Background Undetectable high-sensitivity cardiac troponin (hs-cTn) in a single determination upon admission may rule out acute coronary syndrome. We investigated undetectable hs-cTnT (<detection limit; <5 ng/l) together with clinical risk scores (GRACE, TIMI, HEART and a previously published simple score), for one-year outcomes in patients with chest pain and normal hs-cTnT (<99th percentile; <14 ng/l) upon admission. Methods This study was a retrospective design involving 2254 consecutive patients (July 2016–November 2017). The primary endpoint was one-year death or acute myocardial infarction; the secondary endpoint added unstable angina requiring revascularization. Early (<90 minutes since pain onset, n = 661) and late ( n = 1593) presenters were separately considered. Results A total of 56 (2.5%) patients reached the primary endpoint and 91 (4%) the secondary endpoint. Undetectable hs-cTnT had a poor C-statistic in early and late presenters (0.648 and 0.703, respectively). Adding hs-cTnT measurable concentrations above the detection limit (as continuous variable) significantly enhanced the C-statistics (0.754 and 0.847, respectively). Addition of the HEART (0.809, p = 0.005) or simple clinical scores (0.804, p = 0.02) further improved the model and significantly reclassified patient risk, in early presenters. The results were similar for the secondary endpoint. The TIMI risk score performed worse and the GRACE score did not give additional information. In late presenters, no clinical score provided significant additional information over hs-cTnT. Conclusions Diagnostic algorithms should consider not only whether hs-cTnT is above or below the detection limit but also its concentration if above, for risk stratification over one year in patients with initial normal hs-cTnT. The clinical scores provide valuable additional information in early presenters.

Refractory congestive heart failure is associated with an ominous prognosis in which the treatments strategies remain scarce and not well validated. In the last years, continuous ambulatory peritoneal dialysis (CAPD) has emerged as a therapeutic alternative in this subset of patients. So far, it has been associated with a significant improvement in functional capacity and quality of life, together with a striking reduction in the risk of readmissions. We present the case of an elderly patient with severe left ventricular dysfunction and severe mitral and tricuspid regurgitation who presents recurrent admissions for anasarca. After its inclusion in a CAPD programme, the patient experienced a marked clinical and biochemical improvement despite the persistence of cardiac abnormalities. CAPD onset translates into greater sodium removal. We want to emphasize the usefulness of this therapy in the management of volume excess in patients with refractory heart failure and renal failure promoting a greater sodium removal compared with traditional diuretic strategies.

Objective To evaluate the 5 components of the Fried frailty phenotype (self-reported unintentional weight loss, physical activity questionnaire, gait speed, grip strength, and self-reported exhaustion) for long-term outcomes in elderly survivors of acute coronary syndrome. Methods A total of 342 consecutive patients (from October 1, 2010, to February 1, 2012) were included. The 5 components of the Fried score and albumin concentration, as malnutrition index, were assessed before hospital discharge. Patients were followed up until April 2020 (median follow-up, 8.7 years). The end point was postdischarge all-cause mortality. Results Mean ± SD age was 77±7 years and mean ± SD Fried score was 2.0±1.1 points. A total of 216 (63%) patients died. After adjusting for clinical covariates, the Fried phenotype was associated with mortality (per points, hazard ratio [HR], 1.35; 95% CI, 1.17 to 1.57; P <.001). Among Fried components, physical activity (HR, 2.21; 95% CI, 1.34 to 3.65; P =.002) and gait speed (HR, 1.77; 95% CI, 1.29 to 2.43; P <.001) were the deficits independendtly associated with mortality. Albumin level provided further prognostic information (per increase in g/dL; HR, 0.63, 95% CI, 0.45 to 0.88; P =.007). The model adding the components of the Fried score and albumin level to the clinical model showed the highest risk reclassification (integrated discrimination improvement, 0.040; 95% CI, 0.018 to 0.075; P =.001; continuous net reclassification improvement, 0.291; 95% CI, 0.132 to 0.397; P =.001) in comparison with the model using clinical covariates alone. Conclusion Frailty assessment using the Fried phenotype has prognostic value for long-term mortality in elderly survivors of acute coronary syndrome. Physical activity and gait speed are the predictive components of the Fried score. Albumin level provides incremental prognostic information.