Effects and mechanisms of mindfulness training and physical exercise on cognition, emotional wellbeing, and brain outcomes in chronic stroke patients: Study protocol of the MindFit project randomized controlled trial.

Background: Post-stroke cognitive and emotional complications are frequent in the chronic stages of stroke and have important implications for the functionality and quality of life of those affected and their caregivers. Strategies such as mindfulness meditation, physical exercise (PE), or computerized cognitive training (CCT) may benefit stroke patients by impacting neuroplasticity and brain health. Materials and methods: One hundred and forty-one chronic stroke patients are randomly allocated to receive mindfulness-based stress reduction + CCT (n = 47), multicomponent PE program + CCT (n = 47), or CCT alone (n = 47). Interventions consist of 12-week home-based programs five days per week. Before and after the interventions, we collect data from cognitive, psychological, and physical tests, blood and stool samples, and structural and functional brain scans. Results: The effects of the interventions on cognitive and emotional outcomes will be described in intention-to-treat and per-protocol analyses. We will also explore potential mediators and moderators, such as genetic, molecular, brain, demographic, and clinical factors in our per-protocol sample. Discussion: The MindFit Project is a randomized clinical trial that aims to assess the impact of mindfulness and PE combined with CCT on chronic stroke patients' cognitive and emotional wellbeing. Furthermore, our design takes a multimodal biopsychosocial approach that will generate new knowledge at multiple levels of evidence, from molecular bases to behavioral changes. Clinical trial registration: www.ClinicalTrials.gov, identifier NCT04759950.

Cause of Death in Heart Failure Based on Etiology: Long-Term Cohort Study of All-Cause and Cardiovascular Mortality.

We assessed differences in long-term all-cause and cardiovascular (CV) mortality in heart failure (HF) outpatients based on the etiology of HF. Consecutive patients admitted to the HF Clinic from August 2001 to September 2019 (N = 2587) were considered for inclusion. HF etiology was divided into ischemic heart disease (IHD), dilated cardiomyopathy (DCM), hypertensive heart disease, alcoholic cardiomyopathy, drug-induced cardiomyopathy (DICM), valvular heart disease, and hypertrophic cardiomyopathy. All-cause death and CV death were the primary end points. Among 2387 patients included in the analysis (mean age 66.5 ± 12.5 years, 71.3% men), 1317 deaths were recorded (731 from CV cause) over a maximum follow-up of 18 years (median 4.1 years, interquartile range (IQR) 2-7.8). Considering IHD as the reference, only DCM had a lower risk of all-cause death (adjusted hazard ratio (aHR) 0.68, 95% confidence interval (CI) 0.56-0.83, p < 0.001), and only DICM had a higher risk of all-cause death (aHR 1.47, 95% CI 1.02-2.11, p = 0.04). However, almost all etiologies had a significantly lower risk of CV death than IHD. Among the studied HF etiologies, DCM and DICM have the lowest and highest risk of all-cause death, respectively, whereas IHD has the highest adjusted risk of CV death.

Head-to-head comparison of contemporary heart failure risk scores.

AIMS: Several heart failure (HF) web-based risk scores are currently used in clinical practice. Currently, we lack head-to-head comparison of the accuracy of risk scores. This study aimed to assess correlation and mortality prediction performance of Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC-HF) risk score, which includes clinical variables + medications; Seattle Heart Failure Model (SHFM), which includes clinical variables + treatments + analytes; PARADIGM Risk of Events and Death in the Contemporary Treatment of Heart Failure (PREDICT-HF) and Barcelona Bio-Heart Failure (BCN-Bio-HF) risk calculator, which also include biomarkers, like N-terminal pro B-type natriuretic peptide (NT-proBNP). METHODS AND RESULTS: A total of 1166 consecutive patients with HF from different aetiologies that had NT-proBNP measurement at first visit were included. Discrimination for all-cause mortality was compared by Harrell's C-statistic from 1 to 5 years, when possible. Calibration was assessed by calibration plots and Hosmer-Lemeshow test and global performance by Nagelkerke's R2 . Correlation between scores was assessed by Spearman rank test. Correlation between the scores was relatively poor (rho value from 0.66 to 0.79). Discrimination analyses showed better results for 1-year mortality than for longer follow-up (SHFM 0.817, MAGGIC-HF 0.801, PREDICT-HF 0.799, BCN-Bio-HF 0.830). MAGGIC-HF showed the best calibration, BCN-Bio-HF overestimated risk while SHFM and PREDICT-HF underestimated it. BCN-Bio-HF provided the best discrimination and overall performance at every time-point. CONCLUSIONS: None of the contemporary risk scores examined showed a clear superiority over the rest. BCN-Bio-HF calculator provided the best discrimination and overall performance with overestimation of risk. MAGGIC-HF showed the best calibration, and SHFM and PREDICT-HF tended to underestimate risk. Regular updating and recalibration of online web calculators seems necessary to improve their accuracy as HF management evolves at unprecedented pace.

Mortality trends in an ambulatory multidisciplinary heart failure unit from 2001 to 2018.

To assess mortality trends at 1 and 3 years from 2001 to 2018 in a real-life cohort of HF outpatients from different etiologies with depressed and preserved LVEF. A total of 2368 consecutive patients with HF (mean age 66.4 ± 12.9 years, 71% men, 15.4% with preserved LVEF) admitted to a HF clinic from August 2001 to September 2018 were included in the study. Patients were divided into five quintiles (Q) according to the period of admission. Trends for all-cause and cardiovascular mortality from Q1 to Q5 were assessed by linear regression. Patients with LVEF < 50% had a progressive decrease in the rates of all-cause and cardiovascular death at 1 year (12.1% in Q1 to 6.5% in Q5, p = 0.003; and 8.4% in Q1 to 3.8% in Q5, p = 0.007, respectively) and 3 years (30.5% in Q1 to 17.0% in Q5, p = 0.003; and 23.9% in Q1 to 9.8% in Q5, p = 0.003, respectively). These trends remained significant after adjusting for clinical characteristics and risk. No significant trend in mortality was observed in patients with LVEF ≥ 50%. In a cohort of real-life ambulatory patients with HF, mortality progressively declined in patients with LVEF < 50%, but the same trend was not observed in patients with preserved LVEF.

[HOSPITALS AS PROMOTERS OF SMOKELESS SPACES: STRATEGIES AIMED AT SMOKING CONTROL] / El hospital como centro promotor de espacios sin humo: estrategias dirigidas al control del tabaquismo.

The objective of this study was to describe the measures introduced at the Hospital Germans Trias i Pujol, Barcelona, aimed at achieving a smoke-free environment, and encouraging research, training, and clinical approaches with respect to smoking. The experience gained as a center attached to the Catalan Network of Smokeless Hospitals since 2002 shows that preventing and controlling smoking requires a specific agenda developed by a competent committee comprising workers from all hospital areas. Likewise, coordination with other centers in the network is essential as it permits the sharing of experiences. The involvement of hospital management is critical for the effective introduction of health protection and promotion strategies, both in workers and in users. The raising of awareness and the ongoing training of all health workers and coordination with other health care providers in the Health network are the main aspects that require strengthening in the future.

El objetivo de este trabajo fue describir las medidas llevadas a cabo en el Hospital Germans Trias i Pujol de Barcelona, destinadas a conseguir un entorno libre de humo, así como al desarrollo de actividades de investigación, formación y abordaje clínico en relación al tabaquismo. La experiencia como centro adherido a la Red Catalana de Hospitales Sin Humo desde 2002 nos revela que para la prevención y control del tabaquismo es necesaria una agenda específica desarrollada por un Comité competente, compuesto por trabajadores de diferentes estamentos y servicios del centro. Del mismo modo, consideramos fundamental la coordinación con otros centros de la Red que permita compartir experiencias, así como la implicación de la Dirección del Centro para la implementación efectiva de las estrategias de promoción y protección de la salud, tanto en los trabajadores como en los usuarios. La sensibilización y formación continuada de todo el personal sanitario y la coordinación con otros servicios proveedores de salud de la red sanitaria se perfilan como los principales puntos a reforzar en el futuro.

El hospital como centro promotor de espacios sin humo: estrategias dirigidas al control del tabaquismo / Hospitals as promoters of smokeless spaces: strategies aimed at smoking control

El objetivo de este trabajo fue describir las medidas llevadas a cabo en el Hospital Germans Trias I Pujol de Barcelona, destinadas a conseguir un entorno libre de humo, así como al desarrollo de actividades de investigación, formación y abordaje clínico en relación al tabaquismo. La experiencia como centro adherido a la Red Catalana de Hospitales Sin Humo desde 2002 nos revela que para la prevención y control del tabaquismo es necesaria una agenda específica desarrollada por un Comité competente, compuesto por trabajadores de diferentes estamentos y servicios del centro. Del mismo modo, consideramos fundamental la coordinación con otros centros de la Red que permita compartir experiencias, así como la implicación de la Dirección del Centro para la implementación efectiva de las estrategias de promoción y protección de la salud, tanto en los trabajadores como en los usuarios. La sensibilización y formación continuada de todo el personal sanitario y la coordinación con otros servicios proveedores de salud de la red sanitaria se perfilan como los principales puntos a reforzar en el futuro

The objective of this study was to describe the measures introduced at the Hospital Germans Trias I Pujol, Barcelona, aimed at achieving a smoke-free environment, and encouraging research, training, and clinical approaches with respect to smoking. The experience gained as a center attached to the Catalan Network of Smokeless Hospitals since 2002 shows that preventing and controlling smoking requires a specific agenda developed by a competent committee comprising workers from all hospital areas. Likewise, coordination with other centers in the network is essential as it permits the sharing of experiences. The involvement of hospital management is critical for the effective introduction of health protection and promotion strategies, both in workers and in users. The raising of awareness and the ongoing training of all health workers and coordination with other health care providers in the health network are the main aspects that require strengthening in the future

Trends in modes of death in heart failure over the last two decades: less sudden death but cancer deaths on the rise.

AIMS: Better management of heart failure (HF) over the past two decades has improved survival, mainly by reducing the incidence of death due to cardiovascular (CV) causes. Deaths due to non-CV causes, particularly cancer, may be increasing. This study explored the modes of death of consecutive patients who attended a HF clinic over 17 years. METHODS AND RESULTS: A total of 935 deaths were ascertained from 2002 to 2018 among 1876 patients (mean age 65.8 ± 12.5 years, 75% men, left ventricular ejection fraction < 50%) admitted to our HF clinic. Median follow-up was 4.2 years [1.9-7.8]. Mode of death was curated from patient health records and verified by the Catalan and Spanish health system databases. Trends for every mode of death were assessed by polynomial regression. Two trends were observed: a significant reduction in sudden death (P = 0.03) without changes in HF progression as mode of death (P = 0.26), and a significant increase in non-CV modes of death (P < 0.001). Non-CV deaths accounted for 17.4% of deaths in 2002 and 65.8% of deaths in 2018. A total 138 deaths were due to cancer (37% of non-CV deaths). A significant trend was observed towards a progressive increase in cancer deaths over time (P = 0.002). The main mode of cancer mortality was lung cancer. CONCLUSIONS: The modes of death in HF have shifted over the last two decades. Patients with HF die less due to sudden death and more due to non-CV causes, mainly cancer. Whether HF triggers cancer, or cancer develops in HF survivors, deserves further insight.

A bio-clinical approach for prediction of sudden cardiac death in outpatients with heart failure: The ST2-SCD score.

BACKGROUND: Sudden cardiac death (SCD) is one of the main modes of death in heart failure (HF) patients and its prediction remains a real challenge. Our aim was to assess the incidence of SCD at 5 years HF contemporary managed outpatients, and to find a simple prediction model for SCD. METHODS: SCD was considered any unexpected death, witnessed or not, occurring in a previously stable patient with no evidence of worsening HF or any other cause of death. A competing risk strategy was adopted using the Fine-Gray method of Cox regressions analyses that considered other causes of death as the competing event. RESULTS: The derivation cohort included 744 consecutive outpatients (72% men, age 67.9 ±â€¯12.2 years, left ventricular ejection fraction [LVEF] 36% ±â€¯14). During follow-up, 312 deaths occurred, 40 SCDs (5.4%). Age, haemoglobin, eGFR, HF duration, high-sensitivity troponin T, NTproBNP, and ST2 were associated with SCD in univariate analyses; HF duration (p = 0.006), eGFR (p < 0.001), LVEF <45% (p = 0.03), and ST2 (p = 0.006) remained in multivariable analysis. A predictive score (ST2-SCD) including dichotomous variables (ST2 > 45, LVEF <45%, HF duration >3 years, eGFR < 55, age ≥ 60 years and male sex) provided a Harrell's C-statistic of 0.82 (0.76-0.89)), reaching 0.87 (0.80-0.95) in the validation cohort (n = 149). CONCLUSIONS: In contemporary managed HF, SCD occurred in 5.4% of outpatients, accounting for 12.8% of all deaths at 5 years. Of the 3 studied biomarkers, only ST2 remained independently associated with SCD. A model containing age, sex, ST2, eGFR, LVEF, and HF duration reasonably predicted 5-years risk of SCD.

Cinética de la hemoglobina y pronóstico a largo plazo en insuficiencia cardiaca / Hemoglobin kinetics and long-term prognosis in heart failure

Introducción y objetivos: La influencia de la cinética de la hemoglobina en la insuficiencia cardiaca no se ha establecido por completo. Métodos: Se determinó la hemoglobina en la primera visita y a los 6 meses. La anemia se definió según los criterios de la Organización Mundial de la Salud (hemoglobina < 13 g/dl los varones y < 12 g/dl las mujeres). Según los valores de hemoglobina, se estableció una clasificación de los pacientes como sin anemia (ambas determinaciones normales), con anemia transitoria (anemia en la primera visita, pero no a los 6 meses), con anemia de nueva aparición (inicialmente sin anemia, pero con anemia a los 6 meses) o con anemia permanente (anemia en ambas determinaciones). Resultados: Se incluyó en el estudio a 1.173 pacientes consecutivos (el 71,9% varones; media de edad, 66,8 ± 12,2 años). Se consideró sin anemia a 476 pacientes (40,6%), con anemia transitoria a 170 (14,5%), con anemia de nueva aparición a 147 (12,5%) y con anemia persistente a 380 (32,4%). Durante un seguimiento de 3,7 ± 2,8 años después de la visita realizada a los 6 meses, fallecieron 494 pacientes. En los análisis multivariables generales, la anemia (p < 0,001) y el tipo de anemia (p < 0,001) continuaron siendo factores independientes predictivos de mortalidad por cualquier causa. En comparación con los pacientes sin anemia, aquellos con anemia persistente (hazard ratio [HR] = 1,62; intervalo de confianza del 95% [IC95%], 1,30-2,03; p < 0,001) o con anemia de nueva aparición (HR = 1,39; IC95%, 1,04-1,87; p = 0,03) presentaron más mortalidad, e incluso los pacientes con anemia transitoria mostraron una tendencia similar, aunque sin alcanzar significación estadística (HR = 1,31; IC95%, 0,97-1,77; p = 0,075). Conclusiones: La anemia —en especial la persistente y la de nueva aparición y, en menor medida, la anemia transitoria— tiene efectos nocivos en la insuficiencia cardiaca (AU)

Introduction and objectives: The influence of hemoglobin kinetics on outcomes in heart failure has been incompletely established. Methods: Hemoglobin was determined at the first visit and at 6 months. Anemia was defined according to World Health Organization criteria (hemoglobin < 13 g/dL for men and hemoglobin < 12 g/dL for women). Patients were classified relative to their hemoglobin values as nonanemic (both measurements normal), transiently anemic (anemic at the first visit but not at 6 months), newly anemic (nonanemic initially but anemic at 6 months), or permanently anemic (anemic in both measurements). Results: A total of 1173 consecutive patients (71.9% men, mean age 66.8 ± 12.2 years) were included in the study. In all, 476 patients (40.6%) were considered nonanemic, 170 (14.5%) had transient anemia, 147 (12.5%) developed new-onset anemia, and 380 (32.4%) were persistently anemic. During a follow-up of 3.7 ± 2.8 years after the 6-month visit, 494 patients died. On comprehensive multivariable analyses, anemia (P < .001) and the type of anemia (P< .001) remained as independent predictors of all-cause mortality. Compared with patients without anemia, patients with persistent anemia (hazard ratio [HR] = 1.62; 95% confidence interval [95%CI], 1.30-2.03; P < .001) and new-onset anemia (HR = 1.39; 95%CI, 1.04-1.87, P= .03) had higher mortality, and even transient anemia showed a similar trend, although without reaching statistical significance (HR = 1.31; 95%CI, 0.97-1.77, P = .075). Conclusions: Anemia, especially persistent and of new-onset, and to a lesser degree, transient anemia, is deleterious in heart failure (AU)

Hemoglobin Kinetics and Long-term Prognosis in Heart Failure.

INTRODUCTION AND OBJECTIVES: The influence of hemoglobin kinetics on outcomes in heart failure has been incompletely established. METHODS: Hemoglobin was determined at the first visit and at 6 months. Anemia was defined according to World Health Organization criteria (hemoglobin < 13g/dL for men and hemoglobin < 12g/dL for women). Patients were classified relative to their hemoglobin values as nonanemic (both measurements normal), transiently anemic (anemic at the first visit but not at 6 months), newly anemic (nonanemic initially but anemic at 6 months), or permanently anemic (anemic in both measurements). RESULTS: A total of 1173 consecutive patients (71.9% men, mean age 66.8±12.2 years) were included in the study. In all, 476 patients (40.6%) were considered nonanemic, 170 (14.5%) had transient anemia, 147 (12.5%) developed new-onset anemia, and 380 (32.4%) were persistently anemic. During a follow-up of 3.7±2.8 years after the 6-month visit, 494 patients died. On comprehensive multivariable analyses, anemia (P < .001) and the type of anemia (P < .001) remained as independent predictors of all-cause mortality. Compared with patients without anemia, patients with persistent anemia (hazard ratio [HR] = 1.62; 95% confidence interval [95%CI], 1.30-2.03; P < .001) and new-onset anemia (HR = 1.39; 95%CI, 1.04-1.87, P = .03) had higher mortality, and even transient anemia showed a similar trend, although without reaching statistical significance (HR = 1.31; 95%CI, 0.97-1.77, P = .075). CONCLUSIONS: Anemia, especially persistent and of new-onset, and to a lesser degree, transient anemia, is deleterious in heart failure.