Treatment with SGLT2 Inhibitors in Patients with Diabetes Mellitus and Extensive Coronary Artery Disease: Mortality and Cardiovascular Outcomes.

INTRODUCTION: Sodium-glucose type 2 cotransporter inhibitors (SGLT2-I) have shown solid benefits in reducing cardiovascular mortality and admissions for heart failure in patients with type 2 diabetes mellitus (T2DM) and cardiovascular disease. However, no specific studies exist in patients with high-risk coronary artery disease (CAD). METHODS: Single-center, retrospective, observational study including patients with T2DM and a new diagnosis of extensive CAD (defined as left main disease or three main coronary vessel disease). Patients were recruited from 2015 until 2020, with a follow-up of at least 12 months. The primary outcome was to compare all-cause mortality in patients treated with or without SGLT2-I at discharge and adjusted by inverse probability of treatment weighting (IPTW) propensity score. RESULTS: A total of 420 patients were included: 104 (24.7%) were treated with SGLT2-I and 316 (75.3%) were not (non-SGLT2-I group). The presentation was acute coronary syndrome in 44.3%. The mean age was 71.2 ± 10.5 years. The mean left ventricular ejection fraction was 51.5 ± 12.5%, and the mean estimated glomerular filtration rate was 73.9 ± 22 ml/min. After a mean follow-up of 3 ± 1.6 years, all-cause mortality was 16.4%, and cardiovascular mortality was 9.5%. After IPTW, the risk of all-cause death was lower in the SGLT2-I group with a hazard ratio of 0.32 (95% confidence interval 0.12-0.81), p = 0.016. With regard to secondary outcomes, patients in the SGLT2-I group were associated with less renal function deterioration but an increase in unplanned revascularizations. CONCLUSIONS: In patients with T2DM and extensive CAD, treatment with SGLT2-I after discharge was associated with a reduced risk of all-cause death.

Angiography-derived assessment of coronary microcirculatory resistance in patients with suspected myocardial ischaemia and non-obstructive coronary arteries.

BACKGROUND: Myocardial ischaemia with non-obstructive coronary arteries (INOCA) represents a challenging and frequent, but largely underdiagnosed, condition. AIMS: We aimed to investigate the feasibility and diagnostic value of angiography-derived coronary microcirculatory resistance in patients with INOCA syndrome. METHODS: This is an investigator-driven, prospective and blinded study. The diagnostic yield of angiography-derived index of coronary microcirculatory resistance (angio-IMR) was investigated against thermodilution-derived IMR (thermo-IMR) in patients with clinically indicated coronary angiography due to suspected myocardial ischaemia and angiographically normal or non-obstructive coronary arteries. The angio-IMR was derived from resting angiograms (contrast-flow angio-IMR [cAngio-IMR]) by an expert analyst blinded to the thermo-IMR. An independent, blinded, physiology core laboratory analysed the raw intracoronary physiology data and provided the final thermo-IMR values. RESULTS: A total of 104 patients (108 coronary vessels) were analysed after fulfilling predefined inclusion criteria. Most patients were female (67%). Obstructive epicardial disease was angiographically (percent diameter stenosis <50%) and physiologically (fractional flow reserve>0.80) ruled out in all cases. Median thermo-IMR and cAngio-IMR were 16.6 (12.7, 23.0) and 16.8 (12.8, 23.1) units, respectively (median difference -0.31, 95% confidence interval: -1.53 to 1.00; p=0.654). cAngio-IMR showed good correlation (Pearson coefficient 0.76; p<0.001), agreement (mean bias 0.4), discriminatory power (area under the curve from the receiver operator characteristics 0.865; p<0.001) and accuracy (85%), compared to thermo-IMR (≥25 U). CONCLUSIONS: Evaluating coronary microcirculatory resistance in patients with INOCA syndrome using cAngio-IMR is feasible and accurate. By circumventing the need of coronary instrumentation and hyperaemic drugs, this method may facilitate the assessment of coronary microcirculatory resistance in patients with suspected INOCA. CLINICALTRIALS: gov: NCT04827498.

Transvascular Balloon Occlusion: A Novel Bailout Strategy in Large Left Main Perforations.

Several complications have been reported in rotational atherectomy, and these complications are closely associated with cardiac tamponade, emergent surgery, and death. Here we describe a case of left main coronary artery, bullet-like perforation treated with a novel approach-transvascular balloon occlusion. (Level of Difficulty: Advanced.).

Score2: A New Updated Algorithm to Predict Cardiovascular Disease Risk in Europe.

The recently published guidelines of the European Society of Cardiology for the prevention of cardiovascular diseases presented in August 2021 at the virtual European Society of Cardiology congress recommend the use of the SCORE2 risk index instead of the classic SCORE risk index to calculate the cardiovascular risk (specifically, ten-year fatal and nonfatal risk) in a healthy population under the age of 70 years, with a level of evidence IB. This new risk index was developed with the collaboration of about 200 investigators, including 45 cohorts in 13 countries with 700,000 participants, and covers the known risk factors for heart and circulatory diseases such as age, sex, lipid levels, blood pressure, and smoking. In addition, it divides the countries into four groups of risk and uses a competing risk model, adjusting the risk for the probability of having another event, which enables better estimation of the risk of fatal and nonfatal events in a younger population (40-69 years).

Low-Density Lipoprotein Cholesterol Targets in Patients With Coronary Heart Disease in Extremadura (Spain): LYNX Registry.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) contributes decisively to the development of cardiovascular disease (CVD). In the LYNX registry we determined the rate of achievement of the target value of LDL-C, the use of lipid-lowering therapy (LLT) and the predictive factors of not reaching the target in patients with stable coronary heart disease (CHD). METHODS: LYNX included consecutive patients with stable CHD treated at the University Hospital of Caceres, Extremadura (Spain) from September 2016 to September 2018, and those who must have an LDL-C target below 70 mg/dL according to the European Society of Cardiology (ESC) 2016 guidelines. The variables independently associated with the breach of the LDL-C objective were evaluated by multivariable logistic regression. RESULTS: A total of 674 patients with stable CHD were included. The average LDL-C levels were 68.3 ± 24.5 mg/dL, with 56.7% showing a level below 70 mg/dL. LLT was used by 96.7% of patients, 71.7% were treated with high-powered statins and 30.1% with ezetimibe. The risk of not reaching the target value of LDL-C was higher in women, in active smokers, and in those who had multivessel CHD or had atrial fibrillation. Patients with diabetes mellitus, those who took potent statins or co-administration treatment with ezetimibe were more likely to reach the target level of LDL-C. CONCLUSIONS: The treatment of dyslipidemia in patients with chronic CHD remains suboptimal; however, an increasing number of very high-risk patients achieve the LDL-C objective, although there is still enormous potential to improve cardiovascular outcome through the use of more intensive LLT.

Baja adherencia al régimen de hemodiálisis en pacientes con enfermedad crónica renal en un hospital de referencia del Ministerio de Salud en Perú / Low adherence to hemodialysis regime in patients with chronic renal disease in a Peruvian Ministry of Health reference hospital

Introducción: La ausencia a una sesión mensual en un esquema de diálisis convencional puede incrementar la mortalidad en 30 por ciento. Objetivos: Describir la frecuencia y la percepción de las causas de falta de adherencia a diálisis en una población prevalente de un hospital público de referencia nacional en Perú. Diseño: Estudio descriptivo. Institución: Servicio de Nefrología, Hospital Nacional 2 de Mayo, Lima, Perú. Participantes: Pacientes con más de un año en diálisis Intervenciones: Se determinó el número de faltas y se aplicó un cuestionario para describir su percepción respecto a las causas de las faltas, validado por juicio de expertos. Principales medidas de resultados: Baja adherencia a diálisis definida como: pacientes con más de una falta al mes o más de 12 faltas, entre julio de 2012 y julio de 2013. Resultados: Se incluyó 54 pacientes, 27 eran varones, con una edad y tiempo de diálisis promedio de 57 ± 16,4 años y 40,6 ± 11,5 meses, respectivamente; 7/54 pacientes tenían educación superior. Hubo 504 faltas (5,45 por ciento). El segundo día de la programación semanal fue el día con mayor frecuencia de faltas (292), seguido del tercer día (145); 13/54 tuvieron baja adherencia. Las principales causas reportadas fueron: una residencia alejada (6/13), la sensación de bienestar (6/13), el contar con escasos recursos económicos para solventar el traslado (5/13). Conclusiones: Uno de cada cuatro pacientes tuvo baja adherencia. El residir lejos o que se sintiera bien fueron las principales causas de la baja adherencia...

Background: Failing to attend a monthly session within a scheme of conventional dialysis may increase mortality by 30 per cent. Objectives: To describe the frequency and perceived causes of non-adherence to dialysis in a Peruvian national reference public hospital. Design: Descriptive study. Setting: Nephrology department, Hospital Nacional 2 de Mayo, Lima, Peru. Participants: Patients with more than one year on dialysis. Interventions: The number of absences to appointed sessions was determined and a validated questionnaire was used to describe perceptions regarding the causes of absences. Main outcomes measures: Low adherence to dialysis defined as patients with more than one absence per month or more than 12 absences between July 2012 and July 2013. Results: The study included 54 patients, of which 27 were male. Average age was 57 ± 16.4 years and average time on dialysis was 40.6 ± 11.5 months. Only 7 patients had higher education. There were 504 absences (5.45 per cent). The second day of the weekly schedule was the day with more absences (292), followed by the third day (145). Overall 13 patients showed low adherence. Main causes of absence reported included a remote residence (6/13), feeling good (6/13), and insufficient financial resources to cover transportation costs (5/13). Conclusions: A quarter of patients had low adherence, and main factors were distance to health facility and wellbeing self-perception...

Características clínicas de los pacientes con injuria renal aguda en diálisis en un hospital general / Clinical features of patients with acute kidney injury in dialysis in a general hospital

Introducción: La injuria renal aguda en diálisis es una patología de alta mortalidad en pacientes hospitalizados, especialmente en UCI, y sin estudios actualizados en nuestro medio. Objetivo: Describir las características de los pacientes con insuficiencia renal aguda (IRA) en diálisis de un hospital general. Diseño: Estudio observacional descriptivo unicéntrico. Lugar: Hospital Nacional 2 de Mayo, Lima, Perú. Participantes: Pacientes con IRA en diálisis. Intervenciones: Se estudió a pacientes con IRA en diálisis hospitalizados entre enero y diciembre 2012. Para describir los hallazgos se utilizó promedios, desviaciones estándar y porcentajes. Principales medidas de resultados: Características clínicas de los pacientes con IRA en diálisis. Resultados: Se halló 43 casos de IRA en diálisis, con una edad promedio de 58,5 años (DE: 16,6), de los cuales 28 fueron varones; 20 pacientes (46,5%) provenían de la UCI. La primera causa de ingreso a diálisis fue oligoanuria (60,5%) seguida de encefalopatía urémica (46,5%) y acidosis metabólica (30,2%). El 39,5% de todos los pacientes falleció; 45% de los pacientes que se encontraban en UCI fallecieron. Al alta, 9,3% de los pacientes continuó en diálisis. Conclusiones: En la población estudiada, 4 de cada 10 pacientes con IRA en diálisis fallecieron y 1 de cada 10 pacientes continuaba en diálisis al alta de hospitalización, en el Hospital Nacional 2 de Mayo.

Introduction: Acute kidney injury on dialysis has high mortality in hospitalized patients especially in ICU and there are no updated studies in our country. Objectives: To describe characteristics of acute kidney injured patients on dialysis at a general hospital. Design: Descriptive single center observational study. Setting: Hospital Nacional Dos de Mayo, Lima, Peru. Patients: Acute kidney injured (AKI) patients on dialysis. Interventions: We studied patients with AKI on dialysis from January to December, 2012. We described averages, percentages, standard deviations. Main outcome measures: Clinical characteristics of patients with AKI on dialysis. Results: Forty-three acute kidney injured cases on dialysis were reported. Average age was 58.5 years (SD: 16.6), 28 were male, 20 patients (46.5%) were from ICU. The main cause of dialysis admission was oligoanuria (60.5%) followed by uremic encephalopathy (46.5%) and metabolic acidosis (30.2%); 39.5% patients died; 45% of patients in ICU died. At hospital discharge 9.3% of the patients continued on dialysis. Conclusions: In the population studied 4 of 10 patients with acute kidney injury on dialysis died and 1 of 10 patients continued on dialysis after hospital discharge.

Mortalidad durante la primera hospitalización en una población que inicia diálisis crónica en un hospital general / Mortality during first hospital admission in a population that begins chronic dialysis in a general hospital

Introducción: El Ministerio de Salud del Perú atiende a población que no cuenta con seguro social y carece de un programa nacional de diálisis, por lo que la atención es limitada a hospitales que cuentan con centros de diálisis. Objetivos: Determinar la mortalidad en la primera hospitalización de pacientes incidentes de diálisis en una población sin seguro social. Diseño: Estudio descriptivo. Lugar: Hospital Nacional 2 de Mayo, Lima, Perú. Participantes: Pacientes con enfermedad renal crónica. Intervenciones: Se estudió a los pacientes que iniciaron diálisis desde enero hasta diciembre del 2012. Para describir se utilizó promedios, porcentajes, desviaciones estándar. Principales medidas de resultados: Características clínicas de los pacientes que iniciaron diálisis. Resultados: Se estudió 105 pacientes con edad promedio de 55,5 años; el 62,9% fue hombre. La etiología más frecuente fue la etiología no filiada (39,1%), seguido de la nefropatía diabética (31,4%). El 71,7% no se atendió previamente en este hospital. El 46,7% conoció su diagnóstico de enfermedad renal crónica durante su hospitalización y 75,2% supo que requería diálisis durante su hospitalización. El 80% no había tenido evaluación nefrológica previa, 89% ingresó por emergencia, con una estancia hospitalaria promedio de 16 días. El catéter venoso central transitorio fue el acceso vascular más usado (96,2%). Las principales indicaciones de diálisis fueron: encefalopatía urémica (59,1%) y acidosis metabólica severa (39,1%). El 23,3% falleció durante su primera hospitalización. Conclusiones: El control prediálisis de los pacientes es deficiente. Cerca de un cuarto de ellos muere durante su primera hospitalización.

Introduction: The Health Ministry attends Peruvian population without social security and without a national dialysis program. Attention is limited to a few hospitals with dialysis centers. objectives: To determine mortality in the first hospitalization for dialysis in a population without social security. design: Descriptive study. Setting: Hospital Nacional Dos de Mayo, Lima, Peru. Patients: Patients with chronic renal disease. Interventions: We studied patients who started dialysis from January to December, 2012. We described averages, percentages, standard deviations. Main outcome measures: Clinical characteristics of patients starting dialysis. results: In 105 patients studied mean age was 55.5 years, 62.9% were men. Most common etiology was not determined (39.1%) followed by diabetic nephropathy (31.4%); 71.7% were not previously attended at our hospital; 46.7% knew their diagnosis of chronic kidney disease, 75.2% learned he required dialysis during hospitalization; 80% had no previous nephrology evaluation, 89% was admitted by emergency, with a mean hospital stay of 16 days. Transient central venous catheter was the most used vascular access (96.2%). Main indications for dialysis were uremic encephalopathy (59.1%) and severe metabolic acidosis (39.1%); 23.3% died during their first hospitalization. Conclusions: Patients’ pre dialysis control was poor. About a quarter of them died during their first hospitalization.