Emergency department triage of acute heart failure triggered by pneumonia; when an intensive care unit is needed?

Community acquired pneumonia (CAP) is a frequent triggering factor for decompensation of a chronic cardiac dysfunction, leading to acute heart failure (AHF). Patients with AHF exacerbated by CAP, are often admitted through the emergency department for ICU hospitalization, even though more than half the cases do not warrant any intensive care treatment. Emergency department physicians are forced to make disposition decisions based on subjective criteria, due to lack of evidence-based risk scores for AHF combined with CAP. Currently, the available risk models refer distinctly to either AHF or CAP patients. Extrapolation of data by arbitrarily combining these models, is not validated and can be treacherous. Examples of attempts to apply acuity scales provenient from different disciplines and the resulting discrepancies, are given in this review. There is a need for severity classification tools especially elaborated for use in the emergency department, applicable to patients with mixed AHF and CAP, in order to rationalize the ICU dispositions. This is bound to facilitate the efforts to save both lives and resources.

Myocardial deformation imaging unmasks subtle left ventricular systolic dysfunction in asymptomatic and treatment-naïve HIV patients.

BACKGROUND: Patients infected by the human immunodeficiency virus (HIV) and receiving highly active antiretroviral therapy have a higher incidence of cardiovascular disease than healthy subjects, but little is known about cardiac function in asymptomatic and treatment-naïve patients. We sought to study cardiac function in asymptomatic HIV-infected, treatment-naïve patients. METHODS: We studied 41 HIV-infected and treatment-naïve patients and 20 age- and sex-matched healthy controls. Patients with cardiac symptoms, history of cardiac disease or NT-proBNP >100 pg/mL were excluded. We addressed cardiac function using standard echocardiography along with tissue Doppler (TDI) measurements, including strain/strain rate assessment. RESULTS: Standard echocardiographic parameters did not differ between groups, except for transmitral E wave velocity (64.8 ± 14 cm/s in HIV vs 76.1 ± 10 cm/s in controls, p = 0.002). In contrast, TDI mitral and tricuspid annulus s velocity and all strain/strain rate measurements were significantly lower in HIV patients: s lateral, 10.2 ± 2.4/11.3 ± 0.7, p = 0.011; s septal, 8.1 ± 1.6/8.7 ± 0.8, p = 0.045; s tricuspid, 13.4 ± 2.3/14.9 ± 1.3, p = 0.002; strain/strain rate, septal (strain/strain rate, 15.1 ± 5.7/-0.9 ± 0.3, 25.3 ± 1.7/-1.9 ± 0.2, p < 0.001), anterior (16.7 ± 3/-1.0 ± 0.1, 26.7 ± 1.7/-1.9 ± 0.2, p < 0.001), lateral (16.0 ± 6/-1.0 ± 0.1, 27.5 ± 1.8/-2.2 ± 0.3, p < 0.001) and posterior (15.2 ± 5.8/-1.0 ± 0.2, 26.2 ± 1.8/-2.2 ± 0.3, p < 0.001) left ventricular wall. CONCLUSIONS: HIV infection itself is accompanied by subclinical systolic dysfunction, not apparent to standard echocardiography that can be unmasked though using sensitive echocardiographic techniques.

Transient reverse takotsubo cardiomyopathy following a spider bite in Greece: a case report.

Black widow spider is endemic in the Mediterranean area and although envenomations are rare, may occasionally lead to death. We present a case of a 64-year-old female developing a rare variant of takotsubo, stress-induced, cardiomyopathy after a spider bite. This resulted in acute heart failure within 24  hours of the bite. With medical treatment and supportive care, the patient's clinical condition improved. Reverse takotsubo cardiomyopathy was diagnosed by echocardiography, which was transient. Clinical and echocardiographic findings have been completely resolved on follow-up 46 days later. Reverse takotsubo cardiomyopathy has not been yet described following a spider bite. Doctors in the emergency department of endemic countries should be familiar with this potential complication.

The role of the immunogenetic background in the development and recurrence of acute idiopathic pericarditis.

OBJECTIVES: We assessed the role of the immunogenetic background in the development and recurrence of acute idiopathic pericarditis (AIP). METHODS: Fifty-five patients with a first episode of AIP were followed for 23.8 ± 6.3 months and recurrences were recorded. The control group consisted of 246 healthy individuals. In all subjects, genomic human leukocyte antigen (HLA) typing was performed. Moreover, circulating lymphocyte subpopulations were studied in 44 randomly selected patients and in 20 controls. RESULTS: An increased frequency of HLA-A*02, -Cw*07 and -DQB1*0202 alleles, and a decreased frequency of the -DQB1*0302 allele was detected in patients with AIP. The recurrence rate was 40% and time to recurrence was 202.8 ± 164.1 days. In patients with idiopathic recurrent pericarditis (RP), increased frequencies of HLA-A*02, -Cw*07 and -DQB1*0202 alleles were found. Notably, no patient with RP exhibited HLA-DRB1*04 and -DQB1*0302 alleles. Patients with RP exhibited lower CD4+/CD45RA+ naïve T cells (p = 0.03) than controls, and higher CD8+DR+ activated T cells (p = 0.01) than patients without recurrence and controls. CONCLUSIONS: HLA alleles may confer either susceptibility or resistance to AIP and RP. Circulating T-cell subpopulations may also predict RP. A combination of the above parameters might help to better define patients prone to recurrence.

The impact of positive airway pressure on cardiac status and clinical outcomes in patients with advanced heart failure and sleep-disordered breathing: a preliminary report.

INTRODUCTION: Heart failure (HF) is a major public health problem associated with high rates of morbidity and mortality. Patients with HF exhibit a high prevalence of sleep-disordered breathing (SDB). We have investigated the long-term impact of positive airway pressure (PAP) therapy on heart function and clinical outcomes in patients with advanced HF and concomitant SDB. MATERIALS AND METHODS: We assessed 18 patients with advanced HF (New York Heart Association (NYHA) functional classification III-IV) and concomitant SDB (diagnosed with polysomnography) either of obstructive or central type. Eleven patients who received PAP therapy (auto-titrating PAP or adaptive servo-ventilation) for 12 months were compared with seven patients who refused this therapy. All participants were assessed at both baseline and end of follow-up for NYHA functional status, left and right ventricular function, neurohormonal activation, and exercise tolerance. The rates of hospitalization, deaths, and the combination of both were also recorded. RESULTS: Patients treated with PAP achieved better functional status, higher left ventricular ejection fraction, improved longitudinal right ventricular contractile function, lower levels of b-type natriuretic peptide, and greater exercise performance compared to those who remained untreated. PAP-treated group had a significantly lower incidence of the prespecified combined end-point (i.e., hospital admissions and death) than the control group (87.5 vs. 18.2%, p = 0.013). Interestingly, the mortality rate was 28% (two out of seven patients) in the control group, while no deaths were recorded in the PAP-treated group. DISCUSSION: In this preliminary study, we found that treatment of SDB, irrespective of type, in stable patients with advanced HF receiving optimal medical therapy was associated with improvement in cardiac functional status, ventricular contraction, physical performance, and neurohormonal status, leading to better clinical outcomes.

Doppler tissue imaging unmasks right ventricular function abnormalities in HIV-infected patients.

BACKGROUND: We sought to investigate right ventricular (RV) function with Doppler tissue imaging (DTI) in human immunodeficiency virus (HIV)-infected patients receiving highly-active antiretroviral treatment, without any heart-related symptoms. METHODS: We studied 38 asymptomatic HIV patients (aged 44.5 ± 9.2 years, 22 of them men) and 25 age-matched and sex-matched controls. All subjects underwent conventional and DTI estimation of left ventricular (LV) systolic and diastolic function, measuring peak systolic and diastolic myocardial velocities at the mitral annulus (Sm, Em, Am). Two-dimensional (2-D) echocardiographic study of the right ventricle (RV) was performed from the four-chamber view, and RV end-diastolic dimensions were measured. DTI recordings from the RV free wall at the tricuspid annulus were used to determine systolic (SmRV) and diastolic function (EmRV and AmRV). RESULTS: HIV-infected patients compared to controls exhibited significantly lower peak systolic velocities at the septal-SmIVS (7.9 ± 1.3 vs 9.1 ± 1.4 cm/s, p = 0.002) and lateral mitral annulus - SmLAT (9.8 ± 1.7 vs 11.2 ± 1.3 cm/s, p = 0.025); no difference was observed regarding conventional 2-D examination of LV systolic and diastolic function and DTI-derived Em and Am. No significant difference occurred between HIV patients and controls regarding RV end-diastolic dimensions and pulmonary artery systolic pressure. However, SmRV (13.8 ± 1.6 vs 14.9 ± 2.2 cm/s, p = 0.040), EmRV (11.6 ± 3 vs 13.5 ± 2.6 cm/s, p = 0.028) and AmRV (10.9 ± 2.5 vs 13.8 ± 4 cm/s, p = 0.003) were significantly reduced in HIV patients as compared to controls. CONCLUSIONS: DTI unmasks subtle and otherwise undetectable abnormalities of the longitudinal LV systolic function and both RV systolic and diastolic function, in asymptomatic HIV patients receiving highly-active antiretroviral treatment.

Functional electrical stimulation of lower limbs in patients with chronic heart failure.

Physical training is an important component of therapy for patients with chronic heart failure (CHF) and is considered complementary to their pharmacological treatment. The majority of conventional rehabilitation programs include aerobic training, which has been demonstrated to induce significant beneficial effects on the neurohumoral, immunoreactive and functional status of patients with moderate CHF. Functional electrical stimulation (FES) of skeletal muscles constitutes an alternative training mode with beneficial effects comparable to classical aerobic exercise, suitable for patients with CHF who cannot participate in traditional training programs due to either advanced grades of CHF or the presence of comorbidities. We present a review of the numerous studies evaluating the effects of FES in CHF, focusing on its main effects on skeletal myopathy reversal, exercise tolerance improvement and quality of life modification.

Functional electrical stimulation is more effective in severe symptomatic heart failure patients and improves their adherence to rehabilitation programs.

BACKGROUND: Functional electrical stimulation (FES) improves exercise capacity and quality of life in chronic heart failure (CHF) patients. However, there is no evidence regarding the effectiveness of this treatment modality according to the severity of CHF. This study compares the effectiveness of FES on exercise capacity, endothelial function, neurohormonal status, and emotional stress in New York Heart Association (NYHA) III-IV versus NYHA II patients. METHODS AND RESULTS: Eighteen NYHA II and 13 age- and sex-matched NYHA III-IV patients with stable CHF (left ventricular ejection fraction <35%) underwent a 6-week FES training program. Questionnaires addressing quality of life (Kansas City Cardiomyopathy Questionnaire, functional and overall), and emotional stress (Zung self-rating depression scale, Beck Depression Inventory), as well as plasma B-type natriuretic peptide (BNP), 6-minute walking distance test (6MWT), and endothelial function (flow-mediated dilatation [FMD]) were assessed at baseline and after completion of training protocol. 6MWT and plasma BNP improved significantly in 2 patient groups (both P < .001) after training program. The improvement of BNP was statistically greater in NYHA III-IV patients posttreatment than in those with NYHA II class (F=315.342, P < .001). Similarly, the improvement of 6MWT was statistically greater in NYHA III-IV group than in NYHA II patients (F=79.818, P < .001). Finally, an FES-induced greater improvement of FMD (F=9.517, P=.004) and emotional stress scores was observed in NYHA III-IV patients in comparison to NYHA II patients. There was a higher proportion of NYHA III-IV patients adhering to the FES training program for additional 3 months compared with the NYHA II group of patients (76.9% vs. 55.6%, P < .001). CONCLUSION: FES might exert a greater beneficial effect on clinical and neurohormonal status of NYHA III-IV patients in comparison to NYHA II patients. This effect may have important clinical relevance leading to increased adherence of severe CHF patients to exercise rehabilitation programs.

Effects of functional electrical stimulation on quality of life and emotional stress in patients with chronic heart failure secondary to ischaemic or idiopathic dilated cardiomyopathy: a randomised, placebo-controlled trial.

OBJECTIVE: Functional electrical stimulation (FES) improves exercise capacity and endothelial function in chronic heart failure (CHF) patients. This study evaluates the impact of FES on quality of life and emotional stress in patients with moderate to severe CHF. METHODS: Thirty patients with stable CHF (24 men; NYHA class II-III; left ventricular ejection fraction <35%) were randomly assigned (2:1) to a 6-week FES training program (n=20) or placebo (n=10). Questionnaires addressing quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ), functional and overall], and emotional stress [Zung self-rating depression scale (SDS), Beck Depression Inventory (BDI)], as well as plasma B-type natriuretic peptide (BNP) and 6-min walking distance test (6MWT) were assessed at baseline and after completion of training protocol. RESULTS: A significant improvement in KCCQ functional (F=76.666, p<0.001), KCCQ overall (F =41.508, p<0.001), BDI (F =17.768, p<0.001) and Zung SDS (F =27.098, p<0.001) was observed in the FES group compared to placebo. Patients in the FES group had also a significant increase in 6MWT (F =19.413, p<0.001) and a trend towards reduction in plasma BNP (F =4.252, p=0.053) compared to placebo. CONCLUSION: FES seems to have a beneficial effect on quality of life, exercise capacity and emotional stress in patients with moderate to severe CHF.

Assessment of cardiac function with Doppler tissue imaging in asymptomatic HIV-infected patients.

Doppler tissue imaging (DTI) is a useful tool for the detection of subtle systolic function abnormalities related to the longitudinal contraction. We assessed left ventricular (LV) systolic function with DTI in 45 human immunodeficiency virus (HIV)-infected patients without any heart-related symptoms and in 30 healthy control subjects. Although conventional echocardiography showed no differences between groups, DTI revealed lower peak systolic velocities in group A patients when compared with group B ones (Sms: 8.84+/-0.94 cm/s vs. 9.42+/-0.84 cm/s, respectively, P<0.001 and Sml: 9.58+/-1.86 cm/s vs. 10.78+/-2.07 cm/s P=0.003). In group A patients, both peak systolic myocardial velocities at the septal (Sms) and lateral mitral annulus (Sml) correlated with CD4 lymphocyte count (P = 0.034 and 0.009, respectively). We conclude that pulse wave DTI reveals subtle and non-otherwise detectable abnormalities of the longitudinal LV contractile function in asymptomatic patients with positive HIV serology. DTI study should potentially be expanded in the population of HIV-infected patients, aiming at an early identification of LV systolic dysfunction.

Physical activity status and acute coronary syndromes survival The GREECS (Greek Study of Acute Coronary Syndromes) study.

OBJECTIVES: We sought to evaluate the association between physical activity levels and the clinical outcome at presentation, as well as the 30-day prognosis of hospitalized patients with acute coronary syndromes (ACS). BACKGROUND: Regular physical activity has been associated with decreased risk of coronary heart disease. However, less is known about the effects of life-long physical activity on ACS prognosis. METHODS: From October 2003 to September 2004, a sample of 6 hospitals located in urban and rural Greek regions were selected, and almost all of their ACS patients were enrolled into the study (2,172 patients were included in the study; 76% men and 24% women). Logistic regression models were applied to evaluate the effect of physical activity status (as assessed using the International Physical Activity Questionnaire) on in-hospital mortality and the 30-day outcome of cardiovascular events (death or rehospitalization due to cardiovascular disease). RESULTS: An inverse association was observed between the level of physical activity and troponin I levels at presentation (p = 0.01). Moreover, after taking into account various potential confounders, physical activity was associated with a 0.56-fold (95% confidence interval [CI] 0.32 to 0.90) lower odds of in-hospital mortality and a 0.80-fold (95% CI 0.50 to 0.99) lower odds of cardiovascular events within the first month after discharge. CONCLUSION: In conclusion, physical activity is associated with a reduced severity of ACS, reduced in-hospital mortality rates, and improved short-term prognosis.

Clinical value of B-type natriuretic peptide for the assessment of left ventricular filling pressures in patients with systolic heart failure and inconclusive tissue Doppler indexes.

Invasive hemodynamic monitoring with Swan-Ganz catheterization to guide treatment decisions in heart failure may be hazardous and may lack prognostic value. We assessed the clinical utility of B-type natriuretic peptide (BNP) in estimating left ventricular filling pressures in patients with inconclusive tissue Doppler indexes. In this study, 50 patients with systolic heart failure and an early transmitral velocity to early diastolic mitral annular velocity ratio (E/Ea) between 8 and 15 were studied. Among them, 25 had been admitted for acutely decompensated heart failure (group A) and the remainder were clinically stable outpatients (group B). All patients underwent simultaneous invasive pulmonary capillary wedge pressure (PCWP) determination, BNP measurement, and echocardiography. In group A, BNP correlated with PCWP (r = 0.803, P < 0.001), deceleration time (DT, r = -0.602, p = 0.001), and end-systolic wall stress (SWS, r = 0.565, P = 0.003). In multivariate analysis, BNP was the only parameter independently associated with PCWP (P = 0.023). In group B, no correlation was found between BNP and PCWP or SWS, while DT correlated significantly with both PCWP (r = -0.817, P < 0.001) and BNP (r = -0.8, P < 0.001). We conclude that BNP may be a useful noninvasive tool for the assessment of left ventricular filling pressures in patients with acutely decompensated heart failure and inconclusive tissue Doppler indexes.

Effects of levosimendan on flow-mediated vasodilation and soluble adhesion molecules in patients with advanced chronic heart failure.

AIM: Endothelial activation and dysfunction may be an important contributor to chronic heart failure (CHF) progression. We sought to investigate whether the calcium sensitizer levosimendan affects beneficially endothelial function and attenuates the deleterious effects of soluble adhesion molecules in patients with advanced CHF. METHODS: Twenty-six advanced CHF patients (mean New York Heart Association class, 2.6+/-0.3; ischemic/dilated, 18/8; mean left ventricular ejection fraction <35%) hospitalized due to syndrome worsening, were randomized (2:1) to receive either a 24-h levosimendan infusion of 0.1 microg/kg/min (n=17) or placebo (n=9). Endothelial function estimated by endothelial-dependent flow-mediated dilatation of the brachial artery (FMD), as well as plasma soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1), were assessed before and 48 h after therapy. RESULTS: Baseline characteristics and medications were well balanced in the two treatment groups. A significant improvement of FMD (6.4+/-4.4% from 4.8+/-3.0%; p<0.05) with concomitant reduction of plasma concentrations of sICAM-1 (231+/-75 pg/ml from 339+/-157 pg/ml; p<0.05) and sVCAM-1 (1134+/-508 pg/ml from 1386+/-602 pg/ml; p<0.05) were observed only in levosimendan treated patients. CONCLUSION: Levosimendan could be an effective treatment in improving the endothelial function and reducing the detrimental adhesion molecule activation in advanced CHF patients.

Changes in coronary flow reserve following stent implantation in the swine descending thoracic aorta.

PURPOSE: To evaluate coronary flow reserve (CFR) changes following stent implantation in the descending thoracic aorta (DTA) of a porcine model. METHODS: Six pigs (3 males; 40 to 44 kg) were anesthetized and kept on mechanical ventilation. A 6-F guiding right Judkins catheter was advanced under fluoroscopy to the right coronary artery, and a pressure wire with a temperature sensor was placed within the vessel lumen at a distance of 4 cm from the ostium. CFR was estimated by the thermodilution method before and after maximal coronary vasodilation with 20 mg of intracoronary papaverine. Aortography was also performed to measure aortic diameter. Subsequently, a self-expanding vascular stent was deployed into the DTA just below the left subclavian artery (LSA), and CFR was measured again. All animals were maintained for 3 weeks; at the end of this period, a further CFR was calculated using the same procedure. RESULTS: The mean aortic diameter below the LSA was 12.15+/-0.15 mm. Following stent deployment, the mean aortic diameter measured at the stented segment was 12.58+/-0.11 (p=0.001 versus baseline). The mean CFR value was 4.70+/-2.00 before stent implantation, 2.68+/-0.86 immediately after, and 4.05+/-1.15 at 3 weeks after stenting. Accordingly, CFR values were significantly depressed immediately after stent placement compared with baseline (p=0.027). However, CFR values obtained 3 weeks following stent deployment were similar to the initial values (p=0.59). CONCLUSION: Stent deployment in the normal swine DTA produces a significant immediate decrease in CFR, which is attenuated 3 weeks later. The clinical impact of CFR changes following DTA endografting remain to be elucidated.

Esmolol facilitated extubation in a patient with severe systolic dysfunction following myocardial infarction.

We describe the case of a 59-year-old-man with acute myocardial infarction and severely impaired left ventricular systolic function who was intubated because of recurrent ventricular fibrillation in the setting of coronary angioplasty. Repeated ventilator weaning attempts and extubation initially failed, as severe tachycardia and hypertension occurred each time the patient began to awaken. Pre-treatment with esmolol infusion prevented the above haemodynamic changes, allowing successful extubation. Esmolol administration at ventilator weaning seems to be a safe and effective option, even in selected patients with impaired left ventricular contractility.

Short-term depressive symptoms and 30-day prognosis of hospitalized patients with acute coronary syndromes; the Greek study of acute coronary syndromes (GREECS).

AIMS: We evaluated whether short-term depressive symptoms are associated with the 30-day prognosis of hospitalized patients presented with acute coronary syndromes (ACS). METHODS: A sample of 6 hospitals located in Greek urban and rural regions was selected. From October 2003 to September 2004, we recorded the non-fatal admissions of ACS. Assessment of depressive symptoms, during past month, was based on the CES-D scale (Radloff S., 1977). RESULTS: 2172 patients were included in the study (1649, 76% were males). The mean CES-D score was 13.5+/-12 in male patients and 13.6+/-12 in females (p=0.89). Compared to patients with angina those who had non-Q-wave MI or Q-wave MI had higher CES-D score (12.3+/-11.6 vs. 15.3+/-12.8 vs. 13.2+/-11.9, p=0.001). The number of events during the first 30-day following discharge was 9.2% in males and 9.7% in females. Multivariable logistic regression analysis revealed that 1-unit increase in CES-D was associated with 10% higher odds (95% CI 1.09-1.12) of re-current events (death or re-hospitalization), after adjusting for various socio-demographic, lifestyle and clinical factors. CONCLUSION: We revealed that short-term depressive symptoms are related to more severe disease and a worsen 30-day prognosis of patients hospitalized for ACS.

The relationship between adherence to the Mediterranean diet and the severity and short-term prognosis of acute coronary syndromes (ACS): The Greek Study of ACS (The GREECS).

BACKGROUND: Although adherence to the Mediterranean diet has long been associated with lower incidence of various chronic diseases among apparently healthy individuals, its relationship with the severity and short prognosis (30 d) of patients with cardiovascular disease has rarely been investigated. OBJECTIVE: We sought to evaluate the association between adherence to the Mediterranean diet and the severity and prognosis of acute coronary syndromes. METHODS: From October 2003 to September 2004, a sample of 6 hospitals located in several urban and rural Greek regions was selected, and almost all survivors after an acute coronary syndrome were enrolled into the study (2172 patients were included in the study; 76% were men and 24% women). Adherence to the Mediterranean diet was assessed by a diet score that incorporated the inherent characteristics of this diet. Higher values of the score (range 0-55) were closer to the Mediterranean diet. Biochemical indices of myocardial damage were also considered. RESULTS: Diet score was inversely correlated with entry values of cardiac troponin I (rho = -0.19, P < 0.001), creatine phosphokinase (rho = -0.09, P < 0.001), and creatine phosphokinase-MB (rho = -0.09, P < 0.001). An increment in the diet score was associated with significant decrease in troponin I and creatine phosphokinase-MB levels (P < 0.01) after adjusting for various potential confounders. Moreover, diet score was associated with lower risk of recurrent events (odds ratio = 0.81, 95% confidence interval 0.61-0.98). However, this association became insignificant when the discharge diagnosis of the patients was taken into account. CONCLUSION: Background dietary habits close to the Mediterranean diet seem to be associated with lower severity of coronary heart disease.

Predictive value of C-reactive protein and left ventricular diastolic filling pattern after a non-ST elevation myocardial infarction.

BACKGROUND: Recent studies have shown that the odds ratio for high-sensitivity C-reactive protein (CRP) in predicting a coronary events in healthy subjects is 1.4, a value substantially less than previously reported. It is unclear whether this extends to acute coronary syndrome patients or if CRP would predict long-term events in this population. We evaluated the predictive value of CRP in patients with non-ST segment elevation myocardial infarction (NSTEMI) as their first manifestation of coronary artery disease and compared it with that of left ventricle diastolic function. METHODS: Serum CRP concentration measurement and left ventricle diastolic function evaluation were performed in 51 consecutive patients with NSTEMI 48 hours, 3 months, and 6 months after infarction. Patients were followed for 1 year and events comprising the endpoints of death, new myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting were reported. RESULTS: Thirty of 51 patients developed the endpoints. Mean CRP concentration in patients who developed any endpoint and those who did not was similar at 48 hours, 3 months, and 6 months. A strong correlation between the presence of impaired relaxation 6 months after the infarction and development of the combined endpoints was noted (P < 0.001). CONCLUSION: CRP has limited value in predicting future cardiovascular events in subjects with NSTEMI. Other biomarkers or a combination of other biomarkers may be needed to identify patients at high risk. Evaluation of diastolic left ventricular function not during the acute phase but 6 months later could predict adverse outcome in our series.