Doxorubicin-related cardiotoxicity: review of fundamental pathways of cardiovascular system injury.

Over the years, advancements in the field of oncology have made remarkable strides in enhancing the efficacy of medical care for patients with cancer. These modernizations have resulted in prolonged survival and improved the quality of life for these patients. However, this progress has also been accompanied by escalation in mortality rates associated with anthracycline chemotherapy. Anthracyclines, which are known for their potent antitumor properties, are notorious for their substantial cardiotoxic potential. Remarkably, even after 6 decades of research, a conclusive solution to protect the cardiovascular system against doxorubicin-induced damage has not yet been established. A comprehensive understanding of the pathophysiological processes driving cardiotoxicity combined with targeted research is crucial for developing innovative cardioprotective strategies. This review seeks to explain the mechanisms responsible for structural and functional alterations in doxorubicin-induced cardiomyopathy.

Inferior vena CAVA and lung ultraSound-guided therapy in acute heart failure: A randomized pilot study (CAVAL US-AHF study).

BACKGROUND: The optimal assessment of systemic and lung decongestion during acute heart failure is not clearly defined. We evaluated whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US) guided therapy is superior to standard care in reducing subclinical congestion at discharge in patients with AHF. METHODS: CAVAL US-AHF was an investigator-initiated, single-center, single-blind, randomized controlled trial. A daily quantitative ultrasound protocol using the 8-zone method was used and treatment was adjusted according to an algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter and collapsibility at discharge. And secondary endpoint exploratory outcome was the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days RESULTS: Sixty patients were randomized to CAVAL US (n = 30) or control (n = 30). The primary endpoint was achieved in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (P < .001). A significant reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank P = .038). Other endpoints such as NT-proBNP reduction at discharge showed a nonstatistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; P = .09). Safety outcomes were similar in both groups. CONCLUSION: IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides preliminary evidence for the potential use of a simple technique to guide decongestive therapy during hospitalization for AHF, which may reduce the composite outcome at 90 days.

Ischaemic and haemorrhagic risk distribution in real-life patients with acute coronary syndromes.

BACKGROUND: Effective treatment of non-ST-segment elevation acute coronary syndromes (NSTEACS) requires careful assessment of both ischaemic and bleeding risks. We aimed to analyse risk distribution and evaluate antiplatelet prescription behaviours in real-life settings. METHODS: Data from 1100 NSTEACS patients in Buenos Aires, Argentina, from the Buenos Aires I Registry, with a 15-month follow-up, were analysed. In-hospital and 6-month GRACE scores, CRUSADE, and Precise DAPT scores were calculated. RESULTS: The mean age was 65.4 ± 11.5 years with a majority being male (77.2%). In-hospital mortality was 2.7%, primarily due to cardiovascular causes (1.8%). Bleeding events occurred in 20.9% of patients, with 4.9% classified as ≥ BARC 3. Predominance of low bleeding (71.3%) and ischaemic (55.8%) risks on admission was observed. At 6 months, the low-risk Precise category (70.9%) and GRACE (44.1%) categories prevailed. Linear correlation analysis showed a moderately positive correlation (r = 0.61, p < .05) between ischaemic-haemorrhagic risks. Regarding the prescription of antiplatelet agents, in the low ischaemic-haemorrhagic risk group, there was a predominance of aspirin + clopidogrel (41.2%) over other high-potency antiplatelet regimens (aspirin + ticagrelor or prasugrel). In the low ischaemic and high haemorrhagic risk group, aspirin and clopidogrel were also predominant (58%). CONCLUSIONS: Our analysis underscores the significant relationship between ischaemic and haemorrhagic risks during NSTEACS hospitalisation. Despite the majority of patients falling into the low-intermediate risk category, the prescription of P2Y12 inhibitors in real-life settings does not consistently align with these risks.

Multinational experience with next-generation sequencing: opportunity to identify transthyretin cardiac amyloidosis and Fabry disease.

Background: Sarcomeric hypertrophic cardiomyopathy (HCM) must be differentiated from phenotypically similar conditions because clinical management and prognosis may greatly differ. Patients with unexplained left ventricular hypertrophy require an early, confirmed genetic diagnosis through diagnostic or predictive genetic testing. We tested the feasibility and practicality of the application of a 17-gene next-generation sequencing (NGS) panel to detect the most common genetic causes of HCM and HCM phenocopies, including treatable phenocopies, and report detection rates. Identification of transthyretin cardiac amyloidosis (ATTR-CA) and Fabry disease (FD) is essential because of the availability of disease-specific therapy. Early initiation of these treatments may lead to better clinical outcomes. Methods: In this international, multicenter, cross-sectional pilot study, peripheral dried blood spot samples from patients of cardiology clinics with an unexplained increased left ventricular wall thickness (LVWT) of ≥13 mm in one or more left ventricular myocardial segments (measured by imaging methods) were analyzed at a central laboratory. NGS included the detection of known splice regions and flanking regions of 17 genes using the Illumina NextSeq 500 and NovaSeq 6000 sequencing systems. Results: Samples for NGS screening were collected between May 2019 and October 2020 at cardiology clinics in Colombia, Brazil, Mexico, Turkey, Israel, and Saudi Arabia. Out of 535 samples, 128 (23.9%) samples tested positive for pathogenic/likely pathogenic genetic variants associated with HCM or HCM phenocopies with double pathogenic/likely pathogenic variants detected in four samples. Among the 132 (24.7%) detected variants, 115 (21.5%) variants were associated with HCM and 17 (3.2%) variants with HCM phenocopies. Variants in MYH7 (n=60, 11.2%) and MYBPC3 (n=41, 7.7%) were the most common HCM variants. The HCM phenocopy variants included variants in the TTR (n=7, 1.3%) and GLA (n=2, 0.4%) genes. The mean (standard deviation) ages of patients with HCM or HCM phenocopy variants, including TTR and GLA variants, were 42.8 (17.9), 54.6 (17.0), and 69.0 (1.4) years, respectively. Conclusions: The overall diagnostic yield of 24.7% indicates that the screening strategy effectively identified the most common forms of HCM and HCM phenocopies among geographically dispersed patients. The results underscore the importance of including ATTR-CA (TTR variants) and FD (GLA variants), which are treatable disorders, in the differential diagnosis of patients with increased LVWT of unknown etiology.

Impacto de la miectomía septal ampliada sobre los cambios ecocardiográficos en la miocardiopatía hipertrófica obstructiva / Impact of Extended Septal Miectomy on Echocardiographic Changes in Hypertophic Obstructivec Cardiomyopathy

RESUMEN Introducción: La miectomía septal ampliada (MSA) ha demostrado ser una estrategia útil para mejorar los síntomas de los pacientes con miocardiopatía hipertrófica obstructiva (MCHO). Objetivos: El objetivo de este trabajo fue analizar el impacto de la MSA en parámetros estructurales y funcionales ecocardiográficos a corto y mediano plazo, en pacientes con MCH y obstrucción dinámica del tracto de salida del ventrículo izquierdo (VI). Material y métodos: Se analizaron los ecocardiogramas en los períodos preoperatorio, postoperatorio inmediato (1 mes post cirugía) y posoperatorio alejado (2 a 3 años) de pacientes sometidos a MSA. Resultados: Se intervinieron 94 pacientes con una edad media de 57,6 ± 13,8 años. Se observó una reducción significativa del máximo espesor septal en el postoperatorio inmediato, que se mantuvo en el posoperatorio alejado, y en el tamaño auricular izquierdo en el postoperatorio inmediato que se profundizó en el alejado (p < 0,001). El gradiente intraventricular en reposo pasó de 49,2 mmHg basal a 6,4 mmHg (p < 0,001) y de allí a 4,6 mmHg (p=0,224) en los períodos inmediato y alejado, y con la maniobra de Valsalva de 93,9 mmHg a 8,7 mmHg (p < 0,001) y de allí a 7,2 mmHg (p=0,226) respectivamente. La función diastólica fue valorada como grado II en el 58,5 % de los pacientes en el preoperatorio, 51,7 % en el postoperatorio inmediato y 29 % en el postoperatorio alejado. En la misma línea se evidenció un cambio en la relación E/e´ y la presión sistólica pulmonar, grado de insuficiencia mitral y dimensiones de la aurícula izquierda. Conclusión: En esta cohorte de pacientes con MCHO, la realización de una MSA se asoció a una mejoría significativa de la función diastólica del VI, reducción de las presiones de llenado y pulmonares y grado de insuficiencia mitral, y remodelado reverso de la aurícula izquierda. Es posible que esta combinación de efectos explique los beneficios clínicos de la intervención.

ABSTRACT Background: Extended septal myectomy (ESM) has proven to be a useful strategy to improve symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). Objectives: The aim of this study was to analyze the impact of ESM on short and mid-term structural and functional echocardiographic parameters in patients with HCM and left ventricular (LV) outflow tract dynamic obstruction. Methods: Preoperative, immediate postoperative (1 month after surgery) and late postoperative (2 to 3 years) echocardiograms of patients undergoing ESM were analyzed. Results: A total of 94 patients with mean age of 57.6 ± 13.8 years underwent surgery. A significant reduction was observed in maximum septal thickness in the immediate postoperative period, which was sustained in the late postoperative period, and in atrial size in the immediate postoperative period, which deepened in the late postoperative period (p < 0.001). Intraventricular gradient at rest dropped from 49.2 to 6.4 mmHg (p < 0.001) and then to 4.6 mmHg (p=0.224) in the immediate and late periods and with Valsalva maneuver from 93.9 to 8.7 mmHg (p < 0.001), and then to 7.2 mmHg (p=0.226), respectively. Preoperative diastolic function was assessed as grade II in 58.5% of patients, decreasing to 51.7% in the immediate postoperative period and to 29% in the late postoperative period. In agreement with these results, a change was evidenced in the E/e´ ratio and pulmonary artery systolic pressure, degree of mitral regurgitation and left atrial dimensions. Conclusion: In this cohort of patients with HOCM, ESM was associated with a significant improvement in LV diastolic function, reduction in filling and pulmonary pressures and degree of mitral regurgitation, and left atrial reverse remodeling. It is possible that this combination of effects explains the clinical benefits of the intervention.

How are the predictors of sudden death modified after septal myectomy surgery?

BACKGROUND: Hypertrophic cardiomyopathy is a condition associated with an increased risk of sudden death compared to the general population. Extended septal myectomy surgery has been suggested to impact the reduction of sudden death events according to various publications. The aim of this study was to assess changes in the prevalence of sudden death predictors in a population of patients undergoing extended septal myectomy surgery. METHODS: Ninety-four consecutive patients underwent extended septal myectomy surgery due to symptomatic hypertrophic cardiomyopathy. Risk factors for sudden death, as defined by the American Heart Association and the European Society of Cardiology, were evaluated before and three months after surgery. RESULTS: The mean age of the population was 57 ± 13 years. A significant reduction was observed in the maximum septal thickness from 21.3 to 14 mm (p<0.001), along with a decrease in the anteroposterior diameter of the left atrium from 51 to 47 mm (p=0.021). Resting intraventricular gradients decreased from 49.2 to 6.4 mmHg (p<0.001), and Valsalva-induced gradients decreased from 93.9 to 8.7 mmHg (p<0.001). Non-sustained ventricular tachycardia decreased from 6% to 2% (p<0.001), and atrial fibrillation decreased from 30% to 15% (p<0.001). Ischemic behavior during exercise stress echo decreased from 6% to 0%, and the European Society of Cardiology sudden death risk score reduced from 3.32 to 1.44 (p<0.001). CONCLUSIONS: In this cohort of hypertrophic cardiomyopathy patients, extended septal myectomy surgery was associated with a reduction in the number and magnitude of sudden death predictors, potentially explaining the reduced mortality reported in the literature.

Intra-pericardial thrombin injection in iatrogenic cardiac tamponade: a case report.

BACKGROUND: Nowadays, percutaneous procedures are expanding in use, and this comes with complications associated with the procedure itself. Cardiac tamponade is rare but may be life threatening since it can involve hemodynamic instability. It is known that after pleural effusion during a percutaneous procedure, pericardiocentesis should be used as drainage of the cavity. However, that does not achieve hemostasis in some cases, and in those patients who are hemodynamically unstable, a sealing agent to promote hemostasis might be useful, like thrombin. CASE PRESENTATION: We present a case report of 89-year-old patient with history of melanoma undergoing treatment with pembrolizumab, who attended the emergency department referring chest pain (intensity 5/10) and palpitations that have lasted hours. He had TnTUs 554/566 ng/L and an echocardiogram that showed dilated right chambers, hypertrophy and global hypokinesia of the left ventricle, increased filling pressures of the left ventricle and pulmonary hypertension. Myocarditis associated with pembrolizumab was suspected, so high dose steroids were initiated and endomyocardial biopsy was conducted, resulting in iatrogenic cardiac tamponade. To determine the etiology of the suspected myocarditis, an endomyocardial biopsy was performed. Unfortunately, an intraprocedural complication arose: pleural effusion resulting in iatrogenic cardiac tamponade, leading to hemodynamic instability. It required immediate pericardial drainage via subxiphoid puncture, obtaining a 550 mL hematic debit. Clinical manifestations raised suspicion of tamponade, prompting a bedside echocardiogram for a definitive diagnosis. Despite these efforts, the patient remained hemodynamically unstable, and due to the elevated surgical risk, intrapericardial thrombin was employed to achieve successful hemostasis. CONCLUSIONS: Cardiac tamponade is a life-threatening condition that can sometimes be induced iatrogenically, resulting from percutaneous interventions. Despite limited evidence regarding this therapeutic strategy, in patients experiencing iatrogenic cardiac tamponade with hemodynamic instability and high surgical risk, the administration of intra-pericardial thrombin could be contemplated.

Prevalence of transthyretin amyloid cardiomyopathy in patients admitted for acute heart failure.

INTRODUCTION: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed cause of AHF that benefits from a specific approach. The aim was to determine the prevalence of ATTR-CM among patients hospitalized for AHF. METHODS: A prospective study was conducted on consecutive patients aged 60 or older admitted for acute AHF without cardiogenic shock. RESULTS: The study included 103 patients, a total of 16 patients (15.5 %) were compatible with ATTR-CM. The ATTR-CM group showed a higher septal wall thickness (18.1 mm vs. 11.8 mm; P = 0.001), lower systolic excursion of the tricuspid annular plane (15 mm vs. 18.3 mm, P = 0.014), and S wave of the right ventricle (8 cm/s vs. 9.2 cm/s P=0.032). CONCLUSION: ATTR-CM is an underdiagnosed condition, there are some variables associated with its diagnosis. The coexistence with other comorbidities causing AHF, highlights the importance of considering screening for this cardiomyopathy in adults hospitalized for AHF.

Herramientas para la toma de decisiones en pacientes con enfermedad de múltiples vasos / Tools for Decision Making in Patients with Multivessel Disease

RESUMEN La decisión sobre la mejor estrategia de revascularización para los pacientes con enfermedad de múltiples vasos se ha tornado una tarea compleja a medida que la angioplastia coronaria ha mejorado sus resultados. En la siguiente revisión nos propusimos evaluar las variables que en nuestra experiencia definen el beneficio de una técnica sobre la otra, entendiendo que de esta manera la decisión del médico tratante se hace más sencilla y objetiva. Por otro lado, y festejando el saludable protagonismo que se le da al paciente, creemos que esta evaluación permite ofrecer argumentos sólidos para ayudarlo en la toma de la decisión.

ABSTRACT The decision on the best revascularization strategy for patients with multivessel disease has become a complex task as coronary angioplasty has improved its results. In the following review, we set out to evaluate the variables that, in our experience, define the benefit of one technique over the other, understanding that in this way the treating physician's decision will become simpler and more objective. On the other hand, and celebrating the healthy prominence given to patients, we believe that this evaluation allows solid arguments to help them in decision making.

Registro de síndromes coronarios agudos en centros de alta complejidad de Argentina. ReSCAR 2022 / Acute Coronary Syndromes in High Complexity Centers of Argentina. The ReSCAR Registry

RESUMEN Introducción : Realizamos un registro multicéntrico para analizar el abordaje diagnóstico y terapéutico de todos los tipos de síndromes coronarios agudos; este registro es el primero en abordar en detalle aquellos cuadros que cursan sin enfermedad coronaria epicárdica significativa. Es importante conocer la realidad del actual accionar médico con el objeto de hallar oportunidades de mejora. Material y métodos : Se registraron en forma prospectiva pacientes hospitalizados por síndrome coronario agudo en 15 centros de Argentina, con diagnóstico con troponina ultrasensible, servicio de unidad coronaria y hemodinamia disponible las 24 horas, entre enero y agosto de 2022. Resultados : Se incluyeron 984 pacientes consecutivos, un 22,2% con angina inestable, 39,1% con infarto agudo de miocardio sin elevación del segmento ST (IAMSEST) y 24,1% con infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Por otro lado, el 4,1% se presentó como IAM tipo 2, 1,2% como miocarditis, 0,7% como síndrome de Takotsubo y 8,6% como infarto de miocardio con enfermedad coronaria no obstructiva (MINOCA). La mediana (rango intercuartílico, RIC) de edad fue de 66 años (56,5-74), con un 75,3% de pacientes de sexo masculino. El manejo inicial de los pacientes sin elevación del segmento ST fue invasivo en el 84%, con una tasa de enfermedad coronaria significativa del 76,5%. En cuanto a la evolución intrahospitalaria, las complicaciones isquémicas más relevantes fueron el reinfarto (2,84%), angina recurrente (2,4%), angina post infarto (2%) y trombosis intra stent (0,5%). El porcentaje de eventos hemorrágicos totales fue de 4,4% y la mortalidad intrahospitalaria total fue de 3,76%. Conclusiones : El registro tiene una buena representación del espectro de pacientes con sospecha inicial de síndrome coronario agudo, manejados en centros con una estrategia inicial principalmente invasiva, con una baja tasa de complicaciones hospitalarias y una mortalidad global aceptable.

ABSTRACT Background : We conducted a multicenter registry to analyze the diagnostic and therapeutic approach to all types of acute coronary syndromes; this registry is the first to provide detailed information on conditions without significant epicardial coronary artery disease. Knowing the reality of current medical practice is important to find opportunities for improvement. Methods : Patients hospitalized for acute coronary syndrome between January and August 2022 in 15 centers of Argentina, with high-sensitivity cardiac troponin, coronary care unit, and catheterization laboratory available 24 hours, were prospectively recorded. Results : A total of 984 consecutive patients were included, 22.2% with unstable angina, 39.1% with non-ST-segment elevation myocardial infarction (NSTEMI) and 24.1% with ST-segment elevation myocardial infarction (STEMI). Additionally, 4.1% presented as type 2 AMI, 1.2% as myocarditis, 0.7% as Takotsubo syndrome and 8.6% as myocardial infarction with non-obstructive coronary arteries (MINOCA). Median age was 66 years [interquartile range (IQR) 56.5-74] and 75.3% were men. An early invasive management was used in 84% of patients without ST segment elevation, and 76.5% of them had significant coronary artery disease. During hospitalization, 2.84% of the patients presented reinfarction, 2.43% recurrent angina, 2% postinfarction angina and 0.5% stent thrombosis. Bleeding events occurred in 4.4% of the patients, and overall in-hospital mortality was 3.76%. Conclusions : The registry has a good representation of the spectrum of patients with initial suspicion of "acute coronary syndrome", managed in centers with an invasive initial strategy and with low rate of in-hospital complications and acceptable overall mortality.

Optimización del tiempo puerta-balón mediante la implementación de un programa de mejora de procesos. Resultados a 5 años de funcionamiento / Optimization of Door-to-Balloon Time Implementing a Process Improvement Program. Results after 5 Years

RESUMEN Introducción : de estar disponible, la angioplastia primaria (ATCp), en tiempos adecuados y en centros con experiencia, es la mejor estrategia de reperfusión para el infarto agudo de miocardio con supradesnivel del segmento ST (IAMCEST). El tiempo puerta-balón (TPB) es una expresión de eficiencia operativa de la institución que realiza la ATCp, con impacto en la evolución del paciente. El objetivo de este trabajo fue analizar los resultados a largo plazo de un programa de mejora continua del proceso TPB. Material y métodos : se incluyeron en forma prospectiva y consecutiva pacientes con diagnóstico de IAMCEST sometidos a ATCp desde enero de 2015 a mayo de 2022. La población se dividió en dos períodos: período de implementación inmediata y período de seguimiento a largo plazo. Resultados : se ingresaron 671 pacientes en forma prospectiva y consecutiva. En el primer período, de implementación, (P1), se incluyeron 91 pacientes, y en el segundo período, de seguimiento del programa, (P2), 580 pacientes. La mediana (rango intercuartilo, RIC) de TPB fue de 46 min (29-59) en P1 vs 42 min(25-52) en el P2, p = 0,055. En el segundo período se evi denció una reducción de las preactivaciones (P1 54,1% vs P2 30%,p = 0,02) y los procedimientos on hours (42% en p1 vs 30% en P2, p = 0,029). Conclusión : el registro mostró el mantenimiento de los buenos resultados a largo plazo a pesar de una reducción de las preactivaciones y los procedimientos on hours.

ABSTRACT Background : If available, primary transluminal coronary angioplasty (PTCA), performed timely and in experienced sites, is the best reperfusion strategy for ST elevation myocardial infarction (STEMI). The door-to-balloon (DTB) time expresses operational efficiency of the site in charge of the PTCA, with an impact on patient's progress. The aim of this study was to analyze the long-term results of a continuous improvement program for the DTB time process. Methods : Patients diagnosed with STEMI who had undergone PTCA from January 2015 to May 2022 were prospectively and consecutively enrolled. The population was divided in two periods: an immediate implementation period and a long-term follow-up period. Results : 671 patients were prospectively and consecutively enrolled. During the implementation period (P1) 91 patients were enrolled, and 580 during the program follow-up (P2). The median (interquartile range, IQR) DTB time was 46 min (29-59) for P1 vs 42 min(25-52) for P2, p=0.055). The second period showed a reduction in pre-activations (P1 54,1% vs P2 30% p=0.02) and on-hour procedures (42% for P1 versus 30% for P2, p=0.029). Conclusion : The registry showed long-term maintenance of good results, despite reduced reactivations and on-hour procedures.

De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy?

Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y12 inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y12 inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.

Precise Score Validation in Buenos Aires 1 Registry.

The PRECISE-DAPT score predicts the bleeding risk in patients treated with dual antiplatelet treatment after PCI. We asess the prediction power of the score in patients suffering from non-ST elevation acute coronary syndromes. Our cohort included 862 patients from Buenos Aires 1 registry. The PRECISE-DAPT score was calculated upon admission and the follow up period was 15 months. The score as a continuous variable had low to moderate ability to predict bleeding events BARC 2, 3 or 5 (c-statistics 0.58 [95% CI, 0.52-0.61]); moderate at BARC 3 or 5 (c-statistics 0.72 [95% CI, 0.64-0.78]), and poor for MACE (c-statistics 0.49 [95% CI, 0,45-0.51]). PRECISE-DAPT score as a dichotomous variable (≥25, n= 210 [24%]) was associated with very high risk of bleeding (HR 2.1) and ischemic events (HR 1.9, 95% CI 1.8-2.1). As conclusion, PRECISE-DAPT score ≥25 was able to identify a subgroup of patients with high bleeding, and thrombotic events.

ORBI Score Validation as Predictor of Cardiogenic Shock in Patients With St Elevation Myocardial Infarction in Two Medical Centers in Argentina.

Cardiogenic shock(CS) after ST-segment elevation myocardial infarction(STEMI) has an in-hospital mortality of 50%. The ORBI score identifies patients at risk of CS after primary angioplasty. We aim to validate the score in an Argentinian cohort. A retrospective validation analysis was carried out from a cohort of patients with STEMI in 2 centers in Buenos Aires Metropolitan Area. The predictive value of the score were estimated through its discrimination power by AUC-ROC and calibration with the Hosmer Lemeshow (HL) goodness of fit test. Four hundred and twenty-four patients were analyzed. The incidence of CS was 8.5%. The median ORBI score was 10 (IQR 7-13) vs 5 in those without CS (IQR 3-7) (P < 0.0001). The performance of the test showed an AUC-ROC of 0.80 (95%CI 0.73-0.87; P < 0.0001); and a HL X² of 4.26 (P = 0.74). The ORBI score presented an adequate predictive capacity and calibration, suggesting its possible application in this population.

Design and rationale of the inferior vena CAVA and Lung UltraSound-guided therapy in Acute Heart Failure (CAVAL US-AHF Study): a randomised controlled trial.

BACKGROUND: Between 25% and 30% of patients hospitalised for acute heart failure (AHF) are readmitted within 90 days after discharge, mostly due to persistent congestion on discharge. However, as the optimal evaluation of decongestion is not clearly defined, it is necessary to implement new tools to identify subclinical congestion to guide treatment. OBJECTIVE: To evaluate if inferior vena cava (IVC) and lung ultrasound (CAVAL US)-guided therapy for AHF patients reduces subclinical congestion at discharge. METHODS: CAVAL US-AHF is a single-centre, single-blind randomised controlled trial designed to evaluate if an IVC and lung ultrasound-guided healthcare strategy is superior to standard care to reduce subclinical congestion at discharge. Fifty-eight patients with AHF will be randomised using a block randomisation programme that will assign to either lung and IVC ultrasound-guided decongestion therapy ('intervention group') or clinical-guided decongestion therapy ('control group'), using a quantitative protocol and will be classified in three groups according to the level of congestion observed: none or mild, moderate or severe. The treating physicians will know the result of the test and the subsequent adjustment of treatment in response to those findings guided by a customised therapeutic algorithm. The primary endpoint is the presence of more than five B-lines and/or an increase in the diameter of the IVC, with and without collapsibility. The secondary endpoints are the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days, variation of pro-B-type natriuretic peptide at discharge, length of hospital stay and diuretic dose at 90 days. Analyses will be conducted as between-group by intention to treat. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Board and registered in the PRIISA.BA platform of the Ministry of Health of the City of Buenos Aires. TRIAL REGISTRATION NUMBER: NCT04549701.

Uso actual de la aspirina como agente antitrombótico: ¿droga vigente u obsoleta? / Present Use of Aspirin as an Antithrombotic Agent: Current or Outdated Drug?

RESUMEN El ácido acetilsalicílico, o aspirina, es una de las herramientas farmacológicas más usadas en el cuidado de los pacientes cardiovasculares. Durante años se utilizó ampliamente en prevención primaria y secundaria para disminuir el riesgo cardiovascular. En los últimos tiempos su uso ha sido cuestionado, con nuevos ensayos en diferentes escenarios dentro de la patología cardíaca, como la enfermedad vascular periférica, el accidente cerebrovascular, la prevención primaria en el contexto del tratamiento médico moderno, o en el paciente con un síndrome coronario agudo y necesidad concomitante de anticoagulación. A su vez, nuevos estudios cuestionan la necesidad de mantener la aspirina durante 12 meses junto a una tienopiridina luego de un síndrome coronario agudo, y proponen esquemas abreviados. En esta revisión, evaluamos la evidencia detrás de las indicaciones actuales del uso de aspirina en diferentes escenarios clínicos, y formulamos recomendaciones en cada uno de los casos.

ABSTRACT Acetylsalicylic acid, or aspirin, is one of pharmacological tools most widely used in the care of cardiovascular patients. For years, it has been widely used in primary and secondary prevention to reduce cardiovascular risk. Aspirin utilization has been questioned in recent times, with new trials in different scenarios of cardiovascular disease, such as peripheral vascular disease, stroke, primary prevention in the context of modern medical treatment, or in patients with acute coronary syndrome and concomitant need for anticoagulation. In turn, new studies question the need to maintain aspirin for 12 months together with a thienopyridine after an acute coronary syndrome, suggesting shorter regimens. In this review, we evaluate the evidence behind the current indications for aspirin use in different clinical scenarios and provide recommendations on a case-by-case basis.

Health-Related Quality of Life in Patients Under Treatment With Apixaban in Latin America.

Atrial fibrillation (AF) has a strong impact on the quality of life (QOL) of patients and anticoagulation has a lot to do with it. We evaluated the QOL of patients with nonvalvular AF who start treatment with apixaban in Latin America. QOL was analyzed through a questionnaire developed to evaluate anticoagulated patients, which was completed by them 3 months after starting treatment. We included 521 patients from Uruguay, Bolivia, Ecuador, Paraguay, and Peru. A high index of general treatment satisfaction (5.34 ± 0.46) and self-efficacy (5.11 ± 0.68) were observed; the distress index was low (1.77 ± 0.88), as was the perception of daily hassles (1.35 ± 0.49) and strain social network related to medication (1.21 ± 0.34). Patients with AF who started treatment with apixaban has good satisfaction and self-efficacy scores with low index of stress, few daily limitations and social disruptions.

Performance of the American Heart Association/American College of Cardiology/Heart Rhythm Society versus European Society of Cardiology guideline criteria for hospital admission of patients with syncope.

BACKGROUND: Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope. OBJECTIVE: The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies. METHODS: The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE). RESULTS: Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines. CONCLUSION: ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.

International Validation of the Canadian Syncope Risk Score : A Cohort Study.

BACKGROUND: The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE: To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN: Prospective cohort study. SETTING: Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS: Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS: Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS: Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION: Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION: This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE: Swiss National Science Foundation & Swiss Heart Foundation.

High-Sensitivity Troponin T For The Risk Assessment Of Patients With Acute Atrial Fibrillation.

Elevations of high-sensitivity troponin T (Hs-TnT) in the setting of acute atrial fibrillation (AF) are not clearly understood. This study evaluated factors associated with these elevations and its prognostic implication. We prospectively included 413 consecutive patients who presented to our institution with acute AF. The median Hs-TnT on admission was 12 ng/l and 39.4% had values above the 99th percentile. At 1-year, AF recurrence occurred in 38.3% of patients, and MACE in 5.6%. Hs-TnT levels were not associated with AF reversion (p 0.869) or with 1-year AF recurrence (p 0.132) but they were with MACE (12 vs 24 ng/l, p 0.001). Thus, Hs-TnT was a strong predictor of MACE (HR 3.486, 95% CI 1.256-5.379, p 0.009) in this population. In conclusion, Hs-TnT elevation was frequently observed in patients with acute AF, and although it was not associated with AF reversion or recurrence, it was highly predictive of MACE at 1-year.