Risk scores for predicting incident heart failure admission in patients with chronic coronary syndromes: Validation in a prospective, monocentric, long-term, cohort study.

BACKGROUND: Heart failure (HF) admission in chronic coronary syndrome (CCS) patients has a prognostic impact. Stratification schemes have been described for predicting this endpoint, but none of them has been externally validated. OBJECTIVES: Our aim was to develop point scores for predicting incident HF admission with data from previous studies, to perform an external validation in an independent prospective cohort and to compare their discriminative ability for this event. METHODS: Independent predictive variables of HF admission in CCS patients without baseline HF were selected from four previous prospective studies (CARE, PEACE, CORONOR and CLARIFY), generating scores based on the relative magnitude of the coefficients of Cox of each variable. Finally, the scores were validated and compared in a monocentric prospective cohort. RESULTS: The validation cohort included 1212 patients followed for up to 17 years, with 171 patients suffering at least one HF admission in the follow-up. Discriminative ability for predicting HF admission was statistically significant for all, and paired comparisons among them were all nonsignificant except for CORONOR score was superior to CLARIFY score (C-statistic 0.73, 95%CI 0.69-0.76 vs. 0.69, 95% CI 0.65-0.73; p = 0.03). CONCLUSION: All tested scores showed significant discriminative ability for predicting incident HF admission in this independent validation study. Their discriminative ability was similar, with significant differences only between the two scores with higher and lower performance.

Long-Term Prognostic Impact of Sex in Patients with Chronic Coronary Syndrome: A 17-Year Prospective Cohort Study.

Background: Women and men with chronic coronary syndrome (CCS) have different clinical features and management, and studies on mid-term prognosis have reported conflicting results. Our objective was to investigate the impact of the female sex in the prognosis of the disease in the very long term. Methods and Results: We investigated differential features and very long-term prognosis in 1268 consecutive outpatients with CCS (337 [27%] women and 931 [73%] men). Women were older than men, more likely to have hypertension, diabetes, angina, and atrial fibrillation, and less likely to be exsmoker/active smoker and to have been treated with coronary revascularization (p < 0.05 for all). The prescription of statins, antiplatelets, and betablockers was similar in both groups. After up to 17 years of follow-up (median = 11 years, interquartile range = 4-15 years), cumulative incidences of acute myocardial infarction (10.2% vs. 11.8%) or stroke (11% vs. 10%) at median follow-up were similar, but the risks of major cardiovascular events (acute myocardial infarction, stroke, or cardiovascular death, 41.2% vs. 33.6%), hospital admission for heart failure (20.9% vs. 11.9%), or cardiovascular death (32.3% vs. 22.1%) were significantly higher for women (p < 0.0005), with a nonsignificant trend to higher overall mortality (45.2% vs. 39.1%, p = 0.07). However, after multivariate adjustment, all these differences disappeared. Conclusion: Although women and men with CCS presented a different clinical profile, and crude rates of major cardiovascular events, heart failure and cardiovascular death were higher in women, female sex was not an independent prognostic factor in this study with up to 17 years of follow-up.

The Role of Left Atrial Longitudinal Strain in the Diagnosis of Acute Cellular Rejection in Heart Transplant Recipients.

Our aim was to investigate the role of left atrial longitudinal strain (LALS) in the non-invasive diagnosis of acute cellular rejection (ACR) episodes in heart transplant (HTx) recipients. Methods: We performed successive echocardiographic exams in 18 consecutive adult HTx recipients in their first year after HTx within 3 h of the routine surveillance endomyocardial biopsies (EMB) in a single center. LALS parameters were analyzed with two different software. We investigated LALS association with ACR presence, as well as inter-vendor variability in comparable LALS values. Results: A total of 147 pairs of EMB and echo exams were carried out. Lower values of LALS were significantly associated with any grade of ACR presence. Peak atrial longitudinal strain (PALS) offered the best diagnostic value for any grade of ACR, with a C statistic of 0.77 using one software (95% CI 0.68−0.84, p < 0.0005) and 0.64 with the other (95% CI 0.54−0.73, p = 0.013) (p = 0.02 for comparison between both curves). Reproducibility between comparable LALS parameters was poor (intraclass correlation coefficients were 0.60 for PALS, 95% CI 0.42−0.73, p < 0.0005; and 0.42 for PALS rate, 95% CI −0.13−0.68, p < 0.0005). Conclusions: LALS variables might be a sensitive marker of ACR in HTx recipients, principally discriminating between those studies without rejection and those with any grade of ACR. Inter-vendor variability was significant.

Tissue Doppler velocities for ruling out rejection in heart transplant recipients in the context of myocardial strain imaging: a multivariate, prospective, single-center study.

To investigate the value of tissue Doppler velocities for ruling out treatment-requiring acute cellular rejection (TR-ACR), in the context of myocardial deformation analysis performed by means of speckle tracking echocardiography. We performed serial echocardiograms in 37 heart transplant recipients in their first year post-transplantation within 3 h of the routine surveillance endomyocardial biopsies (EMB). The association of the sum of lateral mitral annulus systolic (s') and early diastolic (e') velocities, in absolute values, measured by tissue Doppler echocardiography (s'+ e'), with TR-ACR (ACR grade ≥ 2R) was investigated by multivariate analysis, including classic echocardiographic parameters and myocardial deformation variables. A total of 251 pairs of EMB and echo exams were performed, 35 (14%) with rejection grade ≥ 2R (TR-ACR). s' + e' was independently associated to TR-ACR (OR 0.80, 95%CI 0.72-0.89, p < 0.0005), with a C statistic of 0.79 (95%CI 0.71-0.87, p < 0.0005) by ROC curve analysis. An s'+ e' value ≥ 23 cm/s, present in 43% of studies, had a negative predictive value of 98% for ruling out TR-ACR. Moreover, in the same patients, s'+ e' significantly decreased when TR-ACR occurred after a study without this condition (- 3.7 ± 3.3 cm/s, p = 0.003), but it was similar when rejection status was the same in the present versus the previous study. A drop in s'+ e' value < 2.7 cm/s from the previous echocardiogram, had a 99% negative predictive value for ruling out TR-ACR. Tissue Doppler velocities, a widely available echo parameter, were found to be a valuable marker for ruling out TR-ACR in this multivariate study which included myocardial deformation variables.

Long-term Survival in a Spanish Population With Stable Ischemic Heart Disease. The CICCOR Registry.

INTRODUCTION AND OBJECTIVES: Data are lacking on the long-term prognosis of stable ischemic heart disease (SIHD). Our aim was to analyze long-term survival in patients with SIHD and to identify predictors of mortality. METHODS: A total of 1268 outpatients with SIHD were recruited in this single-center prospective cohort study from January 2000 to February 2004. Cardiovascular and all-cause death during follow-up were registered. All-cause and cardiovascular mortality rates were compared with those in the Spanish population adjusted by age, sex, and year. Predictors of these events were investigated. RESULTS: The mean age was 68±10 years and 73% of the patients were male. After a follow-up lasting up to 17 years (median 11 years), 629 (50%) patients died. Independent predictors of all-cause mortality were age (HR, 1.08; 95%CI, 1.07-1.11; P <.001), diabetes (HR, 1.36; 95%CI, 1.14-1.63; P <.001), resting heart rate (HR, 1.01; 95%CI, 1.00-1.02; P <.001), atrial fibrillation (HR, 1.61; 95%CI, 1.22-2.14; P=.001), electrocardiographic changes (HR, 1.23; 95%CI, 1.02-1.49; P=.02) and active smoking (HR, 1.85; 95%CI, 1.31-2.80; P=.001). All-cause mortality and cardiovascular mortality rates were significantly higher in the sample than in the general Spanish population (47.81/1000 patients/y vs 36.29/1000 patients/y (standardized mortality rate, 1.31; 95%CI, 1.21-1.41) and 15.25/1000 patients/y vs 6.94/1000 patients/y (standardized mortality rate, 2.19; 95%CI, 1.88-2.50, respectively). CONCLUSIONS: The mortality rate was higher in this sample of patients with SIHD than in the general population. Several clinical variables can identify patients at higher risk of death during follow-up.

[Left-sided native valve infective endocarditis: Influence of age and the presence of underlying heart disease]. / Endocarditis infecciosa sobre válvula nativa del lado izquierdo: influencia de la edad y de cardiopatía previa.

INTRODUCTION AND OBJECTIVES: Left-sided native valve infective endocarditis (LNVIE) epidemiology has been modified as a result of the increase in average age. The aim of our study is to analyze the influence of age and the presence of predisposing heart disease in the prognosis of these patients. METHODS: We analyzed a series of 257 cases of LNVIE depending on their age (greater than or equal to 70 years old), both in the overall series and in the subgroup of patients without predisposing heart disease. RESULTS: Mean age was 54.6 (18.6) years. There was an increase in the percentage of cases of older patients between 1987-2000 and 2001-2014 (9.8 vs. 34.8%, P<.001). These patients present higher prevalence of degenerative valves (50 vs. 22.8%) or not predisposing heart disease (50 vs. 39.9%), P<.001, health-care associated episodes (41.8 vs. 23.6%, P=.016), lower rate of surgery (43.7 vs. 63.8%, P=.005) and higher in-hospital mortality (39.1 vs. 20.7%, P=.003), with no differences in comorbidities. Older patients who did not have predisposing heart disease also suffered higher in-hospital mortality (47 vs. 22%, P=.01). Age greater than or equal to 70 years old is an independent predictor of mortality in patients with LNVIE (OR 2.53, 95% CI 1.24-5.15, P=.011), as in those without previous heart disease (OR 3.98, 95% CI 1.49-10.62, P=.006). CONCLUSIONS: Patients of age greater than or equal to 70 years old and who suffer an LNVIE are becoming more frequent and have a worse prognosis with a lower rate of surgery and higher rates of in-hospital mortality.

Feasibility of bidimensional speckle-tracking echocardiography for strain analysis in consecutive patients in daily clinical practice.

PURPOSE: We aimed to analyze the feasibility of two-dimensional speckle-tracking echocardiography (2DSTE) in evaluating myocardial strain in consecutive, nonselected patients in daily clinical practice. METHODS: Strain analysis using 2DSTE was attempted in 59 consecutive patients: 24 patients with severe aortic stenosis, 28 patients with dilated cardiomyopathy, and 7 healthy controls. The analysis was done by four expert echocardiographers and one cardiology resident. RESULTS: It was possible to obtain reliable data for radial strain in 175 of 354 segments (49%), circumferential strain in 192 of 354 segments (54%), and longitudinal strain in 319 of 354 segments (90%). Experienced echocardiographers felt assessment of radial and circumferential strain was appropriate in more segments than did the cardiology resident (57% and 58% vs. 23% and 40%, respectively, P < 0.01). CONCLUSION: Longitudinal strain analysis with 2DSTE is feasible in most segments, but the radial and circumferential strain evaluation was only feasible in approximately half of the patients.

Anticoagulación en pacientes menores de 75 años con fibrilación auricular / Anticoagulation in patients aged less than 75 years with atrial fibrillation

Para estudiar la efectividad y seguridad de la anticoagulación en la fibrilación auricular no valvular crónica en pacientes menores de 75 años de la práctica clínica diaria incluimos en un estudio prospectivo 345 pacientes consecutivos atendidos entre el 1 de febrero de 2000 y el 1 de febrero de 2002 en dos consultas de cardiología. Se les indicó tratamiento anticoagulante de acuerdo con las recomendaciones de las sociedades científicas y fueron seguidos para evaluar eventos mayores (muerte, ictus, accidente isquémico transitorio, embolismos periféricos o hemorragia grave) por grupo de tratamiento. Los pacientes con terapia anticoagulante (n = 262,76%) presentaron una mayor frecuencia de hipertensión y embolismo previo y un mayor número de factores de riesgo cardioembólicos (p < 0.001); el 92% de los pacientes tratados sin anticoagulantes recibieron antiagregantes. Tras 23 ± 13 meses de seguimiento, la tasa (por 100 pacientes-año) de eventos embólicos (0.82 versus3.42, p = 0.022) fue menor en los pacientes que recibieron anticoagulantes, sin diferencias significativas en las tasas de sangrado grave (0.61 frente a 1.37, p = 0.39), ni en la mortalidad total (1.23 frente a 1.37, p = 0.96). La anticoagulación oral en la fibrilación auricular no valvular de aucerdo con las recomendaciones de las sociedades científicas es efectiva y segura en pacientes menores de 75 años en la práctica clínica diaria.

Our objective was to study the effectiveness and safety of oral anticoagulation for permanent non-valvular atrial fibrillation in patients younger than 75 years seen in dailyclinical practice. In a prospective study, we included 345 consecutive patients seen since February, 1st 2000 toFebruary 1st 2002 in two outpatient cardiology clinics. Anticoagulant treatment was indicated following scientific societies recommendations; and patients were divided intreatment groups and followed for major events (death,stroke, transient ischemic attack, peripheral embolism orsevere haemorrhage). Anticoagulated patients (n = 262,76%) presented hypertension and previous embolism more frequently; as well as a greater number of cardioembolicrisk factors (p < 0.001). Ninety-two percent ofnon-anticoagulated patients received platelet aggregation inhibitors. After 23 ± 13 months of follow-up, the rateof embolic events (per 100 patients-year) was lower inanticoagulated patients (0.82 versus 3.42, p = 0.022). Rates of severe bleeding (0.61 versus 1.37, p = 0.39) andall-cause mortality (1.23 versus 1.37, p = 0.96) showed no significant differences. Oral anticoagulation in nonvalvularatrial fibrillation following the recommendationsof scientific societies is effective and safe in patients younger than 75 years in daily clinical practice.

[Oral anticoagulation for nonvalvular atrial fibrillation: are scientific recommendations effective and safe in daily clinical practice?]. / Anticoagulación oral en la fibrilación auricular no valvular: 'son efectivas y seguras las recomendaciones científicas en la práctica clínica diaria?

INTRODUCTION AND OBJECTIVES: To study the efficacy and safety of an oral anticoagulation protocol for the treatment of nonvalvular atrial fibrillation, based on scientific associations' recommendations, in unselected patients seen in daily clinical practice. METHODS: The study included all consecutive patients with permanent nonvalvular atrial fibrillation who attended two outpatient cardiology clinics between February 1, 2000 and February 1, 2002. They were treated according to an anticoagulation protocol based on Spanish Society of Cardiology and American College of Cardiology/American Heart Association/European Society of Cardiology guidelines. Patients were followed up prospectively for major events, such as death, stroke, transient ischemic attack, peripheral embolism and severe hemorrhage, which were recorded by treatment group. RESULTS: A total of 624 patients were included in the study. Those receiving anticoagulation therapy (n=425; 68%) more frequently had hypertension, diabetes and previous embolism as well as a greater number of cardioembolic risk factors (P< .001). Overall, 93% of non-anticoagulated patients received platelet aggregation inhibitors (92% received aspirin). After a median follow-up of 21 months, the probability of an embolic event was lower in anticoagulated patients (0.81% vs 14.04%; P< .001), as was all-cause mortality (3.27% vs 6.42%; P=.003). However, there was no significant difference in the probability of severe bleeding (2.75% vs 2.93%; P=.96). Results were unchanged after adjustment for age, sex, and previous embolic events. CONCLUSIONS: Oral anticoagulation therapy for nonvalvular atrial fibrillation implemented according to scientific associations' recommendations is effective and safe in daily clinical practice.

[A prospective protocol increases oral anticoagulant prescription in patients with chronic, nonvalvular atrial fibrillation]. / Un protocolo prospectivo permite incrementar la utilización de anticoagulación oral en pacientes con fibrilación auricular crónica no valvular.

INTRODUCTION AND OBJECTIVES: Observational studies have shown that oral anticoagulants (OAC) prescription is suboptimal in patients with nonvalvular atrial fibrillation (NVAF). Our objective was to evaluate the usefulness of a prospective protocol for increasing OAC usage in these patients. PATIENTS AND METHOD: From 1 February 2000 until 31 October 2002 we enrolled all patients with chronic NVAF seen in two outpatient cardiology clinics, excluding candidates for cardioversion. Each patient was studied to identify cardioembolic risk factors (CERF) and contraindications for OAC. Anticoagulation was suggested to all patients with > or =2 CERF and without contraindications for OAC. The decision to prescribe OAC was made by the physician in charge when there was only one CERF. RESULTS: 721 patients fulfilled the inclusion criteria. Mean age was 73 +/- 8 years; 44% were men. In most cases NVAF was related with hypertension (57%), followed by no structural heart disease (25%) or ischemic heart disease (9%). The most frequent CERFs were hypertension (66%), age > or =75 years (45%) and diabetes (24%). A total of 663 patients had > or =1 CERF (92%), and 125 (19%) of these presented at least one contraindication for OAC. Of the 538 remaining patients (90%), 485 (67% of the whole series) were treated with anticoagulation. Of the patients with > or =2 CERF and without contraindications for OAC, 95% were treated. CONCLUSIONS: A prospective protocol for use in the outpatient cardiology clinic allows to prescribe OAC in a large percentage of patients with NVAF.