Effectiveness of a Prostacyclin IP Receptor Agonist in Patients With Pulmonary Arterial Hypertension in the Real-world Andalusian Setting: The RAMPHA Study.

PURPOSE: The pillar for therapeutic decisions in the evolution of pulmonary arterial hypertension (PAH) is the patients' prognostic stratification. METHODS: A retrospective cohort study was conducted in a Spanish real-world setting to assess the clinical improvement of PAH patients treated with selexipag measured as changes in the risk profile. Secondary objectives were to describe their baseline characteristics, initial risk status, and variables used to assess patient survival and adverse events. FINDINGS: Total 42 patients (mean age 52.36 [SD: 15.09] years) were included. All had received initial endothelin receptor antagonist treatment and 95.2% dual therapy with phosphodiesterase-5 inhibitor or riociguat. At 6 to 12 months from baseline, patients risk stratification tripled the percentage of patients with low risk, and a trend towards improved risk stratification (P = 0.122). World Health Organization functional class changed, with more patients in milder classes (P = 0.003), and symptom progression slowed down (P < 0.0001). At 3-years, survival was 85.7% and the estimated median survival time was 2.73 years (SD: 1.351; 95% CI: 2.51-2.95). IMPLICATIONS: Selexipag did not achieve a significant improvement in risk profile, although it did show an excellent survival rate, effectively improved functional class, and delayed symptom progression in real life. Selexipag was well tolerated and showed a favorable safety profile, supporting a clinical benefit for PAH patients.

Practical Approaches to the Management of Cardiorenal Disease beyond Congestion.

BACKGROUND: The coexistence of heart and kidney diseases, also called cardiorenal syndrome, is very common, leads to increased morbidity and mortality, and poses diagnostic and therapeutic difficulties. There is a risk-treatment paradox, such that patients with the highest risk are treated with lesser disease-modifying medical therapies. SUMMARY: In this document, different scientific societies propose a practical approach to address and optimize cardiorenal therapies and related comorbidities systematically in chronic cardiorenal disease beyond congestion. Cardiorenal programs have emerged as novel models that may assist in delivering coordinated and holistic management for these patients. KEY MESSAGES: (1) Cardiorenal disease is a ubiquitous entity in clinical practice and is associated with numerous barriers that limit medical treatment. (2) The present article focuses on the practical approaches to managing chronic cardiorenal disease beyond congestion to overcome some of these barriers and improve the treatment of this high-risk population.

Congestion as a crucial factor determining albuminuria in patients with cardiorenal disease.

Background: Albuminuria could potentially emerge as a novel marker of congestion in acute heart failure. However, the current evidence linking albuminuria and congestion in patients with congestive heart failure (CHF) remains somewhat scarce. This study aimed to evaluate the prevalence of albuminuria in a cohort of patients with CHF, identify the independent factors associated with albuminuria and analyse the correlation with different congestion parameters. Methods: This is a subanalysis of the Spanish Cardiorenal Registry, in which we enrolled 864 outpatients with heart failure and a value of urinary albumin:creatinine ratio (UACR) at the first visit. Results: The median age was 74 years, 549 (63.5%) were male and 438 (50.7%) had a reduced left ventricular ejection fraction. A total of 350 patients (40.5%) had albuminuria. Among these patients, 386 (33.1%) had a UACR of 30-300 mg/g and 64 (7.4%) had a UACR >300 mg/g. In order of importance, the independent variables associated with higher UACR were estimated glomerular filtration rate determined by the Chronic Kidney Disease Epidemiology Collaboration equation (R2 = 57.6%), systolic blood pressure (R2 = 21.1%), previous furosemide equivalent dose (FED; R2 = 7.5%), antigen carbohydrate 125 (CA125; R2 = 6.1%), diabetes mellitus (R2 = 5.6%) and oedema (R2 = 1.9%). The combined influence of oedema, elevated CA125 levels and the FED accounted for 15.5% of the model's variability. Conclusions: In patients with chronic stable heart failure, the prevalence of albuminuria is high. The risk factors of albuminuria in this population are chronic kidney disease and hypertension. Congestion parameters are also associated with increased albuminuria.

Outcomes of patients with heart failure followed in units accredited by the SEC-Excelente-IC quality program according to the type of unit.

INTRODUCTION AND OBJECTIVES: The development of specific heart failure (HF) units has improved the management of patients with this disease due to improved organization and resource management. The Spanish Society of Cardiology (SEC) has defined 3 types of HF units (community, specialized, and advanced) based on their complexity and service portfolio. Our aim was to compare the characteristics, treatment, and outcomes of patients with HF according to the type of unit. METHODS: We analyzed data from the SEC-Excelente-IC quality accreditation program registry, with 1716 patients consecutively included in two 1-month cutoffs (March and October) from 2019 to 2021 by 45 SEC-accredited HF units. We compared the characteristics, treatment and 1-year outcomes between the 3 types of units. RESULTS: Of the 1716 patients, 13.2% were treated in community units, 65.9% in specialized units, and 20.9% in advanced units. The rates of mortality (27.5 vs 15.5/100 patients-year; P<.001), admissions for HF (39.7 vs 29.2/100 patients-year; P=.019), total decompensations (56.1 vs 40.5/100 patients-year; P=.003), and combined death/admission for HF (45.2 vs 31.4/100 patients-year; P=.005) were higher in community units than in specialized/advanced units. Follow-up in a community unit was an independent predictor of higher mortality and admissions at 1 year. CONCLUSIONS: Compared with follow-up by more specialized units, follow-up in a community unit was associated with a higher decompensation rate and increased 1-year mortality.

Implicaciones de la pandemia por COVID-19 para el paciente con insuficiencia cardiaca, trasplante cardiaco y asistencia ventricular. Recomendaciones de la Asociación de Insuficiencia Cardiaca de la Sociedad Española de Cardiología / COVID-19 pandemic implications for the patient with heart failure, heart transplant and ventricular assistance: Recommendations from the Heart Failure Association of the Spanish Society of Cardiology

La irrupción de la pandemia por COVID-19 está suponiendo un verdadero reto social y sanitario. Su rápida expansión hace que sean muchos los pacientes afectos que desarrollan clínica asociada, incluyendo síntomas cardiológicos. Los pacientes con afectación cardiaca son un grupo especialmente vulnerable, por su mayor riesgo de contagio y gravedad de la enfermedad. La insuficiencia cardiaca, incluyendo al trasplante cardiaco y las asistencias ventriculares, supone un grupo relevante dentro de los pacientes cardiológicos. Por ello, la Asociación de Insuficiencia Cardiaca de la Sociedad Española de Cardiología ha elaborado una serie de recomendaciones para el abordaje de estos pacientes, en los diferentes escenarios en los que se pueden encontrar: ambulatorio y hospitalizado, con y sin COVID-19

The outbreak of the COVID-19 pandemic is a real social and healthcare system challenge. Its rapid expansion implies that many affected patients develop associated symptoms, including cardiological symptoms. Patients with cardiological diseases are at increased risk of being infected and the severity of the disease. Heart failure, including heart transplantation and ventricular assist devices, is a relevant group within the cardiological patients. For this reason, the following text has been intended to give a series of recommendations for the management of these patients, in the different scenarios in which they can be found: outpatient and hospitalized, with and without COVID-19

Recomendaciones de expertos en la mejora de la prevención efectiva del ictus isquémico en la fibrilación auricular no valvular: papel del rivaroxabán / Expert recommendations on improving effective ischemic stroke prevention in nonvalvular atrial fibrillation: the role of rivaroxaban

La fibrilación auricular aumenta de manera marcada el riesgo de ictus isquémico. A pesar de que los antagonistas de la vitamina K (AVK) reducen ese riesgo, tienen una eficacia limitada y numerosos inconvenientes que han hecho que durante años hubiese una proporción importante de pacientes con fibrilación auricular no anticoagulados. En cambio, no solo los ensayos clínicos, sino también los estudios en práctica clínica real y últimamente los estudios poblacionales, han demostrado que los anticoagulantes orales de acción directa (ACOD) tienen más eficacia y seguridad y un mejor beneficio clínico neto que los AVK. De hecho, en las regiones donde la prescripción de ACOD es mayor, está disminuyendo la incidencia de ictus isquémico, además de los costes generales asociados con la fibrilación auricular. A pesar de que en los últimos años ha aumentado la prescripción de ACOD, España es de los países con menores tasas de prescripción de toda Europa, lo que podría asociarse con mayores tasas de ictus isquémico. A pesar de que todas las guías posicionan los ACOD como de primera elección frente a los AVK para los pacientes con fibrilación auricular no valvular, en España, debido a las restricciones impuestas por el informe de posicionamiento terapéutico, con necesidad de visado, y también por la inercia terapéutica, es mayor la prescripción de AVK. Son necesarias medidas inmediatas para corregir esta situación, y así mejorar el pronóstico de nuestros pacientes

Atrial fibrillation markedly increases the risk of ischemic stroke. Although vitamin K antagonists (VKAs) reduce this risk, they have limited efficacy and several disadvantages, which has meant that over the years a substantial proportion of patients with atrial fibrillation have remained without anticoagulation. In contrast, clinical trials, studies in routine clinical practice and, more recently, population-based studies have all demonstrated that direct oral anticoagulants (DOACs) are more effective and safer than VKAs and also have a greater net clinical benefit. In fact, in regions where the DOAC prescription rate is high, the incidence of ischemic stroke has decreased, as have the overall costs associated with atrial fibrillation. Although the prescription of DOACs in Spain has increased in recent years, the country has one of the lowest prescription rates in Europe, which may be associated with a higher incidence of ischemic stroke. Despite clinical guidelines all recommending that DOACs should be used in preference to VKAs in patients with nonvalvular atrial fibrillation, more prescriptions are issued for VKAs in Spain, largely due to restrictions imposed by national statements on appropriate medicine use (including the need for approval), but also because of therapeutic inertia. Immediate action should be taken to correct this situation and to improve patients' prognoses

Disfunción ventricular derecha: ¿qué opciones tenemos? / Right ventricular dysfunction: what are the options?

Durante muchos años, el ventrículo izquierdo ha sido el centro de atención e investigación en el campo cardiovascular, mientras quedaba en un segundo plano el ventrículo derecho. Sin embargo, el conocimiento de la disfunción del ventrículo derecho como el principal predictor pronóstico en la mayoría de las enfermedades cardiovasculares ha llevado a un creciente interés por una comprensión más detallada de la fisiología y la fisiopatología del ventrículo derecho, así como de su tratamiento. La función del ventrículo derecho puede verse afectada por numerosos mecanismos; uno de los principales es la sobrecarga de presión que ocurre en la hipertensión pulmonar, cuya causa más frecuente en nuestro medio son precisamente las enfermedades cardiacas izquierdas. Pero independientemente de la etiología de la hipertensión pulmonar, la función del ventrículo derecho determina el pronóstico de estos pacientes. Por analogía, muchas de las terapias utilizadas en insuficiencia cardiaca izquierda se emplean en la disfunción derecha, aunque sin evidencia consistente que respalde este uso. El presente artículo resume las bases fisiopatológicas del desarrollo de la insuficiencia cardiaca derecha, revisando la evidencia actual en el tratamiento de esta entidad donde el tratamiento de la congestión es esencial. Asimismo se analiza el papel de la modulación neurohormonal y, por último, se revisan las potenciales estrategias terapéuticas en desarrollo. Información sobre el suplemento: este artículo forma parte del suplemento titulado «Controversias para una nueva era en el tratamiento de la insuficiencia cardiaca», que ha sido patrocinado por Novartis

For many years, the left ventricle has been the focus of interest and research in cardiovascular medicine, with the right ventricle remaining on the sidelines. However, the recognition that right ventricular dysfunction is the principle prognostic indicator in the majority of cardiovascular diseases has led to increased interest in achieving a more detailed understanding of the physiology and pathophysiology of the right ventricle and its treatment. Right ventricular function can be affected by numerous mechanisms; one main mechanism is the pressure overload that occurs in pulmonary hypertension, whose most frequent cause in our discipline is, in fact, left heart disease. However, regardless of the etiology of pulmonary hypertension, right ventricular function determines prognosis in affected patients. Correspondingly, many of the therapies employed for left heart failure are also used for right ventricular dysfunction, although firm evidence to support this use is lacking. This article summarizes the pathophysiological basis for the development of right heart failure and reviews current evidence on its treatment when managing congestion is paramount. In addition, the role of neurohormonal modulation is considered and, finally, potential therapeutic strategies currently in development are reviewed. Supplement information: this article is part of a supplement entitled "Questions on a new era for heart failure treatment" which is sponsored by Novartis

Superioridad de iodixanol frente a contrastes hipoosmolares en la prevención de la nefropatía inducida por contrastes en pacientes de riesgo: ¿mito o realidad? / Superiority of iodixanole vs hypoosmolar contrasts in the prevention of contrast-induced nephropathy in patients at risk: Myth or reality?

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