Cardiopulmonary exercise testing in clinical practice: Principles, applications, and basic interpretation

Cardiopulmonary exercise testing (CPET) provides a noninvasive and integrated assessment of the response of the respiratory, cardiovascular, and musculoskeletal systems to exercise. This information improves the diagnosis, risk stratification, and therapeutic management of several clinical conditions. Additionally, CPET is the gold standard test for cardiorespiratory fitness quantification and exercise prescription, both in patients with cardiopulmonary disease undergoing cardiac or pulmonary rehabilitation programs and in healthy individuals, such as high-level athletes. In this setting, the relevance of practical knowledge about this exam is useful and of interest to several medical specialties other than cardiology. However, despite its multiple established advantages, CPET remains underused. This article aims to increase awareness of the value of CPET in clinical practice and to inform clinicians about its main indications, applications, and basic interpretation.

"O meu coração bate saudável" - Results from a pilot project for health education in Portuguese children

INTRODUCTION AND OBJECTIVES

Childhood offers an excellent window of opportunity to start interventions to promote behavioral changes before unhealthy lifestyles become established, leading to cardiovascular diseases. The goal of this pilot educational project for children is the promotion of healthy lifestyles and cardiovascular health.

METHODS

This project was implemented in 4th grade children and included teacher-led classroom activities, a lesson given by a cardiologist and a practical lesson with dietitians. The teacher received a manual containing information on the topics to be discussed in class with the pupils and the children received a book that addresses cardiovascular risk factors and prevention. The components included were diet (D), physical activity (PA) and human body and heart awareness (BH). At the beginning and at the end of the schoolyear, a questionnaire was applied to the children to assess knowledge (K), attitudes (A) and habits (H) on these topics.

RESULTS

A total of 73 children from an urban public school in Lisbon, in a low to medium income area, participated in the project. Following the intervention, there was a 9.5% increase in the overall KAH score, mainly driven by the PA component (14.5%) followed by the BH component (12.3%). No improvement was observed for component D. The benefits were also more significant in children from a lower income area, suggesting that socioeconomic status is a determinant in the response obtained.

CONCLUSIONS

An educational project for cardiovascular health can be implemented successfully in children aged 9 years, but longer and larger studies are necessary.

Analysis of benign prostatic obstruction surgery: A long-term evaluation in a real-life context

Objective: Surgery is the treatment for male lower urinary tract symptoms (LUTS) relat-ed to benign prostatic obstruction (BPO) refractory to pharma-cological treatment or with complications. This study aimed to assess factors associated with the need for surgical reinterven-tion and/or continuation of pharmacological treatment. Materials and methods: A retrospective analysis of patients who underwent prostatic surgery for male LUTS associated with BPO between 1 May 2015 and 1 May 2016, with a minimum follow-up of five years, in an academic tertiary hospital. The type of surgery, preoperative, postoperative and follow-up analysis were collected in a database. Results: A total of 212 patients were included with a mean age of 70 ± 8.66 years at five years follow-up. At 5 years, a total of 86.9% of patients do not need pharmacological treatment and 12% required surgical reintervention. Of the preoperative parameters, it was found a relationship between prior prostatitis and the need for second surgery with an odds ratio of 4.6. Conclusions: Patients should be informed of the potential need for pharmacological treatment following surgery, or even of the need for reintervention. History of prostatitis seems to be a risk factor for reintervention.

Treatment of idiopathic overactive bladder with botulinum toxin: real-life results and patients' expectations

Background

Overactive bladder (OAB) is a prevalent syndrome affecting 11% to 16% of the adult population. When first-line pharmacological therapy is not effective, intradetrusorial injections of onabotulinumtoxinA (BTX-A) might have an important role in controlling symptoms. The main aim of this study was to access both the efficacy and safety of intradetrusor injections of 100U BTX-A in real clinical practice, among women with idiopathic OAB (iOAB).

Methods

Retrospective study, based on clinical diaries in 136 iOAB female patients, with or without urinary incontinence, submitted to BTX-A injections, between 2005 and 2018 in a tertiary university hospital. Positive response was considered only when the patient mentioned she had great improvement after the injection, otherwise, it was considered negative.

Results

A positive response was obtained in 90 patients (66%) after the first injection. Women with a positive response after the first treatment had 7.5 times more chances to improve with the second (P = .01). Discontinuation of the therapy after the first injection was neither dependent on the presence of incontinence at baseline (P = .73) nor it was related to age (P = .6). On univariate analyses, none of the parameters evaluated was useful of predicting successful response, although there was a trend in women who had had a previous midurethral sling surgery for stress urinary incontinence, to have a lower chance of having a positive response after the first injection (P = .06).Thirty-nine women (29%) had at least 1 adverse event, urinary tract infection, and straining to void were the most frequent. Women above 65 years old had less risk of developing a urinary tract infection (P = .04).

Conclusion

In real clinical practice, BTX-A injection is an effective (66%) and safe treatment, capable of improving quality of life. Moreover, responding to the first injection seems to predict good clinical outcomes in the second treatment. This procedure can be done with minimal restrictions.

Daily low dose of tadalafil improves pain and frequency in bladder pain syndrome/interstitial cystitis patients

Objective: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic disease, with consequent high morbidity. Increasing evidence suggests that bladder afferent hyperexcitability, through neurogenic bladder inflammation and urothelial dysfunction, plays a key role in the pathophysiology of BPS/IC. The rationale of using phosphodiesterase type 5 inhibitors (PDE5i) would be to decrease bladder afferent hyperactivity. Detrusor relaxation, improvement of microcirculation, and a decrease in adrenergic nociceptive overactivity would be other effects in bladder tissue. We aimed to evaluate the efficacy, tolerability, and safety of a daily low dose of 5 mg tadalafil in refractory BPS/IC patients.

Material and methods: A total of 14 refractory BPS/IC female patients, previously evaluated with a physical examination, bladder diary, bladder-pain related visual analogue score, O’Leary-Sant Scores (OSS) for symptoms and problems, and quality of life (QoL) question from International Prostate Symptom Score, were treated with 5 mg of tadalafil, for 3 months. Re-evaluations occurred at 4 and 12 weeks. Adverse events were assessed and recorded.

Results: Urinary frequency, OSS, and QoL were significantly improved at 1-month follow-up (10 ± 2.5, 21.9 ± 4.1, and 4 ± 1.5, respectively, P < .05). Pain intensity and volume voided were significantly improved at a 3-month follow-up (3.5 ± 2 and 266.7 ± 60.5, P < .05). Patients referred to urinary frequency as the most important parameter improved at 4 weeks, and pain at 3 months. No differences between ulcerated and nonulcerated patients were observed. Two patients dropped out due to unsatisfactory results and two due to persistent headache and/or tachycardia, but both events were resolved after discontinuing the drug.

Conclusion: Daily low-dose tadalafil is an easy, well-tolerated, and effective treatment for refractory BPS/IC in women.

Can serum endoglin be used to improve the diagnostic performance in prostate cancer?

PURPOSE

New biomarkers may contribute to avoid unnecessary biopsies resulting from the suboptimal performance of prostate-specific antigen (PSA) testing. This study aimed to assess serum endoglin as a prostate cancer (PCa) diagnostic tool among biopsy candidates.

METHODS

A total of 262 consecutive patients referred for prostate biopsy based on abnormal digital rectal examination and/or elevated total PSA (tPSA) who had serum endoglin assessed by solid-phase enzyme-linked immunosorbent assay were selected. Receiver operating characteristic curves were used to compare the predictive accuracy of different combinations of biomarkers to distinguish between PCa and benign prostatic conditions, and to identify cut-offs that maximize the ability of endoglin to rule out patients for biopsy (highest sensitivities).

RESULTS

Serum endoglin levels were higher in patients with PCa (median: 7.86 vs. 5.88 pg/mL, P < 0.001). Among patients with baseline tPSA ≤ 10 ng/mL the area under the curve was 0.69 for endoglin. Approximately one-quarter of the patients had serum endoglin < 4.92 ng/mL (sensitivity: 90.3%; specificity: 32.8%), and the probability of PCa varied from 37.7% before testing to 15.2% among those with low endoglin levels [negative predictive value (NPV) = 84.8%]. When restricting the analyses to patients with free/total PSA ratio > 0.25, the probability of cancer was less than 5% among those with serum endoglin < 6.04 ng/mL (sensitivity: 93.8%; specificity: 56.1%), corresponding to a NPV of 95.8%; this could allow sparing approximately 40% of patients from biopsy.

CONCLUSIONS

Serum endoglin may be useful in clinical practice to distinguish between PCa and non-cancer patients among prostatic biopsy candidates.

Visual Analogue Score for Urinary Symptoms-VASUS, validation of a visual scale for lower urinary tract symptoms (LUTS) in an African country

PURPOSE

Validate a visual scale to assess LUTS, especially in developing countries, as an alternative to IPSS. VASUS consist of five questions, where Q1 and Q2 assess urinary stream quality, Q3 nocturia, Q4 incomplete emptying and Q5 QoL.

METHODS

Between 2014 and 2017, we carried out a study in the male population over 30 years from São Tomé and Príncipe, a Portuguese speaking African Country. A stratified sample (age and district) of subjects completed IPSS, VASUS and a free flowmetry.

RESULTS

We obtained 812 valid responses (average age: 50.72, range: 30-95 years old). In the comparison between IPSS and VASUS, we found positive correlations, with p value < 0.0001, for all variables analyzed and negative correlation for all urodynamic variables. Upon verifying the association of VASUS with IPSS, namely when comparing questions with similar objectives such as nocturia (VASUS-Q3 and IPSS-Q7), the stream quality (VASUS-Q1 and Q2 and IPSS-Q5) or the quality of life (VASUS-Q5 and IPSS-Q8), strong positive correlations were found.

CONCLUSION

VASUS is a visual alternative to IPSS allowing evaluation of LUTS and having correlation with IPSS and flowmetry. Its use in developing countries with low levels of literacy will be an asset. The authors believe that widespread use of a scale such as VASUS in urology consultations is warranted, to increase daily practice objectification of LUTS.

Prognostic Factors in Penile Cancer: Should We Avoid Inguinal Lymph Node Staging?

INTRODUCTION

Penile cancer (PC) is a rare neoplasm, mostly in developed countries. Herewith, we evaluate the main prognostic factors of patients with PC undergoing surgery.

METHODS

This is a retrospective analysis of prognostic factors of overall survival in 65 patients with PC treated at a tertiary referral center over the last 15 years (2004-2018).

RESULTS

Almost half (48%) of the patients were diagnosed at an advanced local stage pT3/4. Thirty-eight (58%) patients underwent inguinal lymphadenectomy, and 25 (66%) were negative for lymph node (LN) invasion. Overall survival was 80% at a median follow-up of 31 months. In the multivariate analysis, the main factors of poor prognosis were nodal staging (pN) (p = 0.008) and perineural invasion (p = 0.023). The presence of LN metastasis and perineural invasion in the primary tumor increased the risk of death by 29 (hazard ratio 29.0, 95% confidence interval 2.4-354.2) and 13 (hazard ratio 12.7, 95% confidence interval 1.4-112.0) times, respectively.

DISCUSSION/CONCLUSION

Late diagnosis of PC has a negative impact on overall survival, as nodal invasion correlates with survival. Despite the high number of negative inguinal lymphadenectomy, we continue to advocate aggressive surgical treatment of this disease due to the poor prognosis associated with LN metastasis.

Metabolic evaluation in urolithiasis - study of the prevalence of metabolic abnormalities in a tertiary centre

Introduction

Metabolic abnormalities are one of the most important risk factors for urinary stone disease. Our objective was to determine the prevalence of metabolic abnormalities in patients referred to the urolithiasis outpatient clinic of a tertiary centre.

Material and methods

We performed a cross-sectional study evaluating 67 patients referred to the urolithiasis outpatient clinic. Metabolic evaluation was performed, including one 24-hour urine sample.

Results

Metabolic abnormalities could be identified in 92.5% patients. Almost a quarter of the patients had only one metabolic abnormality and 67.6% had more than one abnormality. The most prevalent metabolic abnormalities were hypercalciuria (54.5%), hyperoxaluria (34.7%) and hyperuricosuria (32.3%). Patients with hypercalciuria were older (54.7 vs. 47.8 years, p = 0.018) and family history of stone disease was significantly more frequent among patients with hyperoxaluria (71.4% vs. 28.6%, p = 0.013). There was a positive linear relationship between body mass index (BMI) and urinary calcium (r = 0.247, p = 0.048) and a negative linear relationship between BMI and urinary pH (r = −0.254, p = 0.046).

Conclusions

Given the high prevalence of metabolic abnormalities, metabolic evaluation should be performed in every patient with urolithiasis evaluated in a tertiary setting.

Current stepwise recommendations for hypogonadism screening in erectile dysfunction are not cost-effective

Hypogonadism is a prevalent comorbidity with erectile disfunction (ED) and current guidelines recommend screening for hypogonadism with total testosterone (TT). If low TT is detected, further assessment with LH and SHBG plus albumin are needed to establish an etiology and treatment. Our primary objective was to determine the cost benefit of current stepwise approach versus ad initium full hormonal assessment. Two hundred consecutive male patients referred for ED were screened after consent and 81 were included and assessed for hypogonadism according to the current stepwise approach with TT, and only if TT was less than 345 ng/mL, a full hormonal assessment with TT, LH, and SHBG plus albumin to calculate free testosterone was performed. Direct costs were calculated using the national public healthcare system reimbursement tables and were compared with a hypothetical initial full hormonal assessment. Screening TT was less than 345 ng/mL in 34.6% patients leading to a full hormonal assessment on these. Using a stepwise approach there was a direct cost increase of 5.82 € per patient. Moreover, one out of every three patients had two extra venipunctures and an additional follow-up appointment. Current stepwise recommendations may prove costly in high prevalence scenarios such as the ED subpopulation as a direct cost increase was observed.

Misdiagnosis And Undertreatment Of Erectile Dysfunction In The Portuguese Primary Health Care

Introduction

The importance of erectile dysfunction (ED) diagnosis and treatment has been highlighted since the early 2000s. However, nearly 20 years after the first phosphodiesterase 5 inhibitor (PDE5i) was marketed, underdiagnosis and undertreatment of ED in the primary health care setting may still be present.

Aim

To assess the relative frequency of patients who are medically treated for ED before referral to specialized urology care. The secondary objectives were to evaluate possible reasons for non-treatment prior to referral and other signs of undertreatment, namely cardiovascular risk assessment and antihypertensive treatment.

Methods

200 male patients referred for ED to specialist urology care by general practitioners were screened after consent between January 2016–December 2018. A full standardized medical and sexual history were taken. Previous medical treatment of ED, namely pharmacologic name and dosages, and cardiovascular risk factors were noted.

Main Outcome Measures

Of the 115 included patients, only 33.9% of patients had already taken PDE5i before referral, and none had taken alprostadil by intracavernous route.

Results

The mean patient age was 58.68 ± 10.01 years old. Only 45.2% had been prescribed the highest dose of PD5i. From the remaining untreated patients, only 19.7% had ≥3 cardiovascular risk factors, including 5.6% of patients who also presented moderate-to-severe stable or unstable angina requiring a stress test or cardiology assessment before treatment. Regarding the 54 patients with medical history of arterial hypertension, 43.4% and 30.2% were treated for hypertension with a diuretic and a beta blocker, respectively.

Conclusion

More focus on the primary healthcare continuous medical education regarding sexual dysfunction, namely ED, is needed because major undertreatment of ED is still present because low prescription of PD5i before referral is noted.

Morgado A, Moura ML, Dinis P, et al. Misdiagnosis And Undertreatment Of Erectile Dysfunction In The Portuguese Primary Health Care. Sex Med 2019;7:177–183.

Comparison of Three Criteria for Interpretation of Electrocardiogram in the Military

BACKGROUND

Screening of competitive athletes and other individuals exposed to regular and intense physical exercise, such as military personnel, can lead to an early and preclinical identification of cardiac conditions associated with a higher risk for sudden cardiac death. The electrocardiogram (ECG) has been recommended for the precompetitive screening, but its interpretation remains controversial. The aim of this study was to compare three different standardized criteria for interpretation of athletes' ECG applied in military.

METHODS

Prospective study of 1,380 consecutive healthy military, 249 (18%) also involved in competitive sport, screened with clinical history, physical examination, and ECG. The ECG was interpreted according to the European Society of Cardiology (ESC) recommendations, the Seattle Criteria (SC), and the Refined Criteria (RC).

FINDINGS

Independently of the criteria used, the majority of the individuals included had ECG changes, mainly physiological: ESC 55.1%, SC 63.6%, and RC 64.4%. The rate of pathological ECGs was significantly higher with the ESC criteria when compared to SC and RC (ESC 14.8%, SC 5.0% and RC 4.5%; p < 0.001). A significant cardiac abnormality was diagnosed with additional investigations in 4 patients (Brugada syndrome Type 1, mitral valve prolapse, bicuspid aortic valve, and Wolff-Parkinson-White pattern).

DISCUSSION

Electrical cardiac adaptations are frequent in military personnel, similar to competitive athletes. Some ECG changes, previously considered pathological, could in fact correspond to physiological adaptations. The refinement of the ECG interpretation in this athletic population seems to reduce the rate of false-positive cases. This may have a favorable socioeconomic impact, especially by reducing the health cost burden and number of disability days.

From bladder to systemic syndrome: concept and treatment evolution of interstitial cystitis

Interstitial cystitis, presently known as bladder pain syndrome, has been recognized for over a century but is still far from being understood. Its etiology is unknown and the syndrome probably harbors different diseases. Autoimmune dysfunction, urothelial leakage, infection, central and peripheral nervous system dysfunction, genetic disease, childhood trauma/abuse, and subsequent stress response system dysregulation might be implicated. Management is slowly evolving from a solo act by the end-organ specialist to a team approach based on new typing and phenotyping of the disease. However, oral and invasive treatments are still largely aimed at the bladder and are based on currently proposed pathophysiologic mechanisms. Future research will better define the disease, permitting individualization of treatment.

Universal Definition of Myocardial Infarction: Clinical Insights

Aims: The universal definition of myocardial infarction (MI) classifies acute ischaemia into different classes according to lesion mechanism. Our aim was to perform a detailed comparison between these different types of MI in terms of baseline characteristics, management and prognosis. Methods and Results: An observational retrospective single-centre cohort study was performed, including 1,000 consecutive patients admitted for type 1 (76.4%) or type 2 MI (23.6%). Type 2 MI patients were older, had a higher prevalence of comorbidities and worse medical status at admission. In-hospital mortality did not differ significantly between the MI groups (8.8 vs. 9.7%, p = 0.602). However, mortality during follow-up was almost 3 times higher in type 2 MIs (HR 2.75, p < 0.001). Type 2 MI was an independent all-cause mortality risk marker, adding discriminatory power to the GRACE model. Finally, important differences in traditional risk score performances (GRACE, CRUSADE) were found between both MI types. Conclusions: Several important baseline differences were found between these MI types. Regarding prognosis, long-term survival is significantly compromised in type 2 MIs, potentially translating patients' higher medical complexity and frailty. Distinction between type 1 and type 2 MI seems to have important implications in clinical practice and likely also in the results of clinical trials.

Percutaneous patent foramen ovale closure: the Paradoxical Cerebral Embolism Prevention Registry

INTRODUCTION

The natural history and therapeutic interventions for secondary prevention after a cerebrovascular event in patients with patent foramen ovale (PFO) are not yet established. This study aims to assess the safety and efficacy of percutaneous PFO closure in a population of patients with ischemic cerebrovascular disease of unknown etiology.

METHODS

This prospective observational study included patients with a history of cryptogenic transient ischemic attack (TIA) or stroke who underwent percutaneous PFO closure. The effectiveness of the device for the secondary prevention of TIA or stroke was assessed by comparing observed events in the sample with expected events for this clinical setting.

RESULTS

The sample included 193 cases of percutaneous PFO closure (age 46.4 ± 13.1 years, 62.2% female) with a mean follow-up of 4.3 ± 2.2 years, corresponding to a total exposure to ischemic events of 542 patient-years. The high-risk characteristics of the PFO were assessed prior to device implantation. There were seven primary endpoint events during follow-up (1.3 per 100 patient-years), corresponding to a relative risk reduction of 68.2% in recurrent TIA or stroke compared to medical therapy alone. The procedure was associated with a low rate of device- or intervention-related complications (1.5%).

CONCLUSIONS

In this long-term registry, percutaneous PFO closure was shown to be a safe and effective therapy for the secondary prevention of cryptogenic stroke or TIA.

Ulcerative and nonulcerative forms of bladder pain syndrome/interstitial cystitis do not differ in symptom intensity or response to onabotulinum toxin A

OBJECTIVE

To determine whether intratrigonal Onabotulinum toxin A (OnabotA) injection produces a different symptomatic outcome and duration of effect on ulcerative (Ulc) and nonulcerative (NUlc) bladder pain syndrome/interstitial cystitis (BPS/IC) patients and to compare the urinary levels of neurotrophines (NGF, BDNF, and GDNF) in response to OnabotA.

METHODS

Ten Ulc and 14 NUlc bladder pain syndrome/interstitial cystitis patients were included in this study. OnabotA (100 U) was injected in 10 trigonal sites, each receiving 10 U in 1 mL of saline. Outcome measures included pain visual analog scale (0-10), a 3-day voiding chart, O'Leary-Sant Score (OSS), and quality of life (QoL) from International Prostate Symptoms Score assessed before treatment, 1 month after injection, and every 3 months afterwards. Urinary NGF, BDNF, and GDNF were accessed using ELISA, at same time points. Treatment duration was determined at the time patients requested another injection.

RESULTS

Patients had a mean age of 40 ± 12 years in the Ulc and 47 ± 13 years in the NUlc group (ns). Mean values at baseline of pain intensity, frequency, nocturia, OSS, QoL, and urinary NGF, BDNF, GDNF were identical in the 2 groups. Patients with the Ulc phenotype had a longer duration of symptoms (28.8 ± 11 vs 19.2 ± 8 months, P = .018). Both groups responded equally to OnabotA, with significant improvements in pain intensity, frequency, nocturia, OSS, QoL, and urinary NGF, BDNF, GDNF. The effect lasted for 9 ± 2.8 (Ulc) and 10.5 ± 2 (NUlc) months.

CONCLUSION

In this cohort, Ulc and NUlc patients had similar symptoms at baseline and comparable clinical response to intratrigonal OnabotA. These findings suggest that pain may not be directly related with ulcers themselves.

Bladder pain syndrome/interstitial cystitis: present and future treatment perspectives

Bladder pain syndrome/Interstitial cystitis (BPS/IC) is a debilitating chronic disease of unknown etiology. Treatment is not well defined and is still under intense investigation. The aim of this paper was to review existing literature on treatment of BPS/IC and examine current evidence on present and future perspective. PubMed database was researched and publications in English language on the topic were analyzed, emphasis was given to publications that occurred on the last five years. Mainstays of oral therapies are still empirical due to lack of knowledge on etiology of this disease. The few oral drugs that showed efficacy in placebo controlled trials are amytriptiline, pentosan polysulfate sodium, hydroxyzine and cyclosporine A. As for intravesical treatments reasonable evidence is available only for dimethyl sulfoxide and resection of visible Hunner's lesions. Reconstructive surgery can also be recommended in selected cases. Further studies into the causes and mechanisms of the disease are paramount for the development of effective treatments. Foreseeable therapeutic objectives will comprehend oral blockade of sensory nerve receptors, immune system modulation, peripheral nerve fiber inactivation/desensitization, anti-proliferative factor blockade and pain gene therapy. Identification of BPS/IC phenotypical subgroups should help delineate proper individualized treatment which will be aimed at the disease and its multiple manifestations rather than at focalized complaints. Present treatment of BPS/IC comprises pain control in conjunction with control of supposed underlying bladder disease. Based on identified possible therapeutic targets several treatment possibilities warrant further investigation. Identification of BPS/IC phenotype is a important step for correct management.

Mid-term Risk Stratification of Patients with a Myocardial Infarction and Atrial Fibrillation: Beyond GRACE and CHADS

Background: We hypothesize that the discriminative performance of GRACE, ACHTUNG-Rule, CHADS₂ or CHA₂DS₂-VASc may be lower in patients with a Myocardial Infarction (MI) and concurrent atrial fibrillation (AF), as none of these scores seem able to fully capture both atherothrombotic/thromboembolic risks. This study aims to evaluate the mid-term prognostic performance of these algorithms in patients with these two conditions and to analyze the utility of a score combining GRACE and CHA₂DS₂-VASc. Methods: Observational retrospective single-centre cohort study including 1852 patients admitted with a MI. We tested the prognostic performance of the aforementioned risk stratification schemes in patients with vs. without AF at admission or during hospitalization. Primary endpoints: a) total all-cause mortality, comprising intrahospital and post-discharge all-cause mortality; b) intrahospital all-cause mortality and c) all-cause mortality during follow-up. Furthermore, all three versions of the ACHTUNG-Rule were directly compared to their equivalent GRACE score versions, and a new score, entitled GRACE-CHA₂DS₂-VASc, was developed and compared with GRACE. Results: The mid-term prognostic performance of all scores was considerably lower in patients with AF, corroborating our hypothesis. The ACHTUNG-Rule seemed superior to GRACE in the prediction of post-discharge (AUC 0.790±0.032 vs. 0.685±0.038, p=0.079; integrated discrimination improvement index [IDI] of 0.166 and relative IDI of 83.7%) and total mortality (0.762±0.031 vs. 0.712±0.033, p=0.144; IDI of 0.042, relative IDI of 11.7%), but its performance decreased in those with AF as well. GRACE-CHA₂DS₂-VASc was only marginally superior to GRACE in discriminative performance, but detected truly low- (CHA₂DS₂-VASc <2; total mortality 0%) and high-risk patients (GRACE high-risk stratum, and CHA₂DS₂-VASc >4; total mortality 44.3%) with considerable efficacy. Conclusions: In patients with MI and concurrent AF, the GRACE, CHADS₂ and CHA₂DS₂-VASc scores seemed less accurate in the prediction of all-cause mortality. A hypothetic GRACE-CHA₂DS₂-VASc score or the recently developed ACHTUNG-Rule may eventually provide a more rigorous approach to risk stratification in this high-risk setting.

Stroke prediction with an adjusted R-CHA2DS2VASc score in a cohort of patients with a Myocardial Infarction

INTRODUCTION

A new risk stratification scheme incorporating the original CHADS2 score and renal function, entitled R(2)CHADS(2), was validated in the ROCKET-AF and ATRIA study cohorts.

AIMS

Adjusting and validating a modified R-CHA2DS2VASc score as a predictor of ischaemic stroke and all-cause mortality in patients discharged following admission for a Myocardial Infarction (MI).

MATERIALS AND METHODS

Observational retrospective single-centre cohort study including 1711 patients admitted with MI and discharged alive. We tested the prognostic performance of R-CHA2DS2VASc, based on the original CHA2DS2VASc score with few modifications (addition of renal function parameters [glomerular filtration rate and urea], performance of a revascularization procedure and history of atrial fibrillation). R-CHA2DS2VASc was evaluated for its discriminative performance and calibration in the prediction of ischaemic stroke (primary endpoint), all-cause mortality and a composite endpoint of ischemic stroke plus all-cause mortality (secondary outcomes) during follow-up.

RESULTS

R-CHA2DS2VASc score's areas under the curve (AUC) for the occurrence of primary and secondary outcomes were: Ischaemic stroke: AUC 0.717 ± 0.031, p<0.001 (vs. 0.681 ± 0.043 for CHA2DS2VASc, p=0.290); all-cause mortality during follow-up: AUC 0.811 ± 0.014, p<0.001 (vs. 0.782 ± 0.019 for GRACE, p=0.245); composite endpoint: AUC 0.803 ± 0.014, p<0.001. The integrated discrimination improvement index (IDI) and relative IDI for the primary endpoint were 0.015 and 28.2%, respectively, while the IDI and relative IDI for all-cause mortality were 0.13 and 72.1%, suggesting a large improvement in risk stratification. An R-CHA2DS2VASc score below 3 had a negative predictive value of 98.6% for the occurrence of ischaemic stroke.

CONCLUSIONS

The modified R-CHA2DS2VASc score has shown good calibration and high discriminative performance in the prediction of post-discharge ischaemic stroke and all-cause mortality. The inclusion of renal function in thromboembolic risk predicting schemes seems warranted.

BLEED-Myocardial Infarction Score: Predicting mid-term post-discharge bleeding events

AIM: To derive and validate a score for the prediction of mid-term bleeding events following discharge for myocardial infarction (MI).

METHODS: One thousand and fifty patients admitted for MI and followed for 19.9 ± 6.7 mo were assigned to a derivation cohort. A new risk model, called BLEED-MI, was developed for predicting clinically significant bleeding events during follow-up (primary endpoint) and a composite endpoint of significant hemorrhage plus all-cause mortality (secondary endpoint), incorporating the following variables: age, diabetes mellitus, arterial hypertension, smoking habits, blood urea nitrogen, glomerular filtration rate and hemoglobin at admission, history of stroke, bleeding during hospitalization or previous major bleeding, heart failure during hospitalization and anti-thrombotic therapies prescribed at discharge. The BLEED-MI model was tested for calibration, accuracy and discrimination in the derivation sample and in a new, independent, validation cohort comprising 852 patients admitted at a later date.

RESULTS: The BLEED-MI score showed good calibration in both derivation and validation samples (Hosmer-Lemeshow test P value 0.371 and 0.444, respectively) and high accuracy within each individual patient (Brier score 0.061 and 0.067, respectively). Its discriminative performance in predicting the primary outcome was relatively high (c-statistic of 0.753 ± 0.032 in the derivation cohort and 0.718 ± 0.033 in the validation sample). Incidence of primary/secondary endpoints increased progressively with increasing BLEED-MI scores. In the validation sample, a BLEED-MI score below 2 had a negative predictive value of 98.7% (152/154) for the occurrence of a clinically significant hemorrhagic episode during follow-up and for the composite endpoint of post-discharge hemorrhage plus all-cause mortality. An accurate prediction of bleeding events was shown independently of mortality, as BLEED-MI predicted bleeding with similar efficacy in patients who did not die during follow-up: Area Under the Curve 0.703, Hosmer-Lemeshow test P value 0.547, Brier score 0.060; low-risk (BLEED-MI score 0-3) event rate: 1.2%; intermediate risk (score 4-6) event rate: 5.6%; high risk (score ≥ 7) event rate: 12.5%.

CONCLUSION: A new bedside prediction-scoring model for post-discharge mid-term bleeding has been derived and preliminarily validated. This is the first score designed to predict mid- term hemorrhagic risk in patients discharged following admission for acute MI. This model should be externally validated in larger cohorts of patients before its potential implementation.

Overview of resistant hypertension: A glimpse of the cardiologist's current standpoint

Hypertension is a major risk factor for cardiovascular disease, resulting in increased incidence of cerebrovascular events, ischaemic heart disease, heart failure, and renal impairment. Thus, it is one of the most important preventable causes of premature morbidity and mortality. Despite current knowledge on the management of hypertension and the availability of several effective antihypertensive medications, uncontrolled hypertension remains a common and challenging clinical problem. Resistant hypertension is a complex condition with multiple contributing factors and overlapping comorbidities. Although there is limited hard evidence regarding resistant hypertension, our understanding of this condition has improved recently. This article will present an overview of resistant hypertension and highlight recent publications about this topic.

Expression of apoptosis-regulating genes in the rat prostate following botulinum toxin type A injection

Background

Onabotulinumtoxin A (OnabotA) injection has been investigated as a novel treatment for benign prostatic enlargement caused by benign prostatic hyperplasia. An OnabotA - induced volume reduction caused by sympathetic fibers impairment has been proposed as a potential mechanism of action. Our aim was to investigate the expression of apoptosis-regulating proteins in the rat prostate following OnabotA intraprostatic injection.

Methods

Adult Wistar rats were injected in the ventral lobes of the prostate with 10 U of OnabotA or saline. A set of OnabotA-injected animals was further treated with 0.5 mg/kg of phenylephrine (PHE) subcutaneously daily. All animals were sacrificed after 1 week and had their prostates harvested. Immunohistochemical staining was performed for Bax, Bcl-xL and caspase-3 proteins and visualized by the avidin-biotin method. The optical density of the glandular cells was also determined, with measurement of differences between average optical densities for each group.

Results

Saline-treated animals showed intense epithelial staining for Bcl-xL and a faint labelling for both Bax and Caspase-3. OnabotA-treated rats showed a reduced epithelial staining of Bcl-xL and a consistently increased Bax and Caspase-3 staining when compared with saline-treated animals. PHE-treated animals showed a stronger Bcl-xL staining and reduced staining of both Bax and Caspase-3 when compared to the OnabotA group. Mean signal intensity measurements for each immunoreaction confirmed a significant decrease of the signal intensity for Bcl-xL and a significant increase of the signal intensity for Bax and Caspase 3 in OnabotA-injected animals when compared with the control group. In OnabotA+PHE treated animals mean signal intensity for Bcl-xL, Bax and Caspase 3 immunoreactions was identical to that of the control animals.

Conclusions

These results support the hypothesis that OnabotA activates apoptotic pathways in the rat prostate through a mechanism that involves sympathetic outflow impairment.