Conservative management of acute coronary syndromes in chronic kidney disease patients: a deadly sin

Background/Introduction

Chronic kidney disease (CKD) is associated with worse prognosis in acute coronary syndromes (ACS).

Purpose

We sought to investigate the prognostic effect of non-invasive management of ACS in CKD patients in a tertiary University Hospital.

Methods

Two hundred and one patients (mean age 66.5±13.6 years, 150 males) admitted to our Hospital with ACS from 2016–2017 were included in the study. Patients were followed for a median of 2 years post the index event. CKD was defined by an estimated glomerular filtration rate (eGFR) <60 ml/min/m2, as assessed by the Modification of Diet in Renal Disease (MDRD) equation. We grouped patients into four groups according to their CKD status and whether they underwent coronary angiography or not. The primary outcome was all-cause death and secondary outcomes were cardiovascular and non-cardiovascular death.

Results

The majority of patients (n=120, 60%) presented with non-ST elevation ACS (NSTE-ACS), whereas 81 patients as ST-elevation myocardial infarction (STEMI) (40%). Fifty-four patients (27%) were identified as CKD patients (of whom 5 were on dialysis). Overall, 29 patients (14.4%) did not undergo coronary angiography. Patients at a higher age and with CKD were more likely to not undergo angiography. Thirty-seven (18.4%) died during follow-up (25 non-cardiovascular deaths and 12 cardiovascular deaths). Patients with conservative treatment and CKD had the worse prognosis (Hazard ratio [HR] =11.00, 95% Confidence intervals [CI] 4.00 to 30.24, p<0.001) followed by non-CKD patients with conservative treatment (HR=4.37, 95% CI 1.20 to 15.90, p=0.025) compared to non-CKD patients treated invasively (reference group) after adjusting for age, gender, STEMI/NSTE-ACS diagnosis (Figure). Results were similar for non-cardiovascular death, whereas regarding cardiovascular death only the group with CKD and conservative treatment had a lower survival compared to the reference group (HR=26.5, 95% CI 2.9 to 241.7, p=0.004)

Conclusions

Patients with ACS and CKD are less likely to receive invasive management and have higher mortality from both cardiovascular and non-cardiovascular causes than patients without CKD. Conservative management of ACS was associated with higher long-term mortality versus invasive management in all patients, regardless of CKD status.

Funding Acknowledgement

Type of funding sources: None.

The impact of depression and cardiophobia on quality of life in patients with essential hypertension

Patients with chronic conditions like hypertension may experience many negative emotions which endorse the development of anxiety and depression symptomatology, thus they increase their risk for poor quality of life. Several studies have shown an association between symptoms of psychological distress and hypertension. In this study we aimed to quantify the link between depression, cardiophobia and quality of life in hypertensive patients. A cross-sectional design was employed. A sample of 197 hypertensive patients (89 men-108 women, mean age 53 years, SD=12 ranged 25-78) from a university outpatient hypertension clinic in Greece participated. Ninety-four (47.7%) of the participants suffered from essential grade I hypertension; 68 (34.5%) were grade II; 16 (8.1%) were categorized as grade III, while only 11 (5.6%) patients were recorded as normotensives with high normal values. The questionnaires included: (a) question for the recording of social-demographic characteristics and clinical features, (b) The Short Form (SF-36) Health Survey, (c) The Beck Depression Inventory -I, and (d) The Cardiac Anxiety Questionnaire. There were no significant differences between the two genders with exception of marital status (p=0.010), dyslipidemia (p=0.050), grade of hypertension (p=0.014), cardiac left ventricular hypertrophy (p=0.004), renal failure (p=0.043) and stroke (p=0.024). Lower levels of quality of life and higher levels of depression and cardiophobia were observed compared to the general population. There were no significant differences on psychological measures between the two sexes (p>0.05). Cardiophobia was positively related to depressive symptomatology (r=0.533, p=0.000) while negatively to both physical and mental health summary measures of SF-36 health survey (r=-0.467, p=0.000 r=-0.537, p=0.000 respectively). Multiple linear regression models found that for psychical health depression and cardiac anxiety, avoidance activities had an influence on levels of quality of life in hypertensive patients, after controlling for age and other socio-demographic variables and clinical characteristics (Beta=-0.133, p=0.007, Beta=-0.364 p=0.000 and Beta=-0.167 p=0.006, respectively). For mental component summary depression and cardiophobia, heart focused attention had also impact on mental health in hypertensives (Beta=-0.438, p=0.016, Beta=-0.564, p=0.000 and Beta=-0.223, p=0.037, respectively) after adjustments. Heart focused anxiety symptoms-as avoidance activities and/or attention and monitoring cardiac activity, are related to hypertensive patients' present deteriorated depressive symptoms and levels of quality of life. Both depressive symptomatology and heart focused anxiety may be a mechanism partly responsible for hypertensive patients' present impaired levels of quality of life.

Differences in arterial stiffness and target organ damage between native Greek patients and immigrants from Eastern European countries with essential hypertension

AIM

The variance in hypertension-related sequelae between different ethnic groups is highly related to differences in socioeconomic conditions and lifestyle habits, but also to disparities in the awareness and treatment of the disease. In the present study, we sought to evaluate the target organ damage in a vulnerable hypertensive population, such as the Eastern European immigrants.

METHODS

The study population consisted of 128 hypertensive patients: 67 immigrants from Eastern Europe and 61 native inhabitants. Anthropometric, biochemical and echocardiographic data were derived from both groups. Both groups underwent fundoscopic examination and pulse wave velocity (PWV) measurements for assessment of arterial stiffness.

RESULTS

Although immigrants had lower body mass index compared to native inhabitants (P<0.001), they had significantly increased arterial stiffness (P=0.003). In multivariate analysis, higher carotid-femoral PWV was significantly associated with immigration status [β (SE)=0.935(0.443), P=0.041], after adjustment for smoking status. Moreover, immigrants had increased left atrial volume index (LAVI) (P<0.001), left ventricular mass index (P<0.001) and higher rates of left ventricular diastolic dysfunction (p=0.047). In multivariate analysis, LAVI was significantly associated with immigration status (β (SE)=5.17(1.93), P=0.01) after adjustment for serum glucose levels and age. Finally, immigrants had significantly higher levels of sodium urinary excretion (p=0.007) and lower glomerular filtration rate (P<0.001).

CONCLUSION

Our findings suggest that hypertensive immigrants exhibit an aggravated arterial stiffness profile and increased risk of target organ damage. These findings could be attributed to differences in socioeconomic conditions and dietary habits.

Christian Andreas Doppler: A legendary man inspired by the dazzling light of the stars

Christian Andreas Doppler is renowned primarily for his revolutionary theory of the Doppler effect, which has deeply influenced many areas of modern science and technology, including medicine. His work has laid the foundations for modern ultrasonography and his ideas are still inspiring discoveries more than a hundred years after his death. Doppler may well earn the title of Homo Universalis for his broad knowledge of physics, mathematics and astronomy and most of all for his indefatigable investigations for new ideas and his ingenious mind. According to Bolzano: "It is hard to believe how fruitful a genius Austria has in this man". His legacy of scientific achievement have seen Doppler honoured in the later years on coinage and money, names of streets, educational institutions, rock groups, even of a lunar crater; while the ultimate tribute to his work is the countless references to the homonymous medical eponym.

The dominant role of the systolic component of nondipping status on target-organ damage in never-treated hypertensives

BACKGROUND

Blood pressure (BP) nondipping has been associated with target-organ damage (TOD) and adverse outcomes in hypertension. Diverse definitions of nondipping status appear in the literature, regarding the BP components taken into account. Aim of this study was to compare the effects of isolated nondipping of systolic, diastolic and combined systolic and diastolic BP on various indices of TOD.

METHODS

From 630 consecutive subjects with never-treated essential hypertension stage I-II, we selected 279 subjects who were consistently isolated systolic nondippers (SND, n=76) isolated diastolic nondippers (DND, n=64) and combined systolic and diastolic nondippers (SDND, n=139) in two ambulatory BP monitoring sessions. All three subgroups were subjected to echocardiographic examination, carotid-femoral pulse wave velocity (PWV(c-f)) and albumin-to-creatinine ratio (ACR) determination. Metabolic profile was determined in a morning blood sample.

RESULTS

SND compared to DND and SDND exhibited higher left ventricular mass/height(2.7) (42.4 ± 9.9 vs. 38.0 ± 9.1 vs. 40.9 ± 11.0 g/m(2.7), P < 0.05), higher log(10)(PWV(c-f)) (0.94 ± 0.07 vs. 0.86 ± 0.05 vs. 0.91 ± 0.07 m/s, P < 0.005), and higher log(10)(ACR) (1.2 ± 0.5 vs. 0.9 ± 0.3 vs. 1.1 ± 0.4 mg/g, P < 0.05). Isolated systolic BP nondipping was an independent determinant of all the studied indices of TOD whereas isolated diastolic BP nondipping was not.

CONCLUSIONS

Isolated systolic as compared to diastolic and to combined systolic/diastolic BP nondipping is associated with higher left ventricular mass, stiffer arteries, and pronounced urinary albumin excretion.