Internal and emergency medicine
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Percutaneous coronary interventions (PCIs) within a door-to-balloon timing of 90 min have greatly decreased mortality and morbidity of ST-elevation myocardial infarction (STEMI) patients. Post-PCI, they are routinely transferred into the coronary care unit (CCU) regardless of the severity of their condition, resulting in frequent CCU overcrowding. This study assesses the feasibility of step-down units (SDUs) as an alternative to CCUs in the management of STEMI patients after successful PCI, to alleviate CCU overcrowding. ⋯ Patients managed in the SDU incurred significantly lower inpatient costs (p = 0.0003). No significant differences were found between the CCU and SDU patients in terms of patient characteristics, PCI characteristics, in-hospital complications, length of stay, and patient outcomes up to a year after discharge. The SDU is a viable cost-effective option for managing STEMI patients after successful primary PCI to avoid CCU overcrowding, with non-inferior patient outcomes as compared to the CCU.
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Out-of-office blood pressure (BP) measurement is encouraged by recent hypertension guidelines for assessing BP phenotypes. These showed acceptable reproducibility in the short term, but few data exist about long-term reproducibility, particularly for chronic kidney disease (CKD) patients. We evaluated changes of the BP phenotypes at 6 and 12 months in 280 consecutive non-dialysis CKD outpatients (186 males, age 71 ± 12 years, eGFR 38 ± 13 ml/min/1.73), without any change in drug therapy. ⋯ When reproducibility of BP phenotypes both at 6 months and at 12 months was assessed, it was very low (19.6%), particularly for MUCH (0%), CH (14%) and WUCH (15.5%), while it was 31% for SUCH. In a CKD cohort, the overall prevalence of the different BP phenotypes defined by office and home BP remains constant over time. However, only 38% of patients maintained the same phenotype at 12 months, suggesting a poor reproducibility over time for the BP phenotypes.
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Urine and serum NMR-based metabolomics in pre-procedural prediction of contrast-induced nephropathy.
Contrast induced nephropathy (CIN) has been reported to be the third foremost cause of acute renal failure. Metabolomics is a robust technique that has been used to identify potential biomarkers for the prediction of renal damage. We aim to analyze the serum and urine metabolites changes, before and after using contrast for coronary angiography, to determine if metabolomics can predict early development of CIN. 66 patients undergoing elective coronary angiography were eligible for enrollment. ⋯ Glutamic acid, uridine diphosphate, glutamine and tyrosine were the most important serum predictive biomarkers. Several pathways related to amino acid and nicotinamide metabolism were suggested as impaired pathways in CIN prone patients. Changes exist in urine and serum metabolomics patterns in patients who do and do not develop CIN after coronary angiography hence metabolites may be potential predictive identifiers of CIN.
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Some evidence suggests a relationship between thyroid dysfunction and uric acid (UA) metabolism, but the potential influential role of thyroid hormones on UA metabolism is still debated. This report was designed to evaluate the influential role of levothyroxine (L-T4) replacement therapy on circulating levels of UA in patients with recent onset post-thyroidectomy subclinical hypothyroidism. Circulating levels of thyroid hormones, UA and other metabolic parameters were assessed in 155 recently thyroidectomized patients (131 females, mean age 51.1 ± 12.7 years) at baseline (5-7 day after surgery) and after 2 months under replacement therapy with L-T4. ⋯ After 2 months under the replacement therapy with L-T4, both serum UA levels (- 1.2 ± 0.9 mg/dL, p < 0.0001 vs. baseline) and HOMA-IR (- 0.3 ± 1.5 mmol/L, p = 0.0328 vs. baseline) significantly decreased. Multivariate regression analysis revealed that changes in HOMA-IR explained 23% of the variations of serum UA levels under L-T4 replacement therapy (β = 0.295, p < 0.0001, R2 = 0.230). Our study suggests that thyroid hormones could modulate UA metabolism in patients with recent onset subclinical hypothyroidism likely by improving insulin sensitivity.
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Symptomatic atrial fibrillation (AF) is a common cause of emergency department (ED) referrals. In case of hemodynamic stability, the choice to either perform early cardioversion (pharmacologic or electrical) or to prescribe rate-lowering drugs and differ any attempts to restore sinus rhythm (i.e., wait-and-see approach) has been widely debated. Results of the recent Rate Control versus Electrical Cardioversion Trial 7-Acute Cardioversion versus Wait and See (RACE 7 ACWAS) have been considered a strong argument in favor of the wait-and-see approach. ⋯ Furthermore, the wait-and-see approach may translate into a missed opportunity to encourage widespread use of a "pill-in-the-pocket" home treatment: this underused option could allow rapid solving of many AF episodes, potentially avoiding future ED referrals. Our opinion is that a delayed cardioversion may introduce unneeded complications in the straightforward management of a common clinical problem. Therefore, early cardioversion should continue to be the preferred option because of its proven efficacy, safety and convenience.