Impact of Advanced Age on the Incidence of Major Adverse Cardiovascular Events in Patients with Type 2 Diabetes Mellitus and Stable Coronary Artery Disease in a Real-World Setting in Spain.

Patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) without myocardial infarction (MI) or stroke are at high risk for major cardiovascular events (MACEs). We aimed to provide real-world data on age-related clinical characteristics, treatment management, and incidence of major cardiovascular outcomes in T2DM-CAD patients in Spain from 2014 to 2018. We used EHRead® technology, which is based on natural language processing and machine learning, to extract unstructured clinical information from electronic health records (EHRs) from 12 hospitals. Of the 4072 included patients, 30.9% were younger than 65 years (66.3% male), 34.2% were aged 65-75 years (66.4% male), and 34.8% were older than 75 years (54.3% male). These older patients were more likely to have hypertension (OR 2.85), angina (OR 1.64), heart valve disease (OR 2.13), or peripheral vascular disease (OR 2.38) than those aged <65 years (p < 0.001 for all comparisons). In general, they were also more likely to receive pharmacological and interventional treatments. Moreover, these patients had a significantly higher risk of MACEs (HR 1.29; p = 0.003) and ischemic stroke (HR 2.39; p < 0.001). In summary, patients with T2DM-CAD in routine clinical practice tend to be older, have more comorbidities, are more heavily treated, and have a higher risk of developing MACE than is commonly assumed from clinical trial data.

Major Adverse Cardiovascular Events in Coronary Type 2 Diabetic Patients: Identification of Associated Factors Using Electronic Health Records and Natural Language Processing.

Patients with Type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) are at high risk of developing major adverse cardiovascular events (MACE). This is a multicenter, retrospective, and observational study performed in Spain aimed to characterize these patients in a real-world setting. Unstructured data from the Electronic Health Records were extracted by EHRead®, a technology based on Natural Language Processing and machine learning. The association between new MACE and the variables of interest were investigated by univariable and multivariable analyses. From a source population of 2,184,662 patients, we identified 4072 adults diagnosed with T2DM and CAD (62.2% male, mean age 70 ± 11). The main comorbidities observed included arterial hypertension, hyperlipidemia, and obesity, with metformin and statins being the treatments most frequently prescribed. MACE development was associated with multivessel (Hazard Ratio (HR) = 2.49) and single coronary vessel disease (HR = 1.71), transient ischemic attack (HR = 2.01), heart failure (HR = 1.32), insulin treatment (HR = 1.40), and percutaneous coronary intervention (PCI) (HR = 2.27), whilst statins (HR = 0.73) were associated with a lower risk of MACE occurrence. In conclusion, we found six risk factors associated with the development of MACE which were related with cardiovascular diseases and T2DM severity, and treatment with statins was identified as a protective factor for new MACE in this study.

Tratamiento antitrombótico en pacientes con fibrilación auricular tras intervención coronaria percutánea, un equilibrio difícil de conseguir / Antithrombotic treatment in patients with atrial fibrillation after percutaneous coronary intervention, a difficult balance to achieve

La combinación de tratamiento antitrombótico anticoagulante/antiagregante) que deben llevar aquellos pacientes con FA que sufren un SCA y/o deben someterse a ICP no está claro. La asociación de anticoagulación oral con un inhibidor de P2Y12 y aspirina, lo que se denomina triple terapia antitrombótica (TAT) asocia un elevado riesgo de hemorragia. Por otro lado, la terapia antitrombótica dual (DAT) sin aspirina conlleva un riesgo todavía desconocido de eventos isquémicos.(1) El tratamiento debe equilibrar el riesgo isquémico y hemorrágico alcanzando un beneficio clínico neto óptimo. El objetivo de esta revisión es establecer unas pautas más claras de tratamiento en estos pacientes. Analizamos 2 estudios observacionales previos para sentar el punto de partida y 5 ECA que incluían un total de 11532 pacientes. En ellos se comparó la DAT vs. TAT, en pacientes con FA que sufren un SCA y/o son sometidos a ICP.La DAT asoció menor tasa de sangrados frente a la TAT sin aumentar los eventos isquémicos. Sin embargo, ningún ensayo consiguió la suficiente potencia estadística para evaluar de forma consistente los resultados isquémicos de eficacia. De las distintas terapias, mostraron mejores resultados de eficacia aquellas que emplearon DAT frente a TAT y ACOD frente a AVK. Conclusión: En pacientes con FA que sufren un SCA y/o deben someterse a ICP, el régimen de DAT asocia menos eventos hemorrágicos, sin diferencias significativas en cuanto a eventos isquémicos; El uso de ACOD muestra un mejor perfil de beneficio frente a los AVK, por lo que son de preferencia.(AU)

The combination of antithrombotic treatment (anticoagulant / antiplatelet) that those who AF patients who have ACS and / or must undergo PCI is unclear. The association of oral anticoagulation with a P2Y 12 inhibitor and aspirin, called triple antithrombotic therapy (TAT) is associated with a high risk of bleeding. On the other hand, dual antithrombotic therapy (DAT) without Aspirin carries a still unknown risk of ischemic events.(1) Treatment must balance the ischemic and hemorrhagic risk reaching an optimal net clinical benefit. The purpose of this review is to establish clearer treatment guidelines in these patients. We analyzed 2 previous observational studies to establish the starting point and 5 RCTs that included a total of 11,532 patients. In them, DAT vs. TAT, in patients with AF who suffer from ACS and / or undergo PCI.DAT was associated with a lower rate of bleeding compared to TAT without increasing ischemic events. Without However, no trial achieved sufficient statistical power to consistently assess the ischemic efficacy results. Of the different therapies, they showed better efficacy results those that used DAT versus TAT and ACOD versus VKA. Conclusion: In patients with AF who suffer an ACS and / or must undergo PCI, the DAT regimen associates fewer bleeding events, without significant differences regarding ischemic events; The use of ACOD shows a better profile of benefit versus AVK, so they are preferred.(AU)

Assessment of medical management in Coronary Type 2 Diabetic patients with previous percutaneous coronary intervention in Spain: A retrospective analysis of electronic health records using Natural Language Processing.

INTRODUCTION AND OBJECTIVES: Patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) previously revascularized with percutaneous coronary intervention (PCI) are at high risk of recurrent ischemic events. We aimed to provide real-world insights into the clinical characteristics and management of this clinical population, excluding patients with a history of myocardial infarction (MI) or stroke, using Natural Language Processing (NLP) technology. METHODS: This is a multicenter, retrospective study based on the secondary use of 2014-2018 real-world data captured in the Electronic Health Records (EHRs) of 1,579 patients (0.72% of the T2D population analyzed; n = 217,632 patients) from 12 representative hospitals in Spain. To access the unstructured clinical information in EHRs, we used the EHRead® technology, based on NLP and machine learning. Major adverse cardiovascular events (MACE) were considered: MI, ischemic stroke, urgent coronary revascularization, and hospitalization due to unstable angina. The association between MACE rates and the variables included in this study was evaluated following univariate and multivariate approaches. RESULTS: Most patients were male (72.13%), with a mean age of 70.5±10 years. Regarding T2D, most patients were non-insulin-dependent T2D (61.75%) with high prevalence of comorbidities. The median (Q1-Q3) duration of follow-up was 1.2 (0.3-4.5) years. Overall, 35.66% of patients suffered from at least one MACE during follow up. Using a Cox Proportional Hazards regression model analysis, several independent factors were associated with MACE during follow up: CAD duration (p < 0.001), COPD/Asthma (p = 0.021), heart valve disease (p = 0.031), multivessel disease (p = 0.005), insulin treatment (p < 0.001), statins treatment (p < 0.001), and clopidogrel treatment (p = 0.039). CONCLUSIONS: Our results showed high rates of MACE in a large real-world series of PCI-revascularized patients with T2D and CAD with no history of MI or stroke. These data represent a potential opportunity to improve the clinical management of these patients.

Early aspirin desensitization in unstable patients with acute coronary syndrome: Short and long-term efficacy and safety.

BACKGROUND: Aspirin hypersensitivity is not a rare condition among patients with acute coronary syndrome. However, despite the publication of several successful desensitization protocols, the procedure is not as widespread as expected. We present a cohort of patients with acute coronary syndrome undergoing aspirin desensitization to evaluate its short- and long-term efficacy and safety and to reinforce data from previous studies. METHODS: Of 1306 patients admitted to our Coronary Care Unit between February 2011 and February 2013, 24 (1.8%) had a history of aspirin hypersensitivity. All 24 patients underwent an eight-dose aspirin desensitization protocol (0.1, 0.3, 1, 3, 10, 25, 50 and 100 mg of aspirin given by mouth every 15 minutes) after premedication with antihistamines and corticosteroids or antileucotrienes. Previously prescribed ß blockers and angiotensin-converting enzyme inhibitors were not discontinued. All patients were desensitized within 72 hours of admission. Those requiring urgent catheterization (five patients with ST segment elevation myocardial infarction) were desensitized within 12 hours of catheterization and the remainder before catheterization. RESULTS: All patients were successfully desensitized and only one presented with an urticarial reaction. The five patients with ST segment elevation myocardial infarction were treated with abciximab until desensitization was complete. All but one patient underwent catheterization and 20 underwent percutaneous coronary intervention, most (66%) with the implantation of a bare metal stent. At follow-up (a minimum of 6-24 months), only two patients had discontinued aspirin, both due to gastrointestinal bleeding, and no hypersensitivy reaction had occurred. CONCLUSIONS: Aspirin desensitization is effective and safe in unstable patients with acute coronary syndrome in both the short and long term.

[Influence of age in short and long term prognostic of ischemic cardiogenic shock]. / Influencia de la edad en el pronóstico a corto y largo plazo del choque cardiogénico de origen isquémico.

OBJECTIVE: To compare the prognosis during hospitalization and maximum follow-up of 4 years in patients with myocardial infarction complicated with cardiogenic shock. METHOD: Prospective observational study practiced in a coronary Care Unit managed by cardiologists. We included patients with myocardial infarction complicated with cardiogenic shock who received early coronary revascularization. Patients were divided into two groups: older than 75 years (group A) and lower (group B), and we compared the evolution during hospitalization and maximum follow-up of 4 years. Primary end point was mortality rate in the maximum follow-up of 4years. Secondary end point was mortality rate during hospitalization. RESULTS: Ninety-seven patients were included, 45% Group A. Patients of Group B were mostly men (81% vs. 57%; P=.014), diabetics (48% vs. 21%; P=0.006), and smokers (39.6% vs. 5%). Mortality rate during hospitalization was higher in Group A (54.5%) vs. 30.2% in Group B (P=.022). Mortality rate during follow-up (primary variable) was 73% in Group A vs. 38% in Group B (P=.007). CONCLUSIONS: Myocardial infarction complicated with cardiogenic shock in elderly patients is an entity with high mortality during hospitalization and continues to worsen during long term follow-up.

Influencia de la edad en el pronóstico a corto y largo plazo del choque cardiogénico de origen isquémico / Influence of age in short and long term prognostic of ischemic cardiogenic shock

Objetivo: Comparar la evolución durante el ingreso y a largo plazo de pacientes con choque cardiogénico de origen isquémico. Método: Estudio observacional prospectivo unicéntrico llevado a cabo en la unidad coronaria de un hospital terciario manejada por cardiólogos. Se incluyen pacientes con choque cardiogénico de origen isquémico que recibieron revascularización coronaria precoz. Dividimos a los pacientes en 2 grupos: mayores de 75 anos (grupo A) y menores (grupo B), y comparamos la evolución durante el ingreso y en un seguimiento máximo de 4 años. El objetivo principal fue estimar la mortalidad a los 4 años. El objetivo secundario se definió como la mortalidad intrahospitalaria. Resultados: Incluimos a 97 pacientes, 44 del grupo A (45%). Los pacientes del grupo B eran con más frecuencia varones (81 vs. 57%, p = 0.014), diabéticos (49 vs. 21%, p: 0.006) y fumadores (39.6 vs. 4.5%, p < 0.05). La mortalidad hospitalaria fue superior en el grupo A (54.5 vs. 30.2%, p = 0.022). El objetivo principal ocurrió en 32 pacientes del grupo A frente a 20 del grupo B (73 vs. 38%, p = 0.007). Conclusión: El choque cardiogénico de origen isquémico en paciente mayores de 75 anos presenta una alta mortalidad durante la estancia hospitalaria y en el seguimiento a largo plazo.

Objective: To compare the prognosis during hospitalization and maximum follow-up of 4 years in patients with myocardial infarction complicated with cardiogenic shock. Method: Prospective observational study practiced in a coronary Care Unit managed by cardiologists. We included patients with myocardial infarction complicated with cardiogenic shock who received early coronary revascularization. Patients were divided into two groups: older than 75 years (group A) and lower (group B), and we compared the evolution during hospitalization and maximum follow-up of 4 years. Primary end point was mortality rate in the maximum follow-up of 4years. Secondary end point was mortality rate during hospitalization. Results: Ninety-seven patients were included, 45% Group A. Patients of Group B were mostly men (81% vs. 57%; P =.014), diabetics (48% vs. 21%; P = 0.006), and smokers (39.6% vs. 5%). Mortality rate during hospitalization was higher in Group A (54.5%) vs. 30.2% in Group B(P = .022). Mortality rate during follow-up (primary variable) was 73% in Group A vs. 38% in Group B (P =.007). Conclusions: Myocardial infarction complicated with cardiogenic shock in elderly patients is an entity with high mortality during hospitalization and continues to worsen during long term follow-up.

[Transient ventricular dysfunction after emotional stress]. / Disfunción ventricular transitoria tras estrés emocional.

We describe a patient who developed severe ventricular dysfunction and cardiogenic shock after intense emotional stress. Her subsequent course was favorable, with complete recovery of left ventricular systolic function. The coronary arteries were normal and no specific etiologic agent was demonstrated. Her clinical picture was compatible with transient left ventricular apical ballooning. [I123]metaiodobenzyl guanidine cardiac scintigraphy showed a marked decrease in cardiac sympathetic nerve activity. We discuss the pathophysiologic mechanisms of this syndrome.

Utilidad clínica de las troponinas cardíacas / Cardiac troponins and their current clinical application

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Lesiones cutáneas e insuficiencia renal tras infarto agudo de miocardio / Skin Lesions and Renal Failure After Myocardial Infarction

Se describe el caso clínico correspondiente a un paciente con infarto agudo de miocardio tratado con fibrinólisis con t-PA, que desarrolló insuficiencia renal y lesiones cutáneas tipo livedo reticularis, en probable relación con embolismo de cristales de colesterol. Se revisan las principales características de esta rara entidad clínica (AU)