Seguimiento a muy largo plazo de pacientes sometidos a cierre de defectos septales interauriculares / Long-term outcomes after percutaneous atrial septal deffects closure

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Value of the coronary artery disease consortium rule in patients with acute chest pain and negative troponins referred for exercise stress testing.

OBJECTIVE: To assess the value of the pretest probability (PTP) of coronary artery disease (CAD) for predicting stress testing results and coronary events in patients with acute chest pain and negative troponins. PATIENTS AND METHODS: A total of 3527 patients without a history of CAD referred to our chest pain unit with suspected acute coronary syndromes, nondiagnostic ECGs, and negative troponin levels underwent exercise stress testing. PTP was estimated with the CAD consortium prediction rule, and was categorized as low (<15%), low-intermediate (15-65%), intermediate-high (66-85%), and high (>85%). The endpoints were the presence of signs of inducible myocardial ischemia on stress testing and the occurrence of coronary events within 6 months. RESULTS: The probability of exercise-induced myocardial ischemia was 2.6, 12.6, 42.9, and 82.1% in patients with low, low-intermediate, intermediate-high, and high PTP, respectively (Ptrend<0.001). The cumulative rate of coronary events within 6 months was also significantly lower in patients with low PTP of CAD (0.8%) than in those with low-intermediate (6.9%), intermediate-high (32.5%), or high PTP (66.7%) (Ptrend<0.001). Per 10% increment in PTP of CAD, the adjusted odds ratios for inducible myocardial ischemia and coronary events within 6 months were, respectively, 1.71 (95% confidence interval: 1.61-1.85) and 1.87 (95% confidence interval: 1.74-2.01). CONCLUSION: PTP was associated strongly with the likelihood of exercise-induced myocardial ischemia and coronary events in patients with suspected acute coronary syndromes and negative troponins. The yield of stress testing in the subset of patients with low PTP was very low.

Indexed left atrial size predicts all-cause and cardiovascular mortality in patients undergoing aortic valve surgery.

OBJECTIVES: The enlargement of the left atrium has been identified as a marker of chronically increased left ventricular filling pressure and left ventricular diastolic dysfunction. This study aims to evaluate the association of indexed left atrial diameter with stroke, cardiovascular mortality, the combined event, and all-cause mortality in patients who underwent aortic valve surgery. METHODS: Indexed left atrial diameter was measured in 2011 adult patients (mean age, 70.9 ± 10.8 years; 58.7% were men) who underwent aortic valve surgery between January 2008 and March 2016. RESULTS: On the basis of the criteria of the American Society of Echocardiography, indexed left atrial diameter was normal in 64% of patients, mildly enlarged in 12.4% of patients, moderately enlarged in 9.2% of patients, and severely enlarged in 14.3% of patients. Over a mean follow-up period of 3.2 ± 2.1 years, there were 334 deaths and 97 strokes. Cardiovascular mortality survival at 5 years among patients with normal, mild, moderate, and severe left atrial enlargement was 91.6%, 86.8%, 77.9%, and 77.4%, respectively (P < .001). After covariable adjustment, Cox regression analysis showed indexed left atrial diameter as an independent predictor of all-cause mortality (hazard ratio per 1-cm/m2 increment, 1.545; 95% confidence interval, 1.252-1.906, P < .001), cardiovascular death (hazard ratio per 1-cm/m2 increment, 1.971; 95% confidence interval, 1.541-2.520; P < .001), and the combined event (hazard ratio per 1-cm/m2 increment, 1.673; 95% confidence interval, 1.321-2.119; P < .001). CONCLUSIONS: Indexed left atrial diameter is a strong predictor of long-term outcomes in patients with aortic valve diseases who undergo surgery.

Rendimiento diagnóstico y pronóstico del registro Holter de 24horas en pacientes con síncope / Diagnostic and prognostic efficiency of 24-hour Holter monitoring in patients with syncope

Antecedentes y objetivo: El síncope es una entidad frecuente y con un diagnóstico complejo. El rendimiento del Holter-ECG 24h en este contexto no está bien definido. Nuestro objetivo fue evaluar su capacidad diagnóstica y pronóstica en estos pacientes. Pacientes y método: Estudio retrospectivo de 6.006 pacientes consecutivos remitidos a nuestra unidad para la realización de Holter-ECG 24h por síncope. Se registraron los hallazgos diagnósticos y aquellos hallazgos anormales potencialmente relacionados con una causa arrítmica de síncope. El objetivo pronóstico fue un combinado de muerte o necesidad de implante de dispositivo (marcapasos o desfibrilador implantable) a un año. Resultados: En total, 242 pacientes (4%) presentaron hallazgos diagnósticos y 472 (7,9%) tuvieron algún hallazgo anormal. En 328 casos fue necesario el implante de un dispositivo a un año, pero hasta un 66% de estos enfermos no tenían ningún hallazgo relevante en el Holter. Un total de 564 pacientes presentaron el episodio combinado, incluyendo el 36,8% de pacientes con hallazgos diagnósticos y el 8,2% sin hallazgos diagnósticos. Conclusiones: El Holter-ECG 24h presenta un rendimiento diagnóstico y pronóstico limitados en pacientes no seleccionados con síncope (AU)

Background and objective: Syncope is a common condition and complex to diagnose. The yield of the 24h-Holter ECG in this context has not been clearly defined. The aim of this study was to evaluate its diagnostic and prognostic capacity in these patients. Patients and method: Retrospective study of 6,006 consecutive patients sent to our unit for 24h-Holter ECG monitoring for syncope. We registered the diagnostic findings and abnormal findings potentially related to an arrhythmic cause of syncope. The prognostic endpoint was a combination of death or the need for device implantation (pacemaker or defibrillator) within one year. Results: 242 patients (4%) presented diagnostic findings and 472 (7.9%) had some abnormal findings. In 328 cases device implantation was necessary within one year, but up to 66% of these patients did not have any relevant findings on the Holter monitoring. A total of 564 patients presented the combined event, including 36.8% of patients with diagnostic findings and 8.2% without them. Conclusions: 24h-Holter ECG monitoring presents a limited diagnostic and prognostic yield in unselected patients with syncope (AU)

A clinical score to obviate the need for cardiac stress testing in patients with acute chest pain and negative troponins.

INTRODUCTION: Although cardiac stress testing may help establish the safety of early discharge in patients with suspected acute coronary syndromes and negative troponins, more cost-effective strategies are necessary. We aimed to develop a clinical prediction rule to safely obviate the need for cardiac stress testing in this setting. METHODS: A decision rule was derived in a prospective cohort of 3001 patients with acute chest pain and negative troponins, and validated in a set of 1473 subjects. The primary end point was a composite of positive cardiac stress testing (in the absence of a subsequent negative coronary angiogram), positive coronary angiography, or any major coronary events within 3 months. RESULTS: A score chart was built based on 7 variables: male sex (+2), age (+1 per decade from the fifth decade), diabetes mellitus (+2), hypercholesterolemia (+1), prior coronary revascularization (+2), type of chest pain (typical angina, +5; non-specific chest pain, -3), and non-diagnostic repolarization abnormalities (+2). In the validation set, the model showed good discrimination (c statistic = 0.84; 95% confidence interval, 0.82-0.87) and calibration (Hosmer-Lemeshow goodness-of-fit test, P= .34). If stress tests were avoided in patients in the validation sample with a sum score of 0 or lower, the number of referrals would be reduced by 23.4%, yielding a negative predictive value of 98.8% (95% confidence interval, 97.0%-99.7%). CONCLUSION: This novel prediction rule based on a combination of readily available clinical characteristics may be a valuable tool to decide whether stress testing can be reliably avoided in patients with acute chest pain and negative troponins.

[Diagnostic and prognostic efficiency of 24-hour Holter monitoring in patients with syncope]. / Rendimiento diagnóstico y pronóstico del registro Holter de 24horas en pacientes con síncope.

BACKGROUND AND OBJECTIVE: Syncope is a common condition and complex to diagnose. The yield of the 24h-Holter ECG in this context has not been clearly defined. The aim of this study was to evaluate its diagnostic and prognostic capacity in these patients. PATIENTS AND METHOD: Retrospective study of 6,006 consecutive patients sent to our unit for 24h-Holter ECG monitoring for syncope. We registered the diagnostic findings and abnormal findings potentially related to an arrhythmic cause of syncope. The prognostic endpoint was a combination of death or the need for device implantation (pacemaker or defibrillator) within one year. RESULTS: 242 patients (4%) presented diagnostic findings and 472 (7.9%) had some abnormal findings. In 328 cases device implantation was necessary within one year, but up to 66% of these patients did not have any relevant findings on the Holter monitoring. A total of 564 patients presented the combined event, including 36.8% of patients with diagnostic findings and 8.2% without them. CONCLUSIONS: 24h-Holter ECG monitoring presents a limited diagnostic and prognostic yield in unselected patients with syncope.

Troponin levels within the normal range and probability of inducible myocardial ischemia and coronary events in patients with acute chest pain.

BACKGROUND/OBJECTIVES: Patients with suspected acute coronary syndromes and negative cardiac troponin (cTn) levels are deemed at low risk. Our aim was to assess the effect of cTn levels on the frequency of inducible myocardial ischemia and subsequent coronary events in patients with acute chest pain and cTn levels within the normal range. METHODS: We evaluated 4474 patients with suspected acute coronary syndromes, nondiagnostic electrocardiograms and serial cTnI levels below the diagnostic threshold for myocardial necrosis using a conventional or a sensitive cTnI assay. The end points were the probability of inducible myocardial ischemia and coronary events (i.e., coronary death, myocardial infarction or coronary revascularization within 3 months). RESULTS: The probability of inducible myocardial ischemia was significantly higher in patients with detectable peak cTnI levels (25%) than in those with undetectable concentrations (14.6%, p<0.001). These results were consistent regardless of the type of cTnI assay, the type of stress testing modality, or the timing for cTnI measurement, and remained significant after multivariate adjustment (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.21-1.79, p<0.001). The rate of coronary events at 3 months was also significantly higher in patients with detectable cTnI levels (adjusted OR 2.08, 95% CI 1.64-2.64, p<0.001). CONCLUSIONS: Higher cTnI levels within the normal range were associated with a significantly increased probability of inducible myocardial ischemia and coronary events in patients with suspected acute coronary syndromes and seemingly negative cTnI.

Trends in referral patterns, invasive management, and mortality in elderly patients referred for exercise stress testing.

INTRODUCTION: Scarce data are available on the temporal patterns in clinical characteristics and outcomes of elderly patients referred for exercise stress testing. We aimed to assess the trends in baseline characteristics, tests results, referrals for invasive management, and mortality in these patients. METHODS: We evaluated 11,192 patients aged ≥65years who were referred for exercise stress testing between January 1998 and December 2013. Calendar years were grouped into four quadrennia (1998-2001, 2002-2005, 2006-2009, and 2010-2013), and trends in clinical characteristics of the patients, type and results of the tests, referrals for invasive management, and mortality across the different periods were assessed. RESULTS: Despite a progressive decrease in the proportion of patients with non-interpretable baseline electrocardiograms or prior history of coronary artery disease, there was a gradual and marked increase in the use of cardiac imaging from 32.8% in 1998-2001 to 67.6% in 2010-2013 (p<0.001). In addition, despite a gradual decline in the probability of positive exercise stress testing both without imaging (from 18.9 to 13.6%, p<0.001) and with imaging assessment (from 40.2 to 29.7%, p<0.001), the cumulative rate of coronary revascularization at 1year increased (from 10.8 to 13.7%, p<0.001). One-year mortality also decreased progressively from 3% to 1.6% (p<0.001). CONCLUSIONS: Among older adults referred for exercise stress testing, we observed a decline over time in the probability of inducible myocardial ischemia, an increase in the use of cardiac imaging and in the rate of coronary revascularization, and an improvement in the survival rate at 1year.

Incremental value of exercise echocardiography over exercise electrocardiography in a chest pain unit.

BACKGROUND: Limited data are available on the added value of exercise echocardiography (ExEcho) over exercise electrocardiography (ExECG) in patients with suspected acute coronary syndromes (ACS) referred to a chest pain unit. We aimed to assess the incremental value of ExEcho over ExECG in this setting. METHODS: ExECG and ExEcho were performed in parallel in 1052 patients with suspected ACS, nondiagnostic but interpretable electrocardiograms, and negative serial troponin results. The primary outcome was a composite of coronary death, nonfatal myocardial infarction or unstable angina with angiographic documentation of significant coronary artery disease within 6 months. RESULTS: The primary outcome occurred in 2/614 patients (0.3%) with both negative ExECG and ExEcho, 3/60 (5%) with positive ExECG and negative ExEcho, 73/135 (54.1%) with negative ExECG and positive ExEcho, 106/136 (77.9%) with both positive ExECG and ExEcho, and 8/107 (7.5%) with inconclusive results. The addition of ExEcho data to a model based on clinical and ExECG data significantly increased the c statistic from 0.898 to 0.968 (change +0.070, 95% confidence interval 0.052-0.092), with a continuous net reclassification improvement of 1.56 and an integrated discrimination improvement of 22% (p<0.001). Decision curve analysis showed that a strategy of referral to coronary angiography based on ExEcho was associated with the highest net benefit and with the largest reduction in unnecessary coronary angiographies. CONCLUSION: ExEcho provides significant incremental prognostic information and higher net clinical benefit than a strategy based on ExECG in patients referred to a chest pain unit for suspected ACS and negative troponin levels.

Temporal changes in the use and results of exercise echocardiography.

AIMS: Limited data are available regarding changes over time in referral patterns and outcomes of non-invasive cardiac stress testing. Our aim was to evaluate the temporal changes in the use and results of exercise echocardiography in our area of reference. METHODS AND RESULTS: A total of 12 339 patients referred to our unit for exercise echocardiography between 1997 and 2012 were included. We divided the 16-year period into four quadrennia and evaluated the changes in clinical data, results of the tests, referrals for invasive management and outcomes. We observed a gradual decrease in the frequency of detection of myocardial ischaemia from 35.3% in1997-2000 to 25.4% in 2009-12 (P < 0.001). There was also a progressive increase in the prevalence of cardiovascular risk factors and in the frequency of non-ischaemic chest pain and dyspnoea, while the proportion of patients with prior myocardial infarction and non-interpretable electrocardiograms declined. The rate of referral to coronary angiography within 6 months decreased from 24.8% in 1997-2000 to 19.6% in 2009-12 (P < 0.001), but the rate of coronary revascularization remained almost unchanged (13.1 to 11.7%, P for the trend = 0.16). We also observed a progressive decrease in the 1-year mortality rate from 3.4 to 1% (P < 0.001). CONCLUSION: Over a 16-year period, there was a gradual decrease in the frequency of myocardial ischaemia among patients referred to our unit for exercise echocardiography, which was parallel to changes in their clinical profile. However, this was not accompanied by a significant reduction in the rate of coronary revascularization.

The CarboMedics supra-annular Top Hat valve improves long-term left ventricular mass regression.

OBJECTIVE: The present study aimed to identify potential differences in hemodynamic performance between the supra-annular CarboMedics Top Hat valve and the intra-annular CarboMedics standard valve in terms of the long-term left ventricular mass reduction and transvalvular gradients. METHODS: We retrospectively reviewed a series of 186 consecutive patients who had undergone aortic valve replacement with a small size mechanical prosthesis at our institution from 2003 to 2013, receiving either a CarboMedics Top Hat valve (53 patients, valve size, 21 mm in 52.8% and 23 mm in 47.2%) or a CarboMedics standard prosthesis (133 patients, valve size, 19 mm in 14.3% and 21 mm in 85.7%). RESULTS: The in-hospital mortality was 9.4% and 11.3% in the Top Hat and standard groups, respectively (P = .71). The mean percentage of left ventricular mass reduction was greater in the Top Hat group (33% ± 15.8% vs 20.1% ± 16.6%, P < .001). The mean postoperative peak aortic gradient was lower in the Top Hat group (19.9 ± 8.9 vs 29.6 ± 8.6 mm Hg; P < .001). Spearman analysis showed a positive correlation between the indexed effective orifice area and the percentage of left ventricular mass reduction (Rho = +0.65, P = .02). The survival in the Top Hat group was 79.7% and 71.7% at 5 and 10 years, respectively. In the standard group, survival was 66.8% and 61.5% at 5 and 10 years, respectively (log-rank test, 0.19). Cox regression demonstrated severe myocardial hypertrophy (hazard ratio, 2.559; 95% confidence interval, 1.095-5.981) as one of the independent predictors of survival. CONCLUSIONS: The Top Hat valve surpasses hemodynamically the intra-annular valve. We suggest the supra-annular Top Hat prosthesis can be especially recommended for patients with a small aortic root and severe myocardial hypertrophy.