Effects of hyperoxemia in patients with sepsis - A post-hoc analysis of a multicentre randomized clinical trial

BACKGROUND

Administration of supplemental oxygen is a life-saving treatment in critically ill patients. Still, optimal dosing remains unclear during sepsis. The aim of this post-hoc analysis was to assess the association between hyperoxemia and 90-day mortality in a large cohort of septic patients.

METHODS

This is a post-hoc analysis of the Albumin Italian Outcome Sepsis (ALBIOS) randomized controlled trial (RCT). Patients with sepsis who survived the first 48 h since randomization were included and stratified into two groups according to their average PaO₂ levels during the first 48 h (PaO_{2 0-48 h}). The cut-off value was established at 100 mmHg (average PaO_{2 0-48 h} >100 mmHg: hyperoxemia group; PaO_{2 0-48h}≤100: normoxemia group). The primary outcome was 90-day mortality.

RESULTS

1632 patients were included in this analysis (661 patients in the hyperoxemia group, 971 patients in the normoxemia group). Concerning the primary outcome, 344 (35.4%) patients in the hyperoxemia group vs. 236 (35.7%) in the normoxemia group had died within 90 days from randomization (p = 0.909). No association was found after adjusting for confounders (HR 0.87; CI [95%] 0.736-1.028, p = 0.102) or after excluding patients with hypoxemia at enrollment, patients with lung infection or including post-surgical patients only. Conversely, we found an association between lower risk of 90-day mortality and hyperoxemia in the subgroup including patients who had the lung as primary site of infection (HR 0.72; CI [95%] 0.565-0.918). Mortality at 28 days, ICU mortality, incidence of acute kidney injury, use of renal replacement therapy, days to suspension of vasopressor or inotropic agents, and resolution of primary and secondary infections did not differ significantly. Duration of mechanical ventilation and length of stay in ICU were significantly longer in patients with hyperoxemia.

CONCLUSIONS

In a post-hoc analysis of a RCT enrolling septic patients, hyperoxemia as average PaO₂>100 mmHg during the first 48 h was not associated with patients' survival.

Circulating secretoneurin concentrations provide independent prognostic information to established risk indices in patients with chronic heart failure

Background

Secretoneurin (SN) is a 33-amino acid peptide that directly influences cardiomyocyte Ca2+ handling. Circulating SN concentrations increase in situations of systemic stress, myocardial dysfunction, and renal failure, and SN concentrations provide independent prognostic information in patients with acute myocardial dysfunction. Whether SN concentrations provide prognostic information in patients with chronic heart failure (HF) is not known.

Purpose

To examine whether SN concentrations provide incremental prognostic information to established risk indices and biomarkers in patients with chronic HF from a large, randomized controlled trial.

Methods

We measured SN concentrations at randomization (n=1224) and after 3 months (n=1103) in the GISSI-HF trial that used a 2x2 factorial design to test the addition of rosuvastatin and n-3 PUFA to established HF therapy. The co-primary outcome measures of GISSI-HF were (1) all-cause mortality, and (2) mortality or hospitalization for cardiovascular disease during follow-up. Rosuvastatin did not improve outcomes, while the addition of n-3 PUFA provided a small beneficial effect on both primary outcome measures. SN measurements were performed with a new CE-marked SN assay (ELISA).

Results

Mean age was 67 years and 80% were male. Median (quartile 1–3) SN concentrations were 42.6 (35.0–62.8) pmol/L on randomization and 42.0 (34.5–53.1) pmol/L after 3 months, which are higher than SN concentrations in healthy subjects. SN concentrations at randomization were associated with lower body-mass index (BMI), lower systolic blood pressure, lower estimated glomerular filtration rate (eGFR), higher B-type natriuretic peptide (BNP) concentrations, and diagnosis of chronic obstructive pulmonary disease. SN concentrations did not correlate with left ventricular ejection fraction. During median follow-up of 3.9 years, 344 patients (27.0%) died. SN concentrations on randomization stratified patients with a poor and favourable prognosis (Figure 1). SN concentrations were associated with mortality in multivariable analysis that adjusted for age, sex, left ventricular ejection fraction, BMI, functional class, ischemic etiology, heart rate, blood pressure, eGFR, bilirubin, comorbidities, and BNP concentrations: HR (logarithmical transformed SN) 2.60 (95% CI 1.01–6.70), p=0.047. SN concentrations were also associated with risk of mortality or hospitalization for cardiovascular disease, but the association was attenuated and no longer significant in multivariable analysis. SN concentrations were mainly stable from randomization to 3 months (rho=0.66, p<0.001) and the addition of rosuvastatin and n-3 PUFA did not influence SN concentrations.

Conclusion

We found SN concentrations to provide incremental prognostic information to established risk indices and biomarkers in patients with chronic HF from a large multicenter, randomized controlled trial.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Council of Norway

P148 CANCER INCIDENCE AND MORTALITY ACCORDING TO PRE–EXISTING HEART FAILURE IN A COMMUNITY–BASED COHORT

Background

Studies assessing whether heart failure (HF) is associated with an excess risk of cancer and cancer–related mortality yielded conflicting results. Here, we assessed the incidence and mortality of cancer according to the presence of HF in a community–based cohort.

Methods

By reviewing the health care records of the Puglia region in Italy, we first selected the individuals ≥50–year–old, with no history of cancer within 3 years before the baseline evaluation and ≥5 years of follow–up, during the period from January 1st, 2005 to December 31st, 2013. Next, we matched 1:1 104,020 subjects with HF at baseline and 104,020 controls based on age, sex, Drug–Derived Complexity Index, and follow–up duration. Cancer incidence and mortality were analyzed by Kaplan–Meier method and Cox regression models. Fine and Grey’s regression model was also used to compare cancer–specific mortality while taking into account the competing risk of non–cancer death.

Results

Overall, the mean age of the study population was 76±10 years and the mean follow–up was 5.7 years. The incidence rate of cancer in HF patients and controls was 21.36 (95%CI, 20.98–21.74) and 12.42 (95%CI, 12.14–12.72) per 1000 person/years, respectively, corresponding to a 76% higher risk of incident cancer in HF patients (HR, 1.76; 95%CI, 1.71–1.81). HF patients also died from cancer more frequently than controls (HR 4.11; 95%CI, 3.86–4.38; Figure 1). This excess mortality was highest when age was <70 years (HR 7.54, 95%CI 6.33–8.98), and declined in subjects aged 70–79 years (HR 3.80, 95%CI 3.44–4.19) and ≥80 years (HR 3.10, 95%CI 2.81–3.43). The association of HF with cancer mortality was confirmed in the competing risk analysis (subdistribution HR 3.48, 95%CI 3.27–3.72), as well as the interaction with age: <70 years of age: SHR 6.65, 95%CI 5.60–7.94; 70–80 years: SHR 3.14, 95%CI 2.84–3.48; and ≥80 years: SHR 2.81, 95%CI 2.55–3.10. The HF–related risk applied to the majority of cancer types. Interestingly, among HF patients a high consumption of loop diuretic (≥80 mg/d of furosemide equivalents for ≥30 days in the year before the index date) was associated with a higher mortality for cancer (HR 1.35, 95%CI 1.19–1.53 vs. ≤37.5 mg/d).

Conclusions

The analysis of this large community–based sample suggests that HF does portend an increased risk of cancer and cancer–related mortality, which is blunted, yet remains substantial, with increasing age and competing risk of dying from other causes.

Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest

AIM

We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) of various aetiologies.

METHODS

We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method.

RESULTS

Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 688 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4361) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) µg/L vs. 8.5 (5.8-13.2) µg/L at 24 h and 20.4 (8.1-56.6) µg/L vs. 8.2 (5.9-12.1) µg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001.

CONCLUSION

Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.

Prognostic value of sST2 in heart failure patients with diabetes

Background

Soluble suppression of tumorigenesis-2 (sST2) is released in response to inflammation and vascular injury, and holds prognostic value in heart failure (HF). Type 2 diabetes (T2D) is characterized by a pro-inflammatory status and is highly prevalent among HF patients, with adverse impact on outcomes. The clinical value of sST2 in HF patients with T2D has never been characterized.

Purpose

We aimed to assess sST2 clinical correlates and prognostic value in HF patients with T2D.

Methods

Individual data of 3476 patients with stable chronic HF from 5 cohorts from the BIOS (Biomarkers In Heart Failure Outpatient Study) dataset were analysed, with available N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and sST2 levels.

Results

Mean age was 65±12 years (75% males). T2D was present in 1386 patients (40%), who had higher body mass index (BMI, 27 [24–30] vs. 26 [23–29] kg/m2, p&lt;0.001), lower estimated glomerular filtration rate (eGFR, 56±22 vs. 60±19 mL/min/1,73 m2, p&lt;0.001), higher sST2 (33 [24–47] vs. 27 [20–40] ng/mL, p&lt;0.001), NT-proBNP (1735 [742–3963] vs. 1450 [514–3299] ng/L, p&lt;0.001), hs-TnT (28 [16.2–51.5] vs. 17 [9–31] ng/L, p&lt;0.001) and high-sensitivity C-reactive protein (hs-CRP, 6 [2–11] vs. 4. [2–9] mg/L, p=0.003) (Figure). Differences between sST2 levels in patients with or without T2D were influenced by hs-CRP (p for interaction=0.010) and hs-TnT (p=0.031), but not by NT-proBNP and eGFR. At multivariate linear regression analysis, NT-proBNP, hs-TnT and hs-CRP were independently associated with sST2 levels in both T2D and non-T2D patients. Compared with patients without T2D, those with T2D showed higher 1-year all-cause mortality (12% vs. 10%, p=0.034), cardiovascular mortality (9% vs. 7%, p=0.011), and HF hospitalization rate (22% vs. 12%, p&lt;0.001). In a prognostic model including age, sex, eGFR, ischemic vs- non-ischemic aetiology, left ventricular ejection fraction class, New York Heart Association class, NT-proBNP, hs-TnT, and hs-CRP, sST2 retained independent prognostic value in both patients with or without T2D for 1-year all-cause and cardiovascular mortality, and 1-year HF hospitalization, with higher optimal cut-offs for mortality prediction in T2D vs. non-T2D (39 and 45 vs. 29 and 29 ng/mL respectively for 1-year all-cause and cardiovascular mortality).

Conclusions

sST2 is higher in HF patients with T2D and likely linked to a pro-inflammatory status. sST2 maintains its prognostic value both in diabetic and non-diabetic HF patients, independently of NT-proBNP, hs-TnT and hs-CRP.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Cancer incidence and mortality according to pre-existing heart failure in a community-based cohort

Background

Studies assessing whether heart failure (HF) is associated with an excess risk of cancer and cancer-related mortality yielded conflicting results. Here, we assessed the incidence and mortality of cancer according to the presence of HF in a community-based cohort.

Methods

By reviewing the health care records of the Puglia region in Italy, we first selected individuals ≥50-year-old, with no history of cancer within 3 years before the baseline evaluation and ≥5 years of follow-up, during the period from January 1st, 2005 to December 31st, 2013. Next, we matched 1:1 104,020 subjects with HF at baseline and 104,020 controls based on age, sex, Charlson Comorbidity Index, Drug-Derived Complexity Index, and follow-up duration. Cancer incidence and mortality were analyzed by Kaplan-Meier method and Cox regression models. Fine and Grey's regression model was also used to compare cancer-specific mortality while taking into account the competing risk of non-cancer death.

Results

Overall, the mean age of the study population was 76±10 years and the mean follow-up was 5.7 years. The incidence rate of cancer in HF patients and controls was 21.36 (95% CI, 20.98–21.74) and 12.42 (95% CI, 12.14–12.72) per 1000 person/years, respectively, corresponding to a 76% higher risk of incident cancer in HF patients (HR, 1.76; 95% CI, 1.71–1.81). HF patients also died from cancer more frequently than controls (HR 4.11; 95% CI, 3.86–4.38; Figure 1). This excess mortality was highest when age was &lt;70 years (HR 7.54, 95% CI 6.33–8.98), and declined in subjects aged 70–79 years (HR 3.80, 95% CI 3.44–4.19) and ≥80 years (HR 3.10, 95% CI 2.81–3.43). The association of HF with cancer mortality was confirmed in the competing risk analysis (HR 3.48, 95% CI 3.27–3.72), as well as the interaction with age: &lt;70 years of age: HR 6.65, 95% CI 5.60–7.94; 70–80 years: HR 3.14, 95% CI 2.84–3.48; and ≥80 years: HR 2.81, 95% CI 2.55–3.10.

The HF-related risk applied to the majority of cancer types, with the exception of neoplasm of the male reproductive system. Interestingly, among HF patients a high consumption of loop diuretic (&gt;37.5 mg/d of furosemide) was associated with a higher mortality for cancer (HR 1.34, 95% CI 1.26–1.42 vs. ≤37.5 mg/d).

Conclusions

The analysis of this large community-based sample suggests that HF does portend an increased risk of cancer and cancer-related mortality, which is blunted, yet remains substantial, with increasing age and competing risk of dying from other causes. The risk of cancer may be heightened when HF is poorly compensated.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Cancer mortality in HF patient

Additive prognostic value of cardiac biomarkers in patients with chronic obstructive pulmonary disease and heart failure

Background

Chronic obstructive pulmonary disease (COPD) is a frequent comorbidity in patients with heart failure (HF). We assessed the influence of COPD on circulating levels and prognostic value of 3 HF biomarkers: N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and soluble suppression of tumorigenesis-2 (sST2).

Methods

Individual data from patients with chronic HF, known COPD status and NT-proBNP, hs-TnT, sST2 values (n=13328) were analysed.

Results

As compared to patients without COPD, those with COPD (n=2155, 16%) were older (age 71 years [64–77] vs. 66 [57–75]; p&lt;0.001), more frequently men (79% vs. 74%; p&lt;0.001), had more severe dyspnoea (43% in New York Heart Association [NYHA] class III-IV vs. 31%; p&lt;0.001), slightly worse renal function (median estimated glomerular filtration rate [eGFR] 58 mL/min/1.73 m2 [43–73] vs. 60 [46–77]; p&lt;0.001), higher NT-proBNP (1508 ng/L [650–3363] vs. 1239 ng/L [479–2911]; p&lt;0.001), hs-TnT (22 ng/L [13–38] vs. 17 ng/L [9–30]; p&lt;0.001), and sST2 (31 ng/mL [23–45] vs. 29 [21–43]; p=0.040). In both the COPD and no-COPD subgroups, the best cut-offs of the 3 biomarkers refined the prediction of 1- and 5-year all-cause and cardiovascular mortality and 1- to 12-month HF hospitalization over a prognostic model including age, sex, ischemic aetiology, eGFR, HF categories, NYHA III-IV, beta-blocker use and the NT-proBNP cut-off alone.

Conclusions

Among patients with HF, those with COPD have higher circulating cardiac biomarkers. Patient classification based on COPD-specific cut-offs refines risk reclassification for all-cause and cardiovascular mortality and HF hospitalization and might be helpful for decision making and management.

Funding Acknowledgement

Type of funding sources: None.

PCSK9 is associated with mortality in patients with septic shock: data from the ALBIOS study

BACKGROUND

Pro-protein convertase subtilisin/kexin 9 (PCSK9) is a proenzyme primarily known to regulate low-density lipoprotein receptor re-uptake on hepatocytes. Whether PCSK9 can concurrently trigger inflammation or not remains unclear. Here, we investigated the potential association between circulating levels of PCSK9 and mortality in patients with severe sepsis or septic shock.

METHODS

Plasma PCSK9 levels at days 1, 2 and 7 were measured in 958 patients with severe sepsis or septic shock previously enrolled in the Albumin Italian Outcome Sepsis (ALBIOS) trial. Correlations between levels of PCSK9 and pentraxin 3 (PTX3), a biomarker of disease severity, were evaluated with ranked Spearman's coefficients. Cox proportional hazards models were used to assess the association of PCSK9 levels at day 1 with 28- and 90-day mortality.

RESULTS

Median plasma PCSK9 levels were 278 [182-452] ng mL^-1 on day 1. PCSK9 correlated positively with PTX3 at the three time-points, and patients with septic shock within the first quartile of PCSK9 showed higher levels of PTX3. Similar mortality rates were observed in patients with severe sepsis across PCSK9 quartiles. Patients with septic shock with lower PCSK9 levels on day 1 (within the first quartile) showed the highest 28- and 90-day mortality rate as compared to other quartiles.

CONCLUSION

In our sub-analysis of the ALBIOS trial, we found that patients with septic shock presenting with lower plasma PCSK9 levels experienced higher mortality rate. Further studies are warranted to better evaluate the pathophysiological role of PCSK9 in sepsis.

Prognostic value of NT-proBNP and best cut-offs for risk prediction in obese patients with chronic systolic heart failure

Background

N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) is a strong predictor of outcome in chronic systolic heart failure (CHF). Although plasma NT-proBNP has been reported to display an inverse correlation with body-mass-index (BMI), its prognostic value in obese patients has been poorly investigated so far.

Objectives

To evaluate the prognostic value and the best cut-offs for risk prediction of NT-proBNP in obese individuals from a multinational cohort of patients with systolic CHF.

Methods

We analyzed data from the BIOS (Biomarkers In Heart Failure Outpatient Study) Consortium. Patients with left ventricular ejection fraction (LVEF) ≤50% were selected and classified as nonobese (BMI &lt;30 kg/m2), mildly obese (BMI 30–35 kg/m2), moderately obese (BMI 35–40 kg/m2), or severely obese (BMI ≥40 kg/m2), according to standard nomenclature. Clinical and bio-humoral data, including NT-proBNP testing, were retrieved, and 5-year cardiac and all-cause mortality status were considered as primary and secondary outcome, respectively. The independent prognostic role of NT-proBNP was evaluated through Cox regression analysis, adjusting the model for age, gender, New York Heart Association class, ischaemic aetiology, LVEF, and estimated glomerular filtration rate (eGFR).

Results

The study population included 11,574 patients (age 65±12 years, LVEF 30±9%, males 78%). Most of patients were nonobese (n=8,937, 77%), while mildly, moderately, and severely obese patients were 1,887 (16%), 499 (4%), and 251 (3%), respectively. Median values of plasma NT-proBNP were progressively lower from nonobese to mildly, moderately, and severely obese patients (1455 ng/L, 903 ng/L, 767 ng/L, 660 ng/L, respectively) and BMI was predictive of NT-proBNP independently from age, LVEF, and eGFR (r=−0.152, p&lt;0.001). The best NT-proBNP cut-offs to predict 5-year cardiac mortality were significantly lower in mildly [1044 ng/L; AUC 0.663 (Sen 66%; Spe 59%), p&lt;0.001] moderately [736 ng/L; AUC 0.670 (Sen 76%; Spe 52%), p&lt;0.001]), and severely [1060 ng/L; AUC 0.635 (Sen 57%; Spe 69%), p=0.021] obese patients compared to nonobese individuals [2034 ng/L; AUC 0.714 (Sens. 65%; Spec. 66%), p&lt;0.001]. Further, NT-proBNP independently predicted 5-year cardiac death in nonobese, mildly and moderately obese patients (all p&lt;0.001), but not in severely obese patients (p=0.457). Similar findings were observed for the secondary endpoint of 5-year all-cause mortality.

Conclusions

Compared to nonobese CHF patients, obese patients have lower circulating NT-proBNP levels, which retain independent prognostic significance for cardiac and all-cause mortality across most categories of obesity. BMI-adjusted NT-proBNP cut-offs might be considered for prognostic stratification in obese patients with CHF.

Funding Acknowledgement

Type of funding source: None

Chronic obstructive pulmonary disease in heart failure: influence on circulating biomarkers and outcome

Background

Chronic obstructive pulmonary disease (COPD) is common in patients with chronic heart failure (CHF).

Purpose

We aimed to explore the impact of COPD on HF biomarkers (N-terminal fraction of pro-B-type natriuretic peptide [NT-proBNP], high-sensitivity troponin T [hs-TnT], and soluble suppression of tumorigenesis-2 [sST2]) and outcome.

Methods

Individual data from 14 cohorts of patients with stable chronic HF and NT-proBNP and hs-TnT values were analysed. Patients with known COPD status were evaluated.

Results

Patients (n=13,178) were aged 67 years (58–75), 75% males, and 76%, 11%, 13% with HF with reduced, mid-range, or preserved ejection fraction (HFrEF/HFmrEF/HFpEF), respectively. Patients with COPD were older than those without COPD (age 71 years [64–77] vs. 66 [57–75]; p&lt;0.001), more frequently males (79% vs. 74%; p&lt;0.001), had more often ischaemic HF (54% vs. 52%; p&lt;0.001), and HFpEF (14% vs. 12%; p=0.011), but not HFpEF (12% vs. 11%; p=0.097). COPD patients had also more severe dyspnoea (44% in NYHA class III-IV vs. 31%; p&lt;0.001), and slightly worse renal function (median estimated glomerular filtration rate [eGFR] 58 mL/min/1.73 m2 [44–74] vs. 60 [46–67]; p&lt;0.001). Patients with COPD had higher NT-proBNP (1501 ng/L [642–3333] vs. 1225 ng/L [476–2902]; p&lt;0.001), hs-TnT (22 ng/L [13–38] vs. 17 ng/L [9–30]; p&lt;0.001), and sST2 (30 ng/mL [22–45] vs. 29 [21–43]; p&lt;0.001).

Over a median follow-up of 2.1 years (1.5–3.7, range 0–18 years), 3,865/12,489 patients (31%) died; among them, 2,443/12,450 (20%) died for cardiovascular causes; 3,373/12,469 patients (27%) were hospitalized for HF over 35 months (15–63, range 0–216 months). Patients with COPD had a significantly higher all-cause mortality, cardiovascular mortality, and worse survival free from HF hospitalization (all p&lt;0.001; Figure). In a model including age, gender, ischaemic vs. non-ischaemic aetiology, eGFR, HFrEF/HFmrEF/HFpEF, and NYHA class III-IV, COPD retained independent prognostic significance from NT-proBNP for 1-year all-cause (p=0.009) and cardiovascular mortality (p=0.022), 5-year all-cause (p&lt;0.001) and cardiovascular mortality (p=0.011) as well as 3- (p=0.033), 6- (p=0.019) and 12-month HF hospitalization (p=0.033). COPD lost its independent prognostic significance when hs-TnT and sST2 were included in the model.

Conclusions

COPD in HF is characterized by higher NT-proBNP, hs-TnT and sST2 levels. COPD adds prognostic significance over NT-proBNP alone, but not over the combination of NT-proBNP, hs-TnT, and sST2.

Funding Acknowledgement

Type of funding source: None

P3515Gender differences in plasma levels and prognostic value of NT-proBNP in chronic heart failure

Background

Natriuretic peptides are established biomarkers of heart failure (HF). The existence of gender-related differences in circulating levels and prognostic value are still controversial.

Methods

Individual patient data from studies assessing cardiac biomarkers (N-terminal fraction of pro-B-type natriuretic peptide - NT-proBNP - and high-sensitivity troponin T) for risk prediction in stable chronic HF were analysed.

Results

Women (n=1964, 23%) had higher median [interquartile interval] NT-proBNP concentrations than men (1678 [659–4215] vs. 1294 [522–2973] ng/L, p<0.001). Female gender predicted higher NT-proBNP independently from age, body mass index, glomerular filtration rate, left ventricular ejection fraction (LVEF), and atrial fibrillation.

Over a 2.4-year follow-up (1.6–3.2), 2351 patients (27%) died, and cardiovascular death occurred in 1558/8271 (19%). HF hospitalization was recorded in 2088/7944 (26%) over 2.0 years (1.3–2.6). Women and men had similar areas under the curve for the 3 endpoints, with higher cut-offs among women: all-cause death, 2328 ng/L vs. 1319 ng/L; cardiovascular death, 2328 ng/L vs. 1413 ng/L; HF hospitalization, 1265 ng/L vs. 907 ng/L. In the prognostic model above, the risk of the three endpoints increased by 32%, 35%, and 17%, respectively, per doubling of NT-proBNP in women, and by 41%, 45%, and 30% in men.

Conclusions

Women with chronic HF display higher NT-proBNP levels than men in the whole population as well as across many patient subgroups. This difference is not entirely explained by heterogeneity in age, BMI, or renal function. NT-proBNP holds independent prognostic significance in both genders, although alternative prognostic cut-offs might be considered for women.

P4542Revisiting the obesity paradox in heart failure: percent body fat as predictor of biomarkers and outcome

Background

Obesity defined by body mass index (BMI) is characterized by better prognosis and lower plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF). We assessed whether another anthropometric measure, percent body fat (PBF), reveals different associations with outcome and HF biomarkers (NT-proBNP, high-sensitivity troponin T [hs-TnT], soluble suppression of tumorigenesis-2 [sST2]).

Methods

In an individual patient dataset, BMI was calculated as weight (kg)/height (m)2, and PBF through the Jackson-Pollock and Gallagher equations.

Results

Out of 6468 patients (median 68 years, 78% men, 76% ischaemic HF, 90% reduced EF), 24% died over 2.2 years (1.5–2.9), 17% from cardiovascular death. Median PBF was 26.9% (22.4–33.0%) with the Jackson-Pollock equation, and 28.0% (23.8–33.5%) with the Gallagher equation, with an extremely strong correlation (r=0.996, p<0.001). Patients in the first PBF tertile had the worst prognosis, while patients in the second and third tertile had similar survival. The risks of all-cause and cardiovascular death decreased by up to 36% and 27%, respectively, per each doubling of PBF. Furthermore, prognosis was better in the second or third PBF tertiles than in the first tertile regardless of model variables. Both BMI and PBF were inverse predictors of NT-proBNP, but not hs-TnT. In obese patients (BMI ≥30 kg/m2, third PBF tertile), hs-TnT and sST2, but not NT-proBNP, independently predicted outcome.

Conclusion

Patient prognosis improves with either BMI or PBF. Obesity, assessed with BMI or PBF, is associated with lower NT-proBNP but not hs-TnT or sST2. hs-TnT or sST2 are stronger prognostic predictors than NT-proBNP among obese patients.

Incretin-based drugs and hospitalization for heart failure in the clinical practice: A nested case-control study

BACKGROUND AND AIMS

There are concerns that incretin-based antidiabetic drugs - including dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists - increase the risk of hospitalization for heart failure (HF). To further analyse this issue, we conducted a nested case-control study within a cohort of antidiabetic users in a real world setting.

METHODS AND RESULTS

Within a cohort of 133,639 subjects with a first prescription of an antidiabetic drug (new-users) between 2010 and 2016 in Lombardy, Italy, and were followed-up to 2016, we identified 4057 subjects with a first hospitalization for HF and 80,450 controls matched on sex, age, and date of cohort-entry. The multivariate odds ratios (ORs) of HF in relation to current use of incretin-based drugs as compared to current use of two or more oral antidiabetics was 1.06 (95% confidence interval, CI, 0.83-1.35), with no evidence of a trend in risk with increasing duration of use. The corresponding ORs were 1.10 (95% CI 0.85-1.41) for DPP-4 inhibitors and 0.84 (95% CI 0.48-1.47) for GLP-1 receptor agonists. Estimates were consistent in various sensitivity analyses.

CONCLUSIONS

This study indicates that incretin-based drugs are not associated with an increased risk of hospitalization for HF, thus providing further reassurance on the cardiovascular safety of these antidiabetic drugs in the clinical practice.

Adjuvant Radiochemotherapy in High-Risk Rectal Cancer Results of a Prospective Non-Randomized Study

Aims and Background

In 1990 the National Institutes of Health Consensus Conference recommended adjuvant combined therapy for patients with radically resected rectal cancer at high risk for relapse (ie, stage II-III). The purpose of our prospective non-randomized study was to verify the feasibility and effectiveness of postoperative radiochemotherapy in terms of improvement in disease-free and overall survival in this patient subgroup.

Study design

From January 1990 to October 1998, 191 consecutive patients with radically resected stage II-III rectal cancer were treated. A total of 159 patients with a 24-month follow-up were assessable for toxicity and survival. Anterior resection was performed in 129 (81%) and abdomino-perineal resection in 30 (19%) patients. Fifty-four (34%) stage II and 105 (66%) stage III patients entered the study. Within 45-60 days of surgery, all patients received 5-fluorouracil chemotherapy at the dose of 500 mg/m2 as an iv bolus on days 1-5, every 4 weeks, for 6 cycles. Chemotherapy cycles III and IV were administered at the same daily dose on radiotherapy days 1-3 and 29-31. Radiotherapy consisted of 45 Gy/25 fractions plus a boost dose of 5.4 Gy.

Results

After a median follow-up of 57 months (range, 25-123), overall recurrent disease was reported in 58 (36%) patients: local, systemic, and both local and systemic relapses in 12 (8%), 37 (23%) and 9 (6%) cases, respectively. According to local extension, recurrence rates were 15% and 48% in stage II and III, respectively. Five-year overall and disease-free survival were 71% and 66%, respectively. Overall survival was 87% in stage II and 62% in stage III patients, and disease-free survival was 84% and 56% in stage II and III disease, respectively. According to univariate and multivariate analyses, significant prognostic factors for better tumor control were: stage (II vs III, P <0.001), the number of involved nodes (≤3 vs >3, P <0.0001), and no extracapsular node invasion (P <0.0001). The recommended dose of the combined radiochemotherapy regimen was generally well tolerated. The incidence of any ≥ grade 3 acute toxicity (according to the WHO scale) was 13% diarrhea, 11% proctitis, 5% perineal dermatitis and 4% myelosuppression. Four (3%) patients had radiotherapy-related severe late toxicity which required surgery.

Conclusions

The study provided recurrence rates and survival similar to other adjuvant radiochemotherapy regimens published in the literature. However, in view of the low 5-year survival rate recorded in stage III patients, a different approach should be investigated.

Screening for unknown atrial fibrillation in older people: a feasibility study in community pharmacies

INTRODUCTION

Atrial fibrillation (AF) is the most common heart arrhythmia. It is associated with an increased risk of morbidity and mortality and its prevalence rises with age. The arrhythmia is often asymptomatic, and systematic AF screening could help identify asymptomatic individuals to implement therapeutic and preventive strategies. The main study aims were to test the technical feasibility and citizens' acceptance of a freely offered service in older people using community pharmacies.

MATERIALS AND METHODS

During 2 months, a 30-s single-lead electrocardiogram (ECG) with a telemedicine device was used for screening in 20 pharmacies in a mixed rural-urban health district of Northern Italy.

RESULTS

A total of 289/335 older adults 70 years old or more agreed to participate in the study. A cardiologist considered 80% of the ECG tracings readable and unknown AF was identified in 1.3%.

CONCLUSIONS

The screening scheme appears technically feasible and acceptable both to professionals and citizens/participants. Training the pharmacists could ensure broader participation and substantially improve the pharmacies' overall performance.

The fibroblast growth factor-23 and Vitamin D emerge as nontraditional risk factors and may affect cardiovascular risk

OBJECTIVES

Fibroblast growth factor-23 (FGF-23) and vitamin D are hormones involved in phosphate homoeostasis. They also directly influence cardiomyocyte hypertrophy. We examined whether the relationships between levels of vitamin D or FGF-23, cardiac phenotype and outcome were independent of established cardiac biomarkers in a large cohort of community-dwelling elderly subjects.

DESIGN AND SETTING

Plasma levels of FGF-23 and vitamin D were measured in 1851 men and women (65-84 years) resident in the Lazio region of Italy. Participants were referred to eight cardiology centres for clinical examination, electrocardiography, comprehensive Doppler echocardiography and blood sampling. All-cause mortality or hospitalizations were available after a median follow-up of 47 months with record linkage of administrative data.

RESULTS

Vitamin D deficiency (<20 ng mL(-1) ) was found in 72.3% of subjects, but FGF-23 levels were normal [74 (58-97) RU per mL]. After adjustment for cardiovascular risk factors and morbidities, low concentrations of vitamin D and high levels of FGF-23 were associated with a higher left ventricular (LV) mass index. Levels of FGF-23 [hazard ratio (HR) (95% confidence interval (CI)) 1.71 (1.28-2.28), P < 0.0001] but not vitamin D [0.76 (0.57-1.01), P = 0.08] were independently associated with mortality after adjustment for clinical risk factors and two cardiac markers together (N-terminal pro-brain natriuretic peptide and high-sensitivity cardiac troponin T), but did not predict hospital admission. People with above median values of FGF-23 and below median values of vitamin D had greater LV hypertrophy and higher mortality.

CONCLUSIONS

In community-dwelling elderly individuals with highly prevalent vitamin D deficiency, FGF-23 levels were associated with LV hypertrophy and predicted mortality independently of two robust cardiac biomarkers. A causal relationship was not demonstrated, but the hormones involved in mineral metabolism emerged as nontraditional risk factors and may affect cardiovascular risk.

Autonomic cardiovascular modulation with three different anesthetic strategies during neurosurgical procedures

BACKGROUND

Autonomic cardiovascular modulation during surgery might be affected by different anesthetic strategies. Aim of the present study was to assess autonomic control during three different anesthetic strategies in the course of neurosurgical procedures by the linear and non-linear analysis of two cardiovascular signals.

METHODS

Heart rate (EKG-RR intervals) and systolic arterial pressure (SAP) signals were analyzed in 93 patients during elective neurosurgical procedures at fixed points: anesthetic induction, dura mater opening, first and second hour of surgery, dura mater and skin closure. Patients were randomly assigned to three anesthetic strategies: sevoflurane+fentanyl (S-F), sevoflurane+remifentanil (S-R) and propofol+remifentanil (P-R).

RESULTS

All the three anesthetic strategies were characterized by a reduction of RR and SAP variability. A more active autonomic sympathetic modulation, as ratio of low to high frequency spectral components of RR variability (LF/HF), was present in the P-R group vs. S-R group. This is confirmed by non-linear symbolic analysis of RR series and SAP variability analysis. In addition, an increased parasympathetic modulation was suggested by symbolic analysis of RR series during the second hour of surgery in S-F group.

CONCLUSION

Despite an important reduction of cardiovascular signal variability, the analysis of RR and SAP signals were capable to detect information about autonomic control during anesthesia. Symbolic analysis (non-linear) seems to be able to highlight the differences of both the sympathetic (slow) and vagal (fast) modulation among anesthetics, while spectral analysis (linear) underlines the same differences but only in terms of balance between the two neural control systems.

The cardiokine secreted Frizzled-related protein 3, a modulator of Wnt signalling, in clinical and experimental heart failure

OBJECTIVES

Experimental studies have shown involvement of Wnt signalling in heart failure (HF). We hypothesized that secreted frizzled-related protein 3 (sFRP3), a modulator of Wnt signalling, is related to the progression of HF.

DESIGN

Circulating sFRP3 was measured in 153 HF patients and compared with 25 healthy controls. The association of sFRP3 with mortality was evaluated in 1202 patients (GISSI-HF trial). sFRP3 mRNA expression was assessed in failing human and murine left ventricles (LV), and cellular localization was determined after fractioning of myocardial tissue. In vitro studies were carried out in cardiac fibroblasts subjected to cyclic mechanical stretch.

RESULTS

(i) Heart failure patients had significantly raised serum sFRP3 levels compared with controls, (ii) during a median follow-up of 47 months, 315 patients died in the GISSI-HF substudy. In univariable Cox regression, tertiles of baseline sFRP3 concentration were significantly associated with all-cause and cardiovascular mortality. After adjustment for demographic and clinical variables, but not for CRP and NT-proBNP, the associations with mortality remained significant for the third tertile (all-cause, HR 1.45, P = 0.011; cardiovascular, HR 1.66, P = 0.003), (iii) sFRP3 mRNA expression was increased in failing human LV, with a decline following LV assist device therapy. LV from post-MI mice showed an increased sFRP3 mRNA level, particularly in cardiac fibroblasts, and (iv) mechanical stretch enhanced sFRP3 expression and release in myocardial fibroblasts.

CONCLUSION

There is an association between increased sFRP3 expression and adverse outcome in HF, suggesting that the failing myocardium itself contributes to an increase in circulating sFRP3.

High-sensitivity cardiac troponin T for detection of subtle abnormalities of cardiac phenotype in a general population of elderly individuals

OBJECTIVE

To investigate the association between circulating cardiac biomarkers and minor abnormalities in cardiac phenotype [left ventricular (LV) mass and midwall fractional shortening (MFS)] in elderly individuals in a general population sample.

DESIGN AND SETTING

We examined the relationship between plasma concentrations of high-sensitivity cardiac troponin T (hs-cTnT) or N-terminal probrain natriuretic peptide (NT-proBNP) and elevated LV mass (LV mass/body surface area >95 g m(-2) for women and 115 g m(-2) for men), reduced MFS (<15%) or isolated LV diastolic dysfunction in 1973 elderly subjects (mean age 73 ± 5 years, range 65-84) resident in the Lazio region of Italy and enrolled in the PREDICTOR study.

RESULTS

Overall, 24.8% of subjects had elevated LV mass, and 30.4% had reduced MFS. Median [quartile 1-3] plasma concentrations of hs-cTnT and NT-proBNP were higher in individuals with elevated than those with normal LV mass: 6.6 [3.5-11.6] and 147 [64-296] ng L(-1) vs. 4.6 [3.0-8.1] and 79 [41-151] ng L(-1) respectively (P < 0.001). There was a graded increase in median hs-cTnT concentrations across clinical categories of LV hypertrophy: 4.6 [3.0-8.1], 5.8 [3.1-10.2], 7.6 [3.8-13.7] and 8.4 [3.8-17.6] ng L(-1) for subjects with normal LV mass and mild, moderate or severe LV hypertrophy respectively (P < 0.0001); hs-cTnT also increased with increasing quartiles of MFS or grades of isolated LV diastolic dysfunction.

CONCLUSIONS

Within an extremely low range of concentrations, increased hs-cTnT amongst community-dwelling elderly subjects is associated with subtle alterations in cardiac phenotype, suggesting that minor injury to cardiac myocytes and subsequent release of troponin reflect subclinical pathophysiological LV deterioration in this population.

Effect of canrenone on left ventricular mechanics in patients with mild systolic heart failure and metabolic syndrome: the AREA-in-CHF study

BACKGROUND AND AIM

We analyzed the effect of the mineralocorticoid receptor antagonist canrenone on LV mechanics in patients with or without metabolic syndrome (MetS) and compensated (Class II NYHA) heart failure (HF) with reduced ejection fraction (EF≤45%) on optimal therapy (including ACE-i or ARB, and β-blockers).

METHODS AND RESULTS

From a randomized, double-blind placebo-controlled trial (AREA-in-CHF), patients with (73 on canrenone [Can] and 77 on placebo [Pla]), based on modified ATPIII definition (BMI≥30kg/m(2) instead of waist girth) or without MetS (146 by arm). In addition to traditional echocardiographic parameters, we also evaluated myocardial mechano-energetic efficiency (MME) based on a previously reported method. At baseline, Can and Pla did not differ in age, BMI, blood pressure (BP), metabolic profile, BNP, and PIIINP. Compared with MetS-Pla, and controlling for age, sex and diabetes, at the final control MetS-Can exhibited increased MME, preserved E/A ratio, and decreased atrial dimensions (0.04<p<0.0001). At baseline, degree of diastolic dysfunction was similar in MetS-Can and MetS-Pla but after 12 months, diastolic function improved in MetS-Can, compared to MetS-Pla (p<0.002): moderate-to-severe diastolic dysfunction decreased from 26% to 12% with canrenone whereas it was unchanged with placebo (both 26%). Can, but not Pla, reduced BNP in both patients with or without MetS (p<0.0001).

CONCLUSIONS

Treatment with canrenone given on the top of optimal therapy in patients with MetS and chronic, stabilized HF with reduced EF, protects deterioration of MME, improves diastolic dysfunction and maximizes the decrease in BNP.

Circulating cardiovascular biomarkers in recurrent atrial fibrillation: data from the GISSI-atrial fibrillation trial

OBJECTIVE

we evaluated the prognostic role of circulating cardiovascular biomarkers in patients with a history of recent atrial fibrillation (AF).

BACKGROUND

predicting long-term maintenance of sinus rhythm in patients with AF is difficult.

METHODS

plasma concentrations of three specific cardiac markers [high-sensitivity troponin T (hsTnT), N-terminal probrain natriuretic peptide (NT-proBNP) and mid-regional proatrial natriuretic peptide (MR-proANP)] and three stable fragments of vasoactive peptides [mid-regional proadrenomedullin (MR-proADM), copeptin (CT-proAVP) and CT-proendothelin-1 (CT-proET-1)] were measured at baseline and after 6 and 12 months in 382 patients enrolled in the GISSI-AF study, a prospective randomized trial to determine the effect of valsartan to reduce the recurrence of AF. The association between these markers, clinical characteristics and recurrence of AF was tested by univariate and multivariate Cox models.

RESULTS

mean patient age was 68 ± 9 years (37.2% females). A total of 84.8% of patients had a history of hypertension. In total, 59.7% qualified for history of AF because of successful cardioversion, 11.8% because of two or more episodes of AF in the 6 months preceding randomization and 28.5% because of both. Patients in AF at 6 or 12 months (203 (53.1%) with first recurrence) had significantly higher concentrations of most biomarkers. Despite low baseline levels, higher concentrations of hsTnT {adjusted hazard ratio (HR) [95% confidence intervals (CIs) for 1 SD increment] (1.15 [1.04-1.28], P = 0.007), MR-proANP (1.15 [1.01-1.30], P = 0.04), NT-proBNP (1.24 [1.11-1.39], P = 0.0001) and CT-proET-1 (1.16 [1.01-1.33], P = 0.03) independently predicted higher risk of a first recurrence of AF. Changes over time of MR-proANP tended to predict subsequent recurrence (adjusted HR [95%CI]) (1.53 [0.98-2.37], P = 0.06).

CONCLUSION

circulating markers of cardiomyocyte injury/strain and endothelin are related to recurrence of AF in patients in sinus rhythm with a history of recent AF.

Aldosterone status associated with insulin resistance in patients with heart failure--data from the ALOFT study

BACKGROUND

Aldosterone has a key role in the pathophysiology of heart failure. In around 50% of such patients, aldosterone "escapes" from inhibition by drugs that interrupt the renin-angiotensin axis; such patients have a worse clinical outcome. Insulin resistance is a risk factor in heart failure and cardiovascular disease. The relation between aldosterone status and insulin sensitivity was investigated in a cohort of heart failure patients.

METHODS

302 patients with New York Heart Association (NYHA) class II-IV heart failure on conventional therapy were randomised in the ALiskiren Observation of heart Failure Treatment study (ALOFT), designed to test the safety of a directly acting renin inhibitor. Plasma aldosterone and 24-hour urinary aldosterone excretion, as well as fasting insulin and homeostasis model assessment of insulin resistance (HOMA-IR) were measured. Subjects with aldosterone escape and high urinary aldosterone were identified according to previously accepted definitions.

RESULTS

20% of subjects demonstrated aldosterone escape and 34% had high urinary aldosterone levels. At baseline, there was a positive correlation between fasting insulin and plasma (r = 0.22 p<0.01) and urinary aldosterone(r = 0.19 p<0.03). Aldosterone escape and high urinary aldosterone subjects both demonstrated higher levels of fasting insulin (p<0.008, p<0.03), HOMA-IR (p<0.06, p<0.03) and insulin-glucose ratios (p<0.006, p<0.06) when compared to low aldosterone counterparts. All associations remained significant when adjusted for potential confounders.

CONCLUSIONS

This study demonstrates a novel direct relation between aldosterone status and insulin resistance in heart failure. This observation merits further study and may identify an additional mechanism that contributes to the adverse clinical outcome associated with aldosterone escape.

Prothrombotic gene expression profile in vascular smooth muscle cells of human saphenous vein, but not internal mammary artery

BACKGROUND

The resistance of internal mammary artery (IMA) toward thrombotic occlusion and accelerated atherosclerosis is not well understood. This study analyzed gene expression profiles of vascular smooth muscle cells (VSMCs) from IMA versus saphenous vein (SV).

METHODS AND RESULTS

54'675 probe sets were examined by Affymetrix microarrays. Thirty-one genes belonged to the coagulation system; 2 were differentially expressed, namely tissue factor (TF) and tissue-type plasminogen activator (tPA). TF was 3.1-fold lower in IMA than SV (P=0.006), whereas tPA was 9.0-fold higher (P<0.001). TF mRNA expression was lower in IMA than SV (P<0.05); tPA was higher (P<0.001). TF protein expression was 4.2+/-0.5-fold lower in IMA than SV (P<0.001); tPA was 2.6+/-0.4-fold higher (P<0.01). In IMA VSMC supernatant, TF protein and activity was lower (P<0.05), TFPI and tPA protein higher (P<0.05 and P<0.005), and clotting time of human plasma prolonged (P<0.05) as compared to SV. Migration to TF/FVIIa (10(-9) mol/L) was 3-fold lower in IMA than SV (P=0.01); PAR-2 protein expression was similar (P=NS), PAR-2 blockade without effect (P=NS).

CONCLUSIONS

Among the genes of the coagulation system, TF and tPA are differentially expressed in VSMCs from IMA versus SV. This is consistent with protection of IMA from thrombus formation and vascular remodeling.

Feasibility, limits and problems of clinical studies in Intensive Care Unit

In critical care medicine there is still a paucity of evidence on how to manage most of the clinical problems commonly encountered in critically ill patients. Randomized controlled trials (RCTs) are the most powerful instruments to evaluate the efficacy of a therapeutic intervention and to generate evidence for clinical practice. Unfortunately, the design and conduct of RCTs in our field are particularly complicated, because of some intrinsic and structural problems (e.g. lack of reliable nosography, concomitant use of different therapies, problems in the definition of end-points besides mortality) that will be discussed in this review. Further challenges are represented by the lack of tradition of large ICU networks, difficulties in linking or integrating physiologic and therapeutic objectives in designing clinical protocols, scarcity of independent or non-profit funds. A particularly stimulating opportunity of development is represented also by the relationship of critical care to EBM. Because of the above problems, metanalyses could be less informative than in other areas of medicine, as they are based on few trials which are often contradictory and of unsatisfactory quality. Few suggestions are formulated which could help looking forwards.

Murine models of myocardial and limb ischemia: Diagnostic end-points and relevance to clinical problems

Ischemic disease represents the new epidemic worldwide. Animal models of ischemic disease are useful because they can help us to understand the underlying pathogenetic mechanisms and develop new therapies. The present review article summarizes the results of a consensus conference on the status and future development of experimentation in the field of cardiovascular medicine using murine models of peripheral and myocardial ischemia. The starting point was to recognize the limits of the approach, which mainly derive from species- and disease-related differences in cardiovascular physiology. For instance, the mouse heart beats at a rate 10 times faster than the human heart. Furthermore, healing processes are more rapid in animals, as they rely on mechanisms that may have lost relevance in man. The main objective of the authors was to propose general guidelines, diagnostic end points and relevance to clinical problems.

Starc II, a multicenter randomized placebo-controlled double-blind clinical trial of trapidil for 1-year clinical events and angiographic restenosis reduction after coronary angioplasty and stenting

The objective of this study was to investigate the effect of trapidil 200 mg t.i.d. in preventing the occurrence of death, of myocardial infarction and the need for repeat revascularization at 12 months after balloon PTCA with or without stenting. Coronary restenosis after stenting is still a major drawback of percutaneous coronary interventions (PCI) for 30-40% of patients. Trapidil has been shown to prevent restenosis after PTCA. Eligible patients were randomized to placebo or oral trapidil 200 mg t.i.d. at least 48 hr before PCI and continuing 6 months after a successful balloon angioplasty or stent implantation. Aspirin was given to all patients, and ticlopidine 250 mg b.i.d. to those who received a stent for 4 weeks. In a randomized subgroup of 216 patients, quantitative coronary angiography was performed also at 6-month follow-up. Out of the 933 patients enrolled, primary endpoint incidence was 20.3% in trapidil and 18.0% in placebo (P = 0.37). When recurrence or deterioration of angina was added to the combined endpoint, incidence was 27.4% in trapidil and 23.0% in placebo (P = 0.12). Restenosis rate in patients with 6-month angiography was 25.0% in trapidil arm vs. 30.1% in placebo (P = 0.43). Stent restenosis rate was similar in patients randomized to trapidil or placebo (30.2% vs. 23.8%, respectively; P = 0.44), while in patients treated with balloon angioplasty, it was lower in trapidil (17.1%) than in placebo (40.0%; P = 0.03). Oral trapidil 200 mg t.i.d. for 6 months in addition to aspirin did not influence the occurrence of major cardiac events after coronary angioplasty with or without stenting. In a prespecified subgroup of 191 patients treated with balloon angioplasty only, trapidil reduced angiographic restenosis.

Prediction of 6 months left ventricular dilatation after myocardial infarction in relation to cardiac morbidity and mortality. Application of a new dilatation model to GISSI-3 data

AIMS

To predict the long-term left ventricular volume index early after myocardial infarction and to investigate the relationship between long-term left ventricular dilatation risk and clinical outcome.

METHODS AND RESULTS

By applying a previously developed dilatation model, we predicted the 6-month left ventricular volume index early after myocardial infarction (median 9 days) in 13,679 GISSI-3 patients, to identify patients at high risk of long-term left ventricular dilatation. The left ventricular systolic and diastolic volume indexes at 6 months were predicted with r=0.72 and r=0.68, respectively, in the subgroup of patients in whom a pre-discharge echo was available (n=7842). Patients predicted to be at risk for long-term left ventricular dilatation had an increased risk of mortality (RR 1.87, 95% CI: 1.48 to 2.36) and heart failure at 6 months (RR 2.59, 95% CI:2.04 to 3.28), but no increased risk of reinfarction at 6 months (RR 1.12, 95% CI: 0.87 to 1.45) or of angina pectoris (RR 1.07, 95% CI: 0.95 to 1.20).

CONCLUSION

Our prediction of long-term left ventricular dilatation, obtained by applying our new dilatation model in over 13,000 GISSI-3 patients, correlated well with mortality and heart failure after myocardial infarction. Therefore, our new dilatation model may contribute to more efficient risk stratification early after myocardial infarction.

Cardiac protection by pharmacological modulation of inflammation

Inflammation is a reaction to primary injury of various kinds, such as infection and trauma, which has both beneficial and detrimental effects. Inflammation has been associated with major diseases of the heart and vessels. Research has focused not only on ischaemia but also on post-ischaemic reperfusion, which is known to activate and amplify the inflammatory response. Although reperfusion should always be attempted in the clinical environment, it has been shown experimentally that it can cause some cardiac damage, in addition to that caused by ischaemia. Therefore, it is reasonable to attempt to increase the benefit obtainable with reperfusion by modulating inflammatory processes triggered by reperfusion itself. In this field, different potential therapeutic targets have been identified and interventions have been tested over the last 30 years. With the exception of adenosine, which probably does not act merely through inhibition of the inflammatory response, no other compounds have yet proven successful in clinical trials. Active research is ongoing. Broadening the approach from the heart to the cardiovascular system, promising data is emerging on cardiovascular protection conferred by statins in patients with coronary heart disease (CHD) and high levels of C-reactive protein (CRP), a systemic marker of inflammation. Similarly, results of trials aimed at preventing cardiovascular events by eradicating chronic infections will be among the first to directly test whether such therapies will decrease risks of cardiovascular disease.

Effect of prone positioning on the survival of patients with acute respiratory failure

BACKGROUND

Although placing patients with acute respiratory failure in a prone (face down) position improves their oxygenation 60 to 70 percent of the time, the effect on survival is not known.

METHODS

In a multicenter, randomized trial, we compared conventional treatment (in the supine position) of patients with acute lung injury or the acute respiratory distress syndrome with a predefined strategy of placing patients in a prone position for six or more hours daily for 10 days. We enrolled 304 patients, 152 in each group.

RESULTS

The mortality rate was 23.0 percent during the 10-day study period, 49.3 percent at the time of discharge from the intensive care unit, and 60.5 percent at 6 months. The relative risk of death in the prone group as compared with the supine group was 0.84 at the end of the study period (95 percent confidence interval, 0.56 to 1.27), 1.05 at the time of discharge from the intensive care unit (95 percent confidence interval, 0.84 to 1.32), and 1.06 at six months (95 percent confidence interval, 0.88 to 1.28). During the study period the mean (+/-SD) increase in the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen, measured each morning while patients were supine, was greater in the prone than the supine group (63.0+/-66.8 vs. 44.6+/-68.2, P=0.02). The incidence of complications related to positioning (such as pressure sores and accidental extubation) was similar in the two groups.

CONCLUSIONS

Although placing patients with acute respiratory failure in a prone position improves their oxygenation, it does not improve survival.

CHF-1024, a DA2/alpha2 agonist, blunts norepinephrine excretion and cardiac fibrosis in pressure overload

We compared the effects of an ACE inhibitor, captopril, with those of a DA2-dopaminergic/alpha2-adrenergic receptor agonist (CHF-1024) on neuroendocrine activation and cardiac fibrosis in a model of pressure-overload hypertrophy. Interrenal aortic stenosis was performed in 89 rats, treated with CHF-1024 (0.33, 2 or 6 mg kg(-1) day(-1)), or captopril (1 g/L). Hemodynamic variables were recorded. Cardiac and renal weights, plasma aldosterone, renin activity and urinary catecholamine excretion were measured, as well as cardiac collagen. Blood pressure was lower in stenotic animals treated with CHF-1024 compared to vehicle (161 +/- 10 vs 219 +/- 10 mmHg, p < 0.01), but LV weight was similar. CHF-1024 elicited a marked dose-dependent attenuation of urinary norepinephrine excretion (1.80 +/- 0.18 in controls compared to 0.40 +/- 0.14 microg/24 h at the highest dose, p < 0.01) and of LV perivascular fibrosis. Captopril provoked a marked hypotension, reduced cardiac and body weights, plasma aldosterone concentration, dopamine excretion and perivascular collagen. The DA2/alpha2 agonist CHF-1024 effectively blunts adrenergic drive and cardiac fibrosis in a rat model of pressure overload.

PTX3, A prototypical long pentraxin, is an early indicator of acute myocardial infarction in humans

BACKGROUND

Inflammation is an important component of ischemic heart disease. PTX3 is a long pentraxin whose expression is induced by cytokines in endothelial cells, mononuclear phagocytes, and myocardium. The possibility that PTX3 is altered in patients with acute myocardial infarction (AMI) has not yet been tested.

METHODS AND RESULTS

Blood samples were collected from 37 patients admitted to the coronary care unit (CCU) with symptoms of AMI. PTX3 plasma concentrations, as measured by ELISA, higher than the mean+2 SD of age-matched controls (2.01 ng/mL) were found in 27 patients within the first 24 hours of CCU admission. PTX3 peaked at 7.5 hours after CCU admission, and mean peak concentration was 6.94+/-11.26 ng/mL. Plasma concentrations of PTX3 returned to normal in all but 3 patients at hospital discharge and were unrelated to AMI site or extent, Killip class at entry, hours from symptom onset, and thrombolysis. C-reactive protein peaked in plasma at 24 hours after CCU admission, much later than PTX3 (P<0.001). Patients >64 years old and women had significantly higher PTX3 concentrations at 24 hours (P<0.05). PTX3 was detected by immunohistochemistry in normal but not in necrotic myocytes.

CONCLUSIONS

PTX3 is present in the intact myocardium, increases in the blood of patients with AMI, and disappears from damaged myocytes. We suggest that PTX3 is an early indicator of myocyte irreversible injury in ischemic cardiomyopathy.