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T2 weighted cardiovascular magnetic resonance (CMR) can detect intramyocardial hemorrhage (IMH) after ST-elevation myocardial infarction (STEMI). The long-term prognostic value of IMH beyond a comprehensive CMR assessment with late enhancement (LE) imaging including microvascular obstruction (MVO) is unclear. The value of CMR-derived IMH for predicting major adverse cardiac events (MACE) and adverse cardiac remodeling after STEMI and its relationship with MVO was analyzed.CMR including LE and T2 sequences was performed in 304 patients 1 week after STEMI. Adverse remodeling was defined as dilated left ventricular end-systolic volume indexes (dLVESV) at 6 months CMR.During a median follow-up of 140 weeks, 47 MACE (10 cardiac deaths, 16 myocardial infarctions, 21 heart failure episodes) occurred. Predictors of MACE were ejection fraction (HR .95 95% CI [.93-.97], p=.001, per %) and IMH (HR 1.17 95% CI [1.03-1.33], p=.01, per segment). The extent of MVO and IMH significantly correlated (r=.951, p.0001). dLVESV was present in 40% of patients. CMR predictors of dLVESV were: LVESV (OR 1.11 95% CI [1.07-1.15], p.0001, per ml/m(2)), infarct size (OR 1.05 95% CI [1.01-1.09], p=.02, per %) and IMH (OR 1.54 95% CI [1.15-2.07], p=.004, per segment). Addition of T2 information did not improve the LE and cine CMR-model for predicting MACE (.744 95% CI [.659-.829] vs. .734 95% CI [.650-.818], p=.6) or dLVESV (.914 95% CI [.875-.952] vs. .913 95% CI [.875-.952], p=.9).IMH after STEMI predicts MACE and adverse remodeling. Nevertheless, with a strong interrelation with MVO, the addition of T2 imaging does not improve the predictive value of LE-CMR.

Resumen Introduccion y objetivos Se ha demostrado el valor pronostico de varios indices de resonancia magnetica cardiaca a medio plazo tras un infarto agudo de miocardio con elevacion del segmento ST. La extension de la necrosis transmural permite una prediccion simple y exacta de viabilidad miocardica. Sin embargo, se desconoce su valor pronostico a largo plazo mas alla de una completa evaluacion clinica y por resonancia. Nuestra hipotesis es que la evaluacion semicuantitativa de la extension de la necrosis transmural es el mejor indice de resonancia para predecir el pronostico a largo plazo tras un infarto con elevacion del segmento ST. Metodos Se realizo un estudio cuantitativo con resonancia a 206 pacientes consecutivos tras un infarto con elevacion del segmento ST. Tambien se evaluo semicuantitativamente (numero de segmentos alterados, modelo de 17 segmentos) edema, contractilidad basal y tras dobutamina, perfusion de primer paso, obstruccion microvascular y extension de la necrosis transmural. Resultados Durante el seguimiento (mediana, 51 meses), 29 pacientes sufrieron un primer evento cardiaco adverso (8 muertes cardiacas, 11 infartos y 10 reingresos por insuficiencia cardiaca). Estos eventos se asociaron con mayor alteracion de los indices de resonancia. Tras un ajuste multivariable, la extension de la necrosis transmural fue el unico indice de resonancia con asociacion independiente con los eventos cardiacos adversos (razon de riesgos = 1,34 [1,19-1,51] por cada segmento con necrosis transmural > 50%; p Conclusiones Un sencillo analisis semicuantitativo de la extension de la necrosis transmural es el indice de resonancia cardiaca mas potente para predecir el pronostico a largo plazo tras un infarto agudo de miocardio con elevacion del segmento ST.

Early stratification of patients according to the risk for developing microvascular obstruction (MVO) after ST-segment elevation myocardial infarction (STEMI) is desirable. We aimed to identify predictors of cardiovascular magnetic resonance (CMR)-derived MVO from clinical+ECG, laboratory and angiographic parameters available on admission.Characteristics available on admission were documented in 97 STEMI patients referred for primary angioplasty. MVO was determined using contrast-enhanced CMR.MVO was present in 44 patients (45%). The C-statistic for predicting MVO was: clinical+ECG (.832), laboratory (.743), and angiographic parameters (.669). Adding laboratory to clinical+ECG information did not improve the C-statistic (.873 vs. .832, p=.2). Further addition of angiographic data (.904) improved the C-statistic of clinical+ECG (p=.04) but not of clinical+ECG and laboratory (p=.2). Independent predictors of MVO using clinical and ECG parameters were: Killip class1 (OR 15.97 95%CI [1.37-186.76], p=.03), diabetes (OR 6.15 95%CI [1.49-25.39], p=.01), age55years (OR 4.70 95%CI [1.56-14.17], p=.006), sum of ST-segment elevation10mm (OR 4.5 95%CI [1.58-12.69], p=.005) and delayed presentation3h (OR 3.80 95%CI [1.19-12.1], p=.02). A score was constructed assigning Killip class1 2 points and the remaining indexes 1 point. The incidence of MVO increased with the score: 0 point: 8.7%; 1 point: 28.1%; 2 points: 71.4%; and 3+ points: 93% (p.0001).MVO can be predicted using parameters already available on patient admission. We developed a clinical-ECG score allowing for early and reliable classification of STEMI patients according to the risk of MVO.

Resumen Fundamento y objetivos El reingreso precoz tras una hospitalizacion por insuficiencia cardiaca aguda (ICA) es frecuente, sin embargo, los factores asociados a este no estan claramente establecidos. Los valores plasmaticos del antigeno carbohidrato 125 (CA125) han mostrado asociarse con la presencia de congestion sistemica y aumento del riesgo de muerte en pacientes con ICA. El objetivo de este trabajo fue determinar la relacion entre los valores de CA125 (durante el ingreso, en la primera visita ambulatoria o sus cambios) y el reingreso por ICA a 6 meses de seguimiento. Pacientes y metodo Analizamos 293 pacientes consecutivos ingresados por ICA en los que se determino el CA125 durante la hospitalizacion indice (T1) y en la primera visita ambulatoria (T2) tras el alta (mediana 31 dias). Evaluamos la relacion entre el CA125, tanto sus determinaciones aisladas como sus cambios seriados (absolutos, relativos o categoricos), y el reingreso precoz por ICA mediante analisis de regresion de Cox adaptado para episodios competitivos. La tecnica de reclasificacion « integrated discrimination improvement index» se utilizo para evaluar la capacidad discriminativa adicional de este biomarcador sobre el modelo multivariante final. Resultados A 6 meses de seguimiento, se identificaron 32 (10,9%) y 54 (18,4%) muertes y reingresos por ICA, respectivamente. Los cambios categoricos de CA125 (descenso y normalizacion en T2 [C1, n = 153], descenso pero no normalizacion en T2 [C2, n = 72] e incremento con valores elevados en T2 [> 35 U/ml] [C3, n = 68]), seguidos de su determinacion aislada en T2, mostraron la mejor capacidad discriminativa sobre el modelo basal. Asi, con respecto a los pacientes en la categoria C1, los pacientes en las categorias C2 y C3 presentaron un mayor riesgo de reingreso por ICA: C2 frente a C1: hazard ratio (HR) = 3,48, intervalo de confianza del 95% (IC 95%) 1,84-6,59, p 35 U/ml) en T2 (41%) triplicaron el riesgo de reingreso por ICA a 6 meses con respecto a aquellos con valores normales de CA125 en T2: HR = 3,06, IC 95% 1,79-5,23, p Conclusiones Tras un episodio de ICA, la elevacion de CA125 (> 35 U/ml) tras las primeras semanas del ingreso se asocia a un incremento del riesgo de reingreso precoz por ICA.

Resumen Introduccion y objetivos Analizar mediante resonancia magnetica cardiaca los factores que determinan la magnitud del miocardio salvado tras infarto de miocardio y su valor predictivo del remodelado adverso ventricular. Metodos A 118 pacientes con un primer infarto de miocardio con elevacion del ST (angioplastia primaria, 65 pacientes; estrategia farmacoinvasiva, 53 pacientes) se les realizo resonancia magnetica (6 [5-8] dias y 6 meses; n = 83). Se cuantifico el indice de miocardio salvado como el porcentaje de area en riesgo (secuencias ponderadas en T2) que no muestra realce tardio. Resultados El indice de miocardio salvado > 31% (mediana) se asocia a menor tiempo dolor-reperfusion (153 frente a 258 min), menor frecuencia de diabetes (el 12 frente al 32%), menor retraso hasta la resonancia magnetica y mejores parametros cardiovasculares (p 31% son el retraso hasta la reperfusion (odds ratio = 0,42 [0,29-0,63]; p 50% (odds ratio = 1,51 [1,21-1,90]; p Conclusiones La resonancia magnetica permite cuantificar el miocardio salvado tras el infarto. La rapidez en recibir el tratamiento de reperfusion constituye su principal predictor. Se debe confirmar la posible relacion entre el retraso en la realizacion de la resonancia magnetica y el miocardio salvado. El miocardio salvado no mejora el valor de la resonancia para predecir remodelado adverso.

Heat shock protein 60 (HSP60) is a mitochondrial protein constitutively expressed in the majority of cells, and its expression is up-regulated by a variety of stressors. In heart failure, HSP60 is released from cardiomyocytes. The authors speculate that increased serum HSP60 (sHSP60) may be related to the severity of heart failure. This investigation sought to assess the association between sHSP60 and the composite end point of death ⁄ readmission in patients with acute heart failure (AHF). A total of 132 consecutive patients were admitted for AHF. The independent association between sHSP60 and the end point was assessed with Cox regression. During a median follow-up of 7 months (interquartile range, 3–14), 35 (26.5%) deaths, 40 (30.3%) readmissions, and 65 (49.2%) deaths ⁄ readmission were identified. Patients who exhibited the outcome showed higher median sHSP60 values (6.15 ng ⁄ mL [8.49] vs 4.71 ng ⁄ mL [7.55] P=.010). A monotonic increase in the incidence of the composite end point was observed when moving from lower to higher tertile (4.74, 4.76, and 6.98 per 10 patients-years of follow-up, P for trend

To evaluate remote myocardial function after ST-elevation myocardial infarction (STEMI) and the impact of infarct size (IS) using cardiovascular magnetic resonance (CMR). 161 patients and 15 controls underwent CMR at 1st week and 6th month after STEMI. Using the 17-segments model, segments were categorized into infarcted, adjacent and remote myocardium. Relative systolic wall thickening (SWT, %) was assessed using the centerline method. IS (% of left ventricular mass) was determined in late enhancement imaging. Overall, in remote myocardium, SWT was comparable (83 ± 32) to controls (77 ± 25, P = .5) and did not increase significantly (P = .2) at the 6th month (88 ± 35, P = .3 vs. control). When IS was categorized into tertiles (13.6%, (n = 49), 13.7-28.2%, (n = 60),28.2%, (n = 52)), SWT in the remote area at the 1st week was not different from controls, regardless of infarct size (p between .2 and .8 for all tertiles). At 6 months, SWT was larger compared to controls only in small infarctions (98 ± 34 vs. 77 ± 25, P = .03). In medium and large infarctions there was no difference in SWT of the remote area compared to controls (87 ± 33 and 79 ± 34, P = .3 and P = .09) and there was no significant increase at 6 months (P between .2 and .9). In remote myocardium there was no difference in contractility compared to controls after STEMI. After 6 month a slight hypercontractility can only be observed in small infarctions. In medium and large infarctions no difference of SWT in remote myocardium compared to controls can be observed.

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.

Introduccion y objetivos La utilidad de las estatinas en pacientes con insuficiencia cardiaca es motivo de controversia. Bajo la hipotesis de que el tratamiento con estatinas seria util en los pacientes con insuficiencia cardiaca y mayor actividad inmunoinflamatoria, pretendimos conocer si la elevacion del antigeno carbohidrato 125, un biomarcador asociado a la congestion sistemica y actividad inflamatoria, identificaria a los que se beneficiarian, en cuanto a mortalidad, del tratamiento con estatinas tras un ingreso por insuficiencia cardiaca aguda. Metodos Analizamos a 1.222 pacientes consecutivos ingresados por insuficiencia cardiaca aguda. El antigeno carbohidrato 125 se determino durante el ingreso hospitalario y se dicotomizo segun los valores de referencia (> 35 U/ml). Resultados Se observaron valores elevados del antigeno carbohidrato 125 en 793 pacientes (64,9%) y a 455 (37,2%) se les prescribio estatinas. Entre los pacientes con antigeno carbohidrato 125>35 U/ml, la mortalidad de los tratados con estatinas fue inferior (1,89 frente a 2,80/10 pacientes-ano de seguimiento; p 35 U/ml (hazard ratio=0,65; intervalo de confianza del 95%, 0,51-0,82; p

Background: Data on the effect of revascularization on outcome in patients with high-risk non–ST-segment elevation acute coronary syndrome (NSTEACS) and significant comorbidities are scarce. Recently, a simple comorbidity index (SCI) including 5 comorbidities (renal failure, dementia, peripheral artery disease, heart failure, and prior myocardial infarction [MI]) has shown to be a useful tool for risk stratification. Nevertheless, therapeutic implications have not been derived. Hypothesis: We sought to evaluate the prognostic effect attributable to revascularization in NSTEACS according the SCI score. Methods: We included 1017 consecutive patients with NSTEACS. The effect of revascularization on a combined end point of all-cause mortality or nonfatal MI was evaluated by Cox regression according to SCI categories. Results: A total of 560 (55.1%), 236 (23.2%), and 221 (21.7%) patients showed 0, 1, and ≥2 points according to the SCI, respectively. Coronary angiography was performed in 725 patients (71.5%), and 450 patients (44.3%) underwent revascularization. During a median follow-up of 16 months (interquartile range, 12–36 months), 305 (30%) patients experienced the combined end point (202 deaths [19.9%] and 170 MIs [16.7%]). In multivariate analysis, a differential prognostic effect of revascularization was observed comparing SCI ≥2 vs 0 (P for interaction = 0.008). Thus, revascularization was associated with a greater prognostic benefit in patients with SCI ≥2 (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.29–0.89), P = 0.018), whereas no significant benefit was observed in those with 0 and 1 point (HR: 1.31, 95% CI: 0.88–1.94, P = 0.171 and HR: 1.11, 95% CI: 0.70–1.76, P = 0.651, respectively). Conclusions: In NSTEACS, the SCI score appears to be a useful tool for identifying a subset of patients with a significant long-term death/MI risk reduction attributable to revascularization. © 2011 Wiley Periodicals, Inc. This study was supported by a grant from the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III, RED HERACLES (FEDER) RD06/0009/1001 (Madrid, Spain). The authors have no other funding, financial relationships, or conflicts of interest to disclose.

The prognostic value of arterial blood gases (ABG) in patients with acute decompensated heart failure (ADHF) is not well-established. We therefore conducted the present study to determine the relationship between ABG on admission and long-term mortality in patients with ADHF.We studied 588 patients consecutively admitted to our department with ADHF. ABG and classical prognostic variables were determined at patients' arrival to the emergency department. The independent association among the main variables of ABG (pO2, pCO2 and pH) and mortality was assessed with Cox regression analysis.At a median follow-up of 23months, 221 deaths (37.6%) were registered. 308 (52.4%), 54 (9.2%) and 50 (8.5%) patients showed hypoxemia (pO260mmHg), hypercapnia (pCO250mmHg) and acidosis (pH7.35), respectively. Patients with hypoxemia, hypercapnia and acidosis did not show higher mortality rates (38% vs. 37.1%, 42.6% vs. 37.1%, and 48% vs. 36.6%, respectively; p-value=ns for all comparisons). In multivariate analysis, after adjusting for well-known prognostic covariates, pO2, pCO2 and pH did not show a significant association with mortality. Hazard ratios (HR) for these variables were: pO2, per increase in 10mmHg: 0.99 (95% CI: 0.90-1.09), p=0.861; pCO2, per increase in 10mmHg: 1.12 (95% CI: 0.91-1.39), p=0.262; pH per increase in 0.1: 1.01 (95% CI: 0.99-1.04), p=0.309. When dichotomizing these variables according to established cut-points, the HR were: hypoxemia (pO260mmHg):1.07 (95% CI: 0.81-1.40), p=0.637; hypercapnia (pCO250mmHg): 0.98 (95% CI: 0.62-1.57), p=0.952; acidosis (pH7.35): 1.38 (95% CI: 0.87-2.19), p=0.173.In patients admitted with ADHF, admission arterial pO2, pCO2 and pH were not associated with all-cause long-term mortality.

Background Evaluation of chest pain of uncertain origin in the emergency department is a challenge. Chest pain units, involving non-invasive stress testing, have logistic constraints. Our aim was to identify very low risk patients for early discharge using clinical data. Methods A total of 772 patients were studied. Ischemia in the electrocardiogram, troponin elevation or history of ischemic heart disease, were exclusion criteria. The primary end point was 30day cardiac events (death, myocardial infarction or revascularization). The secondary end point was 1year major events (death or myocardial infarction). Results The primary and secondary end point rates were 123 (18%) and 31 (4%). Predictive variables for the primary end point were typical chest pain (OR=1.8, p =0.007), ≥2 pain episodes in last 24h (OR=3.4, p =0.0001), age≥55years (OR=1.8, p =0.03), male (OR=2.2, p =0.001), diabetes (OR=1.8, p =0.01) and family history of ischemic heart disease (OR=2.0, p =0.02). A very low risk category could be distinguished ( n =114) that showed only 3 (2.6%) events at 30days (all 3 revascularizations), compared with 120 (18%) in the remaining patients ( p =0.0001). The very low risk criteria had 97% negative predictive for 30day cardiac events. No very low risk patient presented major events at 1year compared with 31 (4.7%) in the remaining patients ( p =0.009). Conclusion In patients presenting to the emergency department with chest pain of uncertain origin and without prior ischemic heart disease, very low risk patients can be identified using clinical data. These patients could be quickly discharged without further non-invasive stress testing.

Inflammation plays a crucial pathophysiological role in the entire continuum of the atherosclerotic process, from its initiation, progression, and plaque destabilization leading ultimately to an acute coronary event. Furthermore, once the clinical event has occurred, inflammation also influences the left ventricular remodelling process. Under the same paradigm, there is evidence that lymphocytes play an important role in the modulation of the inflammatory response at every level of the atherosclerotic process. Low lymphocyte count (LLC) is a common finding during the systemic inflammatory response, and clinical and animal studies suggest that LCC plays a putative role in accelerated atherosclerosis. For instance, there is recent evidence that LLC is associated with worse outcomes in patients with heart failure, chronic ischemic heart disease and acute coronary syndromes. Further indirect evidence supports the pathologic role of LLC related to the fact that 1) lymphopenia--due to a decreased count of lymphocyte T cells--normally occurs as a part of the human ageing process, and 2) increased incidence of cardiovascular events has been reported in conditions where lymphopenia is common, such as renal transplant recipients, human immunodeficiency virus infection, survivors of nuclear disasters and autoimmune diseases. The aim of the present article is to review: a) the pathophysiological mechanisms that have been proposed for the observed association between LLC and cardiovascular diseases (CVD), b) the available evidence regarding the diagnostic and prognostic role attributable to LLC in patients with CVD, and; c) the potential therapeutic implications of these findings.

Several works have endorsed a significant role of the immune system and inflammation in the pathogenesis of heart failure. As indirect evidence, an association between a low relative lymphocyte count (RLC%) and worse outcomes found in this population has been suggested. Nevertheless, the role of RLC% for risk stratification in a large and nonselected population of patients with acute heart failure (AHF) has not yet been determined. Thus, the aim of this study was to determine the association between low RLC% and 1-year mortality in patients with AHF and consequently to define whether it has any role for early risk stratification. A total of 1,192 consecutive patients admitted for AHF were analyzed. Total white blood cell and differential counts were measured on admission. RLC% (calculated as absolute lymphocyte count/total white blood cell count) was categorized in quintiles and its association with all-cause mortality at 1 year assessed using Cox regression. At 1 year, 286 deaths (24%) were identified. A negative trend was observed between 1-year mortality rates and quintiles of RLC%: 31.5%, 27.2%, 23.1%, 23%, and 15.5% in quintiles 1 to 5, respectively (p for trend0.001). After thorough covariate adjustment, only patients in the lowest quintile (9.7%) showed an increased risk for mortality (hazard ratio 1.76, 95% confidence interval 1.17 to 2.65, p = 0.006). When RLC% was modeled with restricted cubic splines, a stepped increase in risk was observed patients in quintile 1: those with RLC% values7.5% and5% showed 1.95- and 2.66-fold increased risk for death compared to those in the top quintile. In conclusion, in patients with AHF, RLC% is a simple, widely available, and inexpensive biomarker, with potential for identifying patients at increased risk for 1-year mortality.

Introduccion y objetivos La utilidad de la resolucion del segmento ST (RST) para la prediccion de la reperfusion epicardica esta bien establecida. La asociacion de los cambios del segmento ST con la obstruccion microvascular (OMV) observada en la resonancia magnetica cardiovascular (RMC) tras una intervencion coronaria percutanea primaria (ICPp) en el infarto de miocardio con elevacion del ST (IMEST) no se ha aclarado todavia. Metodos Estudiamos a 85 pacientes consecutivos ingresados por un primer IMEST y tratados con una ICPp que tenian una arteria relacionada con el infarto permeable. Se registro un ECG al ingreso, tras 90 min y tras 6, 24, 48 y 96 h de la ICPp. Se calculo la RST y la suma de la elevacion del ST (sumEST) en todas las derivaciones. Resultados La RMC revelo una OMV en 37 pacientes. En los infartos con OMV, el valor de la sumEST antes y despues de la revascularizacion fue mayor que en los infartos sin OMV (p ≤ 0,001 en todos los casos). En cambio, no hubo diferencias significativas en la cantidad de RST entre los infartos con y sin OMV a los 90 min de la revascularizacion (p = 0,1), sino solo a partir de las 6 h (p 3 mm a los 90 min de la ICPp, pero no una RST ≥ 70%, predijo de manera independiente la OMV observada en la RMC ( odds ratio = 3,1; intervalo de confianza del 95%, 1,2-8,4; p = 0,02). Conclusiones La OMV se asocio a un valor significativamente superior de la sumEST en todos los momentos de valoracion tras la revascularizacion. La diferencia en la cantidad de RST entre los infartos con OMV y sin OMV solo fue significativa a partir de las 6 h tras la revascularizacion. La OMV se predijo mejor con una sumEST > 3 mm a los 90 min de la ICPp.

Background Decision making in chest pain of uncertain origin is challenging. Objectives To evaluate the predictive value of simple characteristics of pain presentation in patients coming to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin. Methods 789 patients were studied. The following categorical pain characteristics were collected: effort related pain, pressing character, radiation, associated symptoms, and ≥2 episodes in 24 h. Additionally, a predefined semi-quantitative pain score including seven items (Geleijnse score) was completed. Risk factors and co-morbidities were also recorded. The primary and secondary endpoints were cardiac events at 30 days and at 1 year. Results After adjusting for risk factors and co-morbidites, the pain characteristics associated with the primary and secondary endpoints were effort related pain (HR=2.1, 95% CI 1.5 to 3.0, p=0.0001; HR=1.8, 95% CI 1.3 to 2.5, p=0.0003) and ≥2 episodes in 24 h (HR=2.4, 95% CI 1.7 to 3.5, p=0.0001; HR=2.3, 95% CI 1.7 to 3.2, p=0.0001). Both variables retained their predictive value in women, diabetics and elderly (>70 years) patients. The discriminatory capacity of the predictive models including these two pain characteristics for the primary and secondary endpoints (C-statistic 0.76 and 0.76) was better than using the complex semi-quantitative pain score (C-statistic 0.69 and 0.71). Conclusion In patients presenting to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin, effort related pain and ≥2 episodes in 24 h are the main characteristics to be considered for decision making.

Introduccion y objetivos. La informacion disponible acerca del impacto pronostico de un episodio de rehospitalizacion por insuficiencia cardiaca aguda (ICA) tras un sindrome coronario agudo sin elevacion del segmento ST (SCASEST) es escasa. El objetivo de este trabajo fue evaluar el valor pronostico atribuible a un primer ingreso por ICA en cuanto a riesgo de infarto agudo de miocardio (IAM) y mortalidad en pacientes supervivientes a un episodio de SCASEST de alto riesgo. Metodos. Analizamos consecutivamente a 972 pacientes supervivientes a la fase hospitalaria de un SCASEST de alto riesgo. El reingreso por ICA se considero como la variable principal de estudio, y su asociacion con IAM y mortalidad por cualquier causa se analizo mediante regresion de Cox para variables dependientes del tiempo y, ademas, se aplico ajuste para episodios competitivos. Resultados. Tras una mediana de seguimiento de 30 [intervalo intercuartilico, 12-48] meses, 82 (8,4%) pacientes ingresaron por ICA, 146 (15%) presentaron un IAM y 202 (20,8%) fallecieron. El reingreso por ICA se produjo con una mediana de 203 [56-336] dias tras el SCASEST. Los pacientes que reingresaron por ICA presentaron un mayor riesgo de muerte (hazard ratio [HR] = 1,67; intervalo de confianza [IC] del 95%, 1,13-2,45; p = 0,009) e IAM (HR = 2,15; IC del 95%, 1,41-3,27; p < 0,001), independientemente de las variables pronosticas basales y las dependientes del tiempo. Conclusiones. Tras un SCASEST de alto riesgo, el reingreso por ICA se asocia con un mayor riesgo de IAM ulterior y muerte.

AHF (acute heart failure) causes significant morbidity and mortality. Recent studies have postulated that the expression of inflammatory mediators, such as cytokines and chemokines, plays an important role in the development and progression of heart failure. A pro-inflammatory state has been postulated as a key factor in triggering CMV (cytomegalovirus) reactivation. Therefore we sought to determine the prevalence of active CMV infection in immunocompetent patients admitted for AHF and to quantify the association with the risk of the combined end point of death or AHF readmission. A total of 132 consecutive patients admitted for AHF were enrolled in the present study. Plasma CMV DNAaemia was assessed by qRT-PCR (quantitative real-time PCR), and cytokine measurements in plasma were performed by ELISA. Clinical data were evaluated by personnel blinded to CMV results. The independent association between active CMV infection and the end point was determined by Cox regression analysis. During a median follow-up of 120 [IQR (interquartile range), 60–240] days, 23 (17.4%) deaths, 34 (24.2%) readmissions for AHF and 45 (34.1%) deaths/readmissions for AHF were identified. Plasma CMV DNAaemia occurred in 11 (8.3%) patients, albeit at a low level (

Introduccion y objetivos Escasa evidencia respalda la implantacion de una estrategia invasiva (EI) en pacientes con sindrome coronario agudo sin elevacion del segmento ST (SCASEST) y disfuncion sistolica (DS). El objetivo de este trabajo es evaluar el impacto pronostico atribuible a una EI en sujetos con SCASEST segun tengan DS o no. Metodos Se incluyo a 972 pacientes consecutivos ingresados por SCASEST (descenso del segmento ST y/o elevacion de troponina I). Se definio la DS como fraccion de eyeccion Resultados El 23,4% presento DS. Un total de 303 (31%) pacientes alcanzaron el objetivo primario, hecho que fue mas frecuente en los pacientes con DS (el 49,8 frente al 25,5%; p Conclusiones La presencia de DS permite la identificacion de los SCASEST que mas se benefician de aplicar una EI.

To perform a comparison of cardiac magnetic resonance (MR) imaging-derived ejection fraction (EF) during low-dose dobutamine infusion (EF(D)) with the extent of segments with transmural necrosis in more than 50% of their wall thickness (ETN) for the prediction of major adverse cardiac events (MACEs) and late systolic recovery soon after a first ST-segment elevation myocardial infarction (STEMI).Institutional ethics committee approval and written informed consent were obtained. One hundred nineteen consecutive patients with a first STEMI, a depressed left ventricular EF, and an open infarct-related artery underwent MR imaging at 1 week after infarction. EF(D) and ETN (by using a 17-segment model) were determined, and the prediction of MACEs and systolic recovery at follow-up was assessed by using area under the receiver operating characteristic curve (AUC) and multivariable regression analysis.During follow-up (median, 613 days; range, 312-1243 days), 18 MACEs (five cardiac deaths, six myocardial infarctions, seven readmissions for heart failure) occurred. MACEs were associated with a lower EF(D) (43% +/- 12 [standard deviation] vs 49% +/- 10, P = .02) and a larger ETN (seven segments +/- three vs four segments +/- three, P.001). Patients with systolic recovery (increase in EF of5% at follow-up compared with baseline EF, n = 44) displayed a higher EF(D) (51% +/- 10 vs 47% +/- 9, P = .04) and a smaller ETN (three segments +/- two vs five segments +/- three, P = .002) at 1 week. ETN and EF(D) both related to MACEs (AUC: 0.78 vs 0.67, respectively, P = .1) and systolic recovery (AUC: 0.68 vs 0.62, respectively, P = .3). According to multivariable analysis, ETN was the only MR variable associated with time to MACEs (hazard ratio, 1.38; 95% confidence interval: 1.19, 1.60; P.001) and systolic recovery (odds ratio, 0.76; 95% confidence interval: 0.64, 0.92; P = .004) independent of baseline characteristics.ETN is as useful as EF(D) for the prediction of MACEs and systolic recovery soon after STEMI.

The evolution of white blood cells after ST elevation myocardial infarction (STEMI) and their association with infarct size and major adverse cardiac events (MACE) remains unclear. Two hundred eleven patients underwent CMR after STEMI. Infarct mass (grams) was determined. Neutrophil, lymphocyte, and monocyte counts (×1,000 cells/ml) were measured upon arrival and at 12, 24, 48, 72, and 96 h. Patients with large infarctions (3rd tertile ≥ 28.5 g vs. 1st and 2nd tertiles

To compare a quantitative assessment of contrast cardiovascular magnetic resonance (CMR) after ST-segment elevation myocardial infarction (STEMI) with visual analysis for predicting depressed ejection fraction (dEF) and major adverse cardiac events (MACE). 192 patients underwent CMR at 1 week and 6 months after STEMI. Three quantitative (initial slope, maximal signal intensity and contrast delay in first-pass imaging) and 2 visual perfusion indexes (hypoenhancement in first-pass and microvascular obstruction in late enhancement imaging (LE)) were determined. Quantification of infarct mass and visual assessment of the extent of transmural necrosis (ETN) were also performed. At 6 months, 69 patients displayed dEF. During follow-up (mean 655 days) 20 MACE (death, re-infarction, re-admission for heart failure) occurred. Perfusion quantification took longer (P < 0.001) and, in ROC curve analyses and the C-statistic, was not superior to visual perfusion analysis for predicting late EF or MACE (P = ns). Similarly, infarct size quantification was not superior to visual assessment of ETN (P = ns). In multivariate analyses, only visual assessment of ETN (per segment) predicted dEF (OR 1.30 95%CI [1.04-1.61], P = 0.02) and MACE (HR 1.38 95%CI [1.19-1.60], P < 0.001). Visual analysis of CMR after STEMI is not time consuming and predicts dEF and MACE comparable to quantification. ETN was the strongest parameter.

Background Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro–B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation. Methods A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year. Results A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy ( P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n=6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n=28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04). Conclusions A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed. (ClinicalTrials.govNCT00493844)

Objective We sought to determine the relationship between the lowest lymphocyte count (lymphocyte(min))obtained within the first 96 h of symptoms onset and the risk of postdischarge recurrent spontaneous myocardial infarction (re-MI) in patients admitted with ST-segment elevation MI (STEMI). Methods We analyzed 549 consecutive patients admitted with STEMI from a single academic hospital. Lymphocyte counts were determined at admission and routinely during the first 96 h. Lymphocyte(min) was selected as the main exposure. Patients with inflammatory or infectious diseases, in-hospital death, or reinfarction were excluded from the analysis (final sample= 426 patients). Lymphocyte(min) was divided into quartiles (Q) and their association with re-MI was assessed by competing risk analysis. Postdischarge death and coronary revascularization were considered competing events. Results During a median follow-up of 36 months, 53 re-MI (12.4%) were registered. The re-MI crude rate was significantly higher in patients in the lowest lymphocyte(min) quartile (Q1r1045 cells/ml) compared with Q2-Q4: 22.4, 9.4, 8.4, 9.4%, respectively; P =0.005. In a multivariate setting, Q1 was also associated with a significant increased risk of re-MI compared with Q2-Q4 (hazard ratio: 2.04, 95% confidence interval: 1.11-3.76; P = 0.021). Conclusion Low lymphocyte count obtained within the first 96 h of a STEMI predicts the risk of re-MI.

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.

Introduccion y objetivos La presencia de enfermedad arterial periferica se asocia con un peor pronostico cardiovascular en el paciente coronario; sin embargo, la mayor parte de ellos estan asintomaticos e infradiagnosticados. El indice tobillo-brazo (ITB) es un metodo sencillo para el diagnostico de esta entidad. El objetivo del presente estudio es determinar el papel de un ITB patologico en la identificacion de enfermedad coronaria multivaso en pacientes con sindrome coronario agudo (SCA). Metodos Se analizaron todos los pacientes con SCA del registro multicentrico PAMISCA (94 centros participantes) a los que se les habia realizado un cateterismo durante su ingreso. Se considero enfermedad coronaria multivaso la afectacion de dos o mas vasos mayores epicardicos y/o enfermedad de tronco coronario izquierdo. Se considero patologico un ITB > 1,4 o ≤ 0,9. Resultados Se incluyeron 1.031 pacientes, con una edad media de 67,7 anos. De ellos, 542 pacientes presentaron afectacion multivaso (52,6%). Respecto a los pacientes sin afectacion multivaso, este grupo presentaba una mayor edad (66,6 frente a 62,6; p Conclusiones En el paciente con SCA, un ITB patologico se asocia de manera independiente con la probabilidad de padecer enfermedad coronaria multivaso.

Introduction The role of the angiotensin converting enzyme (ACE) gene on the result of thrombolysis at the microvascular level has not been addressed so far. We analyzed the implications of the insertion/deletion (I/D) polymorphism of the ACE gene on the presence of abnormal cardiovascular magnetic resonance (CMR)-derived microvascular perfusion after ST-segment elevation myocardial infarction (STEMI). Materials and Methods We studied 105 patients with a first anterior STEMI treated with thrombolytic agents and an open left anterior descending artery. Microvascular perfusion was assessed using first-pass perfusion CMR at 7 ±1 days. CMR studies were repeated 184 ± 11 days after STEMI. The ACE gene insertion/deletion (I/D) polymorphism was determined using polymerase chain reaction amplification. Results Overall genotype frequencies were II-ID 58% and DD 42%. Abnormal perfusion (≥ 1 segment) was detected in 56% of patients. The DD genotype associated to a higher risk of abnormal microvascular perfusion (68% vs. 47%, p = 0.03) and to a larger extent of perfusion deficit (median [percentile 25 - percentile 75]: 4 [0-6] vs. 0 [0-4] segments, p = 0.003). Once adjusted for baseline characteristics, the DD genotype independently increased the risk of abnormal microvascular perfusion (odds ratio [95% confidence intervals]: 2.5 [1.02-5.9], p = 0.04). Moreover, DD patients displayed a larger infarct size (35 ± 17 vs. 27 ± 15 g, p = 0.01) and a lower ejection fraction at 6 months (48 ± 14 vs. 54 ± 14%, p = 0.03). Conclusions The DD genotype associates to a higher risk of abnormal microvascular perfusion after STEMI.

Background Low lymphocyte count (LLC), a surrogate for inflammation, has emerged as a potential risk factor for cardiovascular outcomes, especially new ischemic events. To identify patients with non-ST segment elevation acute coronary syndromes (NSTEACS) who benefit from an invasive revascularization strategy remains a challenge. We sought to determine if patients with high-risk NSTEACS who exhibited LLC have a greater reduction in long-term post-discharge myocardial infarction (MI) when managed under a revascularization invasive strategy (RIS) as compared with conservative strategy (CS). Methods Nine hundred seventy two consecutive patients with high-risk NSTEACS were treated under two revascularization strategies (RS): 1) CS, from January 2001 to October 2002 (345 patients; 35.5%) and 2) RIS, from November 2002 to May 2005 (627 patients; 64.5%). LLC was defined as lymphocytes count ≤ 1200 cells/ml (1 vs. 2–4 quartiles). The association between the type of RS and MI was stratified by lymphocyte count status and assessed by Cox regression adapted for competing events. Results At 3-year follow-up, 145 deaths (14.9%), 135 MI (13.9%) and 76 revascularization procedures (7.8%) were registered. In a multivariable setting, LLC patients exhibited a greater MI risk reduction when managed under RIS (HR: 0.40; 95% CI = 0.22–0.72, p = 0.003). Conversely, when LLC was not present, no difference in the rate of MI was detected between the two RS. Conclusions LLC identifies a subgroup of patients with greater reduction in the risk of postdischarge MI when a RIS is applied.

Introduction The association of the temporal evolution of cardiac necrosis marker release with cardiovascular magnetic resonance-derived microvascular perfusion after ST-elevation myocardial infarction is unknown. Methods We analyzed 163 patients with a first ST-elevation myocardial infarction and a patent infarct-related artery treated with thrombolysis (67%) or primary angioplasty (33%). Using first-pass perfusion CMR, abnormal perfusion was defined as a lack of contrast arrival into the infarct area in > 1 segment. Troponin I, creatine kinase MB and myoglobin were measured upon arrival and at 6, 12, 24, 48 and 96 hours after reperfusion. Results Abnormal perfusion was detected in 75 patients (46%) and was associated with a larger release of all 3 necrosis markers after reperfusion and higher peak values. This association was observed in the whole group and separately in patients treated with thrombolysis and primary angioplasty. Out of the 3 markers, troponin levels at 6 hours after reperfusion yielded the largest area under the receiver operating characteristic curve for prediction of abnormal perfusion (troponin: 0.69, creatine kinase MB: 0.65 and myoglobin: 0.58). In a comprehensive multivariate analysis, adjusted for clinical, angiographic, cardiovascular magnetic resonance parameters and all necrosis markers, high troponin levels at 6 hours after reperfusion (>median) independently predicted abnormal microvascular perfusion (OR 2.6 95%CI [1.2 - 5.5], p = .012). Conclusions In ST-elevation myocardial infarction, a larger release of cardiac necrosis markers soon after reperfusion therapy relates to abnormal perfusion. Troponin appears as the most reliable necrosis marker for an early detection of cardiovascular magnetic resonance-derived abnormal microvascular reperfusion.

Introduccion y objetivos La obstruccion microvascular tras un infarto agudo de miocardio con elevacion del segmento ST se asocia a mal pronostico. La fisiopatologia de este fenomeno no esta totalmente definida. Analizamos las implicaciones de la linfopenia post-reperfusion en la existencia de obstruccion microvascular. Metodos Estudiamos prospectivamente a 212 pacientes que habian sufrido un primer infarto agudo de miocardio con elevacion del segmento ST reperfundido con agentes tromboliticos o con angioplastia primaria y con la arteria responsable abierta. Cuantificamos de manera seriada las cifras de linfocitos, neutrofilos y monocitos. Usamos la resonancia magnetica cardiaca para determinar la existencia de obstruccion microvascular en la primera semana post-infarto. Se repitio el estudio a los 6 meses del infarto. Resultados Detectamos obstruccion microvascular en 67 (32%) pacientes. Observamos que una cifra de linfocitos post-reperfusion Conclusiones En el infarto de miocardio con elevacion del segmento ST, la linfopenia post-reperfusion es un predictor precoz y potente de la existencia de obstruccion microvascular. Las posibles implicaciones fisiopatologicas y terapeuticas de esta asociacion requieren mas estudios.

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.

Introduccion y objetivos Los objetivos del estudio son caracterizar el edema miocardico tras un infarto agudo de miocardio con elevacion del ST mediante resonancia magnetica cardiaca y analizar sus implicaciones en los parametros ventriculares y su evolucion temporal. Metodos Se practico resonancia a 134 pacientes ingresados con un primer infarto con elevacion del ST y arteria abierta. Se obtuvieron imagenes de cine (reposo y dobutamina a dosis bajas), edema, perfusion y viabilidad. Se repitio la prueba al sexto mes. Resultados En la primera semana del infarto se detecto edema en algun segmento en el 96,6% de los pacientes (4 ± 2,1 segmentos por paciente). El edema extenso (≥ 4 segmentos) se asocio a mayores volumenes ventriculares telediastolico y telesistolico (p Conclusiones La resonancia magnetica cardiaca permite caracterizar el edema miocardico tras un infarto agudo de miocardio con elevacion del ST. El edema extenso se asocia a peores parametros ventriculares. Es un fenomeno transitorio que desaparece antes del sexto mes.

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

ObjectivesTo evaluate the prognostic value of a comprehensive cardiac magnetic resonance (CMR) assessment soon after a first ST-segment elevation myocardial infarction (STEMI).BackgroundCMR allows for a simultaneous assessment of wall motion abnormalities (WMA), WMA with low-dose dobutamine (WMA-dobutamine), microvascular obstruction, and transmural necrosis. This approach has been proven to be useful to predict late systolic recovery soon after STEMI. Its prognostic value and the relative prognostic weight of these indexes are not well-defined.MethodsWe studied 214 consecutive patients with a first STEMI treated with thrombolytic therapy or primary angioplasty discharged from hospital. In the first week (7 ± 1 day after infarction), with CMR we determined the extent (number of segments) of WMA, WMA-dobutamine, microvascular obstruction, and transmural necrosis.ResultsDuring a median follow-up of 553 days, 21 major adverse cardiac events (MACE) including 4 cardiac deaths, 6 nonfatal myocardial infarctions, and 11 readmissions for heart failure were documented. The MACE was associated with a larger extent of WMA (8 ± 4 segments vs. 5 ± 3 segments, p < 0.001), WMA-dobutamine (6 ± 4 segments vs. 4 ± 3 segments, p = 0.004), microvascular obstruction (3 ± 3 segments vs. 1 ± 2 segments 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.

Introduccion y objetivos El acceso radial derecho (RD) se ha incorporado a la practica clinica diaria como una alternativa valida al acceso femoral (AF). La via radial izquierda (RI) se utiliza en menos centros y hay pocos datos de trabajos aleatorizados que la comparen con el AF y el RD. Metodos Se aleatorizo a 1.005 pacientes consecutivos remitidos a un hospital terciario para cateterismo cardiaco. Realizaron los procedimientos tres hemodinamistas expertos en cateterismo transradial. No se aplicaron criterios de exclusion. Como objetivo primario se analizo la tasa de finalizacion por la via asignada y como objetivos secundarios, la tasa de finalizacion en ausencia de contraindicaciones para alguna via, los tiempos del procedimiento y la incidencia de complicaciones vasculares. Resultados Se finalizaron mas casos por via femoral (RI, 71%; AF, 92%; RD, 68%; p Conclusiones El acceso RI es una alternativa tan valida como el RD al AF.

Introduccion y objetivos La perfusion con dipiridamol en resonancia magnetica cardiaca (RMC) de estres se utiliza para la deteccion de enfermedad de las arterias coronarias (EAC). Sin embargo, se carece de informacion sobre el valor diagnostico de la disfuncion sistolica (DS) inducida con dipiridamol. Este estudio se centra en investigar si la DS inducida aporta un valor diagnostico adicional junto con la perfusion para la deteccion de las EAC. Metodos Se sometio a 166 pacientes a una RMC con dipiridamol y a una angiografia coronaria cuantitativa. Se definio EAC para valores ≥ 70% de estenosis. Se analizo la extension de la DS en reposo, la DS con dipiridamol, la DS inducida, el deficit de perfusion (DP) de primer paso en estres y el realce tardio. Resultados En un analisis multivariable, el DP (1,6 [1,33-1,91]; p Conclusiones La DS inducida, junto con la imagen de perfusion, ofrece un valor diagnostico adicional para la deteccion de EAC y permite la identificacion de pacientes con isquemia severa y alta probabilidad de EAC.

El valor pronostico del peptido natriuretico cerebral (BNP) tras un episodio de insuficiencia cardiaca aguda (ICA) no ha sido totalmente establecido. El objetivo de este trabajo fue evaluar la relacion entre las concentraciones de BNP y la mortalidad y los reingresos por ICA. Analizamos a 569 pacientes ingresados consecutivamente con el diagnostico de ICA. Se determino el BNP tras la estabilizacion inicial del paciente. La relacion entre el BNP y la mortalidad fue evaluada mediante regresion de Cox y la relacion con el reingreso, mediante regresion con ajuste para episodios competitivos. Durante una mediana de seguimiento de 9 (3-18) meses, se registraron 156 muertes (27,4%) y 140 reingresos (24,6%). En el analisis multivariable se observo una asociacion positiva y lineal entre el riesgo de mortalidad y los quintiles de BNP. Para reingreso por ICA, el BNP no mostro tener valor predictivo debido al efecto de la mortalidad como episodio competitivo.

Recently, the theory that hyperinflammation is the body's primary response to potent stimulus has been challenged. Indeed, a deregulation of the immune system could be the cause of multiple organ failure. So far, clinicians have focused on the last steps of the inflammatory cascade. However, little attention has been paid to lymphocytes, which play an important role as strategists of the inflammatory response. Experimental evidence suggests a crucial role of T lymphocytes in the pathophysiology of atherosclerosis and acute myocardial infarction (AMI). In summary, from the bottom of an imaginary inverted pyramid, a few regulatory T-cells control the upper parts represented by the wide spectrum of the inflammatory cascade. In AMI, a loss of regulation of the inflammatory system occurs in patients with a decreased activity of regulatory T-cells. As a consequence, aggressive T-cells boost and anti-inflammatory T-cells drop. A pleiotropic proinflammatory imbalance with damaging effects in terms of left ventricular performance and patient outcome is the result of this uncontrolled immune response. It is needed to unravel the thread of the inflammatory cells to better understand the pathophysiology as well as to open innovative therapeutic options in AMI.

To determine the prognostic and therapeutic implications of stress perfusion cardiovascular magnetic resonance (CMR) on the basis of the ischaemic cascade.Single centre study in a teaching hospital in Spain.Dipyridamole stress CMR was performed on 601 patients with ischaemic chest pain and known or suspected coronary artery disease. On the basis of the ischaemic cascade, patients were categorised in C1 (no evidence of ischaemia, n = 354), C2 (isolated perfusion deficit at stress first-pass perfusion imaging, n = 181) and C3 (simultaneous perfusion deficit and inducible wall motion abnormalities, n = 66). CMR-related revascularisation (n = 102, 17%) was defined as the procedure prompted by the CMR results and carried out within the next three months.During a median follow-up of 553 days, 69 major adverse cardiac events (MACE), including 21 cardiac deaths, 14 non-fatal myocardial infarctions and 34 admissions for unstable angina with documented abnormal angiography were detected. In non-revascularised patients (n = 499), the MACE rate was 4% (14/340) in C1, 20% (26/128) in C2 and 39% (12/31) in C3 (adjusted p value = 0.004 vs C2 and0.001 vs C1). CMR-related revascularisation had neutral effects in C2 (20% vs 19%, 1.1 (0.5 to 2.4), p = 0.7) but independently reduced the risk of MACE in C3 (39% vs 11%, 0.2 (0.1 to 0.7), p = 0.01).Dypiridamole stress CMR is able to stratify risk on the basis of the ischaemic cascade. A small group of patients with severe ischaemia-simultaneous perfusion deficit and inducible wall motion abnormalities-are at the highest risk and benefit most from MACE reduction due to revascularisation.

ObjectiveA significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes.MethodsThe PAMISCA register is a prospective, multicenter study involving patients ≥40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event.Results1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03–1.06; p

Fundamento y objetivo La influencia de la fraccion de eyeccion del ventriculo izquierdo (FEVI) en el pronostico de los pacientes con insuficiencia cardiaca es motivo de controversia. El objetivo de nuestro estudio ha sido determinar, durante un seguimiento a largo plazo, el valor pronostico de la FEVI sobre la mortalidad y el reingreso hospitalario por insuficiencia cardiaca aguda (ICA) en una poblacion no seleccionada de pacientes ingresados por ICA. Pacientes y metodo Estudiamos a 507 pacientes consecutivos ingresados por ICA en el Servicio de Cardiologia de nuestro centro. Se determino la FEVI mediante ecocardiografia transtoracica durante el ingreso indice, y durante el seguimiento se registraron la mortalidad global y la existencia de nuevos ingresos por ICA. Para establecer la relacion ajustada entre la FEVI y la mortalidad se utilizaron la regresion de Cox tradicional y la regresion de Cox para episodios competitivos, cuando el objetivo era el estudio de los reingresos por ICA. Resultados Un total de 236 pacientes (47%) presentaron una FEVI de al menos el 50%. Durante el seguimiento (mediana de un ano) se registraron 151 (30%) muertes y 139 (27%) reingresos por ICA. Los pacientes con FEVI inferior al 50% presentaron una mayor mortalidad (el 34 frente al 25%; p = 0,028) pero similar porcentaje de reingresos que aquellos con FEVI del 50% o superior (el 26 frente al 29%; p = 0,510). En el analisis multivariante, tras ajustar por variables pronosticas contrastadas, la presencia de FEVI inferior al 50% no se considero asociada de manera independiente ni con la mortalidad (razon de riesgo [HR, de hazard ratio] = 1,08; intervalo de confianza [IC] del 95%, 0,76-1,57; p = 0,645) ni con los reingresos por ICA (HR = 1,00; IC del 95%, 0,68-1,47; p = 1). Conclusiones Los pacientes con FEVI conservada representan una proporcion sustancial de los pacientes con ICA y presentan riesgos de mortalidad y reingresos por ICA similares a aquellos con FEVI deprimida.

Decision making and risk stratification for patients with acute chest pain, nondiagnostic electrocardiogram results, and normal troponin levels are challenging. The aim of this study was to optimize the clinical history for the evaluation of these patients. A total of 1,011 patients presenting to an emergency department were included. The following data were collected: clinical presentation (pain characteristics and number of pain episodes), coronary risk factors, previous ischemic heart disease, and extracardiac vascular disease (peripheral artery disease, stroke, or creatinine >1.4 mg/dl). Two different predictive models were calculated according to the end points: model 1 for 1-year major events (death or myocardial infarction) and model 2 for 30-day cardiac events (major events or revascularization). For 1-year major events, model 1 showed optimal discrimination capacity (C statistic = 0.80), which was significantly better than that of model 2 (C statistic = 0.77, p = 0.04). With respect to 30-day cardiac events, however, discrimination was lower in the 2 models, without differences between them (C statistic = 0.74 vs 0.75, p = NS). Using model 1, a large low-risk subgroup with

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.

Background The optimal revascularization strategy for non-ST elevation acute coronary syndromes (NSTE-ACS) remains controversial, especially in a real world context. The objective of this work was to assess differences at 1 year in all-cause mortality and the composite endpoint of mortality or acute myocardial infarction (MI) between two management strategies for NSTE-ACS: a conservative strategy (CS) versus a routine invasive strategy (RIS). Methods Of 799 consecutive patients admitted to our institution, 369 were treated with CS (from January 2001 to October 2002); 430 patients admitted with the same diagnosis were treated with RIS (from November 2002 to November 2004). A propensity score (PS) matched sample was created and included 694 patients (87% of the original population). The event rate was compared between each paired member of the PS-matched sample, one receiving RIS and the other CS, and their differences were tested by Cox proportional analysis. Results No significant differences in baseline characteristics were noted between the two management cohorts. By design, the rate of in-hospital catheterization and revascularization procedures increased in RIS compared with CS. The mortality rate was lower, but not significant, in RIS (HR: 0.76, 95% CI = 0.51–1.11; p = 0.155). For the composite of death or MI, RIS showed a relative risk reduction of 29% (HR: 0.71, 95% CI = 0.53–0.94); p = 0.018) compared with CS, differences that become non-significant (p = 0.680) if we adjust for differences in rate of revascularization procedures and changes in medication prescription. Conclusions RIS was associated with a 1-year lower risk of the combined endpoint of all-cause death and MI in patients with NSTE-ACS, attributable to changes in frequency of revascularization procedures and in medical treatment.

To assess whether circulating levels of carbohydrate antigen 125 (CA125) predict subsequent 6-month all-cause mortality in patients after the index hospitalisation for acute heart failure (HF).Prospective cohort study at a single teaching centre in Spain.529 consecutive patients with acute HF admitted in a single university centre were analysed. In addition to the traditional clinical information, CA125 (U/ml) was measured during the early course of hospitalisation. The independent association between baseline CA125 and mortality was assessed with Cox regression analysis. The follow-up was limited to 6 months.349 (66%) patients showed serum levels of CA12535 U/ml (established cut-off point value). At a 6-month follow-up, 89 (16.8%) deaths were identified. A positive trend between mortality and CA125 quartiles was observed; 3.8%, 15.2%, 22% and 26.5% of deaths occurred from quartile 1 to 4 of CA125 (p0.001). Likewise, a monotonic, ascending trend in the risk ratios was estimated from the multivariable Cox model. Compared with the first quartile of CA125, the HRs (95% CI) for the second, third and fourth quartiles were 3.25 (1.20 to 8.79), 4.91 (1.88 to 12.85) and 8.41 (3.24 to 21.79), respectively.Serum levels of CA125 obtained in patients admitted with a diagnosis of acute HF was shown to be an independent predictor of mortality up to the 6-month follow-up.

Introduccion y objetivos Se ha senalado que la perfusion anormal analizada mediante resonancia magnetica cardiaca (RMC) es una alteracion transitoria de la microcirculacion despues de un infarto agudo de miocardio (IAM) con flujo TIMI 3. Planteamos la hipotesis de que las alteraciones de la perfusion miocardica pueden persistir en los meses siguientes. Metodos Estudiamos 47 pacientes con un primer IAM y flujo TIMI 3 mantenido mediante ecografia miocardica con inyeccion intracoronaria de contraste (EMC) en la primera semana y el sexto mes postinfarto. Se considero que habia perfusion anormal mediante EMC si habia mas de un segmento hipoperfundido. Resultados En la primera semana 20 pacientes mostraron perfusion anormal mediante EMC. En el sexto mes, 10 pacientes presentaron perfusion anormal persistente mediante EMC. Estos pacientes mostraron mayores volumenes ventriculares y peor fraccion de eyeccion en la fase cronica (p Conclusiones Mediante EMC pueden detectarse defectos de la perfusion que pueden persistir en fase cronica y se relacionan con mayor dilatacion ventricular y peor funcion sistolica.

The objective of this study was to evaluate the simultaneous evolution of 5 cardiovascular magnetic resonance-derived myocardial viability indexes.We studied 72 patients with a first ST-elevation myocardial infarction and sustained TIMI 3 flow. In the first week and in the sixth month of the study, using cardiovascular magnetic resonance imaging, we determined wall thickening (WT) and the following viability indexes: wall thickness, WT with low-dose dobutamine, microvascular perfusion in first-pass imaging, microvascular obstruction in late-enhancement imaging, and transmural extent of necrosis.In 250 dysfunctional segments, the evolution outcomes for the viability indexes were as follows: (1) wall thickness thinned (8.6 +/- 2.9 versus 7.7 +/- 3 mm, P.001), (2) WT with low-dose dobutamine improved (1.5 +/- 1.9 versus 2.6 +/- 3 mm, P.001), (3) the number of segments showing abnormal microvascular perfusion in first-pass imaging decreased (22% versus 7%, P.001), (4) the number of segments showing microvascular obstruction in late-enhancement imaging decreased (14% versus 2%, P.001), and (5) the transmural extent of necrosis remained stable throughout follow-up (56% +/- 40% versus 54% +/- 39%, P = .3).After reperfused myocardial infarction, dynamic changes in wall thickness, contractile reserve, microvascular perfusion, and microvascular obstruction take place. These changes may affect their accuracy as viability indexes early after myocardial infarction. The transmural extent of necrosis does not vary, however.

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.

To characterise the evolution of myocardial perfusion during the first 6 months after myocardial infarction by first-pass perfusion cardiovascular magnetic resonance imaging (CMR) and determine its significance.Prospective cohort design.Single-centre study in a teaching hospital in Spain.40 patients with a first ST-elevation myocardial infarction, single-vessel disease and thrombolysis in myocardial infarction (TIMI) grade 3 flow (stent in 33 patients) underwent rest and low-dose dobutamine CMR 7 (SD 1) and 184 (SD 11) days after infarction. Microvascular perfusion was assessed at rest by visual assessment and quantitative analysis of first-pass perfusion CMR. Of the 640 segments, 290 segments subtended by the infarct-related artery (IRA) were focused on.Both 1 week and 6 months after infarction, segments with normal perfusion showed more wall thickening, contractile reserve and wall thickness, and less transmural necrosis, p0.05 in all cases. Of 76 hypoperfused segments at the first week, 47 (62%) normalised perfusion at the sixth month. However, 42 segments (14% of the whole group) showed chronic abnormal perfusion; these segments showed worse CMR indices in the late phase (p0.05 in all cases).In patients with an open IRA, more than half of the segments with abnormal perfusion at the first week are normally perfused after six months. First-pass perfusion CMR shows that in a small percentage of segments, abnormal perfusion may become a chronic phenomenon-these areas have a more severe deterioration of systolic function, wall thickness, contractile reserve and the transmural extent of necrosis.