Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial.

JAMA. 2010 Jan 27;303(4):341-8

Authors: , Annane D, Cariou A, Maxime V, Azoulay E, D'honneur G, Timsit JF, Cohen Y, Wolf M, Fartoukh M, Adrie C, Santré C, Bollaert PE, Mathonet A, Amathieu R, Tabah A, Clec'h C, Mayaud J, Lejeune J, Chevret S

CONTEXT: Corticosteroid therapy induces potentially detrimental hyperglycemia in septic shock. In addition, the benefit of adding fludrocortisone in this setting is unclear. OBJECTIVES: To test the efficacy of intensive insulin therapy in patients whose septic shock was treated with hydrocortisone and to assess, as a secondary objective, the benefit of fludrocortisone. DESIGN, SETTING, AND PATIENTS: A multicenter, 2 x 2 factorial, randomized trial, involving 509 adults with septic shock who presented with multiple organ dysfunction, as defined by a Sequential Organ Failure Assessment score of 8 or more, and who had received hydrocortisone treatment was conducted from January 2006 to January 2009 in 11 intensive care units in France. INTERVENTIONS: Patients were randomly assigned to 1 of 4 groups: continuous intravenous insulin infusion with hydrocortisone alone, continuous intravenous insulin infusion with hydrocortisone plus fludrocortisone, conventional insulin therapy with hydrocortisone alone, or conventional insulin therapy with intravenous hydrocortisone plus fludrocortisone. Hydrocortisone was administered in a 50-mg bolus every 6 hours, and fludrocortisone was administered orally in 50-microg tablets once a day, each for 7 days. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: Of the 255 patients treated with intensive insulin, 117 (45.9%), and 109 of 254 (42.9%) treated with conventional insulin therapy died (relative risk [RR], 1.07; 95% confidence interval [CI], 0.88-1.30; P = .50). Patients treated with intensive insulin experienced significantly more episodes of severe hypoglycemia (<40 mg/dL) than those in the conventional-treatment group, with a difference in mean number of episodes per patient of 0.15 (95% CI, 0.02-0.28; P = .003). At hospital discharge, 105 of 245 patients treated with fludrocortisone (42.9%) died and 121 of 264 (45.8%) in the control group died (RR, 0.94; 95% CI, 0.77-1.14; P = .50). CONCLUSIONS: Compared with conventional insulin therapy, intensive insulin therapy did not improve in-hospital mortality among patients who were treated with hydrocortisone for septic shock. The addition of oral fludrocortisone did not result in a statistically significant improvement in in-hospital mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00320099.

PMID: 20103758 [PubMed - in process]

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Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.

JAMA. 2010 Jan 27;303(4):333-40

Authors: Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A, Macle L, Daoud EG, Calkins H, Hall B, Reddy V, Augello G, Reynolds MR, Vinekar C, Liu CY, Berry SM, Berry DA,

CONTEXT: Antiarrhythmic drugs are commonly used for prevention of recurrent atrial fibrillation (AF) despite inconsistent efficacy and frequent adverse effects. Catheter ablation has been proposed as an alternative treatment for paroxysmal AF. OBJECTIVE: To determine the efficacy of catheter ablation compared with antiarrhythmic drug therapy (ADT) in treating symptomatic paroxysmal AF. DESIGN, SETTING, AND PARTICIPANTS: A prospective, multicenter, randomized (2:1), unblinded, Bayesian-designed study conducted at 19 hospitals of 167 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before randomization. Enrollment occurred between October 25, 2004, and October 11, 2007, with the last follow-up on January 19, 2009. INTERVENTION: Catheter ablation (n = 106) or ADT (n = 61), with assessment for effectiveness in a comparable 9-month follow-up period. MAIN OUTCOME MEASURES: Time to protocol-defined treatment failure. The proportion of patients who experienced major treatment-related adverse events within 30 days of catheter ablation or ADT was also reported. RESULTS: At the end of the 9-month effectiveness evaluation period, 66% of patients in the catheter ablation group remained free from protocol-defined treatment failure compared with 16% of patients treated with ADT. The hazard ratio of catheter ablation to ADT was 0.30 (95% confidence interval, 0.19-0.47; P < .001). Major 30-day treatment-related adverse events occurred in 5 of 57 patients (8.8%) treated with ADT and 5 of 103 patients (4.9%) treated with catheter ablation. Mean quality of life scores improved significantly in patients treated by catheter ablation compared with ADT at 3 months; improvement was maintained during the course of the study. CONCLUSION: Among patients with paroxysmal AF who had not responded to at least 1 antiarrhythmic drug, the use of catheter ablation compared with ADT resulted in a longer time to treatment failure during the 9-month follow-up period. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00116428.

PMID: 20103757 [PubMed - in process]

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Management of perioperative hypertensive urgencies with parenteral medications.

J Hosp Med. 2010 Jan 26;5(2):E11-E16

Authors: Ahuja K, Charap MH

BACKGROUND:: Hypertension is the major risk factor for cardiovascular (CV) disease such as myocardial infarction (MI) and stroke. This risk is well known to extend into the perioperative period. Although most perioperative hypertension can be managed with the patient’s outpatient regimen, there are situations in which oral medications cannot be administered and parenteral medications become necessary. They include postoperative nil per os status, severe pancreatitis, and mechanical ventilation. This article reviews the management of perioperative hypertensive urgency with parenteral medications. METHODS:: A PubMed search was conducted by cross-referencing the terms “perioperative hypertension,” “hypertensive urgency,” “hypertensive emergency,” “parenteral anti-hypertensive,” and “medication.” The search was limited to English-language articles published between 1970 and 2008. Subsequent PubMed searches were performed to clarify data from the initial search. RESULTS:: As patients with hypertensive urgency are not at great risk for target-organ damage (TOD), continuous infusions that require intensive care unit (ICU) monitoring and intraarterial catheters seem to be unnecessary and a possible misuse of resources. CONCLUSIONS:: When oral therapy cannot be administered, patients with hypertensive urgency can have their blood pressure (BP) reduced with hydralazine, enalaprilat, metoprolol, or labetalol. Due to the scarcity of comparative trials looking at clinically significant outcomes, the medication should be chosen based on comorbidity, efficacy, toxicity, and cost. Journal of Hospital Medicine 2010;5:E11-E16. (c) 2010 Society of Hospital Medicine.

PMID: 20104635 [PubMed - as supplied by publisher]

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Management of ischemic stroke: Part 2. The inpatient stay.

J Hosp Med. 2010 Jan 26;5(2):88-93

Authors: Lu-Emerson C, Likosky D, Amin A, Tirschwell D

BACKGROUND:: Acute ischemic stroke is commonly encountered by the hospitalist. There have been dramatic changes in our ability to care for these patients both acutely and in secondary prevention. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) primary stroke center certification has become progressively more important to institutions nationally and emphasizes many elements of the inpatient stay and discharge process. PURPOSE:: After admission, the focus changes to avoidance of complications and the appropriate initiation of allied therapies and secondary prevention. DATA SOURCES:: Primary trials, current guidelines. CONCLUSIONS:: The hospitalist is well-positioned to play a major role in the treatment of stroke patients as well as the systems work that aids in the management of this population. Journal of Hospital Medicine 2010;5:88-93. (c) 2010 Society of Hospital Medicine.

PMID: 20104624 [PubMed - as supplied by publisher]

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Impact and recognition of cognitive impairment among hospitalized elders.

J Hosp Med. 2010 Jan 26;5(2):69-75

Authors: Boustani M, Baker MS, Campbell N, Munger S, Hui SL, Castelluccio P, Farber M, Guzman O, Ademuyiwa A, Miller D, Callahan C

BACKGROUND:: Older adults are predisposed to developing cognitive deficits. This increases their vulnerability for adverse health outcomes when hospitalized. OBJECTIVE:: To determine the prevalence and impact of cognitive impairment (CI) among hospitalized elders based on recognition by lCD-coding versus screening done on admission. DESIGN:: Observational cohort study. SETTING:: Urban public hospital in Indianapolis. PATIENTS:: 997 patients age 65 and older admitted to medical services between July 2006 and March 2008. MEASUREMENTS:: Impact of CI in terms of length of stay, survival, quality of care and prescribing practices. Cognition was assessed by the Short Portable Mental Status Questionnaire (SPMSQ). RESULTS:: 424 patients (43%) were cognitively impaired. Of those 424 patients with CI, 61% had not been recognized by ICD-9 coding. Those unrecognized were younger (mean age 76.1 vs. 79.1, P <0.001); had more comorbidity (mean Charlson index of 2.3 vs.1.9, P = 0.03), had less cognitive deficit (mean SPMSQ 6.3 vs. 3.4, P < 0.001). Among elders with CI, 163 (38%) had at least one day of delirium during their hospital course. Patients with delirium stayed longer in the hospital (9.2 days vs. 5.9, P < 0.001); were more likely to be discharged into institutional settings (75% vs. 31%, P < 0.001) and more likely to receive tethers during their care (89% vs. 69%, P < 0.001), and had higher mortality (9% vs. 4%, P = 0.09). CONCLUSION:: Cognitive impairment, while common in hospitalized elders, is under-recognized, impacts care, and increases risk for adverse health outcomes. Journal of Hospital Medicine 2010;5:69-75. (c) 2010 Society of Hospital Medicine.

PMID: 20104623 [PubMed - as supplied by publisher]

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Predictors of serious injury among hospitalized patients evaluated for falls.

J Hosp Med. 2010 Jan 26;5(2):63-68

Authors: Bradley SM, Karani R, McGinn T, Wisnivesky J

BACKGROUND:: Inpatient falls are common and result in significant patient morbidity. OBJECTIVE:: To identify predictors of serious injury being found on imaging studies of inpatients evaluated after a fall. DESIGN:: Retrospective study. SETTING:: An 1171-bed urban academic medical center. PATIENTS:: All inpatients who fell on thirteen medical and surgical units from January 1 to December 31, 2006. MEASUREMENTS:: Patient characteristics, circumstances surrounding falls, fall-related injuries, and length of stay were collected through review of incident reports and computerized medical records. Primary outcome of fall-related injury was determined by evidence of injury on imaging studies within two weeks of the fall. Univariate and multivariate logistic regression were used to calculate adjusted odds ratios (ORs) for injury after an inpatient fall. RESULTS:: A total of 513 patients had 636 falls during the study time period. Fall incidence rate was 1.97 falls per 1,000 patient days. 95 patients (19%) fell multiple times (range, 2-6 events); 74% of the falls occurred in patients who were previously assessed as being "at risk" by the nursing staff. Multivariate analysis, adjusting for age and sex, found evidence of trauma after a fall (OR = 24.6, P < 0.001) and ambulatory status (OR = 7.3, P < 0.01) to be independent predictors of injury being found on imaging studies. CONCLUSIONS:: Inpatient falls are common despite high-risk patients being identified. After adjusting for age and sex, evidence of trauma and ambulatory status were independent predictors of an injury being found on imaging studies after an inpatient fall. Journal of Hospital Medicine 2010;5:63-68. (c) 2010 Society of Hospital Medicine.

PMID: 20104622 [PubMed - as supplied by publisher]

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Ciclesonide and the treatment of asthma.

Expert Opin Pharmacother. 2010 Feb;11(3):463-79

Authors: Korenblat PE

Importance of the field: Asthma is a chronic disease characterized by airway inflammation and hyper-responsiveness. Inhaled corticosteroids (ICSs) constitute the guideline-recommended first-line therapy for persistent asthma. However, concerns regarding ICS-related adverse events may contribute to their underutilization by physicians and patients. Areas covered in this review: The currently available published data on the pharmacokinetic and pharmacodynamic properties, safety and efficacy of the ICS, ciclesonide, is described. Peer-reviewed publications (1996 – 2009) on the pharmacodynamic and pharmacokinetic profile, safety and efficacy of ciclesonide were reviewed. What the reader will gain: Ciclesonide is delivered as an inactive prodrug, which is cleaved to the active molecule by intracellular esterases located in the lungs. This and other pharmacodynamic and pharmacokinetic properties may limit the amount of active molecule outside the lung and may reduce the incidence of side effects. Randomized placebo-controlled studies found that ciclesonide can initiate and maintain disease control in subjects with persistent asthma of all disease severities. Moreover, studies have found that ciclesonide is as effective as other ICSs in establishing and controlling disease symptoms. Controlled clinical trials also showed that ciclesonide is associated with minimal systemic and local treatment-related adverse events. Take home message: Published findings indicate that ciclesonide is effective at initiating and maintaining asthma control and is well tolerated, with a positive safety profile.

PMID: 20102309 [PubMed - in process]

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Prucalopride for constipation.

Expert Opin Pharmacother. 2010 Feb;11(3):451-61

Authors: Camilleri M, Deiteren A

Importance of the field: Chronic constipation has a high prevalence, and current medical and pharmacological therapies do not restore normal bowel function in all patients. Areas covered in the review: A PubMed search (1965 – 2009) using the following terms alone or in combination: prucalopride, 5-HT(4), R093877, safety, toxicity, pharmacokinetics, pharmacodynamics, transit, cardiac, hERG, arrhythmia, potassium current, elderly. What the reader will gain: Understanding of the mechanisms of action, safety, efficacy and indications for prucalopride in patients with chronic constipation. Take home message: Prucalopride is an efficacious and generally safe, new therapeutic option in the management of chronic constipation.

PMID: 20102308 [PubMed - in process]

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Roflumilast in chronic obstructive pulmonary disease: evidence from large trials.

Expert Opin Pharmacother. 2010 Feb;11(3):441-9

Authors: Cazzola M, Picciolo S, Matera MG

Importance of the field: Chronic inflammation plays a central role in chronic obstructive pulmonary disease (COPD). Suppression of the inflammatory response is a logical approach to the treatment of COPD. Corticosteroids are highly effective as an anti-inflammatory treatment, but patients with COPD are poorly responsive to these drugs. The phosphodiesterase (PDE)-4 isoenzyme is a major therapeutic target in COPD because its inhibition increases intracellular cAMP concentrations, which ultimately results in reduction of cellular inflammatory activity. At present roflumilast is the most advanced PDE-4 inhibitor undergoing clinical trials for COPD. Areas covered in this review: In this paper, we describe the importance of roflumilast as an anti-inflammatory drug and critically review the results of four large trials with roflumilast in COPD (NCT00297102, NCT00297115, NCT00313209, NCT00424268). What the reader will gain: An unbiased description of trials that have explored the therapeutic effects of roflumilast in COPD. Take home message: At the moment, roflumilast should only be considered as a second-line treatment, and the exact indication remains to be determined. Apparently, it should be reserved for patients who have frequent exacerbations despite treatment with inhaled bronchodilators. However, considering the high risk of adverse events induced by this drug, the published evidence seems to indicate limiting its use to the treatment of patients suffering from very severe COPD.

PMID: 20102307 [PubMed - in process]

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Inhaled corticosteroids in chronic obstructive pulmonary disease: a review.

Expert Opin Pharmacother. 2010 Feb;11(3):405-21

Authors: Telenga ED, Kerstjens HA, Postma DS, Ten Hacken NH, van den Berge M

Importance of the field: Chronic obstructive pulmonary disease (COPD) is a disease characterized by chronic airflow obstruction and a progressive lung function decline. Although widely used, the efficacy of inhaled corticosteroids (ICS) in the treatment of COPD remains a matter of debate. Areas covered in this review: This article reviews the evidence about the effects of inhaled corticosteroids in the treatment of COPD. What the reader will gain: Short-term treatment with ICS improves lung function and quality of life; in addition, several studies with longer follow-up have shown less decline over time in quality of life, and fewer exacerbations. By contrast, long-term studies have been unable to show substantial improvement in the decline of lung function in COPD. Based on these findings, it was concluded that the use of ICS did not influence the natural course of COPD. However, this conclusion has been challenged by two subsequent studies, TORCH and GLUCOLD, which both showed a reduction in lung-function decline over time with the use of ICS. These two studies indicate that ICS might indeed influence the natural course of the disease, at least in a subgroup of COPD patients. Take home message: Further studies are needed to identify which individuals have a favorable short- and long-term response to ICS treatment.

PMID: 20102305 [PubMed - in process]

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Pharmacological treatment of biliary cirrhosis with ursodeoxycholic acid.

Expert Opin Pharmacother. 2010 Feb;11(3):387-92

Authors: Abbas G, Lindor KD

Importance of the field: Primary biliary cirrhosis is a cholestatic liver disease that at one time was the leading indication for liver transplantation. Treatment with ursodeoxycholic acid has clearly improved the natural history of primary biliary cirrhosis. Areas covered in this review: The treatment of primary biliary cirrhosis with a focus on ursodeoxycholic acid is covered. Papers related to treatment of primary biliary cirrhosis and associated conditions, using a variety of drugs but with a focus on ursodeoxycholic acid, are included. The papers reviewed date from 1984 – 2009. What will the reader gain: The reader will gain an up-to-date understanding of current treatment strategies for primary biliary cirrhosis using ursodeoxycholic acid and an appreciation of what conditions are improved with this therapy and what associated conditions are not. Take-home message: Ursodeoxycholic acid in a dose of 13 – 15 mg/kg/day should be considered in all patients with primary biliary cirrhosis who have abnormal liver enzymes.

PMID: 20102304 [PubMed - in process]

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Treatment strategies for infective endocarditis.

Expert Opin Pharmacother. 2010 Feb;11(3):345-60

Authors: Chopra T, Kaatz GW

Importance of the field: Despite significant advances in medical, surgical, and critical care interventions, infective endocarditis (IE) remains a disease associated with considerable morbidity and mortality. Estimates from the American Heart Association place the incidence of IE in the US at 10,000 – 15,000 new cases each year. This may be due to the changing epidemiology of IE, including increasing antimicrobial resistance, increasing heart surgeries, prosthetic valve implantation, and widespread use of intravenous drugs. Furthermore, a new form of the disease, healthcare-associated IE, which is associated with new therapeutic modalities such as intravenous catheters, hyperalimentation lines, pacemakers, and dialysis shunts, has emerged. Areas covered in this review: We present the latest therapeutic and preventive strategies for IE caused by a variety of bacterial and fungal pathogens. The general methods employed included an extensive literature search, confined to the last 10 years, using key words such as ‘infective endocarditis’, ‘culture-negative endocarditis’, ‘treatment guidelines for IE’, and ‘prophylaxis for IE’. What the reader will gain: Comprehensive information regarding the changing epidemiology of IE is provided. The latest guidelines with respect to therapy and prophylaxis of IE are reviewed. Take home message: Successful management of IE depends on maintaining a high index of suspicion for the disease and, when IE is diagnosed, close cooperation of medical and surgical disciplines is required. Further research is needed to better understand and provide optimal therapy for complex situations such as multidrug-resistant and polymicrobial IE.

PMID: 20102302 [PubMed - in process]

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Safety and feasibility of early hospital discharge in ST-segment elevation myocardial infarction-A prospective and randomized trial in low-risk primary percutaneous coronary intervention patients (the Safe-Depart Trial).

Am Heart J. 2010 Jan;159(1):117.e1-117.e6

Authors: Kotowycz MA, Cosman TL, Tartaglia C, Afzal R, Syal RP, Natarajan MK

BACKGROUND: Patients with ST-segment elevation myocardial infarction (STEMI) have traditionally been hospitalized for 5 to 7 days to monitor for serious complications such as heart failure, arrhythmias, reinfarction, and death. The Zwolle Primary Percutaneous Coronary Intervention (PCI) Index is an externally validated risk score that has been used to identify low-risk STEMI patients who have undergone primary PCI and can safely be discharged from hospital within 72 hours. Previous studies have shown that many low-risk patients remain in hospital significantly longer. METHODS: We randomly assigned 54 low-risk STEMI patients treated with primary or rescue PCI to 1 of 2 groups. Patients in the intervention group (n = 27) were actively targeted for early hospital discharge (48-72 hours) and received outpatient follow-up with an advanced practice nurse (APN). In the control group (n = 27), discharge planning and follow-up were left to the treating physician, and there was no added nursing intervention. The 2 primary outcomes of this pilot study were to demonstrate feasibility and safety. Secondary outcomes included compliance with medications, smoking cessation, attendance at cardiac rehabilitation, and quality of life, measured in both groups at 6 weeks time. RESULTS: In the intervention group, 74% of patients were discharged within 72 hours, 100% had follow-up with the APN within 3 days (74% in person, 26% by phone), and 100% had >/= 3 APN follow-ups in total, meeting our prespecified criteria for feasibility. The median length of stay was 55 hours in both groups. There were no deaths in either group, and there was no difference in rehospitalization between patients in the intervention and control groups (8% vs 4%, P = .56). There was no difference in rates of medication compliance, smoking cessation, attendance at cardiac rehabilitation, or quality of life between the 2 groups, although our small pilot study was not powered to detect a difference in these outcomes. CONCLUSION: In low-risk STEMI patients treated with primary or rescue PCI, a strategy of early hospital discharge facilitated by close nursing follow-up is feasible. Although our study did not identify differences in compliance or quality of life between the 2 groups, it did provide a functional study design for a larger trial powered to detect these important clinical end points.

PMID: 20102876 [PubMed - as supplied by publisher]

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Prognostic role of highly sensitive cardiac troponin I in patients with systolic heart failure.

Am Heart J. 2010 Jan;159(1):63-7

Authors: Tsutamoto T, Kawahara C, Nishiyama K, Yamaji M, Fujii M, Yamamoto T, Horie M

BACKGROUND: Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are useful biomarkers in patients with chronic heart failure (CHF). However, the clinical use has limitations due to the low sensitivity of a conventional commercial assay system. Recently, a high sensitive-cTnI (hs-cTnI) commercial assay has become available. METHODS: To compare the prognostic value of cTnT and hs-cTnI, we measured hemodynamic parameters and serum levels of cTnT, hs-cTnI and N-terminal pro-brain natriuretic peptide (NT-proBNP)in 258 consecutive CHF patients and then followed these patients for a mean period of 2.6 years. In both assays of cTnT and hs-cTnI, the lowest concentration at which the coeffi cient of variation was < or =10% were 0.03 ng/mL, respectively. Therefore, in the present study, an elevated cTnT or cTnI test was defined as a level of > or =0.03 ng/mL. RESULTS: During long-term follow up, there were 20 cardiac deaths. In 258 CHF patients, serum cTnT were elevated (> or =0.03 ng/mL) in 32 patients (12%) and serum hs-cTnI was elevated (> or =0.03 ng/mL) in 112 patients (43%). On stepwise multivariate analyses, high plasma NT-proBNP (> or =627 pg/mL, P = .0063) and hs-cTnI (> or =0.03 ng/mL) (P = .016) were independent significant prognostic predictors but cTnT (> or =0.03 ng/mL) was not. The hazard ratio for mortality of patients with high plasma NT-proBNP (> or =627 pg/mL) and hs-cTnI (> or =0.03 ng/mL) was 5.74 (95% CI, 2.33-14.28, P < .0001) compared to that of those with low NT-proBNP (<627 pg/mL) or hs-cTnI (<0.03 ng/mL). CONCLUSIONS: These findings indicate that a high plasma concentration of hs-cTnI is an independent and useful prognostic predictor in patients with CHF.

PMID: 20102868 [PubMed - in process]

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Noninvasive assessment of left ventricular filling pressure after acute myocardial infarction: A prospective study of the relative prognostic utility of clinical assessment, echocardiography, and B-type natriuretic peptide.

Am Heart J. 2010 Jan;159(1):47-54

Authors: Kruszewski K, Scott AE, Barclay JL, Small GR, Croal BL, Møller JE, Oh JK, Hillis GS

BACKGROUND: Elevated left ventricular filling pressure after acute myocardial infarction (AMI) may be identified using clinical assessment, echocardiography, and B-type natriuretic peptide (BNP) levels. All of these predict outcome in this setting. There are, however, no data assessing their relative prognostic value. The current study addresses this. METHODS: Four hundred patients underwent detailed echocardiography and measurement of BNP levels after AMI (median 1 day). The study end points were (1) a composite of death, recurrent AMI, and/or admission to hospital with heart failure within 1 year and (2) all-cause mortality during medium-term follow-up (median 2.9 years). RESULTS: Both an elevated ratio of early transmitral flow to early mitral annulus velocity (E/e') and higher BNP levels were associated with an increased risk of an adverse event within the first year (odds ratio 6.14 for E/e' >15, P < .001; odds ratio 1.19 per 50-pg/mL increase in BNP, P < .001) and medium-term mortality (hazard ratio 4.67 for E/e' >15, P < .001; hazard ratio 1.10 per 50-pg/mL increase in BNP, P < .001). Among patients with BNP levels higher than the median or in the upper quartile, an E/e' ratio >15 identified a subgroup at greatest risk of mortality (P < .001 for both). CONCLUSIONS: The E/e' ratio and BNP levels play important and complementary roles in the risk stratification of patients after AMI.

PMID: 20102866 [PubMed - in process]

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