ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 (ending).

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Esc guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 (ending)

Myocardial infarction in the absence of obstructive coronary artery disease is found in ≈5% to 6% of all patients with acute infarction who are referred for coronary angiography. There are a variety of causes that can result in this clinical condition. As such, it is important that patients are appropriately diagnosed and an evaluation to uncover the correct cause is performed so that, when possible, specific therapies to treat the underlying cause can be prescribed. This statement provides a formal and updated definition for the broadly labelled term MINOCA (incorporating the definition of acute myocardial infarction from the newly released "Fourth Universal Definition of Myocardial Infarction") and provides a clinically useful framework and algorithms for the diagnostic evaluation and management of patients with myocardial infarction in the absence of obstructive coronary artery disease.

Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association

Background —Type 2 myocardial infarction and myocardial injury are common in clinical practice, but long-term consequences are uncertain. We aimed to define long-term outcomes and explore risk stratification in patients with type 2 myocardial infarction and myocardial injury. Methods —We identified consecutive patients (n=2,122) with elevated cardiac troponin I concentrations (≥0.05 μg/L) at a tertiary cardiac center. All diagnoses were adjudicated as per the Universal Definition of Myocardial Infarction. The primary outcome was all-cause death. Secondary outcomes included major adverse cardiovascular events (MACE; non-fatal myocardial infarction or cardiovascular death) and non-cardiovascular death. To explore competing risks, cause-specific hazard ratios were obtained using Cox regression models. Results —The adjudicated index diagnosis was type 1 or type 2 myocardial infarction or myocardial injury in 1,171 (55.2%), 429 (20.2%) and 522 (24.6%) patients, respectively. At five years, all-cause death rates were higher in those with type 2 myocardial infarction (62.5%) or myocardial injury (72.4%) compared with type 1 myocardial infarction (36.7%). The majority of excess deaths in those with type 2 myocardial infarction or myocardial injury were due to non-cardiovascular causes (HR 2.32, 95%CI 1.92-2.81, versus type 1 myocardial infarction). Despite this, the observed crude MACE rates were similar between groups (30.6% versus 32.6%), with differences apparent after adjustment for co-variates (HR 0.82, 95%CI 0.69-0.96). Coronary heart disease was an independent predictor of MACE in those with type 2 myocardial infarction or myocardial injury (HR 1.71, 95%CI 1.31-2.24). Conclusions —Despite an excess in non-cardiovascular death, patients with type 2 myocardial infarction or myocardial injury have a similar crude rate of major adverse cardiovascular events to those with type 1 myocardial infarction. Identifying underlying coronary heart disease in this vulnerable population may help target therapies that could modify future risk.

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Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury

Background: Empagliflozin reduces the risk of cardiovascular death or hospitalization for heart failure in patients with heart failure and a reduced ejection fraction, with or without diabetes, but...

Effect of Empagliflozin on the Clinical Stability of Patients With Heart Failure and a Reduced Ejection Fraction: The EMPEROR-Reduced Trial.

Type 2 Myocardial Infarction: JACC Review Topic of the Week

Background —Despite growing recognition of Type 2 myocardial infarction (T2MI; related to supply-demand mismatch), little is known about its risk factors or its association with outcome.

Methods —A single center cohort of patients undergoing coronary or peripheral angiography with or without intervention was prospectively enrolled and followed for incident type 1 and T2MI, as well as major adverse cardiovascular events (MACE, a composite of all-cause death, non-fatal MI, heart failure, stroke, transient ischemic attack, peripheral arterial complication and cardiac arrhythmia). T2MI was adjudicated using criteria from the Third Universal Definition of MI. Baseline characteristics, blood samples and angiography information were obtained. Major end points subsequent to first MI were assessed using landmark analyses to compare the rates of first events only where everyone with a prior history of any MACE prior to MI were censored and adjusted for follow up times. Cox proportional hazard models were used for time-to-event analyses with age and sex forced into all models and additional covariates evaluated using the stepwise option for the selection.

Results —1251 patients were enrolled and followed for a median of 3.4 years. 152 (12.2%) had T2MI during follow up; T2MI was frequently recurrent. Multivariable predictors of T2MI were older age, lower systolic blood pressure, history of coronary artery disease, heart failure, chronic obstructive pulmonary disease, diabetes mellitus, nitrate use, and elevated concentrations of glucose, N-terminal pro-B type natriuretic peptide and cystatin C. Patients with T2MI had higher rates of subsequent adverse events compared with those without T2MI (per 100 person/years: MACE, 53.7 vs. 21.1, p<0.001; all-cause death, 23.3 vs. 3.3, p<0.001; cardiovascular death, 17.5 vs. 2.6, p<0.001; heart failure events: 22.4 vs. 7.4 p<0.001); these rates are similar to those seen in those with Type 1 MI. Incident diagnosis of T2MI strongly predicted risk for subsequent MACE (adjusted HR 1.90, 95% CI=1.46-2.48; p<0.001), all-cause death (adjusted HR 2.96, 95% CI=2.01-4.36; p<0.001) and cardiovascular death (adjusted HR 2.16, 95% CI=1.36-3.43; p=0.001). 

Conclusions —T2MI is common and associated with poor prognosis. Studies evaluating treatment strategies for management of T2MI are needed.

Clinical Trial Registration —https://clinicaltrials.gov/ct2/show/[NCT00842868][1], Clinical Trials.Gov # [NCT00842868][1].

 [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00842868&atom=%2Fcirculationaha%2Fearly%2F2016%2F11%2F21%2FCIRCULATIONAHA.116.023052.atom

Incident Type 2 Myocardial Infarction in a Cohort of Patients Undergoing Coronary or Peripheral Arterial Angiography

The care of patients with acutely decompensated heart failure is being reshaped by the availability and understanding of several novel and emerging heart failure biomarkers. The gold standard biomarkers in heart failure are B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, which play an important role in the diagnosis, prognosis, and management of acute decompensated heart failure. Novel biomarkers that are increasingly involved in the processes of myocardial injury, neurohormonal activation, and ventricular remodeling are showing promise in improving diagnosis and prognosis among patients with acute decompensated heart failure. These include midregional proatrial natriuretic peptide, soluble ST2, galectin-3, highly-sensitive troponin, and midregional proadrenomedullin. There has also been an emergence of biomarkers for evaluation of acute decompensated heart failure that assist in the differential diagnosis of dyspnea, such as procalcitonin (for identification of acute pneumonia), as well as markers that predict complications of acute decompensated heart failure, such as renal injury markers. In this article, we will review the pathophysiology and usefulness of established and emerging biomarkers for the clinical diagnosis, prognosis, and management of acute decompensated heart failure.

Biomarkers in Acute Heart Failure

Resumen La asistencia de los pacientes con descompensacion aguda de la insuficiencia cardiaca esta cambiando gracias a la disponibilidad y el conocimiento de varios nuevos biomarcadores de la insuficiencia y otros que estan apareciendo Los patrones de referencia como biomarcadores en la insuficiencia cardiaca son el peptido natriuretico tipo B y la fraccion aminoterminal del propeptido natriuretico tipo B, que desempenan un papel importante en el diagnostico, el pronostico y el tratamiento de la insuficiencia cardiaca aguda descompensada Los nuevos biomarcadores que se relacionan de manera creciente con los procesos de lesion miocardica, activacion neurohormonal y remodelado ventricular son prometedores para mejorar el diagnostico y el pronostico de los pacientes con insuficiencia cardiaca aguda descompensada Entre ellos se encuentran la region media del propeptido natriuretico auricular, la ST2 soluble, la galectina-3, la troponina de alta sensibilidad y la region media de proadrenomedulina Tambien se ha asistido a la aparicion de biomarcadores para la evaluacion de la insuficiencia cardiaca aguda descompensada que facilitan el diagnostico diferencial de la disnea, como la procalcitonina (para la identificacion de la neumonia aguda), asi como de marcadores que predicen las complicaciones de la insuficiencia cardiaca aguda descompensada, como son los marcadores de la lesion renal En este articulo se examina la fisiopatologia y la utilidad de los biomarcadores establecidos y los nuevos biomarcadores surgidos para el diagnostico clinico, el pronostico y el tratamiento de la insuficiencia cardiaca aguda descompensada

Biomarcadores en la insuficiencia cardiaca aguda

Objectives The goal of this study was to define and assess the significance of worsening heart failure (WHF) in patients with chronic ambulatory heart failure with reduced ejection fraction (HFrEF). Background WHF has been identified as a potentially relevant clinical event in patients with acute heart failure (HF) and is increasingly used as an endpoint in clinical trials. No standardized definition of WHF exists. It remains uncertain how WHF relates to risk for other HF events or how treatment may affect WHF. Methods A total of 151 symptomatic patients with chronic HFrEF were randomized to standard of care HF management or a goal to lower N-terminal pro–B-type natriuretic peptide (NT-proBNP) concentrations ≤1,000 pg/ml in addition to standard of care. WHF was prospectively defined as: 1) new or progressive symptoms and/or signs of decompensated HF; and 2) unplanned intensification of diuretic therapy. Results Over a mean follow-up of 10 months, 45 subjects developed WHF. At baseline, patients developing incident WHF had higher ejection fraction (31% vs. 25%; p = 0.03), were more likely to have jugular venous distension and edema (p  Conclusions In chronic HFrEF, WHF was associated with substantial risk for morbidity and mortality. NT-proBNP–guided care reduced risk for WHF.

The Importance of Worsening Heart Failure in Ambulatory Patients: Definition, Characteristics, and Effects of Amino-Terminal Pro-B-Type Natriuretic Peptide Guided Therapy

Worsening Renal Function during Management for Chronic Heart Failure with Reduced Ejection Fraction: Results From the Pro-BNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study

Aditi Mallick

Papers

Incident Type 2 Myocardial Infarction in a Cohort of Patients Undergoing Coronary or Peripheral Arterial Angiography

Biomarkers in Acute Heart Failure

Biomarcadores en la insuficiencia cardiaca aguda

The Importance of Worsening Heart Failure in Ambulatory Patients: Definition, Characteristics, and Effects of Amino-Terminal Pro-B-Type Natriuretic Peptide Guided Therapy

Worsening Renal Function during Management for Chronic Heart Failure with Reduced Ejection Fraction: Results From the Pro-BNP Outpatient Tailored Chronic Heart Failure Therapy (PROTECT) Study