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Lazzeri C.,Intensive Cardiac Coronary Unit | Valente S.,Intensive Cardiac Coronary Unit | Chiostri M.,Intensive Cardiac Coronary Unit | Gensini G.F.,Intensive Cardiac Coronary Unit | Gensini G.F.,University of Florence
Journal of Cardiovascular Medicine | Year: 2015

Patients with renal impairment have decreased excretion of uric acid, thus being particularly prone to having elevated serum uric acid concentrations. No data are available on the long-term prognostic role of uric acid in patients with STelevation myocardial infarction (STEMI) and renal dysfunction, submitted to percutaneous coronary intervention (PCI). We therefore prospectively assessed, in 329 patients with STEMI and renal dysfunction (admission estimated glomerular filtration rate <60 ml/min/1.73m2), all submitted to PCI, whether uric acid levels are associated with increased mortality at 1-year postdischarge follow-up. Patients in the third tertile of uric acid showed a higher BMI (PU0.014), a higher incidence of hypertension (PU0.029), and two or more comorbidities (PU0.034). The highest incidence of bleeding and of acute kidney injury was detectable in patients in the third tertile (PU0.011 and P<0.001, respectively) who showed the highest mortality rate at 1-year postdischarge follow-up (PU0.008). At Cox regression analysis, uric acid was an independent predictor of 1-year postdischarge mortality (hazard ratio 1.26, 95% confidence interval 1.06â"1.51, PU0.011). In STEMI patients with estimated glomerular filtration rate below 60 ml/min/1.73m2 treated with PCI, uric acid helps in identifying a subset of patients at a higher risk of bleeding and acute kidney injury. Increased uric acid is an independent prognostic risk factor for 1-year mortality. Further studies performed in larger cohorts of patients are needed to confirm our findings and to evaluate whether lowering uric acid in these patients is beneficial. © 2015 Wolters Kluwer Health, Inc. All rights reserved. Source

Lazzeri C.,Intensive Cardiac Coronary Unit | Bernardo P.,Intensive Cardiac Coronary Unit | Sori A.,Intensive Cardiac Coronary Unit | Innocenti L.,Intensive Cardiac Coronary Unit | And 4 more authors.
European Heart Journal: Acute Cardiovascular Care | Year: 2013

Guidelines stated that extracorporeal membrane oxygenation (ECMO) may improve outcomes after refractory cardiac arrest (CA) in cases of cardiogenic shock and witnessed arrest, where there is an underlying circulatory disease amenable to immediate corrective intervention. Due to the lack of randomized trials, available data are supported by small series and observational studies, being therefore characterized by heterogeneity and controversial results. In clinical practice, using ECMO involves quite a challenging medical decision in a setting where the patient is extremely vulnerable and completely dependent on the medical team's judgment. The present review focuses on examining existing evidence concerning inclusion and exclusion criteria, and outcomes (in-hospital and long-term mortality rates and neurological recovery) in studies performed in patients with refractory CA treated with ECMO. Discrepancies can be related to heterogeneity in study population, to differences in local health system organization in respect of the management of patients with CA, as well as to the fact that most investigations are retrospective. In the real world, patient selection occurs individually within each center based on their previous experience and expertise with a specific patient population and disease spectrum. Available evidence strongly suggests that in CA patients, ECMO is a highly costly intervention and optimal utilization requires a dedicated local health-care organization and expertise in the field (both for the technical implementation of the device and for the intensive care management of these patients). A careful selection of patients guarantees optimal utilization of resources and a better outcome. © The European Society of Cardiology 2013. Source

Lazzeri C.,Intensive Cardiac Coronary Unit | Valente S.,Intensive Cardiac Coronary Unit | Chiostri M.,Intensive Cardiac Coronary Unit | Picariello C.,Intensive Cardiac Coronary Unit | Gensini G.F.,Intensive Cardiac Coronary Unit
Diabetes and Vascular Disease Research | Year: 2011

The relationship between insulin secretion and acute insulin resistance (as assessed by Homeostatic Model Assessment [HOMA] index) and clinical and biochemical parameters in the early phase of non-diabetic ST-elevation myocardial infarction (STEMI) is so far unexplored. We aimed at assessing this relation in 286 consecutive STEMI patients without previously known diabetes submitted to primary percutaneous coronary intervention (PCI). Insulin resistance (as indicated by HOMA) was detectable in 67.1%. Non-parametric correlation showed that HOMA index was significantly correlated with BMI (r = 0.242; p < 0.0001) and HbA1c (r = 0.189; p < 0.001). At multivariable backward linear regression analysis, glycaemia was directly related to leukocyte count (p = 0.0003), age (p = 0.0001), creatine kinase isoform MB (CK-MB) (p = 0.00278) and lactate (p < 0.0001). Insulin was directly and significantly related to glycaemia (p = 0.0006), body mass index (BMI) (p = 0.00028) and lactate (p = 0.0096) In the early phase of STEMI without previously known diabetes the acute glucose dysmetabolism is quite complex, comprising increased glucose values and the development of acute insulin resistance. While insulin secretion is strictly related to BMI, apart from glucose levels, increased glucose values can be mainly related to the acute inflammatory response (as indicated to leukocyte count and C-RP), to age and to the degree of myocardial damage (as inferred by CK-MB) © The Author(s) 2011. Source

Lazzeri C.,Intensive Cardiac Coronary Unit | Valente S.,Intensive Cardiac Coronary Unit | Chiostri M.,Intensive Cardiac Coronary Unit | Picariello C.,Intensive Cardiac Coronary Unit | Gensini G.F.,Intensive Cardiac Coronary Unit
Internal and Emergency Medicine | Year: 2011

Elderly patients are under-represented in trials assessing strategies of early coronary revascularization in acute myocardial infarction, though they are the fastest growing segment of our population. The aims of the present investigation, performed in 357 elderly (≥75 years) patients with ST elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI) consecutively admitted to our Intensive Cardiac Care Unit (ICCU) from 1 January 2006 to 31 December 2009, were as follows: (a) to identify predictors for in-ICCU mortality among clinical, angiographic and metabolic factors and (b) to evaluate whether there are gender-related differences in management, outcome and in the metabolic and inflammatory responses to acute myocardial ischemia. At multivariable backward stepwise logistic regression analysis, the following variables were independent predictors for in-ICCU mortality in the overall population: age (OR 1.15; 95% CI 1.05-1.27; p < 0.003), admission glycemia (OR 2.24; 95% CI 1.41-3.56; p < 0.001), left ventricular ejection fraction (LVEF) (OR 0.92; 95% CI 0.88-0.97; p < 0.001), primary PCI failure (OR 4.70; 95% CI 1.70-12.98; p < 0.003). In elderly STEMI patients submitted to primary PCI, early mortality can be related to age, hemodynamic derangement (as indicated by LVEF), the rate of procedural success, and increased glucose values. No gender-related differences in management were detectable in our series. Our data strongly suggest that, in elderly patients in the acute phase of STEMI, since hyperglycemia is a modifying factor, glucose values deserve a more intensive treatment. Further studies, performed specifically in elderly STEMI patients, should be addressed to identify the glucose cut-off values able to influence the outcome. © 2010 SIMI. Source

Lazzeri C.,Intensive Cardiac Coronary Unit | Valente S.,Intensive Cardiac Coronary Unit | Chiostri M.,Intensive Cardiac Coronary Unit | Picariello C.,Intensive Cardiac Coronary Unit | Gensini G.F.,Intensive Cardiac Coronary Unit
Diabetes and Vascular Disease Research | Year: 2010

In elderly patients with AMI, hyperglycaemia is associated with increased mortality. Recently it has been observed that insulin resistance, as assessed by the HOMA index, proved an independent predictor of in-hospital mortality.The interaction between age and glucose metabolism response in the acute phase of patients with STEMI without previously known diabetes has not yet been explored.We aimed to assess this relationship in 346 consecutive patients with STEMI admitted to our ICCU after primary PCI. When compared with the other age subgroups, the very oldest patients (aged > 79 years) showed the lowest LVEF (p=0.0l I), the highest incidence of 2- and 3-vessel coronary artery disease (p=0.002), and, finally, the highest mortality (p=0.037). Advancing age was associated with increased values of fibrinogen (p=0.022) and ESR (p=0.00l), as well as of NT-pro-BNP (p<0.00l).The very oldest patients (aged > 79 years) exhibited the highest values of glycaemia and peak glycaemia, while the incidence of insulin resistance (as inferred by HOMA index) remained unchanged across the age subgroups.This glycaemic pattern was confirmed after exclusion of patients with HbA|c > 6.5%, that is patients with a poor glycaemic control in the previous 2-3 months. In the acute phase of STEMI acute glucose metabolism is affected by age, since older patients showed the highest glucose levels and the poorest glycaemic control during ICCU stay despite the lack of differences in insulin resistance incidence. © The Author(s) 2010. Source

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