Do physicians correctly calculate thromboembolic risk scores? A comparison of concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores.

BACKGROUND: Clinical risk scores, CHADS2 and CHA2 DS2 -VASc scores, are the established tools for assessing stroke risk in patients with atrial fibrillation (AF). AIM: The aim of this study is to assess concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores, as well as to analyse the patient categories using CHADS2 and the potential improvement on stroke risk stratification with CHA2 DS2 -VASc score. METHODS: We linked data from Atrial Fibrillation Spanish registry FANTASIIA. Between June 2013 and March 2014, 1318 consecutive outpatients were recruited. We explore the concordance between manual scoring and computer-based calculation. We compare the distribution of embolic risk of patients using both CHADS2 and CHA2 DS2 -VASc scores RESULTS: The mean age was 73.8 ± 9.4 years, and 758 (57.5%) were male. For CHADS2 score, concordance between manual scoring and computer-based calculation was 92.5%, whereas for CHA2 DS2 -VASc score was 96.4%. In CHADS2 score, 6.37% of patients with AF changed indication on antithrombotic therapy (3.49% of patients with no treatment changed to need antithrombotic treatment and 2.88% of patients otherwise). Using CHA2 DS2 -VASc score, only 0.45% of patients with AF needed to change in the recommendation of antithrombotic therapy. CONCLUSION: We have found a strong concordance between manual and computer-based score calculation of both CHADS2 and CHA2 DS2 -VASc risk scores with minimal changes in anticoagulation recommendations. The use of CHA2 DS2 -VASc score significantly improves classification of AF patients at low and intermediate risk of stroke into higher grade of thromboembolic score. Moreover, CHA2 DS2 -VASc score could identify 'truly low risk' patients compared with CHADS2 score.

Vericiguat in heart failure: From scientific evidence to clinical practice.

Despite currently available treatments, risk of death and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) remains high. The pathophysiology of HFrEF includes neurohormonal activation characterized by stimulation of deleterious pathways (i.e., sympathetic nervous and renin-angiotensin-aldosterone systems) and suppression of protective pathways such as nitric oxide-dependent pathways. Inhibition or stimulation of some, but not all, of these pathways is insufficient. In HFrEF, there is reduced nitric oxide, soluble guanylate cyclase, and cGMP activity, leading to deleterious effects in the myocardial, vascular, and renal systems. Vericiguat is able to stimulate the activity of this protective pathway. The VICTORIA study demonstrated that the addition of vericiguat to optimal medical treatment in patients with HFrEF and recent decompensation significantly reduced the incidence of the primary endpoint, a composite of cardiovascular death or HF hospitalization, with a number needed to treat of 24 patients and excellent tolerability.

Does nutritional intervention maintain its prognostic benefit in the long term for malnourished patients hospitalised for heart failure? / ¿Mantiene la intervención nutricional en pacientes hospitalizados por insuficiencia cardiaca desnutridos su beneficio pronóstico a largo plazo?

OBJECTIVE: To assess the long-term effect of nutritional intervention on malnourished, hospitalised patients with heart failure (HF). METHODS: A total of 120 malnourished patients hospitalized for HF were randomised to undergo (or not) an individual nutritional intervention for 6 months. The primary event was the combination of all-cause death and readmission for HF. We performed an intent-to-treat analysis and assessed the effect of the intervention at 24 months. RESULTS: The combined event occurred in 47.5% of the intervention group and in 73.8% of the control group (hazard ratio: 0.45; 95% confidence interval: 0.28-0.72; P=.001). Thirty-nine percent of the intervention group and 59% of the control group died (hazard ratio: 0.53; 95% confidence interval: 0.31-0.89; P=.017). CONCLUSION: A nutritional intervention for malnourished patients hospitalised for HF maintains its prognostic benefit in the long-term follow-up.

[The lessons from clinical trials in congestive heart failure]. / Lecciones de los ensayos clínicos en la insuficiencia cardíaca congestiva.

During the last years, our knowledge on the pathophysiology and therapy of congestive heart failure has experienced a great growth. The goals of the therapy for heart failure have changed since new drugs have demonstrated to increase survival as well as to improve symptoms and functional capacity in patients with this syndrome. It has also been shown that therapeutic intervention can prevent the development of heart failure and decrease long-term mortality in patients with asymptomatic left ventricular dysfunction. In this article, we have reviewed the results from the most important clinical trials carried out during the last years in patients with overt congestive heart failure and asymptomatic left ventricular dysfunction with several drugs (digitalis, diuretics, angiotension-converting-enzyme inhibitors, other vasodilators, calcium-antagonists, non-glycoside inotropics antiarrhythmics, etc.). Nevertheless, in spite of this impressive increase in the knowledge on heart failure, some important questions remain unanswered.

[Arterial hypertension and systolic left ventricular dysfunction: therapeutic approach]. / Hipertensión arterial y disfunción sistólica ventricular izquierda: abordaje terapéutico.

Arterial hypertension is a cardinal precursor of congestive heart failure, and diastolic dysfunction is the most frequent mechanism for it. Systolic left ventricular dysfunction, although less frequent, has a worse prognosis. Most cases of systolic dysfunction in patients with hypertension is due to acute myocardial infarction, although other mechanisms can be involved. In some studies, non-ischemic hypertensive systolic dysfunction is the etiology of chronic heart failure in up to 10% of patients with dilated cardiomyopathy. Diastolic dysfunction and left ventricular hypertrophy are also associated with a higher risk of heart failure and systolic dysfunction. Given the poor prognosis of patients with congestive heart failure and dilated cardiomyopathy, it is fundamental to try to prevent the development of left ventricular dysfunction by means of a correct control of blood pressure, regression of left ventricular hypertrophy and prevention of coronary artery disease. When systolic dysfunction is established, angiotensin converting enzyme inhibitors are the treatment of choice; diuretics and digoxin can be added in patients with overt congestive heart failure. Recent studies suggest that other drugs, such as carvedilol and losartan, can be beneficial, but current evidence is still scarce.

[Cardio-protection and cardio-reparation in systemic arterial hypertension]. / Cardioprotección y cardiorreparación en la hipertensión arterial sistémica.

Left ventricular hypertrophy in systemic hypertension is an important independent risk factor for adverse cardiovascular events. Hypertrophy is due to increase of the myocytic and non-myocytic compartments of the myocardium. The changes in architecture, shape and function of the left ventricular is considered as remodelling. The concept of cardioreparation implies a restoration of structural (regression of both intersticial and perivascular fibrosis and myocyte hypertrophy) and functional consequences of remodelling. The concept of cardio-protection implies prevention of remodelling. Remodelling is caused not only because high pressure but there are many other factors, mainly hormonal, as activation of renin angiotensin aldosterone system promoting nuclear oncogens. Functional changes are mainly due to fibrosis with diastolic impairment at a first step and dilatation later. Therapeutic goal in systemic hypertension is to achieved, not only a normal pressure but a normal structural and functional heart.

[Fungal endocarditis in non drug-addict patients. 10-year experience]. / Endocarditis por hongos en pacientes no adictos a drogas por vía parenteral. Nuestra experiencia en 10 años.

INTRODUCTION AND OBJECTIVES: Fungal endocarditis is an uncommon but serious disease. Five cases of fungal endocarditis, involving non-addict patients, were diagnosed at our hospital in the last 10 years. RESULTS: Causal organisms included Candida albicans (3 patients), Saccharomyces (1 patient) and Torulopsis glabrata (1 patient). The predisposing condition to fungal infection was previous cardiac surgery in four cases (three of them with prosthetic heart valves, and the other patient underwent total surgical correction of Tetralogy of Fallot). No predisposing cause was found in one patient. All patients developed important complications. Three cases underwent cardiac surgery that evolved favorably, and two patients had contraindications for surgery and died from multiorgan septic involvement (overall survival was 60%). CONCLUSIONS: The incidence of fungal endocarditis involving non-addict patients has represented 3% of all cases of infective endocarditis. Even nowadays, fungal endocarditis is a disease with a high mortality and a precocious diagnosis is important to approach surgical treatment and to improve its prognosis.

[Austrian's syndrome (endocarditis, meningitis and pneumonia caused by Streptococcus pneumoniae). Apropos of a rare case]. / Síndrome de Austrian (endocarditis, meningitis y neumonía por Streptococcus pneumoniae). A propósito de un caso poco frecuente.

We report a case of a mitral endocarditis caused by Streptococcus pneumoniae in a 48 year old man diagnosed with moderate mitral stenosis and liver cirrhosis. The clinical features were fever with penicillin-sensitive pneumococcal bacteremia, meningitis and pneumonia. Only transesophageal echocardiography could confirm the presence of vegetations. In spite of vancomycin therapy, the patient required mitral valve replacement, with good results. Some clinical aspects of this uncommon cause of infective endocarditis are discussed.

[Constrictive pericarditis and Behçet's disease: a very rare association]. / Pericarditis constrictiva y enfermedad de Behçet: una asociación muy infrecuente.

Although benign acute pericarditis can be considered a common cardiac complication of Behçet's disease, the association of this systemic vasculitis with constrictive pericarditis has not been described. A case of this peculiar clinical association is presented, and some interesting diagnostic points are discussed.

[Mobile thrombus in the right cardiac cavities in patients with severe pulmonary thromboembolism. Importance of echocardiography]. / Trombos móviles en cavidades cardíacas derechas en pacientes con tromboembolismo pulmonar grave. Importancia de la ecocardiografía.

The pulmonary thromboembolism is a frequent and severe disease, usually difficult to recognize, specially in patients with thrombotic material trapped within right heart cavities. We present our experience in three patients with severe pulmonary thromboembolism where echocardiographic study demonstrated the presence of huge mobile thrombus in right heart cavities, which demanded urgent therapy with excellent results. We would like to stress that echocardiographic study in these patients could be elective diagnostic procedure, avoiding the realization of pulmonary arteriography, which could bring risk of possible thrombus mobilization.

[Isolated left ventricular myxoma discovered incidentally by echocardiography]. / Mixoma ventricular izquierdo aislado descubierto casualmente por ecocardiografía.

We describe the case of a young patient in whom two-dimensional echocardiography, performed because of episodes of palpitations, discovered the presence of a small mass in the left ventricle, attached to the posterior wall. Transesophageal echocardiography was performed to further assess the mass's attachments and to verify the lack of involvement of the mitral valve and its associated structures. The patient had a cardiopulmonary bypass, surgery and the mass was removed approaching into the left ventricular cavity through the atrial septum via a right atriotomy, without any complication during the postoperative period. In the histologic study the mass appeared to be a typical myxoma. This case has a great interest because the ventricular location of the myxoma is unusual; and because the use of two-dimensional echocardiography, even in the absence of significant symptoms and/or signs, avoided dangerous embolic complications, which often represent the first sign of this neoplastic pathology.

[Aneurysm of the anterior mitral valve in a case of aortic endocarditis in a patient with ulcerative colitis]. / Aneurisma de la valva anterior mitral en un caso de endocarditis aórtica en un paciente diagnosticado de colitis ulcerosa.

We report a case of an aortic endocarditis caused by Enterococcus faecium in a 34 year old patient diagnosed with ulcerative colitis. A Doppler echocardiogram showed an anterior mitral valve leaflet aneurysm, which made surgery necessary. Mitral valve leaflet aneurysm is a rare, though well-known complication of aortic valve endocarditis which can eventually perforate.

[Acute pericarditis as the initial manifestation in Still's disease in an adult]. / Pericarditis aguda como manifestación inicial de la enfermedad de Still del adulto.

Almost 90% of primary acute pericarditis are idiopathic. Between specifics forms, a very low percentage of cases are due to chronic rheumatic diseases. A case of adult Still's disease (juvenile chronic rheumatoid arthritis) with acute pericarditis being the first clinical manifestation (besides fever and general syndrome) is presented. Therapy with oral prednisone was rapidly effective, and pericardial effusion resolved after 3 weeks of treatment, as echocardiography showed.

[Abscess of the mitral-aortic confluence and perforation of the mitral valve in a patient with Brucella endocarditis]. / Absceso de la confluencia mitroaórtica y perforación de la válvula mitral en un paciente con endocarditis por Brucella.

We report a case of Brucella aortic valve endocarditis in a 36 year-old patient with no underlying heart disease who required urgent surgery. In the postoperative follow-up, he suffered from congestive heart failure due to an anterior mitral valve rupture. In the echocardiogram, a periprosthetic abscess was seen and a second intervention was necessary. This report suggests that treating Brucella endocarditis requires a combined medical and surgical approach.

[Clinical features and prognosis of infective endocarditis in the elderly]. / Características clínicas y pronósticas de la endocarditis infecciosa en el anciano.

INTRODUCTION AND OBJECTIVES: In recent decades the mean age of patients with infective endocarditis has progressively increased. The objective of the present study was to describe the clinical features and prognoses of infective endocarditis in the elderly. METHODS: A prospective study was performed of 125 non drug abuser patients over the age of 14 years and admitted from 1987 until 1997 in a single institution. Twenty-one patients were older than 65 years. RESULTS: No significant differences were observed among the age groups with respect to delay in diagnosis, clinical signs, site of the infection and the rate of negative blood cultures. Prosthetic valve endocarditis was more frequent in elderly than in younger adults (41 and 33%, respectively). S. viridans and enterococcus were more frequent (47 compared with 29% in younger adults, p < 0.05). Elderly patients underwent surgery less frequently (46 versus 56%) and most surgery was performed on an emergency basis. The in hospital mortality was higher in the elderly (50 versus 15%), p < 0.05. CONCLUSIONS: Prosthetic valve endocarditis and severe complications during the active phase are more frequent in the elderly and this is related to a worse prognosis in the short and intermediate term. A higher rate of elective surgery during the active phase could improve the prognosis of infective endocarditis in the elderly.

[A comparison of bezafibrate and lovastatin treatment at the usual doses in post-heart transplant hyperlipemia]. / Comparación del tratamiento con bezafibrato y lovastatina a dosis habituales en la hiperlipemia postrasplante cardíaco.

INTRODUCTION: Coronary artery disease is a major limiting factor for long-term survival after heart transplantation. Hyperlipidemia is a probable risk factor for coronary artery disease in this kind of patient. Bezafibrate and lovastatin have proved to be effective in lowering total and low density lipoprotein cholesterol. The present study tested the safety and efficacy of both drugs on lipid levels in 21 patients with post-heart transplantation hyperlipidemia. PATIENTS AND METHODS: Patients maintained the same diet for three months. Then, they were randomized to lovastatin (20 mg/day) or bezafibrate (400 mg/day) for 8 weeks, and then, crossovered to an additional 8 weeks of bezafibrate or lovastatin. RESULTS: Both drugs were effective in lowering total and low density lipoprotein cholesterol and apoprotein B concentrations, but the effect of lovastatin was significantly greater. Only bezafibrate produced a significant reduction in total triglycerides and a significant rise in high density lipoprotein cholesterol and apoprotein AI. The total cholesterol/high density lipoprotein cholesterol and low density lipoprotein cholesterol/high density lipoprotein cholesterol ratios were decreased under both treatments. CONCLUSION: Both drugs, bezafibrate and lovastatin appear to be safe, effective and well-tolerated therapies for hyperlipidemia in cardiac transplant recipients.

[Short and long-term prognosis of prosthetic valve endocarditis in non-drug addicts]. / Pronóstico a corto y largo plazo de la endocarditis sobre prótesis en pacientes no drogadictos.

INTRODUCTION AND OBJECTIVES: Prosthetic valve infective endocarditis is a complication of valvular replacement surgery with a high morbimortality during the in-hospital phase and an important risk of complications during follow-up. The objective of the present study is to assess the clinical features and the short and long-term prognosis of this disease. PATIENTS AND METHODS: A prospective study of 43 consecutive cases of prosthetic valve endocarditis in non-addict patients from January 1987 to March 1997. RESULTS: The mean age was 51 +/-16 years. Eight patients (19%) had early prosthetic valve endocarditis (two months following heart surgery), fourteen patients (32%) had intermediate (between 2 and 12 months post surgery) and twenty-one (49%) had late prosthetic valve endocarditis (more than one year after heart surgery). Transesophageal echocardiography was performed in 32 patients with a sensibility of 81%. Complications occurred in 86% of patients and 53% of patients underwent surgery during the active phase (25% was emergency surgery). Inpatient mortality was 23% (50% in early prosthetic valve endocarditis). After a mean follow-up of 56 months there were 5 cases of recurrence, four patients required late surgery and 5 patients died. Survival (excluding early mortality) was 82% at 5 years with no significant differences among patients who received only medical treatment and those who underwent surgery in the active phase. CONCLUSIONS: Early mortality of prosthetic valve endocarditis is, according to our experience of 20%. The prognosis of survivors to the active phase is favourable in the majority. Early prosthetic valve endocarditis still causes a high mortality rate despite the use of combined medical surgical treatment in most cases.

[The general characteristics and short- and long-term results of infective endocarditis in non-drug addicts]. / Características generales y resultados a corto y largo plazo de la endocarditis infecciosa en pacientes no drogadictos.

INTRODUCTION AND OBJECTIVES: Infective endocarditis is a disease with a high morbimortality during the active phase and a considerable risk of complications during follow-up. The aim of our study is to describe the clinical and prognostic features of infective endocarditis in non-drug addict patients in short and long terms. PATIENTS AND METHODS: A prospective study of 138 cases of infective endocarditis in non-drug addict patients through the parenteral pathway treated in our institution from 1987 to 1997. RESULTS: The mean age was 44 +/- 20 years. Ninety-five patients (69%) had native valve infective endocarditis and forty-three (31%) had prosthetic valve endocarditis. Streptococci were the causal microorganism in 34% and staphylococci in 33%. 83% of patients developed some type of complications during hospital stay. 51% of patients were operated on during the active phase (22% were urgent). The in-hospital mortality rate was 21%. 10 patients (9%) needed late cardiac surgery and seven patients (5%) died during follow-up. Global survival at 10 years was 71%. There were no statistical differences in survival in as much as the type of treatment received during the hospital stay in the active phase (medical alone or combined medical-surgical). CONCLUSIONS: A high early surgery rate in the active phase related to good long-term results and does not increase early in-hospital mortality. Medical treatment also offers good long-term results in cases of infectious endocarditis with absence of bad prognostic factors and good clinical outcome.