Dapagliflozin Improved Cardiac Function and Structure in Diabetic Patients with Preserved Ejection Fraction: Results of a Single Centre, Observational Prospective Study.

Sodium-glucose cotransporter inhibitors (SGLT2i) have demonstrated a reduction in cardiovascular events in diabetes and heart failure (HF). The mechanisms underlying this benefit are not well known and data are contradictory. The purpose of this study is to analyse the effect of dapagliflozin on cardiac structure and function in patients with normal ejection fraction. Between October 2020 and October 2021, we consecutively included 31 diabetic patients without prior history of SGLT2i use. In all of them, dapagliflozin treatment was started. At inclusion and during six months of follow-up, different clinical, ECG, analytical, and echocardiographic (standard, 3D, and speckle tracking) variables were recorded. After a follow-up period of 6.6 months, an average reduction of 18 g (p = 0.028) in 3D-estimated left ventricle mass was observed. An increase in absolute left ventricle global longitudinal strain (LV-GLS) of 0.3 (p = 0.036) was observed, as well as an increase in isovolumetric relaxation time (IVRT) of 10.5 ms (p = 0.05). Moreover, dapagliflozin decreased the levels of plasma creatin-kinase (CK-MB) and atrial natriuretic peptide (ANP). In conclusion, our data show that the use of SGLT2i is associated with both structural (myocardial mass) and functional (IVRT, LV-GLS) cardiac improvements in a population of diabetic patients with normal ejection fraction.

The Synthetic Flavonoid Hidrosmin Improves Endothelial Dysfunction and Atherosclerotic Lesions in Diabetic Mice.

In diabetes, chronic hyperglycemia, dyslipidemia, inflammation and oxidative stress contribute to the progression of macro/microvascular complications. Recently, benefits of the use of flavonoids in these conditions have been established. This study investigates, in two different mouse models of diabetes, the vasculoprotective effects of the synthetic flavonoid hidrosmin on endothelial dysfunction and atherogenesis. In a type 2 diabetes model of leptin-receptor-deficient (db/db) mice, orally administered hidrosmin (600 mg/kg/day) for 16 weeks markedly improved vascular function in aorta and mesenteric arteries without affecting vascular structural properties, as assessed by wire and pressure myography. In streptozotocin-induced type 1 diabetic apolipoprotein E-deficient mice, hidrosmin treatment for 7 weeks reduced atherosclerotic plaque size and lipid content; increased markers of plaque stability; and decreased markers of inflammation, senescence and oxidative stress in aorta. Hidrosmin showed cardiovascular safety, as neither functional nor structural abnormalities were noted in diabetic hearts. Ex vivo, hidrosmin induced vascular relaxation that was blocked by nitric oxide synthase (NOS) inhibition. In vitro, hidrosmin stimulated endothelial NOS activity and NO production and downregulated hyperglycemia-induced inflammatory and oxidant genes in vascular smooth muscle cells. Our results highlight hidrosmin as a potential add-on therapy in the treatment of macrovascular complications of diabetes.

Seventy-six-year-old man with progressive dyspnoea.

CLINICAL INTRODUCTION: A 76-year-old man with 50 years of smoking history was diagnosed in 2012 with diffuse interstitial lung disease, with radiological data of usual interstitial pneumonia. He came to the emergency room presenting with progression of dyspnoea for 1 week, concomitant with loss of 5 kg of weight, anorexia and poor general condition. He had tachypnoea at rest (30 breaths/min), peripheral cyanosis, speech interfered by cough and breathlessness, baseline oxygen saturation 90%, heart rate 40 beats/min and blood pressure 130/70 mm Hg. Chest X-ray was performed and there was basal atelectasia of the right lung. ECG and urgent echocardiogram (transthoracic echocardiogram, TTE) were also performed (figure 1). QUESTION: Which of the following best explains the patient's situation?heartjnl;105/1/74/F1F1F1Figure 1(A) ECG. (B) Long-axis parasternal view from the transthoracic echocardiogram (TTE). (C) Four-chamber view from the TTE.Acute pulmonary embolismNon-ST elevation myocardial infarctionCardiac lymphomaCardiac myxomaMobitz type II AV block.

Comparison of pharmacological treatment alone vs. treatment combined with implantable cardioverter defibrillator therapy in patients older than 75 years.

AIMS: Implantable cardioverter defibrillator (ICD) reduces mortality in selected patients. However, its role in patients older than 75 years is not well established. METHODS AND RESULTS: We performed a retrospective, non-randomized study using a historical cohort from a single centre. Between January 2008 and July 2014, we assessed patients aged ≥75 years with left ventricular ejection fraction ≤ 35%, identifying 385 patients with a Class I or IIa recommendation for ICD implantation. At the decision of the patient or attending cardiologists, 92 patients received an ICD. To avoid potential confounding factors, we used propensity-score matching. Finally, 126 patients were included (63 with ICD). The mean age was 79.1 ± 3.1 years (86.5% male). As compared with the medical therapy group, the ICD patients had a lower percentage of chronic obstructive pulmonary disease (19.0% vs. 38.1%, P < 0.05) and more frequent use of beta-blockers (BBs) (85.7 vs. 70.0%, P < 0.05). Other treatments were otherwise similar in both groups. There were no differences related to age, aetiology, or other co-morbidities. During follow-up (39.2 ± 22.4 months), total mortality was 46.0% and cardiovascular events (death or hospitalization) occurred in 66.7% of the patients. A multivariate analysis revealed that only BB therapy was shown to be an independent protective variable with respect to mortality [hazard ratio 0.4 (0.2-0.7)]. ICD therapy did not reduce overall mortality or the rate of cardiovascular events. CONCLUSIONS: According to our results, the use of ICD, as compared with medical therapy, in patients older than 75 years did not demonstrate any benefit. Well-designed randomized controlled studies in patients older than 75 years are needed to ascertain the value of ICD therapy.

Silent atrial fibrillation in pacemaker early post-implantation period: an unintentionally provoked situation?

Aims: Atrial high-rate episodes (AHREs) compatible with silent AF detected in pacemakers (PM) are related to an increased risk of stroke and silent ischaemic brain lesions (IBL) on CT scan. AHREs soon after PM implantation could be related with the procedure itself and the prognosis might be different. Methods and results: We analysed the incidence of AHREs >5 min and the presence of silent IBL in 110 patients (56% men, aged 75 ± 9 year-old) with PM and no history of AF, in relation to time from implantation (≤3 months vs. >3 months) and the atrial lead fixation (LF) (active vs. passive). Mean CHADS2 and CHA2DS2VASc scores were 1.9 ± 1.2 and 3.5 ± 1.5, respectively. Time from implantation was ≤3 months in 88 patients (80%). Active LF was used in 55 patients (50%). After 24 ± 9 months, AHREs were present in 40 patients (36.4%). CT-scan showed silent IBL in 26 patients (23.6%). The presence of AHREs at 3 months was more frequent in the patients with recent PM implantation (17% vs. 4.5%, P = 0.09) and significantly related to active LF (OR 5.36, 1.43-20.07; P < 0.05). The presence of silent IBL was related to the detection of AHREs during follow up (OR 3.12, 1.29-7.97; P < 0.05) but not with AHREs at first 3 months (OR 1.58, 0.49-5.05; P = 0.44). Conclusions: AHREs occur frequently during the first 3 months after PM implantation and could be related with procedure itself and the use of active LF. AHREs in this period might not be related to worse outcomes and should be interpreted cautiously.

Usefulness of speckle myocardial imaging modalities for differential diagnosis of left ventricular non-compaction of the myocardium.

BACKGROUND/OBJECTIVES: Current diagnostic criteria for left ventricular non-compaction (LVNC) may result in over-diagnosis of the disease. We evaluate the role of speckle imaging in differential diagnosis of LVNC. METHODS AND RESULTS: We included all patients who, between January 2012 and May 2015, fulfilled currently accepted criteria for LVNC (28 patients). A control group of 28 healthy individuals and a third group of 13 patients with dilated cardiomyopathy (DCM) were created. Speckle-tracking echocardiography was performed in all groups. Thirteen patients with LVNC had an ejection fraction (EF) <50% (33.5%, SD 10). When compared to controls, patients with LVNC and EF<50% had a larger LV, larger left atrial diameter (LA), reduced e', and reduced global longitudinal strain (GLS). All but one patient with LVNC and EF<50% showed an abnormal LV rotation. This abnormal pattern was observed in 4 LVNC patients (27%) with EF≥50% and in none of the controls. In patients with LVNC, EF ≥50%, and abnormal rotation, GLS was lower than in controls, (-17 (SD 3) vs -21 (SD 3)). Rigid body rotation (RBR) was also observed in 2 DCM patients, with significant differences in EF, GLS, LV diameters relative to the rest of the DCM group. CONCLUSIONS: In patients who fulfil the morphologic criteria for LVNC, speckle myocardial imaging techniques could be useful in differentiating between healthy individuals (functionally normal LV) and patients with LVNC (with functional abnormalities in the myocardium in spite of a preserved EF).

Silent brain infarcts in high blood pressure patients with cardiac implantable electronic devices: unmasking silent atrial fibrillation.

BACKGROUND: Hypertensive patients present a higher risk for developing atrial fibrillation and its complications. Cardiac implantable electronic devices (CIEDs) have shown reliable atrial fibrillation detection as atrial high-rate episodes (AHREs). The presence of AHRE more than 5 min has been related to increased risk of stroke, but a high proportion of ischemic brain lesions (IBLs) could be subclinical and thromboembolic risk underestimated. METHODS: We included hypertensive patients with CIED and we analyzed the incidence of AHRE and the presence of IBL on computed tomography (CT) scan. RESULTS: One hundred and twenty-three patients (57% men) aged 77 ± 8 years were evaluated during a mean follow-up of 15 ± 9 months. AHREs were documented in 46 patients (37%). Cranial CT scan showed silent IBL in 34 patients (27%). Univariate analysis showed that age, CHADS2 and CHADS2VA2Sc scores, history of prior stroke/ transient ischemic attack and the presence of AHRE were significantly related to higher risk for IBL on CT scan (P < 0.05). Multivariate analysis showed that the presence of AHRE more than 5 min [odds ratio 3.05 (1.19-7.81; P < 0.05)] was an independent predictor of IBL. CONCLUSION: Silent atrial fibrillation detected by CIED as AHRE is really prevalent in hypertensive patients. AHREs were independently associated with a higher incidence of silent IBL on CT scan.

Comparison of pharmacological treatment alone versus treatment combined with cardiac resynchronization therapy in patients over 75 years.

BACKGROUND: The role of cardiac resynchronization therapy (CRT) in patients aged ≥75 years is not well established. METHODS: We identified 607 patients aged ≥75 years with left ventricular ejection fraction (LVEF) of ≤35 %, of whom 78 met the guidelines for indication of CRT. Based on the decision of the patients or attending cardiologists, 34 patients received a CRT defibrillator (CRT-D). RESULTS: The age of patients with a CRT indication was 80 ± 4 years, and 73 % were males. As compared with patients on medical therapy, CRT-D patients were younger (79 ± 3 vs. 83 ± 4, P < 0.001), had lower LVEF (23 ± 7 vs. 27 ± 7 %, P = 0.008) and higher rate of decompensated heart failure episodes (77 vs. 55 %, P = 0.04), were more frequently New York Heart Association (NYHA) class III-IV (53 vs. 25 %, P = 0.01), and were more likely to be on beta-blockers (88 vs. 66 %, P = 0.023), anticoagulants (61 vs. 32 % P = 0.02), and anti-aldosterone drugs (82 vs. 50 %, P = 0.003). After a median follow-up of 26 months, seven patients in the CRT-D group (21 %) and 20 non-CRT patients (46 %) died (hazard ratio (HR) 0.16 [95 % confidence interval (CI) 0.06-0.46]). The end point of mortality or hospitalization was not reduced because of a similar rate of hospitalizations for heart failure of CRT-D patients. Four CRT-D patients (12 %) had received appropriate device therapy, and one had been inappropriately discharged. During follow-up, 44 % of CRT-D patients improved their LVEF by >40 %. CONCLUSION: CRT-D is potentially of benefit in terms of mortality in our population; this effect persists after correction for use of beta-blockers. In patients ≥75 years, CRT indications should be similar to those accepted for younger subjects.

Silent ischaemic brain lesions related to atrial high rate episodes in patients with cardiac implantable electronic devices.

AIMS: Monitoring capabilities of cardiac implantable electronic devices have revealed that a large proportion of patients present silent atrial fibrillation (AF) detected as atrial high rate episodes (AHREs). Atrial high rate episodes >5 min have been linked to increased risk of clinical stroke, but a high proportion of ischaemic brain lesions (IBLs) could be subclinical. METHODS AND RESULTS: We prospectively analysed the incidence of AHRE > 5 min in 109 patients (56% men, aged 74 ± 9 years) and the presence of silent IBL on computed tomography (CT) scan. Mean CHADS2 and CHA2DS2VASc scores were 2.3 ± 1.3 and 3.9 ± 1.6, respectively. Seventy-five patients (69%) had no history of AF or stroke/transient ischaemic attack (TIA). After 12 months, 28 patients (25.7%) showed at least one AHRE. Patients with AHREs were more likely to have history of AF. Computed tomography scan showed silent IBL in 28 (25.7%). The presence of IBL was significantly related to older patients, prior history of AF or stroke/TIA, higher CHADS2 or CHA2DS2VASc scores, and the presence of AHRE. Multivariable analysis demonstrated that AHRE was an independent predictor for silent IBL in overall population [hazard ratio (HR) 3.05 (1.06-8.81; P < 0.05)] but also in patients without prior history of AF or stroke/TIA [HR 9.76 (1.76-54.07; P < 0.05)]. CONCLUSION: Cardiac implantable electronic devices can accurately detect AF as AHRE. Atrial high rate episodes were associated to a higher incidence of silent IBL on CT scan. Atrial high rate episodes represent a kind of silent AF where management recommendations are lacking despite the fact that a higher embolic risk is present.

Diagnóstico de amiloidosis cardiaca por lesiones cutáneas / Diagnosis of cardiac amyloidosis by skin lesions

No disponible

Limitations of the AutoCapture™ Pacing System in patients with cardiac stimulation devices.

AIMS: AutoCapture (St Jude Medical) is a technological development that confirms ventricular capture analysing the evoked response after a pacing impulse and adjusts the energy output to changes in the stimulation threshold. Although this algorithm is aimed to assure capture minimizing energy consumption, some patients might not benefit from it. The objective of this study is to identify them. METHODS AND RESULTS: Long-term AutoCapture efficiency was assessed using the data recorded in the programmer reports of patients undergoing scheduled pacemaker check-ups during 2012 in our institution. We have evaluated 160 consecutive patients (58% men) aged 78 ± 9 years. Pacemaker stimulation mode was DDD in 116 patients (72.5%) and VVI in 44 patients (27.5%). During the scheduled visits for pacemaker check-up, 73 patients (45.6%) showed abnormalities in the long-term AutoCapture function report (high variability in the AutoCapture stimulation threshold and/or out-of-range values). After multivariate analysis, abnormal AutoCapture pattern was associated to the presence of atrial fibrillation [odds ratio (OR) 3.96 (1.59-9.82; P < 0.05)]; and a ventricular pacing ≤25% of the time [OR 4.80 (2.09-11.05; P < 0.05)]. AutoCapture abnormalities were also described in three (1.8%) patients with very low stimulation threshold. CONCLUSION: Although AutoCapture algorithm has shown both efficacy and safety, our findings suggest that some patients with atrial fibrillation or those requiring ventricular pacing ≤25% of the time may not benefit from it. Activation of the algorithm should be individualized according to the patient's characteristics and long-term AutoCapture pattern checked in the routine follow-up.

Hipotermia terapéutica tras parada cardiaca. Respuesta / No disponible

No disponible

Determinants of long-term survival in patients hospitalized for heart failure.

BACKGROUND AND OBJECTIVES: Current models used to stratify patients with heart failure are complex, difficult to use, and limited by short follow-up and patient selection. Our aim was to determine predictors of long-term survival in patients hospitalized for heart failure and to develop a simple mortality risk score to estimate long-term mortality. METHODS: We prospectively followed up, during 10 years after hospitalization, 701 patients with confirmed heart failure from the HOLA (Heart failure: Observation of Local Admissions) registry. RESULTS: Mean age was 72.4 +/- 11.7 years; 45% were men. During follow-up, 465 patients died and 5 underwent heart transplantation. A total of 231 patients (33%) were alive and transplant-free at the end of follow-up (5.2 +/- 4.2 years). Median survival was 3.2 years. Multivariate analysis showed that six variables (age, previous renal disease, previous stroke, chronic obstructive pulmonary disease, left ventricular ejection fraction and aortic stenosis) were independent predictors of shorter survival time. By dichotomizing these variables, we obtained six factors with similar predictive values (hazard ratio between 1.5 and 2.0). A risk score for mortality was developed using these predictors by assigning 1 point to each and adding the total for each patient. Median survival for patients with 0, 1, 2, and 3 or more points were 6.5, 5.5, 3.3, and 1.7 years, respectively. One-year mortality rates were 15, 20, 28, and 49%, respectively. CONCLUSION: The prognosis of patients hospitalized with heart failure is highly variable. A simple risk score, based on six variables readily obtainable on admission can effectively stratify patients according to their predicted mortality.

Utility of real-time three-dimensional transesophageal echocardiography in evaluating the success of percutaneous transcatheter closure of mitral paravalvular leaks.

BACKGROUND: The percutaneous closure of mitral paravalvular leaks has been reported in patients who are poor operative candidates. Unsuccessful percutaneous closure of leaks may be related to morphologic characteristics of the defects. METHODS: Ten patients were selected from a database for mitral dehiscence closure, in whom two-dimensional transesophageal echocardiography revealed inadequate leak closure. Another 4 patients with optimal results were also selected. Real-time three-dimensional transesophageal echocardiography (3DTEE) was performed in all of them. RESULTS: Real-time 3DTEE enabled the determination of the locations and number of the leaks, as well as their shapes, lengths, widths, areas, and extent. We were also able to observe the position of the device (or devices) implanted during percutaneous closure. CONCLUSION: According to this preliminary study, 3DTEE can improve understanding of the causes underlying failure of these techniques to reduce regurgitation secondary to a defect. This could improve patient selection and procedure results, but further studies are needed.