Prediction of 30-day mortality in older patients with a first acute myocardial infarction

This study sought predictors of mortality in patients aged >or=75 years with a first ST-segment elevation myocardial infarction (STEMI) and evaluated the validity of the GUSTO-I and TIMI risk models. Clinical variables, treatment and mortality data from 433 consecutive patients were collected. Univariable and multivariable logistic regression analyses were applied to identify baseline factors associated with 30-day mortality. Subsequently a model predicting 30-day mortality was created and compared with the performance of the GUSTO-I and TIMI models. After adjustment, a higher Killip class was the most important predictor (OR 16.1; 95% CI 5.7-45.6). Elevated heart rate, longer time delay to admission, hyperglycemia and older age were also associated with increased risk. Patients with hypercholesterolemia had a significantly lower risk (OR 0.46; 95% CI 0.24-0.86). Discrimination (c-statistic 0.79, 95% CI 0.75-0.84) and calibration (Hosmer-Lemeshow 6, p = 0.5) of our model were good. The GUSTO-I and TIMI risk scores produced adequate discrimination within our dataset (c-statistic 0.76, 95% CI 0.71-0.81, and c-statistic 0.77, 95% CI 0.72-0.82, respectively), but calibration was not satisfactory (HL 21.8, p = 0.005 for GUSTO-I, and HL 20.6, p = 0.008 for TIMI). In conclusion, short-term mortality in elderly patients with a first STEMI depends most importantly on initial clinical and hemodynamic status. The GUSTO-I and TIMI models are insufficiently adequate for providing an exact estimate of 30-day mortality risk.

Early intravenous beta-blockers in patients with ST-segment elevation myocardial infarction before primary percutaneous coronary intervention

The impact of intravenous (IV) beta-blockers before primary percutaneous coronary intervention (PPCI) on infarct size and clinical outcomes is not well established. This study sought to conduct the first double-blind, placebo-controlled international multicenter study testing the effect of early IV beta-blockers before PPCI in a general ST-segment elevation myocardial infarction (STEMI) population. STEMI patients presenting <12 h from symptom onset in Killip class I to II without atrioventricular block were randomized 1:1 to IV metoprolol (2 × 5-mg bolus) or matched placebo before PPCI. Primary endpoint was myocardial infarct size as assessed by cardiac magnetic resonance imaging (CMR) at 30 days. Secondary endpoints were enzymatic infarct size and incidence of ventricular arrhythmias. Safety endpoints included symptomatic bradycardia, symptomatic hypotension, and cardiogenic shock. A total of 683 patients (mean age 62 ± 12 years; 75% male) were randomized to metoprolol (n = 336) or placebo (n = 346). CMR was performed in 342 patients (54.8%). Infarct size (percent of left ventricle [LV]) by CMR did not differ between the metoprolol (15.3 ± 11.0%) and placebo groups (14.9 ± 11.5%; p = 0.616). Peak and area under the creatine kinase curve did not differ between both groups. LV ejection fraction by CMR was 51.0 ± 10.9% in the metoprolol group and 51.6 ± 10.8% in the placebo group (p = 0.68). The incidence of malignant arrhythmias was 3.6% in the metoprolol group versus 6.9% in placebo (p = 0.050). The incidence of adverse events was not different between groups. In a nonrestricted STEMI population, early intravenous metoprolol before PPCI was not associated with a reduction in infarct size. Metoprolol reduced the incidence of malignant arrhythmias in the acute phase and was not associated with an increase in adverse events.

Gender differences in right ventricular function in patients with non-ischaemic cardiomyopathy

The aim of this study is to evaluate sex-related differences in right ventricular (RV) function, assessed with cardiac magnetic resonance imaging, in patients with stable non-ischaemic dilated cardiomyopathy. Mean age was 60.9 ± 12.2 years. Men presented higher levels of haemoglobin and white blood cell counts than women, and performed better in cardiopulmonary stress testing. A total of 24 patients (12 women) presented severe left ventricular (LV) systolic dysfunction, 32 (13 female) moderate and 15 (8 women) mild LV systolic dysfunction. In the group with severe LV systolic dysfunction, average right ventricular ejection fraction (RVEF) was normal in women (52 ± 4 %), whereas it was reduced in men (39 ± 3 %) p = 0.035. Only one woman (8 %) had severe RV systolic dysfunction (RVEF < 35 %) compared with 6 men (50 %) p < 0.001. In patients with moderate and mild LV dysfunction , the mean RVEF was normal in both men and women. In the 14 healthy volunteers, the lowest value of RVEF was 48 % and mean RVEF was normal in women (56 ± 2 %) and in men (51 ±  1 %), p = 0.08. In patients with dilated cardiomyopathy, RV systolic dysfunction is found mainly in male patients with severe LV systolic dysfunction.

Outpatient follow-up during the first year after heart transplantation, is it feasible?

First year follow-up after heart transplantation requires invasive tests. Although patients used to be hospitalized for this purpose, ambulatory invasive procedures now offer the possibility of outpatient follow-up. The feasibility and security of this strategy is unknown. From 2007 we transitioned to outpatient follow-up. We have retrospectively reviewed the clinical course of the outpatient group (2007 to 2014) and an inpatient group (2000–2006). Basal characteristics, hospital stay, infections, rejection episodes and vascular complications were evaluated. 87 patients had Inpatient Follow-up (IF) and 98 Outpatient Follow-up (OF). Basal characteristics were similar, with significant differences in immunosuppression (tacrolimus IF 44.8% vs. OF 90.8%, and mycophenolate IF 86.2% vs OF 100%, both p values < 0.001) and age (IF 52 ± 11.5 years vs. OF 56.1 ± 11 years, p = 0.016). In the OF group more clinical visits were performed (IF 10 vs. OF 13, p < 0.001) while hospital stay was lower (IF 23 days vs. OF 3 days, p < 0.001). The rate of infection, rejection, and vascular complications was similar. No difference was found in 1-year mortality (IF 2.3% vs. 1.0%, p = 0.60). First year post-cardiac transplantation outpatient follow-up seems to be feasible and safe in terms of infection, rejection, vascular complications and mortality.

Hospital without dyspnea: Rationale and design of a multidisciplinary intervention

Dyspnea is a common and disabling symptom of respiratory and heart diseases, which is growing in incidence. During hospital admission, breathlessness is under-diagnosed and under-treated, although there are treatments available for controlling the symptom. We have developed a tailored implementation strategy directed to medical staff to promote the application of these pharmacological and non-pharmacological tools in dealing with dyspnea. The primary aim is to decrease the rate of patients that do not receive an adequate relief of dyspnea. This is a four-stage quasi-experimental study. The intervention consists in two teaching talks that will be taught in Cardiology and Respiratory Medicine Departments. The contents will be prepared by Palliative Care specialists, based on available tools for management of dyspnea and patients' needs. A cross-sectional study of dyspnea in hospitalized patients will be performed before and after the intervention to ascertain an improvement in dyspnea intensity due to changes in medical practices. The last phase consists in the creation of consensus protocols for dyspnea management based in our experience. The results of this study are expected to be of great value and may change clinical practice in the near future and promote a changing for the better of dyspnea care.

Lethal heparin-induced thrombocytopenia after transfemoral aortic valve implantation

SIN FINANCIACIÓN

Outpatient follow-up during the first year after heart transplantation, is it feasible?

First year follow-up after heart transplantation requires invasive tests. Although patients used to be hospitalized for this purpose, ambulatory invasive procedures now offer the possibility of outpatient follow-up. The feasibility and security of this strategy is unknown. From 2007 we transitioned to outpatient follow-up. We have retrospectively reviewed the clinical course of the outpatient group (2007 to 2014) and an inpatient group (2000–2006). Basal characteristics, hospital stay, infections, rejection episodes and vascular complications were evaluated. 87 patients had Inpatient Follow-up (IF) and 98 Outpatient Follow-up (OF). Basal characteristics were similar, with significant differences in immunosuppression (tacrolimus IF 44.8% vs. OF 90.8%, and mycophenolate IF 86.2% vs OF 100%, both p values < 0.001) and age (IF 52 ± 11.5 years vs. OF 56.1 ± 11 years, p = 0.016). In the OF group more clinical visits were performed (IF 10 vs. OF 13, p < 0.001) while hospital stay was lower (IF 23 days vs. OF 3 days, p < 0.001). The rate of infection, rejection, and vascular complications was similar. No difference was found in 1-year mortality (IF 2.3% vs. 1.0%, p = 0.60). First year post-cardiac transplantation outpatient follow-up seems to be feasible and safe in terms of infection, rejection, vascular complications and mortality.

Predictors of in-hospital mortality among cardiogenic shock patients. Prognostic and therapeutic implications

Cardiogenic shock (CS) has a poor prognosis. The heterogeneity in the mortality through different subgroups suggests that some factors can be useful to perform risk stratification and guide management. We aimed to find predictors of in-hospital mortality in these patients. We analyzed all cases of cardiogenic shock due to medical conditions admitted in our intensive acute cardiovascular care unity from November 2010 till November 2015. Clinical, biochemical and hemodynamic variables were registered, as was the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile at 24 h of CS diagnosis. From a total of 281 patients, 28 died within the first 24 h and were not included in the analysis. A total of 253 patients survived the first 24 h, mean age was 68.8 ± 14.4 years, and 174 (68.8%) were men. Etiologies: acute coronary syndrome 146 (57.7%), acute heart failure 60 (23.7%), arrhythmias 35 (13.8%), and others 12 (4.8%). A total of 91 patients (36.0%) died during hospitalization. We found the following independent predictors of in-hospital mortality: age (odds ratio [OR] 1.032, 95% confidence interval [CI] 1.003–1.062), blood glucose (OR 1.004, 95% CI 1.001–1.008), heart rate (OR 1.014, 95% CI 1.001–1.028), and INTERMACS profile (OR 0.168, 95% CI 0.107–0.266). In patients with CS the INTERMACS profile at 24 h of diagnosis was associated with higher in-hospital mortality. This and other prognostic variables (age, blood glucose, and heart rate) may be useful for risk stratification and to select appropriate medical or invasive interventions.

End-of-life care in a cardiology department: have we improved?

nd-of-life care is not usually a priority in cardiology departments. We sought to evaluate the changes in end-of-life care after the introduction of a do-not-resuscitate (DNR) order protocol. Retrospective analysis of all deaths in a cardiology department in two periods, before and after the introduction of the protocol. Comparison of demographic characteristics, use of DNR orders, and end-of-life care issues between both periods, according to the presence in the second period of the new DNR sheet (Group A), a conventional DNR order (Group B) or the absence of any DNR order (Group C). The number of deaths was similar in both periods (n = 198 vs. n = 197). The rate of patients dying with a DNR order increased significantly (57.1% vs. 68.5%; P = 0.02). Only 4% of patients in both periods were aware of the decision taken about cardiopulmonary resuscitation. Patients in Group A received the DNR order one day earlier, and 24.5% received it within the first 24 h of admission (vs. 2.6% in the first period; P < 0.001). All patients in Group A with an implantable cardioverter defibrillator (ICD) had shock therapies deactivated (vs. 25.0% in the first period; P = 0.02). The introduction of a DNR order protocol may improve end-of-life care in cardiac patients by increasing the use and shortening the time of registration of DNR orders. It may also contribute to increase ICD deactivation in patients with these orders in place. However, the introduction of the sheet in late stages of the disease failed to improve patient participation.

Very low risk ST-segment elevation myocardial infarction? It exists and may be easily identified

Early discharge protocols have been proposed for ST-segment elevation myocardial infarction (STEMI) low risk patients despite the existence of few but significant cardiovascular events during mid-term follow-up. We aimed to identify a subgroup of patients among those considered low-risk in which prognosis would be particularly good. We analyzed 30-day outcomes and long-term follow-up among 1.111 STEMI patients treated with reperfusion therapy. Multivariate analysis identified seven variables as predictors of 30-day outcomes: Femoral approach; age > 65; systolic dysfunction; postprocedural TIMI flow < 3; elevated creatinine level > 1.5 mg/dL; stenosis of left-main coronary artery; and two or higher Killip class (FASTEST). A total of 228 patients (20.5%), defined as very low-risk (VLR), had none of these variables on admission. VLR group of patients compared to non-VLR patients had lower in-hospital (0% vs. 5.9%; p < 0.001) and 30-day mortality (0% vs. 6.25%: p < 0.001). They also presented fewer in-hospital complications (6.6% vs. 39.7%; p < 0.001) and 30-day major adverse events (0.9% vs. 4.5%; p = 0.01). Significant mortality differences during a mean follow-up of 23.8 ± 19.4 months were also observed (2.2% vs. 15.2%; p < 0.001). The first VLR subject died 11 months after hospital discharge. No cardiovascular deaths were identified in this subgroup of patients during follow-up. About a fifth of STEMI patients have VLR and can be easily identified. They have an excellent prognosis suggesting that 24–48 h in-hospital stay could be a feasible alternative in these patients.

Influence of fat percentage, front thigh skinfold and girth on the maximum radial displacement of the dominant rectus femoris

4.171 JCR (2013) Q1, 6/81 Sport sciences

Changes in the mechanical characteristics of the knee musculature in professional female volleyball players

The technical efficiency in volleyball is closely related to the ability to perform displacements or jump (1). Therefore, it is necessary that precise, individualized, and localized evaluation of the muscles frequently involved in volleyball practice be studied (2,3). The aim of this study was to analyze the neuromuscular changes of the knee musculature in professional volleyball players using Tensiomyography (TMG) and jump tests.