La majorite des patients se presentant aux urgences pour douleur thoracique aigue n’ont pas de modification significative de l’electrocardiogramme, du dosage de la troponine ou d’antecedents de cardiopathie ischemique. Les strategies diagnostiques ont pour objectif d’identifier les patients qui presentent ou vont developper un syndrome coronaire aigu dans ce sous-groupe considere comme a faible risque. Chez ces patients, l’objectif des explorations complementaires fonctionnelles ou morphologiques est l’exclusion de la maladie coronaire. Le scanner cardiaque a une sensibilite de 96 % avec un rapport de vraisemblance negatif de 0,09 et s’avere, en combinaison avec le dosage de la troponine ultrasensible, une technique hautement contributive au diagnostic avec le meilleur rapport cout-efficacite. La realisation d’un scanner cardiaque est indiquee en cas de douleur thoracique aigue avec un electrocardiogramme normal ou non contributif associe a un dosage de troponine ultrasensible negatif ou une modification modeste et lente. Le scanner cardiaque devrait etre realise idealement entre une heure et 72 heures apres la consultation initiale.
the association between C-Reactive Protein (CRP) levels following PPCI and clinical outcome in patients at our tertiary referral centre.Methods: All patients accepted for PPCI between September 2009 and November 2011 were eligible for inclusion.Patient data were obtained from Cardiac Services Database System (Phillips CVIS), and mortality data from the Summary Care Record (SCR) database.Patient characteristics and clinical outcomes were compared according to CRP groups: low (≤10 mg/L), intermediate (10-50 mg/L), and high (>50 mg/L).Continuous variables were compared using oneway ANOVA.Categorical variables were compared using the chi-squared test.A p-value of <0.05 was taken to indicate statistical significance.Results: 1299 of 1877 eligible patients had a recorded CRP and were analysed.Patients in the high CRP group were more likely to be female (32.6% vs. 23.1%,p 0.024) and older (mean age 67.3±14.1 vs. 63.8±12.5 years, p 0.011).Other characteristics were similar across groups (hypertension, diabetes mellitus, previous MI, CABG).30-day mortality was significantly higher in the high group compared to the low group (1.3% vs. 16.7%,p <0.0001), as was overall mortality (hazard ratio 1.8, 95% CI 1.3-2.8)during a mean follow-up period of 2.1 years (Figure 1). Figure 1.Kaplan-Meier Survival CurveConclusions: Our large-cohort retrospective study suggests that elevated CRP at PPCI is associated with significantly higher long-term mortality.Further work is required on strategies to modify inflammatory response following STEMI and improve clinical outcomes following PPCI.
Background: Primary prevention of major ventricular arrhythmias (MVA) in patients with idiopathic dilated cardiomyopathy (IDCM) is primarily based on left ventricular ejection fraction (LVEF) assessment. Nonetheless, unexpected MVA still affect patients considered at low-risk (LR), attesting the limitation of the current risk stratification. We sought to identify the clinical predictors of MVA in patients with IDCM and no conventional indications for implantable cardioverter defibrillator (ICD). Methods: In this retrospective, case-control study, among 922 patients enrolled in the Heart Muscle Disease Registry of Trieste from 1988 to 2013, we analyzed 414 IDCM patients considered at LR according to the following criteria: LVEF≥36% and no previous episodes of MVA (sustained ventricular tachycardia/non-fatal ventricular fibrillation (SVT/VF), appropriate ICD intervention and sudden cardiac death (SD)). Data were recorded at the last available medical examination before the index event. Patients were optimally treated at the time of index evaluation (87% and 84% of ACE-inhibitors/sartans and beta-blockers, respectively). Results: Over a median follow-up of 43 (IQR 16-116) months, 45 patients (11 % of patients at LR; 31% of the all MVA in whole IDCM population) experienced MVA. The mean age at the time of event was 51±14 years. They were characterized by a previous history of syncope in 10 patients (22%), LVEF of 42±6% with a normal value (>50%) in 10 patients (22%), significant LV dilation (VTDi>90ml/m 2 ) in 16 patients (35%) and left bundle branch block 12 patients (27%). Independent risk factors for MVA in LR subgroup were previous history of syncope (OR 3.41, 1.45-8.03, p=0.004), larger left ventricular dilation (OR 2.62, 1.72-3.99, p<0.0001) and longer duration of disease (OR 1.39, 1.42-2.63, p<0.0001). Conclusions: in a large cohort of IDCM patients nearly one-third of the MVA occurred in a population apparently at LR of events. History of syncope, larger LV dilatation and significant duration of disease emerged as strong predictors of MVA and should be considered in the arrhythmic risk stratification of patients without conventional criteria for SD primary protection.
Aims: Admission hyperglycemia is a frequent condition in ST elevation myocardial infarction (STEMI) associated with an increased risk of contrast induced nephropathy (CIN)after primary percutaneous coronary intervention (pPCI). We evaluate the possible different role of acute and chronic hyperglycemia on CIN and the impact of its early spontaneous or pharmacologic normalization. Methods and results: 679 STEMI patients treated with pPCI were enrolled in our prospective study. CIN was defined as an absolute serum creatinine increase ≥0.3 mg/dl after procedure. Admission hyperglycemia was defined as glucose levels >198 mg/dl: acute or chronic increase was identified respectivelyin patients with a glycated haemoglobin A1c ≤7% and >7%.In hyperglicemic patients, a decrease of fasting glucose levels <140 mg/dl in second day was considered for early normalization. Admission hyperglycemia (17%) was an independent predictor for CIN incidence, but at subgroup analysis its prognostic impact emerged only in non diabetic patients. Similarly, only in this subgroup its rapid normalization was associated to a lower incidence of CIN and to a better outcome. Actually, CIN incidence was significantly higher in patients with acute hyperglycemia than in those with chronic hyperglycemia (34.5% vs 16.9%, p=0.03), irrespective of diabetes mellitus. Conclusions: Admission hyperglycemia relates to an increase risk of CIN, especially when it occurs acutely. A condition ofglycemic levels ≥198 mg/dl and glycated haemoglobin A1c ≤7%, identifies patients at higher risk, in whom a rapid glycemic control could become a further strategy of CIN prevention.
Arrhythmic risk stratification is a challenging issue in patients with dilated cardiomyopathy (DCM), particularly when left ventricular ejection fraction (LVEF) is more than 35%. We studied the prevalence and predictors of sudden cardiac death or malignant ventricular arrhythmias (SCD/MVAs) in DCM patients categorized at low arrhythmic risk because of intermediate left ventricular dysfunction under optimal medical treatment (OMT).DCM patients considered at low arrhythmic risk (LVEF >35% and New York Heart Association class I-III after 6 ± 3 months of OMT) were analysed. An arrhythmogenic profile was defined as the presence of at least one among a history of syncope, nonsustained ventricular tachycardia, at least 1000 premature ventricular contractions/24 h, at least 50 ventricular couplets/24 h at Holter ECG monitoring. SCD/MVAs was considered as the study end-point.During a median follow-up of 152 months (interquartile range 100-234), 30 out of 360 (8.3%) patients at low arrhythmic risk (LVEF 47 ± 7%) experienced the study end-point [14 (3.9%) SCD and 16 (4.4%) MVA]. Compared with survivors, patients who experienced SCD/MVAs had more frequently an arrhythmogenic profile and a larger left atrium. Their LVEF at the last available evaluation before the arrhythmic event was 36 ± 12%. At multivariable analysis, left atrial end-systolic area [hazard ratio 1.107; 95% confidence interval (95% CI) 1.039-1.179, P = 0.002 for 1 mm increase] and arrhythmogenic profile (hazard ratio 3.667; 95% CI 1.762-7.632, P = 0.001) emerged as predictors of SCD/MVAs during follow-up.A consistent quota of DCM patients with intermediate left ventricular dysfunction receiving OMT experienced SCD/MVA during follow-up. Left atrial dilatation and arrhythmogenic pattern were associated with a higher risk of SCD/MVA.
