New combined risk score to predict atrial fibrillation after cardiac surgery: COM-AF.

Background and Aims: Atrial fibrillation frequently occurs in the postoperative period of cardiac surgery, associated with an increase in morbidity and mortality. The scores POAF, CHA2DS2-VASc and HATCH demonstrated a validated ability to predict atrial fibrillation after cardiac surgery (AFCS). The objective is to develop and validate a risk score to predict AFCS from the combination of the variables with highest predictive value of POAF, CHA2DS2-VASc and HATCH models. Methods: We conducted a single-center cohort study, performing a retrospective analysis of prospectively collected data. The study included consecutive patients undergoing cardiac surgery in 2010-2016. The primary outcome was the development of new-onset AFCS. The variables of the POAF, CHA2DS2-VASc and HATCH scores were evaluated in a multivariate regression model to determine the predictive impact. Those variables that were independently associated with AFCS were included in the final model. Results: A total of 3113 patients underwent cardiac surgery, of which 21% presented AFCS. The variables included in the new score COM-AF were: age (≥75: 2 points, 65-74: 1 point), heart failure (2 points), female sex (1 point), hypertension (1 point), diabetes (1 point), previous stroke (2 points). For the prediction of AFCS, COM-AF presented an AUC of 0.78 (95% CI 0.76-0.80), the rest of the scores presented lower discrimination ability (P < 0.001): CHA2DS2-VASc AUC 0.76 (95% CI 0.74-0.78), POAF 0.71 (95% CI 0.69-0.73) and HATCH 0.70 (95% CI: 0, 67-0.72). Multivariable analysis demonstrated that COM-AF score was an independent predictor of AFCS: OR 1,91 (IC 95% 1,63-2,23). Conclusion: From the combination of variables with higher predictive value included in the POAF, CHA2DS2-VASc, and HATCH scores, a new risk model system called COM-AF was created to predict AFCS, presenting a greater predictive ability than the original ones. Being necessary future prospective validations.

Impact of COVID-19 Pandemic Lockdown in Decompensated Heart Failure Hospitalizations.

Background and Objectives: Coronavirus disease 2019 (COVID-19) pandemic lockdown may have collaterally affected the care of patients with acute decompensated heart failure (ADHF). We aimed to evaluate the impact of lockdown pandemic on hospitalizations for ADHF. Methods: We conducted a single-center study, performing a retrospective analysis of prospectively collected data. We included consecutive adult patients with a primary diagnosis of ADHF admitted to a cardiovascular disease specialized hospital. We compared those patients admitted between March-June of 2019 (before COVID-19 [BC]) and 2020 (after COVID-19 [AC]), during mandatory lockdown. Results: A total 79 corresponding to BC period and 60 to AC period were included, representing a decrease of 25% (interquartile range [IQR], 11-33). During the BC period, 31.6% of patients were referred from other centers compared to 15% during the pandemic (p=0.02). In the AC period patients were older (median age, 81[IQR, 73-87] years vs. 77 [IQR, 64-84] years, p=0.014). The etiology of HF, cause of decompensation, left ventricular function, and laboratory parameters were similar in both periods. The use of mechanical ventilation (13.9% vs. 3.3%, p=0.03) and circulatory support (7.6% vs. 0%, p=0.02) was higher in the BC period. During the BC period, 5 emergency heart transplants were performed, and none in AC, (p=0.004). In-hospital mortality was similar in both periods (3.8% vs. 3.3%; p=0.80). Conclusions: We observed a reduction in the number of hospitalizations and referral of patients for ADHF during COVID-19 pandemic.

Development and Validation of A Simple Clinical Risk Prediction Model for New-Onset Postoperative Atrial Fibrillation After Cardiac Surgery: Nopaf Score.

INTRODUCTION: Postoperative atrial fibrillation (POAFib) occurs in 20 to 40% of patients following cardiac surgery, and is associated with an increased perioperative morbidity and mortality. We aimed to develop and validate a simple clinical risk model for the prediction of POAFib after cardiac surgery. METHODS: An analytical single center retrospective cohort study was conducted, including consecutive patients undergoing cardiac surgery between 2004 and 2017 with POAFib. To create the predictive risk score, a logistic regression model was performed using a random sample of 75% of the population. Coefficients of the model were then converted to a numerical risk score, and three groups were defined: low risk (≤1 point), intermediate risk (2-5 points) and high risk (≥6 points). The score was validated using the remaining 25% of the patients. Discrimination was evaluated through the area under the curve (AUC) ROC, and calibration using the Hosmer-Lemeshow (HL) test, calibration plots, and ratio of expected and observed events (E/O). RESULTS: Six thousand five hundred nine patients underwent cardiac surgery: 52% coronary artery bypass grafting (CABG), 20% valve surgery, 14% combined (CABG and valve surgery) and 12% other. New-onset AF occurred in 1222 patients (18.77%). In the multivariate analysis, age, use of cardiopulmonary bypass pump, severe reduction in left ventricular ejection fraction (LVEF), chronic renal disease and heart failure were independent risk factors for POAFib, while the use of statins was a protective factor. The NOPAF score was calculated by adding points for each independent risk predictor. In the derivation cohort, the AUC was 0.71 (CI95% 0.69-0.72), and in the validation cohort the model also showed good discrimination (AUC 0.67 IC 0.64-0.70) and excellent calibration (HL P = 0.24). The E/O ratio was 1 (CI 95%: 0.89-1.12). According to the risk category, POAFib occurred in 5% of low; 11% of intermediate and 27.7% of high risk patients in the derivation cohort (P <0.001), and 5.7%; 12.6%; and 23.6% in the validation cohort respectively (P <0.001). CONCLUSION: From a large hospitalized population, we developed and validated a simple risk score named NOPAF, based on clinical variables that accurately stratifies the risk of POAFib. This score may help to identify high-risk patients prior to cardiac surgery, in order to strengthen postoperative atrial fibrillation prophylaxis.

Síndrome coronario agudo en mujeres jóvenes por disección coronaria espontánea / Acute Coronary Syndrome in Young Women due to Spontaneous Coronary Artery Dissection

RESUMEN Introducción: La disección coronaria espontánea (DCE) es una causa infrecuente de síndrome coronario agudo (SCA). Es conocida su mayor frecuencia en mujeres jóvenes; sin embargo, sus características clínicas y evolutivas permanecen insuficientemente estudiadas. Objetivo: Evaluar las características clínicas y la evolución de la DCE y su comparación con el síndrome coronario agudo ateroesclerótico (SCAA) en mujeres jóvenes. Material y métodos: Estudio de cohorte prospectivo, realizado entre 2015 y 2017, en el que se compararon mujeres menores de 60 años que ingresaron por SCA por DCE con otro cohorte que presentaba SCAA. Resultados: Se incluyeron 49 pacientes, 7 (14,29%) presentaban DCE. La mediana de seguimiento fue de 10 meses (Pc 25-75 2-18). La mediana de edad fue de 44 años (Pc 25-75 38-45) en grupo DCE y de 55 (Pc 25-75 49-58) en SCAA (P = 0,002), con mayor prevalencia de hipertensión arterial, dislipemia en grupo SCAA (69% vs. 14,3% P = 0,006 y 71% vs. 14% P = 0,004 respectivamente). En el grupo DCE hubo mayor estrés (57,1% vs. 4,8% P = 0,001) y uso de ergotamina (28,6% vs. 0% P = 0,0001) y se presentaron más frecuentemente como infarto agudo de miocardio con elevación del ST (71,4% vs. 28,6%; P = 0,02. El punto final primario ocurrió en 3 pacientes (42,9%) del grupo con DCE y fue menor en el SCAA (9,5%, P = 0,02. En el seguimiento, el 14,9% del grupo DCE y el 14,8% de SCAA presentaron el punto final secundario (P = 0,9). Conclusiones: Las mujeres con DCE tuvieron menor prevalencia de factores de riesgo cardiovascular y presentaron un SCA con peor impacto hemodinámico y mayores complicaciones. La evolución a largo plazo no mostró diferencias significativas.

ABSTRACT Background: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Its prevalence is higher in young women, but its clinical characteristics and outcome remain insufficiently studied. Objective: The aim of this study was to evaluate the baseline characteristics and outcome of SCAD compared with atheroscle-rotic acute coronary syndrome (AACS) in young women. Methods: This prospective cohort study compared women <60 years admitted with ACS due to SCAD with another cohort with AACS, between 2015 and 2017. Results: A total of 49 patients were included, 7 of which (14.29%) presented SCAD. Median follow-up was 10 months (25-75 IQR: 2-18). Median age was 44 years (25-75 IQR: 38-45) in the SCAD group and 55 years (25-75 IQR: 40-58) in the AACS group (p=0.002), with greater prevalence of hypertension and dyslipidemia (69% vs. 14.3%, p=0.006 and 71% vs. 14% p=0.004, respectively). Episodes of acute stress (57.1% vs. 4.8%, p=0.001) and use of ergotamine (28.6% vs. 0%, p=0.0001) were more common in the SCAD group, and ST-segment elevation myocardial infarction was the most frequent presentation (71.4% vs. 28.6%; p=0.02). The primary endpoint occurred in 3 patients (42.9%) of the SCAD group and was less frequent in the AACS group (9.5%, p=0.02). During follow-up, 14.9% of patients in the SCAD group and 14.8% in the AACS group presented the secondary endpoint (p=0.9). Conclusions: Women with SCAD had lower prevalence of cardiovascular risk factors and presented ACS with worse hemody-namic impact and more complications. The long-term outcome did not show significant differences.