Response to interleukin-1 blockade with anakinra in women and men with ST-segment elevation myocardial infarction.

BACKGROUND: Interleukin-1 blockade with anakinra reduces high-sensitivity C-reactive protein (hsCRP) levels and prevents heart failure (HF) events after ST-segment myocardial infarction (STEMI). Sex-based differences in STEMI patients have been reported, but no data are available regarding response to anakinra. METHODS: We analyzed the systemic inflammation and composite end-point of new-onset HF or death in women and men with STEMI treated with anakinra from three different Virginia Commonwealth University Anakinra Response Trial (VCUART) randomized clinical trials. RESULTS: We analyzed 139 patients, 29 (21%) were women while 110 (79%) were men. Baseline hsCRP was higher in women compared to men (8.9 [5.2-13.5] vs. 4.2 [2.1-7.7] mg/L, P<0.001). Eighty-four patients were treated with anakinra (22 [75%] women and 62 [56%] men). The area under the curve of hsCRP (hsCRP-AUC) after 14 days was numerically lower in patients receiving anakinra versus placebo both in men (86 [37-130] vs. 223 [119-374] mg day/L) and in women (73 [46-313] vs. 242 [102-988] mg day/L) (P<0.001 for multiple groups, P for interaction 0.22). The incidence of the composite endpoint was also numerically lower in the anakinra group compared to placebo, both in men (4 [6.4%] vs. 14 [29.1%]) and in women (3 [13.6%] vs. 2 [28.5%]) (P=0.019 for multiple groups, P for interaction 0.44). There were no statistically significant differences between women and men in hsCRP-AUC and death or HF events when comparing separately the anakinra and placebo groups (all P>0.05). CONCLUSIONS: Women were underrepresented in the VCUART trials, they appeared to have higher hsCRP levels at time of presentation, yet to benefit similar to men by treatment with anakinra in STEMI.

Prognostic relevance of female gender on mortality after peripheral artery disease revascularization.

INTRODUCTION: Lower limb peripheral artery disease (PAD) presents high morbidity and mortality. Women represent a small subgroup in different studies, with scarce evidence regarding the prognosis of this gender on PAD. The aim of the present work was to determine the prognostic impact of female gender on lower limb PAD revascularization. METHODS: This was a retrospective, single-center study, including patients undergoing symptomatic lower limb PAD revascularization. RESULTS: Among a total of 309 patients included in the study, 109 belonged to the female gender (35%). Women were older and presented lower prevalence of cardiovascular risk factors compared with the male gender. All-cause mortality (22% vs. 12%, p = 0.02) and rehospitalizations for chronic limb-threatening ischemia (18% vs. 10%, p = 0.04) rates were significantly higher in women. In a multivariate regression model, female gender was independently associated with all-cause mortality (OR 2.19 [95% CI: 1.06-4.51], p = 0.03). The timeto-event showed that women exhibited 93% more risk of suffering death than men, after adjusting for clinically relevant variables (HR 1.93 [95% CI: 1.04-3.56], p = 0.04). DISCUSSION: Women with symptomatic PAD revascularization presented worse prognosis than men in terms of all-cause mortality and re-hospitalizations for chronic limb-threatening ischemia rates. Therefore, it is essential to achieve an adequate control of cardiovascular risk factors, as well as to optimize medical treatment in female patients.

Introducción: La enfermedad arterial de miembros inferiores (EAMI) presenta elevada morbimortalidad. Las mujeres constituyen un subgrupo minoritario en distintos estudios, con escasa evidencia acerca del pronóstico por género en EAMI. Nuestro objetivo fue determinar el impacto pronóstico del género femenino en la revascularización de EAMI. Métodos: Estudio de cohorte retrospectivo y unicéntrico, que incluyó pacientes con EAMI sintomática y revascularizada. Resultados: Se incluyeron 309 pacientes, de los cuales 109 (35%) eran mujeres. Las mujeres fueron más añosas y presentaron menor prevalencia de factores de riesgo cardiovascular en comparación a los hombres. Las tasas de mortalidad por todas las causas (22% vs. 12%, p = 0.02) y de hospitalizaciones por isquemia crítica (18% vs. 10%, p 0.04) fueron significativamente mayores en mujeres. En el modelo de regresión multivariado, el sexo femenino se asoció de forma independiente con mortalidad por todas las causas (OR 2.19 [IC 95%: 1.06-4.51], p = 0.03). En el análisis de tiempo al evento, las mujeres tuvieron 93% más riesgo de morir que los hombres, luego de ajustar por variables clínicamente relevantes (HR 1.93 [IC 95%: 1.04-3.56], p = 0.04). Discusión: Las mujeres con EAMI sintomática y revascularizada presentaron un peor pronóstico en comparación a los hombres en términos de tasas de mortalidad por todas las causas y de hospitalizaciones por isquemia crítica de miembros inferiores. Por lo tanto, es fundamental lograr un adecuado control de factores de riesgo cardiovascular, como así también, optimizar el tratamiento médico en el género femenino.

Procedural and long-term outcomes of elective endovascular abdominal aortic aneurysm repair in octogenarians / Resultados perioperatorios y a largo plazo de la reparación electiva endovascular del aneurisma de aorta abdominal en octogenarios

Abstract Objective: The aim of the study was to compare the immediate and long-term outcomes of endovascular aneurysm repair (EVAR) between patients under and over the age of 80 with abdominal aortic aneurysm (AAA). Methods: From 2011 to 2017, we conducted a retrospective cohort study with AAA patients who received elective EVAR. Primary outcomes included hospital mortality, length of stay, acute kidney injury, and the need for re-interventions. Secondary outcomes included aneurysm-related mortality, acute myocardial infarction, stroke, acute limb ischemia, and prolonged mechanical ventilation. Results: A total of 77 (62.6%) patients under the age of 80 years old and 46 (37.4%) octogenarians were included in the study. The male gender and AAA diameter did not differ among groups (92.2% vs. 82.6%, p = 0.11 and 5.4 cm [4.9-6.2 cm] vs. 5.4 cm [5-6 cm], p = 0.53, respectively). The younger patients had a higher prevalence of tobacco use (72.7% vs. 41.7%, p = 0.01). There were no deaths during the index hospitalization. The incidence of reinterventions (5.3% vs. 15.2%, p = 0.11) and acute kidney injury (14.3% vs. 23.9%, p = 0.18) did not differ between groups, but the length of stay was longer for octogenarian patients (3 days [2-4] vs. 2 days [2-3, p = 0.04]). Endoleaks were the most common cause for re-interventions (81.8%), with a prevalence of 34% across the entire cohort. There were no differences in any of the secondary outcomes between groups. Conclusion: In octogenarian patients with AAA, EVAR represents a safe procedure both during the index hospitalization and during long-term follow-up.

Resumen Objetivo: Comparar los resultados inmediatos y a largo plazo de la reparación endovascular del aneurisma de aorta abdominal (REVA) entre pacientes menores de 80 años y octogenarios. Método: Cohorte retrospectiva que incluyó pacientes con aneurisma de aorta abdominal (AAA) sometidos a REVA electiva desde 2011 hasta 2017. Se evaluaron como punto finales primarios la mortalidad hospitalaria, la duración de la estadía hospitalaria, la incidencia de insuficiencia renal aguda y el requerimiento de reintervenciones. Los puntos finales secundarios incluyeron la mortalidad asociada al aneurisma, infarto agudo de miocardio, accidente cerebrovascular, isquemia arterial aguda de las extremidades y ventilación mecánica prolongada. Resultados: Se incluyeron 77 (62.6%) pacientes menores de 80 años y 46 (37.4%) octogenarios. La prevalencia de sexo masculino y el diámetro del AAA no difirieron entre ambos grupos (92.2% vs. 82.6%, p = 0.11 y 5.4 cm [4.9-6.2 cm] vs. 5.4 cm [5-6 cm], p = 0.53, respectivamente). Los pacientes más jóvenes presentaron una mayor prevalencia de tabaquismo (72.7% vs. 41.7%, p = 0.01). No se registraron muertes durante la hospitalización índice. La incidencia de reintervenciones (5.3% vs. 15.2%, p = 0.11) e insuficiencia renal aguda (14.3% vs. 23.9%, p = 0.18) no difirieron entre ambos grupos, pero la estadía hospitalaria fue más prolongada en pacientes octogenarios (3 días [2-4 días] vs. 2 días [2-3 días], p = 0.04). La causa más frecuente de reintervenciones fue la presencia de endofugas (81.8%), con una prevalencia del 34% en toda la cohorte. No se observaron diferencias en ninguno de los puntos finales secundarios entre ambos grupos. Conclusión: En pacientes octogenarios con AAA, la REVA presentó un buen perfil de seguridad perioperatorio y a largo plazo.

Chronic systemic glucocorticoid therapy is associated with increased risk of major vascular complications and cardiac tamponade after transcatheter aortic valve implantation: a systematic review and meta-analysis.

INTRODUCTION: TAVI-related complications, such as conduction disturbances, vascular complications or death may be related to increased inflammatory response. The aim of this study was to elucidate the efficacy and safety of the systemic glucocorticoid therapy regarding the adverse events after TAVI deployment. EVIDENCE ACQUISITION: We conducted a systemic search of PubMed, a reference list of relevant articles, and Medline. The main efficacy outcomes of interest were all-cause death, cardiac and non-cardiac death, permanent pacemaker implantation (PPM), new left bundle branch block (LBBB), stroke, and myocardial infarction (MI). Safety endpoints were major vascular complications, major bleeding events, and cardiac tamponade. EVIDENCE SYNTHESIS: A total of 7 studies including data from 3439 patients with a median follow-up was 30 days. Systemic glucocorticoid compared to the control group were associated with an increased risk of non-cardiac death (Relative Risk [RR] 5.90 95%CI [2.95; 11.80], P<0.001) major vascular complications (RR 1.78, 95%CI [1.22 - 2.61], P=0.003) and cardiac tamponade (RR 3.42, 95%CI [1.69 - 6.92], P<0.001). However, there were no differences in all-cause death, cardiac death, new LBBB, stroke, MI, or major bleeding events (all P values >0.05). CONCLUSIONS: Glucocorticoid therapy before the TAVI procedure was associated with an increase in non-cardiac death, major vascular events and cardiac tamponade. There were no differences in the risk of all-cause death, cardiac death, PPM or LBBB, stroke, or MI.

Clinical impact of the infrapatellar location in symptomatic peripheral arterial disease patients / Impacto clínico de la localización infrapatelar en pacientes con enfermedad arterial periférica sintomática

Abstract Background: Peripheral artery disease (PAD) frequently affects multiple segments of the limbs. Contradictory data have reported worse prognosis in aortoiliac lesions, nevertheless, diabetes and chronic limb ischemia frequently affects the infrapatellar territory. Our aim was to assess the impact of infrapatellar disease in cardiovascular outcomes. Methods: We performed a retrospective, observational cohort study at a university hospital in Argentina. Electronic health records were retrospectively reviewed including symptomatic PAD patients requiring revascularization. A multivariable regression model was performed to account for confounders. The primary endpoint was a composite of hospitalizations due to chronic limb threatening ischemia (CLTI) and major amputation events between infrapatellar and suprapatellar patients. Minor amputation events, all-cause death, myocardial infarction (MI), stroke, and major cardiovascular events (MACE) were secondary endpoints. Results: From January 2014 through July 2020, a total of 309 patients were included in the analysis. 151 patients had suprapatellar disease, and 158 had infrapatellar disease. The primary composite endpoint occurred in 35 patients (22.2%) in the infrapatellar patients and 18 patients (11.9%) in the suprapatellar patients (HR = 2.16; 95% confidence interval [CI] = [1.22-3.82]; p = 0.008). Both components of the primary outcomes occurred more frequently in infrapatellar patients. Minor amputation events were more prevalent in infrapatellar patients (HR = 5.09; 95% CI = [1.47-17.6]; p = 0.010). Death, MI, stroke, and MACE events were not different among groups (all p > 0.05). Conclusion: Infrapatellar disease was an independent factor for increased hospitalization of CLTI, major and minor amputations events, compared to suprapatellar disease in symptomatic revascularized PAD patients.

Resumen Objetivo: La enfermedad vascular periférica (EVP) afecta generalmente múltiples segmentos de los miembros. Existe información contradictoria con respecto al pronóstico de pacientes con enfermedad aortoilíaca, sin embargo, la diabetes y la enfermedad critica de miembros inferiores habitualmente afecta el territorio infrapatelar. Nuestro objetivo es determinar el impacto de la afectación infrapatelar en eventos cardiovasculares. Métodos: Estudio retrospectivo, observacional en un hospital universitario de Argentina. Se revisó la historia clínica electrónica de pacientes con EVP con requerimiento de revascularización. Se generó un modelo de regresión multivariado incluyendo variables clínicamente relevantes. El punto final primario fue un combinado de hospitalización por isquemia crítica y amputaciones mayores entre pacientes con afectación infrapatelar y suprapatelar. Amputaciones menores, muerte por todas las causas, infarto agudo de miocardio (IAM), accidente cerebrovascular (ACV) y un combinado de eventos cardiovasculares (MACE) fueron los puntos secundarios. Resultados: Se reclutó un total de 309 pacientes desde enero de 2014 hasta julio de 2020. 151 pacientes presentaron enfermedad suprapatelar y 158 infrapatelar. El punto final primario ocurrió en 35 pacientes (22.2%) en el grupo infrapatelar y en 18 pacientes (11.9%) en suprapatelares (HR 2.16; intervalo de confianza 95% [1.22-3.82]; p = 0.008). Ambos componentes ocurrieron con mayor frecuencia en pacientes con afectación infrapatelar. Los eventos de amputación menor fueron mas prevalentes en pacientes con afectación infrapatelar (HR 5.09; IC95% [1.47-17.6]; p = 0.010) La mortalidad por todas las causas, IAM, ACV y MACE no fueron diferentes entre los grupos (p > 0.05). Conclusión: La enfermedad infrapatelar fue un factor independiente para mayor riesgo de hospitalización por isquemia critica, amputación mayor y menor comparado con pacientes con afectación suprapatelar en EVP sintomática revascularizada.

[Procedural and long-term outcomes of elective endovascular abdominal aortic aneurysm repair in octogenarians]. / Resultados perioperatorios y a largo plazo de la reparación electiva endovascular del aneurisma de aorta abdominal en octogenarios.

Objective: The aim of the study was to compare the immediate and long-term outcomes of endovascular aneurysm repair (EVAR) between patients under and over the age of 80 with abdominal aortic aneurysm (AAA). Methods: From 2011 to 2017, we conducted a retrospective cohort study with AAA patients who received elective EVAR. Primary outcomes included hospital mortality, length of stay, acute kidney injury, and the need for re-interventions. Secondary outcomes included aneurysm-related mortality, acute myocardial infarction, stroke, acute limb ischemia, and prolonged mechanical ventilation. Results: A total of 77 (62.6%) patients under the age of 80 years old and 46 (37.4%) octogenarians were included in the study. The male gender and AAA diameter did not differ among groups (92.2% vs. 82.6%, p = 0.11 and 5.4 cm [4.9-6.2 cm] vs. 5.4 cm [5-6 cm], p = 0.53, respectively). The younger patients had a higher prevalence of tobacco use (72.7% vs. 41.7%, p = 0.01). There were no deaths during the index hospitalization. The incidence of reinterventions (5.3% vs. 15.2%, p = 0.11) and acute kidney injury (14.3% vs. 23.9%, p = 0.18) did not differ between groups, but the length of stay was longer for octogenarian patients (3 days [2-4] vs. 2 days [2-3, p = 0.04)]. Endoleaks were the most common cause for re-interventions (81.8%), with a prevalence of 34% across the entire cohort. There were no differences in any of the secondary outcomes between groups. Conclusion: In octogenarian patients with AAA, EVAR represents a safe procedure both during the index hospitalization and during long-term follow-up.

Objetivo: Comparar los resultados inmediatos y a largo plazo de la reparación endovascular del aneurisma de aorta abdominal (REVA) entre pacientes menores de 80 años y octogenarios. Método: Cohorte retrospectiva que incluyó pacientes con aneurisma de aorta abdominal (AAA) sometidos a REVA electiva desde 2011 hasta 2017. Se evaluaron como punto finales primarios la mortalidad hospitalaria, la duración de la estadía hospitalaria, la incidencia de insuficiencia renal aguda y el requerimiento de reintervenciones. Los puntos finales secundarios incluyeron la mortalidad asociada al aneurisma, infarto agudo de miocardio, accidente cerebrovascular, isquemia arterial aguda de las extremidades y ventilación mecánica prolongada. Resultados: Se incluyeron 77 (62.6%) pacientes menores de 80 años y 46 (37.4%) octogenarios. La prevalencia de sexo masculino y el diámetro del AAA no difirieron entre ambos grupos (92.2% vs. 82.6%, p = 0.11 y 5.4 cm [4.9-6.2 cm] vs. 5.4 cm [5-6 cm], p = 0.53, respectivamente). Los pacientes más jóvenes presentaron una mayor prevalencia de tabaquismo (72.7% vs. 41.7%, p = 0.01). No se registraron muertes durante la hospitalización índice. La incidencia de reintervenciones (5.3% vs. 15.2%, p = 0.11) e insuficiencia renal aguda (14.3% vs. 23.9%, p = 0.18) no difirieron entre ambos grupos, pero la estadía hospitalaria fue más prolongada en pacientes octogenarios (3 días [2-4 días] vs. 2 días [2-3 días], p = 0.04). La causa más frecuente de reintervenciones fue la presencia de endofugas (81.8%), con una prevalencia del 34% en toda la cohorte. No se observaron diferencias en ninguno de los puntos finales secundarios entre ambos grupos. Conclusión: En pacientes octogenarios con AAA, la REVA presentó un buen perfil de seguridad perioperatorio y a largo plazo.

Impact of acute and persistent stent malapposition after percutaneous coronary intervention on adverse cardiovascular outcomes.

INTRODUCTION: The association of coronary stent malapposition (SM) and adverse clinical outcomes after percutaneous coronary intervention (PCI) remains unclear. We aimed to perform a systematic review and meta-analysis of randomized and observational studies to assess the association between acute and persistent SM detected using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and adverse cardiovascular outcomes. EVIDENCE ACQUISITION: Available studies were identified through a systematic search of PubMed, reference lists of relevant articles, and Medline. Main efficacy outcomes of interest were: device-oriented composite endpoint (DoCE, including cardiac death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]), major safety events (MSE, including cardiac death, MI and ST), TLR, and ST. A sensitivity analysis regarding the impact of major malapposition was also performed. EVIDENCE SYNTHESIS: A total of 9 studies enrolling 6497 patients were included in the meta-analysis. After a mean follow-up of 24±14 months, overall acute and/or persistent malapposition was not significantly associated with the occurrence of all the outcomes of interest, including DoCE (risk ratio [RR] 1.00, 95% confidence interval [CI, 0.79-1.26], P=0.99), MSE (RR 1.42, 95%CI [0.81-2.50], P=0.22), TLR (RR 0.84, 95%CI [0.59-1.19], P=0.33), and ST (RR 1.16, 95%CI [0.48-2.85], P=0.74). In the sensitivity analysis, we found a significant increase of MSE in patients with major malapposition (RR 2.97, 95%CI [1.51-5.87], P=0.001). CONCLUSIONS: Acute and persistent SM were not overall associated with adverse cardiovascular clinical outcomes at follow-up. However, major malapposition was associated with an increased risk of major safety events, including cardiac death, MI and ST. These findings should be taken into account during stent implantation and PCI optimization.

Iatrogenic coronary dissection: state of the art management.

Iatrogenic coronary artery dissections (ICAD) are rare but potentially devastating complications during coronary angiography and percutaneous coronary interventions (PCI). Intima media complex separation may be produced either by the catheter tip or during PCI. Patient characteristics and procedure related risk factors are intimately linked to catheter induced ICAD over diagnostic angiography. Moreover, the increasing complexity of patients undergoing PCI, which frequently involves treatment of heavily calcified or occluded vessels, has increased the likelihood of dissections during PCI. A prompt recognition, along with a prompt management (either percutaneous, surgical or even careful watching), are key in preventing catastrophic consequences of ICAD, such as left ventricular dysfunction, cardiogenic shock, periprocedural myocardial infarction (MI) or cardiac death. This review aims to summarize the main updates concerning the pathophysiology, highlight key risk factors and suggest recommendations in management and treatment of ICAD.

Clinical impact of the infrapatellar location in symptomatic peripheral arterial disease patients.

Background: Peripheral artery disease (PAD) frequently affects multiple segments of the limbs. Contradictory data have reported worse prognosis in aortoiliac lesions, nevertheless, diabetes and chronic limb ischemia frequently affects the infrapatellar territory. Our aim was to assess the impact of infrapatellar disease in cardiovascular outcomes. Methods: We performed a retrospective, observational cohort study at a university hospital in Argentina. Electronic health records were retrospectively reviewed including symptomatic PAD patients requiring revascularization. A multivariable regression model was performed to account for confounders. The primary endpoint was a composite of hospitalizations due to chronic limb threatening ischemia (CLTI) and major amputation events between infrapatellar and suprapatellar patients. Minor amputation events, all-cause death, myocardial infarction (MI), stroke, and major cardiovascular events (MACE) were secondary endpoints. Results: From January 2014 through July 2020, a total of 309 patients were included in the analysis. 151 patients had suprapatellar disease, and 158 had infrapatellar disease. The primary composite endpoint occurred in 35 patients (22.2%) in the infrapatellar patients and 18 patients (11.9%) in the suprapatellar patients (HR = 2.16; 95% confidence interval [CI]= [1.22-3.82]; p = 0.008). Both components of the primary outcomes occurred more frequently in infrapatellar patients.Minor amputation events were more prevalent in infrapatellar patients (HR = 5.09; 95% CI = [1.47-17.6]; p = 0.010). Death,MI, stroke, and MACE events were not different among groups (all p > 0.05). Conclusion: Infrapatellar disease was anindependent factor for increased hospitalization of CLTI, major and minor amputations events, compared to suprapatellardisease in symptomatic revascularized PAD patients.

Objetivo: La enfermedad vascular periférica (EVP) afecta generalmente múltiples segmentos de los miembros. Existe información contradictoria con respecto al pronóstico de pacientes con enfermedad aortoilíaca, sin embargo, la diabetes y la enfermedad critica de miembros inferiores habitualmente afecta el territorio infrapatelar. Nuestro objetivo es determinar el impacto de la afectación infrapatelar en eventos cardiovasculares. Métodos: Estudio retrospectivo, observacional en un hospital universitario de Argentina. Se revisó la historia clínica electrónica de pacientes con EVP con requerimiento de revascularización. Se generó un modelo de regresión multivariado incluyendo variables clínicamente relevantes. El punto final primario fue un combinado de hospitalización por isquemia crítica y amputaciones mayores entre pacientes con afectación infrapatelar y suprapatelar. Amputaciones menores, muerte por todas las causas, infarto agudo de miocardio (IAM), accidente cerebrovascular (ACV) y un combinado de eventos cardiovasculares (MACE) fueron los puntos secundarios. Resultados: Se reclutó un total de 309 pacientes desde enero de 2014 hasta julio de 2020. 151 pacientes presentaron enfermedad suprapatelar y 158 infrapatelar. El punto final primario ocurrió en 35 pacientes (22.2%) en el grupo infrapatelar y en 18 pacientes (11.9%) en suprapatelares (HR 2.16; intervalo de confianza 95% [1.22-3.82]; p = 0.008). Ambos componentes ocurrieron con mayor frecuencia en pacientes con afectación infrapatelar. Los eventos de amputación menor fueron mas prevalentes en pacientes con afectación infrapatelar (HR 5.09; IC95% [1.47-17.6]; p = 0.010) La mortalidad por todas las causas, IAM, ACV y MACE no fueron diferentes entre los grupos (p > 0.05). Conclusión: La enfermedad infrapatelar fue un factor independiente para mayor riesgo de hospitalización por isquemia critica, amputación mayor y menor comparado con pacientes con afectación suprapatelar en EVP sintomática revascularizada.

QT Prolongation and In-Hospital Ventricular Arrhythmic Complications in Patients With Apical Ballooning Takotsubo Syndrome.

BACKGROUND: Takotsubo syndrome is associated with life threatening arrhythmias, and the apical ballooning pattern is characterized by a peculiar QT prolongation and particularly high-risk of arrhythmias. OBJECTIVES: The aim of the study was to determine the association of QT interval on electrocardiogram for ventricular arrhythmic complications in patients with apical ballooning Takotsubo syndrome in a diverse population at a large urban hospital in the U.S. METHODS: We reviewed 105 cases of apical ballooning Takotsubo syndrome in patients admitted between 2011 and 2017. Two cardiologists reviewed the electrocardiograms to measure QT interval, adjusted for rate using the Fridericia formula (QTCF), and ventricular arrhythmic complications during the hospitalization. Data are reported as median and interquartile range or number and percentage. RESULTS: Of the 105 patients, 86 (82%) were female, and 34 (32%) were self-reported Black or African American. The mean age was 65 years (range: 58-72 years). Left ventricular ejection fraction was 25% (range: 25%-35%). Heart rate was 101 beats/min (range: 83-121 beats/min). Ten (11%) patients experienced a ventricular arrhythmic complication and had significantly longer QTCF (470 [range: 422-543] milliseconds) than did those without complications (417 [range: 383-456] milliseconds, P = 0.031). The area under the curve for QTCF was 0.708 (95% CI: 0.536-0.880; P = 0.031). Twenty-eight (27%) patients had a QTCF ≥460 milliseconds and significantly more arrhythmic complications (21% vs 5%, odds ratio 4.997 [95% CI: 1.288-19.237], P = 0.021). QTCF was an independent predictor of ventricular arrhythmias: odds ratio 1.090 for each 10-millisecond increase in QTCF (95% CI: 1.004-1.183; P = 0.040, corrected for sex). CONCLUSIONS: In a diverse population of patients with apical ballooning Takotsubo syndrome admitted to a large urban hospital in the United States, QTCF at admission ≥460 milliseconds identifies patients at high risk for in-hospital arrhythmic complications. Further studies are needed to determine strategies aimed at shortening QT interval to potentially prevent life-threatening arrhythmic events.

Comparison of Cardiorespiratory Fitness in Black or African American Versus Caucasian Patients With Heart Failure.

PURPOSE: Cardiopulmonary exercise testing (CPX) is a well-established assessment with important insight into prognosis and therapeutic efficacy in patients with heart failure (HF). Prior studies have identified several clinical differences between Black or African American (B-AA) and Caucasian patients with HF. Differences in key CPX responses between these two groups require further investigation. METHODS: Using a database consisting of subjects with symptomatic HF who had undergone CPX for inclusion in various prospective randomized clinical trials, we identified 198 (n = 94 [47%] B-AA; n = 105 [53%] Caucasian) patients with a qualifying baseline CPX. Significant univariate predictors of peak oxygen uptake (V˙o2peak) were included in a multivariate linear regression model. RESULTS: When compared with Caucasian patients, B-AA were younger (mean ± SD = 54.8 ± 10.0 vs 57.9 ± 9.6 yr, P = .03), had higher C-reactive protein (CRP) (median [IQR] = 4.9 [2.3, 8.8] vs 1.9 [0.6, 5.5] mg/L, P < .0001), lower hemoglobin (13.0 ± 1.8 vs 13.8 ± 1.6 g/dL, P = .003), and lower left ventricular ejection fraction (LVEF) (40 [32, 51] vs 53 [43, 59]%, P < .00010). During CPX, B-AA patients also had lower V˙o2peak (14.6 ± 3.9 vs 17.6 ± 4.8 mL·kg-1·min-1, P < .0001). No differences were observed between B-AA and Caucasian in the minute ventilation/carbon dioxide production (V˙e/V˙co2) slope (P = .14). The difference in V˙o2peak between B-AA and Caucasian was largely attenuated after adjusting for age, body mass index, CRP, N-terminal pro-brain natriuretic peptide, hemoglobin, LVEF, and peak HR (14.1: 95% CI, 13.2-14.9 vs 15.6: 95% CI, 14.4-16.8 mL·kg-1·min-1, P = .053). CONCLUSIONS: Directly measured V˙o2peak was significantly lower in B-AA than in Caucasians with HF. This is largely explained by differences in clinical characteristics, whereas no significant differences were observed in the V˙e/V˙co2 slope.

Additive prognosis of clinical presentation in revascularized peripheral arterial disease patients.

BACKGROUND: Peripheral artery disease (PAD) is a frequent cause of morbidity and mortality. It may present with diverse clinical presentations. The aim of this study was to evaluate the prognosis of these clinical presentations. METHODS: We performed a retrospective cohort study, in which symptomatic PAD patients were included from 2014 to 2020 at a university hospital in Argentina. We classified symptomatic PAD in intermittent claudication (IC), chronic limb-threatening ischemia (CLTI) and acute ischemia (AI). Our primary endpoint was to compare the composite of all-cause mortality and major amputation events between the three groups. RESULTS: We included 309 patients, with a median follow up of 1.87 years (IQR 0.72-3.67). The primary endpoint was more prevalent in CLTI and AI patients (33% and 33.3%) compared to IC patients (8.1%), P<0.001. CLTI and AI were independently associated with the primary endpoint after adjusting for clinical variables of interest (OR 4.04 95%CI [1.86-9.07], P<0.001 and OR 5.40 95%CI [2.18-13.7], P<0.001, respectively). Mortality incidence rate (per 100 patients/year) was similar between AI and CLTI patients (14.2 95% CI [8.0-24.1] and 13.1 95%CI [8.8-19.7], respectively, P=0.67) but higher compared to IC (2.9 95%CI [1.6-5.1], P<0.01). Major amputation events were more prevalent in CLTI (16.5%) compared to AI (8.9%) and IC patients (1.2%), P<0.01. CONCLUSIONS: Those with CLTI and AI have a particular increased risk of all-cause death and major amputation events. Although mortality incidence was similar between AI and CLTI patients, the latter have an increased risk of major amputation events compared to AI and IC patients.

Prevalencia, predictores e impacto clínico de la rehospitalización en pacientes con estenosis valvular aórtica valorados por un Heart Team / Prevalence, Predictors and Clinical Impact of Readmission in Patients with Aortic Stenosis Evaluated by a Heart Team

RESUMEN Introducción: En nuestro medio existe escasa evidencia sobre la incidencia de rehospitalización, factores predictores y evolución clínica de los pacientes con estenosis aórtica (EAo) grave valorados por un Heart Team. Objetivos: Determinar la prevalencia, los predictores de rehospitalización y la evolución clínica de pacientes con EAo grave valorados por el Heart Team. Material y métodos: Estudio unicéntrico de cohorte retrospectivo, que incluyó pacientes con EAo grave valorados por el Heart Team. Se analizaron las características del total de la cohorte, y según la presencia o ausencia de rehospitalización, en un seguimiento de 2 años. Resultados: La edad promedio de la población (n = 275) fue de 83,3 ± 6,9 años, con 51,1% de sexo femenino y una incidencia de rehospitalización de 21,5%. Los pacientes rehospitalizados fueron más añosos (85,54 ± 6,66 vs. 82,62 ± 6,87 años; p = 0,003), más frágiles (97,4% vs. 89,3%; p = 0,035), con mayor riesgo quirúrgico (STS score 6,11 ± 4,79 vs. 4,72 ± 4,12; p = 0,033), y fibrilación auricular (FA) previa (40,7% vs. 23,6%; p = 0,009), en comparación con los no rehospitalizados. Se identificó la FA previa como factor de riesgo independiente de rehospitalización (OR 4,59; IC 95% 1,95-10,81, p<0,001). La incidencia de rehospitalización fue de 33,9% para el implante percutáneo de válvula aórtica (TAVI), 1,7% para la cirugía de reemplazo valvular (CRVAo), y 64,4% para el tratamiento conservador (p = 0,002). A 2 años, la rehospitalización se asoció a una mayor mortalidad (47,5% vs. 13,4%; p <0,001). Conclusiones: En pacientes con EAo grave valorados por un Heart Team se observó una significativa incidencia de rehospitalización a 2 años, que se asoció a mayor mortalidad. La FA fue un factor de riesgo independiente de rehospitalización.

ABSTRACT Background: There is scarce evidence in our setting regarding the prevalence of readmission, risk factors and clinical evolution of patients with severe aortic stenosis (AS) evaluated by a Heart Team. Objective: The aim of this study was to assess the prevalence, predictors and clinical evolution of readmission in patients with severe AS evaluated by a Heart Team. Methods: This was an observational, single-center, retrospective cohort study including patients with severe AS evaluated by a Heart Team. Total cohort characteristics were analyzed at baseline, and after stratification according to the presence or absence of readmission during a 2-year follow-up period. Results: Mean population age (n = 275) was 83.3 ± 6.9 years, and 51.1% were female patients. The prevalence of readmissions was 21.5%. Readmitted patients were older (85.54 ± 6.66 vs. 82.62 ± 6.87 years; p = 0.003) and had greater frailty (97,4% vs. 89.3%; p = 0.035), surgical risk (STS 6.11 ± 4.79 vs. 4.72 ± 4.12; p = 0.033), and previous history of atrial fibrillation (AF) (40.7% vs. 23.6%; p = 0.009), compared with non-readmitted patients. Prior AF was an independent risk factor of readmission (OR 4.59 [IC95% 1.95-10.81]; p <0.001). The prevalence of readmission was 33.9% for percutaneous aortic valve implantation (TAVI), 1.7% for valve replacement surgery (AVRS), and 64.4% for conservative treatment (p = 0.002). At 2 years, readmission was associated with lower survival (47.5% vs. 13.4%; p <0.001). Conclusions: In patients with severe AS evaluated by a Heart Team, a significant prevalence of readmission was observed at 2 years, and this was associated with higher mortality. Atrial fibrillation was an independent risk factor of readmissions.

Pericarditis Recurrence After Initial Uncomplicated Clinical Course.

Acute pericarditis is an inflammatory disease associated with a non-negligible risk of acute complications and future recurrence. However, the exact incidence of pericarditis recurrence in patients with a first uncomplicated clinical course is unknown. We sought to evaluate the incidence and clinical predictors of recurrence after a first episode of acute uncomplicated pericarditis in a large urban hospital in the United States. We conducted a retrospective review, through electronic health records, to complete a database that includes patients admitted with a first episode of acute pericarditis and selected only those with an uncomplicated course (without in-hospital death, large pericardial effusion [>20 mm] or tamponade, constriction, or incessant pericarditis) at the VCU Medical Center (Richmond, Virginia) from 2009 to 2018. A total of 240 patients met acute pericarditis criteria: of the 240 patients, 164 patients (68%) had an uncomplicated course (median age [interquartile range] in years: 50 [32 to 62], 43% females). The median follow-up time was 186 (19 to 467) days. Pericarditis was idiopathic in 84 patients (51%). Fifteen patients (9%) had at least 1 episode of recurrent pericarditis. Compared with those without recurrence, patients with recurrent pericarditis were younger (37 [25 to 59] vs 51 [34 to 62] years, p = 0.034), had a higher prevalence of subacute/delayed presentation (2 [13%] vs 1 [1%], p = 0.023), and less frequently received colchicine (6 [40%] vs 100 [67%], p = 0.036). At multivariate logistic regression analysis, subacute presentation and younger age remained predictors of recurrence at follow-up. In conclusion, 9% of patients with acute pericarditis experienced a recurrence over a 6-month median follow-up despite an initial uncomplicated course. Younger age and subacute presentation were associated with a significantly increased risk of recurrence.

Prognosis of patients with acute pulmonary embolism and discordant right ventricle strain serum biomarkers.

BACKGROUND: Right ventricle strain serum biomarkers, such as high-sensitivity cardiac troponin T (hs-cTnT) and NT-pro-brain natriuretic peptide (NT-proBNP), are prognostic in patients with pulmonary embolism (PE). Prognosis accuracy in patients with discordancy between serum biomarkers remains, however, unknown. METHODS: We performed a retrospective analysis in patients with intermediate or high risk PE and discordant serum biomarkers of RV strain as follows: high hs-cTnT and low NT-proBNP ('high troponin discordance'), compared to patients with low hs-cTnT and high NT-proBNP ('high NT-proBNP discordance'). Cut-off values for high hs-cTnT were ≥14 pg/mL in patients <75 years and ≥45 pg/mL in patients >75-year. Cut-off values for high NT-proBNP were ≥600 pg/mL. The primary end-point was a composite of death, resuscitated cardiac arrest, mechanical ventilation, and inotrope use at one month. 'High troponin discordance', age, sex and body mass index (BMI) were included in a logistic regression model. Time to event analysis was performed using Kaplan Meier curves and Log-rank test. RESULTS: 73 patients were included. 'High troponin discordance' patients (n=41) were younger, presented with a higher heart rate, more frequent bilateral PE, and received more thrombolytics as treatment compared with 'high NT-proBNP discordance' patients (n = 32). Primary end-point was significantly higher in the 'high troponin discordance' patients (29.3% vs 9.4%, p=0.045). 'High troponin discordance' was independently associated with the primary end-point after adjusting for age, sex and BMI. Log rank test confirmed worse outcome in the high troponin discordance group (p=0.037). CONCLUSIONS: High troponin discordance' patients with intermediate/high risk PE, had worse outcomes than patients with high BNP discordance.

[Single center retrospective study of catheter directed thrombolysis in patients with acute pulmonary embolism]. / Estudio unicéntrico del tratamiento con trombolíticos dirigidos por catéter en el tromboembolismo pulmonar agudo.

We performed a single center retrospective study in patients wi th pulmonary embolism (PE) undergoing catheter directed thrombolysis (CDT) from 2014 to 2020. Efficacy was defined by mean pulmonary pressure drop, and safety was assessed by intracranial and severe bleeding (defined by GUSTO). Forty-three patients were included, aged 64 (56-79) years old, 5 (12%) with shock, most with right ventricle dilation (95%) and bilateral PE (95%) or unilateral (5%) in patients with only one functional lung. CDT was used as first treatment (53%), upscale after anticoagulation alone (42%), or after failed systemic thrombolytics (5%). Median recombinant tissue plasminogen activator (rtPA) dose was 30 (25-35) mg over 20 (20-20) hours, and rtPA bolus was used after catheter placement in 38 cases (89%), consisting of 5 mg (95%) or 1 mg (5%). Only one lung was treated for technical reasons, and 4 (9%) were repositioned in the same lung for continuation of infusion. A significant reduction in mean pulmonary pressure was observed (pre 35 [29-41] mmHg vs. post 24 [20-34] mmHg, p < 0.001) with no intracranial bleeding. One patient (2%) experienced severe bleeding, while 5 (12%) presented access site bleeding, and 3 (7%) required blood transfusions. In-hospital mortality was 12% but only one case (2%) due to PE. Our results are similar to previously reported studies.

Se realizó un estudio unicéntrico retrospectivo para evaluar la eficacia y seguridad de trombolisis dirigida por catéter (TDC) en pacientes con tromboembolismo pulmonar agudo (TEP) de 2014 a 2020. Se analizó la efectividad (mejoría de presión pulmonar), y seguridad (sangrado intracraneal y grave definido por compromiso hemodinámico). Se incluyeron 43 pacientes, de 67(56-79) años, 5 (12%) con shock, 41 (95%) con dilatación del ventrículo derecho y TEP bilateral. La decis ión de TDC fue: tratamiento inicial (53%), escalada de anticoagulación (42%) y rescate de trombolisis sistémica (5%). Se utilizó TDC facilitada por ultrasonido en 40 casos (93%), utilizándose 30 (25-35) mg de activador tisular del plasminógeno recombinante (rtPA) durante 20 h. Se administró un bolo de rtPA en 38 (89%) casos, que fue 5 mg (95%) o 1 mg (5%). Se utilizó un solo catéter por paciente. En 4 (9%) se decidió recolocación (mismo pulmón) para continuar infusión en otro sector. Se observó una disminución significativa de la presión media pulmonar (pre 35 [29-41] mmHg vs. post 24 [20-34] mmHg, p < 0.001). No se observó ningún caso de hemorragia intracr aneal, y un caso (2%) de sangrado grave. Se observó hematoma del sitio de punción en 5 (12%) (incluyendo el sangrado grave), y requirió transfusiones en 3 (7%). La mortalidad intrahospitalaria fue 12%, siendo un solo c aso (2%) atribuido al TEP. El tratamiento con TDC fue efectivo asociándose a una reducción significativa de la presión pulmonar, sin observarse ningún sangrado intracraneal y con un sangrado grave. Nuestros resultados se asemejan a lo publicado en otros estudios.

La paradoja de la obesidad en la insuficiencia cardíaca en ancianos / The Obesity Paradox of Heart Failure in the Elderly

RESUMEN Introducción: Múltiples estudios demostraron una relación "protectora" del índice de masa corporal (IMC) incrementado por sobre el IMC normal o bajo en el desarrollo y el pronóstico de la insuficiencia cardíaca. Las categorías de IMC de la población adulta no son adecuadas en la población anciana. Nos proponemos comparar la incidencia de mortalidad global y de reinternación por insuficiencia cardíaca durante el primer año según la categoría de IMC en esta población. Materiales y métodos: Estudio observacional y analítico de una cohorte retrospectiva de pacientes mayores de 65 años internados en la unidad de cuidados intensivos cardiológicos del Hospital Italiano de Buenos Aires (HIBA) con diagnóstico de síndrome de insuficiencia cardíaca aguda (SICA) entre enero de 2013 y diciembre de 2017. Resultados: Se incluyeron 409 pacientes. Los subgrupos con mayor IMC presentaron menor mortalidad al año (peso insuficiente: 53%, normopeso: 41%, sobrepeso: 33%, obesos: 27%, p = 0,008). En el análisis multivariado, el HR para mortalidad anual ajustado por edad, sexo, reinternaciones, insuficiencia renal y tipo de insuficiencia cardíaca fue de 0,51 (IC95% 0,29-0,90) en los pacientes con sobrepeso y de 0,36 (IC95% 0,19-0,67) en los pacientes obesos con respecto a los de peso insuficiente. No hubo diferencias en la mortalidad intrahospitalaria ni en las reinternaciones al año entre los diferentes subgrupos de IMC. Conclusión: En la población de ancianos con SICA, los subgrupos con mayor IMC tienen mejor pronóstico durante el primer año, por lo que se cumple la "paradoja de la obesidad".

ABSTRACT Background: Multiple studies have demonstrated a "protective" relationship of increased body mass index (BMI) over normal or low BMI in the development and prognosis of heart failure. The BMI categories of the adult population are not adequate in the elderly population. We propose to compare the incidence of global mortality and/or readmission for heart failure during the first year according to the BMI category in this population. Methods: This was an observational and analytical study of a retrospective cohort of patients ≥65 years admitted to the cardiology intensive care unit of Hospital Italiano de Buenos Aires with a diagnosis of Acute Heart Failure Syndrome (AHFS) between January 2013 and December 2017. Results: The study included 409 patients. The subgroups with higher BMI had lower mortality at one year (Underweight: 53%, Normal weight: 41%, Overweight: 33%, Obese: 27%, p = 0.008). In the multivariate analysis, annual mortality HR adjusted for age, gender, readmissions, kidney failure and type of heart failure was 0.51 (95% CI 0.29-0.90) for overweight patients and 0.36 (95% CI 0.19-0.67) for patients with obesity compared with underweight patients. There were no differences in inhospital mortality or in readmissions at one year between the different BMI subgroups. Conclusion: In the elderly population with AHFS, the subgroups with higher BMI have a better prognosis during the first year, fulfilling the "obesity paradox".

Estudio unicéntrico del tratamiento con trombolíticos dirigidos por catéter en el tromboembolismo pulmonar agudo / Single center retrospective study of catheter directed thrombolysis in patients with acute pulmonary embolism

Resumen Se realizó un estudio unicéntrico retrospectivo para evaluar la eficacia y seguridad de trombolisis dirigida por catéter (TDC) en pacientes con tromboembolismo pulmonar agudo (TEP) de 2014 a 2020. Se analizó la efectividad (mejoría de presión pulmonar), y seguridad (sangrado intracraneal y grave definido por compromiso hemodinámico). Se incluyeron 43 pacientes, de 67(56-79) años, 5 (12%) con shock, 41 (95%) con dilatación del ventrículo derecho y TEP bilateral. La decis ión de TDC fue: tratamiento inicial (53%), escalada de anticoagulación (42%) y rescate de trombolisis sistémica (5%). Se utilizó TDC facilitada por ultrasonido en 40 casos (93%), utilizándose 30 (25-35) mg de activador tisular del plasminógeno recombinante (rtPA) durante 20 h. Se administró un bolo de rtPA en 38 (89%) casos, que fue 5 mg (95%) o 1 mg (5%). Se utilizó un solo catéter por paciente. En 4 (9%) se decidió recolocación (mismo pulmón) para continuar infusión en otro sector. Se observó una disminución significativa de la presión media pulmonar (pre 35 [29-41] mmHg vs. post 24 [20-34] mmHg, p<0.001). No se observó ningún caso de hemorragia intracraneal, y un caso (2%) de sangrado grave. Se observó hematoma del sitio de punción en 5 (12%) (incluyendo el sangrado grave), y requirió transfusiones en 3 (7%). La mortalidad intrahospitalaria fue 12%, siendo un solo c aso (2%) atribuido al TEP. El tratamiento con TDC fue efectivo asociándose a una reducción significativa de la presión pulmonar, sin observarse ningún sangrado intracraneal y con un sangrado grave. Nuestros resultados se asemejan a lo publicado en otros estudios.

Abstract We performed a single center retrospective study in patients with pulmonary embolism (PE) undergoing catheter directed thrombolysis (CDT) from 2014 to 2020. Efficacy was defined by mean pulmonary pressure drop, and safety was assessed by intracranial and severe bleeding (defined by GUSTO). Forty-three patients were included, aged 64 (56-79) years old, 5 (12%) with shock, most with right ventricle dilation (95%) and bilateral PE (95%) or unilateral (5%) in patients with only one functional lung. CDT was used as first treatment (53%), upscale after anticoagulation alone (42%), or after failed systemic thrombolytics (5%). Median recombinant tissue plasminogen activator (rtPA) dose was 30 (25-35) mg over 20 (20-20) hours, and rtPA bolus was used after catheter placement in 38 cases (89%), consisting of 5 mg (95%) or 1 mg (5%). Only one lung was treated for technical reasons, and 4 (9%) were repositioned in the same lung for continuation of infusion. A significant reduction in mean pulmonary pressure was observed (pre 35 [29-41] mmHg vs. post 24 [20-34] mmHg, p<0.001) with no intracranial bleeding. One patient (2%) experienced severe bleeding, while 5 (12%) presented access site bleeding, and 3 (7%) required blood transfusions. In-hospital mortality was 12% but only one case (2%) due to PE. Our results are similar to previously reported studies.