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The treatment of heart failure continues to pose a real challenge for clinicians. This condition is sometimes reversible and therapy should therefore pursue this outcome. In the context of coronary ischemic syndromes, myocardial stunning can cause heart failure and even cardiogenic shock, with important prognostic repercussions. Myocardial stunning is mainly due to calcium overload in the cytosol of myocardial cells, the loss of myofilaments and their reduced sensitivity to calcium. Enhanced immune activation with inflammatory phenomena also plays an important role in the pathophysiology of cardiac dysfunction. Increasing evidence has shown that the myocardial ATP-dependent potassium channel (K(ATP)) plays an important role in many myocardial cell functions and that it is involved in ischemia-reperfusion injury and myocardial stunning. K(ATP) is thus considered a therapeutic target in this setting. Currently used inotropic drugs improve contractility by increasing intracellular concentrations of free calcium, but they increase myocardial consumption of energy and even produce arrhythmia; therefore, in this clinical context, they do not seem to be 'pathophysiologically correct' drugs. Levosimendan, a new calcium-sensitizing agent, increases contractility by enhancing the sensitivity of myofilaments to calcium by binding to the C cardiac troponin in cardiac muscle in a calcium-dependent way. Levosimendan also exerts a coronary and systemic vasodilatory effect through its K(ATP) channel-opening properties and may exert other cardioprotective actions through this mechanism. Levosimendan produces positive hemodynamic effects without increasing myocardial oxygen demand or causing arrhythmias. Intravenous levosimendan is generally well tolerated and has been approved by several European countries, and recently recommended in European Society of Cardiology guidelines, as inotropic therapy for the short-term treatment of acute severe decompensated heart failure in adults. Randomized, double-blind trials have shown that levosimendan is not only more clinically and hemodynamically effective but also that it significantly reduces morbidity and mortality when compared with dobutamine or placebo. Clinical trials addressing the use and efficacy of intravenous levosimendan in acute heart failure in patients with systolic dysfunction or cardiogenic shock due to myocardial stunning are scarce. Beneficial effects on myocardial contractility in patients with myocardial stunning have only been shown in small clinical trials. A positive experience with levosimendan in a small series of patients with cardiogenic shock complicating ST-elevation myocardial infarction suggests that the use of this drug in cardiogenic shock should be further evaluated. [ABSTRACT FROM AUTHOR]

Heart failure is a highly prevalent disease, which courses with frequent readmissions, mainly by Acute Heart Failure (AHF). Reduced renal function is associated with increased mortality in patients with HF. Therefore, an accurate and precise evaluation of renal function in patients with HF is crucial. The error of estimated GFR (eGFR) is wide and common, showing a ± 30% variability compared to measured GFR (mGFR). However, there is no evidence on the error of formulas in reflecting real renal function and particularly the consequences of this error in patients with AHF. This is a prospective study comparing the impact of mGFR versus eGFR in the onset of cardiovascular (CV) outcomes in patients with AHF. This was tested with cox survival analysis. Measured GFR was determined by the plasma clearance of iohexol-dbs and eGFR by Cockroft-Gould, MDRD, CKD-EPI creatinine, CKD-EPI cystatin-C and CKD-EPI creatinine + cystatin-C equations formulas. Also the agreement between mGFR and eGFR was analyzed. A total of 90 patients were included. Average age was 66 (± 12 years) and 52 (58%) were male. Of them 53 patients (59%) had a cardiovascular event during follow-up, 22 fatal (41%). The agreement between mGFR and eGFR indicated moderate precision and accuracy (concordance correlation coefficient of 0.77; CI = 0.73-0.82). In multiple cox survival analysis, mGFR was significantly associated with cardiovascular events together with NTproBNP, BMI, LVEF and previous coronary artery disease (p = 0.037; HR = 0.98, 95% CI = 0.95-0.99). Estimated GFR by formulas was not significant. In patients with AHF the error of formulas is large, frequent and random, also, mGFR and not eGFR predicted future CV events. The error of eGFR may have clinical consequences in specific subpopulations., (© 2024. The Author(s).)

Aim: The LeoDOR trial explored the efficacy and safety of intermittent levosimendan therapy in the vulnerable phase following a hospitalization for acute heart failure (HF)., Methods and Results: In this prospective multicentre, double-blind, two-armed trial, patients with advanced HF were randomized 2:1 at the end of an index hospitalization for acute HF to intermittent levosimendan therapy or matching placebo for 12 weeks. All patients had left ventricular ejection fraction (LVEF) ≤30% during index hospitalization. Levosimendan was administered according to centre preference either as 6 h infusion at a rate of 0.2 μg/kg/min every 2 weeks, or as 24 h infusion at a rate of 0.1 μg/kg/min every 3 weeks. The primary efficacy assessment after 14 weeks was based on a global rank score consisting of three hierarchical groups. Secondary clinical endpoints included the composite risk of tiers 1 and 2 at 14 and 26 weeks, respectively. Due to the COVID-19 pandemic, the planned number of patients could not be recruited. The final modified intention-to-treat analysis included 145 patients (93 in the combined levosimendan arm, 52 in the placebo arm), which reduced the statistical power to detect a 20% risk reduction in the primary endpoint to 60%. Compared with placebo, intermittent levosimendan had no significant effect on the primary endpoint: the mean rank score was 72.55 for the levosimendan group versus 73.81 for the placebo group (p = 0.863). However, there was a signal towards a higher incidence of the individual clinical components of the primary endpoint in the levosimendan group versus the placebo group both after 14 weeks (hazard ratio [HR] 2.94, 95% confidence interval [CI] 1.12-7.68; p = 0.021) and 26 weeks (HR 1.64, 95% CI 0.87-3.11; p = 0.122)., Conclusions: Among patients recently hospitalized with HF and reduced LVEF, intermittent levosimendan therapy did not improve post-hospitalization clinical stability., (© 2023 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

A 77-year-old male presented to the emergency department with dyspnea. A third-degree atrioventricular block was present in the electrocardiogram and an echocardiography showed a moderate mitral regurgitation with a diastolic functional insufficiency. Hemodynamic variations were assessed in the context of heart rhythm disturbances. ( Level of Difficulty: Intermediate. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2023 The Authors.)

Despite the efforts made to improve the care of cardiogenic shock (CS) patients, including the development of mechanical circulatory support (MCS), the prognosis of these patients continues to be poor. In this context, CS code initiatives arise, based on providing adequate, rapid, and quality care to these patients. In this multidisciplinary document we try to justify the need to implement the SC code, defining its structure/organization, activation criteria, patient flow according to care level, and quality indicators. Our specific purposes are: a) to present the peculiarities of this condition and the lessons of infarction code and previous experiences in CS; b) to detail the structure of the teams, their logistics and the bases for the management of these patients, the choice of the type of MCS, and the moment of its implantation, and c) to address challenges to SC code implementation, including the uniqueness of the pediatric SC code. There is an urgent need to develop protocolized, multidisciplinary, and centralized care in hospitals with a large volume and experience that will minimize inequity in access to the MCS and improve the survival of these patients. Only institutional and structural support from the different administrations will allow optimizing care for CS., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Aims: The aim of the LAICA study was to evaluate the long-term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF)., Methods and Results: This was a multicentre, randomized, double-blind, placebo-controlled clinical trial of intermittent levosimendan 0.1 μg/kg/min as a continuous 24-h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre-specified time-to-event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32-1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed., Conclusions: In our study, intermittent levosimendan in patients with AdHF produced a statistically non-significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Cardiogenic shock (CS) is associated with a high in-hospital mortality despite the achieved advances in diagnosis and management. Invasive mechanical ventilation and circulatory support constitute the highest step in cardiogenic shock therapy. Once established, taking the decision of weaning from such support is challenging. Intensive care unit (ICU) bedside echocardiography provides noninvasive, immediate, and low-cost monitoring of hemodynamic parameters such as cardiac output, filling pressure, structural disease, congestion status, and device functioning. Supplemented by an ultrasound of the lung and diaphragm, it is able to provide valuable information about signs suggesting a weaning failure. The aim of this article was to review the state of the art taking into account current evidence and knowledge on ICU bedside ultrasound for the evaluation of weaning from mechanical ventilation and circulatory support in cardiogenic shock.

Background: Patients with moderate-severe systolic dysfunction undergoing coronary artery bypass graft have a higher incidence of postoperative low cardiac output. Preconditioning with levosimendan may be a useful strategy to prevent this complication. In this context, design cost-effective strategies like preconditioning with levosimendan may become necessary., Methods: In a sequential assignment of patients with Left Ventricle Ejection Fraction less than 40%, two strategies were compared in terms of cost-effectiveness: standard care (n = 41) versus preconditioning with Levosimendan (n = 13). The adverse effects studied included: postoperative new-onset atrial fibrillation, low cardiac output, renal failure and prolonged mechanical ventilation. The costs were evaluated using deterministic and probabilistic sensitivity analysis, and Monte Carlo simulations were performed., Results: Preconditioning with levosimendan in moderate to severe systolic dysfunction (Left Ventricle Ejection Fraction < 40%), was associated with a lower incidence of postoperative low cardiac output in elective coronary artery bypass graft surgery 2(15.4%) vs 25(61%) (P < 0.01) and lesser intensive care unit length of stay 2(1-4) vs 4(3-6) days (P = 0.03). Average cost on levosimendan group was 14,792€ while the average cost per patient without levosimendan was 17,007€. Patients with no complications represented 53.8% of the total in the levosimendan arm, as compared to 31.7% in the non-levosimendan arm. In all Montecarlo simulations for sensitivity analysis, use of levosimendan was less expensive and more effective., Conclusions: Preconditioning with levosimendan, is a cost-effective strategy preventing postoperative low cardiac output in patients with moderate-severe left ventricular systolic dysfunction undergoing elective coronary artery bypass graft surgery.

BACKGROUND Tumor disease has improved survival due to therapeutic advances and early diagnosis. However, anti-neoplastic treatment involves generating harmful side effects in the body, both in the short-term and in the long-term. One of the most important side effects is cardiovascular disease after radiotherapy, which in addition to being influenced by classic cardiovascular risk factors, can be also be influenced by anti-neoplastic therapy, and represents the main cause of death after a second cancer. We present a case that synthesizes the most relevant and determining aspects of radiotherapy-induced heart disease. CASE REPORT We present the case of a 48-year-old male with a personal history of mediastinal Hodgkin lymphoma who was treated with local radiotherapy 20 years ago, and who was admitted to hospital due to dyspnea and oppressive chest pain with efforts. He was diagnosed with severe aortic stenosis, and a coronary angiography confirmed the existence of coronary disease. Two years before, he had been admitted to hospital due to syncope and a pacemaker had been implanted. This patient experienced several cardiovascular complications that could be attributed to the radiotherapy treatment received in his past. CONCLUSIONS Radiotherapy shows multiple cardiological complications, especially when applied at the thoracic level. This fact is very relevant, and this report can help determine the aspects of radiotherapy-induced heart disease affecting the mortality and morbidity of these patients.

Purpose: Postoperative atrial fibrillation (POAF) is frequent after cardiac surgery. We aimed to establish a predictive model of POAF based on postoperative transthoracic echocardiography (TTE) findings., Methods: This study included 147 patients (aged 67 ± 11 years; 109 men) undergoing coronary artery bypass grafting and/or aortic valve replacement. TTE and Doppler tissue imaging were performed on intensive care unit arrival after surgery. All patients were continuously monitored during hospitalization. The end point was the appearance of POAF., Results: POAF appeared in 37 patients (25.2%). These patients were older (69 ± 16 vs. 65 ± 12 years; P < 0.001) and had increased long axis of the left atrium (LA) dimension (5.4 ± 1 vs. 4.8 ± 0.9 cm, P = 0.02), lower early diastolic velocity of the mitral annulus (e') (6.9 ± 2.1 vs. 8 ± 1.8 cm/sec; P < 0.01), and higher early diastolic pulsed Doppler mitral ratio (E)/e' (E/e') (17.4 ± 6.8 vs. 13.8 ± 6; P = 0.01). Left ventricle diastolic dysfunction grade (DFG) of 2 or 3 relative to grade 0 was significant: odds ratio (OR) 22.5, 95% confidence interval (CI) 4.52-57.2; P < 0.001, and OR: 23.6, 95% CI: 3.57-60.1; P = 0.001), respectively. On multivariate analysis, the independent predictors of POAF were age (OR: 1.10, 95% CI: 1.01-1.18; P < 0.05), long-axis LA dimension (OR: 6.24, 95% CI: 1.97-8.23; P = 0.0017), DFG-2 (OR: 4.1, 95% CI: 1.57-15.81; P < 0.001), and DFG-3 (OR: 8.3, 95% CI: 4.11-25.37; P < 0.001)., Conclusions: Apart from age, the simple determination by postoperative TTE of long-axis LA dimension and DFG after cardiac surgery proved to be powerful independent predictors of POAF and may be useful for risk stratification of these patients., (© 2016, Wiley Periodicals, Inc.)

Aims: To study the hemodynamic effect of levosimendan administration in acute heart failure patients with severe aortic stenosis (AS) and reduced left ventricular ejection fraction (LVEF)., Methods: Hemodynamic response to 24 h intravenous levosimendan infusion (0.1 μg/kg/min without a loading dose) in patients with severe AS (aortic valve area ≤1 cm(2) , time-velocity integral between left ventricular out-flow tract and aortic valve <0.25), reduced LVEF (≤40%), and a depressed cardiac index (CI) <2.2 L/min/m(2) was determined in a sequential group of nine patients aged 76 ± 10 years (5 men)., Results: Baseline mean ejection fraction was 33 ± 0.7%; mean aortic valve area was 0.37 ±0.11 cm(2) /m(2) ; peak and mean gradients of 63.6 ± 20.53 and 36.7 ± 12.62 mmHg, respectively; and mean CI was 1.65 ± 0.20 L/min/m(2) . At 6 and 12 h of levosimendan therapy, mean CI had increased to 2.00 ± 0.41 L/min/m(2) (P = 0.02) and 2.17 ± 0.40 L/min/m(2) (P = 0.01), respectively. At 24 h, mean CI had increased further to 2.37 ± 0.49 L/min/m(2) (P = 0.01). A significant beneficial effect was also observed in pulmonary capillary wedge pressure, pulmonary artery mean pressure, central venous pressure, systemic vascular resistances, pulmonary vascular resistances, stroke volume index, left ventricular stroke work index. NTproBNP levels decreased at 24 h of levosimendan treatment. Levosimendan infusion was also well tolerated. Five patients subsequently underwent aortic valve surgery replacement. One died (of postoperative multiorgan failure). At 30 days, overall survival was 75%., Conclusions: Levosimendan administration improves hemodynamic parameters in critically ill patients with severe AS and reduced LVEF. In our study, it provides a safe and effective bridge to aortic-valve replacement or oral vasodilator therapy in surgical contraindicated patients. A controlled study is needed to confirm these preliminary findings., (© 2015 John Wiley & Sons Ltd.)

To determine whether left ventricular (LV) global longitudinal strain (GLS) predicts adverse LV remodeling and cardiac events. In a prospective cohort study of patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), we recorded clinical data and GLS, global circumferential strain and radial strain using two-dimensional speckle-tracking echocardiography of the left ventricle. At 6-month and 3-year follow-ups, patients were grouped by presence or absence of adverse LV remodeling. We used logistic regression to identify factors associated with adverse LV remodeling and a Cox model to determine the relationships between these factors and cardiac events. Of 97 patients (mean age 56 ± 12 years; 76 men), 38 showed LV remodeling. Diabetes mellitus [odds ratio (OR) 1.95% confidence interval (CI) 1.2-4.8, p = 0.05], peak troponin I (OR 1.2, 95% CI 1.1-1.3, p = 0.004), and GLS (OR 1.6, 95% CI 1.3-2.3, p = 0.009) independently predicted LV remodeling. During follow-up (22.8 ± 12.3 months), 20 patients suffered adverse events, which were independently predicted by GLS alone (OR 4.9, 95% CI 1.7-13.9, p = 0.002). Optimal GLS cutoffs for predicting adverse LV remodeling and cardiac events were >-12.46% [area under receiver operating-characteristic curve (AUC) 0.88, 95% CI 0.79-0.96, p < 0.001] and >-9.27% (AUC 0.86, 95% CI 0.64-0.98, p < 0.001), respectively. GLS measured immediately after primary PCI is an excellent predictor of adverse LV remodeling and cardiac events in patients with AMI.

Background: The intravenous inodilator levosimendan was developed for the treatment of patients with acutely decompensated heart failure. In the last decade scientific and clinical interest has arisen for its repetitive or intermittent use in patients with advanced chronic, but not necessarily acutely decompensated, heart failure. Recent studies have suggested long-lasting favourable effects of levosimendan when administered repetitively, in terms of haemodynamic parameters, neurohormonal and inflammatory markers, and clinical outcomes. The existing data, however, requires further exploration to allow for definitive conclusions on the safety and clinical efficacy of repetitive use of levosimendan., Methods and Results: A panel of 30 experts from 15 countries convened to review and discuss the existing data, and agreed on the patient groups that can be considered to potentially benefit from intermittent treatment with levosimendan. The panel gave recommendations regarding patient dosing and monitoring, derived from the available evidence and from clinical experience., Conclusions: The current data suggest that in selected patients and support out-of-hospital care, intermittent/repetitive levosimendan can be used in advanced heart failure to maintain patient stability. Further studies are needed to focus on morbidity and mortality outcomes, dosing intervals, and patient monitoring. Recommendations for the design of further clinical studies are made., (Copyright © 2014. Published by Elsevier Ireland Ltd.)

Background: Advanced heart failure (HF) is associated with high morbidity and mortality; it represents a major burden for the health system. Episodes of acute decompensation requiring frequent and prolonged hospitalizations account for most HF-related expenditure. Inotropic drugs are frequently used during hospitalization, but rarely in out-patients. The LAICA clinical trial aims to evaluate the effectiveness and safety of monthly levosimendan infusion in patients with advanced HF to reduce the incidence of hospital admissions for acute HF decompensation., Methods: The LAICA study is a multicenter, prospective, randomized, double-blind, placebo-controlled, parallel group trial. It aims to recruit 213 out-patients, randomized to receive either a 24-h infusion of levosimendan at 0.1 μg/kg/min dose, without a loading dose, every 30 days, or placebo., Results: The main objective is to assess the incidence of admission for acute HF worsening during 12 months. Secondarily, the trial will assess the effect of intermittent levosimendan on other variables, including the time in days from randomization to first admission for acute HF worsening, mortality and serious adverse events., Conclusions: The LAICA trial results could allow confirmation of the usefulness of intermittent levosimendan infusion in reducing the rate of hospitalization for HF worsening in advanced HF outpatients.

Introduction and Objectives: Activation of the cell-mediated immune system plays an important role in atherogenesis and in triggering the development of acute coronary syndrome. Neopterin, a biomarker of cell-mediated immune system activity, is also a well-known biomarker of coronary artery disease. It is known that the occurrence of coronary heart disease events is not distributed evenly throughout the day but instead undergoes cyclical variation. In addition, both the number and activity level of immune system cells also vary throughout the 24-h circadian period. We studied how the serum concentration of neopterin varies during the light and dark phases of the day in patients with ST-segment elevation acute coronary syndrome who had undergone primary angioplasty and in a group of control subjects without evidence of atherosclerotic disease., Methods: The serum concentration of neopterin was determined at 10:00 in the morning (i.e., in light) and at 03:00 at night (i.e., in darkness) in 96 patients and 84 control subjects under strictly controlled conditions of light and darkness., Results: Significant light-dark variations were observed in the serum concentration of neopterin in both patients with ST-segment elevation acute coronary syndrome (i.e., 10.2+/-3.8 nmol/L in light vs. 8.84+/-2.22 nmol/L in darkness; P< .001) and control subjects (i.e., 6.98+/-1.96 nmol/L in light vs. 5.87+/-2 nmol/L in darkness; P< .001). Moreover, levels were significantly higher in patients (P< .001)., Conclusions: Diurnal variations in cell-mediated immune system activity were observed in both patients with ST-segment elevation acute coronary syndrome who underwent primary angioplasty and in a control group. Moreover, activity was significantly higher in patients.

Objective: The aim of this study was to determine the influence of gender on in hospital outcome in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary angioplasty (PA)., Design and Scope: Prospective study of a cohort of patients consecutively admitted to the Coronary Unit of a tertiary hospital in the period of January to October 2004 with the diagnoses of IAMEST and treated with PA., Patients: Consecutive sample of 86 patients with this diagnosis divided into two groups based on sex: 52 men and 34 women., Main Variables of Interest: In both groups, we analyzed the baseline clinical-demographic characteristics, extension of the coronary disease (ECD), success of the PA, appearance of heart failure (HF) and in-hospital mortality in the first 28 days after admission. We analyzed predictors of mortality in a multivariate model., Results: The women were older (70+/-8 versus 65+/-11; p=0.02) and had greater prevalence of diabetes (37% versus 18%; p=0.002) and hypertension (58% versus 37%; p<0.001) than the men while the men had greater frequency of smoking (34% versus 22%; p=0.001). There were no differences in the presence of hyperlipidemia, ECD or the success of PA. Women had a higher incidence of HF on admission (22% versus 12%; p=0.01) and in-hospital mortality (17% versus 8%; p=0.002). In the multivariate analyses, female sex and HF on admission continued to be predictors of in-hospital mortality., Conclusions: In our study, female gender was an independent predictor of in-hospital mortality in patients with IAMEST treated with PA.

Objective: To assess the incidence, clinical profile and influence on outcome of systemic inflammatory response syndrome (SIRS) in patients with acute myocardial infarction (AMI) treated with primary angioplasty (PA)., Design: Prospective observational study., Scope: A 12-beds coronary care unit at a university hospital., Patients and Methods: Patients with AMI treated with PA, admitted in 2004 were studied. PRINCIPAL VARIABLES OF INTEREST: Age, gender, anterior localization of AMI, smoking, arterial hypertension, diabetes mellitus, troponin Ic levels, time delays until PA, heart failure, left ventricular ejection fraction (LVEF), in-hospital length of stay and mortality., Results: Ninety patients were included. SIRS was diagnosed in 15 patients (16.6%), who were older (72 +/- 7 vs 66 +/- 9 years; p = 0,01). These patients had a greater frequency of diabetes mellitus (42% vs 17%; p = 0.01), higher troponin Ic levels (80 +/- 12 vs 68 +/- 19 ng/ml; p = 0.02), lower LVEF (41 +/- 8% vs 51 +/- 12%; p = 0.002), longer in-hospital length of stay (18 +/- 5 vs 7 +/- 3 days, p = 0.001), and higher in-hospital mortality (10 vs 3%, p = 0.03) compared with patients without SIRS. Diabetes mellitus (OR: 1.7; 95% CI: 1.2-1.9) and lower ejection fraction (OR: 2.3; 95% CI: 1.5-3.1) were the independent predictors of the presence of systemic inflammatory response syndrome. In multivariant analysis SIRS was an independent predictor of mortality in AMI patients treated with PA (OR: 3.3; 95% CI: 1.3-6)., Conclusions: Systemic inflammatory response syndrome may be present in AMI patients treated with PA and its presence is associated to a worse outcome and longer in-hospital stay.

Background: Levosimendan is a new calcium sensitizer with positive inotropic properties. Cardiac power output (CPO) has been shown to be instrumental in the diagnosis of cardiogenic shock (CS) and is an important determinant of outcomes., Aims: To evaluate the haemodynamic effects of levosimendan compared to dobutamine in acute myocardial infarction (AMI) patients revascularised by primary percutaneous coronary intervention (PCI), who developed CS., Methods and Results: Twenty two consecutive AMI patients revascularised by PCI, who developed CS, were randomly assigned to levosimendan (24 microg kg(-1) bolus plus 24-h continuous infusion 0,1 microg kg(-1) min(-1)) or dobutamine (initial dose 5 microg kg(-1) min(-1), with a maximum dose adjustment in order to reach the desired haemodynamic effect). Evaluations were performed from baseline to 30 h. The primary end-point was an increase > or =30% in CPO, after 24 h of therapy. The baseline clinical and haemodynamic characteristics were similar in both groups. Levosimendan had a consistently better effect on CPO than dobutamine, while the decrease in PCWP was similar., Conclusion: The primary objective of our study was achieved better by the end of the 24 h infusion of levosimendan than by dobutamine.

The presence of diabetes mellitus worsens prognosis in acute coronary syndromes. The aim of our study was to analyze retrospectively the influence of diabetes mellitus on the management and prognosis of patients with non-ST-segment elevation acute coronary syndrome. We compared the baseline clinical characteristics of 273 patients (93 diabetic and 180 non-diabetic) admitted consecutively to our department with the diagnosis of non-ST-segment elevation acute coronary syndrome. In both groups, we assessed the medical treatment given during hospitalization and the use of coronary angiography, percutaneous coronary intervention, and coronary artery bypass grafting. Finally, we determined the incidence of heart failure during hospitalization and mortality at 28 days and 6 months in both groups. Multifactorial analysis revealed that diabetes was an independent risk factor for mortality during the study period. Data from our registry indicate that these findings were not associated with more extensive use of interventions in diabetic patients.

Introduction and Objectives: Interleukin 10 (IL-10) is an anti-inflammatory cytokine that inhibits the synthesis of proinflammatory cytokines. It has been shown that IL-10 is released into the circulation during post-ischemic myocardial reperfusion. The objective of this study was to determine whether the serum IL-10 concentration in patients with acute myocardial infarction who were undergoing primary angioplasty was related to the subsequent presence or absence of heart failure., Patients and Method: The study included 65 patients who underwent successful primary angioplasty. During their subsequent stay in the coronary unit, their maximum degree of heart failure was recorded. Patients were then divided into 2 groups: group A patients were in Killip class I and group B patients in Killip classes II-IV. The serum IL-10 concentration was measured during the 24 hours following admission to the coronary unit., Results: The 2 groups were similar with regard to age, sex, and coronary risk factors. The IL-10 concentration was significantly higher in the group of patients with acute myocardial infarction without heart failure than in the group with heart failure (30.4+/-10.8 vs 19.8+/-7.9 pg/mL; P<.001)., Conclusions: In patients with acute myocardial infarction who had undergone successful primary angioplasty, the serum IL-10 concentration measured during the following 24 hours was significantly higher in those who did not develop heart failure. These findings suggest that this anti-inflammatory cytokine has a protective effect on the myocardium during ischemia or reperfusion, or both.

Objective: A rise in plasma levels of the amino acid homocysteine (HCY) is a possible risk factor in cardiovascular disease. The mechanisms proposed to explain how HCY can increase the risk of vascular disease include its direct effect on the vascular endothelium and its role in increasing the risk of thrombosis. The present work has been designed to determine HCY levels in patients with coronary artery disease (CAD) residents in the Canary Islands and to establish whether hyperhomocysteinemia can be considered as an risk factor., Methods: The sample studied consisted of 132 patients with, angiographically demonstrated, CAD and 18 controls with normal coronary arteries. Biochemical parameters determined included: HCY, vitamin B12, vitamin B6, folic acid, creatinine, cholesterol and its fractions, triglycerides, glucose and fibrinogen., Results: Mean levels of HCY were not significantly different between the cases and controls (p = 0.37). In the distribution of HCY levels into quintiles there was no significant association between the quintiles and the occurrence of CAD (p = 0.57). Multiple logistic regression analysis in which the risk factors were compared with quintiles 2, 3, 4 and 5 of HCY did not reveal a significant relation between HCY levels and risk of CAD., Conclusions: This study questions the previously accepted consideration that hyperhomocysteinemia is a risk factor of CAD. Controlled intervention trials are, therefore, necessary to clarify the possible association between total HCY levels and cardiovascular disease.

Arrhythmogenic right ventricular cardiomyopathy is a entity of unknown etiology, that is pathologically characterized by right ventricular myocardial atrophy and fibroadipous tissue replacement. We present the case of a 65-year-old male patient with the diagnosis of chronic liver disease, whose study lead a diagnosis of Arrhythmogenic right ventricular cardiomyopathy.

We present the case of a male patient with aortic and mitral valve bioprostheses who developed infectious endocarditis due to Staphylococcus capitis, which has recently been described as an agent producing infectious endocarditis in native and prosthetic cardiac valves. The patient's course evolved unfavorably, despite specific antibiotic treatment, leading to the surgical replacement of the valve, which completely resolved the problem. This case points out that, although rare, in infectious endocarditis due to Staphylococcus capitis its pathogenicity is significant.

Thrombolytic therapy has shown to be effective in acute myocardial infarction, and its benefits on left ventricular function and later survival are well known. However it is not a therapy free of complications and side effects. Allergic reactions, anafilaxia, hypotension, and several kinds of hemorrhages have been reported. Adult respiratory distress syndrome after streptokinase administration has been also described, and one case, recently communicated, after APSAC therapy. We present the case of a male with acute myocardial infarction who developed adult respiratory distress syndrome after APSAC therapy, with different outcome than the first case published in the literature. Finally, we discussed the mechanisms by means these drugs can produce such a complication.