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The aim was to investigate the association between continuing angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB) with postinduction hypotension and vasoactive drug use in elderly orthopedic surgery patients under regional anesthesia. Retrospective design consisted of 114 patients (mean age 66) undergoing elective total knee arthroplasty, including 84 patients with chronic hypertension, and they were divided as group I (n = 37), ACEI/ARB continued; group II (n = 23), ACEI/ARB withdrawn; group III (n = 24), β-blocker/calcium channel blocker continued; and group IV (n = 30), without hypertension (control). Primary end points are systolic blood pressures (SBPs) and mean arterial blood pressures (MAPs) at 0, 30, 60, and 90 minutes postinduction, incidence of hypotension (SBP <85 mm Hg), and ephedrine requirements. Repeated measurements were analyzed using generalized estimating equations controlling for baseline characteristics and accounting for correlations. Logistic regression was used for remaining variables. Hypotension occurred more frequently (P = .02) in group I (30%) versus groups II-IV (9%, 13%, 3%). Ephedrine use was increased (P < .001) in group I (51%) compared with groups II-IV (26%, 17%, 7%). Group I had lower mean SBPs compared with group II (110 vs. 120; P = .0045) and group IV (110 vs. 119; P = .0013). Lower mean MAPs were found in group I versus group II (74 vs. 81, P = .001) and group IV (74 vs. 80; P = .001). Group I had an increased odds of receiving ephedrine versus group IV (odds ratio, 16.27; 95% confidence interval, 3.10-85.41; P = .001). No adverse clinical events were recorded. Day of surgery ACEI/ARB use is associated with a high incidence and severity of postinduction hypotension with associated high vasopressor requirements. Associated clinical outcomes merit further study., (Copyright © 2014 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Several biomarkers have been documented, singly or jointly, to improve risk prediction, but the extent to which they improve prediction-model performance in populations with high prevalences of obesity and diabetes has not been specifically examined. The aim of this study was to evaluate the ability of various biomarkers to improve prediction-model performance for death and major cardiovascular disease (CVD) events in a high-risk population. The relations of 6 biomarkers with outcomes were examined in 823 American Indians free of prevalent CVD or renal insufficiency, as were their contributions to risk prediction. In single-marker models adjusting for standard clinical and laboratory risk factors, 4 of 6 biomarkers significantly predicted mortality and major CVD events. In multimarker models, these 4 biomarkers-urinary albumin/creatinine ratio (UACR), glycosylated hemoglobin, B-type natriuretic peptide, and fibrinogen-significantly predicted mortality, while 2-UACR and fibrinogen-significantly predicted CVD. On the basis of its robust association in participants with diabetes, UACR was the strongest predictor of mortality and CVD, individually improving model discrimination or classification in the entire cohort. Singly, all remaining biomarkers also improved risk classification for mortality and enhanced average sensitivity for mortality and CVD. The addition of > or =1 biomarker to the single marker UACR further improved discrimination or average sensitivity for these outcomes. In conclusion, biomarkers derived from diabetic cohorts, and novel biomarkers evaluated primarily in lower risk populations, improve risk prediction in cohorts with prevalent obesity and diabetes. Risk stratification of these populations with multimarker models could enhance selection for aggressive medical or surgical approaches to prevention.

Among patients that present with cardiac masses, thrombus is an important diagnostic consideration that affects both clinical management and prognosis. Although thrombus can occasionally be difficult to diagnose using structural criteria alone, it can be distinguished from other structures according to tissue characteristics. Because thrombus is inherently avascular, absence of contrast uptake was used as a highly specific identifying feature. Delayed-contrast cardiac computed tomography (CT) imaging has been previously used for myocardial tissue characterization, distinguishing between viable and infarcted myocardium based upon differences in contrast uptake. This technique also offers potential diagnostic utility for assessment of thrombus. In this report, we describe a case of a patient with a giant left atrial mass in whom delayed-contrast CT was employed as a useful diagnostic technique for identification of cardiac thrombus.

Background: Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is useful for the diagnosis and exclusion of congestive heart failure (HF). Little is known about the effect of race on NT-proBNP concentrations. Also, NT-proBNP levels may be higher in apparently well women, but the effect of gender on NT-proBNP concentrations in dyspneic patients is not known., Methods and Results: NT-proBNP (Elecsys proBNP, Roche, Indianapolis, IN) was measured in 599 dyspneic patients in a prospective study. Of these, 44 were African American; 295 were female. NT-proBNP levels were examined according to race and gender in patients with and without acute HF using analysis of covariance. Receiver operating characteristic (ROC) curves assessed NT-proBNP by race and gender. Cutpoints for diagnosis (450, 900, and 1800 pg/mL for ages < 50, 50 to 75, and > 75 years) and exclusion (300 pg/mL) were examined in African-American and female subjects. There was no difference in the rates of acute HF between African-American and non-African-American (30% versus 35%, P = .44) or male and female (35% versus 35%, P = .86) subjects. In subjects with HF, there was no difference in median NT-proBNP concentrations between African American and non-African American (6196 versus 3597 pg/mL, P = .37). In subjects without HF, unadjusted NT-proBNP levels were lower in African-American subjects than in non-African-American subjects (68 versus 148 pg/mL, P < .03); however, when adjusted for factors known to influence NT-proBNP concentrations (age, prior HF, creatinine clearance, atrial fibrillation, and body mass index), race no longer significantly affected NT-proBNP concentrations. There was no statistical difference in median NT-proBNP concentrations between male and female subjects with (4686 versus 3622 pg/mL, P = .53) or without HF (116 pg/mL versus 150 pg/mL, P = .62). Among African Americans, NT-proBNP had an area under the ROC for acute HF of 0.96 (P < .0001), and at optimal cutpoints, had a sensitivity of 100% and a specificity of 90%. Among females, NT-proBNP had an area under the ROC for acute HF of 0.95 (P < .0001), and had a sensitivity of 89% and a specificity of 88%; 300 pg/mL had negative predictive value of 100% in African Americans and females., Conclusion: NT-proBNP is useful for the diagnosis and exclusion of acute HF in dyspneic subjects, irrespective of race or gender.

Left ventricular hypertrophy (LVH) is a strong, independent predictor of cardiovascular events and all-cause mortality. Patients with LVH are at increased risk for stroke, coronary heart disease, congestive heart failure, and sudden cardiac death. Hypertension is a major influence on the development of LVH. The prognostic power of LVH is likely multifactorial. LVH represents both a manifestation of the effects of hypertension and other cardiac risk factors over time as well as an intrinsic condition causing pathologic changes in cardiac structure and function. Angiotensin II plays a central role in the development of LVH. Several antihypertensive treatments, especially angiotensin II receptor blockers, can reverse LVH and improve cardiovascular outcomes independent of blood pressure reduction. Further studies are required to determine if these agents should become first-line therapy for all patients with hypertension and LVH.

Aims: The objective of this study was to determine the integrative utility of measuring plasma NT-proBNP levels with echocardiography in the evaluation of dyspnoeic patients., Methods and Results: Of 599 emergency department patients enrolled in a clinical study of NT-proBNP at a tertiary-care hospital, 134 (22%) had echocardiographic results available for analysis. Echocardiographic parameters correlating with NT-proBNP levels were determined using multivariable linear-regression analysis. Independent predictors of 1-year mortality were determined using Cox-proportional hazard analysis. Independent relationships were found between NT-proBNP levels and ejection fraction (P = 0.012), tissue Doppler early and late mitral annular diastolic velocities (P = 0.007 and 0.018), right ventricular (RV) hypokinesis (P = 0.006), and tricuspid regurgitation severity (P < 0.001) and velocity (P = 0.007). An NT-proBNP level <300 pg/mL had a negative predictive value of 91% for significant left ventricular systolic and diastolic dysfunction. Overall 1-year mortality was 20.1% and was independently predicted by NT-proBNP level [HR 8.65, 95% confidence interval (CI) 2.7-27.8, P = 0.0003], ejection fraction (HR 0.95, 95% CI 0.91-0.99, P = 0.009), RV dilation (HR 2.98, 95% CI 1.05-12.8, P = 0.04), and systolic blood pressure (HR 0.97, 95% CI 0.96-0.99, P = 0.01)., Conclusion: NT-proBNP levels correlate with, and provide important prognostic information beyond, echocardiographic parameters of cardiac structure and function. Routine NT-proBNP testing may thus be useful to triage patients to more timely or deferred echocardiographic evaluation.

Background: No method integrating amino-terminal pro-brain natriuretic peptide (NT-proBNP) testing with clinical assessment for the evaluation of patients with suspected acute heart failure (HF) has been described., Methods: Amino-terminal pro-brain natriuretic peptide results and clinical factors from 599 patients with dyspnea were analyzed. The beta coefficients of the 8 independent predictors of HF were used to assign a weighted integeric score for predictor. The sum of these integers provided a diagnostic HF "score" for each patient. Receiver operating characteristic curve analysis determined the optimal cut point for the diagnosis of acute HF. The performance of the score was evaluated in the development cohort and subsequently in a patient population from a separate clinical trial of patients with dyspnea conducted in Christchurch, New Zealand., Results: Eight factors comprised the score: elevated NT-proBNP (4 points), interstitial edema on chest x-ray (2 points), orthopnea (2 points), absence of fever (2 points), loop diuretic use, age > 75 years, rales, and absence of cough (all 1 point). Median scores in patients with acute HF were higher than those without acute HF (9 vs 3 points, P < .001). At a cut point of > or = 6 points, the score had a sensitivity of 96% and a specificity of 84% for the diagnosis of acute HF (P < .001). The score improved diagnostic accuracy over NT-proBNP testing alone and retained discriminative capacity in patients in whom clinical uncertainty was present. Lastly, the accuracy of the score was validated in the external data set of patients with suspected acute HF., Conclusion: We report a simple and accurate scoring system combining NT-proBNP testing and clinical assessment for the diagnosis or exclusion of acute HF in patients with dyspnea.

Neurologic toxicity is an infrequently reported and under-recognized consequence of amiodarone, symptoms of which may include tremor, peripheral sensorimotor neuropathy, proximal weakness, and ataxia. The investigators report the rapid and complete remission of 4 months of progressively debilitating ataxia with the discontinuation of small-dose amiodarone in an elderly woman with hypertrophic obstructive cardiomyopathy and paroxysmal atrial fibrillation. Despite the long half-life of amiodarone, her symptoms began to reduce after several days, and she was walking without assistance within 1 week. Wider recognition of this syndrome may avoid unnecessary and lengthy diagnostic evaluation and promote earlier neurologic recovery.

Background: Limited data exist regarding the impact of left ventricular ejection fraction (LVEF) on N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) levels in patients with acute congestive heart failure (CHF)., Methods and Results: LVEF data were analyzed for 153 subjects with acute CHF. LVEF > or =50% was defined as non-systolic CHF (NS-CHF); LVEF >50% was defined as systolic CHF (S-CHF). 76 subjects (49.7%) had NS-CHF. Median NT-proBNP and BNP levels were significantly higher among patients with S-CHF (6196 pg/mL, 592 pg/mL, respectively) compared with those patients with NS-CHF (2849 pg/mL, 259 pg/mL, respectively). With optimal cut-points, a false-negative rate of 7% was observed for both assays among patients with S-CHF. Among patients with NS-CHF, BNP had a significantly higher false-negative rate (20%) than did NT-proBNP (9%; P < .001 for difference). NT-proBNP, but not BNP, significantly correlated with CHF symptom severity among patients with NS-CHF., Conclusion: Levels of both NT-proBNP and BNP are significantly lower in patients with NS-CHF; however, in contrast to NT-proBNP, BNP may be falsely negative in up to 20% of patients with NS-CHF and does not correlate with symptom severity in NS-CHF. NT-proBNP appears superior to BNP for the evaluation of suspected acute CHF in patients with preserved LVEF.

The utility of aminoterminal pro-brain natriuretic peptide (NT-proBNP) testing in the emergency department to rule out acute congestive heart failure (CHF) and the optimal cutpoints for this use are not established. We conducted a prospective study of 600 patients who presented in the emergency department with dyspnea. The clinical diagnosis of acute CHF was determined by study physicians who were blinded to NT-proBNP results. The primary end point was a comparison of NT-proBNP results with the clinical assessment of the managing physician for identifying acute CHF. The median NT-proBNP level among 209 patients (35%) who had acute CHF was 4,054 versus 131 pg/ml among 390 patients (65%) who did not (p <0.001). NT-proBNP at cutpoints of >450 pg/ml for patients <50 years of age and >900 pg/ml for patients >or=50 years of age were highly sensitive and specific for the diagnosis of acute CHF (p <0.001). An NT-proBNP level <300 pg/ml was optimal for ruling out acute CHF, with a negative predictive value of 99%. Increased NT-proBNP was the strongest independent predictor of a final diagnosis of acute CHF (odds ratio 44, 95% confidence interval 21.0 to 91.0, p <0.0001). NT-proBNP testing alone was superior to clinical judgment alone for diagnosing acute CHF (p = 0.006); NT-proBNP plus clinical judgment was superior to NT-proBNP or clinical judgment alone. NT-proBNP measurement is a valuable addition to standard clinical assessment for the identification and exclusion of acute CHF in the emergency department setting.

Background: Obesity is associated with lower B-type natriuretic peptide (BNP) levels in healthy individuals and patients with chronic congestive heart failure (CHF). Neither the mechanism of natriuretic peptide suppression in the obese patient nor whether obesity affects natriuretic peptide levels among patients with acute CHF is known., Methods: The associations of amino-terminal pro-BNP (NT-proBNP), BNP, and body mass index (BMI) were examined in 204 subjects with acute CHF. Multivariable regression analyses were performed to identify factors independently related to NT-proBNP and BNP levels., Results: Across clinical strata of normal (<25 kg/m2), overweight (25-29.9 kg/m2), and obese (> or =30 kg/m2) patients, median NT-proBNP and BNP levels decreased with increasing BMI (both P values < .001). In multivariable analyses adjusting for covariates known to affect BNP levels, the inverse relationship between BMI and both NT-proBNP and BNP remained ( P < .05 for both). Using a cut point of 900 pg/mL, NT-proBNP was falsely negative in up to 10% of CHF cases in overweight patients (25-29.9 kg/m2) and 15% in obese patients (> or =30 kg/m2). Using the standard cut point of 100 pg/mL, BNP testing was falsely negative in 20% of CHF cases in both overweight and obese patients. The assays for NT-proBNP and BNP exhibited similar overall sensitivity for the diagnosis of CHF., Conclusions: When adjusted for relevant covariates, compared with normal counterparts, overweight and obese patients with acute CHF have lower circulating NT-proBNP and BNP levels, suggesting a BMI-related defect in natriuretic peptide secretion. NT-proBNP fell below the diagnostic cutoff for CHF less often than BNP in overweight and obese individuals; however, when used as a diagnostic tool to identify CHF in such patients, both markers may have reduced sensitivity.

Dyspnea is a primary clinical manifestation of acute congestive heart failure (CHF) among patients presenting to the emergency department (ED). Unfortunately, other critical illnesses, including acute coronary syndromes, pulmonary embolism, chronic obstructive pulmonary disease, and pneumonia, may present with clinical symptoms and signs similar to acute CHF. N-terminal pro-brain natriuretic peptide (NT-proBNP) has proven to be a powerful tool in the diagnostic assessment of dyspnea as a result of its ability to confirm or exclude the presence of acute CHF. However, many of the disorders that mimic acute CHF may result in elevated NT-proBNP levels as well. Results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study recently demonstrated that a strategy integrating NT-proBNP testing into routine clinical assessment demonstrated a better diagnostic yield than each strategy used in isolation. We present a diagnostic algorithm integrating NT-proBNP testing with clinical assessment for use in routine clinical practice.

To determine the capacity of the left ventricle to expand after biventricular repair of left ventricular (LV) outflow tract obstruction, we studied pre- and postoperative echocardiographic variables from 14 infants (< 2 months old) who underwent successful repair of isolated aortic coarctation. We show that in this lesion, LV volume is a dynamic entity, and that the left ventricle achieves a larger cavity size once surgery relieves compression and normalizes loading conditions.