An electronic consultation program impacts on heart failure patients' prognosis: implications for heart failure care.

AIMS: e-consults are asynchronous, clinician-to-clinician exchanges that answer focused, non-urgent, patient-specific questions using the electronic medical record. We instituted an e-consultation programme (2013-2019) for all general practitioners (GPs) referrals to cardiologists that preceded patients' in-person consultations when considered. In our study, we aimed to analyse the clinical characteristics, 1 year prognosis and the prognostic determinants of patients with a previous diagnosis of HF referred for an e-consult, categorized by their previous HF-related hospitalization status (recent hospitalization, <1 year before; remote hospitalization, >1 year before or never been hospitalized because of HF), and to analyse the impact of reducing the time elapsed between e-consultation and response by the cardiologist in terms of prognosis. METHODS AND RESULTS: Epidemiological and clinical data were obtained from 4851 HF patients referred by GPs to the cardiology department for an e-consultation 2013 and 2020. The delay of time to e-consults were solved was 8.6 + 8.6 days with 84.3% solved in <14 days. For the 1 year prognosis evaluation after the e-consult were assessed the cardiovascular hospitalizations, HF-related hospitalizations, HF-related mortality, cardiovascular mortality, and all-cause mortality. Compared with the group without a previous hospitalization, patients with recent and remote HF hospitalization were at higher risk of a new HF-related hospitalization (OR: 19.41 [95% CI: 12.95-29.11]; OR: 8.44 [95% CI: 5.14-13.87], respectively), HF-related mortality (OR: 2.47 [95% CI: 1.43-4.27]; OR: 1.25 [95% CI: 0.51-3.06], respectively), as well as cardiovascular hospitalizations and mortality and all-cause mortality. Reduction in the time elapsed because e-consultation was solved was associated with lower risk of HF-related mortality (OR: 0.94 [95% CI: 0.89-0.99]), cardiovascular mortality (OR: 0.96 [95% CI: 0.93-0.98]), and all-cause mortality (OR: 0.98 [95% CI: 0.97-1.00]). CONCLUSIONS: A clinician-to-clinician e-consultation programme between GPs and cardiologists in patients with HF allows to solve the demand of care in around 25% e-consults without an in-person consultation; the patients with a previous history of HF-related hospitalization showed a worse 1 year outcome. A reduction in the time elapsed because e-consultation was solved was associated with a mortality reduction.

Longer-Term Results of a Universal Electronic Consultation Program at the Cardiology Department of a Galician Healthcare Area.

BACKGROUND: Telemedicine models play a key role in organizing the growing demand for care and healthcare accessibility, but there are no described longer-term results in health care. Our objective is to assess the longer-term results (delay time in care, accessibility, and hospital admissions) of an electronic consultation (e-consultation) outpatient care program. METHODS: Epidemiological and clinical data were obtained from the 41 258 patients referred by primary care to the cardiology department from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010-2012). In 2013, we instituted an e-consultation program (2013-2019) for all primary care referrals to cardiologists that preceded patients' in-person consultations when considered. We used an interrupted time series regression approach to investigate the impact of the e-consultation on (1) delay time (days) in care and (2) hospital admissions. We also analyzed (3) total number and referral rate (population-adjusted referred rate) in both periods (in-person consultation and e-consultation), and (4) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital. RESULTS: During the e-consultation, the demand increased (7.2±2.4% versus 10.1±4.8% per 1000 inhabitants, P<0.001), and referrals from different areas were equalized. The reduction in delay to consultation during the in-person consultation (-0.96 [95% CI, -0.951 to -0.966], P<0.001) was maintained with e-consultations (-0.064 [95% CI, 0.043-0.085], P<0.001). After the implementation of e-consultation, we observed that the increasing of hospital admission observed in the in-person consultation (incidence rate ratio, 1.011 [95% CI, 1.003-1.018]), was stabilized (incidence rate ratio, 1.000 [95% CI, 0.985-1.015]; P=0.874). CONCLUSIONS: Implementing e-consultations in the outpatient management model may improve accessibility of care for patients furthest from the referral hospital. After e-consultations were implemented, the upward trend of hospital admissions observed during the in-person consultation period was stabilized with a slight downward trend.

Prognostic impact of renal function trajectories in patients with STEMI and kidney dysfunction undergoing primary percutaneous coronary intervention: An analysis of ten years all-comers registry.

BACKGROUND: Renal dysfunction in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) indicates a poor long-term prognosis. However, the prognostic value of the improvement or stabilisation of renal function during follow-up has not yet been assessed. This study aimed to investigate the long-term predictive impact of the improvement or stabilisation of renal function after one year of follow-up in patients with STEMI undergoing pPCI with renal dysfunction at discharge. METHODS: This prospective, single-centre cohort study included 2170 consecutive patients with STEMI who underwent pPCI. The glomerular filtration rate (GFR) was determined at hospital discharge and one-year follow-up. The median clinical follow-up was 72 months. RESULTS: Among the 2004 patients, 393 (19.6%) had a GFR <60 ml/min, and 1611 (80.4%) had a GFR ≥ 60 ml/min at discharge. Among patients with GFR <60 ml/min, data at one-year follow-up were available for 342. Of these patients, 127 (32%) showed improvement in renal function (defined as improvement in the Kidney Disease Improving Global Outcomes (KDIGO) chronic kidney disease (CKD) classification), 47 (12%) showed worsening of renal function (defined as worsening of the KDIGO CKD classification), and 168 (43%) showed no category changes. Improvement or stabilisation of GFR at one year of follow-up was associated with a reduction of major adverse cardiovascular events (MACE) [HR 0.51, 95% CI: 0.35-0.75, p = 0.001] and all-cause mortality [HR 0.54, 95% CI: 0.34-0.84, p = 0.007] during follow-up. CONCLUSIONS: The improvement or stabilisation of renal function at one-year follow-up in patients with STEMI and renal dysfunction is associated with a better long-term prognosis.

Should PRECISE-DAPT be included for long-term prognostic stratification of diabetic patients with NSTEACS?

AIMS: There are insufficient data regarding risk scores validation in patients with diabetes mellitus and non-ST elevation acute coronary syndrome (NSTEACS). We performed a diabetes mellitus-specific analysis of cardiovascular outcomes after NSTEACS. We tested the predictive power of the Global Registry of Acute Coronary Events (GRACE) and PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti-Platelet Therapy (PRECISE-DAPT) scores. METHODS: This work is a retrospective analysis that included 7,415 consecutive NSTEACS patients from two Spanish Universitarian hospitals between the years 2003 and 2017. The area under the ROC curve among with and without diabetes mellitus patients was calculated, to evaluate the predictive power of both scores.  RESULTS: Among the study participants, 2124 patients (28.0%) were diabetic. The median follow-up was 54,3 months (IQR 24,7-80,0 months). Diabetic patients were more women (30.5% vs. 25.7%) and older (70.0 ± 10.8 vs. 65.3 ± 13.2 years old); they had higher GRACE (146 ± 36 vs. 137 ± 36), PRECISE-DAPT (15 ± 7 vs. 18 ± 9) at admission. Early invasive coronary angiography (≤ 24 h after admission) was performed more frequently in non-diabetic. We tested the predictive power of the GRACE and PRECISE-DAPT risk scores among diabetic and non-diabetic. PRECISE-DAPT risk score showed a good predictive power for all-cause mortality, cardiovascular mortality and MACE in diabetic admitted with NSTEACS, without differences compared to non-diabetic. CONCLUSIONS: PRECISE-DAPT risk score has an appropriate predictive power in diabetic patients admitted with NSTEACS compared to non-diabetic NSTEACS. However, GRACE would be predictive worse in diabetic during long-term follow-up in a large contemporary registry.

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry.

BACKGROUND: In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. METHODS: This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS. RESULTS: Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. CONCUSIONS: In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. BRIEF SUMMARY: In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

Prognostic benefit from an early invasive strategy in patients with non-ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines.

OBJECTIVES: The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. METHODS: This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (< 24 h) in patients with: (a) GRACE risk score > 140 and (b) patients with "established NSTEMI" (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score < 140. RESULTS: From 2003 to 2017, 6454 patients with "new high-risk NSTEACS" were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary intervention in patients with NSTEACS and GRACE > 140 [HR 0.62 (IC 95% 0.57-0.67), HR 0.62 (IC 95% 0.56-0.68), HR 0.57 (IC 95% 0.53-0.61), respectively]. In patients with NSTEACS and GRACE < 140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56-0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78-1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75-1.24)]. CONCLUSIONS: An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score < 140 with established NSTEMI or ST/T-segment changes.

Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions.

Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA). This acute coronary syndrome differs from type 1 myocardial infarction (MI) regarding patient characteristics, presentation, physiopathology, management, treatment, and prognosis. Two-thirds of MINOCA subjects present ST-segment elevation; MINOCA patients are younger, are more often female and tend to have fewer cardiovascular risk factors. Moreover, MINOCA is a working diagnosis, and defining the aetiologic mechanism is relevant because it affects patient care and prognosis. In the absence of relevant coronary artery disease, myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries, coronary microcirculation, or both. Epicardial causes of MINOCA include coronary plaque disruption, coronary dissection, and coronary spasm. Microvascular MINOCA mechanisms involve microvascular coronary spasm, takotsubo syndrome (TTS), myocarditis, and coronary thromboembolism. Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients. The diagnostic arsenal includes invasive and non-invasive techniques. Medical history and echocardiography can help indicate vasospasm or thrombosis, if one finite coronary territory is affected, or specify TTS if apical ballooning is present. Intravascular ultrasound, optical coherence tomography, and provocative testing are encouraged. Cardiac magnetic resonance is a cornerstone in myocarditis diagnosis. MINOCA is not a benign diagnosis, and its polymorphic forms differ in prognosis. MINOCA care varies across centres, and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.

Coronary Artery Dominance and Long-term Prognosis in Patients With ST-segment Elevation Myocardial Infarction Treated With Primary Angioplasty.

INTRODUCTION AND OBJECTIVES: The long-term prognostic significance of coronary artery dominance pattern in patients with ST-segment elevation myocardial infarction is poorly characterized. We investigated the prognosis of such patients according to whether they had right dominance, left dominance, or codominance. METHODS: This was a retrospective study of 767 patients, who were admitted to hospital between 2007 and 2012 with ST-segment elevation myocardial infarction and treated with primary percutaneous coronary intervention. We determined the effect of the coronary dominance pattern on all-cause mortality and readmission for infarction, adjusting for mortality as a competing event. RESULTS: A total of 80.9% of patients had right coronary dominance, and 8.6% had left coronary dominance. Over 40.8 months' [interquartile range, 21.9-58.3 months] follow-up, 118 (15.4%) deaths were recorded, of which 39 (5.1%) were in hospital. Mortality for right dominance, left dominance, and codominance was 7.1%, 36.4%, and 13.8% (P ˂ .001), respectively. Cause of death was cardiovascular in 7.1%, 21.2%, and 2.4%. On Cox multivariate analysis, left dominance was significantly associated with mortality (hazard ratio = 1.76; P = .02). Taking "coronary dominance" into account in prediction of risk of death improved the discrimination and calibration capacity of GRACE (Global Registry of Acute Coronary Events) scoring. At follow-up, 9.3% (71 patients) had reinfarction. On multivariate analysis, left dominance was an independent predictor of reinfarction (subhazard ratio = 2.06; P = .01). CONCLUSIONS: In ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, left coronary artery dominance confers a higher risk of death and reinfarction than right coronary artery dominance, and should be included in prognostic stratification.

Influence of diabetes on the survival of patients hospitalized with heart failure: a 12-year study.

AIM: To investigate the influence of diabetes mellitus (DM) on the prognosis of heart failure (HF) patients, focussing specifically on aetiology and patients with preserved left ventricular systolic function (LVSF), which to date has not been fully investigated. METHOD AND RESULTS: 1659 Patients hospitalized for HF between 1991 and 2002 in the Cardiology Department of a tertiary hospital, aged 69+/-12 years, 60% male were studied prospectively. Arterial hypertension was present in 54% of patients, DM in 26% and ischaemic cardiomyopathy in 51%. A survival analysis performed in April 2003 showed that DM worsens the prognosis of the whole group (median survival (MS): 3.6 vs. 5.4 years; p<0.001), of ischaemic and non-ischaemic patients (MS: 3.8 vs. 4.9 years; p=0.13 and 3.6 vs. 6.0 years; p<0.001, respectively). A similar effect of DM was shown in patients with preserved LVSF (MS: 3.8 vs. 5.8 years; p=0.03) and in patients with impaired LVSF (3.6 vs. 6.3 years; p<0.0001). CONCLUSION: DM increases mortality among HF patients with preserved and impaired LVSF and those without ischaemic cardiomyopathy.

[Long-term trends in drug prescription for hospitalized patients with congestive heart failure. Influence of type of dysfunction]. / Evolución a largo plazo de la prescripción de fármacos en pacientes hospitalizados por insuficiencia cardíaca congestiva. Influencia del patrón de disfunción.

INTRODUCTION AND OBJECTIVES: To evaluate changes in drug prescription during 1991-2002 in patients hospitalized for congestive heart failure (CHF) with preserved or depressed left ventricular (LV) systolic function. PATIENTS AND METHOD: A total of 1252 CHF patients (mean age, 69.4 (11.7) years; 61.3% male) hospitalized in a cardiology department were studied. Ischemic heart disease was present in 616 (49.2%), hypertension in 693 (55.4%), and diabetes in 335 (26.8%). Some 498 (39.8%) had preserved LV systolic function, defined as an echocardiographically determined ejection fraction > or =50% at admission. Pharmacotherapy at hospital discharge was recorded for all patients. RESULTS: The changes in drug prescription observed in CHF patients with preserved LV systolic function paralleled those in patients with depressed LV systolic function. Change was influenced by the publication of major clinical trials on CHF and depressed LV systolic function. Consequently, the use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, and spironolactone progressively increased during follow-up for both types of CHF. Diuretics were prescribed for more than 70% of patients, with the rate being higher in those with depressed LV systolic function. Digoxin use decreased markedly in patients with preserved LV systolic function. CONCLUSIONS: An increase in the prescription of drugs with proven effects on mortality and morbidity in patients with CHF was observed. Nevertheless, beta-blocker and spironolactone use remains suboptimal. The trend seen after hospitalization in CHF patients with preserved LV systolic function was similar, though slightly less marked.

[Influence of sex on mortality in hospitalized patients with congestive heart failure and preserved or depressed systolic function]. / Influencia del sexo en la mortalidad a largo plazo de pacientes hospitalizados por insuficiencia cardíaca con función sistólica conservada o deprimida.

INTRODUCTION AND OBJECTIVES: There is some controversy about the impact of sex on mortality in patients with heart failure. Moreover, little is known about its influence on prognosis in patients with preserved systolic function. The objective of this study was to investigate the influence of sex on survival in patients with heart failure, including subgroups with preserved or depressed left ventricular ejection fraction (LVEF). PATIENTS AND METHOD: The study included 1252 patients (767 male, 61.3%) who were admitted with heart failure to the cardiology department of a tertiary hospital. The median follow-up period was 2.3 years, with the mortality rate rising to 41% after 12 years of follow-up. A LVEF less than 50% was observed in 60.2% of patients. Female patients were older (73.4 +/- 10.0 years vs 66.8 +/- 11.9 years; P < .001), a higher proportion had preserved systolic function (52.2% vs 31.9%; P < .001), and fewer had ischemic cardiopathy (44.1% vs 53.2%; P < .001). RESULTS: In the group as a whole, the influence of sex on prognosis did not reach statistical significance: the hazard ratio in males compared with females was 1.253 (95%CI, 0.978-1.605; P = .074). In addition, no influence of sex on survival was observed in subgroups with preserved or depressed systolic function. CONCLUSIONS: In a large cohort, we did not observe any influence of sex on mortality in hospitalized patients with heart failure, either in the group as a whole or in subgroups with preserved or depressed left ventricular systolic function, despite a tendency towards higher mortality in males.

[Anemia as a new predictor of mortality in patients hospitalized with congestive heart failure]. / Anemia como nuevo predictor de la mortalidad de pacientes hospitalizados por insuficiencia cardíaca congestiva.

BACKGROUND AND OBJECTIVE: The search for novel and modifiable risk factors in heart failure (HF), a condition with still high mortality and morbidity rates, can open new strategies for treatment of a growing number of patients. We decided to evaluate the prevalence of anemia and determine its influence on the prognosis of hospitalized HF patients. PATIENTS AND METHOD: 557 consecutive patients hospitalized for HF between 31st January 2000 and 31st December 2002 in a Cardiology Department of a tertiary hospital were studied. Demographic and clinical characteristics, as well as treatment upon hospital discharge and survival data were obtained in May 2003. RESULTS: Mean follow-up was 1.4 years. 44.5% of the whole group of patients presented anemia with mean (standard deviation) hemoglobin levels of 111 (12) g/l, were older, with higher prevalence of ischemic cardiopathy, had higher levels of globular sedimentation rate but lower cholesterol and glomerular filtration rate levels. The prescription of angiotensin converting enzyme inhibitors and betablockers was less frequent among patients with anemia. The presence of anemia was related in a independent way with higher mortality (relative risk: 2.554; p = 0.001), the relation between survival and haemoglobin levels being direct. CONCLUSION: The prevalence of anemia among hospitalized HF patients is very high and its presence constitutes a powerful mortality determinant in this group of patients.

Systemic sclerosis: a rare cause of heart failure?

Systemic sclerosis (SS) is a chronic disease in which there may be multisystem involvement. It is rare (estimated prevalence: 0.5-2/10000) with high morbidity and mortality, and there is as yet no curative treatment. We report the case of a young woman newly diagnosed with SS, in whom decompensated heart failure was the main manifestation.

Mortality and cardiovascular morbidity within 30 days of discharge following acute coronary syndrome in a contemporary European cohort of patients: How can early risk prediction be improved? The six-month GRACE risk score.

OBJECTIVES: Given the increasing focus on early mortality and readmission rates among patients with acute coronary syndrome (ACS), this study was designed to evaluate the accuracy of the GRACE risk score for identifying patients at high risk of 30-day post-discharge mortality and cardiovascular readmission. METHODS: This was a retrospective study carried out in a single center with 4229 ACS patients discharged between 2004 and 2010. The study endpoint was the combination of 30-day post-discharge mortality and readmission due to reinfarction, heart failure or stroke. RESULTS: One hundred and fourteen patients had 30-day events: 0.7% mortality, 1% reinfarction, 1.3% heart failure, and 0.2% stroke. After multivariate analysis, the six-month GRACE risk score was associated with an increased risk of 30-day events (HR 1.03, 95% CI 1.02-1.04; p<0.001), demonstrating good discrimination (C-statistic: 0.79 ± 0.02) and optimal fit (Hosmer-Lemeshow p=0.83). The sensitivity and specificity were adequate (78.1% and 63.3%, respectively), and negative predictive value was excellent (99.1%). In separate analyses for each event of interest (all-cause mortality, reinfarction, heart failure and stroke), assessment of the six-month GRACE risk score also demonstrated good discrimination and fit, as well as adequate predictive values. CONCLUSIONS: The six-month GRACE risk score is a useful tool to predict 30-day post-discharge death and early cardiovascular readmission. Clinicians may find it simple to use with the online and mobile app score calculator and applicable to clinical daily practice.

Síndrome de tako-tsubo complicado con taponamiento cardiaco y shock cardiogénico / Tako-tsubo cardiomyopathy complicated with cardiac tamponade and cardiogenic shock

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Daño cardiaco en paciente con enfermedad de Behçet. Integración diagnóstica y terapéutica / Cardiac involvement in a patient with Behçet disease. Diagnostic and therapeutic approach

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Dominancia coronaria y pronóstico a largo plazo de los pacientes con infarto de miocardio con elevación del segmento ST tratado con angioplastia primaria / Coronary artery dominance and long-term prognosis in patients with ST-segment elevation myocardial infarction treated with primary angioplasty

Introducción y objetivos: El significado pronóstico a largo plazo del patrón de dominancia coronaria en pacientes con infarto de miocardio con elevación del segmento ST está mal caracterizado. Se investigó el pronóstico de esos pacientes según tuvieran dominancia derecha, izquierda o codominancia. Métodos: Estudio retrospectivo de 767 pacientes, ingresados entre 2007 y 2012 por infarto de miocardio con elevación del segmento ST y tratados con intervencionismo coronario percutáneo primario. Se determinó el impacto del patrón de dominancia coronaria, en la mortalidad por cualquier causa y los reingresos por infarto ajustando por mortalidad como evento competitivo. Resultados: La dominancia coronaria fue derecha en el 80,9% e izquierda en el 8,6%. Durante 40,8 [intervalo intercuartílico, 21,9-58,3] meses de seguimiento, se registraron 118 (15,4%) muertes, 39 (5,1%) de ellas, intrahospitalarias. La mortalidad fue del 7,1, el 36,4 y el 13,8% (p < 0,001) en dominancia derecha, izquierda y codominancia, respectivamente. La causa de muerte fue cardiovascular en el 7,1, el 21,2 y el 2,4%. En el análisis multivariable de Cox, la dominancia izquierda se asoció significativamente con la mortalidad (hazard ratio = 1,76; p = 0,02). Considerar «dominancia coronaria» en la predicción de riesgo de muerte mejoró la capacidad de discriminación y calibración de la puntuación GRACE (Global Registry of Acute Coronary Events). El 9,3% (71 pacientes) presentó reinfarto durante el seguimiento. En el análisis multivariable, la dominancia izquierda fue predictora independiente de reinfarto (sub-hazard ratio = 2,06; p = 0,01). Conclusiones: En el infarto con elevación del segmento ST tratado con intervencionismo coronario percutáneo primario, la dominancia izquierda confiere mayor riesgo de muerte y reinfarto que la dominancia derecha, y debería tenerse en cuenta en la estratificación pronóstica (AU)

Introduction and objectives: The long-term prognostic significance of coronary artery dominance pattern in patients with ST-segment elevation myocardial infarction is poorly characterized. We investigated the prognosis of such patients according to whether they had right dominance, left dominance, or codominance. Methods: This was a retrospective study of 767 patients, who were admitted to hospital between 2007 and 2012 with ST-segment elevation myocardial infarction and treated with primary percutaneous coronary intervention. We determined the effect of the coronary dominance pattern on all-cause mortality and readmission for infarction, adjusting for mortality as a competing event. Results: A total of 80.9% of patients had right coronary dominance, and 8.6% had left coronary dominance. Over 40.8 months’ [interquartile range, 21.9-58.3 months] follow-up, 118 (15.4%) deaths were recorded, of which 39 (5.1%) were in hospital. Mortality for right dominance, left dominance, and codominance was 7.1%, 36.4%, and 13.8% (P < .001), respectively. Cause of death was cardiovascular in 7.1%, 21.2%, and 2.4%. On Cox multivariate analysis, left dominance was significantly associated with mortality (hazard ratio = 1.76; P = .02). Taking 'coronary dominance' into account in prediction of risk of death improved the discrimination and calibration capacity of GRACE (Global Registry of Acute Coronary Events) scoring. At follow-up, 9.3% (71 patients) had reinfarction. On multivariate analysis, left dominance was an independent predictor of reinfarction (subhazard ratio = 2.06; P = .01). Conclusions: In ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, left coronary artery dominance confers a higher risk of death and reinfarction than right coronary artery dominance, and should be included in prognostic stratification (AU)

Influencia del sexo en la mortalidad a largo plazo de pacientes hospitalizados por insuficiencia cardíaca con función sistólica conservada o deprimida / Influence of sex on mortality in hospitalized patients with congestive heart failure and preserved or depressed systolic function

Introducción y objetivos. Hay una relativa controversia sobre el impacto del sexo en la mortalidad de los pacientes con insuficiencia cardíaca y es escasa la información acerca de su influencia en el grupo de pacientes con función sistólica ventricular izquierda conservada. El objetivo es estudiar la influencia del sexo en el pronóstico de la insuficiencia cardíaca, así como en los subgrupos con función sistólica conservada y deprimida. Pacientes y método. Se incluyó a 1.252 pacientes, 767 varones (61,3%), ingresados con insuficiencia cardíaca en un servicio de cardiología de un hospital terciario. La mediana del seguimiento ha sido de 2,3 años, con una mortalidad total al final de los 12 años de seguimiento de un 41%. El 60,2% presentaba una fracción de eyección < 50%. Las mujeres tuvieron mayor edad (73,4 ± 10,0 frente a 66,8 ± 11,9 años; p < 0,001), mayor proporción de función sistólica conservada (el 52,2 frente al 31,9%; p < 0,001) y menor proporción de cardiopatía isquémica (el 44,1 frente al 53,2%; p < 0,001). Resultados. La influencia del sexo en el pronóstico no alcanzó significación estadística en el análisis multivariable en el grupo global (varón frente a mujer hazard ratio [HR] = 1,253; intervalo de confianza [IC] del 95%, 0,978-1,605; p = 0,074). Tampoco se objetivaron diferencias significativas en la supervivencia entre ambos sexos cuando se analizaron los subgrupos de función sistólica conservada y deprimida. Conclusiones. En nuestro estudio no observamos influencia significativa del sexo en la mortalidad de los pacientes hospitalizados por insuficiencia cardíaca ni tampoco en los subgrupos de función sistólica conservada y deprimida, a pesar de la tendencia hacia una mayor mortalidad en el grupo de los varones

Introduction and objectives. There is some controversy about the impact of sex on mortality in patients with heart failure. Moreover, little is known about its influence on prognosis in patients with preserved systolic function. The objective of this study was to investigate the influence of sex on survival in patients with heart failure, including subgroups with preserved or depressed left ventricular ejection fraction (LVEF). Patients and method. The study included 1252 patients (767 male, 61.3%) who were admitted with heart failure to the cardiology department of a tertiary hospital. The median follow-up period was 2.3 years, with the mortality rate rising to 41% after 12 years of follow-up. A LVEF less than 50% was observed in 60.2% of patients. Female patients were older (73.4 ± 10.0 years vs 66.8 ± 11.9 years; P<.001), a higher proportion had preserved systolic function (52.2% vs 31.9%; P<.001), and fewer had ischemic cardiopathy (44.1% vs 53.2%; P<.001).Results. In the group as a whole, the influence of sex on prognosis did not reach statistical significance: the hazard ratio in males compared with females was 1.253 (95%CI, 0.978-1.605; P=.074). In addition, no influence of sex on survival was observed in subgroups with preserved or depressed systolic function. Conclusions. In a large cohort, we did not observe any influence of sex on mortality in hospitalized patients with heart failure, either in the group as a whole or in subgroups with preserved or depressed left ventricular systolic function, despite a tendency towards higher mortality in males