Background-Circulating cardiac troponin T, a marker of cardiomyocyte injury, predicts adverse outcome in patients with heart failure (HF) but is detectable in only a small fraction of those with chronic stable HF. We assessed the prognostic value of circulating cardiac troponin T in patients with stable chronic HF with a traditional (cTnT) and a new precommercial highly sensitive assay (hsTnT). Methods and Results-Plasma troponin T was measured in 4053 patients with chronic HF enrolled in the Valsartan HeartFailure Trial (Val-HeFT). Troponin T was detectable in 10.4% of the population with the cTnT assay (detection limit Յ0.01 ng/mL) compared with 92.0% with the new hsTnT assay (Յ0.001 ng/mL). Patients with cTnT elevation or with hsTnT above the median (0.012 ng/mL) had more severe HF and worse outcome. In Cox proportional hazards models adjusting for clinical risk factors, cTnT was associated with death (780 events; hazard ratioϭ2. Key Words: heart failure Ⅲ natriuretic peptides Ⅲ prognosis Ⅲ troponin C ardiac troponins I and T (cTnT) are sensitive and specific markers of myocardial injury used routinely for the diagnosis of acute coronary syndromes. 1-5 Elevated troponin blood levels have been reported in several cohorts of patients with heart failure (HF), and the magnitude of elevation has been correlated with the severity of the disease and with adverse outcomes. 6 -16 Because of their high cardiac specificity, elevated troponins in patients with HF may suggest ongoing myocardial damage and may serve as a marker for the progression of HF. Measurement of troponin has been proposed since 1997 to monitor patients with HF. 17,18 The prevalence of elevated troponin T in the general population is Ͻ1% and is associated with underlying cardiovascular disease or high-risk phenotypes. 19 Editorial p 1217 Clinical Perspective p 1249The levels of cardiac troponins in HF are generally lower than those in patients with acute coronary syndromes and lack the characteristic rise and fall pattern. 4 Few reports exist on cTnT elevations in chronic stable HF. 6,8,16,20 Previous studies included more frequently patients with severe HF (New York Heart Association [NYHA] class III and IV) and/or with decompensated HF, recruited in a single center. 6,8,10,11,15,16 As expected, lesser severity of HF is associated with a larger fraction of patients with undetectable troponin. The commercial assays for troponins have sufficient sensitivity (0.01 ng/mL) for screening patients with suspected myocardial infarction 21 but may be inadequate for risk stratification of patients with stable chronic HF who may have levels below Methods Study Design and PatientsVal-HeFT was a randomized, placebo-controlled, double-blind, parallel-arm multicenter trial of 5010 patients with stable, symptomatic HF, who were on prescribed HF therapy. The patients had a left ventricular ejection fraction (LVEF) Ͻ40% and a left ventricular diameter in diastole adjusted for body surface area (LVIDD/BSA) Ն2.9 cm/m 2 . Results of the main trial have been published....

Background-The optimal duration of dual-antiplatelet therapy and the risk-benefit ratio for long-term dual-antiplatelet therapy after coronary stenting remain poorly defined. We evaluated the impact of up to 6 versus 24 months of dual-antiplatelet therapy in a broad all-comers patient population receiving a balanced proportion of Food and Drug Administration-approved drug-eluting or bare-metal stents. Methods and Results-We randomly assigned 2013 patients to receive bare-metal, zotarolimus-eluting, paclitaxel-eluting, or everolimus-eluting stent implantation. At 30 days, patients in each stent group were randomly allocated to receive up to 6 or 24 months of clopidogrel therapy in addition to aspirin. The primary end point was a composite of death of any cause, myocardial infarction, or cerebrovascular accident. The cumulative risk of the primary outcome at 2 years was 10.1% with 24-month dual-antiplatelet therapy compared with 10.0% with 6-month dual-antiplatelet therapy (hazard ratio, 0.98; 95% confidence interval, 0.74 -1.29; Pϭ0.91). The individual risks of death, myocardial infarction, cerebrovascular accident, or stent thrombosis did not differ between the study groups; however, there was a consistently greater risk of hemorrhage in the 24-month clopidogrel group according to all prespecified bleeding definitions, including the recently proposed Bleeding Academic Research Consortium classification. Conclusions-A regimen of 24 months of clopidogrel therapy in patients who had received a balanced mixture of drug-eluting or bare-metal stents was not significantly more effective than a 6-month clopidogrel regimen in reducing the composite of death due to any cause, myocardial infarction, or cerebrovascular accident. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00611286.

Background: Renal function is a powerful prognostic variable in patients with heart failure (HF). Hospitalisations for acute HF (AHF) may be associated with further worsening of renal function (WRF). Methods and results: We analysed the clinical significance of WRF in 318 consecutive patients admitted at our institute for AHF. WRF was defined as the occurrence, at any time during the hospitalisation, of both a ≥25% and a ≥ 0.3 mg/dL increase in serum creatinine (s-Cr) from admission (WRF-Abs-%). Results: Patients were followed for 480 ± 363 days. Fifty-three patients (17%) died and 132 (41%) were rehospitalised for HF. WRF-Abs-% occurred in 107 (34%) patients. At multivariable survival analysis, WRF-Abs-% was an independent predictor of death or HF rehospitalisation (adjusted HR, 1.47; 95%CI, 1.13-1.81; p = 0.024). The independent predictors of WRF-Abs-%, evaluated using multivariable logistic regression, were history of chronic kidney disease (p = 0.002), LV ejection fraction (p = 0.012), furosemide daily dose (p = 0.03) and NYHA class (p = 0.05) on admission. Conclusion: WRF is a frequent finding in patients hospitalised for AHF and is associated with a poor prognosis. Severity of HF and daily furosemide dose are the most important predictors of the occurrence of WRF.