Although neither of these studies examined risk stratification before hospital discharge, both of them stratified risk in patients who had had a myocardial infarction weeks or months earlier.. Algorithm used at Mayo Clinic to evaluate ventricular arrhythmias after reperfusion therapy. Nevertheless, the moment at which risk stratification is performed is extremely important. If the change in ejection fraction from day 1 to day 90 is considered, only a very small change occurs in most patients.
However, it has a relative interest for stratifying risk after the first 3 months because high-risk patients have already died.
The greatest risk of sudden death is in the first 3 days after infarction, and this is a problem that we cannot escape.. The results of the MADIT 2 study, involving patients who had had a myocardial infarction more than 30 days earlier, have just been published Although the results of this study do not answer the question of how risk stratification should be carried out before hospital discharge, they are the most solid findings available.
An important question is what should be the role of T-wave alternans, heart rate variability, or anomalous baroreflex sensitivity, because the preliminary findings of the MADIT 2 study for these variables are discouraging. We do not know if the development of new antiarrhythmic drugs can help eliminate the uncertainty about how to stratify risk in this subgroup of patients. However, there is no doubt that because of the inadequacy of the results now available, we must seek out and evaluate new methods for risk stratification..
Certain noncardiac factors modify the prognosis of patients after myocardial infarction. In the CAST trial of encainide and flecainide, investigators studied how keeping pets influenced the 1-year survival rate. The results demonstrated a 3. This difference increased still more if the pet was a dog; dog owners had a mortality rate of 1. Unexpectedly, cat owners had a greater mortality rate than those who did not have cats, although the difference was small 7. To summarize, the management of patients who have survived myocardial infarction must include the administration of aspirin, beta-blockers, ACE inhibitors, and lipid-lowering drugs.
The role of amiodarone remains to be seen, although it seems clear that ICD implantation produces a significant benefit in many patients. There is no doubt that coronary revascularization has an important effect on survival after myocardial infarction. Also, we should not forget that having a dog is a highly cost-effective alternative for preventing sudden death, given the effect of this noncardiac risk factor on prognosis..
Correspondence: Dr. Division of Cardiovascular Diseases and Internal Medicine. Mayo Clinic. Home Articles in press Current Issue Archive. ISSN: Previous article Next article. Issue 6. Pages June More article options. Download PDF. Bernard J Gersh a. Estados Unidos. This item has received. Article information. Show more Show less. The prognosis of patients with ischemic heart disease has improved markedly with the introduction of reperfusion therapy and with aggressive efforts to modify risk factors.
In this context, it is unlikely that the results of previous studies in the prereperfusion era can be applied to this group of patients. Others have demonstrated that the identification of subgroups of patients at greater risk and the search for new risk markers can significantly improve survival of patients who are at high risk despite reperfusion therapy.
Other factors that determine poor prognosis after myocardial infarction are transitory heart failure, left ventricular dysfunction, and advanced age. The active search for new risk markers has identified other factors such as nonresolution of ST-segment changes, impaired ventricular filling, anomalous baroreflex sensitivity, or T-wave alternans that may be of benefit in assessing risk.
Also, the timing of risk stratification can be critical. Often, risk factors have been analyzed weeks or even months after infarction instead of before hospital discharge.
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Baroreflex sensitivity. Por otra parte, el momento en el que se estratifica el riesgo de un paciente puede ser decisivo. Palabras clave:. Sensibilidad barorrefleja. The challenge for the twenty-first century is to determine if risk stratification before hospital discharge can significantly improve the prognosis of these patients. In other words, a positive diagnostic test confirms what we already know, and a negative diagnostic test may be a false-positive result. Exercise testing in the early period after myocardial infarction in the evaluation of prognosis.. Cardiol Clin, 2 , pp. The prognostic significance of serial exercise testing after myocardial infarction..
Circulation, 60 , pp. Prognostic value of electrocardiographic exercise testing and noninvasive assessment of left ventricular ejection fraction soon after acute myocardial infarction.. Am J Cardiol, 57 , pp. Prognostic significance of maximal exercise testing after myocardial infarction treated with thrombolytic agents: the GISSI-2 data-base.
Lancet, , pp. J Am Coll Cardiol, 27 , pp. Determinants of survival in patients with ventricular tachyarrhythmias.. N Engl J Med, , pp. Circulation, 95 , pp. Time to treatment influences the impact of ST-segment resolution on one-year prognosis: insights from the assessment of the safety and efficacy of a new thrombolytic ASSENT-2 trial.. Circulation, , pp. Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction..
J Am Coll Cardiol, 37 , pp. Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction.. T-wave alternans as a predictor for sudden cardiac death after myocardial infarction.. Am J Cardiol, 89 , pp. Recovery of ventricular function after myocardial infarction in the reperfusion era: the Healing and Early Afterload Reducing Therapy study.. Ann Intern Med, , pp. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction..
Am J Cardiol, 76 , pp. Subscribe to our newsletter. Print Send to a friend Export reference Mendeley Statistics. Clinical Profile and Incidence of Ventricular Arrhythmia in Instructions for authors Submit an article Ethics in publishing Information for reviewers Frequently asked questions. Images subject to Copyright, to apply for permission to reprint, please contact spainpermissions elsevier. Article options. Various risk factors, clinical course and treatment options were analysed. Results A total of 28 patients Oral anticoagulants and steroids appear to be the main risk factors, CUA is a challenge; a registry of patients and determining standard therapy are required.
Palabras clave:. Introduction Calciphylaxis, also called calcific uraemic arteriolopathy CUA , is an uncommon but serious condition with a high rate of mortality. Material and methods An observational and retrospective study was performed on a series of patients diagnosed with calciphylaxis between December and December at Hospital Universitario 12 de Octubre in Madrid. Results General epidemiological data We identified 28 patients diagnosed with calciphylaxis, a Figure 1. Risk factors prior to the onset of calciphylaxis.
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X-ray of left-hand showing vascular calcifications left. Figure 2. Biochemical parameters of bone metabolism and serum albumin. Table 3. Treatment options used. Table 4. Influence of different factors on calciphylaxis-related mortality. Different variables related to the presence or absence of CKD and death due to calciphylaxis. Analysis of survival regarding death due to calciphylaxis in the different groups NRF: normal renal function; HD: haemodialysis; RTx: renal transplant.
Figure 3. Mizobuchi, D. Towler, E. Vascular calcification: the killer of patients with chronic kidney disease. J Am Soc Nephrol, 20 , pp. Weening, L.
Sewell, M. Davis, J. McCarthy, M. Calciphylaxis: natural history, risk factor analysis and outcome.
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J Am Acad Dermatol, 56 , pp. Perspectiva actual. Mazhar, R. Johnson, D. Gillen, J.
METABOLIC SYNDROME AND ITS COMPONENTS IN SPANISH POSTMENOPAUSAL WOMEN.
Stivelman, M. Ryan, C. Davis, et al. Risk factors and mortality associated with calciphylaxis in end-stage renal disease. Kidney Int, 60 , pp. Rogers, P. Calcific uremic arteriolopathy: an update. Curr Opin Nephrol Hypertens, 17 , pp. Mawad, B. Sawaya, R. Sarin, H. Calcific uremic arteriolopathy in association with low turnover uremic bone disease. Clin Nephrol, 52 , pp. Control of serum phosphorus: implications for coronary artery calcification and calcific uremic arteriolopathy calciphylaxis.
Curr Opin Nephrol Hypertens, 10 , pp. Goicoechea, A. Mosse, J. Hayasi, I. Takamatsu, Y. Kanno, T. Yoshida, T. Abe, Y. A case-control study of calciphylaxis in Japanese end stage renal disease patients. Nephrol Dial Transplant, 27 , pp. Moe, M. Reslerova, M. Ketteler, K.
Duan, J. Koczman, et al. Role of calcification inhibitors in the pathogenesis of vascular calcification in chronic kidney disease. Kidney Int, 67 , pp. Westenfeld, C. Haarmann, L.
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Schurgers, C. Reutelingsperger, et al. Fetuin A protects against atherosclerotic calcification in CKD. Evolution of treatment strategies for calciphylaxis. Am J Nephrol, 34 , pp. Baldwin, M. Farah, M. Leung, P. Taylor, R. Werb, M. Kiaii, et al. Multi-intervention management of calciphylaxis: a report of 7 cases. Am J Kidney Dis, 58 , pp. Russo, A. Capuano, M. Cozzolino, P. Napolitano, F. Mosella, L.
Russo, et al. Multimodal treatment of calcific uraemic arteriolopathy calciphylaxis : a case series. Clin Kidney J, 9 , pp. Jovanovich, M. Nigwekar, M. Wolf, R. Sterns, J. Calciphylaxis from nonuremic causes: a systematic review. Clin J Am Soc Nephrol, 3 , pp. Jeong, A. Calciphylaxis: controversies in pathogenesis, diagnosis and treatment.
Am J Med Sci, , pp. Farah, R. Crawford, A. Levin, C. Chan Yan. Nephrol Dial Transplant, 26 , pp. Brandenburg, M. Cozzolino, S. Calcific uremic arteriolopathy: a call for action. Semin Nephrol, 6 , pp. Nigwekar, S. Zhao, J. Wenger, J. Hymes, F. Maddux, R. Thadhani, K. A nationally representative study of calcific uremic arteriolopathy risk factors. Progression of vascular calcification in uraemic patients: can it be stopped?. Nephrol Dial Transplant, 17 , pp. Brandenburg, R. Kraman, H. Rothe, N. Kaesler, J. Korbiel, P. Specht, et al. Calcific uraemic arteriolopathy calciphylaxis : a data from a large nationwide registry.
Guerra, R. Shah, E.
Rapid resolution of calciphylaxis with intravenous sodium thiosulfate and continuous venovenous haemofiltration using low calcium replacement fluid: case report. Nephrol Dial Transplant, 20 , pp. Tratamiento de calcifilaxis distal con terapia asociada de sevelamer y bifosfonatos. Wanat, C. Stewart, D.
Negoianu, M. Severe nonuremic calciphylaxis due to hyperphosphatemia resolving with multimodality treatment including phosphate binders. JAMA Dermatology, , pp. Salmhofer, M. Franzen, W. Hitzl, J. Koller, B. Kreymann, F. Fend, et al. Multimodal treatment of calciphylaxis with sodium thiosulfate, cinacalcet and sevelamer including long term data. Kidney Blood Press Res, 37 , pp. Mohammed, V. Sekar, A.
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