Risk scores for predicting incident heart failure admission in patients with chronic coronary syndromes: Validation in a prospective, monocentric, long-term, cohort study.

BACKGROUND: Heart failure (HF) admission in chronic coronary syndrome (CCS) patients has a prognostic impact. Stratification schemes have been described for predicting this endpoint, but none of them has been externally validated. OBJECTIVES: Our aim was to develop point scores for predicting incident HF admission with data from previous studies, to perform an external validation in an independent prospective cohort and to compare their discriminative ability for this event. METHODS: Independent predictive variables of HF admission in CCS patients without baseline HF were selected from four previous prospective studies (CARE, PEACE, CORONOR and CLARIFY), generating scores based on the relative magnitude of the coefficients of Cox of each variable. Finally, the scores were validated and compared in a monocentric prospective cohort. RESULTS: The validation cohort included 1212 patients followed for up to 17 years, with 171 patients suffering at least one HF admission in the follow-up. Discriminative ability for predicting HF admission was statistically significant for all, and paired comparisons among them were all nonsignificant except for CORONOR score was superior to CLARIFY score (C-statistic 0.73, 95%CI 0.69-0.76 vs. 0.69, 95% CI 0.65-0.73; p = 0.03). CONCLUSION: All tested scores showed significant discriminative ability for predicting incident HF admission in this independent validation study. Their discriminative ability was similar, with significant differences only between the two scores with higher and lower performance.

Role of obesity and blood pressure in epicardial adipose tissue thickness in children.

BACKGROUND: Elevated body mass index (BMI) has been associated with cardiac changes, such as higher epicardial adipose tissue (EAT) thickness. This fat has been identified as a predictive factor of cardiovascular diseases during adulthood. However, few studies have tested the association of multiple cardiovascular risk factors (high weight or blood pressure) with EAT in adolescents and children. Therefore, the main objective of this current research was to determine the impact of BMI, overweight, obesity, and blood pressure on EAT thickness in children. METHODS: A descriptive cross-sectional study focused on elementary and high school students aged 6-16 years was carried out by utilizing diverse measurements and instruments, such as echocardiography. RESULTS: EAT thickness (N = 228) was linked to sex (more predominant in boys 2.3 ± 0.6; p = 0.044), obesity (2.3 ± 0.6; p < 0.001), and hypertension (2.6 ± 0.6; p = 0.036). The logistic regression indicated that age, sex, and BMI seemed to be more relevant factors in EAT thickness in children (adjusted R square = 0.22; p < 0.001). CONCLUSIONS: This paper examined the associations of sex, age, and cardiovascular risk factors (arthrometric measures and blood pressure) with EAT thickness, indicating that it is necessary to assess whether the findings are associated with future events. IMPACT: Excessive weight gain and blood pressure in the early stages of life have been associated with adipose tissue. This increase in weight and blood pressure has been attributed to alterations in the epicardial adipose tissue linked to anthropometric markers in adults, but no related study has been implemented in Spanish children. This study revealed how higher epicardial adipose tissue is linked to body mass index, other anthropometric parameters, and blood pressure in Spanish children. These measurements are related to high epicardial adipose tissue thickness, which in early stages does not imply pathology but increases the risk of developing cardiovascular diseases.

Variables affecting the quality of anticoagulation in atrial fibrillation patients newly initiating vitamin K antagonists: insights from the national and multicentre SULTAN registry.

AIMS: Vitamin K antagonists (VKAs) are effective drugs reducing the risk for stroke in atrial fibrillation (AF), but the benefits derived from such therapy depend on the international normalized ratio (INR) maintenance in a narrow therapeutic range. Here, we aimed to determine independent variables driving poor anticoagulation control [defined as a time in therapeutic range (TTR) <65%] in a 'real world' national cohort of AF patients. METHODS AND RESULTS: The SULTAN registry is a multicentre, prospective study, involving patients with non-valvular AF from 72 cardiology units expert in AF in Spain. At inclusion, all patients naïve for oral anticoagulation were started with VKAs for the first time. For the analysis, the first month of anticoagulation and those patients with <3 INR determinations were disregarded. Patients were followed up during 1 year. A total of 870 patients (53.9% male, the mean age of 73.6 ± 9.2 years, mean CHA2DS2-VASc and HAS-BLED of 3.3 ± 1.5 and 1.4 ± 0.9, respectively) were included in the full analysis set. In overall, 7889 INR determinations were available. At 1-year, the mean TTR was 63.1 ± 22.1% and 49.2% patients had a TTR < 65%. Multivariate Cox regression analysis showed that coronary artery disease [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.14-2.87; P = 0.012] and amiodarone use (OR 1.54, 95% CI 1.01-2.34; P = 0.046) were independently associated with poor quality of anticoagulation (TTR <65%). CONCLUSION: This study demonstrated that the quality of anticoagulation in AF patients newly starting VKAs is sub-optimal. Previous coronary artery disease and concomitant use of amiodarone were identified as independent variables affecting the poor quality of VKA therapy during the first year.

Incidence and outcomes of hospital treated acute myocarditis from 2003 to 2015 in Spain.

BACKGROUND: There are no data on population-based epidemiological changes in acute myocarditis in Europe. Our aim was to evaluate temporal trends in incidence, clinical features and outcomes of hospital treated acute myocarditis (AM) in Spain from 2003 to 2015. METHODS: We conducted a retrospective longitudinal study using information of all hospital discharges of the Spanish National Health System. All episodes with a discharge diagnosis of AM from 1 January 2003 to 31 December 2015 were included. The risk-standardized in-hospital mortality ratio (RSMR) was calculated using a multilevel risk-adjustment model developed by the Medicare and Medicaid Services. Temporal trends for in-hospital mortality were modelled using Poisson regression analysis. RESULTS: A total of 11 147 episodes of AM were analysed, most of them idiopathic (94.7%). The rate of AM discharges increased along the period, from 13 to 30/million inhabitants/year (2003-2015), and this increase was statistically significant when weighted by age and sex (incidence rate ratio, IRR 1.06, 95% CI 1.04-1.08, P = .001). In-hospital crude mortality rate was 3.1%, diminishing significantly along 2003-2015 (IRR 0.95, 95% CI 0.92-0.99, P = .02). RSMR also significantly diminished along the period (IRR 0.95, 95% CI 0.92-0.99, P = .01). Renal failure (OR 7.03, 5.38-9.18, P = .001), liver disease (OR 4.61, 2.59-8.21, P = .001), pneumonia (OR 4.13, 2.75-6.20, P = .001) and heart failure (OR 1.91, 95% CI 1.47-2.47, P = .001) were the strongest independent factors associated with in-hospital mortality. CONCLUSIONS: Acute myocarditis is an uncommon entity, although hospital discharges have increased in Spain along the study period. Most of AM were idiopathic. Adjusted mortality was low and seemed to decrease from 2003 to 2015, suggesting an improvement in AM management.

Thirteen-year trends in hospitalization and outcomes of patients with heart failure in Spain.

BACKGROUND: Heart failure is one of the most pressing current public health concerns. However, in Spain there is a lack of population data. We aimed to examine thirteen-year nationwide trends in heart failure hospitalization, in-hospital mortality and 30-day readmission rates in Spain. METHODS: We conducted a retrospective observational study of patients discharged with the principal diagnosis of heart failure from The National Health System' acute hospitals during 2003-2015. The source of the data was the Minimum Basic Data Set. Temporal trends were modelled using Poisson regression analysis. The risk-standardized in-hospital mortality ratio was calculated using a multilevel risk adjustment logistic regression model. RESULTS: A total of 1 254 830 episodes of heart failure were selected. Throughout 2003-2015, the number of hospital discharges with principal diagnosis of heart failure increased by 61%. Discharge rates weighted by age and sex increased during the period [incidence rate ratio (IRR): 1.03; 95% confidence interval (95% CI): 1.03-1.03; P < .001)], although this increase was motivated by the increase in older age groups (≥75 years old). The crude mortality rate diminished (IRR: 0.99; 95% CI: 0.98-1, P < .001), but 30-day readmission rate increased (IRR: 1.05; 95% CI: 1.04-1.06; P < .001). The risk-standardized in-hospital mortality ratio did not change throughout the study period (IRR: 0.997; 95% CI: 0.992-1; P = .32). CONCLUSIONS: From 2003 to 2015, heart failure admission rates increased significantly in Spain as a consequence of the sustained increase of hospitalization in the population ≥75 years. 30-day readmission rates increased, but the risk-standardized in-hospital mortality ratio did not significantly change for the same period.

Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A report from the FANTASIIA registry.

BACKGROUND: Atrial fibrillation (AF) and peripheral artery disease (PAD) are common conditions that increase cardiovascular risk. We determined the association between PAD and prognosis in a cohort of real-world patients receiving oral anticoagulant therapy for nonvalvular AF. METHODS: We prospectively included 1956 patients (mean age 73.8 ± 9.5 years, 44.0% women) receiving oral anticoagulant therapy for AF. Clinical characteristics were collected at baseline. Patients were followed for a period of 3 years. Survival analysis and multivariable regression analyses were performed to assess variables related to death, stroke, bleeding, myocardial infarction and major adverse cardiovascular events (MACE). RESULTS: Patients with PAD (n = 118; 6%) exhibited higher rates of cardiovascular risk factors and cardiovascular diseases. After 3 years of follow-up, there were a total of 255 deaths (no PAD 233, vs PAD 22), 45 strokes (43 vs 2), 146 major bleedings (136 vs 10) and 168 MACE (148 vs 20). On univariate analysis, there was a higher risk of cardiovascular mortality (2.02%/year no PAD vs 4.08%/year PAD, P = .02), myocardial infarction (0.99%/year no PAD vs 2.43%/year PAD, P = .02) and MACE (3.18%/year no PAD vs 6.99%/year PAD, P < .01). There was no statistically significant association with these events after multivariable adjustment. CONCLUSIONS: In a large cohort of anticoagulated patients with AF, the presence of PAD represents a higher risk subgroup and is associated with worse crude outcomes. The exact contribution of the PAD independently of other cardiovascular diseases or risk factors requires further investigation.

Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study.

BACKGROUND: Advanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events. METHODS AND RESULTS: Prospective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging. CONCLUSION: Our study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.

Myocardial deformation and acute cellular rejection after heart transplantation: Impact of inter-vendor variability in diagnostic effectiveness.

PURPOSE: Our objective was to investigate the impact of inter-vendor variability in the ability of myocardial strain analysis to detect acute cellular rejection (ACR) in heart transplant recipients. METHODS: We performed serial echocardiographic examinations in 18 consecutive adult heart transplanted patients, in their first year post-transplantation, within 3 hours of the routine surveillance endomyocardial biopsies (EMB) in a single center. Myocardial strain was analyzed using two software in two different institutions, and inter-vendor variability of strain values and its association with ACR (any grade or grade ≥2R) was investigated. The parameter of comparison was the peak value of the average curve of strain during the entire cardiac cycle. RESULTS: A total of 147 pairs of EMB-echocardiogram were performed, 65 with no ACR, 63 with ACR grade 1R, and 19 with ACR grade ≥2R. Intra-class correlation coefficients for left ventricle longitudinal, radial, and circumferential strain were 0.38, 0.39, and 0.77, respectively, and 0.32 for right ventricular longitudinal strain. Neither software found significant association of left ventricular longitudinal strain with rejection. Grade ≥2R ACR was associated with left ventricular circumferential strain measured with the first software and with left ventricular radial strain with the other; and ACR of any grade was only significantly associated with right ventricle longitudinal strain measured with the first software. CONCLUSIONS: Inter-vendor reproducibility of strain values was low in this study. Some strain parameters were associated to ACR, although these results were inconsistent between two commercially available software. Specific validation of each software is warranted for this clinical indication.

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.

Quality of oral anticoagulation with vitamin K antagonists in 'real-world' patients with atrial fibrillation: a report from the prospective multicentre FANTASIIA registry.

Aims: The efficacy and safety of oral anticoagulation (OAC) using the vitamin K antagonists (VKA) are closely associated with the quality of anticoagulation, reflected by time in therapeutic range (TTR). The SAMe-TT2R2 is a risk score developed to predict the quality of anticoagulation control among VKA users. To analyse the quality of anticoagulation and its clinical determinants based on different methods in a prospective cohort of atrial fibrillation patients on VKA treatment participating in the multicentre Spanish observational registry FANTASIIA. Methods and results: Estimated TTR was calculated from Rosendaal, direct method, international normalized ratio variability, and NICE criteria. Time in therapeutic range values were compared for those patients with a SAMe-TT2R2 score 0-2 and >2. One thousand four hundred and seventy patients were analysed (56.4% male, mean age 74.1 ± 9.5 years). Mean TTR was 61.5 ± 25.1 with Rosendaal and 64.7 ± 24.2 with direct method. There was a high correlation between both methods (ρ = 0.805). The prevalence of poor anticoagulation control was 55%. Diabetes mellitus [odds ratio (OR) 1.38; P = 0.008], peripheral artery disease (PAD, OR 1.62; P = 0.048), and HAS-BLED (OR 1.13; P = 0.022) were independently associated with TTR < 70%. SAMe-TT2R2 score 0-2 had a higher mean TTR than patients with SAMe-TT2R2 >2 (P = 0.044), with a specificity of > 90% for predicting TTR < 70%. Patients with TTR < 70% had higher risk of events (21.7 vs. 16.8%; P = 0.021). Conclusion: In a multicentre prospective registry, 55% of AF patients had poor anticoagulation control with diabetes mellitus, PAD, and HAS-BLED being independently associated with TTR < 70%. A high SAMe-TT2R2 scores had a high specificity for predicting a TTR < 70% as an indicator of poor quality anticoagulation.

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.

Impact of asymptomatic acute cellular rejection on left ventricle myocardial function evaluated by means of two-dimensional speckle tracking echocardiography in heart transplant recipients.

BACKGROUND: Our objective was to evaluate the impact of asymptomatic acute cellular rejection (ACR) in left ventricular myocardial strain in heart transplant (HT) recipients by means of two-dimensional speckle tracking echocardiography (2DSTE). METHODS: From September 1, 2009 to December 15, 2010 a conventional echocardiography and 2DSTE exam was performed on all consecutive HT recipients in their first year posttransplantation within 3 hours of the surveillance endomyocardial biopsies, as well as on 14 healthy controls. The association of strain echocardiographic variables with different grades of ACR was investigated. RESULTS: Of the 78 studies performed 4 ± 3 months after HT in 20 patients, 32 studies were coincident with grade 0R rejection, 41 with grade 1R, and 5 with grade 2R. Significantly lower values of average radial strain were found with higher grades of ACR (29.1 ± 7.7%, 23.2 ± 8.5%, and 14.3 ± 8.8% for grades 0R, 1R, and 2R of ACR, P = 0.001). Average deformation was similar for controls versus transplanted patients, in the absence of acute rejection: radial 29.1 ± 10.0% versus 29.1 ± 7.7%, P = 0.98; circumferential -19.3 ± 3.2% versus -20.2 ± 5.9%, P = 0.62; and longitudinal -20.7 ± 4.1% versus -18.5 ± 5.4%, P = 0.19. An average radial strain <25% presented 100% sensitivity, 48% specificity, 6% positive predictive value, and 100% negative predictive value for the presence of 2R rejection (area under the curve 0.80, IC 95% 0.60-0.99, P = 0.048). CONCLUSION: In this study, HT recipients showed significantly lower values of average radial left ventricle strain, evaluated by means of 2DSTE, with the presence of ACR.

Letter to the Editor Ross procedure valve function, clinical outcomes and predictors after 25 years follow up.

The following letter presents an answer of a comment of our work titled "Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up," recently published in your journal by Rangwala et al.1 As our colleagues point out, the Ross procedure has excellent survival rates but a significant risk of valve dysfunction and therefore reintervention at follow-up. Although the survival advantage with the Ross procedure appears to be consistent compared with mechanical valve substitutes, this benefit is not as clear compared with biological valve substitutes. However, biological valve substitutes also have significant reintervention rates during follow-up. The different surgical modifications of the Ross procedure have not clearly demonstrated better results in follow-up in terms of autograft reintervention. This procedure can be performed in a medium-volume center with good results as long as adequate patient selection and adequate surgical training are carried out.

Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up.

OBJECTIVE: To describe long-term outcomes of the Ross procedure in a single center and retrospective series after 25 years follow-up. METHODS: From 1997-2019 we included all consecutive patients who underwent Ross procedure at our center. Clinical and echocardiographic evaluations were performed at least yearly. Echocardiographic valvular impairment was defined as at least moderate autograft or homograft dysfunction. Reintervention outcomes included surgical and percutaneous approach. RESULTS: 151 Ross procedures were performed (mean age 28±12years, 21 %<16years, 70 %male). After 25 years follow-up (median 18 years, interquartile range 9-21, only 3 patients lost) 12 patients died (8 %); Autograft, homograft or any valve dysfunction were present in 38(26 %), 48(32 %) and 75(51 %), respectively; and reintervention in 22(15%), 17(11%) and 38(26 %) respectively. At 20 years of follow-up, probabilities of survival free from autograft, homograft or any valve dysfunction were 63 %, 60 % and 35 %; and from reintervention, 80 %, 85 % and 67 %, respectively. The learning curve period (first 12 cases) was independently associated to autograft dysfunction (HR 2.78, 95 %CI:1.18-6.53, p = 0.02) and reintervention (HR 3.76, 95 %CI: 1.46-9.70, p = 0.006). Larger native pulmonary diameter was also an independent predictor of autograft reintervention (HR 1.22, 95 %CI:1.03-1.45, p = 0.03). Homograft dysfunction was associated with younger age (HR 5.35, 95 %CI: 2.13-13.47, p<0.001) and homograft reintervention, with higher left ventricle ejection fraction (HR 1,10, 95 %CI:1.02-1.19, p<0.02). CONCLUSIONS: In this 25 years' experience after the Ross procedure, global survival was high, although autograft and homograft dysfunction and reintervention rates were not negligible. Clinical and echocardiographic variables can identify patients with higher risk of events in follow up.

Incidence and prediction of hospitalization for heart failure in patients with atrial fibrillation: the REFLEJA scale.

INTRODUCTION AND OBJECTIVES: Hospitalization for heart failure (HHF) is common in patients with atrial fibrillation (AF) and is associated with increased mortality. The aims of this study were to determine the incidence of HHF, identify the clinical predictors of its occurrence, and develop a new risk scale. METHODS: The incidence of HHF was estimated using data from the prospective single-center REFLEJA registry of outpatients with AF (October 2017-October 2018). A multivariate Cox regression model was calculated to detect HHF predictors, and a nomogram was created for individual risk assessment. RESULTS: Of the 1499 patients included (mean age 73.8±11.1 years, 48.1% women), 127 had HHF (incidence rate of 8.51 per 100 persons/y) and 319 died (rate of death from any cause of 21.1 per 100 persons/y) after a 3-year follow-up. The independent predictors of HHF were age, diabetes, chronic kidney disease, pulmonary hypertension, previous pacemaker implantation, baseline use of diuretics, and moderate-severe aortic regurgitation. The c-statistic for predicting the event was 0.762 (95%CI after boostrapping resampling, 0.753-0.791). The cumulative incidences of the main outcome for the risk scale quartiles were 1.613 (Q1), 3.815 (Q2), 8.378 (Q3), and 20.436 (Q4) cases per 100 persons/y (P <.001). CONCLUSIONS: HHF was common in this AF cohort. The combination of certain clinical characteristics can identify patients with a very high risk of HHF.

New severity criteria for tricuspid regurgitation in a broad population of "real life" patients: Prevalence and prognostic impact.

Introduction Our objective was to determine, in "real life" patients, the prevalence of massive and torrential regurgitation among patients diagnosed with severe tricuspid regurgitation (TR), as well as its impact on long-term prognosis. Methods In a single-center retrospective study, all patients with an echocardiographic diagnosis of severe TR attended at a tertiary care hospital of an European country from January 2008 to December 2017 were recruited. Images were analysed off-line to measure the maximum vena contracta (VC) and TR was classified into three groups: severe (VC ≥ 7 mm), massive (VC 14-20 mm), and torrential (VC ≥ 21 mm). The impact of this classification on the combined event of heart failure (HF) admission and all-cause death in follow-up was investigated. Results A total of 614 patients (70 ± 13 years, 72 % women) were included. 81.4 % had severe TR, 15.8 % massive TR, and 2.8 % torrential TR. The 5-year HF-free survival  was 42 %, 43 %, and 12 % (p = 0.001), for the different subgroups of severe TR, respectively. After adjusting for baseline characteristics, TR severity was an independent predictor of survival free of the combined end-point: HR 0.91 [95 % CI 0.70-1.18] p = 0.46, for massive TR; and HR 2.5 [95 % CI 1.49-4.21] p = 0.001, for torrential TR considering severe TR as reference. Conclusions The prevalence of massive and torrential TR is not negligible among patients with severe TR in real life. The prognosis is significantly worse for patients with torrential TR measured by the maximum VC.

Clinical outcomes and mortality in patients with atrial fibrillation and recently diagnosed lung cancer in oncology outpatient settings.

INTRODUCTION: Our aim was to investigate the prevalence of atrial fibrillation (AF) and recently diagnosed lung cancer in the outpatient oncology clinic and to describe the clinical profile, management and outcomes of this population. METHODS: Among 6984 patients visited at the outpatient oncology clinics attending lung cancer patients in five university hospitals from 2017 to 2019, all consecutive subjects with recently diagnosed (<1 year) disease and AF were retrospectively selected and events in follow up were registered. RESULTS: A total of 269 patients (3.9 % of all attended, 71 ± 8 years, 91 % male) were included. Charlson, CHA2DS2-VASc and HAS-BLED indexes were 6.7 ± 2.9, 2.9 ± 1.5 y 2.5 ± 1.2, respectively. Tumour stage was I, II, III and IV in 11 %, 11 %, 33 % and 45 % of them, respectively. Anticoagulants were prescribed to 226 patients (84 %): direct anticoagulants (n = 99;44 %), low molecular weight heparins (n = 69;30 %) and vitamin K antagonists (n = 58;26 %). After 46 months of maximum follow-up, 186 patients died (69 %). Cumulative incidences of events at 3 years were 3.3 ± 1.3 % for stroke/systemic embolism (n = 7); 8.9 ± 2.2 % for thrombotic events (n = 18); 9.9 ± 2.6 % for major bleeding (n = 16), and 15.9 ± 3,0 % for cardiovascular events (n = 33). In patients with early stages of cancer (I-II), 2-year mortality was significantly higher in those with cardiovascular events or major bleeding (85 % vs 25 %, p = 0.01). CONCLUSION: Nearly 4 % or all outpatients in the oncology clinic attending lung cancer present recently diagnosed disease and AF. Major bleeding and cardiovascular event rates are high in this population, with an impact on mortality in early stages of cancer.

Long-term survival in elderly patients with stable coronary disease.

BACKGROUND: This study aimed to assess long-term prognosis of stable coronary artery disease (sCAD) in patients aged ≥ 75 years and to identify clinical predictors of cardiovascular and overall mortality. MATERIALS AND METHODS: From February 2000 to January 2007, 391 outpatients aged ≥ 75 years (median 78 years, interquartile range [IQR] 76-81 years, 66% male) with sCAD were recruited in this prospective cohort study. Associations of baseline variables with long-term cardiovascular and all-cause death were investigated. RESULTS: After up to 11 years of follow-up (median 4 years, IQR 2-6 years), 89 patients died (23%, 5·45%/year), 35 from cardiovascular causes (9%, 2·14%/year). Multivariate analysis identified family history of coronary disease (HR 4·28, 95% CI 1·22-15·02, P = 0·02), baseline atrial fibrillation (HR 3·18, 95% CI 1·37-7·39, P = 0·007), age (HR 1·61 per 5 year increase, 95% CI 1·04-2·50, P = 0·03), resting heart rate (HR 1·26 per 5 bpm increase, 95% CI 1·09-1·47, P = 0·003) and previous revascularization (HR 0·17, 95% CI 0·04-0·77, P = 0·02) as independent predictors of cardiovascular death, and previous acute coronary syndrome (HR 4·93, 95% CI 1·49-16·30, P = 0·009), baseline atrial fibrillation (HR 1·96, 95% CI 1·12-3·43, P = 0·02), tobacco use (HR 1·69, 95% CI 1·00-2·84, P = 0·049 for ex-smoking and HR 6·78, 95% CI 0·89-51·47, P = 0·06 for active smoking), age (HR 1·58 per 5 year increase, 95% CI 1·18-2·11, P = 0·002), resting heart rate (HR 1·10 per 5 bpm increase, 95% CI 1·00-1·22, P = 0·05) and diastolic blood pressure (HR 0·97, 95% CI 0·94-0·99, P = 0·01) as independent predictors of overall mortality. CONCLUSIONS: In this study, 4-years overall mortality was 23% among elderly patients with sCAD. Simple clinical variables can identify patients at higher risk of mortality.

Improvement of left ventricular ejection fraction in patients with heart failure with reduced ejection fraction: Predictors and clinical impact.

BACKGROUND: A percentage of patients with heart failure with reduced ejection fraction (HFrEF) improve left ventricular ejection fraction (LVEF) in the evolution. This entity, defined for the first time in an international consensus as heart failure with improved ejection fraction (HFimpEF), could have a different clinical profile and prognosis than HFrEF. Our main aim was to analyze the differential clinical profile between the two entities, as well as the mid-term prognosis. MATERIAL-METHODS: Prospective study of a cohort of patients with HFrEF who had echocardiographic data at baseline and follow-up. A comparative analysis of patients who improved LVEF with those who did not was made. Clinical, echocardiographic and therapeutic variables were analyzed, and the mid-term impact in terms of mortality and hospital readmissions for HF was assessed. RESULTS: Ninety patients were analyzed. Mean age was 66.5(10.4) years, with a male predominance (72.2%). Forty five patients (50%) improved LVEF (Group-1,HFimpEF) and forty five patients (50%) sustained reduced LVEF (Group-2,HFsrEF). The mean time to LVEF improvement in Group-1 was 12.6(5.7) months. Group-1 had a more favorable clinical profile: lower prevalence of cardiovascular risk factors, higher prevalence of de novo HF (75.6% vs. 42.2%; p<0.05), lower prevalence of ischemic etiology (22.2% vs. 42.2%; p<0.05), with less basal dilatation of the left ventricle. At the end of follow-up (mean 19(1) months) Group-1 had a lower hospital readmission rate (3.1% vs. 26.7%; p<0.01), as well as lower mortality (0% vs. 24.4%; p<0.01). CONCLUSION: Patients with HFimpEF seem to have a better mid-term prognosis in terms of reduced mortality and hospital admissions. This improvement could be conditioned by the clinical profile of patients HFimpEF.

Long-Term Prognostic Impact of Sex in Patients with Chronic Coronary Syndrome: A 17-Year Prospective Cohort Study.

Background: Women and men with chronic coronary syndrome (CCS) have different clinical features and management, and studies on mid-term prognosis have reported conflicting results. Our objective was to investigate the impact of the female sex in the prognosis of the disease in the very long term. Methods and Results: We investigated differential features and very long-term prognosis in 1268 consecutive outpatients with CCS (337 [27%] women and 931 [73%] men). Women were older than men, more likely to have hypertension, diabetes, angina, and atrial fibrillation, and less likely to be exsmoker/active smoker and to have been treated with coronary revascularization (p < 0.05 for all). The prescription of statins, antiplatelets, and betablockers was similar in both groups. After up to 17 years of follow-up (median = 11 years, interquartile range = 4-15 years), cumulative incidences of acute myocardial infarction (10.2% vs. 11.8%) or stroke (11% vs. 10%) at median follow-up were similar, but the risks of major cardiovascular events (acute myocardial infarction, stroke, or cardiovascular death, 41.2% vs. 33.6%), hospital admission for heart failure (20.9% vs. 11.9%), or cardiovascular death (32.3% vs. 22.1%) were significantly higher for women (p < 0.0005), with a nonsignificant trend to higher overall mortality (45.2% vs. 39.1%, p = 0.07). However, after multivariate adjustment, all these differences disappeared. Conclusion: Although women and men with CCS presented a different clinical profile, and crude rates of major cardiovascular events, heart failure and cardiovascular death were higher in women, female sex was not an independent prognostic factor in this study with up to 17 years of follow-up.