Relation of quality of anticoagulation control with different management systems among patients with atrial fibrillation: Data from FANTASIIA Registry.

BACKGROUND: Anticoagulation control in patients with atrial fibrillation (AF) has a multidisciplinary approach although is usually managed by general practitioners (GP) or haematologists. The aim of our study was to assess the quality of anticoagulation control with vitamin K antagonists (VKAs) in relation to the responsible specialist in a "real-world" AF population. METHODS: We consecutively enrolled VKA anticoagulated patients included in the FANTASIIA Registry from 2013 to 2015. We analysed demographical, clinical characteristics and the quality of anticoagulation control according to the specialist responsible (ie GPs or haematologists). RESULTS: Data on 1584 patients were included (42.5% females, mean age 74.0 ± 9.4 years): 977 (61.7%) patients were controlled by GPs and 607 (38.3%) by haematologists. Patients managed by GPs had higher previous heart disease (53.2% vs 43.3%, P < .001), heart failure (32.9% vs 26.5%, P < .008) and dilated cardiomyopathy (15.2% vs 8.7%, P < .001) with better renal function (69.3 ± 24.7 vs 63.1 ± 21.4 mL/min, P < .001) compared to patients managed by haematologists. There was no difference between groups in the type of AF, CHA2 DS2 -VASc or HAS-BLED scores, but patients with electrical cardioversion were more prevalent in GP group. The overall mean time in therapeutic range (TTR) assessed by Rosendaal method was 61.5 ± 24.9%; 52.6% of patients had TTR<65% and 60% of patients had TTR<70%. TTR was significantly lower in patients controlled by haematologists than by GPs (63 ± 24.4 vs 59.2 ± 25.6, P < .005). CONCLUSIONS: About 60% of AF patients anticoagulated with VKAs had poor anticoagulation control (ie TTR<70%), and their management was only slightly better than when it is managed by general practitioners.

Inappropriate doses of direct oral anticoagulants in real-world clinical practice: prevalence and associated factors. A subanalysis of the FANTASIIA Registry.

Aims: To describe the prevalence and associated factors of inappropriate doses of direct oral anticoagulants (DOAC) in a national registry of patients of real clinical practice. Methods and results: Five hundred and thirty outpatients with atrial fibrillation treated with DOAC were included in a prospective, national, multicentre study. The appropriateness of the doses of DOAC was defined according to the recommendations of the European Heart Rhythm Association. Mean age was 73 ± 9 years, with a 46% of women. Two hundred and sixty-seven patients were prescribed dabigatran, 190 rivaroxaban, and 73 apixaban. A total of 172 patients (32%) did not receive the appropriate dose: 93 patients received a lower dose (18%) and 79 patients a higher dose (15%). In the comparisons among the subgroups of inappropriately low, appropriate, and inappropriately high dose, we observed significant trends to older age (69 ± 8 years vs. 73 ± 10 years vs. 77 ± 6 years), more frequent female sex (37% vs. 46% vs. 59%), antiplatelet drugs (5% vs. 8% vs. 25%), rivaroxaban (14% vs. 38% vs. 53%), and apixaban use (5% vs. 15% vs. 19%), higher CHAD2DS2-VASc (3.00 ± 1.38 vs. 3.58 ± 1.67 vs. 4.59 ± 1.44) and HAS-BLED scores (1.83 ± 0.87 vs. 1.92 ± 1.07 vs. 2.47 ± 1.13), lower body mass index (30 ± 6 kg/m2 vs. 29 ± 4 kg/m2 vs. 28 ± 4 kg/m2) and glomerular filtration rate (74 ± 27 mL/min vs. 70 ± 22 mL/min vs. 63 ± 16 mL/min), and lower frequency of dabigatran use (81% vs. 47% vs. 28%) (all comparisons P ≤ 0.01). Conclusion: In this real-life study, 32% of patients received an inappropriate dose of DOAC. Several clinical factors can identify patients at risk of this situation.

RNA-sequencing analysis reveals new alterations in cardiomyocyte cytoskeletal genes in patients with heart failure.

Changes in cardiomyocyte cytoskeletal components, a crucial scaffold of cellular structure, have been found in heart failure (HF); however, the altered cytoskeletal network remains to be elucidated. This study investigated a new map of cytoskeleton-linked alterations that further explain the cardiomyocyte morphology and contraction disruption in HF. RNA-Sequencing (RNA-Seq) analysis was performed in 29 human LV tissue samples from ischemic cardiomyopathy (ICM; n=13) and dilated cardiomyopathy (DCM, n=10) patients undergoing cardiac transplantation and six healthy donors (control, CNT) and up to 16 ICM, 13 DCM and 7 CNT tissue samples for qRT-PCR. Gene Ontology analysis of RNA-Seq data demonstrated that cytoskeletal processes are altered in HF. We identified 60 differentially expressed cytoskeleton-related genes in ICM and 58 genes in DCM comparing with CNT, hierarchical clustering determined that shared cytoskeletal genes have a similar behavior in both pathologies. We further investigated MYLK4, RHOU, and ANKRD1 cytoskeletal components. qRT-PCR analysis revealed that MYLK4 was downregulated (-2.2-fold; P<0.05) and ANKRD1 was upregulated (2.3-fold; P<0.01) in ICM patients vs CNT. RHOU mRNA levels showed a statistical trend to decrease (-2.9-fold). In DCM vs CNT, MYLK4 (-4.0-fold; P<0.05) and RHOU (-3.9-fold; P<0.05) were downregulated and ANKRD1 (2.5-fold; P<0.05) was upregulated. Accordingly, MYLK4 and ANKRD1 protein levels were decreased and increased, respectively, in both diseases. Furthermore, ANKRD1 and RHOU mRNA levels were related with LV function (P<0.05). In summary, we have found a new map of changes in the ICM and DCM cardiomyocyte cytoskeleton. ANKRD1 and RHOU mRNA levels were related with LV function which emphasizes their relevance in HF. These new cytoskeletal changes may be responsible for altered contraction and cell architecture disruption in HF patients. Moreover, these results improve our knowledge on the role of cytoskeleton in functional and structural alterations in HF.

Trends in cardiovascular care in the National Health System in Spain. Data from the RECALCAR project 2011-2020.

INTRODUCTION AND OBJECTIVES: The RECALCAR project (Resources and Quality in Cardiology), an initiative of the Spanish Society of Cardiology, aims to standardize information to generate evidence on cardiovascular health outcomes. The objective of this study was to analyze trends in the resources and activity of cardiology units and/or services and to identify the results of cardiovascular care during the last decade in Spain. METHODS: The study was based on the 2 annual data sources of the RECALCAR project: a survey on resources and activity of cardiology units and/or services (2011-2020) and the minimum data set of the National Health System (2011-2019), referring to heart failure (HF), STEMI, and non-STEMI. RESULTS: The survey included 70% of cardiology units and/or services in Spain. The number of hospital beds and length of stay decreased, while there was a notable increase in the number of cardiac imaging studies and percutaneous therapeutic procedures performed. Age- and sex-adjusted admissions for HF tended to decrease, despite an increase in mortality and the percentage of readmissions. In contrast, the trend in mortality and readmissions was highly favorable in STEMI; in non-STEMI, although positive, the trend was less marked. CONCLUSIONS: The information provided by the RECALCAR project shows a favorable trend in the last decade in resources, activity and results of certain cardiovascular processes and constitutes an essential source for future improvements and decision-making in health policy.

Direct Anticoagulants Versus Vitamin K Antagonists in Patients Aged 80 Years or Older With Atrial Fibrillation in a "Real-world" Nationwide Registry: Insights From the FANTASIIA Study.

OBJECTIVE: To describe major events at follow up in octogenarian patients with atrial fibrillation (AF) according to anticoagulant treatment: direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs). METHODS: A total of 578 anticoagulated patients aged ≥80 years with AF were included in a prospective, observational, multicenter study. Basal features, embolic events (stroke and systemic embolism), severe bleedings, and all-cause mortality at follow up were investigated according to the anticoagulant treatment received. RESULTS: Mean age was 84.0 ± 3.4 years, 56% were women. Direct oral anticoagulants were prescribed to 123 (21.3%) patients. Compared with 455 (78.7%) patients treated with VKAs, those treated with DOACs presented a lower frequency of permanent AF (52.9% vs 61.6%, P = .01), cancer history (4.9% vs 10.9%, P = .046), renal failure (21.1% vs 32.2%, P = .02), and left ventricular dysfunction (2.4% vs 8.0%, P = .03); and higher frequency of previous stroke (26.0% vs 16.6%, P = .02) and previous major bleeding (8.1% vs 3.6%, P = .03). There were no significant differences in Charlson, CHA2DS2VASc, nor HAS-BLED scores. At 3-year follow up, rates of embolic events, severe bleedings, and all-cause death (per 100 patients-year) were similar in both groups (DOACs vs VKAs): 0.34 vs 1.35 (P = .15), 3.45 vs 4.41 (P = .48), and 8.2 vs 11.0 (P = .18), respectively, without significant differences after multivariate analysis (hazard ratio [HR]: 0.25, 95% confidence interval [CI]: 0.03-1.93, P = .19; HR: 0.88, 95% CI: 0.44-1.76, P = .72 and HR: 0.84, 95% CI: 0.53-1.33, P = .46, respectively). CONCLUSION: In this "real-world" registry, the differences in major events rates in octogenarians with AF were not statistically significant in those treated with DOACs versus VKAs.

Prognostic value of low ankle-brachial index in patients with hypertension and acute coronary syndromes.

BACKGROUND: Peripheral arterial disease (PAD) is associated with an increased risk of cardiovascular morbidity and mortality. Nevertheless, many patients are asymptomatic, and this condition frequently remains underdiagnosed. An ankle-brachial index (ABI) of less than 0.9 is a noninvasive and simple marker in the diagnosis of PAD and is also predictive of target organ damage in hypertension. The prognostic value of such measurements in hypertensive patients with acute coronary syndrome (ACS) is unknown. METHODS: The Prevalence of Peripheral Arterial Disease in Patients with Acute Coronary Syndrome registry is a multicentre, observational and prospective study that aims to describe the prevalence of and prognosis for PAD, diagnosed by ABI in hypertensive patients with ACS. RESULTS: One thousand one hundred and one hypertensive patients with ACS and at least 40 years of age were prospectively studied. Mean age of the population was 67.4 (11.4) years, and 67.7% were men. The prevalence of ABI less than 0.9 was 42.6% (469 patients). This subgroup was significantly older, had a higher prevalence of diabetes, previous coronary heart disease or stroke, left ventricular hypertrophy and more severe coronary lesions. Hospital mortality was higher in hypertensive patients with ABI less than 0.9 (2.3 vs. 0.2%; P< 0.01). An ABI less than 0.9 was associated with an increased risk of heart failure after ACS (odds ratio, 1.4; P=0.04), higher hospital mortality (odds ratio, 13.0; P=0.03) and the composite endpoint of mortality, heart failure and angina (odds ratio, 1.4; P=0.03). CONCLUSION: Asymptomatic PAD is highly prevalent in hypertensive patients with ACS. An ABI less than 0.9 identifies a subset of patients with more extensive target organ damage and higher risk of hospital cardiovascular complications after an ACS.

Management of myocardial infarction in the elderly. Insights from Spanish Minimum Basic Data Set.

BACKGROUND: We aimed to assess the impact of implementation of reperfusion networks, the type of hospital and specialty of the treating physician on the management and outcomes of ST segment elevation myocardial infarction in patients aged ⩾75 years. METHODS: We analysed data from the Minimum Basic Data Set of the Spanish public health system, assessing hospital discharges between 2004 and 2013. Discharges were distributed in three groups depending on the clinical management: percutaneous coronary intervention, thrombolysis or no reperfusion. Primary outcome measure was all cause in-hospital mortality. For risk adjustment, patient comorbidities were identified for each index hospitalization. RESULTS: We identified 299,929 discharges, of whom 107,890 (36%) were in-patients aged ⩾75 years. Older patients had higher prevalence of comorbidities, were less often treated in high complexity hospitals and were less frequently managed by cardiologists ( p<0.001). Both percutaneous coronary intervention and fibrinolysis were less often performed in elderly patients ( p<0.001). A progressive increase in the rate of percutaneous coronary intervention was observed in the elderly across the study period (from 17% in 2004 to 45% in 2013, p<0.001), with a progressive reduction of crude mortality (from 23% in 2004 to 19% in 2013, p<0.001). Adjusted analysis showed an association between being treated in high complexity hospitals, being treated by cardiologists and lower in-hospital mortality ( p <0.001). CONCLUSIONS: Elderly patients with ST segment elevation myocardial infarction are less often managed in high complexity hospitals and less often treated by cardiologists. Both factors are associated with higher in-hospital mortality.

Clinical profile and management of hypertensive patients with chronic ischemic heart disease and renal dysfunction attended by cardiologists in daily clinical practice.

OBJECTIVE: The present study was designed to assess the influence of renal function on the clinical profile and management of the hypertensive outpatients with chronic ischemic heart disease. METHODS: A total of 112 investigators, all cardiologists, were asked to consecutively enrol outpatients of at least 18 years of age, both sexes, with an established diagnosis of hypertension and chronic ischemic heart disease. Renal function was assessed by serum creatinine levels and estimated glomerular filtration rate using the Modification of Diet in Renal Disease formula. Renal impairment was considered a serum creatinine of at least 1.2/1.3 mg/dl (women/men) or an estimated glomerular filtration rate less than 60 ml/min/1.73 m2. Blood pressure was considered controlled when it was less than 140/90 mmHg and less than 130/80 mmHg in diabetic patients or patients with chronic kidney disease. RESULTS: A total of 2024 patients (66.8+/-10.1 years; 31.7% women) were included. A total of 666 (32.9%) and 498 (24.6%) patients exhibited renal function impairment assessed by estimated glomerular filtration rate and serum creatinine, respectively. The subgroup of patients with renal dysfunction was older, with a higher proportion of women with atrial fibrillation, diabetes, organ damage, associated clinical conditions and a worse blood pressure control. No differences were found in clinical profile when the two subgroups of patients with impaired renal function [serum creatinine >or=1.2/>or=1.3 mg/dl (women/men) vs. estimated glomerular filtration rate <60 ml/min per 1.73 m2] were compared. CONCLUSION: Renal function impairment is frequent in the hypertensive population with coronary artery disease. Patients with renal dysfunction represent a subgroup of very high-risk population with more risk factors and comorbidities and worse blood pressure control. The clinical profiles of hypertensive patients with renal function impairment are similar whether renal dysfunction is detected by high serum creatinine or by low estimated glomerular filtration rate.

Obese and nonobese patients with essential hypertension show similar N-terminal proBNP plasma levels.

BACKGROUND: Multiple studies have focused on the influence of obesity on natriuretic peptide levels. However, the effect of obesity on amino-terminal propeptide of B-type natriuretic peptide (NT-proBNP) levels in hypertensive (HT) patients remains uncertain. METHODS: We studied 252 asymptomatic patients (60 +/- 13 years, 136 men) with essential HT. A routine physical examination, anthropometry, laboratory analyses, echo-Doppler study, and NT-proBNP level determination were performed. RESULTS: NT-proBNP levels were similar in both obese and nonobese HT (median 56 (25-130) pg/ml vs. median 51 (26-129) pg/ml, P = 0.488). No significant differences were found in obese or nonobese patients with left ventricular hypertrophy (LVH) (median 135 (73-425) pg/ml vs. median 151 (64-274) pg/ml, P = 0.597). The area under the curve was 0.89 +/- 0.03 for NT-proBNP to diagnose LVH in the obese HT patients and 0.88 +/- 0.03 in the nonobese. A logistic regression analysis showed that age, gender, and left ventricular mass index (LVMI) were independent predictors of NT-proBNP levels. Body mass index (BMI) was not significantly associated with NT-proBNP in LVH HT patients. CONCLUSIONS: Obesity is not statistically associated with NT-proBNP levels in HT asymptomatic patients. The same results were observed in our group of patients with LVH. These data are in contrast with those previously found in heart failure, and raise questions about the role of obesity per se as primary cause of decreased NT-proBNP levels in other pathophysiological conditions.

Implantation of single-lead atrioventricular permanent pacemakers guided by electroanatomic navigation without the use of fluoroscopy.

AIMS: Fluoroscopy is the standard and almost unique tool used for cardiac imaging during permanent pacemaker implantation, and its use implies exposure of patients and operators to radiation. The usefulness for this purpose of electroanatomic systems not based on fluoroscopy is unknown. Our aim was to study the feasibility of implanting single-lead VDD pacemakers without the use of fluoroscopy. METHODS AND RESULTS: EnSite NavX, a catheter navigation tool based on the creation of a voltage gradient across the thorax of the patient, was used as an exclusive imaging tool during the implantation of single-lead atrioventricular (VDD) permanent pacemakers in 15 consecutive patients with atrioventricular block and normal sinus node function. A retrospective series of 15 consecutive patients in whom VDD pacemakers were implanted under fluoroscopic guidance was used as a control group. The pacemaker could be implanted in all patients. Time spent to obtain the right ventricle anatomy was 10.1 +/- 5.4 min and time to place the lead in an adequate position was 10.1 +/- 7.8 min. Total implant time was 59.3 +/- 15.6 min (51.5 +/- 12.3 min in the control group; P = 0.14). In one patient, a short pulse of radioscopy was needed for a correct catheterization of the subclavian vein. No complications were observed during the procedure. One lead dislodgement that required re-operation was detected 24 h after implantation. At 3 months follow-up, all pacemakers were functioning properly, with adequate pacing and sensing thresholds. CONCLUSION: Electroanatomic navigation systems such as NavX can be used for cardiac imaging during single-lead atrioventricular pacemaker implantation as a reliable and safe alternative to fluoroscopy.

Cardiac incoordination induced by left bundle branch block: its relation with left ventricular systolic function in patients with and without cardiomyopathy.

BACKGROUND: Although left bundle branch block (LBBB) alters the electrical activation of the heart, it is unknown how it might change the process of myocardial coordination (MC) and how it may affect the left ventricular (LV) systolic function. The present study assessed the effects of LBBB on MC in patients with LBBB with and without dilated (DCMP) or ischemic cardiomyopathy (ICMP). METHODS: Tissue Doppler echocardiography (TDE) was performed in 86 individuals: 21 with isolated LBBB, 26 patients with DCMP + LBBB, 19 patients with ICMP + LBBB and in 20 healthy individuals (Controls). MC was assessed analyzing the myocardial velocity profiles obtained from six basal segments of the LV using TDE. The LV systolic function was assessed by standard two-dimensional echocardiography and by TDE. RESULTS: Severe alterations in MC were observed in subjects with LBBB as compared with controls (P < 0.01 for all comparisons); these derangements were even worse in patients with DCMP and ICMP (P < 0.001 for comparisons with Controls and P < 0.01 for comparison with individuals with isolated LBBB). Some parameters of MC differed significantly between DCMP and ICMP (P < 0.01). A good or very good correlation coefficient was found between variables of MC and variables of LV systolic function. CONCLUSION: LBBB induces severe derangement in the process of MC that are more pronounced in patients with cardiomyopathies and that significantly correlates with the LV systolic function. The assessment of MC may help in the evaluation of the etiology of dilated cardiomyopathy.

Sex differences in the hypertensive population with chronic ischemic heart disease.

Cardiopatía Isquémica Crónica e Hipertensión Arterial en la Práctica Clínica en España (CINHTIA) was a survey designed to assess the clinical management of hypertensive outpatients with chronic ischemic heart disease. Sex differences were examined. Blood pressures (BP) was considered controlled at levels of <140/90 or <130/80 mm Hg in diabetics (European Society of Hypertension/European Society of Cardiology 2003); low-density lipoprotein cholesterol (LDL-C) was considered controlled at levels <100 mg/dL (National Cholesterol Education Program Adult Treatment Panel III). In total, 2024 patients were included in the study. Women were older, with a higher body mass index and an increased prevalence of atrial fibrillation. Dyslipidemia, smoking, sedentary lifestyle, and peripheral arterial disease were more frequent in men. In contrast, diabetes, left ventricular hypertrophy, and heart failure were more common in women. BP and LDL-C control rates, although poor in both groups, were better in men (44.9% vs 30.5%, P<.001 and 33.0% vs 25.0%, P<.001, respectively). Stress testing and coronary angiography were more frequently performed in men.

Urinary B-type natriuretic peptide levels in the diagnosis and prognosis of heart failure.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) is a useful biomarker for diagnosis and prognosis of heart failure (HF); however, urine BNP has never been calculated. We sought to compare urinary and plasma BNP levels and to investigate the potential diagnostic and prognostic value of this peptide in HF. METHODS AND RESULTS: Urine and plasma BNP levels were measured in 92 HF patients and 30 control subjects. Urinary BNP levels were higher in HF patients than in control subjects (P < .0001), correlating with plasma BNP levels (r = 0.64, P < .0001). Urine BNP was a good tool for the diagnosis of HF, the area under the curve (AUC) being 0.91 +/- 0.06 (P < .0001). Urinary BNP levels had prognostic power for cardiac events (cardiac admissions + mortality) with an odds ratio of 6.6 (P < .05). To determine the prognostic power of urinary BNP in detecting 12-month cardiac mortality, we obtained an AUC of 0.76 +/- 0.6 (P = .014). CONCLUSIONS: The data suggest that urine BNP is a new candidate marker for diagnosis and prognosis of HF mortality and cardiac events. This raises the possibility of using this relatively simple noninvasive test in primary care settings or in specific conditions where the collection of blood samples could be difficult.

Characteristics and outcome of acute myocardial infarction in young patients. The PRIAMHO II study.

BACKGROUND: The objective was to analyze the incidence, risk factors, management, and complications of acute myocardial infarction (AMI) in the young patient in Spain. METHODS: Clinical characteristics, treatment, and outcome were analyzed in patients younger than 45 years admitted with an AMI diagnosis to the Coronary Units of 58 Spanish hospitals from 15th May to 15th December 2000. RESULTS: Six thousand two hundred and ten consecutive patients were registered, 7% out of them were <45 years old. Outcome was better in the younger group, with a lower mortality rate at 28 days (3.7 vs. 11.9%; p < 0.001), demonstrating that age <45 years is an independent protective factor for mortality (relative risk: 0.41; 95% CI: 0.23-0.73; p < 0.001). This difference remained at 1-year follow-up. CONCLUSIONS: AMI in young patients presents distinct clinical characteristics, a different treatment, management and outcome with respect to the older group.

Patterns of inpatient care for acute myocardial infarction and 30-day, 3-month and 1-year cardiac diseases readmission rates in Spain.

BACKGROUND: Acute myocardial infarction (AMI) is a common cause of hospital discharges and readmissions. Readmissions may indicate poor patient care and avoidable health expenditure, being key in quality improvement strategies. Our aim was to analyse cardiac diseases (CDs) readmissions in patients with AMI in Spain. METHODS: A retrospective analysis of 33,538 hospital discharges with AMI being the "principal diagnosis" at hospitals of the Spanish National Health System in 2012 was performed using administrative data. We developed a logistic regression model and calculated 30-day, 3-month and 1-year CDs risk-standardized readmission rates (RSRRs) using a multivariate mixed model. RESULTS: Variables of the model (AMI location, age, previous angina pectoris/myocardial infarction or acute coronary syndrome, chronic kidney disease, rheumatic valvular disease, diabetes mellitus, vascular disease, female sex, chronic pulmonary disease, and anemia) were able to predict 30-day, 3-month and 1-year readmission rates and RSRRs after AMI (5.4%, 9.3% and 20.2%, respectively). For RSRRs the area under the ROC curve was 0.74 (p=0.0037), 0.77 (p=0.0041), and 0.73 (p=0.0025) for 1, 3months and 1-year readmission rate, respectively. Angioplasty, cardiology as the medical unit responsible for the discharge and a higher volume of activity (>204 AMI) were all significantly (p<0.001) associated with lower mortality, risk of development of heart failure and RSRRs. CONCLUSIONS: Angioplasty, cardiology as the medical unit responsible for the discharge and a higher volume of activity explain variability in CDs readmission rates after AMI, which can have implications for strategies to reduce readmissions rates.

Metformin and risk of long-term mortality following an admission for acute heart failure.

AIMS: Optimal diabetic treatment in patients with established heart failure remains unclear. Metformin has been traditionally considered well tolerated in patients with cardiovascular disease, although there is scarce information regarding the prognostic implications of metformin in acute heart failure. We sought to evaluate the association between metformin therapy and risk of long-term mortality in patients discharged for decompensated heart failure. METHODS: We included 835 consecutive type 2 diabetic patients discharged from a cardiology department of a third-level center. All-cause mortality was considered as the primary endpoint and the effect of metformin therapy across the most representative subgroups in heart failure as a secondary endpoint. The association between metformin with all-cause mortality was evaluated by using a Cox regression method. Multivariate analysis included solid prognostic covariates in heart failure. RESULTS: At a mean follow-up of 2.4 ±â€Š2 years, mortality rates were significantly lower in patients on treatment with metformin: 1.34 (1.04-1.65) × 10 vs. 2.24 (2.0-2.51) × 10 person-years (P < 0.001). Kaplan-Meier curve revealed a progressive separation of curves already observed during first months of follow-up (log-rank test P < 0.001). In multivariate analysis, this prognostic association remained significant. CONCLUSION: In this cohort of patients with acute heart failure and diabetes, metformin appears to be well tolerated and may be associated with favorable clinical outcomes.

Impact on Mortality of Different Network Systems in the Treatment of ST-segment Elevation Acute Myocardial Infarction. The Spanish Experience.

INTRODUCTION AND OBJECTIVES: To analyze the association between the development of network systems of care for ST-segment elevation myocardial infarction (STEMI) in the autonomous communities (AC) of Spain and the regional rate of percutaneous coronary intervention (PCI) and in-hospital mortality. METHODS: From 2003 to 2012, data from the minimum basic data set of the Spanish taxpayer-funded health system were analyzed, including admissions from general hospitals. Diagnoses of STEMI and related procedures were codified by the International Diseases Classification. Discharge episodes (n = 302 471) were distributed in 3 groups: PCI (n = 116 621), thrombolysis (n = 46 720), or no reperfusion (n = 139 130). RESULTS: Crude mortality throughout the evaluation period was higher for the no-PCI or thrombolysis group (17.3%) than for PCI (4.8%) and thrombolysis (8.6%) (P < .001). For the aggregate of all communities, the PCI rate increased (21.6% in 2003 vs 54.5% in 2012; P < .001) with a decrease in risk-standardized mortality rates (10.2% in 2003; 6.8% in 2012; P < .001). Significant differences were observed in the PCI rate across the AC. The development of network systems was associated with a 50% increase in the PCI rate (P < .001) and a 14% decrease in risk-standardized mortality rates (P < .001). CONCLUSIONS: From 2003 to 2012, the PCI rate in STEMI substantially increased in Spain. The development of network systems was associated with an increase in the PCI rate and a decrease in in-hospital mortality.

Prognostic usefulness of white blood cell count on admission and one-year outcome in patients with non-ST-segment elevation acute chest pain.

Little is known about the prognostic value of leukocyte count on admission for patients with chest pain. In total, 1,461 patients who presented to the emergency department with non-ST-segment elevation chest pain were studied by clinical history, electrocardiography, serial troponin I determination, and leukocyte count on admission. End points were 1-year mortality and major events (mortality or infarction). Overall patient distribution by quartiles of leukocyte count showed increased mortality (6%, 7%, 6%, and 17%, p = 0.0001) and major events (13%, 13%, 15%, and 24%, p = 0.0001) in the fourth quartile. After adjustment for other risk factors, the fourth quartile cut-off value (>10,000 cells/ml) predicted mortality (hazard ratio 2.0, 95% confidence interval 1.4 to 2.8, p = 0.0001) but not major events (p = 0.07). When analysis was performed to assess troponin status, in the subgroup with increased troponin (n = 634, 16% mortality), a leukocyte count >10,000 cells/ml was related to mortality (hazard ratio 2.2, 95% confidence interval 1.5 to 3.4, p = 0.0001). However, in the subgroup with normal troponin levels (n = 827, 4.2% mortality), there were no differences in mortality between patients with or without a leukocyte count >10,000 cells/ml (4.4% vs 4.2%, p = 0.8), with survival curves showing a tight overlap (p = 0.9). Further, in the subgroup with normal troponin levels, leukocyte count was not significantly different between patients with or without ST depression (7,969 +/- 2,171 vs 8,108 +/- 2,356 cells/ml, p = 0.6) and was not associated with mortality in patients with ST depression (p = 0.7). In conclusion, leukocyte count on admission is predictive of mortality in patients with chest pain and non-ST-segment elevation myocardial infarction. However, in the absence of myocardial necrosis, leukocyte count lacks prognostic value.

Diagnostic and prognostic value of urine NT-proBNP levels in heart failure patients.

BACKGROUND: Plasma NT-proBNP levels are sensitive markers of ventricular dysfunction. However, studies of natriuretic peptides in urine are limited. AIMS: To compare urine and plasma NT-proBNP levels and to investigate the diagnostic and prognostic value of urine levels in heart failure (HF). METHODS: Urinary and plasma NT-proBNP levels were measured in 96 HF patients and 20 control subjects. The patients were functionally classified according to the NYHA criteria. RESULTS: Urine NT-proBNP was higher in HF patients than in control subjects (94+/-31 pg/ml vs. 67+/-6 pg/ml, p<0.0001), correlating with plasma NT-proBNP levels (r=0.78, p<0.0001). Urinary levels were elevated in the more severe functional classes and diminished in obese patients. Urine NT-proBNP was a good tool for diagnosis of HF, the area under the curve (AUC) being 0.96+/-0.02 (p<0.0001), and for predicting 12-month cardiac events (p=0.011). To determine the prognostic power of urinary NT-proBNP in detecting 12-month cardiac mortality, we obtained an AUC of 0.75+/-0.10 (p=0.015). CONCLUSION: Urinary NT-proBNP, a relatively simple non-invasive test, is a new candidate marker for the diagnosis and evaluation of prognosis in HF and for the characterization of functional status in these patients.

Clinical course of acute myocardial infarction in the hypertensive patient in Eastern Spain: the PRIMVAC registry.

OBJECTIVE: The study's objective was to analyze the acute complications and prognosis of acute myocardial infarction (AMI) in hypertensive patients in Spain. METHOD: Complications and early mortality were recorded among the patients with AMI admitted to the coronary care units of the 17 hospitals in the Valencia Community (Spain) between 1995 and 2000. RESULTS: A total of 12.071 patients were registered, of whom 46% were hypertensive (5.550 cases). Atrial fibrillation was more frequent in the hypertensive group, whereas ventricular fibrillation was more common among normotensive patients. We found higher mortality rates in the hypertensive group (14.4% vs 12.4%; P<.001). However, after multivariate adjustment, hypertension was not independently associated with mortality (odds ratio: .95; P=.46), and remained independently associated with a lower risk of primary ventricular fibrillation (odds ratio: .83; P<.05). CONCLUSION: Hypertensive patients do not present comparatively greater mortality during AMI, although primary ventricular fibrillation is less common in such subjects.