The role of peak NT-proBNP/peak cardiac troponin T ratio obtained within 3 days of admission to discriminate Takotsubo from acute coronary syndrome

Background

Takotsubo syndrome (TS) is not usually diagnosed until a patient with suspected acute coronary syndrome (ACS) is found to have no hemodynamically significant lesions on coronary angiography (CA).

Purpose

We explored whether a cardiac biomarker profile can contribute to early diagnosis of TS, which could be useful when CA is either not available or does not provide a definitive diagnosis.

Methods

Ratios of N-terminal-pro brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) [admission and peak levels of the two consecutive days following admission, expressed in pg/mL] were compared in 41 patients with TS and 50 ACS patients.

Results

Both admission NT-proBNP/cTnT ratio and peak NT-proBNP/peak cTnT ratio were higher in patients with TS compared to those with ACS (38.8±57.1 vs 15.2±33.1, p=0.038 and 29.1±26.2 vs 2.2±3.9, p<0.001, respectively). Only the association of peak NT-proBNP/peak cTnT ratio remained statistically significant after adjustment for age and gender when multiple linear regression analysis was used (R square=0.746, p<0.001). ROC curve analysis of peak NT-proBNP/peak cTnT ratio discriminated patients with TS as opposed to those with ACS (AUC=0.921 with 95% CI: 0.851–0.990, p<0.001). A cut-off value of peak NT-proBNP/peak cTnT ratio >5.5 had a sensitivity of 85%, a specificity of 90% and an accuracy of 88.1% in detecting TS as opposed to ACS.

Conclusions

Peak NT-proBNP/peak cTnT ratio >5.5 obtained within the first 3 days of admission has a good diagnostic accuracy to identify patients with TS among those presenting with ACS. This could be useful for the early discrimination between the two entities when CA is not easily available, particularly in patients without ST-segment elevation and low or intermediate-risk.

Funding Acknowledgement

Type of funding sources: None.

Heart rate turbulence as potential adjuvant index for optimal treatment guidance in severe pulmonary artery hypertension

Purpose

Despite significant progress achieved in the management of pulmonary arterial hypertension (PAH), the prognosis remains poor. Sudden cardiac death is one main cause of death in advanced disease. It is already known that in pts with PAH there is an alteration in cardiac autonomic nervous activity. Heart rate turbulence (HRT) is an ECG–related autonomic marker, helpful in risk stratification of proarrhythmia and sudden cardiac death. Aim of the study was to examine HRT in patients with severe idiopathic PAH (IPAH) and its relation to disease's progress.

Methods

The study population consisted of 46 pts, (32 men and 14 women), mean age 50±9 years, Group A 20 pts: NYHA III, III–IV diagnosed as severe IPAH and Group B 26 pts: NYHA II, II–III diagnosed as moderately severe IPAH. They underwent 24h Holter monitoring-HRT analysis with calculation of 2 parameters, turbulence onset (TO) and turbulence slope (TS) (Abnormal values: TO>0, TS<2.5msec/RR). Pts were defined as HRT(+) when TO and/or TS were abnormal and as HRT(−) when both TO and TS were normal or when HRT could not be calculated because of none or too few suitable PVCs. Reassessment of HRT was undertaken in 6 mo and 1 year in case of change in clinical status. Six pts from group A and 7 pts from group B underwent HRT reassessment because of change in clinical status.

Results

Initially abnormal HRT was found in 12 out of 20 pts (n=12, 60%) in group A and in none out of 26 (n=0, 0%) in group B (p=0,001). In 5 pts out of 8 with clinical improvement and 4 pts with clinical deterioration who had HRT reassessed, significant positive correlation was found between TS and change of clinical status (r=0,64, p=0,04). There was a tendency to greater normal TS mean values with clinical improvement even in group where TS was already normal (6,95±4,5 vs 3±0,3 p=0.077).

Conclusion

In severe IPAH cardiac autonomic system impairment was demonstrated mainly as abnormal TS in HRT. Significant positive correlation between normalization of TS and clinical improvement was revealed and that raises promises for use of HRT optimization as adjuvant index to guide optimal IPAH therapy and efficacy.

Funding Acknowledgement

Type of funding sources: None.

Differences in arterial stiffness and target organ damage between native Greek patients and immigrants from Eastern European countries with essential hypertension

AIM

The variance in hypertension-related sequelae between different ethnic groups is highly related to differences in socioeconomic conditions and lifestyle habits, but also to disparities in the awareness and treatment of the disease. In the present study, we sought to evaluate the target organ damage in a vulnerable hypertensive population, such as the Eastern European immigrants.

METHODS

The study population consisted of 128 hypertensive patients: 67 immigrants from Eastern Europe and 61 native inhabitants. Anthropometric, biochemical and echocardiographic data were derived from both groups. Both groups underwent fundoscopic examination and pulse wave velocity (PWV) measurements for assessment of arterial stiffness.

RESULTS

Although immigrants had lower body mass index compared to native inhabitants (P<0.001), they had significantly increased arterial stiffness (P=0.003). In multivariate analysis, higher carotid-femoral PWV was significantly associated with immigration status [β (SE)=0.935(0.443), P=0.041], after adjustment for smoking status. Moreover, immigrants had increased left atrial volume index (LAVI) (P<0.001), left ventricular mass index (P<0.001) and higher rates of left ventricular diastolic dysfunction (p=0.047). In multivariate analysis, LAVI was significantly associated with immigration status (β (SE)=5.17(1.93), P=0.01) after adjustment for serum glucose levels and age. Finally, immigrants had significantly higher levels of sodium urinary excretion (p=0.007) and lower glomerular filtration rate (P<0.001).

CONCLUSION

Our findings suggest that hypertensive immigrants exhibit an aggravated arterial stiffness profile and increased risk of target organ damage. These findings could be attributed to differences in socioeconomic conditions and dietary habits.

Relationship between plasma osteopontin and oxidative stress in patients with coronary artery disease

BACKGROUND

It is known that oxidative stress plays an important role in the pathogenesis of atherosclerosis and that an association exists between osteopontin (OPN) and atherosclerosis.

OBJECTIVES

It was proposed that malondialdehyde (MDA), a biomarker of lipid peroxidation and oxidative stress, would be related to plasma OPN levels in patients with coronary artery disease (CAD).

METHODS/RESULTS

Plasma OPN and MDA levels were measured in 71 patients (60 males and 11 females; mean age 61.7 +/- 10 years). Fifty-eight patients had significant CAD (group I) and 13 patients were free of CAD as defined angiographically (group II). Plasma OPN was measured by enzyme-linked immunosorbent assay (ELISA), while MDA was determined spectrophotometrically. Multivariate regression analysis revealed that ln-transformed OPN levels were independently associated with MDA after adjustment for age, hypertension and diabetes mellitus (R(2) = 0.278, p = 0.0004 and beta regression coefficient = 0.252 [standard error = 0.0958], p = 0.011). OPN and MDA levels were higher in patients with diabetes (73.6 +/- 36.2 ng/ml versus 56.1 +/- 30.9 ng/ml, p = 0.02 and 2.5 +/- 0.5 microM versus 2.0 +/- 0.5 microM, p = 0.002, respectively).

CONCLUSIONS

The association between OPN and MDA levels in patients with CAD suggests an interaction between OPN and oxidative stress. This interaction may play a role in the pathogenesis of atherosclerosis.

Hepatocellular carcinoma with invasion into the right atrium. Report of two cases and review of the literature

We report two rare cases of hepatocellular carcinoma with invasion into the right atrium. In both our cases, the patients had liver cirrhosis and were admitted to our department due to symptoms such as worsening of the jaundice, ascites and edema of the lower extremities. The diagnosis of the HCC was established when we found high levels of alpha-fetoprotein, and the patients underwent MRI and CT-scan that were indicative of HCC. The clinical suspicion of invasion of the RA by the tumor emerged from the presence of heart-related symptoms, such as dyspnea and chest discomfort. The patients underwent two-dimensional transthoracic echocardiogram, which revealed from the sub-costal view a mobile atrial mass protruding from the inferior vena cava. In conclusion, when a patient with a history of chronic hepatic disease presents with symptoms of right heart failure one must be cautious and should bear in mind that right heart involvement from a malignant tumor may be present.