Tratamiento antiagregante en el Síndrome coronario agudo. Seguridad y eficacia del cruce entre antiagregantes

Introducción. La doble antiagregación (DAPT) es un pilar fundamental del tratamiento del síndrome coronario agudo (SCA). Sin embargo, la eficacia y seguridad de cambio entre los antagonistas del receptor del ADP P2Y12 en pacientes con SCA es poco conocida. El objetivo de este trabajo es evaluar la seguridad del cruce entre antiagregantes en términos de sangrado mayor en pacientes con SCA. Material y método. Estudio observacional de cohortes prospectivo y monocéntrico. Se incluyeron 246 pacientes consecutivos con SCA tipo 1 ingresados en Unidad de Críticos Cardiológicos entre el 27 de febrero de 2015 al 31 de mayo de 2016. Se excluyeron pacientes con necesidad de revascularización quirúrgica durante el evento índice y pacientes que no recibían un inhibidor del receptor del ADP P2Y12 al alta hospitalaria. Un análisis de riesgos proporcionales de Cox se utilizó para determinar los predictores asociados con el tiempo hasta la presentación de un sangrado mayor (BARC 3) y la realización del cruce entre antiagregantes al año de seguimiento. Resultados. El cruce entre antiagregantes se produjo en 122 pacientes (49,6%). Los pacientes con cruce fueron más jóvenes, presentaron mejor función renal, menor puntuación de riesgo isquémico (GRACE), menor antecedente personal de arritmia cardiaca, más uso de fibrinolítico en el SCACEST y más implante de stent farmacoactivo. Se observó una menor tasa del evento cardiovascular mayor (MACE) (10,7% [IC 95%: 5,2-16,1] vs 20,2% [IC 95%: 13,1-27,2]; p=0,039) en el grupo cruce, a expensas de una reducción significativa de la mortalidad (4,1% [IC 95%: 1,3-9,3] vs 12,9 % [IC 95%: 7,0- 18,8]; p=0,013). Los predictores contrarios al cruce fueron la edad (HR: 0,97; IC 95%:0,95-0,98; p=0,00005) y el uso de inhibidores del receptor del ADP P2Y12 potentes. 112 pacientes (45,5%) presentaron un evento hemorrágico en algún momento del seguimiento. La incidencia de sangrado mayor fue 8,5%. El sangrado gastrointestinal fue el sangrado mayor más frecuente. No se observaron diferencias significativas en la tasa de sangrado mayor cruda (no cruce 10,5% [IC 95%: 5,1-15,9] vs 6,6% [IC 95%: 1,8-11,4]; p=0,270) ni ajustada entre los grupos de tratamiento. La mayor puntuación en la escala de riesgo CRUSADE (HR: 1,05; IC 95%: 1,03-1,08; p=0,00005) y la anticoagulación al alta (HR: 5,07; IC 95%: 1,11-23,14; p=0,010) fueron predictores de riesgo de tiempo hasta el sangrado mayor en el seguimiento. El pretratamiento fue un predictor protector de tiempo hasta la presentación de un sangrado mayor (HR: 0,32; IC 95%: 0,13-0,83; p=0.019). El cruce entre antiagregante no se estableció como un predictor de sangrado mayor. Conclusiones. El cruce entre inhibidores del receptor del ADP P2Y12 en pacientes con SCA no se asoció con un mayor riesgo de sangrado mayor en la población analizada. Sin embargo, el aumento de la puntuación en la escala de riesgo hemorrágico CRUSADE y el tratamiento anticoagulante al alta fueron predictores de riesgo de sangrado mayor y el pretratamiento con inhibidores del receptor del ADP P2Y12 fue un factor protector de sangrado mayor en la población analizada.Aims. Dual antiplatelet therapy (DAPT) is a cornerstone for the management of patients with acute coronary syndrome (ACS). However, the efficacy and safety of switching between P2Y12 ADP receptor inhibitors in patients with ACS remain unclear. We assessed the safety of switching between P2Y12 ADP receptor inhibitors in terms of major bleeding in patients with ACS. Methods. Observational, prospective, monocenter registry study. A total of 246 consecutive patients after admission by ACS in acute cardiac care unit were enrolled from 27 February 2015 to 31 May 2016. Cox proportional hazard regression modeling was used to determine clinical factors associated with mayor bleeding (BARC 3) or switching antiplatelet strategy over a year period. Results. Switching between P2Y12 ADP receptor inhibitors occurred in 122 patients (49.6%). The switching group patients were younger, better renal function, lower GRACE ischemic risk score, lower history of cardiac arrhythmia, more fibrinolytic use in the SCACEST and more pharmacoactive stent implantation. A lower rate of major cardiovascular event (MACE) was detected (10.7% [95% CI: 5.2-16.1] vs 20.2% [95% CI: 13.1-27.2]; p=0.039) in the switching group, at the expense mainly of mortality reduction (4.1% [95% CI: 1.3-9.3] vs 12.9% [95% CI: 7.0-18.8]; p=0.013). Predictors against switching were age (HR: 0.97; 95% CI: 0.95-0.98; p=0.00005) and the use of potent P2Y12 ADP receptor inhibitors. Bleeding occurred in 112 patients (45.5%) at follow-up. The incidence of major bleeding was 8.5%. Gastrointestinal bleeding was the most frequent major bleeding. No significant differences were observed in the crude rate of major bleeding (no switching group 10.5% [95% CI: 5.1-15.9] vs switching 6.6% [95% CI: 1.8-11.4]; p=0.270) or adjusted rate between treatment groups. The highest CRUSADE risk score (HR: 1.05; 95% CI: 1.03-1.08; p=0.0005) and anticoagulation at discharge (HR: 5.07; 95% CI: 1.11-23.14; p=0.010) they were risk predictors until major bleeding. Pretreatment was a protective predictor until the presentation of major bleeding (HR: 0.32; 95% CI: 0.13-0.83; p=0.019). Switching between antiplatelet will not be seen as a predictor of major bleeding. Conclusions. Switching between P2Y12 ADP receptor inhibitors in patients with ACS is not associated with an increased risk of major bleeding in the population analyzed. However, the highest CRUSADE risk score and anticoagulation at discharge were predictors of major bleeding and de pretreatment with P2Y12 ADP receptor inhibitors was a major bleeding protective factor in the population analyzed

Repolarization parameters and ventricular arrhythmias in Takotsubo syndrome: A substudy from the RETAKO national registry

Arrhythmias; Repolarization; TakotsuboArritmias; Repolarización; TakotsuboArítmies; Repolarització; TakotsuboThe registry webpage was funded by an AstraZeneca nonconditioned grant and by FIC (Fundación Interhospitalaria para la Investigación en Cardiología)

Smoking influence in Takotsubo syndrome: insights from an international cohort

Takotsubo syndrome; Mortality; Smoking habitSíndrome de Takotsubo; Mortalidad; Hábito de fumarSíndrome de Takotsubo; Mortalitat; Hàbit de fumarAims: To assess the influence of tobacco on acute and long-term outcomes in Takotsubo syndrome (TTS). Methods: Patients with TTS from the international multicenter German Italian Spanish Takotsubo registry (GEIST) were analyzed. Comparisons between groups were performed within the overall cohort, and an adjusted analysis with 1:1 propensity score matching was conducted. Results: Out of 3,152 patients with TTS, 534 (17%) were current smokers. Smoker TTS patients were younger (63 ± 11 vs. 72 ± 11 years, p < 0.001), less frequently women (78% vs. 90%, p < 0.001), and had a lower prevalence of hypertension (59% vs. 69%, p < 0.01) and diabetes mellitus (16% vs. 20%, p = 0.04), but had a higher prevalence of pulmonary (21% vs. 15%, p < 0.01) and/or psychiatric diseases (17% vs. 12%, p < 0.01). On multivariable analysis, age less than 65 years [OR 3.85, 95% CI (2.86–5)], male gender [OR 2.52, 95% CI (1.75–3.64)], history of pulmonary disease [OR 2.56, 95% CI (1.81–3.61)], coronary artery disease [OR 2.35, 95% CI (1.60–3.46)], and non-apical ballooning form [OR 1.47, 95% CI (1.02–2.13)] were associated with smoking status. Propensity score matching (PSM) 1:1 yielded 329 patients from each group. Smokers had a similar rate of in-hospital complications but longer in-hospital stays (10 vs. 9 days, p = 0.01). During long-term follow-up, there were no differences in mortality rates between smokers and non-smokers (5.6% vs. 6.9% yearly in the overall, p = 0.02, and 6.6%, vs. 7.2% yearly in the matched cohort, p = 0.97). Conclusions: Our findings suggest that smoking may influence the clinical presentation and course of TTS with longer in-hospital stays, but does not independently impact mortality.FIC (Fundación Interhospitalaria para la Investigación en Cardiología) supported RETAKO

Tomar la palabra. Intertextualidad e intermedialidad como herramientas pedagógicas para la enseñanza de la literatura y otros discursos

Depto. de Lengua Española y Teoría de la LiteraturaFac. de FilologíaFALSEsubmitte

Smoking influence in Takotsubo syndrome: insights from an international cohort

Aims: To assess the influence of tobacco on acute and long-term outcomes in Takotsubo syndrome (TTS).Methods: Patients with TTS from the international multicenter German Italian Spanish Takotsubo registry (GEIST) were analyzed. Comparisons between groups were performed within the overall cohort, and an adjusted analysis with 1:1 propensity score matching was conducted.Results: Out of 3,152 patients with TTS, 534 (17%) were current smokers. Smoker TTS patients were younger (63 +/- 11 vs. 72 +/- 11 years, p < 0.001), less frequently women (78% vs. 90%, p < 0.001), and had a lower prevalence of hypertension (59% vs. 69%, p < 0.01) and diabetes mellitus (16% vs. 20%, p = 0.04), but had a higher prevalence of pulmonary (21% vs. 15%, p < 0.01) and/or psychiatric diseases (17% vs. 12%, p < 0.01). On multivariable analysis, age less than 65 years [OR 3.85, 95% CI (2.86-5)], male gender [OR 2.52, 95% CI (1.75-3.64)], history of pulmonary disease [OR 2.56, 95% CI (1.81-3.61)], coronary artery disease [OR 2.35, 95% CI (1.60-3.46)], and non-apical ballooning form [OR 1.47, 95% CI (1.02-2.13)] were associated with smoking status. Propensity score matching (PSM) 1:1 yielded 329 patients from each group. Smokers had a similar rate of in-hospital complications but longer in-hospital stays (10 vs. 9 days, p = 0.01). During long-term follow-up, there were no differences in mortality rates between smokers and non-smokers (5.6% vs. 6.9% yearly in the overall, p = 0.02, and 6.6%, vs. 7.2% yearly in the matched cohort, p = 0.97).Conclusions: Our findings suggest that smoking may influence the clinical presentation and course of TTS with longer in-hospital stays, but does not independently impact mortality.Fundación Interhospitalaria para la Investigación en Cardiología3.6 Q2 JCR 20221.391 Q1 SJR 2022No data IDR 2022UE

Comparative Safety and Effectiveness of Ticagrelor versus Clopidogrel in Patients With Acute Coronary Syndrome: An On-Treatment Analysis From a Multicenter Registry.

The net clinical benefit of ticagrelor over clopidogrel in acute coronary syndrome (ACS) has recently been questioned by observational studies which did not account for time-dependent confounders. We aimed to assess the comparative safety and effectiveness of ticagrelor vs. clopidogrel accounting for non-adherence in a real-life setting. This is a prospective, multicenter cohort study of patients with ACS discharged on ticagrelor or clopidogrel between 2015 and 2019. Major exclusions were previous intracranial bleeding, and the use of prasugrel or oral anticoagulation. Association of P2Y12 inhibitor therapy with 1-year risk of Bleeding Academic Research Consortium Type 3 or 5 bleeding; major adverse cardiac events (MACEs), a composite endpoint of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, or urgent target lesion revascularization; definite/probable stent thrombosis; vascular death; and net adverse clinical event (a composite endpoint of major bleeding and MACE) were analyzed according to the "on-treatment" principle, using fully adjusted Cox and Fine-Gray regression models with doubly robust inverse probability of censoring weighted estimators. Among 2,070 patients (mean age 63 years, 27% women, 62.5% ST-elevation MI), 1,035 were discharged on ticagrelor and clopidogrel, respectively. Ticagrelor-treated patients were younger and had few comorbidities, but high rates of medication non-compliance, compared with clopidogrel users. After comprehensive multivariate adjustments, ticagrelor did not increase the risk of major bleeding compared with clopidogrel [subhazard ratio, 1.40; 95% confidence interval (CI), 0.96-2.05], while proved superior in reducing MACE (hazard ratio 0.62; 95% CI, 0.43-0.90), vascular death (subhazard ratio, 0.71; 95% CI, 0.52-0.97) and definite/probable stent thrombosis (subhazard ratio, 0.54; 95% CI, 0.30-0.79); thereby resulting in a favorable net clinical benefit (hazard ratio 0.78; 95% CI, 0.60-0.98) compared with clopidogrel. Results from sensitivity analyses were consistent with those from the primary analysis, whereas those from the intention-to-treat (ITT) analysis went in the opposite direction. Among all-comers with ACS, ticagrelor did not significantly increase the risk of major bleeding, while resulting in a net clinical benefit compared with clopidogrel. Further research is warranted to confirm these findings in high bleeding risk populations. (ClinicalTrials.gov Identifier: NCT02500290); Current pre-specified analysis (ClinicalTrials.gov Identifier: NCT04630288)

Repolarization parameters and ventricular arrhythmias in Takotsubo syndrome: A substudy from the RETAKO national registry

Sin financiación1.9 Q* JCR 20220.71 Q2 SJR 2022No data IDR 2022UE

Renal impairment and outcome in Takotsubo syndrome: Insights from a national multicentric cohort

ntroduction: Data on the association between kidney function and Takotsubo syndrome (TTS) outcomes are scarce and conflictive. Objective: To assess the impact of chronic kidney disease (CKD) and acute renal failure (ARF) in patients with TTS. Material and methods: Patients from the prospective nation-wide (RETAKO) registry were included and divided into quartiles of maximum creatinine (Cr) level during hospitalization. Results: The prevalence of CKD and ARF in the whole RETAKO cohort was 5.4% and 11.7%, respectively. Compared to Q1 (Cr 1.1) had lower left ventricular ejection fraction on admission (38.5 ± 12 vs 43.3 ± 11.3, p = 0.002) and higher bleeding rates during hospitalization (6.7% vs 2%, p = 0.005). In addition, compared to Q1, Q4 patients have a greater incidence of cardiogenic shock (17.3% vs 5.6%, p < 0.001), and a higher rate of 5-year all-cause death and major adverse cardiovascular events (31.5% vs 15.8%, p < 0.001 and 22.5% vs 9.3%, p < 0.001, respectively). Conclusions: TTS patients with CKD have a higher incidence of ARF and exhibit greater Cr on admission, which were linked with higher rates of cardiogenic shock, bleeding during hospitalization as well as major adverse cardiovascular events and all-cause death during a 5-year follow-up.Sociedad Española de CardiologíaMayo Clinic3.5 Q1 JCR 20221.126 Q1 SJR 2023No data IDR 2022UE

Peripartum Takotsubo Cardiomyopathy: A Review and Insights from a National Registry

Takotsubo syndrome (TTS) during the peripartum period is a relevant cause of morbidity in this population; its clinical course and prognosis, compared to the general TTS population, is yet to be elucidated. Our aim was to analyze the clinical features and prognosis of peripartum TTS in a nationwide prospective specifically oriented registry database and consider the published literature. Peripartum TTS patients from the prospective nationwide RETAKO registry—as well as peripartum TTS patients from the published literature—were included, and multiple comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between the groups. Patients with peripartum TTS exhibit a higher prevalence of secondary forms, dyspnea, atypical symptoms, and echocardiographic patterns, as well as less ST-segment elevation than the general TTS population. In the literature, patients with peripartum TTS had a higher Killip status on admission. TTS during the peripartum period has a higher prevalence of angina and dyspnea, as well as physical triggers, neither of which are related to a worse prognosis. Killip status on admission was higher in the literature for patients with TTS but with excellent mid- and long-term prognoses after the acute phase, despite mostly being secondary forms

Measurements of the Total and Differential Higgs Boson Production Cross Sections Combining the H??????? and H???ZZ*???4??? Decay Channels at s\sqrt{s}=8??????TeV with the ATLAS Detector

Measurements of the total and differential cross sections of Higgs boson production are performed using 20.3~fb$^{-1}$ of $pp$ collisions produced by the Large Hadron Collider at a center-of-mass energy of $\sqrt{s} = 8$ TeV and recorded by the ATLAS detector. Cross sections are obtained from measured $H \rightarrow \gamma \gamma$ and $H \rightarrow ZZ ^{*}\rightarrow 4\ell$ event yields, which are combined accounting for detector efficiencies, fiducial acceptances and branching fractions. Differential cross sections are reported as a function of Higgs boson transverse momentum, Higgs boson rapidity, number of jets in the event, and transverse momentum of the leading jet. The total production cross section is determined to be $\sigma_{pp \to H} = 33.0 \pm 5.3 \, ({\rm stat}) \pm 1.6 \, ({\rm sys}) \mathrm{pb}$. The measurements are compared to state-of-the-art predictions.Measurements of the total and differential cross sections of Higgs boson production are performed using 20.3  fb-1 of pp collisions produced by the Large Hadron Collider at a center-of-mass energy of s=8  TeV and recorded by the ATLAS detector. Cross sections are obtained from measured H→γγ and H→ZZ*→4ℓ event yields, which are combined accounting for detector efficiencies, fiducial acceptances, and branching fractions. Differential cross sections are reported as a function of Higgs boson transverse momentum, Higgs boson rapidity, number of jets in the event, and transverse momentum of the leading jet. The total production cross section is determined to be σpp→H=33.0±5.3 (stat)±1.6 (syst)  pb. The measurements are compared to state-of-the-art predictions.Measurements of the total and differential cross sections of Higgs boson production are performed using 20.3 fb$^{-1}$ of $pp$ collisions produced by the Large Hadron Collider at a center-of-mass energy of $\sqrt{s} = 8$ TeV and recorded by the ATLAS detector. Cross sections are obtained from measured $H \rightarrow \gamma \gamma$ and $H \rightarrow ZZ ^{*}\rightarrow 4\ell$ event yields, which are combined accounting for detector efficiencies, fiducial acceptances and branching fractions. Differential cross sections are reported as a function of Higgs boson transverse momentum, Higgs boson rapidity, number of jets in the event, and transverse momentum of the leading jet. The total production cross section is determined to be $\sigma_{pp \to H} = 33.0 \pm 5.3 \, ({\rm stat}) \pm 1.6 \, ({\rm sys}) \mathrm{pb}$. The measurements are compared to state-of-the-art predictions