Mortality and Morbidity in Adults With Rheumatic Heart Disease.

Importance: Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries. Objective: To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Design, Setting, and Participants: Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs. Main Outcomes and Measures: The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models. Results: Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors. Conclusions and Relevance: Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.

Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation.

BACKGROUND: Testing of factor Xa inhibitors for the prevention of cardiovascular events in patients with rheumatic heart disease-associated atrial fibrillation has been limited. METHODS: We enrolled patients with atrial fibrillation and echocardiographically documented rheumatic heart disease who had any of the following: a CHA2DS2VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating a higher risk of stroke), a mitral-valve area of no more than 2 cm2, left atrial spontaneous echo contrast, or left atrial thrombus. Patients were randomly assigned to receive standard doses of rivaroxaban or dose-adjusted vitamin K antagonist. The primary efficacy outcome was a composite of stroke, systemic embolism, myocardial infarction, or death from vascular (cardiac or noncardiac) or unknown causes. We hypothesized that rivaroxaban therapy would be noninferior to vitamin K antagonist therapy. The primary safety outcome was major bleeding according to the International Society of Thrombosis and Hemostasis. RESULTS: Of 4565 enrolled patients, 4531 were included in the final analysis. The mean age of the patients was 50.5 years, and 72.3% were women. Permanent discontinuation of trial medication was more common with rivaroxaban than with vitamin K antagonist therapy at all visits. In the intention-to-treat analysis, 560 patients in the rivaroxaban group and 446 in the vitamin K antagonist group had a primary-outcome event. Survival curves were nonproportional. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the vitamin K antagonist group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P<0.001). A higher incidence of death occurred in the rivaroxaban group than in the vitamin K antagonist group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted. CONCLUSIONS: Among patients with rheumatic heart disease-associated atrial fibrillation, vitamin K antagonist therapy led to a lower rate of a composite of cardiovascular events or death than rivaroxaban therapy, without a higher rate of bleeding. (Funded by Bayer; INVICTUS ClinicalTrials.gov number, NCT02832544.).

Cardiovascular autonomic responses during head-up tilt test in newly diagnosed type 2 diabetes.

BACKGROUND: Autonomic dysfunction is commonly observed in patients with long-standing type 2 diabetes. Previous studies have confirmed the value of both subjectively assessed symptoms and objective measurements of autonomic nervous system function in diagnosing cardiovascular autonomic neuropathy. However, the head-up tilt test (HUTT) has been rarely used to investigate cardiovascular autonomic responses in subjects with high risk of newly diagnosed type 2 diabetes (nT2D). OBJECTIVE: To evaluate autonomic cardiovascular responses through passive orthostatic challenge along the diabetes continuum. METHODS: The study population was stratified as normoglycemic (n = 16), prediabetes (n = 20), and nT2D (n = 20). The prevalence of orthostatic intolerance and autonomic cardiovascular responses was evaluated with the Task Force Monitor during a 30-min passive HUTT. Spectral indices of heart rate and blood pressure variability and baroreceptor effectiveness index (BEI) were calculated through the HUTT. BEI was obtained by the sequence method. RESULTS: There were no differences in the prevalence of orthostatic intolerance or in the indices of heart rate and blood pressure variability among the three groups of study. The BEI was attenuated in the nT2D group in supine rest and throughout HUTT compared with normoglycemic and prediabetes groups. The multivariable linear regression analysis showed that BEI was associated with fasting glucose (ß = - 0.52, p < 0.001) and HbA1c (ß = - 0.57, p  < 0.001) independently of cardiovascular risk factors. CONCLUSION: Cardiovascular autonomic neuropathy, expressed as blunted BEI, is the only abnormal autonomic nervous test detected in nT2D, and it was independently associated with fasting glucose and HbA1c values.

Post-Acute COVID-19 Symptoms, a Potential Link with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A 6-Month Survey in a Mexican Cohort.

The aim of this study was to describe the clinical evolution during 6 months of follow-up of adults recovered from COVID-19. We tried to determine how many met the definition of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). A total of 130 patients (51.0 ± 14 years, 34.6% female) were enrolled. Symptoms were common, participants reported a median number of 9 (IQR 5-14) symptoms. Fatigue was the most common symptom (61/130; 46.9%). Patients with fatigue were older 53.9 ± 13.5 years compared with 48.5 ± 13.3 years in those without fatigue (p = 0.02) and had a longer length of hospital stay, 17 ± 14 days vs. 13 ± 10 days (p = 0.04). There was no difference in other comorbidities between patients with fatigue and those without it, and no association between COVID-19 severity and fatigue. After multivariate adjustment of all baseline clinical features, only age 40 to 50 years old was positively associated with fatigue, OR 2.5 (95% CI 1.05-6.05) p = 0.03. In our survey, only 17 (13%) patients met the Institute of Medicine's criteria for "systemic exertion intolerance disease," the new name of ME/CFS. In conclusion, in some patients, the features of post-acute COVID-19 syndrome overlap with the clinical features of ME/CFS.

Early Cerebral Hypoperfusion in Patients with Orthostatic Intolerance Without Tachycardia During Head-Up Tilt Test is Independent of Vasovagal Response.

BACKGROUND: Cerebral hypoperfusion before syncope has been shown in patients with chronic orthostatic intolerance (OI) without tachycardia, but it is unknown if an initial decrease of cerebral blood flow velocity (CBFv) could be related to the vasovagal response (VVR) to head-up tilt test (HUTT). OBJECTIVE: The objective of the study was to compare cardiovascular, cerebrovascular, and autonomic variables during HUTT in OI patients with or without a VVR. METHODS: We included 74 subjects (58% female, mean age 33 ± 12 years) who underwent a 30-min HUTT and were divided into three groups: OI with VVR positive (VVR+), OI without VVR negative (VVR-), and asymptomatic healthy subjects with negative HUTT (control group). Cardiovascular, cerebrovascular, and autonomic variables were assessed beat-to-beat during HUTT with a Task Force monitor and a trans-cranial Doppler. Mean values were evaluated at baseline and throughout the first 10 min of tilting. RESULTS: Cardiovascular variables were similar in the three groups. Systolic, diastolic, and mean CBFv were similar in VVR+ and VVR-, but both groups had lower CBFv than the control group. Systolic and diastolic CBFv decreased from baseline since min 1 in VVR+ and VVR- and since min 5 in the control group. The mean CBFv had a significant decrease since min 1 compared to baseline in all groups. Spectral indices of heart rate and blood pressure variability showed a similar autonomic response to HUTT in all groups. CONCLUSION: Patients with chronic OI without tachycardia have early postural cerebral hypoperfusion, regardless of the VVR during HUTT.

Transient Orthostatic Hypertension During Head-Up Tilt Test in Young Adults: A Phenotype of Blood Pressure Variability.

PURPOSE: The mechanisms underlying orthostatic hypertension (OHT) remain poorly understood. The authors evaluated the cardiovascular, cerebrovascular dynamics, and autonomic response to head-up tilt test (HUTT) in young adults with symptoms of orthostatic intolerance and transient OHT. METHODS: Forty-four female subjects were included (34 ± 13 years old) and categorized in three groups after a 30-minute 70° passive HUTT: symptomatic patients with OHT (surge of systolic blood pressure ≥20 mm Hg for at least 5 minutes at any given time during HUTT), orthostatic intolerance (symptomatic patients without orthostatic blood pressure changes), and healthy asymptomatic control subjects. RESULTS: At baseline, OHT patients had lower systolic blood pressure than orthostatic intolerance patients (103 ± 8 vs. 116 ± 10 mm Hg, p < 0.01) and lower baroreflex sensitivity than control subjects (15.8 ± 8.3 vs. 27.1 ± 11.7 ms/mm Hg, p = 0.01). On tilt, cardiac output decreased in OHT patients from 6.1 ± 1.4 L/minute during baseline to 5.2 ± 0.8 L/minute after 10 minutes of HUTT (p = 0.01). In OHT patients at 30 minutes of HUTT, sympathetic efferent heart activity was higher (77.4 ± 14.9 normalized units or nu) than orthostatic intolerant patients (63.5 ± 11.8 nu, p = 0.02) and control subjects (65.8 ± 11.2 nu, p = 0.05). Cerebrovascular resistance in OHT was higher than control subjects after 30 minutes (2.2 ± 0.8 vs. 1.6 ± 0.3 cm/second, respectively, p = 0.02). CONCLUSIONS: This study demonstrates that transient OHT can occur at any given time during HUTT. These patients exhibit a decrease in cardiac output and a hyperadrenergic response to tilt.

Anticoagulation Therapy by Age and Embolic Risk for Nonvalvular Atrial Fibrillation in Mexico, an Upper-Middle-Income Country: The CARMEN-AF Registry.

Background: Documenting the patterns of oral anticoagulation therapy (OAT) is essential to prevent thromboembolic complications of nonvalvular atrial fibrillation (NVAF). Objective: To report the patterns of OAT according to age and thromboembolic risk in patients included in CARMEN-AF, a nationwide registry of NVAF in Mexico, an upper middle-income country. Material and methods: There were 1,423 consecutive patients ≥18 years old and with at least one thromboembolic risk factor enrolled in the CARMEN-AF Registry at their regular clinical visit during a three-year period. They were analyzed according to 1) age, 2) AF type, and 3) CHA2DS2-VASc score. Results: Overall, 16.4% of patients did not receive antithrombotic treatment, 19.4% received antiplatelet drugs (APD), 29.2% vitamin K antagonists (VKA), and 34.6% direct oral anticoagulants (DOAC). With increasing age, the proportion of subjects treated with VKA decreased significantly from 36.2% in subjects <65 years to 22.5% in those ≥75 years old (P <0.0001). Concomitantly, an increase in both APD and no antithrombotic treatment was observed with increasing age. DOAC were prescribed equally among all age groups (34.2% in <65, 36.0% in 65-74, and 33.9% in ≥75). According to the type of AF, VKA use was more common in patients with permanent AF (32.7%). A lower use of DOAC was observed in high thromboembolic risk subjects (33.6% in CHA2DS2-VASc ≥2) compared with the moderate risk group (41% in CHA2DS2-VASc = 1). Conclusions: VKA use for NVAF in Mexico decreased in relation to increasing age. The proportion of DOAC therapy was the same in all age groups. Nevertheless, elderly patients with high thromboembolic risk received a suboptimal thromboprophylaxis. These data could help to improve gaps in the implementation of global guidelines. Clinical trial registration: http://www.clinicaltrials.gov. Unique identifier: NCT02334852. Highlights: CARMEN-AF is a nationwide multi-centric registry seeking to bridge the data gap on anticoagulation therapy for NVAF in Mexico.Elderly patients are more prone to receive suboptimal OAT for NVAF.DOAC were less frequently used in high thromboembolic risk patients (CHA2DS2-VASc ≥2).

Similar Cerebral Blood Flow and Autonomic Responses to Upright Tilt Test in Adult Patients With Different Hemodynamic Mechanisms Leading to Reflex Syncope.

PURPOSE: Although the underlying mechanisms of reflex syncope remain under debate, there is evidence that it results from decreased cardiac output related to splanchnic blood pooling or a fall in systemic vascular resistance. The aim was to evaluate the response of cerebrovascular and autonomic variables to passive orthostatic challenge in adult patients with different mechanisms leading to reflex syncope. METHODS: The study included 30 subjects (66% women, mean age 34 ± 14 years) who suffered a hemodynamic collapse during a drug-free head-up tilt test. They were categorized into three groups according to their hemodynamic cardiovascular response during the head-up tilt test: (1) reduced cardiac output (patients, n = 10), (2) reduced systemic vascular resistance (patients, n = 10), and (3) reduced cardiac output and systemic vascular resistance, (reduced cardiac output reduced systemic vascular resistance patients, n = 10). Cardiovascular and cerebrovascular dynamics, as well as autonomic variables, were noninvasively assessed during the head-up tilt test and median values were calculated at baseline and throughout the three phases of the tilt. RESULTS: At baseline, the reduced systemic vascular resistance group had lower cardiac output and higher total peripheral resistance index and a sustained increase of heart rate throughout the head-up tilt test in comparison to the other groups. Cerebrovascular dynamics and autonomic variables showed no difference among groups throughout the test. Compared with baseline, these variables had similar percentual change during the orthostatic challenge. CONCLUSIONS: Although different cardiovascular hemodynamic mechanisms of reflex syncope exist in adult patients, cerebrovascular hypoperfusion and autonomic modulation occur to a similar extent.

The World Heart Federation Roadmap for Nonvalvular Atrial Fibrillation.

BACKGROUND: The World Heart Federation has undertaken an initiative to develop a series of Roadmaps to promote development of national policies and health systems approaches, and to identify potential roadblocks on the road to effective prevention, detection, and management of cardiovascular disease in low-and middle-income countries (LMICs) and develop strategies for overcoming these. This Roadmap focuses on atrial fibrillation (AF). AF is the most common, clinically significant arrhythmia and, among other clinical outcomes, is associated with increased risk of stroke. METHODS: Development of this Roadmap included a review of published guidelines and research papers, and consultation with an expert committee comprising experts in clinical management of AF and health systems research in LMICs. The Roadmap identifies 1) key interventions for detection, diagnosis, and management of AF; 2) gaps in implementation of these interventions (knowledge-practice gaps); 3) health system roadblocks to implementation of AF interventions in LMICs; and 4) potential strategies for overcoming these. RESULTS: More research is needed on determinants and primary prevention of AF. Knowledge-practice gaps for detection, diagnosis, and management of AF are present worldwide, but may be more prominent in LMICs. Potential barriers to implementation of AF interventions include long distances to health facilities, shortage of health care professionals with training in AF, including interpretation of ECG, unaffordability of oral anticoagulants for patient households, reluctance on the part of physicians to initiate oral anticoagulant (OAC) therapy, and lack of awareness of the importance of persistent adherence to OAC therapy. Potential solutions include training of nonphysician health workers and pharmacists in pulse-taking, use of telemedicine technologies to transmit electrocardiogram results, engagement of nonphysician health workers in OAC therapy adherence support, and country-specific support and education programs for noncardiologist health care professionals. CONCLUSIONS: AF affects millions of people worldwide and, left untreated, increases the risk and severity of stroke and heart failure. Although guidelines for the detection, diagnosis, and management of AF exist, there are gaps in implementation of these guidelines globally, and in particular in LMICs. This Roadmap identifies some potential solutions that may improve AF outcomes in LMICs but require further evaluation in these settings.

[Psychopathology and personality in patients with vasovagal syncope]. / Estudio descriptivo de la personalidad y psicopatología en pacientes con síncope vasovagal.

UNLABELLED: Syncope is characterized by a sudden and brief Loss of the normal state of consciousness (fainting), caused by multiple factors (biological, psychological and social), which consequences can be Lethal if it is not timely diagnosed and treated. These episodes affect the total sphere of the subject (on an individual, work, school, social, and family level). PURPOSE OF THE STUDY: Contribute to the study of vasovagal syncope (WS) patients, describing their personality and psychopathological characteristics. METHOD: Minnesota Multiphasic Personality Inventory (MMPI) was used to evaluate psychopathology in a sample of 30 subjects diagnosed with (WS), attended in the National Institute of Cardiology "lgnacio Chávez", making a descriptive analysis of the complete sample, regarding demographic variables and inventory scores. RESULTS: The scales with higher scores found within these subjects were hypochondriasis (= 67.43), depression (= 69.83), hysteria (= 67.83) among others. CONCLUSIONS: In general, patients with (WS) show significant levels of anxiety and depression, dissatisfaction, bad mood, pessimism, concern, somatic complaints, difficulty to solve problems adaptively, among others. This study remarks the importance of knowing these characteristics to implement treatments that manage this disease properly and may improve patients quality of life, as well as their physical and mental health.

Estudio descriptivo de la personalidad y psicopatología en pacientes con síncope vasovagal / Psychopathology and personality in patients with vasovagal syncope

Syncope is characterized by a sudden and brief Loss of the normal state of consciousness (fainting), caused by multiple factors (biological, psychological and social), which consequences can be Lethal if it is not timely diagnosed and treated. These episodes affect the total sphere of the subject (on an individual, work, school, social, and family level). PURPOSE OF THE STUDY: Contribute to the study of vasovagal syncope (WS) patients, describing their personality and psychopathological characteristics. METHOD: Minnesota Multiphasic Personality Inventory (MMPI) was used to evaluate psychopathology in a sample of 30 subjects diagnosed with (WS), attended in the National Institute of Cardiology "lgnacio Chávez", making a descriptive analysis of the complete sample, regarding demographic variables and inventory scores. RESULTS: The scales with higher scores found within these subjects were hypochondriasis (= 67.43), depression (= 69.83), hysteria (= 67.83) among others. CONCLUSIONS: In general, patients with (WS) show significant levels of anxiety and depression, dissatisfaction, bad mood, pessimism, concern, somatic complaints, difficulty to solve problems adaptively, among others. This study remarks the importance of knowing these characteristics to implement treatments that manage this disease properly and may improve patients quality of life, as well as their physical and mental health.

[Vasovagal syncope: from genetic to bedside]. / Avances en síncope vasovagal: de la genética a la clínica.

Recent studies suggest vasovagal syncope has a significant heritable component indicating that, at least some forms of vasovagal syncope may have a genetic cause. The beta1-adrenergic receptor is a key cell surface signaling protein expressed in the heart and major determinant of cardiac function. The role of genetics in the phenotypic manifestations of vasovagal syncope is unclear. Here, we report the characteristics of several families with several affected members with vasovagal syncope, as well as the results of several genetic studies exploring the prevalence of polymorphisms in the beta1 adrenergic receptors which may be associated with vasovagal syncope.

Avances en síncope vasovagal: de la genética a la clínica / Vasovagal syncope: from genetic to bedside

Recent studies suggest vasovagal syncope has a significant heritable component indicating that, at least some forms of vasovagal syncope may have a genetic cause. The beta1-adrenergic receptor is a key cell surface signaling protein expressed in the heart and major determinant of cardiac function. The role of genetics in the phenotypic manifestations of vasovagal syncope is unclear. Here, we report the characteristics of several families with several affected members with vasovagal syncope, as well as the results of several genetic studies exploring the prevalence of polymorphisms in the beta1 adrenergic receptors which may be associated with vasovagal syncope.

[Permanent cardiac pacing in vasovagal syncope: when and which?]. / Marcapasos en síncope vasovagal: Cudádo y cuáles?

Vasovagal syncope is a common clinical problem forming the pathophysiological basis of half the cases of syncope. Although it usually has a favourable prognosis, it may be a highly limiting clinical problem in a particular subset of patients among whom syncopal recurrences are frequent and without prodromic symptoms, or have a traumatic outcome. For this subgroup of patients the term "malignant vasovagal syncope" has been proposed. The treatment of these highly symptomatic patients is necessary to avoid dangerous injuries and to improve the quality of life. Pacemaker therapy has been advocated as a potential therapy in severe or drug refractory cases. This paper reviews the concepts behind pacemaker therapy for vasovagal syncope and the results of various clinical trials that have evaluated its potential utility as a primary therapeutic modality.

Marcapasos en síncope vasovagal: Cudádo y cuáles? / Permanent cardiac pacing in vasovagal syncope: when and which?

Vasovagal syncope is a common clinical problem forming the pathophysiological basis of half the cases of syncope. Although it usually has a favourable prognosis, it may be a highly limiting clinical problem in a particular subset of patients among whom syncopal recurrences are frequent and without prodromic symptoms, or have a traumatic outcome. For this subgroup of patients the term [quot ]malignant vasovagal syncope[quot ] has been proposed. The treatment of these highly symptomatic patients is necessary to avoid dangerous injuries and to improve the quality of life. Pacemaker therapy has been advocated as a potential therapy in severe or drug refractory cases. This paper reviews the concepts behind pacemaker therapy for vasovagal syncope and the results of various clinical trials that have evaluated its potential utility as a primary therapeutic modality.

[Challenges and opportunities for the control of ventricular arrhythmia]. / Retos y oportunidades para el control de las arritmias ventriculares.

Sudden cardiac death continues to be a significant health care problem. Patients with prior myocardial infarction, severe left ventricular dysfunction, and nonsustained ventricular tachycardia are at high risk for sudden death. Identification of patients prone to sudden cardiac death is still unresolved, although a number of strategies have been applied over the past two decades based on the degree of left ventricular dysfunction, frequency of spontaneous ventricular arrhythmias, and ventricular late potentials. It has been recognized that patients with myocardial infarction and depressed left ventricular function have enhanced sympathetic relative to vagal tone controlling cardiac rhythm and rate. This can be measured as depressed heart rate variability and baroreflex sensitivity. Other markers of risk have been explored, QT dispersion, post-extrasystolic heart rate turbulence and T wave alternans. Development of the automatic ICD has been one of the most spectacular achievements of the last 20 years in cardiology. The ICD reduces sudden death in postmyocardial infarction patients. Nevertheless, a clearer delineation is needed of the subsets of patients in whom an optimal medical regimen might be the best option for preventing sudden death.

[ Segmental ostial ablation to interrupt electrical conduction in a single pulmonary vein for the prevention of idiopathic paroxysmal atrial fibrillation]. / Ablación segmentaria del ostium de la vena pulmonar superior izquierda para eliminar actividad eléctrica anormal generadora de fibrilación atrial paroxística idiopática.

Several studies have shown the role of focal trigers in the pulmonary veins initiating episodes of atrial fibrillation. Radiofrequency catheter ablation of this foci is a curative therapy for paroxysmal atrial fibrillation. We report a case of idiopathic paroxysmal atrial fibrillation triggered by abnormal electrical activity in a single pulmonary vein. Mapping was performed during sinus rhythm with a 4F decapolar catheter (Spiral Supreme, Daig, St. Jude Medical) positioned near the ostium by a transseptal approach. Pulmonary vein potentials were only identified in the left superior pulmonary vein. Segmental ostial ablation (30 W) performed during left atrial pacing resulted in complete cesation of conduction in the pulmonary vein. There were no complications. The clinical response (suppression of the paroxysms of atrial fibrillation in a 9-month follow-up) observed in this patient imply that atrial fibrillation was triggered by this pulmonary vein. This case report illustrates several aspects of catheter-based ablation of pulmonary vein foci for the treatment of paroxysmal atrial fibrillation and demonstrates its efficacy.