Use of anticoagulation at the time of discharge in patients with heart failure and atrial fibrillation

[Resumen] Introducción y objetivos. Evaluar el grado de cumplimiento de las guías sobre uso de anticoagulación crónica en pacientes con insuficiencia cardíaca y fibrilación auricular. Pacientes y método. Se usó la base de datos del estudio INCARGAL, analizando datos de 195 pacientes consecutivos (88 varones, edad 76 ± 10 años) admitidos con ambos diagnósticos en tres hospitales gallegos entre enero y junio de 1999. Se asumió que todos deberían de haber recibido anticoagulación al alta hospitalaria en ausencia de contraindicaciones. Se comparó el tratamiento al alta (anticoagulación o no) con la presencia o ausencia de contraindicaciones. Resultados. Un total de 152 pacientes (78%) no tenían contraindicaciones para la anticoagulación y 43 presentaban alguna (absoluta, 11; relativa, 32). De los pacientes sin contraindicación, sólo recibieron anticoagulación al alta el 50%. Ningún paciente con contraindicación absoluta y tres con contraindicación relativa recibieron anticoagulación. La prescripción de anticoagulación en los pacientes sin contraindicaciones fue menor en los que tenían una mayor edad, antecedente de cardiopatía isquémica, ausencia de valvulopatía, uso de bloqueadores beta, no realización de ecocardiograma e ingreso en un servicio diferente del de cardiología (p < 0,05). En el análisis multivariante, la edad, el infarto de miocardio previo y la ausencia de valvulopatía significativa permanecieron como predictores independientes de menor uso de anticoagulación. Conclusiones. El empleo de anticoagulación al alta hospitalaria en pacientes sin contraindicación para su uso, con fibrilación auricular e insuficiencia cardíaca, es menor del recomendado. La edad avanzada disminuye su empleo. La presencia de otras indicaciones para la antiagregación o la anticoagulación parecen determinar la elección de una u otra terapia. No hubo mala adecuación por exceso de prescripción.[Abstract] Introduction and objectives. To assess the degree of compliance with current guidelines for chronic anticoagulation in patients with heart failure and atrial fibrillation. Patients and method. From the INCARGAL Study database, we analyzed data from 195 consecutive patients (88 men; mean age 76 ± 10 years) with both conditions, admitted to three Galician hospitals between January and March 1999. It was assumed that these patients should have received anticoagulant therapy at discharge, unless contraindicated. We studied the association of treatment at discharge (anticoagulation or not) with the presence or absence of contraindications. Results. -152 patients (78%) had no contraindication for anticoagulation and 43 had at least one (absolute: 11, relative: 32). Only 50% of patients without contraindications received anticoagulation at the time of discharge. No patient with an absolute contraindication and 3 with a relative one received anticoagulation. Factors related with the less frequent prescription of anticoagulation therapy in patients without a formal contraindication were: age, a previous history of coronary heart disease, absence of valvular heart disease, prior' myocardial infarction, treatment with beta-blocking agents, non performance of an echocardiogram, and admission to a department other than cardiology. On multivariate analysis, age, prior myocardial infarction, and non-valvular disease were found to be independent predictors of less use of anticoagulation. Conclusions. Anticoagulant therapy is used less often than recommended at discharge in patients with heart failure and atrial fibrillation for whom there were no contraindications. Advanced age reduces its use. The presence of other indications for antiplatelet or anticoagulatión therapy appears to determine the choice of one or the other. Noncompliance with the guidelines due to overprescription was not found

Pitx2c is reactivated in the failing myocardium and stimulates Myf5 expression in cultured cardiomyocytes

[Abstract] Background. Pitx2 (paired-like homeodomain 2 transcription factor) is crucial for heart development, but its role in heart failure (HF) remains uncertain. The present study lays the groundwork implicating Pitx2 signalling in different modalities of HF. Methodology/Principal Findings. A variety of molecular, cell-based, biochemical, and immunochemical assays were used to evaluate: (1) Pitx2c expression in the porcine model of diastolic HF (DHF) and in patients with systolic HF (SHF) due to dilated and ischemic cardiomyopathy, and (2) molecular consequences of Pitx2c expression manipulation in cardiomyocytes in vitro. In pigs, the expression of Pitx2c, physiologically downregulated in the postnatal heart, is significantly re-activated in left ventricular (LV) failing myocardium which, in turn, is associated with increased expression of a restrictive set of Pitx2 target genes. Among these, Myf5 was identified as the top upregulated gene. In vitro, forced expression of Pitx2c in cardiomyocytes, but not in skeletal myoblasts, activates Myf5 in dose-dependent manner. In addition, we demonstrate that the level of Pitx2c is upregulated in the LV-myocardium of SHF patients. Conclusions/Significance. The results provide previously unrecognized evidence that Pitx2c is similarly reactivated in postnatal/adult heart at distinct HF phenotypes and suggest that Pitx2c is involved, directly or indirectly, in the regulation of Myf5 expression in cardiomyocytes.Galicia. Consellería de Cultura, Educación e Ordenación Universitaria; GRC 2013/061Andalucía. Junta. Consejería de Innovación, Ciencia y Empresa; CTS1416Centro Nacional de Investigaciones Cardiovasculares Carlos III; CNIC-T 2009/0

Effect of a simple educational program for physicians on adherence to secondary prevention measures after discharge following acute coronary syndrome: the CAM project

[Abstract] Introduction and objectives. Adherence to established guidelines for patients discharged from the hospital after acute coronary syndrome is known to be suboptimal. The aim of this study was to assess the efficacy of a program for physicians centered on the treatment of acute coronary syndrome. Patients and method. 39 hospitals participated. Intervention: a set of measures was developed by consensus for the creation and distribution of educational materials. Outcomes of interest: proportion of patients in whom ejection fraction and residual ischemia were evaluated, treatment at discharge, and health and dietary recommendations to patients (smoking, diet, exercise, etc.) referred to all patients in whom these measures or treatments should have been used (“ideal patients”). Changes were assessed with four cross-sectional surveys. Results. A total of 1157, 1162, 1149, and 1158 patients were included. There were no relevant differences between these groups in baseline characteristics. In general, there was improvement in all variables between the first and the last survey. The proportion of patients who were weighed and measured increased (from 33.5% to 53.4%; P<.0001), as did the proportion of those in whom cholesterol was measured early (42.6 to 53.7%; P=.006). The proportion in whom residual ischemia was not measured despite indications for this test decreased (18.2% to 10.8%; P=.013), and the proportion increased for appropriate treatment with statins on discharge (68.6% to 81.4%; P<.0001), advice to quit smoking (60.1% to 72.2%; P<.0001) and advice to exercise (58.3% to 67.4%; P=.003). Conclusions. The educational intervention seems to have had a positive effect on improving the appropriateness of procedures and treatments for patients discharged after acute coronary syndrome.[Resumen] Introducción y objetivos. El cumplimiento de las recomendaciones establecidas como eficaces en el momento del alta en los pacientes hospitalizados por un síndrome coronario agudo es subóptimo. El objetivo de este estu-dio es evaluar la eficacia de un programa de intervención centrado en el abordaje y tratamiento del síndrome coronario agudo. Pacientes y método. Participaron en el proyecto 39 hospi-tales. La intervención realizada consistió en el desarrollo con-sensuado de acuerdos de mínimos y la elaboración y difusión de materiales educativos. Entre las medidas de interés cabe destacar la proporción de pacientes en la que se evaluaron la fracción de eyección, la isquemia residual y los tratamientos y recomendaciones higiénico-dietéticas en el momento del alta (tabaco, dieta, ejercicio, etc.) del total de pacientes en los que se deben determinar según el acuerdo de mínimos («pacientes ideales»). Asimismo, se valoraron los cambios en 4 cortes transversales. Resultados. Se incluyó a 1.157, 1.162, 1.149 y 1.158 pacientes, respectivamente. No había diferencias en las características basales de pacientes analizados en cada corte. En general, se aprecia una mejoría entre el primer y el último corte en todas las variables analizadas. Mejoró especialmente la proporción de pacientes en los que se determi-naron el peso y la talla (del 33,5 al 53,4%; p < 0,0001). También se observó una mejoría en la medición precoz del colesterol (del 42,6 al 53,7%; p = 0,006) y una reducción del porcentaje de pacientes en los que no se realizó un test de isquemia pese a estar indicado (del 18,2 al 10,8%; p = 0,013); asimismo, aumentó la propoción de pacientes con un tratamiento adecuado con estatinas en el momento del alta (del 68,6 al 81,4%; p < 0,0001) y el número de recomendaciones sobre tabaquismo (del 60,1 al 72,2%; p < 0,0001) y ejercicio (del 58,3 al 67,4%; p = 0,003). Conclusiones. La intervención educativa parece que tie-ne un efecto positivo en la mejora de la adecuación de los procedimientos realizados y en los tratamientos prescritos en el momento del alta tras un síndrome coronario agudo

Prediction of Mortality and Major Cardiac Events by Exercise Echocardiography in Patients With Normal Exercise Electrocardiographic Testing

ObjectivesWe sought to assess the value of exercise echocardiography (EE) for predicting outcome in patients with known or suspected coronary artery disease and normal exercise electrocardiogram (ECG) testing.BackgroundThe prognostic value of EE in patients with normal exercise ECG testing has not been characterized.MethodsWe studied 4,004 consecutive patients (2,358 men, mean age [± SD] 59.6 ± 12.5 years) with interpretable ECG who underwent treadmill EE and did not develop chest pain or ischemic ECG abnormalities during the tests. Wall motion score index (WMSI) was evaluated at rest and with exercise, and the difference (ΔWMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (MACE).ResultsOverall, 669 patients (16.7%) developed ischemia with exercise. During a mean follow-up of 4.5 ± 3.4 years, 313 patients died, and 183 patients had a MACE before any revascularization procedure. The 5-year mortality and MACE rates were 6.4% and 4.2% in patients without ischemia versus 12.1% and 10.1% in those with ischemia, respectively (p < 0.001). In the multivariate analysis, ΔWMSI remained an independent predictor of mortality (hazard ratio [HR]: 2.73, 95% confidence interval [CI]: 1.40 to 5.32, p = 0.003) and MACE (HR: 3.59, 95% CI: 1.42 to 9.07, p = 0.007). The addition of the EE results to the clinical, resting echocardiographic and exercise hemodynamic data significantly increased the global chi-square of the models for the prediction of mortality (p = 0.005) and MACE (p = 0.009).ConclusionsThe use of EE provides significant prognostic information for predicting mortality and MACE in patients with interpretable ECG and normal exercise ECG testing