Effect of selected cardiovascular factors on mortality in patients with ST-segment elevation myocardial infarction treated with primary coronary intervention.

OBJECTIVE: This work was aimed at analyzing in-hospital, 30-day and 1-year mortality rates, impact of selected cardiovascular factors on mortality of patients with ST-segment elevation myocardial infarction (STEMI) manifested on electrocardiogram (ECG) and treated by the percutaneous coronary intervention (PCI) at our cardiac center, comparing the subgroup of non-shock (survivors and deceased) patients after STEMI and evaluating how these patients differ from each other. METHODS: In total, 270 patients with STEMI manifested on ECG and treated by PCI were enrolled between April 1, 2018, and March 31, 2019, at our cardiologic center. Our study sought to determine the risk of death after acute myocardial infarction with carefully selected factors and parameters such as the presence of cardiogenic shock, ischemic time, left ventricular ejection fraction (LVEF), post­PCI TIMI (thrombolysis in myocardial infarction) flow and serum levels of cardio­specific markers, namely troponin T, creatine kinase and N-terminal pro-brain natriuretic peptide (NT-proBNP). Further evaluation included in-hospital, 30-day and 1-year mortality rates in shock and non-shock patients and determination of factors that influence the survival separately in each subgroup. The follow-up was carried out for 12 months after the myocardial infarction in form of outpatient examinations. After 12 months of follow-up, the collected data were statistically evaluated. RESULTS: Shock and non-shock patients differed in mortality and several other parameters including NT-proBNP values, ischemic time, TIMI flow defect and LVEF. In all outcomes (in-hospital, 30-day and 1-year mortality rates) the shock patients did worse than non-shock patients (p < 0.001). In addition, age, gender, LVEF, NT-proBNP and post­PCI TIMI flow less than 3 were found to be important factors influencing the overall survival. In shock patients, the survival was associated with age, LVEF and TIMI flow, while in non-shock patients, the factors predicting survival were age, LVEF, level of NT-proBNP and troponin levels. CONCLUSION: Shock patients differed in terms of mortality in post-PCI TIMI flow, while non-shock patients varied in troponin and NT-proBNP levels. Despite early intervention, certain risk factors might affect the clinical outcome and prognosis of patients with STEMI treated by PCI (Tab. 5, Fig. 1, Ref. 30). Text in PDF www.elis.sk Keywords: myocardial infarction, primary coronary intervention, shock, mortality, cardio­specific markers.

Relation between Mid-Regional Pro-Adrenomedullin in Patients with Chronic Heart Failure and the Dose of Diuretics in 2-Year Follow-Up-Data from FAR NHL Registry.

Background and Objectives: The aim of this paper is to evaluate the impact of humoral substance mid-regional pro-adrenomedullin (MR-proADM) on the two-year survival of patients with chronic heart failure and relate it to the dosage of furosemide. Materials and Methods: The data is taken from the stable systolic heart failure (EF < 50%) FAR NHL registry (FARmacology and NeuroHumoraL activation). The primary endpoint at two-year follow-up was death, heart transplantation, or LVAD implantation. Results: A total of 1088 patients were enrolled in the FAR NHL registry; MR-proADM levels were available for 569 of them. The mean age was 65 years, and 81% were male. The aetiology of HF was ischemic heart disease in 53% and dilated cardiomyopathy in 41% of patients. The mean EF was 31 ± 9%. Statistically significant differences (p < 0.001) were obtained in several parameters: patients with higher MR-proADM levels were older, rated higher in NYHA class, suffered more often from lower limb oedema, and had more comorbidities such as hypertension, atrial fibrillation, diabetes, and renal impairment. MR-proADM level was related to furosemide dose. Patients taking higher doses of diuretics had higher MR-proADM levels. The mean MR-proADM level without furosemide (n = 122) was 0.62 (±0.55) nmol/L, with low dose (n = 113) 1−39 mg/day was 0.67 (±0.30) nmol/L, with mid dose (n = 202) 40−79 mg/day was 0.72 (±0.34) nmol/L, with high dose (n = 58) 80−119 mg/day was 0.85 (±0.40) nmol/L, and with maximum dose (n = 74) ≥120 mg/day was 1.07 (±0.76) nmol/L, p < 0.001. Patients with higher MR-proADM levels were more likely to achieve the primary endpoint at a two-year follow-up (p < 0.001) according to multivariant analysis. Conclusions: Elevated plasma MR-proADM levels in patients with chronic heart failure are associated with an increased risk of death and hospitalization. Higher MR-proADM levels in combination with increased use of loop diuretics reflect residual congestion and are associated with a higher risk of severe disease progression.

Prognostic value of high-sensitivity cardiac troponin I in heart failure patients with mid-range and reduced ejection fraction.

BACKGROUND: The identification of high-risk heart failure (HF) patients makes it possible to intensify their treatment. Our aim was to determine the prognostic value of a newly developed, high-sensitivity troponin I assay (Atellica®, Siemens Healthcare Diagnostics) for patients with HF with reduced ejection fraction (HFrEF; LVEF < 40%) and HF with mid-range EF (HFmrEF) (LVEF 40%-49%). METHODS AND RESULTS: A total of 520 patients with HFrEF and HFmrEF were enrolled in this study. Two-year all-cause mortality, heart transplantation, and/or left ventricular assist device implantation were defined as the primary endpoints (EP). A logistic regression analysis was used for the identification of predictors and development of multivariable models. The EP occurred in 14% of the patients, and these patients had higher NT-proBNP (1,950 vs. 518 ng/l; p < 0.001) and hs-cTnI (34 vs. 17 ng/l, p < 0.001) levels. C-statistics demonstrated that the optimal cut-off value for the hs-cTnI level was 17 ng/l (AUC 0.658, p < 0.001). Described by the AUC, the discriminatory power of the multivariable model (NYHA > II, NT-proBNP, hs-cTnI and urea) was 0.823 (p < 0.001). Including heart failure hospitalization as the component of the combined secondary endpoint leads to a diminished predictive power of increased hs-cTnI. CONCLUSION: hs-cTnI levels ≥ 17 ng/l represent an independent increased risk of an adverse prognosis for patients with HFrEF and HFmrEF. Determining a patient's hs-cTnI level adds prognostic value to NT-proBNP and clinical parameters.

Prognostic value of NT-proBNP added to clinical parameters to predict two-year prognosis of chronic heart failure patients with mid-range and reduced ejection fraction - A report from FAR NHL prospective registry.

BACKGROUND: According to guidelines, the prognosis of patients with chronic heart failure can be predicted by determining the levels of natriuretic peptides, the NYHA classification and comorbidities. The aim our work was to develop a prognostic score in chronic heart failure patients that would take account of patients' comorbidities, NYHA and NT-proBNP levels. METHODS AND RESULTS: A total of 1,088 patients with chronic heart failure with reduced ejection fraction (HFrEF) (LVEF<40%) and mid-range EF (HFmrEF) (LVEF 40-49%) were enrolled consecutively. Two-year all-cause mortality, heart transplantation and/or LVAD implantation were defined as the primary endpoint (EP). The occurrence of EP was 14.9% and grew with higher NYHA, namely 4.9% (NYHA I), 11.4% (NYHA II) and 27.8% (NYHA III-IV) (p<0.001). The occurrence of EP was 3%, 10% and 15-37% in patients with NT-proBNP levels ≤125 ng/L, 126-1000 ng/L and >1000 ng/L respectively. Discrimination abilities of NYHA and NT-proBNP were AUC 0.670 (p<0.001) and AUC 0.722 (p<0.001) respectively. The predictive value of the developed clinical model, which took account of older age, advanced heart failure (NYHA III+IV), anaemia, hyponatraemia, hyperuricaemia and being on a higher dose of furosemide (>40 mg daily) (AUC 0.773; p<0.001) was increased by adding the NT-proBNP level (AUC 0.790). CONCLUSION: The use of prediction models in patients with chronic heart failure, namely those taking account of natriuretic peptides, should become a standard in routine clinical practice. It might contribute to a better identification of a high-risk group of patients in which more intense treatment needs to be considered, such as heart transplantation or LVAD implantation.

Prescription and dosage of RAAS inhibitors in patients with chronic heart failure in the FAR NHL registry.

BACKGROUND: Congestive heart failure with reduced ejection fraction is a common clinical condition with a serious prognosis. Treatment focuses on improving the symptoms and preventing the progression of the disease. First-line therapy include angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs). METHODS: These data come from the FAR NHL registry (FARmacology and NeuroHumoraL activation). This is a multicenter database of patients with stable systolic heart failure (EF < 50 %) collected between November 2014 and November 2015. RESULTS: A population of 1 100 patients was evaluated, the mean age was 65 years, 80.8 % were male. The etiology of heart failure was ischemic heart disease (49.7 %), dilated cardiomyopathy (41.7 %) and other (8.6 %). The total prescription of ACEI/ARB was 88.4 %, the most commonly prescribed ACEI were ramipril and perindopril, ARB was losartan. The prescription of ACEI/ARBs decreased with the severity of the disease according to NYHA classification (all 88.4 %, NYHA I 95.2 %, NYHA II 89.0 %, NYHA III-IV 83.5 %, p < 0.001). 129 subjects (11.6 %) were not treated by ACEI/ARBs at all. The target dose of ACEI/ARB, as it is recommended in the ESC Guidelines, was admissioned to only 13.5 % of patients. The dose was decreasing with the severity of disease evaluated by NYHA, NT-proBNP value, systolic blood pressure and renal functions. CONCLUSIONS: These data show the tendency of pharmacological prescription of RAAS blockers (including doses), which reflects not only the severity of heart failure but also renal functions and blood pressure and points to possible reserves in up-titration of the target dose. Key words: angiotensin-converting enzyme inhibitors - angiotensin receptor blockers - FAR NHL - heart failure - pharmacotherapy - registry - target dose.

Renal Functions and Prognosis Stratification in Chronic Heart Failure Patients and the Importance of Neutrophil Gelatinase-Associated Lipocalin.

BACKGROUND/AIMS: The rate of incidence and prevalence of acute kidney injury is increasing due to an increased number of patients with heart failure. Therefore it is very pertinent to early detect the level of renal injuries and to make necessary heart failure predictions. Thus the aim of this study is to determine renal functions and prognosis stratification in chronic heart failure patients and importance of Neutrophil Gelatinase-Associated Lipocalin (NGAL), an early diagnostic marker of acute kidney injury, as well as stratification of cardiovascular risk in heart failure patients. METHODS: Data including age, gender, comorbidities and medical history of outpatients and hospitalized patients from Farmacology and NeuroHumoraL activation (FAR NHL) multicenter prospective registry comprising three Cardiological Centers in the Czech Republic were collected between 1st October 2014 and 30th November 2015. One-year follow-up data were collected in November 2016 in such a way that all patients had at least one-year data from the time of recruitment, but up to two years to the time of follow-up. One-year data were used for the whole set of patients while data up to 24 months were used with Kaplan-Meier's survival curves to analyse the patients' survival data. Blood samples were collected from the patients and basic parameters were evaluated in order to analyse Neutrophil gelatinase-associated lipocalin (NGAL) and plasma levels of N-terminal pro-brain natriuretic peptide (NT-ProBNP) using Lipocalin-2/NGAL Human ELISA kit (Bio Vendor, Czechia) and the Cobas E411 NT-proBNP Immunoassay kit (Roche Diagnostics, Indianapolis, IN, USA) respectively. Statistical analysis was further carried out to explain the level of significance of the evaluated parameters using Spearman Correlation, Mann Whitney or Kruskal-Wallis test and log-rank test. RESULTS: Out of 547 patients from Farmacology and NeuroHumoraL activation (FAR NHL) multicenter prospective registry with available data on hospitalizations, mortality, biomarkers and one-year follow-up that were recorded, there were 439 males (80.3%) with a median age of 66 years. At least one-month stable patients with left ventricle ejection fraction (LV EF) under 50% were recorded. The etiology of heart failure was ischemic heart disease in 54%, dilated cardiomyopathy in 40% and others in 6%. 69% patients were in New York Heart Association functional class II. There were 76 events (13.9%; all-cause mortality, acute heart failure hospitalization, left ventricle assist device implantation and orthotopic heart transplant) in the first 365 days of follow-up. The area under the receiver operating characteristic curve was higher for NT-proBNP (0.77) than the creatinine (0.57), NGAL (0.55) or creatinine clearance (0.54). In multivariable analyses, NT-proBNP (P= 0.001) and NGAL (P = 0.004) were significant predictors of events. Subjects with NT-proBNP and NGAL above the cut off value (NT-proBNP 1,121 pg/ml, NGAL 80 ng/ml) survived without any event in 55.7%, subjects with NT-proBNP and NGAL under the cut off value survived without any event in 90.5%, after two years (P = 0.001). CONCLUSION: The findings of the study showed that NGAL associated with NT-proBNP was a stronger predictor of the primary endpoint than NGAL or NT-proBNP alone. The level of NGAL was rising in hypertension, ischemia, anemia, hypoalbuminemia, diabetes or arrhythmias.