Does Gender Influence the Indication of Treatment and Long-Term Prognosis in Severe Aortic Stenosis?

INTRODUCTION: It is a matter of controversy whether the therapeutic strategy for severe aortic stenosis (AS) differs according to gender. METHODS: Retrospective study of patients diagnosed with severe AS (transvalvular mean gradient ≥ 40 mmHg and/or aortic valvular area < 1 cm2) between 2009 and 2019. Our aim was to assess the association of sex on AVR or medical management and outcomes in patients with severe AS. RESULTS: 452 patients were included. Women (51.1%) were older than men (80 ± 8.4 vs. 75.8 ± 9.9 years; p < 0.001). Aortic valve replacement (AVR) was performed less frequently in women (43.4% vs. 53.2%; p = 0.03), but multivariate analyses showed that sex was not an independent predictor factor for AVR. Age, Charlson index and symptoms were predictive factors (OR 0.81 [0.82-0.89], OR 0.81 [0.71-0.93], OR 22.02 [6.77-71.64]). Survival analysis revealed no significant association of sex within all-cause and cardiovascular mortalities (log-rank p = 0.63 and p = 0.07). Cox proportional hazards analyses showed AVR (HR: 0.1 [0.06-0.15]), Charlson index (HR: 1.13 [1.06-1.21]) and reduced LVEF (HR: 1.9 [1.32-2.73]) to be independent cardiovascular mortality predictors. CONCLUSIONS: Gender is not associated with AVR or long-term prognosis. Cardiovascular mortality was associated with older age, more comorbidity and worse LVEF.

Left anterior descending coronary artery compressed by a giant coronary fistula aneurysm: a case report.

BACKGROUND: Ischaemic chest pain can be originated by different causes. Among all, coronary fistulas are rarely the reason. Such entities are usually asymptomatic and can be diagnosed by echocardiography or coronary angiography. In an even rarer scenario, coronary fistulas might dilate and form an aneurysm. CASE SUMMARY: We report the case of a 62-year-old patient who was initially referred to the emergency department for stable angina. Coronary angiography and computed tomography scan showed a giant aneurysm relating to a coronary fistula with a course from the circumflex coronary artery to the superior vena cava. The aneurysm was critically compressing the left anterior descending coronary artery. It was confirmed and resolved by surgery. DISCUSSION: Giant aneurysms of a coronary fistula are very uncommon entities. We describe a rare case of angina caused by extrinsic compression of the left anterior descending artery from a giant aneurysm of a coronary fistula.

Adecuación del tratamiento antitrombótico en los pacientes con fibrilación auricular no valvular. Registro AFINVA / Fine-tuning of antithrombotic therapy in patients with non-valvular atrial fibrillation. The AFINVA register

OBJETIVO: Conocer la adecuación del tratamiento antitrombótico (TAT) a las guías de práctica clínica en pacientes con fibrilación auricular no valvular. DISEÑO: Estudio observacional prospectivo. Emplazamiento: Centros de Salud de atención primaria y Servicio de Cardiología de un Departamento de Salud de la Comunidad Valenciana, España. PARTICIPANTES: Un total de 505 pacientes con diagnóstico de fibrilación auricular no valvular en la historia clínica electrónica de atención primaria. Mediciones principales: Pacientes con TAT inadecuado, definido como aquellos con puntuación CHA2DS2-VASc ≥ 1 que no reciban anticoagulación oral, los tratados con fármacos antivitaminaK y deficiente control de la anticoagulación, la antiagregación asociada inapropiadamente con anticoagulantes, y pacientes con CHA2DS2-VASc=0 y TAT. RESULTADOS: La edad media fue 77,4 ± 10 años. El TAT se estimó inadecuado en el 58% de los casos. Los factores relacionados de forma independiente con TAT inadecuado en la muestra global fueron la edad (OR: 1,02 (1-1,04); p = 0,029), el hipotiroidismo (OR: 1,98 (1,14-3,43); p = 0,015], el antecedente de cardiopatía isquémica (OR: 1,73 (1,15-2,59); p = 0,008) y la fibrilación auricular paroxística (OR: 2,11 (1,41-3,17); p < 0,0001). CONCLUSIONES: Los datos muestran la elevada prevalencia de tratamiento antitrombótico inadecuado en la práctica diaria, así como sus diversas causas

OBJECTIVE: To determine whether antithrombotic treatment (ATT) in patients with non-valvular atrial fibrillation in a health area complies with the recommendations of current clinical guidelines. DESIGN: Prospective observational study. LOCATION: Primary Health Care Centres and Cardiology Department of a Health Department of the Valencian Community, Spain. PARTICIPANTS: A total of 505 patients with nonvalvular atrial fibrillation were included in the study. MAIN MEASUREMENTS: ATT was deemed to be inappropriate in patients with a CHA2DS2-VASc score ≥ 1 and who were not under oral anticoagulation, in patients treated with antivitaminK drugs, and poor control of oral anticoagulation, or with antiplatelet therapy inappropriately associated with anticoagulation, and in patients on ATT with a CHA2DS2-VASc score = 0. RESULTS: The median age was 77.4±10years. The ATT was considered inadequate in 58% of cases. Factors independently associated with inadequate ATT were age (OR: 1.02 (1-1.04); P = .029), hypothyroidism (OR: 1.98 (1.14-3.43); P = .015), ischaemic heart disease (OR: 1.3 (1.15-2.59); P = .008) and paroxysmal non-valvular AF (OR: 2.11 (1.41-3.17); P < .0001). CONCLUSIONS: These data underline the high prevalence of inadequate ATT in daily practice, as well its different causes

Utilidad marginal de la escala SAMe-TT 2 R 2 en la predicción de la calidad de la anticoagulación oral con acenocumarol en el "mundo real" / Marginal usefulness of the SAMe-TT 2 R 2 score in the prediction of the quality of oral anticoagulation with acenocoumarol in the "real world"

Resumen Introducción: la escala SAMe-TT2R2 ha sido propuesta para predecir la calidad de la anticoagulación con antagonistas de la vitamina K. Objetivo: validar la capacidad discriminativa de la escala SAMe-TT2R2 en una cohorte de pacientes con fibrilación auricular no valvular de la vida real. Métodos: estudio observacional de pacientes con fibrilación auricular no valvular tratados con antagonistas de la vitamina K al menos seis meses. Se consideró buen control de anticoagulación un tiempo en rango terapéutico ≥ 65% estimado con el método de Rosendaal. Se evaluó la asociación entre puntuación SAMe-TT2R2 y el control de anticoagulación con regresión logística binaria. La capacidad de discriminación se analizó mediante el cálculo del valor del área bajo la curva ROC. Resultados: se incluyeron 241 pacientes de edad media 78,6±8,6 años, 53% mujeres. La media del tiempo en rango terapéutico fue 59,4±25,4%, menor según aumentó la puntuación SAMe-TT2R2. En general, la escala no mostró capacidad para discriminar los pacientes con adecuado control de anticoagulación: área bajo la curva ROC 0,57 (IC95%:0,49-0,64, p=0,06). Solo fue útil para las puntuaciones extremas, con probabilidad de buen control del 65,1% vs. 34,9%, p=0,01 para valor 0 y del 0% vs. 100%, p=0,03 para ≥ 4. La razón de disparidad de tener un tiempo en rango terapéutico <65% para puntuación ≥2 fue de 1,22 (IC95%:0,73-2,02, p=0,44). Conclusión: en una cohorte de pacientes con fibrilación auricular no valvular y datos de la vida real la escala SAMe-TT2R2 no mostró, globalmente, capacidad discriminatoria para control adecuado de anticoagulación con antagonistas de vitamina K. Solo se mostró útil para clasificar correctamente los casos con puntuaciones extremas.

Abstract Introduction: The SAMe-TT2R2 score has been proposed to predict the quality of anticoagulation with vitamin K antagonists. Objective: To validate the discriminatory power of the SAMe-TT2R2 score real-life in a patient cohort with non-valvular atrial fibrillation. Material and methods: An observational study was conducted on patients with non-valvular atrial fibrillation treated with vitamin K antagonists for at least six months. Good anticoagulation control was considered a time in the therapeutic range of ≥ 65%, estimated with the Rosendaal method. The relationship between the SAMe-TT2R2 score and the anticoagulation control was evaluated using a binary logistic regression. The discriminatory power was determined using the calculation of the value of the area under the ROC curve. Results: The study included total of 241 patients, with a mean age of 78.6±8.6 years, and 53% women. The mean time in the therapeutic range was 59.4±25.4%, low according to the increase in the SAMe-TT2R2 score. In general, the scale did not appear to have the power to discriminate patients with adequate anticoagulation control, with an area under the ROC curve of 0.57 (95% CI: 0.49-0.64, P=.06). It was only useful for extreme scores, with a probability of good control of 65.1% vs. 34.9%, P=.01 for a value of 0, and of 0% vs. 100%, P=.03 for ≥ 4. The disparity ratio of having a time in the therapeutic range of <65% for a score ≥2 was 1.22 (95% CI: 0.73-2.02, P=.44). Conclusion: In a cohort of patients with non-valvular atrial fibrillation and with real-life data, the SAMe-TT2R2 scale, did not, on the whole, show discriminatory power for the adequate control of anticoagulation with vitamin K antagonists. It only showed to be useful to correctly classify the cases with extreme scores.

[Fine-tuning of antithrombotic therapy in patients with non-valvular atrial fibrillation. The AFINVA register]. / Adecuación del tratamiento antitrombótico en los pacientes con fibrilación auricular no valvular. Registro AFINVA.

OBJECTIVE: To determine whether antithrombotic treatment (ATT) in patients with non-valvular atrial fibrillation in a health area complies with the recommendations of current clinical guidelines. DESIGN: Prospective observational study. LOCATION: Primary Health Care Centres and Cardiology Department of a Health Department of the Valencian Community, Spain. PARTICIPANTS: A total of 505 patients with nonvalvular atrial fibrillation were included in the study. MAIN MEASUREMENTS: ATT was deemed to be inappropriate in patients with a CHA2DS2-VASc score ≥1 and who were not under oral anticoagulation, in patients treated with antivitaminK drugs, and poor control of oral anticoagulation, or with antiplatelet therapy inappropriately associated with anticoagulation, and in patients on ATT with a CHA2DS2-VASc score=0. RESULTS: The median age was 77.4±10years. The ATT was considered inadequate in 58% of cases. Factors independently associated with inadequate ATT were age (OR: 1.02 [1-1.04]; P=.029), hypothyroidism (OR: 1.98 [1.14-3.43]; P=.015), ischaemic heart disease (OR: 1.3 [1.15-2.59]; P=.008) and paroxysmal non-valvular AF (OR: 2.11 [1.41-3.17]; P<.0001). CONCLUSIONS: These data underline the high prevalence of inadequate ATT in daily practice, as well its different causes.

Long-term prognosis of chronic kidney disease in non-ST elevation acute coronary syndrome treated with invasive strategy. / Pronóstico a largo plazo de la enfermedad renal crónica en el síndrome coronario agudo sin elevación del segmento ST tratado con estrategia invasiva.

BACKGROUND AND AIM: Patients with chronic kidney disease (CKD) have an increased risk of adverse cardiovascular outcomes after non-ST elevation acute coronary syndrome (NSTEACS). However, the information available on this specific population, is scarce. We evaluate the impact of CKD on long-term prognosis in patients with NSTEACS managed with invasive strategy. METHODS: We conduct a prospective registry of patients with NSTEACS and coronary angiography. CKD was defined as a glomerular filtration rate < 60ml/min/1,73m2. The composite primary end-point was cardiac death and non fatal cardiovascular readmission. We estimated the cumulative probability and hazard rate (HR) of combined primary end-point at 3-years according to the presence or absence of CKD. RESULTS: We included 248 p with mean age of 66.9 years, 25% women. CKD was present at baseline in 67 patients (27%). Patients with CKD were older (74.9 vs. 63.9 years; P<.0001) with more prevalence of hypertension (89.6 vs. 66.3%; P<.0001), diabetes (53.7 vs. 35.9%; P=.011), history of heart failure (13.4 vs. 3.9%; P=.006) and anemia (47.8 vs. 16%; P<.0001). No differences in the extent of coronary artery disease. CKD was associated with higher cumulative probability (49.3 vs. 28.2%; log-rank P=.001) and HR of the primary combined end-point (HR: 1.94; CI95%: 1.12-3.27; P=.012). CKD was an independent predictor of adverse cardiovascular outcomes at 3-years (HR: 1.66; CI95%: 1.05-2.61; P=.03). CONCLUSIONS: In NSTEACS patients treated with invasive strategie CKD is associated independently with an increased risk of adverse cardiovascular outcomes at 3years.

Pronóstico a largo plazo de la enfermedad renal crónica en el síndrome coronario agudo sin elevación del segmento ST tratado con estrategia invasiva / Long-term prognosis of chronic kidney disease in non-ST elevation acute coronary syndrome treated with invasive strategy

Introducción y objetivo: Los pacientes con enfermedad renal crónica (ERC) presentan mayor riesgo de eventos adversos cardiovasculares tras un síndrome coronario agudo sin elevación del segmento ST (SCASEST). Sin embargo, la información disponible en esta población específica es escasa. Evaluamos el efecto de la ERC en el pronóstico a largo plazo de pacientes con SCASEST tratados con estrategia invasiva. Métodos: Registro prospectivo de pacientes con SCASEST y coronariografía. Definimos ERC como una tasa de filtrado glomerular < 60ml/min/1,73m2. La variable de valoración final fue el combinado de muerte y reingreso cardiovasculares (nuevo síndrome coronario agudo, insuficiencia cardíaca e ictus no fatales). Estimamos la probabilidad acumulada, estratificada por ERC, y la relación entre esta y la tasa de riesgo del evento combinado a 3 años. Resultados: Incluimos a 248 pacientes, con media de edad de 66,9 años; el 25% eran mujeres. Los 67 casos (27%) con ERC fueron mayores (74,9 vs. 63,9 años; p < 0,0001) y con más prevalencia de hipertensión (89,6 vs. 66,3%; p < 0,0001), diabetes (53,7 vs. 35,9%; p = 0,01), historia de insuficiencia cardíaca (13,4 vs. 3,9%; p = 0,006) y anemia (47,8 vs. 16%; p < 0,0001). Sin diferencias en la extensión de la enfermedad coronaria. La ERC se asoció a mayor probabilidad (49,3 vs. 28,2%; log-rank p = 0,001) y tasa de riesgo del evento combinado (HR ajustada: 1,94; IC 95%: 1,12-3,27; p = 0,012). La ERC fue predictor independiente de eventos (HR: 1,66; IC 95%: 1,05-2,61; p = 0,03). Conclusiones: En pacientes con SCASEST tratados con estrategia invasiva, la ERC se asocia de manera independiente a mayor riesgo de eventos cardiovasculares a 3 años (AU)

Background and aim: Patients with chronic kidney disease (CKD) have an increased risk of adverse cardiovascular outcomes after non-ST elevation acute coronary syndrome (NSTEACS). However, the information available on this specific population, is scarce. We evaluate the impact of CKD on long-term prognosis in patients with NSTEACS managed with invasive strategy. Methods: We conduct a prospective registry of patients with NSTEACS and coronary angiography. CKD was defined as a glomerular filtration rate < 60ml/min/1,73m2. The composite primary end-point was cardiac death and non fatal cardiovascular readmission. We estimated the cumulative probability and hazard rate (HR) of combined primary end-point at 3-years according to the presence or absence of CKD. Results: We included 248 p with mean age of 66.9 years, 25% women. CKD was present at baseline in 67 patients (27%). Patients with CKD were older (74.9 vs. 63.9 years; P<.0001) with more prevalence of hypertension (89.6 vs. 66.3%; P<.0001), diabetes (53.7 vs. 35.9%; P=.011), history of heart failure (13.4 vs. 3.9%; P=.006) and anemia (47.8 vs. 16%; P<.0001). No differences in the extent of coronary artery disease. CKD was associated with higher cumulative probability (49.3 vs. 28.2%; log-rank P=.001) and HR of the primary combined end-point (HR: 1.94; CI95%: 1.12-3.27; P=.012). CKD was an independent predictor of adverse cardiovascular outcomes at 3-years (HR: 1.66; CI95%: 1.05-2.61; P=.03). Conclusions: In NSTEACS patients treated with invasive strategie CKD is associated independently with an increased risk of adverse cardiovascular outcomes at 3years (AU)

Prevalencia de fibrilación auricular y características de la fibrilación auricular no valvular en la población general. Registro AFINVA / Prevalence of atrial fibrillation and features of non-valvular atrial fibrillation in general population

Resumen Fundamento y objetivos: La fibrilación auricular es la arritmia mantenida más común. El estudio pretende conocer la prevalencia de fibrilación auricular en la población general, y evaluar las características y el manejo de los casos con fibrilación auricular no valvular. Métodos: Estudio transversal exploratorio en una muestra de la población de un Departamento de Salud (n = 30.024) de sujetos mayores de 18 años con diagnóstico electrocardiográfico de fibrilación auricular en la historia clínica electrónica de atención primaria. Se analizan características clínicas, manejo y tratamiento. Resultados: De un total de 629 pacientes con diagnóstico de fibrilación auricular, lo que representa una prevalencia del 2,1% (8,06% en > 65 años), fueron seleccionados para el estudio 505 casos con fibrilación auricular no valvular. La edad media fue 77,4 ± 10 años, 55% mujeres. Se objetivó cardiopatía estructural en el 32% de casos e insuficiencia cardiaca en el 29,5%. El 72% de pacientes recibía tratamiento anticoagulante, 60% con antivitamina K y 12% con anticoagulantes directos. Entre los primeros, solo el 53% mantenía un tiempo en rango terapéutico ≥ 65% según el método de Rosendaal. La forma de presentación persistente-permanente fue más frecuente (60,8%), seguida de la paroxística (39,2%). Conclusiones: La prevalencia de fibrilación auricular fue del 2,1%, aumentando con la edad, con elevada proporción de cardiopatía concomitante. La proporción de pacientes anticoagulados y la calidad de la anticoagulación son deficientes, revelándose así la necesidad de mejor monitorización y mayor utilización de nuevos anticoagulantes directos en los casos indicados.

Abstract Background and objectives: Atrial fibrillation is the most common type of constant arrhythmia. The study aims to know the prevalence of atrial fibrillation in the general population and to assess the features and management of non-valvular atrial fibrillation. Methods: Cross-sectional exploratory study of a population sample from a Health department (n=30.024) of individuals over 18 years with electrocardiographic diagnosis of atrial fibrillation in the primary care electronic medical records. Clinical features, management and treatments are analyzed. Results: Out of a total of 629 patients with an atrial fibrillation diagnosis, which represents a 2.1% prevalence (8.06% in >65 years), 505 cases with non-valvular atrial fibrillation were selected for the study. Average age was 77.4 ± 10 years, 55% female patients. Structural heart disease was detected in 32% of the cases, and cardiac failure in 29.5% of the cases. 72% of the patients were receiving anticoagulation therapy, 60% with antivitamin K drugs and 12% with direct anticoagulants. Among the former group, only 53% kept a time within the therapeutic range ≥65% according to the Rosendaal method. The most frequent presentation was persistentpermanent (60.8%), followed by paroxysmal (39.2%). Conclusions: Prevalence of atrial fibrillation was 2.1%, increasing with age, with a high proportion of accompanying heart disease. The proportion of anticoagulated patients and the quality of anticoagulation were poor, thus revealing the need for improved monitoring and wider use of new direct anticoagulants in the indicated cases.

[Prognostic value of troponin T in hospitalized patients with angina or non-ST-segment elevation myocardial infarction]. / Valor pronóstico de la tropinina T en pacientes hospitalizados con angina o infarto sin elevación del segmento ST.

INTRODUCTION AND OBJECTIVES: Cardiac troponins are highly specific and sensitive for detecting minimal myocardial damage. The aim of our study was to determine the prognostic value of troponin T levels in patients hospitalized for suspected angina or myocardial infarction without ST-segment elevation. PATIENTS AND METHOD: We recorded the frequency of death, acute myocardial infarction, heart failure, or need for coronary revascularization in the three months after the onset of symptoms in 346 consecutive patients admitted for suspected acute coronary syndrome, excluding those who developed myocardial infarction with persistent ST-segment elevation. RESULT: . Serum troponin T levels were > or = 0.1 ng/ml in 133 patients (troponin T positive group) and lower in 213 patients (troponin T negative group). The relative risk (RR) and 95 percent confidence intervals (95% CI) of individual and grouped events for the troponin T positive group were 3.2 (95% CI, 1.4-7.3; p = 0.006) for death; 2.8 (95% CI, 1.43-5.51; p = 0.003) for death or myocardial infarction; and 2.8 (95% CI, 1.6-5.0; p < 0.001) for death, myocardial infarction or heart failure. Diabetes mellitus and troponin T levels > or = 0.1 ng/ml had independent prognostic value after adjusting for age, sex, and electrocardiographic changes; with RR 2.5 (95% CI, 1.01-5.9) for death, myocardial infarction or heart failure. CONCLUSIONS: The prognosis of patients hospitalized for chest pain who do not immediately develop transmural necrosis depends on serum troponin T levels at hospital admission. Troponin T levels > or = 0.1 ng/ml almost triple the risk of major events in the three months after the acute episode. The prognostic value of troponin T is independent of age, sex, presence of diabetes mellitus, and electrocardiographic changes.

Valor pronóstico de la troponina T en pacientes hospitalizados con angina o infarto sin elevación del segmento ST / Prognostic value of troponin T in hospitalized patients with angina or non-ST-segment elevation myocardial infarction

Introducción y objetivos. Las troponinas son proteínas estructurales cardioespecíficas con elevadas sensibilidad y especificidad en la detección de daño miocárdico. Nuestro propósito ha sido conocer el valor pronóstico de la determinación de troponina T en pacientes ingresados por sospecha de angina inestable o infarto sin elevación del segmento ST. Pacientes y método. Determinamos la aparición de muerte, infarto agudo de miocardio, insuficiencia cardíaca o necesidad de revascularización en los 3 meses siguientes al inicio de los síntomas en 346 pacientes consecutivos ingresados por sospecha de síndrome coronario agudo, entre los que se excluyó a aquellos que desarrollaron infarto agudo de miocardio con elevación persistente del segmento ST. Resultados. Las concentraciones de troponina T fueron 0,1 ng/ml en 133 pacientes (grupo troponina T positivo) e inferiores en 213 (grupo troponina T negativo). Los riesgos relativos (RR), con sus intervalos de confianza del 95 per cent (IC del 95 per cent) para los sucesos individuales y agrupados en el grupo troponina T positivo completo fueron: 3,2 (IC del 95 per cent, 1,4-7,3; p = 0,006) para riesgo de muerte; 2,8 (IC del 95 per cent, 1,43-5,51; p = 0,003) para muerte o infarto, y 2,8 (IC del 95 per cent, 1,6-5,0; p < 0,001) para muerte, infarto o insuficiencia cardíaca. Junto con la diabetes mellitus, los valores de troponina T 0,1 ng/ml mantienen un valor pronóstico independiente al efectuar el ajuste para edad, sexo y cambios en el ECG inicial, con RR = 2,5 (IC del 95 per cent, 1,01-5,9) para muerte, infarto o insuficiencia cardíaca. Conclusiones. Los pacientes que ingresan por sospecha de síndrome coronario agudo y no evolucionan inmediatamente a infarto transmural presentan un pronóstico distinto según los valores de troponina T en el momento del ingreso, más adverso con la presencia de valores elevados. De modo que cifras 0,1 ng/ml casi triplican el riesgo de acontecimientos mayores durante los 3 meses posteriores al episodio anginoso agudo. El valor pronóstico de los valores plasmáticos de troponina T es independiente de la edad, el sexo, la presencia de diabetes mellitus y los hallazgos electrocardiográficos (AU)