Association of fibrinogen and D‑dimer levels with severity of acute coronary syndromes

Funding Acknowledgements Type of funding sources: None. Background The coronavirus disease 2019 (COVID-19) is mainly a respiratory disease potentially leading to acute respiratory distress syndrome but can have multiple system involvement. Data pertaining to cardiac sequalae is of urgent importance to define subsequent cardiac surveillance. Purpose To describe the short-term impact of COVID-19 pneumonia in patients with reduced Left ventricular ejection fraction (LVEF). Methods This single center, prospective observational study included 141 RT-PCR confirmed COVID-19 patients who had reduced ejection fraction on echocardiography quantitively assessed by modified Simpson’s method. The study group were divided into three groups based on the ejection fraction: 34 patients had mild left ventricular (LV) dysfunction (LVEF>41-50%), 50 patients had moderate left ventricular dysfunction (LVEF=31-40%) and 57 patients had severe left ventricular dysfunction (LVEF <30%). Demographics, clinical characteristics, in hospital events and clinical sequelae of survivors during 6 months follow up period were analyzed. Results Mean age of the study population was 60.22± 12.53 years.71.6% were males and 28.3% were females. Average length of hospital stay in the study group was 10.93±6.9 days. Patients with mild LV dysfunction had longer hospital stay (13.65± 7.09 days) than patients with moderate LV dysfunction (10.90±6.05 days) and patients with severe LV dysfunction (9.33±6.83 days) (p=0.01). Patients with severe LV dysfunction had higher Interleukin-6 levels (IL-6) and BNP levels in comparison to other groups.50% of patients with severe LV dysfunction required invasive ventilation during the course of hospital stay, while it was 20.6% in patients with mild LV dysfunction and 32% in patients with moderate LV dysfunction. 63% of patients with severe left ventricular dysfunction expired in the study period compared to 26.4% of patients with mild LV dysfunction and 40% of patients with moderate LV dysfunction (P=0.001). Patients with severe LV dysfunction had increased major adverse cardiac events in 6 months follow up compared to patients with mild and moderate LV dysfunction. Patients with severe LV dysfunction had increased in hospital mortality (40%) compared to patients with mild LV dysfunction (20%) and patients with moderate LV dysfunction (32%). Patients with higher levels of IL-6 (OR: 1.004, 95% CI: 1.002-1.01, P<0.001), procalcitonin (OR: 1.24, 95% CI: 1.07-1.44, P=0.004) and CT severity score (OR1.21, 95% CI: 1.13-1.28, P<0.01) are independent predictors of mortality in the study population. Conclusion Patient with reduced ejection fraction (LVEF <30%) have a poor 6 month outcome after COVID 19 pneumonia.

Introduction. Acute coronary syndrome (ACS), encompassing unstable angina, non-ST-segment eleva­tion myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), is a major global health concern due to its high morbidity and mortality. Research highlights a link between ACS and elevated acute phase reactants like C-reactive protein, emphasizing the role of inflammation and atherosclerosis. Serum fibrinogen, crucial in thrombus formation and an inflammatory marker, is significant in the coagu­lation process. This study investigates the predictive value of serum fibrinogen levels and the GRACE score for 3-month mortality in ACS patients. Aim. To examine the clinical profile of ACS patients and evaluate serum fibrinogen and GRACE score as prognostic markers for 3-month mortality. Methodology. A prospective observational study was conducted on 50 patients diagnosed with ACS at Saveetha Medical College Hospital. The study included adults over 18 with ACS, excluding those with severe comorbid conditions like end-stage liver disease or malignancy. Serum fibrinogen levels were measured at presentation and at 3 months using an automated coagulation analyzer. GRACE scores were calculated, and clinical assessments including ECG, cardiac markers, and ECHO were conducted. Data analysis involved IBM SPSS Statistics, utilizing descriptive statistics, t-tests, ANOVA, and Pearson's Correlation. Results. The study group had diverse demographics and a high prevalence of cardiovascular symptoms and comorbidities. The clinical profile of ACS showed a higher incidence of STEMI. Serum fibrinogen levels varied significantly across different Killip classes at presentation and at 3 months, with the highest levels in the more severe classes. Higher serum fibrinogen was linked to recurrent heart failure admissions and higher KILIPS class. However, there was no significant difference in fibrinogen levels between patients with and without interventions. The GRACE score was higher in STEMI patients, those with LV dysfunction, and correlated with higher serum fibrinogen. Lower FACIT F scores, indicating higher fatigue, were associated with higher fibrinogen levels and readmissions for heart failure. Conclusion. Higher serum fibrinogen levels and GRACE scores at presentation and at three months are indicators of severe myocardial infarction, increased heart failure readmission rates, and greater fatigue in ACS patients. These markers are valuable for evaluating morbidity in ACS and can aid in enhancing patient management strategies.

Serum amyloid A1 can be a novel biomarker for evaluating the presence and severity of acute coronary syndrome

Brain (B-type) natriuretic peptide (BNP) is a 32 amino acid peptide that is synthesized and released predominantly from ventricular myocardium in response to myocyte stretch. Like atrial natriuretic peptide (ANP), BNP seems to have almost exclusively beneficial physiological properties, including balanced vasodilation, natriuresis, and inhibition of both the sympathetic nervous system and the renin-angiotensin-aldosterone axis. Attempts to exploit these properties for therapeutic benefit has led to the development of recombinant human BNP (nesiritide) for the acute treatment of decompensated heart failure, and also of novel compounds that inhibit neutral endopeptidase, an enzyme that is partially responsible for BNP degradation. See p 2913 In patients with heart failure, the cardiac neurohormonal system is activated, and circulating plasma levels of ANP, BNP, and the N-terminal fragments of their prohormones (N-proANP and N-proBNP) are elevated. Compared with ANP and N-proANP, BNP and N-proBNP undergo a greater proportional rise in disease states (ie, higher “signal-to-noise” ratio), and thus have emerged as the preferred biomarkers for clinical development. With commercially available assays now available, measurement of BNP or N-proBNP can be integrated readily into the care of patients with suspected heart failure. Although data are limited, BNP and N-proBNP seem to provide qualitatively similar information, and for purposes of this editorial, will be referred to interchangeably. Incorporation of BNP measurement into the clinical evaluation facilitates the diagnosis of heart failure due to either left ventricular (LV) systolic or diastolic dysfunction; a normal BNP level virtually rules out the diagnosis of decompensated heart failure, whereas a markedly elevated BNP has a high positive predictive value for heart failure.1 Although BNP levels are correlated with age, sex, intracardiac filling pressures, LV mass and ejection fraction (LVEF), renal function, and symptoms, BNP provides prognostic information in patients with heart failure that is independent of these variables.2 …

Objectives: We aimed to assess whether LV dysfunction assessed by LV angiography (LVA) during PPCI for STEMI predicts subsequent LV dysfunction at follow up. Left ventricular (LV) function as assessed by echocardiography has been demonstrated to improve in the first 6 months following primary percutaneous coronary intervention (PPCI). Data regarding the predictive value of LV angiography (LVA) performed immediately following PPCI are limited.Methods: A retrospective analysis of our tertiary centre angiographic database was performed (2011-2013). Patients were divided into two groups based on LVA. Group 1: normal or mild LV dysfunction and group 2: moderate or severe LV dysfunction.Results: Complete dataset was available for 89 patients (of a total of 194). 28.1% (16 patients) in group 1 compared to 46.9% (15 patients) in group 2 failed to improve LV function from baseline as assessed by follow-up echocardiography. LV function on LVA correlated significantly with subsequent LV function at follow up (Spearman’s rho p=0.007). Binary regression analysis demonstrated that Symptom to Balloon Time (STB) was a significant predictor (OR 1.003, 95% CI 1.001-1.005, p=0.008) of lack of LV function recovery at a median follow up of 10 months. Patients in whom the thrombectomy catheter was used were less likely to have abnormal LV function at follow up (OR 0.214, 95% CI 0.063-0.730, p=0.014).Conclusions: Baseline abnormal LV function on LVA predicted LV dysfunction at follow up. Increased STB time and lack of thrombectomy catheter use are significant predictors of abnormal LV function at follow up.Condensed abstract: We aimed to assess whether LV dysfunction assessed by LV angiography (LVA) during PPCI for STEMI predicts subsequent LV dysfunction at follow up. A retrospective analysis of our tertiary centre angiographic database was performed (2011-2013). Patients were divided into two groups based on LVA - group 1: normal or mild LV dysfunction and group 2: moderate or severe LV dysfunction. Binary regression analysis demonstrated that Symptom to Balloon Time (STB) was a significant predictor (OR 1.003, 95% CI 1.001-1.005, p=0.008) of lack of LV function recovery at a median follow up of 10 months. Patients in whom the thrombectomy catheter was used were less likely to have abnormal LV function at follow up (OR 0.214, 95% CI 0.063-0.730, p=0.014). Baseline abnormal LV function on LVA predicted LV dysfunction at follow up. Increased STB time and lack of thrombectomy catheter use are significant predictors of abnormal LV function at follow up.

Treatment of Diabetes in People with Heart Failure

Background Outcomes in patients with left ventricular (LV) dysfunction after coronary revascularization are influenced by multiple factors; however, it is difficult to compare a direct relationship between LV dysfunction and mortality due to the presence of confounding variables, so we attempted to observe the influence of risk factors on outcomes in severe LV dysfunction patients after revascularization and delineate if any of them have an effect on one-year mortality of such patients. Methodology This is a single center prospective study, where the studied population were severe LV dysfunction patients who underwent percutaneous transluminal coronary angioplasty (PTCA) and followed-up for one year and at the end of one year, impact of gender, age, type 2 diabetes mellitus (DM), hypertension (HTN), obesity, chronic kidney disease (CKD), cerebrovascular accident (CVA), hypothyroidism, smoking and alcohol on one-year mortality and MACE (major adverse cardiovascular events), which included reinfarction (nonfatal), recurrence of angina, repeat percutaneous intervention (PCI) or coronary artery bypass grafting (CABG) and heart failure. The above factors were analyzed and statistically approached to observe the impact of those risk factors on one-year mortality and determine whether the timing and mode of revascularization, and number of coronary arteries involved, had any influence on mortality or MACE events. By comparing different parameters of the study with respect to mortality, a regression analysis was made at the end of one year Results As many as 152 patients of severe LV dysfunction (ejection fraction < 30%) were enrolled in the study, among which 115 (75.6%) patients were males, and 37 patients were females (24.3%), with a mean age of 57.6 years; 89 (58.5%) patients were hypertensive, 80 (52.6%) patients were diabetics, 42 (27.6%) patients were smokers, 20 (13.1%) patients were alcoholics, 9 (5.9%) had CKD, one (0.6%) patient had hypothyroidism and one (0.6%) patient had a history of CVA; 46 (30.2%) patients presented with acute coronary syndrome (ACS) and 106 (69.7) patients had chronic stable angina (CSA); 144 (94.7%) patients underwent PTCA (percutaneous transluminal coronary angioplasty), while eight (5.2%) patients underwent CABG. At the end of one year, mortality was six patients (3.94%). At the end of one year, regression analysis was done for all the confounding variables by observing their influence on the MACE or mortality; none of them showed statistically significant influence (p > 0.05). Conclusion At the end of one year, after revascularization in patients with severe LV dysfunction, no significant relationship could be ascertained between the mortality or MACE events and gender, age, DM, HTN, CKD, and alcohol or smoking. MACE or mortality may be attributed directly to LV dysfunction itself, and the observed mortality was higher than that of normal LV Function. Hence, in our study, LV dysfunction is the cause of mortality in the study population but not the other confounding variables.

Strategies for prevention of sudden cardiac death focus on severe left ventricular (LV) dysfunction, although most sudden cardiac death postmyocardial infarction occurs in patients with mild/moderate LV dysfunction. We tested the hypothesis that infarct heterogeneity by cardiac magnetic resonance is associated with mortality beyond LV ejection fraction (LVEF) in patients with coronary artery disease and LV dysfunction. In addition, we examined the association between infarct heterogeneity and mortality in those with LVEF >35%. We studied 301 patients with coronary artery disease and LV dysfunction referred for cardiac magnetic resonance. We quantified total infarct mass, infarct core mass, and peri-infarct zone (PIZ) normalized for total infarct mass (%PIZ) using signal-intensity criteria of >2 SDs, >3 SDs, and 2- to -3 SDs above remote myocardium, respectively. Mean LVEF was 41 ± 14%. After 3.9 years median follow-up, 66 (22%) patients died (13 sudden cardiac death; 33 with LVEF >35%). In patients with LVEF >35%, below-median %PIZ carried an annual death rate of 2.8% versus 12% in patients with above-median %PIZ (P<0.001). In a multivariable model, %PIZ maintained strong association with mortality adjusted to patient age, LVEF, right ventricular ejection fraction, prolonged QT interval, and total infarct size and resulted in improve risk reclassification 0.492 (95% confidence interval, 0.183-0.817). Cardiac magnetic resonance infarct heterogeneity has a strong association with mortality independent of LVEF in patients with coronary artery disease and LV dysfunction, particularly in patients with mild or moderate LV dysfunction. Further studies incorporating cardiac magnetic resonance in clinical decision making for defibrillator therapy are warranted.

The last 3 decades have witnessed an unprecedented improvement in the outcome of patients with acute coronary syndromes. The widespread use of thrombolytic therapy and percutaneous coronary interventions, in association with increasingly potent antithrombotic agents, has contributed to significant reductions in mortality and morbidity in these patients. Although overall survival has improved, a downside of this success has been the greater number of patients with residual left ventricular (LV) dysfunction undergoing progressive LV remodeling and congestive heart failure. This problem is compounded by the rising age of our population and the higher prevalence of comorbidities such as diabetes mellitus that confer an increased risk of coronary artery disease (CAD) and congestive heart failure. Patients with CAD represent by far the most numerous cohort among those with congestive heart failure, and their treatment remains a partial success.1 Typically, these patients have multivessel disease, increased LV volumes, and variable degrees of regional and/or global systolic dysfunction, although more cases of isolated diastolic dysfunction have been reported recently.2–4 In these patients, coronary revascularization may lead to symptomatic and prognostic improvement, and these clinical benefits are accompanied by evidence of reverse LV remodeling. In this context, the concept of myocardial viability was developed and a number of different techniques have been used to demonstrate the presence of viable tissue before coronary revascularization. The aim of this review article is to summarize our current understanding of the concept of myocardial viability and its clinical implications in patients with CAD and chronic LV dysfunction. Throughout this review, we use the term viability to describe dysfunctional myocardium subtended by diseased coronary arteries with limited or absent scarring that therefore has the potential for functional recovery. Viability is a prospective definition, but it does not imply evidence of functional recovery after interventions. The term hibernation, which …

Aortic Valve Repair in Neonates With Aortic Stenosis and Reduced Left Ventricular Function

Although the use of inotropic agents to treat congestive heart failure (CHF) in patients with coronary artery disease has yielded short-term hemodynamic improvement, long-term mortality has shown less improvement. The loss of cardiac muscle as a result of infarction not only decreases the pumping ability of the heart but also leads to some dramatic changes in myocardial energetics. However, little is known about the mechanoenergetics of the heart in patients with left ventricular (LV) dysfunction after myocardial infarction. The present study was designed to compare by means of the Vo2-pressure-volume area relation (PVA, a measure of total mechanical energy) and Emax (LV contractility index), the incremental oxygen cost of contractility measured as nonmechanical energy per unit increment in contractility in patients with various kinds of LV dysfunction. We assessed Emax, Vo2, and PVA using conductance and Webster catheters under control conditions and during different rates of dobutamine infusion (3 and 6 micrograms x kg-1 x min-1) in 30 patients with coronary artery disease. Patients were divided into three groups according to LV ejection fraction (EF): 10 without LV dysfunction (EF>/= 60%), 10 with mild LV dysfunction (40% </= EF < 60%), and 10 with severe LV dysfunction (EF < 40%). Under control conditions, the Vo2-PVA relation was linear in each group. Contractile efficiency, the reciprocal of the slope of this relation, was comparable among the three groups. The oxygen cost of contractility in the severe LV dysfunction group was significantly greater than in the groups without and with mild LV dysfunction (0.022 +/- 0.014 versus 0.005 +/- 0.002 and 0.0012 +/- 0.005 mL O2 x mL x mm Hg-1 per beat, P <.05). These findings suggest that the alteration in mechanoenergetics in patients with severe LV dysfunction after myocardial infarction may result from the increased oxygen cost of excitation-contraction coupling rather than from a reduction in the efficiency of chemomechanical energy transduction.

Recent-Onset Atrial Fibrillation in Patients With Left Ventricular Dysfunction: Amiodarone or Vernakalant?

Funding Acknowledgements Type of funding sources: None. Background. Right ventricular (RV) systolic dysfunction in patients with left-sided heart disease is known adverse factor. However, the RV adaptation at the different degrees of left ventricular (LV) dysfunction remains to be clarified. Purpose to assess the change in RV contraction pattern in relation to LV ejection fraction (EF) in patients with left-sided heart disease. Methods. LV and RV volumes and EF were measured by 3D-echocardiography in 295 patients with left-sided heart disease (59 ± 17years, 69% male). The 3D meshmodel of the RV was postprocessed by the ReVISION software and its contraction pattern was decomposed along the longitudinal, radial and anteroposterior directions (Fig. A) providing longitudinal, radial and anteroposterior EF (LEF, REF, AEF). Relative contribution of each component to the RV systolic function was measured as the ratio between LEF, REF and AEF and global RVEF (LEFi, REFi, AEFi). Results. Patients with LV systolic dysfunction also had reduced RVEF. Relative contribution of the longitudinal and anteroposterior components decreased, while radial component increased in patients with reduced LVEF (Table). RV LEF and AEF significantly correlated with the LVEF (Rho 0.50 and 0.51, p &amp;lt; 0.0001), while the correlation between REF and LVEF was weak (Rho 0.22, p = 0.0002). There was a significant drop in LEF and AEF (Fig. B) and their relative contribution to the total RVEF (Fig. C) starting from the earlier stages of LV dysfunction. However, it was effectively compensated by significant increase in the radial RV component resulting in preservation of total RVEF in those with normal, mildly and moderately reduced LVEF (50 [46;54] vs 47 [44;52] vs 46 [42;49]%), whereas total RVEF dropped significantly only in severe LV dysfunction (30 [25;39]%; p &amp;lt; 0.0001) (Fig. D). Conclusions. The longitudinal and anteroposterior RV contraction was related to the LVEF and decreased from early stages of the LV systolic dysfunction. Increase in the radial component compensated for the loss of longitudinal and anteroposterior RV components in mild and moderate LV dysfunction to maintain total RVEF. Drop in all three components resulted in significant reduction of total RVEF in severe LV dysfunction. Characteristics of study population Overall (N = 295) LVEF≥50% (N = 166) LVEF &amp;lt; 50% (N = 129) LV EF, % 49.6 ± 14.3 59.9 ± 5.6 36.4 ± 10.9* RV EF, % 46.5 ± 9.2 49.8 ± 6.9 42.3 ± 10.0* RV LEFi 0.42 ± 0.09 0.45 ± 0.09 0.38 ± 0.09* RV REFi 0.47 ± 0.1 0.45 ± 0.1 0.50 ± 0.09* RV AEFi 0.39 ± 0.08 0.41 ± 0.08 0.37 ± 0.07* *p &amp;lt; 0.0001 Abstract Figure.

Aim: To study the clinical profile of diabetic patients who present with Acute Coronary Syndrome (ACS) for the first time, to correlate the Blood Sugar Level (BSL) and Glycosylated hemoglobin (HbA 1C ) at the time of admission and the severity of acute coronary syndrome; and to assess the correlation between tight glycemic control of diabetics based on HbA 1C estimation and presence of end organ damage in diabetics. Materials and Methods: The study was undertaken at our medical college in the medicine department. 64 adult patients who are known diabetics or detected for the first time presenting in outpatient department or emergency department as acute coronary syndrome were studied. Study period was 2 years from January 2011 to December 2012. Results: The study showed a definite male preponderance, with 56.23% males as compared to 43.73% females. Atypical presentations of acute coronary syndrome were more common as compared to typical chest pain (34.37%). Chest pain commonly is prevalent in younger age group. 95.30% of the patient had some or other associated risk factors like hypertension (59.37%), smoking (26.56%), obesity (15.62%) or dyslipidemia (65.62%). ST elevation MI was the commonest presentation (73.40%) and involvement of anterior wall was common (36.20%). On admission BSL (Blood Sugar Level) was not found to have a definite prognostic value in predicting outcome in diabetic patients with acute coronary syndrome. Impaired glycosylated haemoglobin was found to be an independent risk factor and had a definite prognostic value in predicting outcome. Diabetic patient with acute coronary syndrome had LV dysfunction, cardiac rhythm abnormalities, cardiogenic shock and are likely to be readmitted, thus having worst morbidity as well as mortality. Conclusion: The primary aim of this study was to study correlation of blood sugar level and glycosylated haemoglobin at the time of admission with severity of acute coronary syndrome and to study clinical profile of diabetic patients with due consideration to complications which are related to diabetes.

Aim: To study the clinical profile of diabetic patients who present with Acute Coronary Syndrome (ACS) for the first time, to correlate the Blood Sugar Level (BSL) and Glycosylated hemoglobin (HbA1C) at the time of admission and the severity of acute coronary syndrome; and to assess the correlation between tight glycemic control of diabetics based on HbA1C estimation and presence of end organ damage in diabetics. Materials and Methods: The study was undertaken at our medical college in the medicine department. 64 adult patients who are known diabetics or detected for the first time presenting in outpatient department or emergency department as acute coronary syndrome were studied. Study period was 2 years from January 2011 to December 2012. Results: The study showed a definite male preponderance, with 56.23% males as compared to 43.73% females. Atypical presentations of acute coronary syndrome were more common as compared to typical chest pain (34.37%). Chest pain commonly is prevalent in younger age group. 95.30% of the patient had some or other associated risk factors like hypertension (59.37%), smoking (26.56%), obesity (15.62%) or dyslipidemia (65.62%). ST elevation MI was the commonest presentation (73.40%) and involvement of anterior wall was common (36.20%). On admission BSL (Blood Sugar Level) was not found to have a definite prognostic value in predicting outcome in diabetic patients with acute coronary syndrome. Impaired glycosylated haemoglobin was found to be an independent risk factor and had a definite prognostic value in predicting outcome. Diabetic patient with acute coronary syndrome had LV dysfunction, cardiac rhythm abnormalities, cardiogenic shock and are likely to be readmitted, thus having worst morbidity as well as mortality. Conclusion: The primary aim of this study was to study correlation of blood sugar level and glycosylated haemoglobin at the time of admission with severity of acute coronary syndrome and to study clinical profile of diabetic patients with due consideration to complications which are related to diabetes.