Incidence and prediction of hospitalization for heart failure in patients with atrial fibrillation: the REFLEJA scale.

INTRODUCTION AND OBJECTIVES: Hospitalization for heart failure (HHF) is common in patients with atrial fibrillation (AF) and is associated with increased mortality. The aims of this study were to determine the incidence of HHF, identify the clinical predictors of its occurrence, and develop a new risk scale. METHODS: The incidence of HHF was estimated using data from the prospective single-center REFLEJA registry of outpatients with AF (October 2017-October 2018). A multivariate Cox regression model was calculated to detect HHF predictors, and a nomogram was created for individual risk assessment. RESULTS: Of the 1499 patients included (mean age 73.8±11.1 years, 48.1% women), 127 had HHF (incidence rate of 8.51 per 100 persons/y) and 319 died (rate of death from any cause of 21.1 per 100 persons/y) after a 3-year follow-up. The independent predictors of HHF were age, diabetes, chronic kidney disease, pulmonary hypertension, previous pacemaker implantation, baseline use of diuretics, and moderate-severe aortic regurgitation. The c-statistic for predicting the event was 0.762 (95%CI after boostrapping resampling, 0.753-0.791). The cumulative incidences of the main outcome for the risk scale quartiles were 1.613 (Q1), 3.815 (Q2), 8.378 (Q3), and 20.436 (Q4) cases per 100 persons/y (P <.001). CONCLUSIONS: HHF was common in this AF cohort. The combination of certain clinical characteristics can identify patients with a very high risk of HHF.

Everolimus drug-eluting stent performance in patients with long coronary lesions: The multicenter Longprime registry.

OBJECTIVES: To assess the efficacy and safety of the Xience Prime everolimus-eluting stent (EES) in long coronary lesions in a real-world population. BACKGROUND: Long lesions are considered difficult technically and in terms of achieving successful clinical outcomes. With first generation DES, MACE can be as high as 10% at a short-medium term follow-up. There are a few data available in this subset regarding the use of second generation DES METHODS: A prospective, multicenter registry of consecutive patients (aged 64.8 ± 11.2 years, 77% men and 33% diabetics) in 29 tertiary hospitals with de novo > 24 mm lesions in vessels of 2.25-4 mm was performed. The primary and secondary endpoints were major adverse cardiac events (MACE; cardiac death, myocardial infarction, and target lesion revascularization) and stent thrombosis (ST) at 1, 12, and 24 months. Patients were on dual antiplatelet therapy during 12 months. RESULTS: A total of 610 patients with 705 long lesions were included (1.2 per patient). Lesion length was 34.59 ± 11.17 mm and vessel size 2.93 ± 0.41 mm. Stented length was 39.83 ± 14.08 mm (1.4 stents per lesion). Predilatation/postdiltatation was performed in 75 and 33% of the cases, intravascular ultrasound in 15%. The device success rate was 99.1%. MACE and ST rates at 1, 12, and 24-months follow-up were 0.3, 2.1, and 5.4% and 0.2, 0.7, and 1.5%, respectively. CONCLUSION: In this real-world population, the Xience Prime EES performs extremely well in long lesions, with a very low rate of both MACE and ST.

Bleeding Risk of Antithrombotic Treatment in Patients on Hemodialysis.

BACKGROUND: The risk-benefit of antithrombotic treatment (ATT) has not been established in patients on dialysis. Our objective was to determine the influence of ATT on the risk of hemorrhage in patients on hemodialysis. METHODS: We included patients who began dialysis between 2003 and 2007. We determined the rates of fatal bleeding or bleeding leading to hospitalization or transfusion. RESULTS: Two hundred twenty-one patients were included. Over the follow-up period (45.5 ± 34 months), there were 76 hemorrhages in 52 patients. There were 10 fatal bleedings. The annual incidence of patients presenting with hemorrhagia was 6.2%. Bleeding occurred in 5.2% of those being treated with aspirin, 7% with acenocumarol, 12.3% with clopidogrel, 15.2% with aspirin + clopidogrel, 45.9% with anticoagulants + antiplatelets, 49.6% with low-molecular-weight heparin, and 3.9% without ATT. On multivariate analysis, masculine gender [hazard ratio (HR): 2.421; 95% confidence interval (CI), 1.261-4.650; P = 0.003], treatment with dicumarins (HR: 2.406; 95% CI, 1.013-5.718; P = 0.047), treatment with clopidogrel (HR: 2.697; 95% CI, 1.440-5.051; P = 0.002), and treatment with low-molecular-weight heparin (HR: 21.463; 95% CI, 9.067-50.806; P = 0.001) were independent predictors of bleeding. CONCLUSIONS: ATT increases the risk of bleeding in patients on hemodialysis. The incidence of hemorrhage varies with the type of antithrombotics used.

Resolution of left ventricular thrombus by rivaroxaban.

Intracardiac thrombus is a potentially life-threatening condition, with a high risk of embolic complications. Although vitamin K antagonists have been traditionally used for the treatment of intracardiac thrombus, they have relevant disadvantages that limit their use. Rivaroxaban is a once daily oral anticoagulant, currently indicated for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the prevention and treatment of venous thromboembolism. We present the case of a 78-year-old man with nonvalvular atrial fibrillation, heart failure and creatinine clearance of 40 ml/min, anticoagulated with rivaroxaban 15 mg/day as the patient had very difficult access to hematologic controls. The transthoracic echocardiogram showed dilated left ventricle, severe left ventricular dysfunction and two images of thrombus, which disappeared after 4 weeks of treatment with rivaroxaban. To our knowledge, this is the first case reported regarding the resolution of left ventricular thrombosis with rivaroxaban.

Sudden death in incident dialysis patients.

BACKGROUND: Sudden death (SD) constitutes one of the principal causes of death and is an important problem in healthcare provision. Cardiovascular diseases have a high prevalence in dialysis patients and constitute the principal cause of death. We sought to analyze retrospectively the incidence of SD in patients commencing dialysis and the factors related to its presence. METHODS: We evaluated all the patients who began dialysis in our center between 1/11/2003 and 15/9/2007, and who were followed up until death, transplant, or study completion on 31/12/2012. We determined the presence of SD according to the following criteria: SD at 24 h (SD 24H): unexpected death occurring in the 24 h following the start of symptoms, or when the patient was found dead and had been seen alive 24 h earlier; SD at 1 h (SD 1H): death witnessed as occurring in the first hour following the start of symptoms. RESULTS: We evaluated 285 patients, mean age 65.67 ± 15.7 years. In a follow-up of 39.9 ± 34.2 months (947.6 patient-years of follow-up) 168 died (59%), 28 (10%) patients presented SD 24H (2.9/100 patient-years), and 16 (6%) patients presented SD 1H (1.7/100 patient-years). In the multivariate analysis, having had a myocardial infarction or having had electrocardiographic abnormalities (Q wave, negative T wave, subendocardial lesion or QRS >120 ms) were the principal independent predictors of SD 24H (OR 7.83; 95% CI 2.20-27.86; p = 0.001) and of SD 1H (OR 13.43; 95% CI 1.56-115.42; p = 0.018). CONCLUSIONS: SD on dialysis is very frequent. Two groups can be identified easily, with risk profiles clearly differentiated.

In-hospital and 12-month postprocedural clinical outcome of coronary bifurcational lesion treatment with the endeavor stent.

BACKGROUND: The zotarolimus-eluting stent (ZES) has been documented as significantly reducing restenosis and target lesion revascularization (TLR) requirement compared to bare metal stents (BMS). METHODS: In this single-centered, prospective study we sought to evaluate the short- and medium-term outcomes of ZES placement in bifurcated coronary artery lesions. Between August 2006 and December 2007, 107 consecutive patients (110 bifurcations) were recruited to have ZES placement in the lesion. The provisional T stenting (PTS) technique was used in 96.3%. Angiographic success was 100% in main vessel (MV) cases and 97.2% in that of side branch (SB). RESULTS: With a mean follow-up of 12.4 +/- 1.77 (mean +/- SD) months there were four deaths, three from cardiac cause (2.85%). There were 18 patients (19 bifurcations) requiring TLR (17.59%) for clinical reasons. The only predictor of TLR was the use diameter of ZES

Cardiogenic shock in acute coronary syndrome in the Spanish population.

BACKGROUND: To evaluate the frequency and factors associated with cardiogenic shock (CS) in acute myocardial infarction (AMI) and unstable angina (UA) and percutaneous coronary intervention (PCI). MATERIAL/METHODS: Spanish registry. The study period was June 1996 to December 2005. Follow-up was length of stay in an intensive care or coronary care unit (ICU/CCU). Multivariate studies evaluated factors associated with CS, mortality in CS, and PCI performance. RESULTS: The study included 45.688 AMI patients and 17.277 UA patients. Cardiogenic shock occurred in 9.3% of patients with AMI and 1.79% of those with UA, frequencies that decreased over time. Variables associated with cardiogenic shock in AMI patients were female sex, age, type of infarction, diabetes, previous stroke, arrhythmia, previous angiography, complicated angina, and reinfarction. Hypertension and oral beta-blocking, ACE inhibitor, and hypolipidemic agents protected against CS. In UA, these variables were age, previous angina or AMI, right ventricular heart failure, arrhythmia. Beta-blocking agents were associated with a reduction in CS. Deaths from CS and AMI, respectively, were 62.8% and 38.7% in persons with UA. Doing PCIs has increased significantly; it is more prevalent in ex-smokers and those with right ventricular heart failure and mechanical ventilation; lower performance is associated with need for cardiopulmonary resuscitation; patients who die are older or have a history of AMI. CONCLUSIONS: There has been a slight drop in the frequency of CS and its mortality. Factors associated with CS are similar to those associated with acute coronary syndromes. The frequency of PCI was low.

Giant right atrial thrombi treated with thrombolysis.

The present report describes giant atrial thrombi that were treated with thrombolysis in a community hospital. Two patients with giant atrial thrombi whose treatment involved complications are presented. Both patients developed cardiogenic shock and were treated unsuccessfully with thrombolysis. Because thrombolysis of giant thrombi may be ineffective, patients in this situation may require surgery.