Prognostic tools at hospital arrival in acute myocardial infarction: copeptin and hepatocyte growth factor

Background

Prompt evaluation and treatment of acute coronary syndrome has demonstrated to reduce mortality. Although several biomarkers have been studied for risk stratification and prognostic purposes, none is recommended to guide treatment based on its prognostic value. Copeptin and hepatocyte growth factor have been associated with poor outcome in patients with acute myocardial infarction. The aim of this study is to evaluate the early prognostic value of measurements of copeptin and hepatocyte growth factor for hospital mortality risk and 1-year-follow-up mortality, in patients with acute myocardial infarction. In our retrospective observational study, we measured hepatocyte growth factor and copeptin in blood samples collected at hospital arrival in patients with acute myocardial infarction; and follow-up them until 1-year.

Results

84 patients with were included in the study, mainly male (65%) with a median age of 70.3 ± 13.56 years. Hospital mortality was 11.9%. Plasma levels of copeptin at hospital arrival were statistically significant higher in patients who died during hospital admission (145.60 pmol/L [52.21–588.50] vs. 24.79 pmol/L [10.90–84.82], p 0.01). However, we found no statistically significant association between plasma levels of hepatocyte growth factor and hospital mortality (381.05 pg/ml [189.95–736.65] vs. 355.24 pg/ml [175.55–521.76], p 0.73). 1-year follow-up mortality was 21.4%. Plasma levels of copeptin at hospital arrival were higher in those patients who died in the following year (112.28 pmol/L [25.10–418.27] vs. 23.82 pmol/L [10.96–77.30], p 0.02). In the case of HGF, we also find no association between hepatocyte growth factor plasma levels and 1 -year follow-up mortality (350.00 pg/ml [175.05–555.08] vs. 345.53 pg/ml [183.68–561.15], p 0.68).

Conclusions

In patients with acute myocardial infarction measurement of copeptin at hospital arrival could be a useful tool to assess the prognosis of these patients, since their elevation is associated with a higher hospital mortality and higher 1-year follow-up mortality. We have not found this association in the case of hepatocyte growth factor measurement.

Functional Status and Quality of Life in Elderly Intensive Care Unit Survivors

OBJECTIVES

To evaluate functional status and quality of life in elderly intensive care unit (ICU) survivors at 1-year follow-up.

DESIGN

Prospective 18-month observational study.

SETTING

University medical-surgical ICU.

PARTICIPANTS

ICU survivors aged 75 and older.

MEASUREMENTS

Functional status at baseline (Barthel Index (BI)) was compared with that at hospital discharge and 1-year follow-up. Health-related quality of life (HRQL Spanish version of the Medical Outcomes Study 36-item Short-From Survey) was measured at 1-year follow-up and compared with that of the Spanish population of same age.

RESULTS

Of 176 individuals admitted to the ICU, 110 (62.1%) were discharged alive from the hospital, and 94 (53.1%) were alive at 1-year follow-up. ICU admission was associated with significant clinical deterioration (median BI 100 points (interquartile range (IQR) 85-100) at baseline vs 85 (IQR 60-100) at hospital discharge, P < .001). Three months after discharge, there was a significant although modest improvement in functional status (BI 95 (IQR 80-100) P = .03). Baseline functional status was not recovered at 1-year follow-up (BI 95 (IQR 80-100) P < .001). More ICU survivors had moderate to severe dependence at the end of follow-up (20.3%) than at ICU admission (6.6%) (P < .001). Factors independently associated with poor functional recovery were low baseline BI and ICU stay longer than 4 days. At 1-year follow-up, 76.8% of participants who survived were living in their own homes. HRQL was similar to that of the Spanish population of the same age.

CONCLUSION

Elderly ICU survivors experienced significant deterioration in functional status, and although they recovered modestly during the following year, they never regained their baseline status. Good recovery was associated with short ICU stay and better baseline functional status.

New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis

BACKGROUND

The updated Atlanta Classification of acute pancreatitis (AP) in adults defined three levels of severity according to the presence of local and/or systemic complications and presence and length of organ failure. No study focused on complications and mortality of patients with moderately severe AP admitted to intensive care unit (ICU). The main aim of this study is to describe the complications developed and outcomes of these patients and compare them to those with severe AP.

METHODS

Prospective, observational study. We included patients with acute moderately severe or severe AP admitted in a medical-surgical ICU during 5years. We collected demographic data, admission criteria, pancreatitis etiology, severity of illness, presence of organ failure, local and systemic complications, ICU length of stay, and mortality.

RESULTS

Fifty-six patients were included: 12 with moderately severe AP and 44 with severe. All patients developed some kind of complications without differences on complications rate between moderately severe or severe AP. All the patients present non-infectious systemic complications, mainly acute respiratory failure and hemodynamic failure. 82.1% had an infectious complication, mainly non-pancreatic infection (66.7% on moderately severe AP vs. 79.5% on severe, p=0.0443). None of the patients with moderately severe AP died during their intensive care unit stay vs. 29.5% with severe AP (p=0.049).

CONCLUSIONS

Moderately severe AP has a high rate of complications with similar rates to patients with severe AP admitted to ICU. However, their ICU mortality remains very low, which supports the existence of this new group of pancreatitis according to their severity.

Mortality and functional status at one-year of follow-up in elderly patients with prolonged ICU stay

OBJECTIVE

To evaluate mortality and functional status at one year of follow-up in patients>75 years of age who survive Intensive Care Unit (ICU) admission of over 14 days.

DESIGN

A prospective observational study was carried out.

SETTING

A Spanish medical-surgical ICU.

PATIENTS

Patients over 75 years of age admitted to the ICU.

PRIMARY VARIABLES OF INTEREST

ICU admission: demographic data, baseline functional status (Barthel index), baseline mental status (Red Cross scale of mental incapacity), severity of illness (APACHE II and SOFA), stay and mortality. One-year follow-up: hospital stay and mortality, functional and mental status, and one-year follow-up mortality.

RESULTS

A total of 176 patients were included, of which 22 had a stay of over 14 days. Patients with prolonged stay did not show more ICU mortality than those with a shorter stay in the ICU (40.9% vs 25.3% respectively, P=.12), although their hospital (63.6% vs 33.8%, P<.01) and one-year follow-up mortality were higher (68.2% vs 41.2%, P=.02). Among the survivors, one-year mortality proved similar (87.5% vs 90.6%, P=.57). These patients presented significantly greater impairment of functional status at hospital discharge than the patients with a shorter ICU stay, and this difference persisted after three months. The levels of independence at one-year follow-up were never similar to baseline. No such findings were observed in relation to mental status.

CONCLUSIONS

Patients over 75 years of age with a ICU stay of more than 14 days have high hospital and one-year follow-up mortality. Patients who survive to hospital admission did not show greater mortality, though their functional dependency was greater.

Individualized positive end-expiratory pressure application in patients with acute respiratory distress syndrome

Current treatment of acute respiratory distress syndrome is based on ventilatory support with a lung protective strategy, avoiding the development of iatrogenic injury, including ventilator-induced lung injury. One of the mechanisms underlying such injury is atelectrauma, and positive end-expiratory pressure (PEEP) is advocated in order to avoid it. The indicated PEEP level has not been defined, and in many cases is based on the patient oxygen requirements for maintaining adequate oxygenation. However, this strategy does not consider the mechanics of the respiratory system, which varies in each patient and depends on many factors-including particularly the duration of acute respiratory distress syndrome. A review is therefore made of the different methods for adjusting PEEP, focusing on the benefits of individualized application.

Individualized PEEP setting in subjects with ARDS: a randomized controlled pilot study

BACKGROUND

Low-tidal-volume ventilation may be associated with repetitive opening and closing of terminal airways. The use of PEEP is intended to keep the alveoli open. No method of adjusting the optimal PEEP has shown to be superior or to improve clinical outcomes. We conducted a pilot study to evaluate the effect of setting an individualized level of PEEP at the highest compliance on oxygenation, multiple-organ-dysfunction, and survival in subjects with ARDS.

METHODS

Subjects with ARDS ventilated with low tidal volumes and limitation of airway pressure to 30 cm H2O were randomized to either a compliance-guided PEEP group or an FIO2-guided group.

RESULTS

Of the 159 patients with ARDS admitted during the study period, 70 met the inclusion criteria. Subjects in the compliance-guided group showed nonsignificant improvements in PaO2/FIO2 during the first 14 days, and in 28-day mortality (20.6% vs. 38.9%, P = .12). Multiple-organ-dysfunction-free days (median 6 vs 20.5 d, P = .02), respiratory-failure-free days (median 7.5 vs 14.5 d, P = .03), and hemodynamic-failure-free days (median 16 vs 22 d, P = .04) at 28 days were significantly lower in subjects with compliance-guided setting of PEEP.

CONCLUSIONS

In ARDS subjects, protective mechanical ventilation with PEEP application according to the highest compliance was associated with less organ dysfunction and a strong nonsignificant trend toward lower mortality. ClinicalTrials.gov Number NCT01119872.