Vaccine-carditis study: Spanish multicenter registry of inflammatory heart disease after COVID-19 vaccination.

INTRODUCTION AND OBJECTIVES: Vaccines against SARS-CoV-2 have been a major scientific and medical achievement in the control of the COVID-19 pandemic. However, very infrequent cases of inflammatory heart disease have been described as adverse events, leading to uncertainty in the scientific community and in the general population. METHODS: The Vaccine-Carditis Registry has included all cases of myocarditis and pericarditis diagnosed within 30 days after COVID-19 vaccination since August 1, 2021 in 29 centers throughout the Spanish territory. The definitions of myocarditis (probable or confirmed) and pericarditis followed the consensus of the Centers for Disease Control and the Clinical Practice Guidelines of the European Society of Cardiology. A comprehensive analysis of clinical characteristics and 3-month evolution is presented. RESULTS: From August 1, 2021, to March 10, 2022, 139 cases of myocarditis or pericarditis were recorded (81.3% male, median age 28 years). Most cases were detected in the 1st week after administration of an mRNA vaccine, the majority after the second dose. The most common presentation was mixed inflammatory disease (myocarditis and pericarditis). 11% had left ventricular systolic dysfunction, 4% had right ventricular systolic dysfunction, and 21% had pericardial effusion. In cardiac magnetic resonance studies, left ventricular inferolateral involvement was the most frequent pattern (58%). More than 90% of cases had a benign clinical course. After a 3-month follow-up, the incidence of adverse events was 12.78% (1.44% mortality). CONCLUSIONS: In our setting, inflammatory heart disease after vaccination against SARS-CoV-2 predominantly affects young men in the 1st week after the second dose of RNA-m vaccine and presents a favorable clinical course in most cases.

Antiplatelet therapy at discharge and long-term prognosis in Takotsubo syndrome: Insights from the Spanish National Registry (RETAKO).

INTRODUCTION: Endothelial dysfunction and platelet activation have been highlighted as possible mediators in Takotsubo syndrome (TTS). Nevertheless, to date, evidence on the usefulness of antiplatelet therapy in TTS remains controversial. The aim of our study is to evaluate long-term prognosis in TTS patients treated with antiplatelet therapy (APT) at hospitalization discharge. MATERIAL AND METHODS: An ambispective cohort study from the Spanish National Takotsubo Registry database was performed (June 2002 to March 2017). Patients were divided into two groups: those who received APT at hospital discharge (APT cohort) and those who did not (non-APT cohort). Primary endpoint was all-cause death. Secondary endpoints included the composite of recurrence or readmission and a composite of death, recurrence or readmission. RESULTS: From a total of 741 patients, 728 patients were alive at discharge. Follow-up was performed in 544 patients, who were included in the final analysis: 321 patients (59.0%) in the APT cohort and 223 patients (41.0%) in the non-APT cohort. The APT cohort had a better clinical presentation and received more heart failure and acute coronary syndrome-like therapies (angiotensin converting enzyme inhibitors/angiotensin receptor blockers: 75.1% vs. 51.1%; p<0.001, betablockers: 71.3% vs. 50.7%; p<0.001, statins: 67.9% vs. 33.2%; p<0.001). After adjusting for confounder factors, APT at discharge was a protective factor for all-cause death (adjusted hazard ratio (HR) 0.315, 95% confidence interval (CI): 0.106-0.943; p=0.039) and the composite endpoint of all-cause death, recurrence or readmission (adjusted HR 0.318, 95% CI: 0.164-0.619; p=0.001) at month 25 of follow-up. CONCLUSION: Patients with TTS receiving APT at discharge presented better prognosis up to two-years of follow-up compared with their counterparts not receiving APT.

Changes in causes of death and influence of therapeutic improvement over time in patients with heart failure and reduced ejection fraction.

INTRODUCTION AND OBJECTIVES: In patients with heart failure and reduced ejection fraction (HFrEF), several therapies have been proven to reduce mortality in clinical trials. However, there are few data on the effect of the use of evidence-based therapies on causes of death in clinical practice. METHODS: This study included 2351 outpatients with HFrEF (< 40%) from 2 multicenter prospective registries: MUSIC (n=641, period: 2003-2004) and REDINSCOR I (n=1710, period: 2007-2011). Variables were recorded at inclusion and all patients were followed-up for 4 years. Causes of death were validated by an independent committee. RESULTS: Patients in REDINSCOR I more frequently received beta-blockers (85% vs 71%; P <.001), mineralocorticoid antagonists (64% vs 44%; P <.001), implantable cardioverter-defibrillators (19% vs 2%; P <.001), and resynchronization therapy (7.2% vs 4.8%; P=.04). In these patients, sudden cardiac death was less frequent than in those in MUSIC (6.8% vs 11.4%; P <.001). After propensity score matching, we obtained 2 comparable populations differing only in treatments (575 vs 575 patients). In patients in REDINSCOR I, we found a lower risk of total mortality (HR, 0.70; 95%CI, 0.57-0.87; P=.001) and sudden cardiac death (sHR, 0.46; 95%CI, 0.30-0.70; P <.001), and a trend toward lower mortality due to end-stage HF (sHR, 0.73; 95%CI, 0.53-1.01; P=.059), without differences in other causes of death (sHR, 1.17; 95%CI, 0.78-1.75; P=.445), regardless of functional class. CONCLUSIONS: In ambulatory patients with HFrEF, implementation of evidence-based therapies was associated with a lower risk of death, mainly due to a significant reduction in sudden cardiac death.

Mid-range Ejection Fraction Does Not Permit Risk Stratification Among Patients Hospitalized for Heart Failure.

INTRODUCTION AND OBJECTIVES: European Society of Cardiology heart failure guidelines include a new patient category with mid-range (40%-49%) left ventricular ejection fraction (HFmrEF). HFmrEF patient characteristics and prognosis are poorly defined. The aim of this study was to analyze the HFmrEF category in a cohort of hospitalized heart failure patients (REDINSCOR II Registry). METHODS: A prospective observational study was conducted with 1420 patients classified according to ejection fraction as follows: HFrEF, < 40%; HFmrEF, 40%-49%; and HFpEF, ≥ 50%. Baseline patient characteristics were examined, and outcome measures were mortality and readmission for heart failure at 1-, 6-, and 12-month follow-up. Propensity score matching was used to compare the HFmrEF group with the other ejection fraction groups. RESULTS: Among the study participants, 583 (41%) had HFrEF, 227 (16%) HFmrEF, and 610 (43%) HFpEF. HFmrEF patients had a clinical profile similar to that of HFpEF patients in terms of age, blood pressure, and atrial fibrillation prevalence, but shared with HFrEF patients a higher proportion of male participants and ischemic etiology, and use of class I drugs targeting HFrEF. All other features were intermediate, and comorbidities were similar among the 3 groups. There were no significant differences in all-cause mortality, cause of death, or heart failure readmission. The similar outcomes were confirmed in the propensity score matched cohorts. CONCLUSIONS: The HFmrEF patient group has characteristics between the HFrEF and HFpEF groups, with more similarities to the HFpEF group. No between-group differences were observed in total mortality, cause of death, or heart failure readmission.

Mid-range left ventricular ejection fraction: Clinical profile and cause of death in ambulatory patients with chronic heart failure.

BACKGROUND: The intermediate group of patients with heart failure (HF) and mid-range left ventricular ejection fraction (HFmrEF) may constitute a specific phenotype, but a direct evidence is lacking. This study aimed to know whether this HF category is accompanied by a particular clinical phenotype and prognosis. METHODS AND RESULTS: This study includes 3446 ambulatory patients with chronic HF from two national registries. According to EF at enrollment, patients were classified as reduced (HFrEF, <40%), mid-range (HFmrEF, 40-49%) or preserved (HFpEF, ≥50%). Patients were followed-up for a median of 41months and the specific cause of death was prospectively registered. Patients with HFmrEF represented 13% of population and they exhibited a phenotype closer to HFrEF, except for a higher rate of coronary revascularization and diabetes, and a less advanced HF syndrome. The observed all-cause mortality was higher among HFrEF (33.0%), and similar between HFmrEF (27.8%) and HFpEF (28.0%) (p=0.012); however, the contribution of each cause of death differed significantly between categories (p<0.001). After propensity score matching, the risk of cardiovascular death, HF death or sudden cardiac death did not differ between HFmrEF and HFrEF in paired samples; however, patients with HFmrEF were at higher risk of cardiovascular death (sHR 1.71, 95% CI 1.13-2.57, p=0.011) and sudden cardiac death (sHR 2.73, 95% CI 1.07-6.98, p=0.036) than patients with HFpEF. CONCLUSIONS: Patients in the intermediate category of HFmrEF conform a phenotype closer to the clinical profile of HFrEF, and associated to higher risk of sudden cardiac death and cardiovascular death than patients with HFpEF.

La fracción de eyección intermedia no permite estratificar el riesgo de los pacientes hospitalizados por insuficiencia cardiaca / Mid-range ejection fraction does not permit risk stratification among patients hospitalized for heart failure

Introducción y objetivos: La guía de insuficiencia cardiaca de la Sociedad Europea de Cardiología define un nuevo grupo de pacientes con fracción de eyección del ventrículo izquierdo intermedia (40-49%) (ICFEi) cuyas características y pronóstico no están bien definidos. Nuestro objetivo es analizar este grupo en pacientes hospitalizados por insuficiencia cardiaca (Registro REDINSCOR II). Métodos: Estudio observacional prospectivo de 1.420 pacientes clasificados según la fracción de eyección: deprimida (ICFEd), < 40%; intermedia (ICFEi), 40-49% y conservada (ICFEc), ≥ 50%. Se comparan entre los 3 grupos las características clínicas, la mortalidad y sus causas y los ingresos por insuficiencia cardiaca al mes, a los 6 meses y al año. Se obtuvo la puntuación de propensión emparejando según grupo de fracción de eyección. Resultados: La distribución de pacientes fue: 583 (41%) con ICFEd, 227 (16%) con ICFEi y 610 (43%) con ICFEc. El grupo con ICFEi se parece más al de ICFEc en cuanto a edad, prevalencia de hipertensión arterial y fibrilación auricular, aunque comparte con la ICFEd el predominio de varones, la etiología isquémica y el mayor uso de fármacos clase I para ICFEd. Las demás características fueron intermedias. No se detectaron diferencias entre los 3 grupos en la mortalidad total, las causas de muerte y los reingresos por insufiencia cardiaca. Esta similitud en el pronóstico se confirmó en el análisis ajustado por puntuación de propensión. Conclusiones: El grupo de pacientes con ICFEi comparte características con los de ICFEc e ICFEd, aunque está más próximo al de ICFEc. La mortalidad total, las causas de muerte o las rehospitalizaciones por insuficiencia cardiaca eran similares en los 3 grupos (AU)

Introduction and objectives: European Society of Cardiology heart failure guidelines include a new patient category with mid-range (40%-49%) left ventricular ejection fraction (HFmrEF). HFmrEF patient characteristics and prognosis are poorly defined. The aim of this study was to analyze the HFmrEF category in a cohort of hospitalized heart failure patients (REDINSCOR II Registry). Methods: A prospective observational study was conducted with 1420 patients classified according to ejection fraction as follows: HFrEF, < 40%; HFmrEF, 40%-49%; and HFpEF, ≥ 50%. Baseline patient characteristics were examined, and outcome measures were mortality and readmission for heart failure at 1-, 6-, and 12-month follow-up. Propensity score matching was used to compare the HFmrEF group with the other ejection fraction groups. Results: Among the study participants, 583 (41%) had HFrEF, 227 (16%) HFmrEF, and 610 (43%) HFpEF. HFmrEF patients had a clinical profile similar to that of HFpEF patients in terms of age, blood pressure, and atrial fibrillation prevalence, but shared with HFrEF patients a higher proportion of male participants and ischemic etiology, and use of class I drugs targeting HFrEF. All other features were intermediate, and comorbidities were similar among the 3 groups. There were no significant differences in all-cause mortality, cause of death, or heart failure readmission. The similar outcomes were confirmed in the propensity score matched cohorts. Conclusions: The HFmrEF patient group has characteristics between the HFrEF and HFpEF groups, with more similarities to the HFpEF group. No between-group differences were observed in total mortality, cause of death, or heart failure readmission (AU)

Cambio en la causa de muerte e influencia de la mejora terapéutica con el tiempo en pacientes con insuficiencia cardiaca y fracción de eyección reducida / Changes in causes of death and influence of therapeutic improvement over time in patients with heart failure and reduced ejection fraction

INTRODUCCIÓN Y OBJETIVOS: En pacientes con insuficiencia cardiaca y fracción de eyección reducida (IC-FEr), se ha demostrado en ensayos clínicos que diferentes terapias reducen la mortalidad, pero hay pocos datos de la práctica real acerca del efecto en los distintos tipos de muerte. MÉTODOS: Se estudió a 2.351 pacientes ambulatorios con IC-FEr (FE <40%) procedentes de los registros prospectivos multicéntricos MUSIC (n=641, años 2003-2004) y REDINSCOR I (n=1.710, años 2007-2011). Las variables se registraron a la inclusión, y el seguimiento fue de 4 años. Un comité independiente adjudicó la mortalidad y sus causas. RESULTADOS: Los pacientes en el registro más contemporáneo recibieron con mayor frecuencia bloqueadores beta (el 85 frente al 71%; p <0,001), antialdosterónicos (el 64 frente al 44%; p <0,001), desfibrilador automático implantable (el 19 frente al 2%; p <0,001) y resincronización (el 7,2 frente al 4,8%; p = 0,04). La población más contemporánea presentó menos muerte súbita (el 6,8 frente al 11,4%; p <0,001). Tras emparejar por puntuación de propensión, se obtuvieron 2 poblaciones comparables que solo diferían en los tratamientos (575 frente a 575 pacientes): la población más contemporánea presentó menor riesgo de muerte total (HR=0,70; IC95%, 0,57-0,87; p = 0,001) y de muerte súbita (sHR=0,46; IC95%, 0,30-0,70; p <0,001), con una tendencia de muerte por IC (sHR=0,73; IC95%, 0,53-1,01; p = 0,059) y sin diferencias por otras causas (sHR=1,17; IC95%, 0,78-1,75; p = 0,445), independientemente de la clase funcional. CONCLUSIONES: En pacientes ambulatorios con IC-FEr, la mejora terapéutica se asoció con un menor riesgo de muerte, principalmente debido a la significativa reducción de las muertes súbitas

INTRODUCTION AND OBJECTIVES: In patients with heart failure and reduced ejection fraction (HFrEF), several therapies have been proven to reduce mortality in clinical trials. However, there are few data on the effect of the use of evidence-based therapies on causes of death in clinical practice. METHODS: This study included 2351 outpatients with HFrEF (< 40%) from 2 multicenter prospective registries: MUSIC (n=641, period: 2003-2004) and REDINSCOR I (n=1710, period: 2007-2011). Variables were recorded at inclusion and all patients were followed-up for 4 years. Causes of death were validated by an independent committee. RESULTS: Patients in REDINSCOR I more frequently received beta-blockers (85% vs 71%; P <.001), mineralocorticoid antagonists (64% vs 44%; P <.001), implantable cardioverter-defibrillators (19% vs 2%; P <.001), and resynchronization therapy (7.2% vs 4.8%; P=.04). In these patients, sudden cardiac death was less frequent than in those in MUSIC (6.8% vs 11.4%; P <.001). After propensity score matching, we obtained 2 comparable populations differing only in treatments (575 vs 575 patients). In patients in REDINSCOR I, we found a lower risk of total mortality (HR, 0.70; 95%CI, 0.57-0.87; P=.001) and sudden cardiac death (sHR, 0.46; 95%CI, 0.30-0.70; P <.001), and a trend toward lower mortality due to end-stage HF (sHR, 0.73; 95%CI, 0.53-1.01; P=.059), without differences in other causes of death (sHR, 1.17; 95%CI, 0.78-1.75; P=.445), regardless of functional class. CONCLUSIONS: In ambulatory patients with HFrEF, implementation of evidence-based therapies was associated with a lower risk of death, mainly due to a significant reduction in sudden cardiac death

Introducción: The Long and Winding Road

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Administración upstream de inhibidores de la glucoproteína IIb/IIIa en el síndrome coronario agudo sin elevación del segmento ST: la estrategia TACTICS / Upstream administration of tirofiban in Non-ST-elevation acute coronary syndrome: the TACTICS strategy

El empleo de los inhibidores de la glucoproteína IIb/IIIa en el contexto del síndrome coronario agudo sin elevación del segmento ST es un tema muy controvertido. A pesar de la oposición a su uso en las últimas guías de revascularización de la Sociedad Europea de Cardiología, los autores seguimos defendiendo el beneficio de la estrategia utilizada en el ensayo clínico TACTICS: actitud intervencionista facilitada con tirofibán en los pacientes con riesgo moderado y alto. Argumentamos esta defensa basándonos en que consideramos que el tirofibán es superior a los otros inhibidores de la glucoproteína IIb/IIIa en estos pacientes, unido a las dudas que todavía nos plantea la bivalirudina y al convencimiento de que los nuevos antiagregantes no deben considerarse sustitutivos, sino complementarios (AU)

The use of glycoprotein-IIb/IIIa inhibitors in non-ST-elevation acute coronary syndrome is highly controversial. Despite opposition to their use in the European Society of Cardiology’s most recent guidelines on myocardial revascularization, the authors of this article maintain that clear clinical benefits were obtained with the treatment strategy used in the TACTICS clinical trial, namely the invasive approach facilitated by tirofiban that was used in moderate- and high-risk patients. The argument in favor of this approach is based on the contention that tirofiban is superior to other glycoprotein-IIb/IIIa inhibitors in these patients, as well as on the knowledge that there are still uncertainties about bivalirudin and on the conviction that new antiplatelet agents should not be regarded as substitutes but rather as complementary treatments (AU)

Absceso intramiocárdico / Myocardial abscess

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