Does high sensitivity troponin add prognostic value to validated risk scores to predict in-hospital mortality in patients with acute heart failure?

Troponin elevation correlates with an increased short and long-term mortality in patients with acute decompensated heart failure (AHF). However, it has not been included in the development of multiple validated predictive models of mortality. We aim to  determine whether the addition of high-sensitivity troponin T (hs-TnT) to clinical risk scores improves the prediction of in-hospital mortality in patients with AHF. A retrospective analysis of a prospective and consecutive cohort was performed. Adult patients hospitalized between 2015 and 2019 with a primary diagnosis of AHF were included. Hs-TnT was measured on admission. OPTIMIZE-HF, GWTG-HF, and ADHERE risks score were calculated for each patient. The primary endpoint was all-cause in-hospital mortality. Discrimination of isolated hs-TnT and the risk scores with and without the addition of hs-TnT were evaluated using the area under the ROC curve (AUC-ROC). A subanalysis was performed according to left ventricular ejection fraction (LVEF). Of 712 patients, 562 (79%) had hs-TnT measurement upon admission, and was elevated in 91%. In-hospital mortality was 8.7% (n = 49). The AUC-ROC was 0.70 (95% CI 0.63-0.77) for isolated hs-TnT, and 0.80 (0.74-0.87), 0.79 (0.72 -0.86) and 0.79 (0.71-0.86) for the OPTIMIZE-HF, GWTG-HF and ADHERE scores, respectively. The addition of hs-TnT to the models did not increase the AUC: 0.72 (0.66-0.79) for the OPTIMIZE-HF + hs-TnT score (difference between AUC - 0.08 p = 0.04), 0.74 (0.68-0.80) for GWTG-HF (difference between AUC-0.04, p = 0.2) and 0.7 (0.63-0.77) for ADHERE (difference between AUC - 0.085 p = 0.07). The models presented good calibration (p > 0.05). In the sub-analysis, no differences were found between risk scores with the addition of hs-TnT in the population with LVEF < 40% and ≥ 40%. Elevated hs-TnT on admission was frequent and its incorporation into the validated risk scores did not prove an incremental prognostic benefit in patients hospitalized for AHF, regardless of LVEF. Isolated hs-TnT had a modest ability to predict hospital mortality. Additional prospective studies are needed to validate these findings.

Is the Obesity Paradox in Cardiac Surgery Really a Myth? Effect of Body Mass Index on Early and Late Clinical Outcomes.

OBJECTIVE: The present study was conducted to investigate the obesity paradox and assess the effect of body mass index (BMI) on early and late clinical outcomes after cardiac surgery. DESIGN: Cohort study with a retrospective analysis of prospectively collected data. DESIGN: Single-institution cardiology medical center. PARTICIPANTS: The study comprised consecutive patients undergoing cardiac surgery from January 2009 to January 2019. Patients were divided into the following 4 groups defined by BMI: underweight (UW) (≤18.5 kg/m2): 0.5%, n = 27; normal weight (18.5-25 kg/m2): 25.7%, n = 1,393; overweight (OW) (>25-30 kg/m2): 44.7%, n = 2,423; and obese (OB) (≥30 kg/m2): 29.1%, n = 1,576. INTERVENTIONS: No interventions. MEASUREMENTS AND MAIN RESULTS: A multivariate analysis was used to compare clinical outcomes among the different BMI groups. Overall 1-year survival of patients in the BMI categories was determined by the Kaplan-Meier method and compared using the log rank test. The study included 5,419 patients. The BMI groups were significantly different regarding presurgical variables. Mortality according to BMI exhibited a reverse J-shaped relationship: 7.4% in the UW group, 5.2% in the normal weight group, 3.2% in the OW group, and 4.3% in the OB group (p = 0.016). Low- cardiac- output syndrome and bleeding were more frequent in the UW group, whereas mediastinitis and hyperglycemia were more common in the OB group. After adjusting for other risk factors, BMI was not an independent predictor of in-hospital mortality. One-year follow-up was completed in 95% of the patients, and the analysis of long-term mortality did not show a difference among the BMI categories (p log rank = 0.16). CONCLUSION: OW patients had a lower mortality and better outcomes after cardiac surgery. However, when other preoperative variables were taken into account, BMI did not have independent effect on in-hospital and 1-year mortality.

[Electrocardiographic differences between apical hypertrophic cardiomyopathy and apical non-ST segment myocardial infarction]. / Diferencias electrocardiográficas en miocardiopatía hipertrófica apical e infarto apical sin elevación del segmento ST.

Apocal hypertrophic cardiomyopathy (AHCM) is a phenotypic variant within hypertrophic cardiomyopathies, in which ventricular repolarization alterations are present. These electrocardiographic disturbances can mimic an anterior infarction which triggers a series of studies and treatments that may be unnecessary. The aim of this study was to describe and compare electrocardiographic differences in a series of patients with AHCM and apical non-ST segment elevation myocardial infarction in patients (NSTEMI) with T-wave changes. We conducted an observational and retrospective study, including patients with diagnosed AHCM (N = 19) and apical NSTEMI (N = 19) with negative T waves in V1 and V6 lead of the EKG. Those with AHCM presented higher T-wave voltage (7 mV vs. 5 mV, p = 0.001) and peak voltage (29 mV vs. 17 mV, p = 0.003), higher R-waves (25 mV vs. 10 mV, p = 0.0001), and a maximum voltage of R and T sum (R + T) significantly higher (33 vs. 14, p = 0.00001). They also showed a greater T-wave asymmetry, with a TiTp / TpTf ratio > 1. At a cut-off value of 26.5 mV for the R + T variable, 68% sensitivity and 100% specificity were obtained to diagnose AHCM. This study shows the existence of major differences in electrocardiographic presentation of AHCM and apical NSTEMI.

Diferencias electrocardiográficas en miocardiopatía hipertrófica apical e infarto apical sin elevación del segmento ST / Electrocardiographic differences between apical hypertrophic cardiomyopathy and apical non-ST segment myocardial infarction

La miocardiopatía hipertrófica apical (MCHA) es una variante fenotípica dentro de las miocardiopatías hipertróficas que presenta alteraciones de la repolarización ventricular. Estos cambios electrocardiográficos pueden simular en muchos casos un infarto anterior, lo que dispara una serie de estudios y tratamientos que pueden ser innecesarios. El objetivo del trabajo fue describir y comparar las diferencias electrocardiográficas en una serie de pacientes con MCHA e infarto sin elevación del ST apicales (IAMSESTa) que presenten cambios tipo T en el electrocardiograma (ECG). Se realizó un estudio observacional y retrospectivo, incluyendo pacientes con diagnóstico de MCHA (n = 19) e IAMSESTa (n = 19) con ondas T negativas en ECG de ingreso en derivaciones V1-V6. Se excluyeron aquellos con MCHA y enfermedad coronaria asociada. Se analizaron las características clínicas y electrocardiográficas entre ambos grupos. Los pacientes con MCHA presentaron mayor voltaje de ondas T (7 mV vs. 5 mV; p = 0.001) y sumatoria de voltaje de las mismas (29 mV vs. 17 mV; p = 0.003), mayor voltaje de ondas R (25 mV vs. 10 mV; p = 0.0001), con una sumatoria de máximo voltaje de R y T (R+T) significativamente mayor (33 vs. 14; p = 0.00001). Presentaron además mayor asimetría de las ondas T negativas, objetivado mediante una relación TiTp/TpTf > 1. Con un valor de corte de 26.5 mV para la variable R+T, se obtuvo un 68% de sensibilidad y 100% de especificidad para diagnosticar MCHA. El presente trabajo demuestra la existencia de diferencias en el patrón del ECG en MCHA e IAMSESTa.

Apocal hypertrophic cardiomyopathy (AHCM) is a phenotypic variant within hypertrophic cardiomyopathies, in which ventricular repolarization alterations are present. These electrocardiographic disturbances can mimic an anterior infarction which triggers a series of studies and treatments that may be unnecessary. The aim of this study was to describe and compare electrocardiographic differences in a series of patients with AHCM and apical non-ST segment elevation myocardial infarction in patients (NSTEMI) with T-wave changes. We conducted an observational and retrospective study, including patients with diagnosed AHCM (N = 19) and apical NSTEMI (N = 19) with negative T waves in V1 and V6 lead of the EKG. Those with AHCM presented higher T-wave voltage (7 mV vs. 5 mV, p = 0.001) and peak voltage (29 mV vs. 17 mV, p = 0.003), higher R-waves (25 mV vs. 10 mV, p = 0.0001), and a maximum voltage of R and T sum (R + T) significantly higher (33 vs. 14, p = 0.00001). They also showed a greater T-wave asymmetry, with a TiTp / TpTf ratio > 1. At a cut-off value of 26.5 mV for the R + T variable, 68% sensitivity and 100% specificity were obtained to diagnose AHCM. This study shows the existence of major differences in electrocardiographic presentation of AHCM and apical NSTEMI.