiovascular disease is the main cause of death in patients with kidney failure. Moreover, the presence of impaired renal function is an important prognostic factor in patients with heart disease, and is a determinant of outcome during follow-up. The main aim was to investigate the relationship between kidney failure at admission and one-year mortality in patients with non-ST-elevation acute coronary syndrome. Patients and methods. We studied 1029 consecutive patients admitted to our institution. The serum creatinine level and glomerular filtration rate were determined at admission, and classical risk factors and biochemical markers were assessed. The primary endpoint was allcause mortality at one year. Results. Patients who died were older, more frequently had a history of diabetes or coronary artery disease, were more likely to have heart failure at admission, had higher troponin-I, myoglobin and creatinine levels, and were less likely to have dyslipidemia or to be a smoker. Multivariate analysis showed that the independent predictors of allcause mortality at one year were age, diabetes, troponin-I level, Killip class >1, male gender, creatinine level, and glomerular filtration rate. There was a linear correlation between increased risk and creatinine level. Conclusions. Creatinine level at admission is one of the most important covariates in early prognostic stratification in these patients. A high serum creatinine level (or a low glomerular filtration rate) increases the probability of death due to all causes. The serum creatinine level is, moreover, an inexpensive, easy-touse, and widely available prognostic marker.

Although traditionally an elevated white blood cell count (WBC), an indicator of systemic inflammation, has been accepted as part of the healing response following acute myocardial infarction (AMI), it has frequently been shown to be a predictor of adverse cardiovascular events. The present study was designed to assess the association between WBC and long-term mortality in AMI patients either with ST-segment elevation (STEMI) or without ST-segment elevation (non-STEMI). Patients and method. The study included 1118 consecutive patients who were admitted with the diagnosis of AMI: 569 non-STEMI and 549 STEMI. The WBC was measured in the 24 hours following admission. Patients were divided into 3 groups: WBC1 (count,10 x 103 cells/mL), WBC2 (count, 10-14.9 x 10(3) cells/mL), and WBC3 (count,or =15x10(3) cells/mL). All-cause mortality was recorded during a median follow-up period of 10+/-2 months. The relationship between WBC and mortality was assessed by Cox regression analysis for both types of AMI.Long-term mortality during follow-up was 18.5% in non-STEMI patients and 19.9% in STEMI patients. In non-STEMI patients, the adjusted hazard ratios for those in the WBC3 and WBC2 groups compared with those in the WBC1 group were 2.07 (1.08-3.94; P=.027) and 1.61 (1.03-2.51; P=.036), respectively. The corresponding figures in STEMI patients were 2.07 (1.13-3.76; P=.017) and 2.22 (1.35-3.63; P=.002), respectively.WBC on admission was an independent predictor of long-term mortality in both non-STEMI and STEMI patients.

Introduction and objectives. After a myocardial infarction, damage to the microcirculation indicates a worse prognosis. We compared the usefulness of the quantitative analysis of myocardial contrast echocardiography with intravenous injection of contrast (MCE-iv) with intracoronary injection (MCE-ic) for analyzing coronary perfusion. Patients and method. We studied 42 patients with a first ST-elevation myocardial infarction, single-vessel disease and a patent artery (TIMI 3, stenosis 0.75) and MCE-iv (perfusion of SonoVue, singleimage capture in 1 out of each 6 cycles with trigger set at end-systole, perfusion considered normal if >0.9). Perfusion was considered abnormal if 2 or more segments showed altered perfusion. Results. Quantification with MCE-iv took 5±1 minutes. No side effects were observed. MCE-ic was normal in 141 segments (80%) out of 176 segments included in the infarcted area, whereas 35 segments (20%) showed abnormal perfusion. MCE-ic was normal in 31 patients (74%) and was altered in 11 cases (26%). Normal perfusion with MCE-iv had a sensitivity of 91%, a specificity of 84%, and a kappa index of 0.67 for predicting normal perfusion with MCE-ic (r=0.86; P

Introduction and objectives We report the impact on prognosis of an invasive strategy used at our center for non-ST-segment elevation acute coronary syndrome. Patients and method We analyzed 504 consecutive patients with typical chest pain, electrocardiographic changes or increased troponin I serum values, who were divided into 2 cohorts: a ) conservative group, 272 patients admitted between October 2001 and September 2002 and managed with a conservative strategy, and b ) invasive group, 232 patients admitted between October 2002 and September 2003 for whom an invasive strategy was recommended. We recorded major events (death or reinfarction) and minor events (readmission or need for post-discharge revascularization) within a 12-week follow-up period. Results In the invasive group in-hospital angioplasty (21% vs 35%, P P = .001) increased. There were no significant differences between the conservative and the invasive group regarding major events (17% vs 15%). The invasive group was associated with a reduction in minor events (17% vs 9%, P = .01). The incidence of any event was reduced (28% vs 20%, P = .04). In the multivariate analysis for the whole group (n=504) the invasive strategy significantly reduced minor events (hazard ratio 0.5 [0.3-0.8], P = .008) and any event (hazard ratio 0.5 [0.3-0.8], P = .005), but not major events (hazard ratio 0.6 [0.4-1.1], P = .09). Conclusions The results observed in recent randomized clinical trials regarding the use of an invasive strategy were confirmed in the real world. In the short term, the benefits seem to be confined to a reduction in minor events, i.e., fewer readmissions and less need for postdischarge revascularization. Estrategia invasiva en el sindrome coronario agudo sin elevacion del segmento ST. De los grandes estudios al mundo real

Introduction and objectives. The Charlson comorbidity index (CCI), an indicator of comorbidity, has been used as an adjusting variable in multivariate models. Because of its prognostic value per se for cardiovascular complications after acute myocardial infarction (AMI), we sought to determine the predictive value of the CCI for allcause mortality and recurrent AMI 30 days and 1 year after the index event. Patients and method. We analyzed 1035 consecutive patients admitted with the diagnosis of AMI (ST elevation=508 and non-ST elevation=527). The composite endpoint was determined after 30 days (13.9%) and 1 year (26.3%) of follow-up. The CCI was calculated on admission, and other variables with prognostic value were also recorded. CCI was stratified in 4 categories: 1: CCI=0 (control), 2: CCI=1, 3: CCI=2,4: CCI≥3. Cox proportional risks analysis was used for the multivariate analysis, and the C-statistic was calculated to assess the discriminative power of the models. Results. Hazard ratios (95% CI) estimated for each category of CCI were: 2=1.69 (1.10-2.59), 3=1.78 (1.082.92) and 4=1.57 (0.87-2.83) at 30 days; 2=1.62 (1.182.23), 3=2.00 (1.39-2.89) and 4=2.24 (1.50-3.36) at 1 year. Comparisons with the C-statistic between the nested multivariate models (with and without CCI) yielded values of 0.765 vs 0.750 after 30 days, and 0.751 vs 0.735 after 1 year. Conclusions. Our data indicate that CCI is an independent predictor of mortality or recurrent AMI 30 days and 1 year after the index AMI.

Introduction and objective. To assess the reliability of early analysis of the most frequently used cardiac magnetic resonance (CMR)-derived indexes for predicting systolic function recovery and ventricular remodeling in patients after a first acute myocardial infarction with a patent culprit artery. Patients and method. 17 patients were studied with an initial CMR protocol that included regional assessment of wall thickness and wall thickening, low-dose dobutamine response, first-pass gadolinium myocardial perfusion imaging and delayed enhancement. These results were compared with those obtained for segmental and global function in a second CMR study 6 months later. Results. Of the 272 myocardial segments evaluated in the initial study, 73 showed severe systolic dysfunction. The findings were used to calculate sensitivity and specificity of each of the indexes mentioned above for predicting myocardial viability. The sensitivities and specificities for each index were wall thickness ≥5.5 mm, 100% and 12%; low-dose dobutamine response, 41% and 93%; normal myocardial perfusion, 78% and 68%; delayed enhancement, 81% and 95%. Multivariate analysis showed that delayed enhancement was the only independent predictor of contractility (r=‐0.83, P=.0001), ventricular volumes (enddiastolic: r=0.61, P=.009, end-systolic: r=0.67, P=.003) and ejection fraction (r=‐0.73, P=.001) at 6 months. Conclusions. Delayed enhancement seen in CMR is a reliable, quantifiable index for predicting recovery of systolic function and ventricular remodeling in patients after a first infarction with a patent culprit artery.