Funding Acknowledgements Type of funding sources: None. Background Patients with anaemia are at increased risk of composite cardiovascular (CV) events and all-cause mortality. However, anaemia poses a challenge to doctors when in the context of an acute coronary syndrome (ACS) and the urge to offer intervention treatment and therefore antiplatelet therapy. Purpose To study the prognostic impact of anaemia in a population with ACS. Methods 436 ACS patients admitted to a single coronary care with anaemia (male gender, haemoglobin [Hb] <13 g/dL; female gender, Hb < 12 g/dL) who were discharged from hospital were included. The primary endpoint was long-term all-cause mortality. Cox regression was conducted to evaluate the impact on the primary endpoint. The median of follow-up was 36 (± 31) months. Results Sixty-four percent of the patients were male, with a mean age 75 ± 10 years old. The majority (47%) was admitted with non-ST elevation myocardial infarction. Most of them had previous history of hypertension (87%), dyslipidaemia (63%) and chronic kidney disease (58%), while a minority had a diagnosis of diabetes mellitus (46%). Most of the patients remained in Killip-Kimbal class I throughout hospital-stay. Coronary angiography was not conducted in 15% of the patients. Thirty-six percent of the patients were conservatively treated (not submitted to percutaneous coronary intervention or coronary artery bypass graft). At discharge, 1% of the patients had no antiplatelet or anticoagulation therapy prescribed; 7% had simple antiplatelet therapy; 1% only had anticoagulation therapy; 67% had double antiplatelet therapy; 1% had double therapy (anticoagulation plus a single antiplatelet agent) and 5% had triple therapy (anticoagulation plus two antiplatelets agents); missing data about therapy at discharge in 18% of the patients. 224 patients met the primary outcome. In univariate analysis, nor antiplatelet neither anticoagulation strategies were related to the outcome (P = 0.59; P = 0.73, respectively). In a multivariable model adjusted for age, Hb level, glomerular filtration rate, heart failure diagnosis, left ventricular function (3 categories), maximum troponin I and treatment option (conservative vs revascularization), Hb level remains an important prognosis predictor (HR 0.86, 95% CI 0.77-0.97, per each g/dL increase). In this model, besides from Hb level, only age (HR 1.04, 95% CI 1.02-1.05) and moderate to severely impaired LV function (HR 1.91, 95% CI 1.38-2.63) remained associated with the outcome. Conclusion The outcome attributed to anaemia patients seems to be independent of treatment strategies and it is related to the Hb level itself. This reinforces the need to explore reversible causes of anaemia, as small increases in Hb level may have a major impact on the prognosis of these patients.

KeywordsRheumatic fever / complications; heart valve diseases / surgery; aortic valve / abnormalities; aortic valve / surgery.Male, 44 years old, with a history of rheumatic attacks in childhood and adolescence and multiple aortic valve replacement surgeries, was admitted with decompensated heart failure.The present illness began with rheumatic attacks characterized by fever, arthritis of the right knee, when he was 7-11 old. At age 15, paroxysmal palpitations appeared. At age 16, the patient initiated follow-up at the outpatient services at InCor. Double aortic lesion and rheumatic disease activity were diagnosed.At the time, the electrocardiogram (ECG) revealed severe left ventricular hypertrophy; a chest radiograph revealed cardiomegaly +++/ 4+.At age 17, the palpitations became more frequent, dyspnea on moderate exertion appeared.Physical examination in primary care (May 1977) revealed pulse rate of 80 bpm, blood pressure 100/0 mmHg; auscultation was normal, cardiac auscultation revealed systolic murmur +++/ 4+ in the aortic area and diastolic murmur in the left sternal border. There was also the presence of a third heart sound; the abdomen showed no changes, no edema, and the pulse was of rapid ascent and descent. The patient was under use of digoxin (0.25 mg daily) and prophylaxis of rheumatic fever with benzathine penicillin 1.2 million units intramuscularly (IM) every two weeks. Surgical treatment of the aortic valve was prescribed.After the indication for surgical treatment, there were several attempts of hospitalization. However, these were frustrated by frequent episodes of fever and arthralgia of the knees treated as rheumatic disease activity and, due to the persistence of this condition, an investigation was conducted for infective endocarditis. Finally, the patient underwent aortic valve replacement with dura mater bioprostheses in 1979 (at age 19) and remained asymptomatic for five years, until 1984, when complaints similar to those prior to the surgery reappeared. Rough systolic murmur +++/4+ appeared and irradiated to the wishbone and tip.ECG revealed left chamber overload. Radiography revealed cardiomegaly ++/4+.An echocardiogram showed normal left ventricular dimensions (diastole 53 mm and systole 36 mm). The left atrium was 36 mm and there was dilatation of the aortic root (42 mm). There was concentric hypertrophy of the left ventricle and the prosthesis was considered to be normofunctioning.Medication in this period was 0.25 mg digoxin, 40 mg furosemide daily and benzathine penicillin every 15 days.In two years, the patient complained of chest pain and dyspnea initially on major exertion, then on moderate exertion. There were complaints of generalized arthralgias on several occasions.A new evaluation revealed the following echocardiographic changes (July 1986): concentric hypertrophy of the left ventricle with septal and posterior wall thickness of 14 mm, left ventricular dilatation (66 mm) with preserved systolic function (left ventricular ejection fraction of -LVEF = 64%), aortic dilata...

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