Incidence of long-term cardiotoxicity and evolution of the systolic function in patients with breast cancer treated with anthracyclines.

BACKGROUND: Anthracycline cardiotoxicity (AC) may manifest years after treatment (long-term cardiotoxicity). There is little data on the incidence and natural history of AC in the current context, with protocols including lower anthracycline doses. The present study prospectively evaluated the incidence, time of occurrence and clinical correlates of long-term cardiotoxicity and the evolution of systolic function in patients with breast cancer treated with anthracyclines. METHODS: This study prospectively included 85 consecutive patients undergoing chemotherapy (CHT) with anthracyclines without trastuzumab. All patients underwent evaluation at baseline, at the end of CHT, 3 months after the end of CHT and 1 and 4 years subsequent to the beginning of CHT. Clinical data and echocardiographic parameters were evaluated in all examinations. RESULTS: The mean dose of doxorubicin used was 243.53 mg/m2. Median follow-up of the current cohort was 4.5 years. At 1 year the incidence of AC was 1% and at the end of the follow-up 16.5% (14 of 85 patients). Therefore, the incidence of late cardiotoxicity (after the first year) was 15%. Of these 14 patients with AC, 12 had asymptomatic systolic dysfunction, 1 had heart failure and 1 suffered sudden death. Fifteen percent developed systolic dysfunction during follow-up. An early decline in strain was observed in patients who developed long-term AC. CONCLUSIONS: The incidence of long-term cardiotoxicity in patients treated with low-cumulative dose of anthracyclines is high, 16.5% at 4.5 years. This was observed in almost all cases after the first year of follow-up. Therefore, long-term monitoring may be advisable.

Hallazgos electrocardiográficos anormales en la población mayor de 40 años. Prevalencia y significación clínica. Resultados del estudio OFRECE / Abnormal electrocardiographic findings in the population older than 40 years. Prevalence and clinical significance. Results of the OFRECE study

Introducción y objetivos: Las anomalías electrocardiográficas son muy comunes. El propósito de este estudio es analizar la prevalencia de hallazgos electrocardiográficos anormales y su significado clínico en la población general española de 40 o más años. Métodos: Subanálisis del estudio OFRECE; se seleccionó una muestra representativa de la población española de 40 o más años. Se dispuso de datos clínicos y electrocardiograma de todos los participantes. La lectura de los electrocardiogramas fue centralizada, los evaluaron de manera independiente 2 cardiólogos expertos y se consultó con un tercero en caso de desacuerdo, para llegar al diagnóstico final por consenso. Antes de iniciarse la lectura de los electrocardiogramas, se establecieron estrictamente los criterios diagnósticos de cada una de las anomalías analizadas. Se estudiaron la prevalencia y los factores clínicos asociados con: crecimiento de cavidades, trastornos de conducción, anomalías de la repolarización, ondas Q patológicas, extrasistolia auricular y ventricular y preexcitación. Resultados: Se evaluó a 8.343 individuos (media de edad, 59,2 años; el 52,4% mujeres). Solo 4.074 (51,2%) presentaron un electrocardiograma rigurosamente normal. Las anomalías más frecuentes fueron las alteraciones inespecíficas de la repolarización (16%) asociadas con enfermedad coronaria y fibrilación auricular; el bloqueo de rama derecha (8,1%) asociado con enfermedad pulmonar obstructiva crónica; el hemibloqueo anterosuperior izquierdo (6,5%) relacionado con la hipertensión y la insuficiencia cardiaca y el intervalo PR largo (3,7%) se asociaron con enfermedad coronaria. Conclusiones: Las anomalías electrocardiográficas son muy comunes en la población general de 40 o más años. Tan solo la mitad de la población tenía un electrocardiograma rigurosamente normal

Introduction and objectives: Abnormal electrocardiographic findings are highly common. The aim of this study was to analyze the prevalence of abnormal electrocardiographic patterns in the general Spanish population aged 40 years or older. Methods: This subanalysis of the OFRECE study selected a representative sample of the Spanish population aged 40 years or older. Clinical data and electrocardiograms were available in all participants. The electrocardiograms were read centrally. Each electrocardiogram was independently assessed by 2 trained cardiologists and, if there was disagreement, a third was consulted to reach a consensus-based diagnosis. Prior to reading the electrocardiograms, diagnostic criteria were strictly defined for each of the abnormalities analyzed. We analyzed the prevalence and clinical factors associated with cavity enlargement, conduction disorders, repolarization abnormalities, pathological Q waves, atrial and ventricular premature beats, and pre-excitation. Results: A total of 8343 individuals were evaluated, (mean age, 59.2 years; 52.4% women). Only 4074 (51.2%) participants had a completely normal electrocardiogram. The most frequent abnormalities were nonspecific repolarization abnormalities (16%) associated with coronary heart disease and atrial fibrillation; right bundle-branch block (8.1%) associated with chronic pulmonary obstructive disease; left anterior hemiblock (6.5%) related to hypertension and congestive heart failure; and long PR interval (3.7%), which was associated with coronary heart disease. Conclusions: Electrocardiographic abnormalities are very common in the general population aged 40 years or older. Only about half of the population had a completely normal electrocardiogram

Abnormal Electrocardiographic Findings in the Population Older Than 40 Years. Prevalence and Clinical Significance. Results of the OFRECE Study.

INTRODUCTION AND OBJECTIVES: Abnormal electrocardiographic findings are highly common. The aim of this study was to analyze the prevalence of abnormal electrocardiographic patterns in the general Spanish population aged 40 years or older. METHODS: This subanalysis of the OFRECE study selected a representative sample of the Spanish population aged 40 years or older. Clinical data and electrocardiograms were available in all participants. The electrocardiograms were read centrally. Each electrocardiogram was independently assessed by 2 trained cardiologists and, if there was disagreement, a third was consulted to reach a consensus-based diagnosis. Prior to reading the electrocardiograms, diagnostic criteria were strictly defined for each of the abnormalities analyzed. We analyzed the prevalence and clinical factors associated with cavity enlargement, conduction disorders, repolarization abnormalities, pathological Q waves, atrial and ventricular premature beats, and pre-excitation. RESULTS: A total of 8343 individuals were evaluated, (mean age, 59.2 years; 52.4% women). Only 4074 (51.2%) participants had a completely normal electrocardiogram. The most frequent abnormalities were nonspecific repolarization abnormalities (16%) associated with coronary heart disease and atrial fibrillation; right bundle-branch block (8.1%) associated with chronic pulmonary obstructive disease; left anterior hemiblock (6.5%) related to hypertension and congestive heart failure; and long PR interval (3.7%), which was associated with coronary heart disease. CONCLUSIONS: Electrocardiographic abnormalities are very common in the general population aged 40 years or older. Only about half of the population had a completely normal electrocardiogram.

Prevalencia de patrones electrocardiográficos asociados a muerte súbita en la población española de 40 años o más. Resultados del estudio OFRECE / Prevalence of electrocardiographic patterns associated with sudden cardiac death in the spanish population aged 40 years or older. Results of the OFRECE study

Introducción y objetivos: Hay patrones electrocardiográficos asociados a mayor riesgo de muerte súbita por arritmias ventriculares. En España no existe información acerca de su prevalencia en la población. El objetivo es estudiar la prevalencia de estos patrones, así como los factores clinicoepidemiológicos asociados a su presencia. Métodos: Subanálisis del estudio OFRECE en el que se estudió la prevalencia de patrones electrocardiográficos de síndrome de Brugada o anomalías del intervalo QT en una muestra representativa de la población española ≥ 40 años. Se dispuso de datos clínicos y electrocardiogramas de todos los participantes. Los electrocardiogramas fueron evaluados de forma independiente por 2 cardiólogos y, en caso de desacuerdo, se consultó con un tercero. Se analizaron las prevalencias ponderadas y los factores clínicos asociados a patrones tipo Brugada o a anomalías del segmento QT. Resultados: Se evaluó a 8.343 individuos (59,2 años, 52,4% mujeres) y se detectaron 12 casos de patrón Brugada (tipo 1, 2 casos; tipo 2, 10 casos; prevalencia ponderada, 0,13%). Para el análisis del QT corregido (QTc) se excluyó a los participantes con bloqueo de rama izquierda o ritmos no sinusales. Las prevalencias ponderadas fueron: QTc corto (< 340 ms) 0,18%, QTc borderline(441-469 ms) 8,33%, QTc largo (criterio ≥ 470 ms) 1,01% y QTc largo (criterio ≥ 480 ms) 0,42%. Conclusiones: El 0,6-1,1% de la población española de edad ≥ 40 años presenta un patrón electrocardiográfico de riesgo de muerte súbita (síndrome de Brugada, QT largo o QT corto) (AU)

Introduction and objectives: Some electrocardiographic patterns are associated with an increased risk of sudden cardiac death due to ventricular arrhythmias. There is no information on the prevalence of these patterns in the general population in Spain. The objective of this study was to analyze the prevalence of these patterns and associated clinical and epidemiological factors. Methods: This subanalysis of the OFRECE study selected a representative sample of the Spanish population aged ≥ 40 years. We studied the presence or absence of electrocardiographic patterns of Brugada syndrome and QT interval abnormalities. Clinical data and electrocardiograms were available in all participants. Electrocardiograms were evaluated by 2 cardiologists and a third cardiologist was consulted if there was disagreement in the diagnosis. We calculated the weighted prevalence and clinical factors associated with the presence of Brugada-type patterns or QT segment abnormalities. Results: Overall, 8343 individuals were evaluated (59.2 years, 52.4% female). There were 12 Brugada cases (type 1, 2 cases; type 2, 10 cases; weighted prevalence, 0.13%). For corrected QT (QTc) analysis, we excluded participants with left bundle branch block or without sinus rhythm. Weighted prevalences were as follows: short QTc (< 340 ms) 0.18%, borderline QTc (441-469 ms) 8.33%, long QTc (≥ 470 ms criterion) 1.01% and long QTc (≥ 480 criterion) 0.42%. Conclusions: A total of 0.6% to 1.1% of the Spanish population aged ≥ 40 years has an electrocardiographic pattern associated with a higher risk of sudden death (Brugada syndrome, long QT, or short QT) (AU)

Prevalence of Electrocardiographic Patterns Associated With Sudden Cardiac Death in the Spanish Population Aged 40 Years or Older. Results of the OFRECE Study.

INTRODUCTION AND OBJECTIVES: Some electrocardiographic patterns are associated with an increased risk of sudden cardiac death due to ventricular arrhythmias. There is no information on the prevalence of these patterns in the general population in Spain. The objective of this study was to analyze the prevalence of these patterns and associated clinical and epidemiological factors. METHODS: This subanalysis of the OFRECE study selected a representative sample of the Spanish population aged ≥ 40 years. We studied the presence or absence of electrocardiographic patterns of Brugada syndrome and QT interval abnormalities. Clinical data and electrocardiograms were available in all participants. Electrocardiograms were evaluated by 2 cardiologists and a third cardiologist was consulted if there was disagreement in the diagnosis. We calculated the weighted prevalence and clinical factors associated with the presence of Brugada-type patterns or QT segment abnormalities. RESULTS: Overall, 8343 individuals were evaluated (59.2 years, 52.4% female). There were 12 Brugada cases (type 1, 2 cases; type 2, 10 cases; weighted prevalence, 0.13%). For corrected QT (QTc) analysis, we excluded participants with left bundle branch block or without sinus rhythm. Weighted prevalences were as follows: short QTc (< 340ms) 0.18%, borderline QTc (441-469ms) 8.33%, long QTc (≥ 470ms criterion) 1.01% and long QTc (≥ 480 criterion) 0.42%. CONCLUSIONS: A total of 0.6% to 1.1% of the Spanish population aged ≥ 40 years has an electrocardiographic pattern associated with a higher risk of sudden death (Brugada syndrome, long QT, or short QT).

[Coronary revascularization: clinical features and indications]. / Indicaciones de revascularización: aspectos clínicos.

Coronary artery revascularization is an established therapeutic intervention and is therefore included in all treatment guidelines for patients with coronary artery disease. Although the procedure has been available for more than 40 years, constant technical progress in surgical and percutaneous revascularization continues to bring the benefits of revascularization therapy to new groups of patients. Therefore the indications and limitations of this approach need to be reviewed and updated periodically. The aim of revascularization therapy is to improve the prognosis or symptoms and quality of life in patients with ischemic heart disease. The revascularization process comprises two aspects: 1) indication and selection of the revascularization procedure, and 2) performance of the procedure. Involvement of the clinical cardiologist in the first step is fundamental. Basing their decisions on clinical, functional and anatomical features, these professionals detect and select patients who would benefit, and also help to select the revascularization technique. In this Update article on revascularization we review, for stable ischemic heart disease and non-ST segment elevation acute coronary syndromes, the following: 1) the most relevant aspects to consider when evaluating the need for and the type of revascularization (age, sex, diabetes, renal function, electrocardiographic changes, ventricular function and quantification of functional relevance of coronary artery disease and viability of the acinetic areas); 2) indications for surgical or percutaneous intervention, and the choice of therapeutic strategy according to the latest clinical evidence and guidelines of scientific societies, and 3) currently available data on the controversy regarding choice of the revascularization procedure in patients with multivessel disease.

Indicaciones de revascularización: aspectos clínicos / Coronary revascularization: clinical features and indications

La revascularización coronaria es una intervención terapéutica plenamente consolidada y, por tanto, incluida en todas las estrategias de tratamiento de los pacientes con enfermedad coronaria. A pesar de sus más de 40 años de desarrollo, los continuos avances técnicos, tanto de la revascularización quirúrgica como de la percutánea, hacen que cada vez haya más grupos de pacientes en los que se ha demostrado su utilidad. Por tanto, es necesario actualizar periódicamente sus indicaciones y limitaciones. El objetivo de la revascularización es mejorar el pronóstico o la sintomatología y calidad de vida de los pacientes con cardiopatía isquémica. La revascularización comprende2 aspectos: 1) la indicación y selección del tipo de revascularización y 2) la intervención revascularizadora. En el primero, la participación del cardiólogo clínico es fundamental. Su misión consiste en detectar y seleccionar, sobre a base de datos clínicos, funcionales y anatómicos, a los pacientes que se pueden beneficiar de la revascularización, así como ayudar en la selección de la técnica. En este artículo de «Puesta al Día» sobre revascularización se revisarán, referidos a la cardiopatía isquémica estable y al síndrome coronario agudo sin elevación del ST: 1) los aspectos clínicos más relevantes que es necesario considerar en la valoración de la necesidad o el tipo de revascularización (edad, género, diabetes, función renal, alteraciones electrocardiográficas, función ventricular, cuantificación de la importancia funcional de la enfermedad coronaria o el grado de viabilidad de áreas acinéticas); 2) las indicaciones, tanto de la cirugía como de la angioplastia coronaria, y la estrategia terapéutica de acuerdo con las últimas evidencias y recomendaciones de las sociedades científicas, y 3) los datos disponibles en el momento actual sobre la controversia de la selección del tipo de revascularización en los pacientes con enfermedad multivaso

Coronary artery revascularization is an established therapeutic intervention and is therefore included in all treatment guidelines for patients with coronary artery disease. Although the procedure has been available for more than40 years, constant technical progress in surgical and percutaneous revascularization continues to bring the benefits of revascularization therapy to new groups of patients. Therefore the indications and limitations of this approach need to be reviewed and updated periodically. The aim of revascularization therapy is to improve the prognosis or symptoms and quality of life in patients with ischemic heart disease. The revascularization process comprises two aspects: 1) indication and selection of there vascularization procedure, and 2) performance of the procedure. Involvement of the clinical cardiologist in the first step is fundamental. Basing their decisions on clinical, functional and anatomical features, these professionals detect and select patients who would benefit, and also help to select the revascularization technique. In this Update article on revascularization we review, for stable ischemic heart disease and non-ST segment elevation acute coronary syndromes, the following: 1) the most relevant aspects to consider when evaluating the need for and the type of revascularization (age, sex, diabetes, renal function, electrocardiographic changes, ventricular function and quantification of functional relevance of coronary artery disease and viability of the acinetic areas);2) indications for surgical or percutaneous intervention, and the choice of therapeutic strategy according to the latest clinical evidence and guidelines of scientific societies, and 3) currently available data on the controversy regarding choice of the revascularization procedure in patients with multivessel disease

Estrategia invasiva contemporánea en los pacientes con síndrome coronario agudo sin elevación del segmento ST / Contemporary invasive treatment in patients with non-st-segment elevation acute coronary syndrome

Los estudios publicados desde 1999 que compararon una estrategia invasiva moderna (con disponibilidad de stent y nuevos antitrombóticos) y conservadora (invasiva selectiva) en los pacientes con síndrome coronario agudo sin elevación del ST han demostrado que la estrategia invasiva disminuye, a largo plazo, la incidencia de muerte o infarto y mejora la evolución clínica en los pacientes de alto riesgo, aunque durante la hospitalización aumenta levemente las complicaciones isquémicas. El momento de realizar la coronariografía es controvertido, aunque la mayoría de las guías recomiendan que se haga en las primeras 48 h. Los pacientes que más se benefician son los que presentan cambios en el ST, elevación de troponinas o diabetes. Los de bajo riesgo con ambas estrategias tienen resultados similares. El beneficio de la estrategia invasiva se atribuye a la revascularización mecánica, pero también al uso de los nuevos antitrombóticos (clopidogrel e inhibidores de la glucoproteína IIb/IIIa). La utilización de clopidogrel está recomendada por la mayoría de las guías, aunque el momento de su aplicación es objeto de controversia y los datos más recientes indican que parece preferible la heparina no fraccionada si se planifica una estrategia invasiva. La administración precoz de inhibidores de la glucoproteína IIb /IIIa (tirofibán o eptifibatida) está indicada. En los casos en que la coronariografía se realiza tempranamente (menos de 2,5-6 h), el uso de abciximab o eptifibatida en el laboratorio de hemodinámica, una vez conocida la anatomía coronaria, parece una estrategia razonable (AU)

Studies published since 1999 that have compared modern invasive treatment (following the availability of stents and new antithrombotic drugs) in patients with non-STsegment elevation acute coronary syndrome (NSTACS) with more conservative (i.e., selectively invasive) treatment have shown that the long-term outcome is better in high-risk patients when the invasive approach is used. Mortality and myocardial infarction are less likely, although the number of ischemic complications occurring during hospitalization is slightly increased. There is still some controversy about how soon coronary angiography should be performed. Most guidelines recommend carrying it out during the first 48 hours in high-risk patients. The benefit is greatest in those who presented with STsegment alterations, an elevated troponin level, or diabetes. The better results achieved with the invasive approach in high-risk patients are not only due to the effect of mechanical revascularization, but also to the use of new, more aggressive antithrombotic drugs, such as clopidogrel or glycoprotein IIb/IIIa inhibitors. Although clopidogrel is recommended by most guidelines, the timing of administration is still controversial. Recent data indicate that unfractioned heparin should be used in NSTACS patients who are expected to undergo invasive treatment. The early administration of glycoprotein IIb/IIIa inhibitors (e.g., tirofiban or eptifibatide) until several hours after percutaneous intervention is universally indicated, except when coronary angiography is to be carried out within 2.5-6 hours. In these cases, giving abciximab or eptifibatide in the catheterization laboratory seems to be a reasonable approach once the coronary anatomy is known and angioplasty has been decided on (AU)