Cardiac resynchronization therapy in acute heart failure and left bundle-branch block in a real-life registry / Terapia de resincronización cardiaca en insuficiencia cardiaca aguda y bloqueo de rama izquierda en un registro real

Abstract Objectives: To determine the prevalence, characteristics, timing of implementation and prognosis of patients with left bundle branch block (LBBB) and acute heart failure (AHF) treated with cardiac resynchronization therapy (CRT) in a real-life registry. Methods: We analysed the characteristics of patients with AHF and LBBB at the time of inclusion in the EAHFE (Epidemiology Acute Heart Failure Emergency) cohort to determine the indication for CRT, the timing of implementation and its impact on 10-year all-cause mortality. Results: 729 patients with a median age of 82 years and there was a high burden of comorbidities and functional dependence. The median left-ventricle ejection fraction (LVEF) was 40%. Forty-six (6%) patients were treated with CRT at some point during follow-up, with a median time of delay for CRT implementation of 960 (IQR=1,147 days) and at least 108 more untreated patients fulfilled criteria for CRT. Patients receiving CRT were younger, had different comorbidities, less functional dependence (higher Barthel index) and lower LVEF values. The median follow-up was 5.7 years (95% CI: 5.6-5.8) and CRT was not associated with changes in 10-year mortality (adjusted HR 1.33, 95% CI: 0.72-2.48; p-value 0.4). When compared with untreated patients fulfilling criteria for CRT, very similar results were observed (adjusted HR 1.34, 95% CI: 0.67-2.68). Conclusions: CRT implementation was delayed and underused in patients with AHF and LBBB. Under these circumstances, CRT is not associated with a reduction in all-cause mortality in the long term.

Resumen Objetivos: Determinar la prevalencia, características, momento de implantación y pronóstico de los pacientes con bloqueo de rama izquierda del haz de His (BRIHH) e insuficiencia cardiaca aguda (ICA) tratados con terapia de resincronización cardiaca (TRC) en un registro real. Métodos: Se analizaron las características de los pacientes con ICA y BRIHH en el momento de su inclusión en la cohorte EAHFE (Epidemiology Acute Heart Failure Emergency) para determinar la indicación de TRC, el momento de implantación y su impacto en la mortalidad por cualquier causa a 10 años. Resultados: 729 pacientes con una mediana de edad de 82 años con una elevada carga de comorbilidades y dependencia funcional. La mediana de la fracción de eyección del ventrículo izquierdo (FEVI) fue del 40%. 46 pacientes (6%) fueron tratados con TRC en algún momento del seguimiento, con una mediana de tiempo de retraso para la implantación de la TRC de 960 dias (IQR=1,147 días) y al menos 108 pacientes no tratados cumplían criterios para TRC. Los pacientes que recibieron TRC eran más jóvenes, tenían comorbilidades diferentes, menor dependencia funcional (índice de Barthel más alto) y valores de FEVI más bajos. La mediana de seguimiento fue de 5.7 años (IC del 95%: 5.6-5.8) y la TRC no se asoció a cambios en la mortalidad a 10 años (HR ajustado: 1.33; IC del 95%: 0.72-2.48; p-valor 0.4). Cuando se comparó con pacientes no tratados que cumplían criterios para TRC, se observaron resultados muy similares (HR ajustado 1.34; IC del 95%: 0.67-2.68). Conclusiones: La implantación de la TRC se retrasó y se infrautilizó en pacientes con ICA y BRIHH. En estas circunstancias, la TRC no se asocia a una reducción de la mortalidad por cualquier causa a largo plazo.

Cardiac resynchronization therapy in acute heart failure and left bundle-branch block in a real-life registry.

Objectives: To determine the prevalence, characteristics, timing of implementation and prognosis of patients with left bundle branch block (LBBB) and acute heart failure (AHF) treated with cardiac resynchronization therapy (CRT) in a real-life registry. Methods: We analysed the characteristics of patients with AHF and LBBB at the time of inclusion in the EAHFE (Epidemiology Acute Heart Failure Emergency) cohort to determine the indication for CRT, the timing of implementation and its impact on 10-year all-cause mortality. Results: 729 patients with a median age of 82 years and there was a high burden of comorbidities and functional dependence. The median left-ventricle ejection fraction (LVEF) was 40%. Forty-six (6%) patients were treated with CRT at some point during follow-up, with a median time of delay for CRT implementation of 960 (IQR=1,147 days) and at least 108 more untreated patients fulfilled criteria for CRT. Patients receiving CRT were younger, had different comorbidities, less functional dependence (higher Barthel index) and lower LVEF values. The median follow-up was 5.7 years (95% CI: 5.6-5.8) and CRT was not associated with changes in 10-year mortality (adjusted HR 1.33, 95% CI: 0.72-2.48; p-value 0.4). When compared with untreated patients fulfilling criteria for CRT, very similar results were observed (adjusted HR 1.34, 95% CI: 0.67-2.68). Conclusions: CRT implementation was delayed and underused in patients with AHF and LBBB. Under these circumstances, CRT is not associated with a reduction in all-cause mortality in the long term.

Objetivos: Determinar la prevalencia, características, momento de implantación y pronóstico de los pacientes con bloqueo de rama izquierda del haz de His (BRIHH) e insuficiencia cardiaca aguda (ICA) tratados con terapia de resincronización cardiaca (TRC) en un registro real. Métodos: Se analizaron las características de los pacientes con ICA y BRIHH en el momento de su inclusión en la cohorte EAHFE (Epidemiology Acute Heart Failure Emergency) para determinar la indicación de TRC, el momento de implantación y su impacto en la mortalidad por cualquier causa a 10 años. Resultados: 729 pacientes con una mediana de edad de 82 años con una elevada carga de comorbilidades y dependencia funcional. La mediana de la fracción de eyección del ventrículo izquierdo (FEVI) fue del 40%. 46 pacientes (6%) fueron tratados con TRC en algún momento del seguimiento, con una mediana de tiempo de retraso para la implantación de la TRC de 960 dias (IQR=1,147 días) y al menos 108 pacientes no tratados cumplían criterios para TRC. Los pacientes que recibieron TRC eran más jóvenes, tenían comorbilidades diferentes, menor dependencia funcional (índice de Barthel más alto) y valores de FEVI más bajos. La mediana de seguimiento fue de 5.7 años (IC del 95%: 5.6-5.8) y la TRC no se asoció a cambios en la mortalidad a 10 años (HR ajustado: 1.33; IC del 95%: 0.72-2.48; p-valor 0.4). Cuando se comparó con pacientes no tratados que cumplían criterios para TRC, se observaron resultados muy similares (HR ajustado 1.34; IC del 95%: 0.67-2.68). Conclusiones: La implantación de la TRC se retrasó y se infrautilizó en pacientes con ICA y BRIHH. En estas circunstancias, la TRC no se asocia a una reducción de la mortalidad por cualquier causa a largo plazo.

Prevalence and risk factors of mild chronic renal failure in HIV-infected patients: influence of female gender and antiretroviral therapy

ABSTRACT Background In people living with HIV, much is known about chronic kidney disease, defined as a glomerular filtration rate under 60 mL/min. However, there is scarce data about prevalence and risk factors for milder impairment (60-89 mL/min). Objective The present study aims to assess the influence of sex, antiretroviral therapy, and classical risk factors on the occurrence of mild decreased renal function in a large Spanish cohort of HIV-infected patients. Methods Cross-sectional, single center study, including all adult HIV-1-infected patients under antiretroviral treatment with at least two serum creatinine measures during 2014, describing the occurrence of and the risk factors for mildly decreased renal function (eGFR by CKD-EPI creatinine equation of 60-89 mL/min). Results Among the 4337 patients included, the prevalence rate of mildly reduced renal function was 25%. Independent risk factors for this outcome were age older than 50 years (OR 3.03, 95% CI 2.58-3.55), female sex (OR 1.23, 95% CI 1.02-1.48), baseline hypertension (OR 1.57, 95% CI 1.25-1.97) or dyslipidemia (OR 1.48, 95% CI 1.17-1.87), virologic suppression (OR 1.88, 95% CI 1.39-2.53), and exposure to tenofovir disoproxil-fumarate (OR 1.67, 95% CI 1.33-2.08) or ritonavir-boosted protease-inhibitors (OR 1.19, 95% CI 1.03-1.39). Conclusions Females and patients over 50 seem to be more vulnerable to renal impairment. Potentially modifiable risk factors and exposure to tenofovir disoproxil-fumarate or ritonavir-boosted protease-inhibitors are present even in earlier stages of chronic kidney dysfunction. It remains to be determined whether early interventions including antiretroviral therapy changes (tenofovir alafenamide, cobicistat) or improving comorbidities management will improve the course of chronic kidney disease.

Prevalence and risk factors of mild chronic renal failure in HIV-infected patients: influence of female gender and antiretroviral therapy.

BACKGROUND: In people living with HIV, much is known about chronic kidney disease, defined as a glomerular filtration rate under 60mL/min. However, there is scarce data about prevalence and risk factors for milder impairment (60-89mL/min). OBJECTIVE: The present study aims to assess the influence of sex, antiretroviral therapy, and classical risk factors on the occurrence of mild decreased renal function in a large Spanish cohort of HIV-infected patients. METHODS: Cross-sectional, single center study, including all adult HIV-1-infected patients under antiretroviral treatment with at least two serum creatinine measures during 2014, describing the occurrence of and the risk factors for mildly decreased renal function (eGFR by CKD-EPI creatinine equation of 60-89mL/min). RESULTS: Among the 4337 patients included, the prevalence rate of mildly reduced renal function was 25%. Independent risk factors for this outcome were age older than 50 years (OR 3.03, 95% CI 2.58-3.55), female sex (OR 1.23, 95% CI 1.02-1.48), baseline hypertension (OR 1.57, 95% CI 1.25-1.97) or dyslipidemia (OR 1.48, 95% CI 1.17-1.87), virologic suppression (OR 1.88, 95% CI 1.39-2.53), and exposure to tenofovir disoproxil-fumarate (OR 1.67, 95% CI 1.33-2.08) or ritonavir-boosted protease-inhibitors (OR 1.19, 95% CI 1.03-1.39). CONCLUSIONS: Females and patients over 50 seem to be more vulnerable to renal impairment. Potentially modifiable risk factors and exposure to tenofovir disoproxil-fumarate or ritonavir-boosted protease-inhibitors are present even in earlier stages of chronic kidney dysfunction. It remains to be determined whether early interventions including antiretroviral therapy changes (tenofovir alafenamide, cobicistat) or improving comorbidities management will improve the course of chronic kidney disease.

Regional differences in the management and outcome of kidney transplantation in patients with human immunodeficiency virus infection: A 3-year retrospective cohort study.

BACKGROUND: In the developed world, kidney transplantation (KT) in patients with human immunodeficiency virus (HIV) infection is well established. Developing countries concentrate 90% of the people living with HIV, but their experience is underreported. Regional differences may affect outcomes. OBJECTIVES: We compared the 3-year outcomes of patients with HIV infection receiving a KT in two different countries, in terms of incomes and development. METHODS: This was an observational, retrospective, double-center study, including all HIV-infected patients >18 years old undergoing KT. RESULTS: Between 2005 and 2015, 54 KTs were performed (39 in a Brazilian center, and 15 in a Spanish center). Brazilians had less hepatitis C virus co-infection (5% vs 27%, P=.024). Median cold ischemia time was higher in Brazil (25 vs 18 hours, P=.001). Biopsy-proven acute rejection (AR) was higher in Brazil (33% vs 13%, P=.187), as were the number of AR episodes (22 vs 4, P=.063). Patient survival at 3 years was 91.3% in Brazil and 100% in Spain; P=.663. All three cases of death in Brazil were a result of bacterial infections within the first year post transplant. At 3 years, survival free from immunosuppressive changes was lower in Brazil (56% vs 90.9%, P=.036). Raltegravir-based treatment to avoid interaction with calcineurin inhibitor was more prevalent in Spain (80% vs 3%; P<.001). HIV infection remained under control in all patients, with undetectable viral load and no opportunistic infections. CONCLUSION: Important regional differences exist in the demographics and management of immunosuppression and antiretroviral therapy. These details may influence AR and infectious complications. Non-AIDS infections leading to early mortality in Brazil deserve special attention.