Analysis of immortal-time effect in post-infarction ventricular septal defect.

Introduction: Time-fixed analyses have traditionally been utilized to examine outcomes in post-infarction ventricular septal defect (VSD). The aims of this study were to: (1) analyze the relationship between VSD closure/non-closure and mortality; (2) assess the presence of immortal-time bias. Material and methods: In this retrospective cohort study, patients with ST-elevation myocardial infarction (STEMI) complicated by VSD. Time-fixed and time-dependent Cox regression methodologies were employed. Results: The study included 80 patients: surgical closure (n = 26), transcatheter closure (n = 20), or conservative management alone (n = 34). At presentation, patients without VSD closure exhibited high-risk clinical characteristics, had the shortest median time intervals from STEMI onset to VSD development (4.0, 4.0, and 2.0 days, respectively; P = 0.03) and from STEMI symptom onset to hospital arrival (6.0, 5.0, and 0.8 days, respectively; P < 0.0001). The median time from STEMI onset to closure was 22.0 days (P = 0.14). In-hospital mortality rate was higher among patients who did not undergo defect closure (50%, 35%, and 88.2%, respectively; P < 0.0001). Closure of the defect using a fixed-time method was associated with lower in-hospital mortality (HR = 0.13, 95% CI 0.05-0.31, P < 0.0001, and HR 0.13, 95% CI 0.04-0.36, P < 0.0001, for surgery and transcatheter closure, respectively). However, when employing a time-varying method, this association was not observed (HR = 0.95, 95% CI 0.45-1.98, P = 0.90, and HR 0.88, 95% CI 0.41-1.87, P = 0.74, for surgery and transcatheter closure, respectively). These findings suggest the presence of an immortal-time bias. Conclusions: This study highlights that using a fixed-time analytic approach in post-infarction VSD can result in immortal-time bias. Researchers should consider employing time-dependent methodologies.

Application of the SCAI classification to admission of patients with cardiogenic shock: Analysis of a tertiary care center in a middle-income country.

AIMS: The Society of Cardiovascular Angiography and Interventions (SCAI) shock stages have been applied and validated in high-income countries with access to advanced therapies. We applied the SCAI scheme at the time of admission in order to improve the risk stratification for 30-day mortality in a retrospective cohort of patients with STEMI in a middle-income country hospital at admission. METHODS: This is a retrospective cohort study, we analyzed 7,143 ST-segment elevation myocardial infarction (STEMI) patients. At admission, patients were stratified by the SCAI shock stages. Multivariate analysis was used to assess the association between SCAI shock stages to 30-day mortality. RESULTS: The distribution of the patients across SCAI shock stages was 82.2%, 9.3%, 1.2%, 1.5%, and 0.8% to A, B, C, D, and E, respectively. Patients with SCAI stages C, D, and E were more likely to have high-risk features. There was a stepwise significant increase in unadjusted 30-day mortality across the SCAI shock stages (6.3%, 8.4%, 62.4%, 75.2% and 88.3% for A, B, C, D and E, respectively; P < 0.0001, C-statistic, 0.64). A trend toward a lower 30-day survival probability was observed in the patients with advanced CS (30.3, 15.4%, and 8.3%, SCAI shock stages C, D, and E, respectively, Log-rank P-value <0.0001). After multivariable adjustment, SCAI shock stages C, D, and E were independently associated with an increased risk of 30-day death (hazard ratio 1.42 [P = 0.02], 2.30 [P<0.0001], and 3.44 [P<0.0001], respectively). CONCLUSION: The SCAI shock stages applied in patients con STEMI at the time of admission, is a useful tool for risk stratification in patients across the full spectrum of CS and is a predictor of 30-day mortality.

[Los niveles de mediadores prorresolutivos no corresponden con los de mediadores inflamatorios en enfermedades isquémicas coronarias].

BACKGROUND: Inflammation can be grouped into three phases: proinflammatory, anti-inflammatory, and resolution. The latter, mainly attributed to lipid mediators, is the most recently described, and has been studied little in coronary ischemic diseases. OBJECTIVE: To evaluate 1) if acute coronary syndromes (ACS) manifest different circulating levels of resolution mediators compared with stable angina (SA); 2) if their concentrations are related to those of pro and anti-inflammatory mediators; and 3) if such concentrations are associated with the severity of the disease and the damage produced. METHOD: LTB4, RvD1, LXA4, ET-1, MMP-2, MMP-9, TIMP-1, IL-1ß, IL-6, IL-8 and IL-10 were measured in serum. The GRACE score was established as parameter of gravity, and LVEF as a damage parameter. RESULTS: Thirty patients with SA, 37 with NEST-ACS, 38 with STEMI, and 10 individuals with non-cardiogenic chest pain were included. Patients with coronary artery disease showed elevated levels of inflammatory cytokines and low levels of resolution mediators. CONCLUSIONS: The low resolution response even in patients with acute coronary disease suggests an inability to repair damage. Testing this hypothesis would have the potential to suggest new therapies for the management of chronic cardiovascular inflammation.

ANTECEDENTES: La inflamación puede agruparse en tres fases: proinflamatoria, antiinflamatoria y de resolución. Esta última, principalmente atribuida a mediadores lipídicos, es la de más reciente descripción y se ha estudiado poco en las enfermedades isquémicas coronarias. OBJETIVOS: Evaluar 1) si los síndromes coronarios agudos (SICA) manifiestan niveles circulantes distintos de mediadores de resolución comparados con la angina estable (AE); 2) si sus concentraciones se relacionan con las de mediadores proinflamatorios y antiinflamatorios; y 3) si dichas concentraciones se asocian con la gravedad de la enfermedad y el daño producido. MÉTODO: Se midieron LTB4, RvD1, LXA4, ET-1, MMP-2, MMP-9, TIMP-1, IL-1ß, IL-6, IL-8 e IL-10 en suero. Se establecieron la puntuación GRACE como parámetro de gravedad y la fracción de eyección del ventrículo izquierdo (FEVI) como parámetro de daño. RESULTADOS: Se incluyeron 30 pacientes con AE, 37 con SICA sin elevación del segmento ST (SICA-SEST), 38 con Infarto agudo del miocardio con elevación del segmetno ST(IAM-CEST) y 10 con dolor torácico no cardiogénico. Los pacientes con enfermedad coronaria mostraron niveles elevados de citocinas inflamatorias y bajos de mediadores de resolución. CONCLUSIONES: La escasa respuesta de resolución aun en pacientes con enfermedad coronaria aguda sugiere una incapacidad para reparar daños. Probar esta hipótesis tendría el potencial de sugerir nuevas terapias para el manejo de la inflamación cardiovascular crónica.