Exercise training response according to baseline ferrokinetics in heart failure with preserved ejection fraction: A substudy of the TRAINING-HF trial.

BACKGROUND: Iron deficiency (ID) is associated with impaired functional capacity in patients with heart failure (HF), even in those with preserved ejection fraction (HFpEF). This study aimed to evaluate the effect of baseline ferrokinetics on peak oxygen consumption (peakVO2) improvement after a 12-week physical therapy programme in patients with stable HFpEF. METHODS: This study is a post-hoc sub-analysis of a randomized clinical trial in which 59 stable patients with HFpEF were randomized to receive a 12-week programme of inspiratory muscle training (IMT), functional electrical stimulation (FES), IMT + FES or usual care (UC) to evaluate change in peakVO2 (NCT02638961). Serum ferritin and transferrin saturation (TSAT) determinations were assessed at baseline. ID was defined as ferritin <100 ng/mL and/or TSAT <20% if ferritin was within 100-299 ng/mL. We used a linear mixed regression model to analyse between-treatment changes in peakVO2 across ferrokinetics status at 12 and 24 weeks. RESULTS: The mean age was 74 ± 9 years, and 36 (61%) had ID. The mean of peakVO2 was 9.9 ± 2.5 mL/kg/min. The median of ferritin and transferrin saturation (TSAT) was 91 (50-181) ng/mL and 23% (16-30), respectively. A total of 52 patients completed the trial (13 patients per arm). Compared with those patients on UC, patients allocated to any of the active arms showed less improvement in peak VO2 when they showed ID (P-value for interaction <0.001), lower values of ferritin (P-value for interaction <0.001), or TSAT (P-value for interaction <0.001). CONCLUSIONS: Ferrokinetics status plays an essential role in modifying the aerobic capacity response to physical therapies in patients with HFpEF. Further studies are required to confirm these findings.

Cardiovascular prevention in elderly patients.

In recent decades, life expectancy has been increasing significantly. In this scenario, health interventions are necessary to improve prognosis and quality of life of elderly with cardiovascular risk factors and cardiovascular disease. However, the number of elderly patients included in clinical trials is low, thus current clinical practice guidelines do not include specific recommendations. This document aims to review prevention recommendations focused in patients ≥ 75 years with high or very high cardiovascular risk, regarding objectives, medical treatment options and also including physical exercise and their inclusion in cardiac rehabilitation programs. Also, we will show why geriatric syndromes such as frailty, dependence, cognitive impairment, and nutritional status, as well as comorbidities, ought to be considered in this population regarding their important prognostic impact.

Consenso de expertos en la asistencia multidisciplinaria y el abordaje integral de la insuficiencia cardiaca. Desde el alta hospitalaria hasta la continuidad asistencial con primaria / Expert consensus on multidisciplinary management and integrated approaches in heart failure. Continuity of care from hospital discharge to primary care

La insuficiencia cardiaca es una enfermedad que precisa un tratamiento multidisciplinario, dadas la diversidad de causas y entornos clínicos implicados que las tratan y las diferentes estrategias terapéuticas que precisan la participación indispensable de diversas disciplinas. La presencia en los servicios de cardiología de unidades de insuficiencia cardiaca centradas en el tratamiento de los pacientes con esta afección y unidades de rehabilitación cardiaca que, entre sus indicaciones para la reducción de la morbimortalidad, también están implicadas en la atención de esos mismos pacientes puede causar dificultades de coordinación y pérdida de una atención integral centrada en el paciente. Por estos motivos, en el presente documento se plantea una estrategia de coordinación entre las diferentes unidades implicadas en el tratamiento de los pacientes dentro de los servicios de cardiología y la continuidad asistencial con atención primaria, tanto tras haber conseguido la estabilidad como la interrelación para una coordinación posterior más efectiva

Heart failure is a condition that requires a multidisciplinary approach to treatment because of the wide range of causes and clinical contexts that may be involved and because the diverse treatment strategies used necessitate the participation of multiple disciplines. In cardiology departments, the presence of both heart failure units that focus on the treatment of affected patients and cardiac rehabilitation units that, as well as targeting reductions in morbidity and mortality, are also involved in caring for the same patients can create difficulties for coordination and can result in the loss of comprehensive patient-centered care. For these reasons, this paper presents a strategy for coordinating the different units involved in patient management in cardiology departments and for ensuring continuity of care in primary care, both immediately after achieving stabilization and subsequently, when these interactions are important for effective coordination

Coordinación de unidades de rehabilitación cardiaca hospitalaria con atención primaria. Incentivando la creación de unidades comunitarias / Coordination of hospital cardiac rehabilitation units with primary care. Encouraging the creation of community units

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Consenso de expertos en la coordinación de la rehabilitación cardiaca entre cardiología y atención primaria. Proyecto RehaCtivAP / Expert consensus on the coordination of cardiac rehabilitation between cardiology departments and primary care. The RehaCtivAP project

En la continuidad asistencial del paciente que ha sufrido un síndrome coronario agudo es fundamental la rehabilitación cardiaca. Es más, centrar los cuidados en el paciente obliga a coordinar la atención cardiológica con atención primaria para mejorar la adherencia a los programas y una atención continua adecuada. Los programas de rehabilitación cardiaca comunitaria son indispensables para cumplir con los objetivos preventivos, pero somos conscientes de las dificultades de implementación y la necesidad de apoyo de gestores y especialistas. Debemos ayudar a concienciar sobre esta necesidad y apoyar a los especialistas que tengan iniciativas en la creación de este tipo de programas. Este documento trata de sintetizar los puntos básicos de la atención y la coordinación entre cardiología y atención primaria para la creación y el desarrollo de estos programas comunitarios

Cardiac rehabilitation is an essential part of continuing care for patients who have experienced an acute coronary syndrome. Moreover, a patient-centered approach requires the coordination of cardiology care and primary care in order to improve adherence to rehabilitation programs and to ensure appropriate continuing care. Community cardiac rehabilitation programs are essential for achieving the objectives of disease prevention. However, implementation may be difficult and program managers and specialists may need support. It is important to raise awareness of the need to support specialists who have taken the initiative in creating these programs. The aim of this paper was to summarize the basic elements of care and of the coordination between cardiology departments and primary care needed to create and develop community cardiac rehabilitation programs

Aplicabilidad de los consensos de expertos de unidades de insuficiencia cardiaca/rehabilitación cardiaca y RehaCtivAP con respecto a la COVID-19 / Applicability of the consensus of experts from heart failure/cardiac rehabilitation units and RehaCtivAP regarding the COVID-19

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Effect of candesartan on coronary flow reserve in patients with systemic hypertension.

BACKGROUND: Patients with hypertension have structural and functional changes in conductance and resistance vessels. In the absence of coronary stenosis the coronary microvascular function can be analysed by studying the coronary reserve. The aim of this study was to evaluate, non-invasively, the effect of candesartan on coronary microvascular function in hypertensive patients. METHODS: Twenty-two hypertensive patients (> 40 years) without clinical coronary disease (age 63.86 +/- 10.3 years; women, 59.1%) were studied. In addition to blood pressure (BP), measurement of carotid intima-medial thickness (IMT), left ventricle mass index (LVMI) and the coronary flow reserve (CFR) were evaluated with echography at the beginning, and after 3 months of treatment with 16 mg/day of candesartan. Twelve hypertensive controls (64.50 +/- 10.8 years; women, 58.4%) completed the same study without any change in treatment. RESULTS: A 15% improvement in CFR (3.10 +/- 1.02 to 3.56 +/- 1.06; P = 0.001) was observed simultaneously with the BP reduction. There was no change in CFR in the control group (2.9 +/- 1.1 to 3.01 +/- 0.9; P = 0.23). The IMT was not modified significantly at the end of the follow-up (0.86 +/- 0.1 to 0.83 +/- 0.1 mm; P = 0.103). CONCLUSION: Candesartan improves the CFR in hypertensive patients. The improvement was not related to BP control or LVMI regression. Patients with a lower CFR show a better response to candesartan. This fact can be demonstrated non-invasively with echography after 3 months of therapy.

Endothelial dysfunction, intima-media thickness and coronary reserve in relation to risk factors and Framingham score in patients without clinical atherosclerosis.

BACKGROUND: Endothelial dysfunction, decreased coronary flow reserve (CFR) and increased intima-media thickness (IMT) are related to atherosclerosis and can be assessed non-invasively by echography. OBJECTIVES: In order to describe the relationship between these parameters and with cardiovascular risk, this study investigated them simultaneously in patients without clinical atherosclerosis. METHODS: A total of 106 subjects were studied, 91 with and 15 without cardiovascular risk factors. Cardiovascular disease was excluded in all cases. Doppler ultrasound was used to analyse endothelium-dependent vascular dilation in the brachial artery, IMT in the common carotid artery and CFR in the left anterior artery. RESULTS: Patients with cardiovascular risk factors had impaired flow-mediated dilation (FMD; 3.7 +/- 3.2 versus 11.6 +/- 4.4%, P = 0.000); greater IMT (0.89 +/- 0.3 versus 0.56 +/- 0.14 mm, P = 0.000) and lower CFR (2.7 +/- 0.9 versus 4 +/- 1.2, P = 0.000). Correlation was found between IMT and FMD r = -0.240, (P = 0.013), IMT and CFR, r = -0.384 (P = 0.000), and between FMD and CFR of r = 0.289 (P = 0.007). All patients with IMT greater than 1 mm showed depressed FMD, most of them with low values of CFR, but patients with reduced FMD or CFR did not necessarily show increased IMT. There was a significant correlation between the three parameters and the Framingham risk score. Multiple linear regression analysis showed that IMT was the only factor related to the Framingham score. CONCLUSION: In patients without clinical atherosclerotic disease, cardiovascular risk factors are associated with impaired FMD, CFR and increased IMT. Even though a correlation between these changes was found, they showed different dependence on cardiovascular risk factors and with global risk, IMT being the best correlated with the Framingham score.

[Moderate coronary lesion with severe vasospasm and the development of collateral circulation in a patient with effort angina and ST-segment depression]. / Espasmo coronario severo en una lesión moderada y desarrollo de circulación colateral en un paciente con angina estable y descenso del segmento ST con el esfuerzo.

Coronary collateral circulation usually develops as a consequence of recurrent ischemia associated with severe stenosis. In exceptional cases, it can develop with moderate coronary lesions if there is severe recurrent vasospasm. In this situation, the presenting clinical features of vasospastic angina (i.e., effort angina with ST-segment depression) can be identical to those of a severe permanent lesion. We present a patient who exhibited effort angina and ST-segment depression on treadmill testing. Angiography showed severe right coronary artery stenosis and the development of coronary collateral circulation from the other main artery. After repeated intracoronary bolus injection of nitroglycerin, only a moderate stenosis was still apparent and the collateral circulation had disappeared.

Espasmo coronario severo en una lesión moderada y desarrollo de circulación colateral en un paciente con angina estable y descenso del segmento ST con el esfuerzo / Moderate coronary lesion with severe vasospasmand the development of collateral circulation in a patient with effort angina and ST-segment depression

La circulación colateral coronaria aparece como consecuencia de la isquemia miocárdica recurrente, generalmente debida a lesiones coronarias severas y fijas, y de manera excepcional puede desarrollarse en lesiones no significativas provocadas por un vasospasmo coronariosevero. En esta situación, la angina vasospástica puede manifestarse como una angina de esfuerzo con descenso del segmento ST. Presentamos el caso de un paciente con angina de esfuerzo, ergometría clínicamente positiva y descenso horizontal del segmento ST. En la angiografía se observó una estenosis crítica en la arteria coronaria derecha y el desarrollo de circulación colateral heterocoronaria. Tras la administración de nitroglicerina intracoronaria, la lesión finalmente fue moderada con desaparición de la circulación colateral

Coronary collateral circulation usually develops as a consequence of recurrent ischemia associated with severe stenosis. In exceptional cases, it can develop with moderate coronary lesions if there is severe recurrent vasospasm. In this situation, the presenting clinical features of vasospastic angina (i.e., effort angina with ST-segment depression) can be identical to those of a severe permanent lesion. We present a patient who exhibited effort angina and ST-segment depression on treadmill testing. Angiography showed severe right coronary artery stenosis and the development of coronary collateral circulation from the othermain artery. After repeated intracoronary bolus injectionof nitroglycerin, only a moderate stenosis was still apparent and the collateral circulation had disappeared

[Noninvasive assessment of the effect of atorvastatin on coronary microvasculature and endothelial function in patients with dyslipidemia]. / Determinación no invasiva del efecto de atorvastatina en la microvasculatura coronaria y la función endotelial periférica de pacientes dislipémicos.

INTRODUCTION AND OBJECTIVES: The effect of statins has been monitored mainly in peripheral arteries. It is now possible to study coronary microcirculation by analyzing coronary reserve with transthoracic echocardiography. The aim of this study was to use this noninvasive technique to evaluate the effect of atorvastatin on peripheral endothelial function and on the coronary microvasculature in patients with dyslipidemia. PATIENTS AND METHOD: We included 21 patients with dyslipidemia but no clinical antecedents of atherosclerosis. Mean (SD) age was 64.9 (11) years, and women made up 61.9% of the group. All patients were treated with 20 mg atorvastatin during 3 months. Lipid profile, carotid intima-media thickness, endothelium-dependent vasodilation and coronary flow reserve were determined at baseline and at the end of treatment. All studies were performed with echocardiographic techniques. RESULTS: Together with improvements in the lipid profile, we found a 43% increase in endothelium-dependent vasodilation (4.3 [4.4] to 6.2 [3.8]; P=.07) and a 25% increase in coronary flow reserve (2.5 [0.6] vs 3.1 [0.8]; P=.002). The increase in endothelium-dependent vasodilatation correlated with age (r=-0.60; P=.004), intima-media thickness (r=-0.47; P=.029), low-density lipoprotein level before treatment (r=-0.43; P=.05), and baseline endothelium-dependent vasodilatation (r=-0.63; P=.002). The increase in coronary flow reserve correlated with low-density lipoprotein level after treatment (r=-0.51; P=.04). CONCLUSIONS: Short-term treatment with atorvastatin improved the lipid profile, coronary microvascular function and endothelium-dependent vasodilation in the peripheral circulation. The noninvasive assessment of coronary reserve is feasible with transthoracic echocardiography.

[Endothelial dysfunction and intima-media thickness in relation to cardiovascular risk factors in patients without clinical manifestations of atherosclerosis]. / Asociación de la disfunción endotelial y el grosor mediointimal carotídeo con los factores de riesgo coronario en pacientes sin evidencia clínica de aterosclerosis.

INTRODUCTION: Endothelial dysfunction and increased intima-media thickness are early findings in the development of atherosclerosis that can be assessed non-invasively by echography. The aim of this study was to investigate endothelial function and intima-media thickness, and the relation between these processes and cardiovascular risk factors in patients without clinical atherosclerosis. PATIENTS AND METHOD: Fifty-two subjects were studied, 39 with one or more cardiovascular risk factors and 13 with none. Vascular echography was performed to analyze endothelium-dependent vascular dilatation in the brachial artery and intima-media thickness in the common carotid artery. RESULTS: Compared to patients without risk factors, patients with cardiovascular risk factors more frequently had impaired vascular dilatation after ischemia, 11.98 4.61% vs 2.77 2.57%, (P<.0.001; mean difference = 9.21%, 95% CI of the difference 6.33-12.07%) and a greater intima-media thickness, 0.085 0.024% vs 0.057 0.014 cm (P < 0.0001; mean difference = 0.028 cm, 95% CI of the difference, 0.017-0.04 cm). There was a significant negative correlation between intimal-media thickness and endothelial dysfunction (r = -0.357; P<0.01). Linear regression analysis showed that intima-media thickness was independently related to age and the presence of hypertension, while endothelial function was related only with the presence of hypertension, smoking, and hyperlipoproteinemia. CONCLUSIONS: In patients without clinical atherosclerotic disease, cardiovascular risk factors were associated with impaired endothelial function and increased intima-media thickness. There was a negative correlation between endothelial-dependent vascular dilatation and intima-media thickness.

Asociación de la disfunción endotelial y el grosor mediointimal carotídeo con los factores de riesgo coronario en pacientes sin evidencia clínica de aterosclerosis / Endothelial dysfunction and intima-media thickness in relation to cardiovascular risk factors in patients without clinical manifestations of atherosclerosis

Introducción y objetivos. La disfunción endotelial y el aumento del grosor mediointimal carotídeo son fenómenos tempranos en el desarrollo de la aterosclerosis, que pueden estudiarse de forma incruenta por ecocardiografía. Se pretende analizar la función endotelial, el grosor mediointimal carotídeo y la correlación entre ambos parámetros con los factores de riesgo coronario en pacientes sin evidencia clínica de aterosclerosis. Pacientes y método. Se incluyeron 52 sujetos, 13 sin ningún factor de riesgo coronario y 39 con al menos un factor de riesgo coronario. Se les realizó una medición ecocardiográfica de la vasodilatación dependiente del endotelio en la arteria braquial y del grosor mediointimal en la carótida común. Resultados. En comparación con los sujetos sin factores de riesgo coronario, los pacientes con factores de riesgo presentaron una disminución de la vasodilatación dependiente del endotelio: 11,98 ñ 4,61 por ciento frente a 2,77 ñ 2,57 por ciento, (p < 0,0001; diferencia de medias del 9,21 por ciento con un IC del 95 por ciento de 6,33-12,07), y un aumento del grosor mediointimal carotídeo de 0,085 ñ 0,024 cm frente a 0,057 ñ 0,014 cm (p = 0,0002; diferencia de medias de 0,028 cm con un IC del 95 por ciento de 0,017-0,04). Se obtuvo una correlación estadísticamente significativa entre el grosor mediointimal carotídeo y la vasodilatación dependiente del endotelio (r = -0,357; p < 0,01). En el análisis de regresión lineal múltiple, el grosor mediointimal carotídeo dependía de la edad y de la presencia de hipertensión arterial, mientras que la vasodilatación dependiente del endotelio lo hacía de la presencia de hipertensión, tabaquismo y dislipemia. Conclusiones. En pacientes sin evidencia clínica o complicaciones ateroscleróticas pero con factores de riesgo coronario, la función endotelial es peor y el grosor mediointimal carotídeo es mayor que en pacientes sin ellos. Además, existe una asociación lineal negativa entre la vasodilatación dependiente del endotelio y el grosor mediointimal (AU)