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Julio Núñez,
Miguel González,
Gema Miñana,
Rafael Garcia-Ramón,
Juan Sanchis, Vicent Bodí,
Eduardo Núñez,
Maria Jesús Puchades,
Patricia Palau,
Pilar Merlos,
Beatriz Mascarell,
Alfonso Miguel
[show abstract]
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ABSTRACT: INTRODUCTION AND OBJECTIVES: Peritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction. METHODS: A total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses. RESULTS: The peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001). CONCLUSIONS: In refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes. Full English text available from:www.revespcardiol.org.
Revista Espa de Cardiologia 08/2012; 65(11):986-995. · 2.53 Impact Factor
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Julio Núñez,
Eduardo Núñez,
Gema Miñana, Vicent Bodí,
Gregg C Fonarow,
Vicente Bertomeu-González,
Patricia Palau,
Pilar Merlos,
Silvia Ventura,
Francisco J Chorro,
Pau Llàcer,
Juan Sanchis
[show abstract]
[hide abstract]
ABSTRACT: Recent observations in chronic stable heart failure suggest that high-dose loop diuretics (HDLDs) have detrimental prognostic effects in patients with high blood urea nitrogen (BUN), but recent findings have also indicated that diuretics may improve renal function. Carbohydrate antigen 125 (CA125) has been shown to be a surrogate of systemic congestion. We sought to explore whether BUN and CA125 modulate the mortality risk associated with HDLDs following a hospitalization for acute heart failure (AHF).
We analysed 1389 consecutive patients discharged for AHF. CA125 and BUN were measured at a mean of 72 ± 12 h after admission. HDLDs (≥120 mg/day in furosemide equivalent dose) were interacted to a four-level variable according to CA125 (>35 U/mL) and BUN (above the median), and related to all-cause mortality. At a median follow-up of 21 months, 561 (40.4%) patients died. The use of HDLDs was independently associated with increased mortality [hazard ratio (HR) 1.23, 95% confidence interval (CI) 1.01-1.50], but this association was not homogeneous across CA125-BUN categories (P for interaction <0.001). In patients with normal CA125, use of HDLDs was associated with high mortality if BUN was above the median (HR 2.29, 95% 1.51-3.46), but not in those with BUN below the median (HR 1.22, 95% CI 0.73-2.04). Conversely, in patients with high CA125, HDLDs showed an association with increased survival if BUN was above the median (HR 0.73, 95% CI 0.55-0.98) but was associated with increased mortality in those with BUN below the median (HR 1.94, 95% CI 1.36-2.76).
The risk associated with HDLDs in patients after hospitalization for AHF was dependent on the levels of BUN and CA125. The information provided by these two biomarkers may be helpful in tailoring the dose of loop diuretics at discharge for AHF.
European Journal of Heart Failure 06/2012; 14(9):974-84. · 4.90 Impact Factor
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Julio Núñez,
Marifina Chilet,
Maria L Blasco,
María A Clari,
Rafael Sanjuan,
Beatriz Muñoz-Cobo, Vicent Bodí,
Elisa Costa,
Dayana Bravo,
Juan Sanchis,
Gema Miñana,
David Navarro
Atherosclerosis 02/2012; 222(1):295-7. · 3.79 Impact Factor
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Julio Núñez,
Miguel González,
Gema Miñana,
Rafael Garcia-Ramón,
Juan Sanchis, Vicent Bodí,
Eduardo Núñez,
Maria Jesús Puchades,
Patricia Palau,
Pilar Merlos,
Angel Llàcer,
Alfonso Miguel
[show abstract]
[hide abstract]
ABSTRACT: Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an additional therapeutic resource for patients with advanced congestive heart failure (CHF). The objective of this study was to determine the therapeutic role of CAPD, in terms of surrogate endpoints, in the management of patients with advanced CHF and renal dysfunction.
A total of 57 candidates with New York Heart Association (NYHA) class III/IV CHF, renal dysfunction (glomerular filtration rate < 60 mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment, and at least two previous hospitalizations for acute heart failure (AHF) were invited to be included in the CAPD programme; however, 25 patients were finally included. The primary outcome was evaluated by the change at 6 and 24 weeks for the Minnesota Living With Heart Failure Questionnaire (MLWHFQ), the 6 min walk test (6MWT), NYHA class, serum natriuretic peptides [brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)], serum carbohydrate antigen 125 (CA125), and hospitalization rates for AHF. CAPD was associated with a substantial improvement in the MLWHFQ (-21.3, P < 0.001; and -20.4, P < 0.001), the 6MWT (54.0, P < 0.001; and 45.6, P = 0.023), and NYHA class (-1.0, P < 0.001; and -1.4, P < 0.001) at 6 and 24 weeks, respectively. The Ln(CA125) decreased markedly (-0.8, P = 0.003; and -0.98, P = 0.003), with no effect on BNP and NT-proBNP. There was a marked reduction in the number of days hospitalized for AHF (6 month post-CAPD vs. 6 months pre-CAPD: -84%; P < 0.001).
In advanced CHF and renal dysfunction, CAPD was associated with short/mid-term improvement in severity parameters, with an acceptable rate of side effects.
European Journal of Heart Failure 02/2012; 14(5):540-8. · 4.90 Impact Factor
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[show abstract]
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ABSTRACT: Decision making in chest pain of uncertain origin is challenging.
To evaluate the predictive value of simple characteristics of pain presentation in patients coming to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin.
789 patients were studied. The following categorical pain characteristics were collected: effort related pain, pressing character, radiation, associated symptoms, and ≥ 2 episodes in 24 h. Additionally, a predefined semi-quantitative pain score including seven items (Geleijnse score) was completed. Risk factors and co-morbidities were also recorded. The primary and secondary endpoints were cardiac events at 30 days and at 1 year.
After adjusting for risk factors and co-morbidites, the pain characteristics associated with the primary and secondary endpoints were effort related pain (HR=2.1, 95% CI 1.5 to 3.0, p=0.0001; HR=1.8, 95% CI 1.3 to 2.5, p=0.0003) and ≥ 2 episodes in 24 h (HR=2.4, 95% CI 1.7 to 3.5, p=0.0001; HR=2.3, 95% CI 1.7 to 3.2, p=0.0001). Both variables retained their predictive value in women, diabetics and elderly (>70 years) patients. The discriminatory capacity of the predictive models including these two pain characteristics for the primary and secondary endpoints (C-statistic 0.76 and 0.76) was better than using the complex semi-quantitative pain score (C-statistic 0.69 and 0.71).
In patients presenting to the emergency department with chest pain and without electrocardiogram ischaemia or raised troponin, effort related pain and ≥ 2 episodes in 24 h are the main characteristics to be considered for decision making.
Emergency Medicine Journal 10/2011; 28(10):847-50. · 1.44 Impact Factor
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Julio Núñez,
Juan Sanchis,
Eduardo Núñez,
Gregg C Fonarow, Vicent Bodí,
Vicente Bertomeu-González,
Gema Miñana,
Patricia Palau,
Lorenzo Fácila,
Francisco J Chorro,
Vicente Bertomeu-Martínez,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: The prognostic benefit of statins in patients with heart failure is a topic of controversy. Under the hypothesis that statins may provide greater benefit in a subgroup of patients with heightened inflammatory activity, we sought to explore whether statins are associated with a decreased risk of long-term mortality in patients with acute heart failure based on elevated levels of carbohydrate antigen 125, a biomarker related to systemic congestion and proinflammatory status.
We analysed 1222 consecutive patients admitted with acute heart failure in a single teaching center during a median follow-up of 20 months. carbohydrate antigen 125 was measured during index hospitalization and dichotomized according to the established reference cut-off (>35 U/mL).
Increased levels of carbohydrate antigen 125 (>35 U/mL) were observed in 793 (64.9%) and prescription of statins registered in 455 (37.2%) patients. In patients with carbohydrate antigen 125 >35 U/mL, mortality was lower in statin-treated patients (1.89 vs 2.80 per 10 patient-years of follow-up, P <.001). Conversely, in those with carbohydrate antigen 125 in normal range, mortality did not differ (1.76 vs 1.63 per 10 patient-years of follow-up, P = .862). After covariate adjustment, this differential effect persisted (P for interaction = .024) and statin use was associated with a significant mortality reduction in patients with elevated values of carbohydrate antigen 125 (hazard ratio=0.65, 95% confidence interval: 0.51-0.82; P <.001), but not in those with values equal to or below 35 U/mL (hazard ratio=1.02, 95% confidence interval: 0.74-1.41; P = .907).
Elevation of carbohydrate antigen 125 (>35 U/mL) identified a subset of patients with acute heart failure who could benefit from statin treatment in regard to total mortality.
Revista Espa de Cardiologia 09/2011; 64(12):1100-8. · 2.53 Impact Factor
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Julio Núñez,
Eduardo Núñez,
Juan Sanchis, Vicent Bodí,
Gregg C Fonarow,
Gema Miñana,
Patricia Palau,
Vicente Bertomeu-González,
Arturo Carratalá,
Luis Mainar,
Francisco J Chorro,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: The prognostic utility of combining serial measurements of brain natriuretic peptide (BNP) and antigen carbohydrate 125 (CA125) is largely unknown. The aim of this work is to assess the prognostic utility of serial measurements of BNP, CA125, and their optimal combination for predicting long-term mortality, following a hospitalization for acute heart failure (AHF).
We analyzed 293 consecutive patients admitted with AHF where CA125 and BNP were measured at discharge (T1) and at the first ambulatory visit (T2: median 31 days after discharge). Biomarkers were evaluated as snapshot determinations or as serial changes in absolute, relative or categorical changes and related to subsequent mortality with Cox regression analysis. The incremental prognostic value added by each biomarker was evaluated by the integrated discrimination improvement (IDI) index. During a median follow-up of 18 months, 91 deaths (31.1%) were identified. From the different metrics tested, the categorical changes in CA125 (Normalization: decreasing to≤35 U/ml at T2; Decreasing but not normalization: decreasing but T2>35 U/ml; small-increase: increasing but T2≤35 U/ml and; high-increase: increasing and T2>35 U/ml) showed the best discriminative accuracy. For BNP none of the serial changes metrics tested were superior to a single determination at T2 (BNP≥100 pg/ml). Adding these two biomarkers characterization to the clinical model, resulted in a 9.21% (p<0.001) gain in IDI index.
In patients discharged for AHF, CA125 modeled as a pre-post categorical change, and BNP as a single determination at T2, resulted in the best marker combination for predicting all-cause mortality.
International journal of cardiology 03/2011; 159(1):21-8. · 7.08 Impact Factor
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International journal of cardiology 02/2011; 146(3):473-4. · 7.08 Impact Factor
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Julio Núñez,
Eduardo Núñez,
Gema Miñana,
Juan Sanchis, Vicent Bodí,
Eva Rumiz,
Patricia Palau,
Myriam Olivares,
Pilar Merlos,
Clara Bonanad,
Luis Mainar,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: Several works have endorsed a significant role of the immune system and inflammation in the pathogenesis of heart failure. As indirect evidence, an association between a low relative lymphocyte count (RLC%) and worse outcomes found in this population has been suggested. Nevertheless, the role of RLC% for risk stratification in a large and nonselected population of patients with acute heart failure (AHF) has not yet been determined. Thus, the aim of this study was to determine the association between low RLC% and 1-year mortality in patients with AHF and consequently to define whether it has any role for early risk stratification. A total of 1,192 consecutive patients admitted for AHF were analyzed. Total white blood cell and differential counts were measured on admission. RLC% (calculated as absolute lymphocyte count/total white blood cell count) was categorized in quintiles and its association with all-cause mortality at 1 year assessed using Cox regression. At 1 year, 286 deaths (24%) were identified. A negative trend was observed between 1-year mortality rates and quintiles of RLC%: 31.5%, 27.2%, 23.1%, 23%, and 15.5% in quintiles 1 to 5, respectively (p for trend <0.001). After thorough covariate adjustment, only patients in the lowest quintile (<9.7%) showed an increased risk for mortality (hazard ratio 1.76, 95% confidence interval 1.17 to 2.65, p = 0.006). When RLC% was modeled with restricted cubic splines, a stepped increase in risk was observed patients in quintile 1: those with RLC% values <7.5% and <5% showed 1.95- and 2.66-fold increased risk for death compared to those in the top quintile. In conclusion, in patients with AHF, RLC% is a simple, widely available, and inexpensive biomarker, with potential for identifying patients at increased risk for 1-year mortality.
The American journal of cardiology 02/2011; 107(7):1034-9. · 3.58 Impact Factor
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International journal of cardiology 12/2010; 145(3):547-8. · 7.08 Impact Factor
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Vicente Bertomeu-González,
Julio Núñez,
Eduardo Núñez,
Alberto Cordero,
Lorenzo Fácila,
Ricardo Ruiz-Granell,
Juan Quiles,
Juan Sanchis, Vicent Bodí,
Gema Miñana,
Vicente Bertomeu,
Angel Llàcer
International journal of cardiology 12/2010; 145(3):592-3. · 7.08 Impact Factor
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Julio Núñez,
Marifina Chilet,
Juan Sanchis, Vicent Bodí,
Eduardo Núñez,
Gema Miñana,
Nuria Tormo,
Maria A Clari,
Mauricio Pellicer,
Francisco J Chorro,
Angel Llàcer,
David Navarro
[show abstract]
[hide abstract]
ABSTRACT: AHF (acute heart failure) causes significant morbidity and mortality. Recent studies have postulated that the expression of inflammatory mediators, such as cytokines and chemokines, plays an important role in the development and progression of heart failure. A pro-inflammatory state has been postulated as a key factor in triggering CMV (cytomegalovirus) reactivation. Therefore we sought to determine the prevalence of active CMV infection in immunocompetent patients admitted for AHF and to quantify the association with the risk of the combined end point of death or AHF readmission. A total of 132 consecutive patients admitted for AHF were enrolled in the present study. Plasma CMV DNAaemia was assessed by qRT-PCR (quantitative real-time PCR), and cytokine measurements in plasma were performed by ELISA. Clinical data were evaluated by personnel blinded to CMV results. The independent association between active CMV infection and the end point was determined by Cox regression analysis. During a median follow-up of 120 [IQR (interquartile range), 60-240] days, 23 (17.4%) deaths, 34 (24.2%) readmissions for AHF and 45 (34.1%) deaths/readmissions for AHF were identified. Plasma CMV DNAaemia occurred in 11 (8.3%) patients, albeit at a low level (<100 copies/ml). The cumulative rate of the composite end point was higher in patients with CMV DNAaemia (81.8 compared with 29.8%; P<0.001). After adjusting for established risk factors, the occurrence of CMV DNAaemia was strongly associated with the clinical end point [hazard ratio = 4.39 (95% confidence interval, 2.02-9.52); P<0.001]. In conclusion, active CMV infection occurs, although uncommonly, in patients with AHF, and may be a marker of disease severity.
Clinical Science 11/2010; 119(10):443-52. · 4.61 Impact Factor
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Journal of the American College of Cardiology 11/2010; 56(19):1609; author reply 1609-10. · 14.16 Impact Factor
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Julio Núñez,
Juan Sanchis,
Eduardo Núñez, Vicent Bodí,
Luis Mainar,
Gema Miñana,
Pilar Merlos,
Patricia Palau,
Oliver Husser,
Eva Rumiz,
Francisco J Chorro,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: Little is known about how prognosis is influenced by readmission for acute heart failure (AHF) following non-ST-segment elevation acute coronary syndrome (NSTEACS). The aim of this study was to determine the prognostic effect of a first admission for AHF on the risk of acute myocardial infarction (AMI) or death in patients who survived an episode of high-risk NSTEACS.
The study involved 972 consecutive patients with high-risk NSTEACS who survived after hospital admission. Readmission for AHF was selected as the main exposure variable, and its association with subsequent AMI or all-cause death was assessed using Cox proportional hazards models for time-dependent covariates that also included adjustment for competing risks.
After a median follow-up period of 30 [interquartile range, 12-48] months, 82 patients (8.4%) were admitted for AHF, 146 (15%) had an AMI, and 202 (20.8%) died. The median time to readmission for AHF was 203 [56-336] days after NSTEACS. Patients readmitted for AHF had an increased risk of subsequent death (hazard ratio [HR]=1.67; 95% confidence interval [CI], 1.13-2.45; P=.009) or AMI (HR=2.15; 95% CI, 1.41-3.27; P< .001), which was independent of baseline prognostic and time-dependent variables.
Readmission for AHF after high-risk NSTEACS was associated with an increased risk of subsequent death or AMI.
Revista Espa de Cardiologia 09/2010; 63(9):1035-44. · 2.53 Impact Factor
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Patricia Palau,
Julio Núñez,
Juan Sanchis, Vicent Bodí,
Eva Rumiz,
Eduardo Núñez,
Gema Miñana,
Pilar Merlos,
Cristina Gómez,
Lorenzo Fácila,
Francisco J Chorro,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: Few data are available on the use of invasive treatment in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) and systolic dysfunction. The aim of this study was to determine the effect of invasive treatment on the prognosis of patients with NSTEACS, with or without systolic dysfunction.
The study included 972 consecutive patients admitted for NSTEACS (i.e. ST-segment depression or an elevated troponin-I level). Systolic dysfunction was defined as an ejection fraction <50% on transthoracic echocardiography. The primary long-term endpoint was death or myocardial infarction. The effect of invasive treatment on prognosis was evaluated by Cox regression analysis.
Overall, 23.4% of patients had systolic dysfunction, and 303 (31.2%) reached the primary endpoint, which was more frequent in those with systolic dysfunction (49.8% vs. 25.5%; P< .001). Usage of coronary angiography and revascularization procedures were similar in patients with systolic dysfunction and those with an ejection fraction >/=50% (59% vs. 63.4%; P=.239; and 38.3% vs. 38.8%; P=.9; respectively). Detailed adjusted multivariate analysis, including the use of a propensity score, demonstrated that coronary angiography had a differential effect on prognosis depending on the presence or absence of systolic dysfunction (interaction, P=.01). Catheterization was clearly beneficial in patients with systolic dysfunction (hazard ratio [HR]=0.47; 95% confidence interval [CI], 0.3-0.75; P=.001) but not in those with an ejection fraction >/=50% (HR=0.9; 95% CI, 0.63-1.29; P=.567).
The presence of systolic dysfunction identifies those patients with NSTEACS who will benefit most from invasive treatment.
Revista Espa de Cardiologia 08/2010; 63(8):915-24. · 2.53 Impact Factor
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Julio Núñez,
Juan Sanchis, Vicent Bodí,
Gregg C Fonarow,
Eduardo Núñez,
Vicente Bertomeu-González,
Gema Miñana,
Luciano Consuegra,
Maria José Bosch,
Arturo Carratalá,
Francisco J Chorro,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: Elevated brain natriuretic peptide (BNP) and tumour marker antigen carbohydrate 125 (CA125) levels have shown to be associated with higher risk for adverse outcomes in patients with acute heart failure (AHF). Nevertheless, no attempt has been made to explore the utility of combining these two biomarkers. We sought to assess whether CA125 adds prognostic value to BNP in predicting 6-month all-cause mortality in patients with AHF.
We analysed 1111 consecutive patients admitted for AHF. Antigen carbohydrate 125 (U/mL) and BNP (pg/mL) were measured at a median of 72 +/- 12 h after instauration of treatment. Antigen carbohydrate 125 and BNP were dichotomized based on proposed prognostic cutpoints, and a variable with four categories was formed (BNP-CA125): C1 = BNP < 350 and CA125 < 60 (n = 394); C2 = BNP > or = 350 and CA125 < 60 (n = 165); C3 = BNP < 350 and CA125 > or = 60 (n = 331); and C4 = BNP > or = 350 and CA125 > or = 60 (n = 221). The independent association between BNP-CA125 and mortality was assessed with the Cox regression analysis, and their added predictive ability tested by the integrated discrimination improvement (IDI) index. At 6 months, 181 deaths (16.3%) were identified. The cumulative rate of mortality was lower for patients in C1 (7.8%), intermediate for C2 and C3 (17.8% and 16.9%, respectively), and higher for C4 (37.2%), and P-value for trend <0.001. After adjusting for established risk factors, the highest risk was observed when both biomarkers were elevated (C4 vs. C1: HR = 4.05, 95% CI = 2.54-6.45; P < 0.001) and intermediate when only one of them was elevated: (C2 vs. C1: HR = 1.71, 95% CI = 1.00-2.93; P = 0.050) and (C3 vs. C1: HR = 2.10, 95% CI = 1.30-3.39; P = 0.002). Moreover, when CA125 was added to the clinical model + BNP, a 10.4% (P < 0.0001) improvement in the IDI (on the relative scale) was found.
In patients admitted with AHF, CA125 added prognostic value beyond the information provided by BNP, and thus, their combination enables better 6-month risk stratification.
European Heart Journal 07/2010; 31(14):1752-63. · 10.48 Impact Factor
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ABSTRACT: Evaluation of chest pain of uncertain origin in the emergency department is a challenge. Chest pain units, involving non-invasive stress testing, have logistic constraints. Our aim was to identify very low risk patients for early discharge using clinical data.
A total of 772 patients were studied. Ischemia in the electrocardiogram, troponin elevation or history of ischemic heart disease, were exclusion criteria. The primary end point was 30 day cardiac events (death, myocardial infarction or revascularization). The secondary end point was 1 year major events (death or myocardial infarction).
The primary and secondary end point rates were 123 (18%) and 31 (4%). Predictive variables for the primary end point were typical chest pain (OR=1.8, p=0.007), ≥ 2 pain episodes in last 24h (OR=3.4, p=0.0001), age ≥ 55 years (OR=1.8, p=0.03), male (OR=2.2, p=0.001), diabetes (OR=1.8, p=0.01) and family history of ischemic heart disease (OR=2.0, p=0.02). A very low risk category could be distinguished (<2 predictors, n=114) that showed only 3 (2.6%) events at 30 days (all 3 revascularizations), compared with 120 (18%) in the remaining patients (p=0.0001). The very low risk criteria had 97% negative predictive for 30 day cardiac events. No very low risk patient presented major events at 1 year compared with 31 (4.7%) in the remaining patients (p=0.009).
In patients presenting to the emergency department with chest pain of uncertain origin and without prior ischemic heart disease, very low risk patients can be identified using clinical data. These patients could be quickly discharged without further non-invasive stress testing.
International journal of cardiology 05/2010; 150(3):260-3. · 7.08 Impact Factor
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Julio Núñez,
Eduardo Núñez,
Gregg C Fonarow,
Juan Sanchis, Vicent Bodí,
Vicente Bertomeu-González,
Gema Miñana,
Pilar Merlos,
Vicente Bertomeu-Martínez,
Josep Redón,
Francisco J Chorro,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the relationship between systolic blood pressure (SBP) and long-term mortality in patients with acute heart failure (AHF) stratified by ejection fraction (LVEF): reduced (< or =40%) vs. preserved (> or =50%).
We studied 1049 consecutive patients admitted with AHF. Systolic blood pressure was determined in the emergency department. Left-ventricular ejection fraction was categorized as < or =40% (n = 288), 41-49% (n = 174), or > or =50% (n = 587). Cox regression analysis was used for multivariable analysis. Mean age and SBP were 73 +/- 11 years and 150 +/- 36 mmHg, respectively. During a median follow-up of 18 months, 290 deaths (33.1%) were identified. Higher SBP was associated with lower mortality. In multivariable analysis, a differential effect of SBP across LVEF status was documented (P-value for interaction = 0.036). In linear models, SBP was shown to be inversely related with mortality in both groups (per 10 mmHg decrease): HR((LVEF > or = 50%)): 1.06, CI 95% = 1.01-1.11; P = 0.016, and HR((LVEF < or = 40%)): 1.16, 95% CI = 1.08-1.25; P < 0.001). When SBP was modelled with restrictive cubic splines, an inverse and almost linear relationship with mortality was shown in patients with LVEF < or =40% (P < 0.001), whereas in patients with LVEF > or =50%, SBP followed a J-shape curve.
In patients with AHF, SBP showed a differential prognostic effect on mortality according to LVEF status; when LVEF was < or =40%, SBP was linearly and inversely associated with mortality. Conversely, in patients with LVEF > or =50% this relationship showed a J-shape pattern.
European Journal of Heart Failure 01/2010; 12(1):38-44. · 4.90 Impact Factor
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Julio Núñez,
Eduardo Núñez, Vicent Bodí,
Juan Sanchis,
Luis Mainar,
Gema Miñana,
Lorenzo Fácila,
Vicente Bertomeu,
Pilar Merlos,
Helene Darmofal,
Patricia Palau,
Angel Llácer
[show abstract]
[hide abstract]
ABSTRACT: We sought to determine the relationship between the lowest lymphocyte count (lymphocyte(min))obtained within the first 96 h of symptoms onset and the risk of postdischarge recurrent spontaneous myocardial infarction (re-MI) in patients admitted with ST-segment elevation MI (STEMI).
We analyzed 549 consecutive patients admitted with STEMI from a single academic hospital. Lymphocyte counts were determined at admission and routinely during the first 96 h. Lymphocyte(min) was selected as the main exposure. Patients with inflammatory or infectious diseases, in-hospital death, or reinfarction were excluded from the analysis (final sample= 426 patients). Lymphocyte(min) was divided into quartiles (Q) and their association with re-MI was assessed by competing risk analysis. Postdischarge death and coronary revascularization were considered competing events.
During a median follow-up of 36 months, 53 re-MI (12.4%) were registered. The re-MI crude rate was significantly higher in patients in the lowest lymphocyte(min) quartile (Q1r1045 cells/ml) compared with Q2-Q4: 22.4, 9.4, 8.4, 9.4%, respectively; P =0.005. In a multivariate setting, Q1 was also associated with a significant increased risk of re-MI compared with Q2-Q4 (hazard ratio: 2.04, 95% confidence interval: 1.11-3.76; P = 0.021).
Low lymphocyte count obtained within the first 96 h of a STEMI predicts the risk of re-MI.
Coronary artery disease 01/2010; 21(1):1-7. · 1.56 Impact Factor
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Julio Núñez,
Juan Sanchis, Vicent Bodí,
Eduardo Núñez,
Anne M Heatta,
Gema Miñana,
Pilar Merlos,
Eva Rumiz,
Patricia Palau,
Rafael Sanjuán,
Maria L Blasco,
Angel Llàcer
[show abstract]
[hide abstract]
ABSTRACT: Low lymphocyte count (LLC), a surrogate for inflammation, has emerged as a potential risk factor for cardiovascular outcomes, especially new ischemic events. To identify patients with non-ST segment elevation acute coronary syndromes (NSTEACS) who benefit from an invasive revascularization strategy remains a challenge. We sought to determine if patients with high-risk NSTEACS who exhibited LLC have a greater reduction in long-term post-discharge myocardial infarction (MI) when managed under a revascularization invasive strategy (RIS) as compared with conservative strategy (CS).
Nine hundred seventy two consecutive patients with high-risk NSTEACS were treated under two revascularization strategies (RS): 1) CS, from January 2001 to October 2002 (345 patients; 35.5%) and 2) RIS, from November 2002 to May 2005 (627 patients; 64.5%). LLC was defined as lymphocytes count < or =1200 cells/ml (1 vs. 2-4 quartiles). The association between the type of RS and MI was stratified by lymphocyte count status and assessed by Cox regression adapted for competing events.
At 3-year follow-up, 145 deaths (14.9%), 135 MI (13.9%) and 76 revascularization procedures (7.8%) were registered. In a multivariable setting, LLC patients exhibited a greater MI risk reduction when managed under RIS (HR: 0.40; 95% CI=0.22-0.72, p=0.003). Conversely, when LLC was not present, no difference in the rate of MI was detected between the two RS.
LLC identifies a subgroup of patients with greater reduction in the risk of postdischarge MI when a RIS is applied.
European Journal of Internal Medicine 12/2009; 20(8):768-74. · 2.00 Impact Factor
