Nocturnal blood pressure and progression to end-stage renal disease or death in nondiabetic chronic kidney disease stages 3 and 4.

OBJECTIVE: The objective was to assess the role of office and ambulatory blood pressure (BP) on the development of end-stage renal disease (ESRD) in nondiabetic chronic renal failure. DESIGN AND METHOD: Seventy-nine patients [mean age 57 (standard deviation 11) years, 47 men, BMI 28 (4), office BP 151 (25)/92 (14) mmHg, estimated glomerular filtration rate 28 (14) ml/min per 1.73 m3] were included. The causes of renal disease were nephrosclerosis (n = 33), glomerulonephritis (n = 19), interstitial (n = 12) and others (n = 15). The average follow-up was 44 months (range 9-72 months). The primary outcome was a composite of death, from any cause, or the development of ESRD that require initiation of renal replacement therapy. In all patients, 24-h ambulatory BP monitoring and left ventricular mass assessment were performed at the beginning of the study. RESULTS: During the follow-up period, 41 (52%) patients progressed to ESRD. In addition, nine (11%) patients died, four before reaching ESRD. Then the combined endpoint rate, 45 patients, was 6.3/100 patients per year. In a multivariate Cox proportional hazard model, which includes age, sex, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker status and the estimated glomerular filtration rate, office BP still provided no further prognostic information on risk of the primary outcome. In addition, daytime ambulatory BP and the no-dipper status did not further discriminate in terms of predicting endpoint. Nocturnal SBP more than 130 mmHg was associated with a doubling of risk [heart rate 2.07 (95% confidence interval 1.01-4.25)] on top of the other significant factors. CONCLUSION: Glomerular filtration rate and nocturnal SBP values, but not nondipper pattern, were associated with risk to develop ESRD.

[Therapeutic success of a prospective cardioversion protocol for persistent atrial fibrillation]. / Rendimiento terapéutico de un protocolo prospectivo de cardioversión en la fibrilación auricular persistente.

INTRODUCTION AND OBJECTIVES: The best therapeutic approach for persistent atrial fibrillation has yet to be defined. Our aim was to investigate the effects of cardioversion in unselected patients with persistent atrial fibrillation who were treated according to a strict protocol involving pretreatment, cardioversion, and follow-up. METHODS: Consecutive patients with persistent atrial fibrillation of at least 1 months' duration were included prospectively in a cardioversion protocol that involved standard antiarrhythmic pretreatment, with amiodarone being offered first, and follow-up. RESULTS: The study included 295 patients, 87.5% of whom were taking the antiarrhythmic drug amiodarone. Sinus rhythm was restored in 92.5%, with pharmacologic cardioversion occurring in 9.5%. The recurrence rate was 33.5% in the first month and 54.9% by month 12. Antiarrhythmic treatment had to be modified in 10.8% of patients. Independent risk factors for recurrence during the first year after cardioversion were an atrial fibrillation duration greater than one year, previous cardioversion, and left ventricular dilatation. A simple risk scoring system was able to differentiate between subgroups of patients with a low, intermediate or high risk of recurrence in the first year after cardioversion. CONCLUSIONS: Sinus rhythm was maintained for 1 year after effective cardioversion in 45.1% of patients who received homogeneous antiarrhythmic pretreatment. There were few side effects. Recurrence can be predicted using clinical variables such as left ventricular dilatation, arrhythmia duration, and previous cardioversion.

Rendimiento terapéutico de un protocolo prospectivo de cardioversión en la fibrilación auricular persistente / Therapeutic success of a prospective cardioversion protocol for persistent atrial fibrillation

Introducción y objetivos. La mejor estrategia de tratamiento de la fibrilación auricular persistente está por definir. Hemos querido conocer los resultados de la cardioversión en pacientes no seleccionados en los que se aplica un protocolo estricto de preparación, cardioversión y seguimiento. Métodos. Incluimos prospectivamente a pacientes consecutivos con fibrilación auricular persistente de al menos un mes de duración en un protocolo de cardioversión eléctrica con pretratamiento antiarrítmico estandarizado (amiodarona como primera opción) y seguimiento. Resultados. Se incluyó a 295 pacientes, el 87,5% de los cuales tomó amiodarona como fármaco antiarrítmico. Se consiguió restaurar el ritmo sinusal en el 92,5%; en un 9,5% de los casos la cardioversión fue farmacológica. Las recurrencias fueron del 33,5 y el 54,9% a uno y 12 meses. El tratamiento antiarrítmico se tuvo que modificar en un 10,8% de los pacientes. Los predictores independientes de recurrencia durante el primer año fueron la duración de la fibrilación auricular mayor de un año, las cardioversiones previas y la dilatación del ventrículo izquierdo. Una sencilla puntuación de riesgo permite diferenciar a los subgrupos de pacientes con bajo, intermedio y alto riesgo de recurrencia durante el primer año tras la cardioversión. Conclusiones. El mantenimiento del ritmo sinusal tras una cardioversión efectiva en pacientes con un pretratamiento antiarrítmico homogéneo es del 45,1% al año de seguimiento. Los efectos secundarios son escasos. La recurrencia puede predecirse con el uso de variables clínicas, como la dilatación ventricular izquierda, la duración de la arritmia y la historia de cardioversiones previas

Introduction and objectives. The best therapeutic approach for persistent atrial fibrillation has yet to be defined. Our aim was to investigate the effects of cardioversion in unselected patients with persistent atrial fibrillation who were treated according to a strict protocol involving pretreatment, cardioversion, and follow-up. Methods. Consecutive patients with persistent atrial fibrillation of at least 1 months' duration were included prospectively in a cardioversion protocol that involved standard antiarrhythmic pretreatment, with amiodarone being offered first, and follow-up. Results. The study included 295 patients, 87.5% of whom were taking the antiarrhythmic drug amiodarone. Sinus rhythm was restored in 92.5%, with pharmacologic cardioversion occurring in 9.5%. The recurrence rate was 33.5% in the first month and 54.9% by month 12. Antiarrhythmic treatment had to be modified in 10.8% of patients. Independent risk factors for recurrence during the first year after cardioversion were an atrial fibrillation duration greater than one year, previous cardioversion, and left ventricular dilatation. A simple risk scoring system was able to differentiate between subgroups of patients with a low, intermediate or high risk of recurrence in the first year after cardioversion. Conclusions. Sinus rhythm was maintained for 1 year after effective cardioversion in 45.1% of patients who received homogeneous antiarrhythmic pretreatment. There were few side effects. Recurrence can be predicted using clinical variables such as left ventricular dilatation, arrhythmia duration, and previous cardioversion

Predictors of short-term outcome in acute chest pain without ST-segment elevation.

BACKGROUND: Management of acute chest pain in the emergency room constitutes a challenge. METHODS: Seven hundred and one consecutive patients were evaluated by clinical history (chest pain score and risk factors), ECG, troponin I and early (<24 h) exercise testing in low risk patients (n=165). A composite end-point (recurrent unstable angina, acute myocardial infarction or cardiac death) was recorded during hospital stay or in ambulatory care settings for patients discharged after early exercise testing. RESULTS: The end-point occurred in 122 patients (17%). Multivariate analysis identified the following predictors: chest pain score > or =11 points (OR=1.8, 2-2.8, 95% CI, P=0.007), age > or =68 (OR 1.6, 1.1-2.4 CI 95%, P=0.03), insulin-dependent diabetes mellitus (OR 1.9, 1.1-3.4 CI 95%, P=0.02), a history of coronary surgery (OR 3.3, 1.5-7.2 CI 95%, P=0.003), ST-segment depression (OR 1.9, 1.2-3.0 CI 95%, P=0.009) and troponin I elevation (OR 1.6, 1.1-2.5, CI 95%, P=0.05). ST-segment depression produced a high end-point increase (31 vs. 13%, P=0.0001). Troponin I elevation increased the risk in the subgroup without ST-segment depression (20 vs. 11%, P=0.006) but did not further modify the risk in the subgroup with ST depression (31 vs. 28%, ns). Nevertheless, the negative ECG and troponin I subgroup showed a non-negligible end-point rate (16% when pain score > or =11 or 7% when pain score <11, P=0.004). Finally, no patient with a negative exercise test presented events compared to 7% of those with a non-negative test (RR=2.5, 2.1-3.1 95% CI, P=0.01). CONCLUSIONS: Emergency room evaluation of chest pain should not focus on a single parameter; on the contrary, the clinical history, ECG, troponin and early exercise testing must be globally analysed.

Selective use of diagnostic tests inpatients with syncope of unknown cause.

OBJECTIVE: We sought to prospectively assess the diagnostic yielding of a protocol in which electrophysiologic studies (EPS), tilt-table tests (TTTs), and loop recorder implantation are selectively used. BACKGROUND: The optimal strategy in the diagnosis of patients with syncope of unknown cause has not been defined. METHODS: A total of 184 consecutive patients with syncope of unknown cause were classified into two groups. Group A consisted of 72 patients fulfilling any of the following criteria: 1) presence of structural heart disease or family history of sudden death; 2) abnormal electrocardiogram; 3) significant non-symptomatic arrhythmia on Holter monitoring; and 4) paroxysmal palpitations immediately before or after syncope. These patients initially underwent an EPS and, if this study was negative, TTT. In the remaining 112 patients (group B), TTT was performed. RESULTS: The EPS was positive in 32 patients (44%) in group A. The TTT was positive in 80 patients (71%) in group B. An additional patient had carotid sinus hypersensitivity. In patients of group A with a negative EPS, the TTT was positive in 23 (57%). A loop recorder was implanted in 15 patients from group A with negative conventional testing, and diagnostic activation was obtained in seven patients. Overall, a positive diagnosis was achieved in 143 patients (78%). CONCLUSIONS: In patients with syncope of unknown cause, selective use of EPS or TTT leads to a positive diagnosis in >70% of the cases. An implantable loop recorder can be useful in non-diagnosed cases.

[Is troponin I useful for predicting in-hospital risk for unstable angina patients in a community hospital? Results of a prospective study]. / Es la troponina I útil para predecir el riesgo hospitalario en pacientes con angina inestable ingresados en un hospital comarcal? Resultados de un estudio prospectivo.

INTRODUCTION AND OBJECTIVES: Before including troponin I detection in the daily practice of our hospital we performed a prospective study to determine its real usefulness and to establish the best cut-off point. METHODS: We studied 82 consecutive patients admitted with unstable angina to a community hospital. Troponin I was determined (> 10 h after chest pain). Patients were referred to a tertiary hospital for catheterization/revascularization if clinical events developed. RESULTS: Twenty-five patients (31%) suffered events during admission: recurrent angina in 23 cases (28%); heart failure in 5 (6%); exitus in 3 (4%); myocardial infarction in 1 (1%). The cut-off point for troponin I that best predicted events was 0.1 ng/ml. Patients with troponin I > 0.1 (34 patients, 42%) experienced more events [47 vs. 19%; OR = 3.8 (1.4-10.4); p = 0.01] and had higher rates of recurrent angina (42 vs. 19%), heart failure (12 vs. 2%) and exitus (9 vs 0%). Patients with ECG changes and troponin I > 0.1 showed a significantly higher percentage of events (63%) than those with ECG changes alone (23%) or troponin I > 0.1 alone (15%) or those without ECG changes and troponin I < 0.1 (17%) (p < 0.0001). CONCLUSIONS: Troponin I elevation is useful for predicting in-hospital risk for unstable angina patients admitted to a community hospital. A low cut-off value (0.1 ng/ml) predicts events. The association of ECG changes and high troponin I identifies a population at very high risk; however, the absence of both variables in patients with a diagnosis of unstable angina does not preclude the development of events.

¿Es la troponina i útil para predecir el riesgo hospitalario en pacientes con angina inestable ingresados en un hospital comarcal? Resultados de un estudio prospectivo / Is Troponin I Useful for Predicting In-Hospital Risk for Unstable Angina Patients in a Community Hospital? Results of a Prospective Study

Introducción y objetivos. Antes de incluir la troponina I en la práctica diaria de nuestro hospital, realizamos un estudio prospectivo para determinar su utilidad real y el mejor punto de corte. Métodos. Estudiamos a 82 pacientes consecutivos ingresados por angina inestable en un hospital comarcal. Se determinó la troponina I (> 10 h del episodio de dolor torácico). Los pacientes fueron remitidos a un hospital terciario para cateterismo/revascularización en caso de algún acontecimiento clínico. Resultados. Durante el ingreso se detectaron acontecimientos en 25 casos (31 por ciento): angina recurrente en 23 (28 por ciento), insuficiencia cardíaca en 5 (6 por ciento), infarto en 1 (1 por ciento) y muerte en 3 (4 por ciento). El mejor punto de corte de la troponina I para predecir acontecimientos fue 0,1 ng/ml. Los 34 pacientes (42 por ciento) con troponina I > 0,1 presentaron más acontecimientos (47 frente a 19 por ciento; OR = 3,8 [1,4-10,4]; p = 0,01), angina recurrente (42 frente a 19 por ciento), insuficiencia cardíaca (12 frente a 2 por ciento) y fallecimiento (9 frente a 0 por ciento). Los pacientes con cambios ECG y troponina I > 0,1 sufrieron más acontecimientos (63 por ciento; p 0,1 (15 por ciento), o aquellos sin cambios ECG y troponina I < 0,1 (17 por ciento).Conclusiones. La troponina I es de utilidad para predecir el riesgo hospitalario en pacientes con angina inestable en un hospital comarcal. Un punto de corte bajo (0,1 ng/ml) predice la aparición de acontecimientos. La asociación de cambios ECG y troponina I positiva identifica a un grupo de alto riesgo; sin embargo, la ausencia de ambas variables en pacientes con un diagnóstico de angina inestable no asegura una buena evolución (AU)