Impacto de la fragilidad en los resultados de la revascularización coronaria en pacientes ancianos con síndrome coronario agudo

Introducción: La población anciana representa un grupo heterogéneo de pacientes con mayor riesgo de eventos adversos tras un síndrome coronario agudo. La fragilidad refleja la edad biológica, discriminando mejor el pronóstico vital que la edad cronológica. Existe poca información sobre el impacto de la fragilidad en población anciana con SCA. Nuestro objetivo es estudiar la prevalencia de fragilidad en pacientes ancianos ingresados por SCA, analizar su relación con la estrategia de revascularización utilizada y evaluar el impacto pronóstico en los resultados de la revascularización. Material y métodos: Registro prospectivo multicéntrico de pacientes ³ 70 años ingresados por SCA, reclutados entre 2014 y 2016. Se evaluó la presencia de fragilidad según la escala SHARE-FI durante las primeras 48 horas. Durante el ingreso hospitalario se registró la estrategia de revascularización empleada (conservadora vs invasiva). La variable de resultado principal fue la mortalidad intrahospitalaria y durante el seguimiento a 12 meses. Resultados: Se incluyeron 417 pacientes, con una prevalencia de fragilidad del 41%. En 58 (13.9%) pacientes se realizó un manejo conservador del SCA sin realización de coronariografía. La fragilidad se asoció con mayor probabilidad de optar por una estrategia conservadora (OR: 3.24 [1.62-6.44], p=0.001). Durante la hospitalización fallecieron 20 (4.8%), con un mayor riesgo de mortalidad en los pacientes frágiles (OR: 4.38 [1.33-14.3], p= 0.015). Durante el seguimiento a 12 meses fallecieron 78 (18.7%) pacientes, con un mayor riesgo de mortalidad en los pacientes frágiles (HR 4.41 [2.48- 7.83]; p<0.001). El riesgo de mortalidad durante el seguimiento fue mayor en los pacientes que se optó por un manejo conservador del SCA (HR:2.9 [1.8-4.7]; p<0.001). En el grupo de pacientes con manejo invasivo, la fragilidad incrementó el riesgo de mortalidad a 12 meses (HR:4.2 [2.2-7.9]; p<0.001). Conclusiones: La prevalencia de fragilidad es elevada en población anciana y se asocia con mayor riesgo de optar por un manejo conservador. La fragilidad se asocia de forma significativa con mayor mortalidad intrahospitalaria y durante el seguimiento a 1 año, independientemente de la estrategia de revascularización

Response by Caravaca Pérez et al to Letter Regarding Article, "Potential Role of Natriuretic Response to Furosemide Stress Test During Acute Heart Failure".

S

Renal Function Impact in the Prognostic Value of Galectin-3 in Acute Heart Failure

[Abstract] Introduction: Galectin-3 (Gal-3) is an inflammatory marker associated with the development and progression of heart failure (HF). A close relationship between Gal-3 levels and renal function has been observed, but data on their interaction in patients with acute HF (AHF) are scarce. We aim to assess the prognostic relationship between renal function and Gal-3 during an AHF episode. Materials and methods: This is an observational, prospective, multicenter registry of patients hospitalized for AHF. Patients were divided into two groups according to estimated glomerular filtration rate (eGFR): preserved renal function (eGFR ≥ 60 mL/min/1.73 m2) and renal dysfunction (eGFR <60 mL/min/1.73 m2). Cox regression analysis was performed to evaluate the association between Gal-3 and 12-month mortality. Results: We included 1,201 patients in whom Gal-3 values were assessed at admission. The median value of Gal-3 in our population was 23.2 ng/mL (17.3-32.1). Gal-3 showed a negative correlation with eGFR (rho = -0.51; p < 0.001). Gal-3 concentrations were associated with higher mortality risk in the multivariate analysis after adjusting for eGFR and other prognostic variables [HR = 1.010 (95%-CI: 1.001-1.018); p = 0.038]. However, the prognostic value of Gal-3 was restricted to patients with renal dysfunction [HR = 1.010 (95%-CI: 1.001-1.019), p = 0.033] with optimal cutoff point of 31.5 ng/mL, with no prognostic value in the group with preserved renal function [HR = 0.990 (95%-CI: 0.964-1.017); p = 0.472]. Conclusions: Gal-3 is a marker of high mortality in patients with acute HF and renal dysfunction. Renal function influences the prognostic value of Gal-3 levels, which should be adjusted by eGFR for a correct interpretation.Grant No. RD06-0003-0000 Grant No. RD12/0042/000

Serum Potassium Dynamics During Acute Heart Failure Hospitalization

[Abstract] Background. Available information about prognostic implications of potassium levels alteration in the setting of acute heart failure (AHF) is scarce. Objectives. We aim to describe the prevalence of dyskalemia (hypo or hyperkalemia), its dynamic changes during AHF-hospitalization, and its long-term clinical impact after hospitalization. Methods. We analyzed 1779 patients hospitalized with AHF who were included in the REDINSCOR II registry. Patients were classified in three groups, according to potassium levels both on admission and discharge: hypokalemia (potassium  5 mEq/L). Results. The prevalence of hypokalemia and hyperkalemia on admission was 8.2 and 4.6%, respectively, and 6.4 and 2.7% at discharge. Hyperkalemia on admission was associated with higher in-hospital mortality (OR = 2.32 [95% CI: 1.04–5.21] p = 0.045). Among patients with hypokalemia on admission, 79% had normalized potassium levels at discharge. In the case of patients with hyperkalemia on admission, 89% normalized kalemia before discharge. In multivariate Cox regression, dyskalemia was associated with higher 12-month mortality, (HR = 1.48 [95% CI, 1.12–1.96], p = 0.005). Among all patterns of dyskalemia persistent hypokalemia (HR = 3.17 [95% CI: 1.71–5.88]; p < 0.001), and transient hyperkalemia (HR = 1.75 [95% CI: 1.07–2.86]; p = 0.023) were related to reduced 12-month survival. Conclusions. Potassium levels alterations are frequent and show a dynamic behavior during AHF admission. Hyperkalemia on admission is an independent predictor of higher in-hospital mortality. Furthermore, persistent hypokalemia and transient hyperkalemia on admission are independent predictors of 12-month mortality.This work is funded by the Instituto de Salud Carlos III (Ministry of Economy, Industry, and Competitiveness) and co-funded by the European Regional Development Fund, through the CIBER in cardiovascular diseases (CB16/11/00502)

Clinical Utility of HeartLogic, a Multiparametric Telemonitoring System, in Heart Failure

Telemonitoring through multiple variables measured on cardiac devices has the potential to improve the follow-up of patients with heart failure. The HeartLogic algorithm (Boston Scientific), implemented in some implantable cardiac defibrillators and cardiac resynchronisation therapy, allows monitoring of the nocturnal heart rate, respiratory movements, thoracic impedance, physical activity and the intensity of heart tones, with the aim of predicting major clinical events. Although HeartLogic has demonstrated high sensitivity for the detection of heart failure decompensations, its effects on hospitalisation and mortality in randomised clinical trials has not yet been corroborated. This review details how the HeartLogic algorithm works, compiles available evidence from clinical studies, and discusses its application in daily clinical practice

Sacubitril-Valsartan, clinical benefits and related mechanisms of action in heart failure with reduced ejection fraction. A review

Heart failure (HF) is a clinical syndrome characterized by the presence of dyspnea or limited exertion due to impaired cardiac ventricular filling and/or blood ejection. Because of its high prevalence, it is a major health and economic burden worldwide. Several mechanisms are involved in the pathophysiology of HF. First, the renin-angiotensin-aldosterone system (RAAS) is over-activated, causing vasoconstriction, hypertension, elevated aldosterone levels and sympathetic tone, and eventually cardiac remodeling. Second, an endogenous compensatory mechanism, the natriuretic peptide (NP) system is also activated, albeit insufficiently to counteract the RAAS effects. Since NPs are degraded by the enzyme neprilysin, it was hypothesized that its inhibition could be an important therapeutic target in HF. Sacubitril/valsartan is the first of the class of dual neprilysin and angiotensin receptor inhibitors (ARNI). In patients with HFrEF, treatment with sacubitril/valsartan has demonstrated to significantly reduce mortality and the rates of hospitalization and rehospitalization for HF when compared to enalapril. This communication reviews in detail the demonstrated benefits of sacubitril/valsartan in the treatment of patients with HFrEF, including reduction of mortality and disease progression as well as improvement in cardiac remodeling and quality of life. The hemodynamic and organic effects arising from its dual mechanism of action, including the impact of neprilysin inhibition at the renal level, especially relevant in patients with type 2 diabetes mellitus, are also reviewed. Finally, the evidence on the demonstrated safety and tolerability profile of sacubitril/valsartan in the different subpopulations studied has been compiled. The review of this evidence, together with the recommendations of the latest clinical guidelines, position sacubitril/valsartan as a fundamental pillar in the treatment of patients with HFrEF

por Atractylis gummifera L. en Badajoz (España)

[ES] Se comentan cuatro casos de intoxicación por Atractylis gummifera L. ocurridos en Badajoz (España).[EN] Commentary is made of four cases of intoxication by Atractylis gummifera L. occured in Badajoz (Spain)

Feasibility and results of an intensive cardiac rehabilitation program. Insights from the MxM (Más por Menos) randomized trial.

Cardiac rehabilitation programs (CRP) are a set of interventions to improve the prognosis of cardiovascular disease by influencing patients' physical, mental, and social conditions. However, there are no studies evaluating the optimal duration of these programs. We aimed to compare the results of a standard vs a brief intensive CRP in patients after ST-segment elevation and non-ST-segment elevation acute coronary syndrome through the Más por Menos study (More Intensive Cardiac Rehabilitation Programs in Less Time). In this prospective, randomized, open, evaluator-blind for end-point, and multicenter trial (PROBE design), patients were randomly allocated to either standard 8-week CRP or intensive 2-week CRP with booster sessions. A final visit was performed 12 months later, after completion of the program. We assessed adherence to the Mediterranean diet, psychological status, smoking, drug therapy, functional capacity, quality of life, cardiometabolic and anthropometric parameters, cardiovascular events, and all-cause mortality during follow-up. A total of 497 patients (mean age, 57.8±10.0 years; 87.3% men) were finally assessed (intensive: n=262; standard: n=235). Baseline characteristics were similar between the 2 groups. At 12 months, the results of treadmill ergometry improved by ≥ 1 MET in ≥ 93% of the patients. In addition, adherence to the Mediterranean diet and quality of life were significantly improved by CRP, with no significant differences between the groups. The occurrence of cardiovascular events was similar in the 2 groups. Intensive CRP could be as effective as standard CRP in achieving adherence to recommended secondary prevention measures after acute coronary syndrome and could be an alternative for some patients and centers. Registered at ClinicalTrials.gov (Identifier: NCT02619422)

Feasibility and results of an intensive cardiac rehabilitation program. Insights from the MxM (Más por Menos) randomized trial

Introduccion y objetivos: Los programas de rehabilitacion cardiaca (PRC) engloban intervenciones encaminadas a mejorar el pronostico de la enfermedad cardiovascular influyendo en la condicin fısica, mental y social de los pacientes, pero no se conoce su duracion optima. Nuestro objetivo es comparar los resultados de un PRC estandar frente a otro intensivo mas breve tras un sındrome coronario agudo, mediante el estudio Mas por Menos. Metodos: Diseño prospectivo, aleatorizado, abierto, enmascarado a los evaluadores de eventos y multicentrico (PROBE). Se aleatorizoa los pacientes al PRC estandar de 8 semanas u otro intensivo de 2 semanas con sesiones de refuerzo. Se realizo una visita final 12 meses despues, tras la finalizacion del programa. Se evaluo: adherencia a la dieta, esfera psicologica, habito tabaquico, tratamiento farmacologico, capacidad funcional, calidad de vida, parametros cardiometabolicos y antropometricos, eventos cardiovasculares y mortalidad por cualquier causa durante el seguimiento. Resultados: Se analizoa 497 pacientes (media de edad, 57,8 10,0 an ̃ os; el 87,3% varones; programa intensivo, n = 262; estandar, n = 235). Las caracteristicas basales de ambos grupos eran similares. Al año, mas del 93% habıa mejorado en al menos 1 MET el resultado de la ergometría. Además, la adherencia a la dieta mediterranea y la calidad de vida mejoraron significativamente con el PRC, sin diferencias significativas entre grupos. Los eventos cardiovasculares ocurrieron de manera similar en ambos grupos. Conclusiones: La PRC intensiva podrıa ser tan efectiva como la PRC estándar en lograr la adherencia a las medidas de prevencio n secundaria y ser una alternativa para algunos pacientes y centros.Introduction and objectives: Cardiac rehabilitation programs (CRP) are a set of interventions to improve the prognosis of cardiovascular disease by influencing patients’ physical, mental, and social conditions. However, there are no studies evaluating the optimal duration of these programs. We aimed to compare the results of a standard vs a brief intensive CRP in patients after ST-segment elevation and non–ST- segment elevation acute coronary syndrome through the Ma ́s por Menos study (More Intensive Cardiac Rehabilitation Programs in Less Time). Methods: In this prospective, randomized, open, evaluator-blind for end-point, and multicenter trial (PROBE design), patients were randomly allocated to either standard 8-week CRP or intensive 2-week CRP with booster sessions. A final visit was performed 12 months later, after completion of the program. We assessed adherence to the Mediterranean diet, psychological status, smoking, drug therapy, functional capacity, quality of life, cardiometabolic and anthropometric parameters, cardiovascular events, and all-cause mortality during follow-up. Results: A total of 497 patients (mean age, 57.8 10.0 years; 87.3% men) were finally assessed (intensive: n = 262; standard: n = 235). Baseline characteristics were similar between the 2 groups. At 12 months, the results of treadmill ergometry improved by 1 MET in 93% of the patients. In addition, adherence to the Mediterranean diet and quality of life were significantly improved by CRP, with no significant differences between the groups. The occurrence of cardiovascular events was similar in the 2 groups. Conclusions: Intensive CRP could be as effective as standard CRP in achieving adherence to recommended secondary prevention measures after acute coronary syndrome and could be an alternative for some patients and centers

Prevalence and characterization of frailty, depression, and cognitive impairment in patients listed for heart transplantation: Results of the FELICITAR prospective registry

Introduction: It is recommended to assess frailty prior to heart transplantation (HT). Our objective was to assess the prevalence of frailty in patients listed for HT. Methods: The FELICITAR registry (Frailty Evaluation after List Inclusion, Characteristics and Influence on TrAnsplantation And Results) is a prospective registry that includes patients listed for HT in three centers, from January 2017 to April 2019. We assessed the presence of frailty, depression, cognitive impairment, and quality of life when included. Results: Ninety-nine patients were included. Of this group, 30.6% were frail, 55 (56.1%) had depression (treated only in nine patients), and 51 (54.8%) had cognitive impairment. Compared with non-frail patients, frail patients were more frequently hospitalized when included in HT waiting list (P = .048), had a lower upper-arm circumference (P = .026), had a lower Barthel index (P = .001), more anemia (P = .010), higher rates of depression (P = .001), poorer quality of life (P = .001), and lower hand-grip strength (P < .001). In multivariate analysis hand-grip strength (odds ratio .91; 95% confidence interval .87-.96, P < .001) and Barthel index (odds ratio .90; 95% confidence interval .82-.99, P = .024) were associated with frailty. Conclusions: Frailty, depression, and cognitive impairment are common in patients included in HT waiting list. Frailty is strongly associated with hand-grip strength.Sin financiación2.863 JCR (2020) Q2, 80/212 Surgery0.918 SJR (2020) Q2, 15/42 TransplantationNo data IDR 2020UE