The impact of type 2 diabetes mellitus on prognosis in patients with non-ST elevation myocardial infarction

Type 2 diabetes (T2D) is a recognized risk factor for acute coronary syndromes. There is currently no consensus concerning the intensification of antihyperglycemic treatment. According to the available guidelines, it seems that the goal is to achieve glycated hemoglobin (HbA_1c) levels below 7% and avoid hypoglycemia. The choice of a revascularization method is influenced by many factors, such as the anatomy of the coronary arteries, severity of atherosclerosis, anatomical location of lesions, and presence of comorbidities. However, in non-ST elevation myocardial infarction, determining the culprit lesion is often difficult based on ECG or angiography. Experts recommend coronary artery bypass grafting (CABG) in patients with type 2 diabetes and multivessel or complex (SYNTAX score exceeding 22 points) coronary artery disease in order to improve survival. Percutaneous coronary intervention should be considered as an alternative to CABG to control symptoms in patients with type 2 diabetes and less complex forms of the disease (i.e., SYNTAX score of 22 or lower).

Effects of trimetazidine on interleukin-2 and interleukin-8 concentrations in patients with coronary artery disease

Trimetazidine (TMZ) exhibits metabolic and cardioprotective effects. The aim of this study was to assess the effects of TMZ on interleukin-2 (IL-2) and interleukin-8 (IL-8) serum concentrations in 156 patients with stable coronary artery disease. They underwent a treadmill exercise test (TET) before and after 3 months of TMZ treatment. IL-2 and IL-8 concentrations were determined before and after each TET. Before treatment, TET did not influence IL-2 concentrations, whereas IL-8 concentrations increased. TMZ treatment led to a decrease in IL-2 concentrations before TET, as well as it prevented the increase of IL-8 following the second TET. Obtained results confirmed the improvement in TET performance during TMZ treatment and they revealed a significant influence of TMZ on IL-2 and IL-8 concentrations both before and after TET. These changes may reflect potential anti-inflammatory effects of TMZ.

Superficial herpes simplex virus wound infection following lung transplantation

Surgical site infections (SSIs) are infections of tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure. SSIs are classified into superficial, which are limited to skin and subcutaneous tissues, and deep. The incidence of deep SSIs in lung transplant (LTx) patients is estimated at 5%. No reports have been published as to the incidence of superficial SSIs specifically in LTx patients. Common sense would dictate that the majority of superficial SSIs would be bacterial. Uncommonly, fungal SSIs may occur, and we believe that no reports exist as to the incidence of viral wound infections in LTx patients, or in any solid organ transplant patients. We report a de novo superficial wound infection with herpes simplex virus following lung transplantation, its possible source, treatment, and resolution.

Antithyroid drugs during breastfeeding

Antithyroid drugs (ATDs) are widely used for the treatment of Graves' disease (GD) in the general population. Over the past decade, there has been an increasing awareness that several disturbances of thyroid function may occur in mothers after delivery which may be more prevalent than previously appreciated. Exacerbation of immune reactions occurs 3-12 month following delivery. Management of hyperthyroidism during lactation requires special considerations and should be implemented to prevent any adverse outcomes in mother and neonate. Continuation of breastfeeding is safe and should be encouraged in hyperthyroid mothers taking ATDs, whether these are ATDs being continued after gestation or indeed ATD treatment initiated in the postpartum period. Given PTU hepatotoxicity concerns, experts currently recommend using low-to-moderate MMI doses as a first-line therapy in lactating mothers. PTU should be reserved only as a second-line agent for cases of severe hyperthyroidism (thyroid storm) and allergic reactions to previous MMI treatment. ATD should be administered in divided doses immediately following each feeding. Evaluation of thyroid function tests is advisable at least 3-4 weeks after the initiation of breastfeeding.

A novel simplified thrombo-inflammatory score portends poor outcome in diabetic patients following myocardial infarction

AIM

We investigated prognostic value of novel simplified thrombo-inflammatory score (sTIPS) in patients with ST-elevation myocardial infarction (STEMI) and diabetes mellitus.

METHODS

A total of 465 patients with diabetes mellitus and STEMI were included in the study. Based on admission cut-off values for predicting in-hospital mortality of white blood cell count (>13.4 × 10³/mm³) and mean platelet volume-to-platelet count ratio (>0.06), the patients were assigned 0 point for having the lower value of each variable and 1 point for having the upper value of each variable. sTIPS was calculated as the sum of these two variables.

RESULTS

Kaplan-Meier curves demonstrated that higher sTIPS categories were associated with higher in-hospital and 12-month mortality. One-point increment in the score was associated with 51% increase in the risk of in-hospital death and 89% increase in the risk of long term.

CONCLUSION

sTIPS is useful in predicting worse immediate and long-term outcomes following STEMI.

CHA2DS2-VASc score is useful in predicting poor 12-month outcomes following myocardial infarction in diabetic patients without atrial fibrillation

AIMS

TIMI risk score and GRACE risk model are widely available and accepted scores for risk assessment in STEMI patients and include predictors of poor outcomes. CHA2DS2-VASc is a validated score for predicting embolic/stroke risk in patients with non-valvular atrial fibrillation. Its components contribute to the worse prognosis following myocardial infarction. The advantage of the CHA2DS2-VASc score in comparison with other risk scores is that it provides a comprehensive, fast, and simple method for physicians in risk evaluation that requires no calculators or computers. Therefore, we have set out to examine the prognostic significance of CHA2DS2-VASc score following STEMI in diabetic patients without AF.

METHODS

A total of 472 patients with diabetes mellitus and STEMI undergoing primary PCI were enrolled. Based on the estimated CHA2DS2-VASc score, the study population was divided into three groups: group 1 (N = 111) with a moderate CHA2DS2-VASc score of 2 or 3; group 2 (N = 257) with a high CHA2DS2-VASc score of 4 or 5; and group 3 (N = 104) with a very high CHA2DS2-VASc score of 6 or higher.

RESULTS

In diabetic patients with STEMI, the median of CHA2DS2-VASc score was 4 (interquartile range 3-5). In-hospital mortality rate was similar across three groups. CHA2DS2-VASc score was not a risk factor of in-hospital mortality. ROC analysis revealed good diagnostic value of CHA2DS2-VASc score in predicting long-term mortality (AUC 0.62 95 % CI 0.57-0.66 P = 0.0003) and stroke (AUC 0.75 95 % CI 0.71-0.79 P = 0.0003), but no value in predicting long-term myocardial infarction. CHA2DS2-VASc score was an independent predictor of 12-month mortality and stroke. One-point increment in CHA2DS2-VASc score was associated with an increase in the risk of 12-month death by 24 % and for 12-month stroke by 101 %.

CONCLUSIONS

In diabetic patients with STEMI and no previous AF, median CHA2DS2-VASc score was high (4 points) and predicted 12-month death and stroke. However, it failed to predict in-hospital death and 12-month MI. CHA2DS2-VASc score had a similar discrimination performance in predicting 12-month mortality as TIMI risk score and a better discrimination performance in predicting 12-month stroke than TIMI risk score. Thus, it can serve as an additive tool in identifying high-risk patients that require aggressive management.

Mean platelet volume-to-lymphocyte ratio: a novel marker of poor short- and long-term prognosis in patients with diabetes mellitus and acute myocardial infarction

INTRODUCTION

Platelet activation and hyperreactivity plays a pivotal role in developing intravascular thrombus in ST elevation myocardial infarction (STEMI). Mean platelet volume (MPV), which is readily available in clinical settings, has been linked to poor prognosis following STEMI. Recently, platelet-to-lymphocyte ratio (PLR) has emerged as a new marker of worse outcomes linking inflammation and thrombosis. We investigated the prognostic significance of the new marker, MPVLR, in diabetic patients with STEMI undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 623 patients with diabetes mellitus and STEMI undergoing primary PCI were enrolled and divided based on the median MPVLR on admission into two groups: group 1 (N=266) with an MPVLR ≤4.46 and group 2 (N=257) with an MPVLR >4,46.

RESULTS

Despite similar clinical features patients with elevated MPVLR (group 2) had worse angiographic characteristic suggestive of a higher thrombus burden. In-hospital and one-year mortality was higher in group 2. ROC analysis revealed moderate diagnostic value in predicting in-hospital mortality (adjusted HR 1.13; 95% CI 1.04-1.23; P=0.003; MPVLR cut-off >6.13) similar to that of PLR a good diagnostic value in predicting long-term mortality (adjusted HR 1.52; 95% CI 1.42-1.63; P<0.0001; MPVLR cut-off >5.88) better than that of PLR. MPVLR remained an independent risk factor of early and late mortality.

CONCLUSIONS

To the best of our knowledge, this is the first ever study that has investigated MPVLR. Despite similar clinical characteristics, patients with elevated MPVLR had worse angiographic features which may indicate a greater thrombus burden. Elevated MPVLR is an independent risk factor of early and late mortality following STEMI. In addition, it has similar value to PLR in predicting in-hospital mortality, and a better value than PLR in predicting long-term mortality.

Higher serum phosphorus is associated with catabolic/anabolic imbalance in heart failure

BACKGROUND

A higher serum phosphate level is associated with worse outcome. Energy-demanding intracellular transport of phosphate is needed to secure anion bioavailability. In heart failure (HF), energy starvation may modify intracellular and serum levels of phosphate. We analysed determinants of serum phosphates in HF and assessed if catabolic/anabolic balance (CAB) was associated with elevation of serum phosphate.

METHODS

We retrospectively reviewed data from 1029 stable patients with HF and have calculated negative (loss) and positive (gain) components of weight change from the onset of HF till index date. The algebraic sum of these components was taken as CAB. The univariate and multivariable predictors of serum phosphorus were calculated. In quintiles of CAB, we have estimated odds ratios for serum phosphorus above levels previously identified to increase risk of mortality. As a reference, we have selected a CAB quintile with similar loss and gain.

RESULTS

Apart from sex, age, and kidney function, we identified serum sodium, N-terminal fragment of pro-brain-type natriuretic peptide, and CAB as independent predictors of serum phosphorus. The odds for serum phosphorus above thresholds found in literature to increase risk were highest in more catabolic patients. In most catabolic quintile relative to neutral balance, the odds across selected phosphorus thresholds rose, gradually peaking at 1.30 mmol/L with a value of 3.29 (95% confidence interval: 2.00-5.40, P < 0.0001) in an unadjusted analysis and 2.55 (95% confidence interval: 1.38-2.72, P = 0.002) in a fully adjusted model.

CONCLUSIONS

Metabolic status is an independent determinant of serum phosphorus in HF. Higher catabolism is associated with serum phosphorus above mortality risk-increasing thresholds.

Malignant tumors of the heart

Primary malignant cardiac tumors are rare, and mostly manifest as sarcomas in various types. As non-invasive diagnostic modalities, e.g. echocardiography and magnetic resonance imaging, have become more sensitive, there is a marked increase in the number of patients diagnosed. Nevertheless, most patients die within one year of initial diagnosis, either because of the often asymptomatic presentation of cardiac tumors until advanced disease, or a low index of suspicion on the part of the physician. The presenting symptoms, treatment options and, indeed, prognosis are largely controlled by the tumor's anatomic location. Cardiac sarcomas may present with a variety of symptoms and are known to be great mimickers. A quick diagnosis facilitates the initiation of a proper treatment (surgical resection, adjuvant chemotherapy), which may in turn improve the prognosis. Metastases to the heart are far more common, unfortunately, clinical manifestations are mainly dominated by generalized tumor spread. The article summarizes epidemiology, symptoms, diagnostic modalities, and possible treatment options.

Platelet-to-lymphocyte ratio is a marker of poor prognosis in patients with diabetes mellitus and ST-elevation myocardial infarction

Aim: Platelet-to-lymphocyte ratio (PLR) has emerged as a strong marker of worse outcomes. We determined the association between PLR and clinical outcomes in patients with diabetes mellitus and ST-elevation myocardial infarction. Methods: Five hundred and twenty three patients were enrolled. Low PLR (group 1, n = 349) was defined as ≤124 and high PLR (group 2, n = 174) as >124. Results: In-hospital and 1-year mortality was higher in group 2. Receiver operating characteristic analysis revealed moderate diagnostic value in predicting in-hospital (PLR cut-off >155) and long-term (PLR cut-off >146) death. PLR remained an independent risk factor of early and late mortality. Conclusion: PLR proved to have good prognostic value for in-hospital and late mortality. PLR cut-off value for predicting in-hospital mortality was higher to that predicting late mortality. PLR remained an independent risk factor early and late mortality.

Abnormal serum calcium levels are associated with clinical response to maximization of heart failure therapy

INTRODUCTION

Abnormal serum calcium levels are associated with adverse cardiovascular effects. Therapy of heart failure (HF) may result in urinary calcium excretion and calcium apposition to bones, and consequently, in calcemia.

OBJECTIVES

The aim of the study was to assess the prevalence of abnormal calcium levels in the blood of patients receiving maximized HF therapy, to explore clinical and laboratory determinants of abnormal serum calcium levels, and to analyze the relation of abnormal calcium levels to prognosis.

PATIENTS AND METHODS

The study included 722 patients with HF classified as New York Heart Association (NYHA) classes III-IV at baseline (age 53 ±10 years, 13% of women), who underwent HF therapy optimization to maximum tolerated doses.

RESULTS

After therapy maximization, the NYHA class improved in 66.7% of the patients, while it did not change in 31.0% and worsened in 2.4%. Hypocalcemia occurred in 166 patients (22.9%) and was more prevalent in patients in whom the NYHA class improved. Hypercalcemia was diagnosed in 63 patients (8.7%) and was more common in patients with no functional improvement or worsening of the NYHA class. This effect was independent of age, sex, etiology of HF, body mass index, kidney function, or the use of thiazides. Hypercalcemia was associated with increased catabolism, hemodynamic compromise, more intensive inflammation, and lower bone mineral density. Lower albumin and higher phosphorus levels, were significant predictors of hypercalcemia, independently of kidney function. Hypocalcemia was associated with reduced catabolism, higher albumin and lower phosphorus levels, use of thiazides, and smoking history. Neither hypocalcemia nor hypercalcemia was associated with poor prognosis.

CONCLUSIONS

Our study shows that abnormal serum calcium levels are associated with a clinical response to treatment maximization in patients with HF. Mild hypocalcemia after maximization of therapy is not associated with poorer prognosis. Hypercalcemia is associated with lack of response to treatment, and its prognostic value remains unclear.