Evidence-based Management of Left Main Coronary Artery Disease.

Left main coronary artery disease (LMCAD) is associated with high morbidity and mortality due to the large myocardial mass at risk. Although medical treatment may be an option in selected low-risk patients, revascularisation is recommended to improve survival in the majority of patients presenting with a significant left main stenosis. In the past decade, multiple randomised clinical trials and meta-analyses have compared coronary artery bypass grafting surgery (CABG) versus percutaneous coronary intervention (PCI), finding controversial results. The strategy for LMCAD revascularisation is still challenging. Coronary anatomy complexity, clinical features and patient preferences are key elements to be considered by the heart team. The current guidelines define CABG as standard therapy, but the continuous improvements in PCI techniques, the use of intracoronary imaging and functional assessment make PCI a feasible alternative in selected patients, particularly in those with comorbidities and contraindications to CABG. This review analyses the most important studies comparing CABG versus PCI in patients with LMCAD.

Epidemiología de la fibrilación auricular en España / Epidemiology of atrial fibrillation in Spain

La fibrilación auricular es una arritmia que se caracteriza por la contracción de las fibras auriculares de modo caótico e impredecible. Esta disincronía origina la pérdida funcional de contractilidad. Por ello, se favorece la coagulación intraauricular y, consecuentemente, se aumenta la probabilidad de sufrir un ictus por tromboembolia. Es bien conocido que esta arritmia aumenta la mortalidad y la morbilidad. Por lo tanto, su prevención y manejo son de gran importancia tanto para los pacientes como para el sistema sanitario. Este artículo analiza los datos epidemiológicos de la fibrilación auricular en España (AU)

Atrial fibrillation is an arrhythmia that is characterized by the chaotic and unpredictable contraction of muscle fibers in the atrium. The resulting dyssynchrony leads to a loss of contractile function. As a consequence, there is a predisposition to atrial coagulation and, accordingly, the risk of thromboembolic stroke increases. It is well known that this arrhythmia increases mortality and morbidity. Thus, its prevention and treatment are crucially important for both patients and the health-care system in general. This article presents an analysis of the available epidemiologic data on atrial fibrillation in Spain (UA)

Evaluación de riesgo tromboembólico y hemorrágico de los pacientes con fibrilación auricular / Evaluating thromboembolic and hemorrhagic risk in patients with atrial fibrillation

La fibrilación auricular es la arritmia cardiaca más frecuente en la práctica clínica diaria. Además de las alteraciones hemodinámicas que ocasiona -consecuencia de la pérdida de la contracción auricular y la frecuencia cardiaca habitualmente elevada, que pueden causar la aparición de insuficiencia cardiaca-, el principal riesgo de la fibrilación auricular es que la estasis circulatoria en la aurícula cause una embolia arterial. Se sabe que la fibrilación auricular se asocia a un marcado aumento del riesgo de accidentes tromboembólicos arteriales, asociados a elevadas mortalidad y morbilidad y alto riesgo de recurrencia. Está demostrado que el tratamiento antitrombótico con anticoagulantes orales se asocia a un drástico descenso del riesgo de accidentes tromboembólicos. Sin embargo, los anticoagulantes orales incrementan significativamente el riesgo de hemorragias mayores, de las que es especialmente devastadora la hemorragia intracraneal. Por lo tanto, al iniciar el tratamiento anticoagulante de un paciente con fibrilación auricular, resulta imprescindible valorar adecuadamente el beneficio/riesgo del tratamiento según sus características clínicas. Múltiples estudios han mostrado una serie de variables que determinan los riesgos embolígeno y de sangrado asociados al tratamiento anticoagulante, y con base en ellas se han desarrollado diversos sistemas de estratificación para calcular el riesgo de embolia secundaria a la fibrilación auricular y el riesgo de hemorragia relacionado con el tratamiento antitrombótico. En la práctica clínica diaria, la aplicación de estas escalas de riesgo es de gran ayuda para elegir la mejor alternativa terapéutica para un paciente concreto (AU)

Atrial fibrillation is the most common cardiac arrhythmia encountered in clinical practice. In addition to the hemodynamic alterations that result from the loss of atrial contraction and the usually high heart rate, which can lead to the development of heart failure, the main risk of atrial fibrillation is that circulatory stasis in the atrium can cause arterial embolism. It is well known that atrial fibrillation is associated with a marked increase in the risk of arterial thromboembolic events, which are associated with high mortality and morbidity and have a high risk of recurrence. It has been clearly demonstrated that antithrombotic therapy with oral anticoagulants is associated with a dramatic decrease in the risk of thromboembolic events. However, oral anticoagulants significantly increase the risk of major bleeding complications, of which intracranial hemorrhage is particularly devastating. Therefore, for any patient with atrial fibrillation, it is essential that a full evaluation of the benefits and risks of anticoagulation, which takes into account the patient’s clinical characteristics, is carried out at the start of anticoagulant therapy. Numerous studies have identified a range of variables that determine the risk of embolism and bleeding associated with anticoagulant therapy. Various risk stratification systems have been developed using these variables to calculate the risk of embolism secondary to atrial fibrillation and the risk of bleeding associated with antithrombotic therapy. In everyday clinical practice, the application of these risk scales is especially helpful for selecting the best type of therapy for individual patients (AU)

Costs of bleeds relating to acute coronary syndrome therapies.

UNLABELLED: To estimate the costs to manage selected types of bleeding complications in patients with acute coronary syndrome (ACS) treated with antithrombotics, including antiplatelet, and fibrinolytic therapies: decrease in haemoglobin >3 g/dL, puncture site, and bleeding requiring transfusion of blood products. METHODS: Retrospective chart reviews of ACS patients experiencing decrease in Hb, puncture site, or bleeding requiring transfusion were conducted in hospitals in France, Germany, Italy, Spain and Sweden to determine the total length of stay (LOS), stay post-bleeding, procedures to identify the extent of bleeding, number and types of transfusion products, patient demographics, reason for hospital admission and disposition upon discharge. Country-specific costs were applied to estimate the average cost per patient by type of bleeding event. RESULTS: Records of 158 ACS patients with the bleeding complications were examined (26.9% decrease in Hb, 35.5% puncture site, and 37.8% transfusion). The average LOS was 10.6 days for decreasing Hb, 7.7 days for puncture site bleeding, and 11.3 days for patients receiving transfusions due to these bleeding events. The average costs per patient ranged between €3,986 and €10,252. The LOS ranged widely both within and across countries. LIMITATIONS: The study has a small sample size and costs are confounded by co-morbidities. CONCLUSIONS: The estimated costs for decreasing Hb, puncture site bleeding and bleeding resulting in transfusions provide a tool for researchers to conduct economic analyses of bleeding events associated with therapies for ACS.

[Advances in hypertension and diabetes]. / Temas de actualidad en hipertensión arterial y diabetes.

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year.

Temas de actualidad en hipertensión arterial y diabetes / Advances in hypertension and diabetes

Durante 2008 se han publicado importantes ensayos clínicos en patología cardiovascular, principalmente sobre pacientes hipertensos y diabéticos. Sus resultados, algunos inesperados, en ocasiones nos han permitido confirmar lo que ya sabíamos respecto al control de estos factores de riesgo, pero también han creado bastante debate sobre cuestiones previamente establecidas, como hasta dónde bajar la presión arterial y la glucemia en pacientes con enfermedad cardiovascular. También disponemos de información reciente sobre estrategias terapéuticas antihipertensivas basadas en nuevos fármacos o en combinaciones de fármacos ya existentes. En este artículo se revisan estos aspectos y también algunos registros promovidos por nuestra sección, publicados el pasado año (AU)

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year (AU)

[Biological markers of myocardial necrosis]. / Marcadores biológicos de necrosis miocárdica.

New biological markers of myocardial injury have improved the management of patients with acute coronary syndromes. Among these markers, the most relevant are the cardiac troponins (troponin I and troponin T) because of their cardiospecificity, and myoglobin because of its combination of diagnostic sensitivity and usefulness for an early diagnosis. The serial analysis and combined use of both markers fulfill all diagnostic and prognostic requirements, and are helpful in indicating therapeutic strategies for acute coronary syndromes. However, these markers also have limitations, and their concentrations should always be interpreted in the light of the patient's clinical status.

Marcadores biológicos de necrosis miocárdica / Biological markers of myocardial necrosis

La aparición de los nuevos marcadores biológicos de daño miocárdico, especialmente troponinas y mioglobina, ha supuesto un notable avance en el manejo de los pacientes con síndrome coronario agudo.Entre los marcadores biológicos de daño miocárdico destacan de manera especial las troponinas cardíacas (TnTc o TnIc), por su cardioespecificidad, y la mioglobina, por su combinación de sensibilidad y precocidad diagnóstica. El análisis seriado y el uso combinado de ambos marcadores permite cubrir las necesidades diagnósticas, pronósticas y de indicación terapéutica del síndrome coronario agudo. Sin embargo, a pesar sus indudables ventajas, hay que enfatizar la importancia de conocer sus limitaciones e interpretar sus resultados teniendo siempre muy en cuenta el contexto clínico de paciente (AU)