La resonancia magnética cardíaca, pieza clave en el paciente con miocarditis aguda

Inflammation of the myocardium, viral or not, is called myocarditis. Diagnosis can be a real challenge, and appropriate differential diagnosis with other conditions is needed. Endomyocardial biopsy has been the classical gold standard for the diagnosis of this disease, but nowadays it has been largely replaced by cardiac MRI. A case of a patient with acute myocarditis is presented to emphasize the leading role of cardiac MRI as the first choice test for this kind of patients.La inflamación del miocardio, vírica o no, recibe el nombre de miocarditis. Este cuadro supone un reto para el médico clínico en su práctica habitual, ya que es fundamental realizar un diagnóstico diferencial correcto con otros cuadros que puede emular. La biopsia endomiocárdica ha sido clásicamente la técnica de referencia en el diagnóstico de esta entidad, aunque actualmente la cardio-RM es la técnica más empleada para valorar este tipo de pacientes. Se presenta un caso de un paciente con miocarditis aguda con el que se pretende enfatizar el papel protagonista de la cardio-RM como prueba de imagen de elección

INR during stroke and bleeding in patients with atrial fibrillation and on vitamin K antagonists

[Resumen] Introducción y objetivos. La fibrilación auricular tiene un mal pronóstico asociado fundamentalmente al desarrollo de ictus. A pesar del uso de anticoagulantes, algunos pacientes pueden sufrir ictus y también hemorragias graves. El tratamiento con antagonistas de la vitamina K (AVK) se controla mediante la razón internacional normalizada (INR). Nuestro objetivo fue estudiar la incidencia de ictus y hemorragias mayores, e investigar los valores de la INR y el tiempo en rango terapéutico en los 6 meses previos durante dichos episodios en pacientes con fibrilación auricular tratados con AVK. Métodos. Se incluyeron 1.483 pacientes con fibrilación auricular tratados con AVK durante al menos los 6 meses previos, incluidos consecutivamente desde junio de 2013 hasta octubre de 2014, con una mediana de seguimiento de 32,4 meses. Se identificaron aquellos pacientes que ingresaron por ictus o hemorragia mayor y se determinó la INR en cada episodio. Resultados. Se registraron 40 ictus (1,07/100 pacientes/año) y 120 hemorragias mayores (3,28/100 pacientes/año). La INR durante los ictus fue 2,33 ± 0,59, y durante las hemorragias 3,17 ± 1,48. El 57,5% de los pacientes tenían una INR de 2-3 durante los ictus y el 48,3% durante las hemorragias. Los pacientes que sufrieron un ictus con una INR fuera de rango durante el episodio presentaron un tiempo en rango terapéutico más bajo que aquellos con la INR en rango (49,2 ± 20,8% frente a 68,8 ± 19,4%; p = 0,043). Conclusiones. La mitad de los ictus y hemorragias mayores se producen con valores de la INR «adecuados» (2 a 3). Cambios en la estrategia de anticoagulación pueden ser necesarios para disminuir esta elevada tasa de eventos.[Abstract] Introduction and objectives. Atrial fibrillation has a poor prognosis, mainly due to the occurrence of cardioembolic stroke. Despite the use of anticoagulants some patients can develop stroke as well as severe bleeding. Treatment with vitamin K antagonists is usually controlled by means of the international normalized ratio (INR). The aim of this study was to investigate the incidence of stroke and major bleedings, as well the values of INR and the time in therapeutic range within the previous 6 months during these events. Methods. The study included 1483 patients with atrial fibrillation treated with vitamin K antagonists for at least 6 months prior to inclusion, consecutively recruited from June 2013 to October 2014, with a median follow-up of 32.4 months. Those patients admitted due to an episode of stroke or severe bleeding were identified, and an analysis was performed on the INR values obtained for each episode. Results. There was a total of 40 strokes (1.07/100 patients/year) and 120 severe bleedings (3.28/100 patients/year) during the study period. The mean INR value during stroke episodes was 2.33 ± 0.59, and during severe bleeding 3.17 ± 1.48, with 57.5% of patients having had an INR of 2-3 during strokes, and 48.3% during bleedings. Patients with an INR out of range during the stroke had a time in therapeutic range lower than those with an INR between 2 and 3 during the event (49.2 ± 20.8% vs. 68.8 ± 19.4%; P = .043). Conclusions. More than 50% of strokes and almost 50% of severe bleedings occur with ‘adequate’ (2 to 3) INR values. Changes in the anticoagulation strategy seem to be necessary to decrease this high rate of severe events

Efecto de un tratamiento intensivo con insulina sobre la reactividad plaquetaria en pacientes con hiperglucemia que ingresan con un síndrome coronario agudo

El objetivo primario de este trabajo ha sido la valoración del efecto que produce el control estricto de la glucemia mediante un tratamiento intensivo y precoz con insulina sobre la reactividad plaquetaria durante la fase hospitalaria en pacientes que ingresan en una unidad de cuidados intensivos cardiológicos con un síndrome coronario agudo e hiperglucemia, respecto a un tratamiento convencional

Prospective observational registry of perioperative and periprocedural management of antithrombotic therapy in ‘‘real world’’: the REQXAA study

Estudio multicéntrico observacional prospectivo que analizó en 1.266 pacientes el manejo perioperatorio/periprocedimiento de los fármacos antitrombóticos. El estudio objetivó que en esta cohorte la adherencia a las recomendaciones fue baja y que, además, una mala adherencia a las recomendaciones se asoció a una mayor incidencia de eventos adversos, tanto trombóticos como hemorrágicos. Introduction and objectives: There is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events. Methods: This prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs. Results: We included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events. Conclusions: The implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.Depto. de MedicinaFac. de MedicinaTRUEpu

Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU

Dada la variabilidad y heterogeneidad del manejo de los fármacos antitrombóticos pericirugía, desde la Sociedad Española de Cardiología se coordinó y lideró un documento de consenso con otras 20 sociedades para guiar mediante algoritmos sencillos y de fácil utilización el manejo de estos fármacos en la práctica clínica. During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.Depto. de MedicinaFac. de MedicinaTRUEpu

Polypill Strategy in Secondary Cardiovascular Prevention

Background: A polypill that includes key medications associated with improved outcomes (aspirin, angiotensin-converting-enzyme [ACE] inhibitor, and statin) has been proposed as a simple approach to the secondary prevention of cardiovascular death and complications after myocardial infarction. Methods: In this phase 3, randomized, controlled clinical trial, we assigned patients with myocardial infarction within the previous 6 months to a polypill-based strategy or usual care. The polypill treatment consisted of aspirin (100 mg), ramipril (2.5, 5, or 10 mg), and atorvastatin (20 or 40 mg). The primary composite outcome was cardiovascular death, nonfatal type 1 myocardial infarction, nonfatal ischemic stroke, or urgent revascularization. The key secondary end point was a composite of cardiovascular death, nonfatal type 1 myocardial infarction, or nonfatal ischemic stroke. Results: A total of 2499 patients underwent randomization and were followed for a median of 36 months. A primary-outcome event occurred in 118 of 1237 patients (9.5%) in the polypill group and in 156 of 1229 (12.7%) in the usual-care group (hazard ratio, 0.76; 95% confidence interval [CI], 0.60 to 0.96; P = 0.02). A key secondary-outcome event occurred in 101 patients (8.2%) in the polypill group and in 144 (11.7%) in the usual-care group (hazard ratio, 0.70; 95% CI, 0.54 to 0.90; P = 0.005). The results were consistent across prespecified subgroups. Medication adherence as reported by the patients was higher in the polypill group than in the usual-care group. Adverse events were similar between groups. Conclusions: Treatment with a polypill containing aspirin, ramipril, and atorvastatin within 6 months after myocardial infarction resulted in a significantly lower risk of major adverse cardiovascular events than usual care.Unión EuropeaDepto. de MedicinaFac. de MedicinaTRUEpu

Contemporary epidemiology and prognosis of septic shock in infective endocarditis

Aims: The prognosis of patients with infective endocarditis (IE) remains poor despite the great advances in the last decades. One of the factors closely related to mortality is the development of septic shock (SS). The aim of our study was to describe the profile of patients with IE complicated with SS, and to identify prognostic factors of new-onset SS during hospitalization. Methods and results: We conducted a prospective study including 894 episodes of IE diagnosed at three tertiary centres. A backward logistic regression analysis was undertaken to determine prognostic factors associated with SS development. Multivariable analysis identified the following as predictive of SS development: diabetes mellitus [odds ratio (OR) 2.06; confidence interval (CI) 1.16-3.68], Staphylococcus aureus infection (OR: 2.97; CI: 1.72-5.15), acute renal insufficiency (OR: 3.22; CI: 1.28-8.07), supraventricular tachycardia (OR: 3.29; CI: 1.14-9.44), vegetation size ≥15 mm (OR: 1.21; CI: 0.65-2.25), and signs of persistent infection (OR: 9.8; CI: 5.48-17.52). Risk of SS development could be stratified when combining the first five variables: one variable present: 3.8% (CI: 2-7%); two variables present: 6.3% (CI: 3.2-12.1%); three variables present: 14.6% (CI: 6.8-27.6%); four variables present: 29.1% (CI: 11.7-56.1%); and five variables present: 45.4% (95% CI: 17.5-76.6%). When adding signs of persistent infection, the risk dramatically increased, reaching 85.7% (95% CI: 61.2-95.9%) of risk. Conclusions: In patients with IE, the presence of diabetes, acute renal insufficiency, Staphylococcus aureus infection, supraventricular tachycardia, vegetation size ≥15 mm, and signs of persistent infection are associated with the development of SS.Depto. de MedicinaFac. de MedicinaTRUEpu

Impact of insulin receptor substrate-1 genotypes on platelet reactivity and cardiovascular outcomes in patients with type 2 diabetes mellitus and coronary artery disease

Estudio observacional prospectivo donde se evaluaron 187 pacientes con enfermedad coronaria estable y diabetes mellitus y su respuesta a la inhibición plaquetaria con clopidogrel en función de las variaciones genéticas del receptor de substrato insulínico-1 de la plaqueta. El estudió concluyó que los portadores del alelo C en el marcador rs956115 del gen que codifica el receptor IRS-1 presenta mayor reactividad plaquetaria y un mayor riesgo de presentar eventos cardiovasculares.Objectives: The aim of this study was to assess the association between genetic variants of the insulin receptor substrate (IRS)-1 gene, platelet function, and long-term outcomes in patients with type 2 diabetes mellitus (DM) and stable coronary artery disease while on aspirin and clopidogrel therapy. Background: The effects of pharmacogenetic determinants on platelet function and cardiovascular outcomes in type DM patients are unknown. Methods: The association between IRS-1 genetic variants, platelet function, and the risk of major adverse cardiac events (MACE) at 2 years was assessed in 187 patients with type 2 DM and stable coronary artery disease on maintenance aspirin and clopidogrel therapy. Results: Seven tag single nucleotide polymorphisms were selected. Individuals with high platelet reactivity were more frequent among carriers of the C allele (GC and CC genotypes; approximately 20% of population) of the rs956115 marker (44.4% vs. 20.5%; odds ratio: 3.1, 95% confidence interval [CI]: 1.44 to 6.67; p = 0.006). These patients were at higher risk of MACE (28.0% vs. 10.9%; hazard ratio: 2.90, 95% CI: 1.38 to 6.11; p = 0.005). The C allele carriers of the rs956115 marker were more commonly associated with a hyperreactive platelet phenotype. This was confirmed in an external validation cohort of patients with type 2 DM but not in an external validation cohort of patients without DM. Carriers of the C allele of the rs956115 marker also had a significantly higher risk of MACE compared with noncarriers (30.6% vs. 11.4%; hazard ratio: 2.88, 95% CI: 1.35 to 6.14; p = 0.006). Conclusions: Type 2 DM patients who are carriers of the C allele of the rs956115 marker of the IRS-1 gene have a hyperreactive platelet phenotype and increased risk of MACE.Depto. de MedicinaFac. de MedicinaTRUEpu

Apical ballooning syndrome and previous coronary artery disease: a novel relationship

Apical transient left ventricular diskynesia is a recently described entity able to imitate acute coronary syndrome. The presence of previous coronary artery disease (CAD) is an exclusion criterion for this diagnosis in several studies. We report the case of a sixty-three year-old-caucasian man with previously known CAD, left anterior descending artery (LAD) stented-disease, presenting in the emergency room with angina and ST-segment elevation. A coronariography was urgently performed. No new coronary lesions could be demonstrated. LAD-placed stents were patent and showed no change in their angiographic appearance. Left ventriculogram demonstrated apical diskynesia (Takotsubo-like). Complete and rapid resolution of left ventricular dysfunction was echocardiographycally displayed seven days later. Months after, coronary lesions increased associated with new acute coronary syndromes and new revascularization procedures were required. The present case supports the idea that CAD and apical transient diskynesia could coexist in the same patient, arising further questions about the pathophysiology, prognosis and management of the latter.Depto. de FisiologíaFac. de MedicinaTRUEpu

Clinical profile and prognosis in patients on oral anticoagulation before admission for COVID-19

Estudio observacional donde se compararon en 1.002 pacientes con COVID-19 durante la primera ola de la pandemia el efecto del tratamiento anticoagulante previo sobre la mortalidad intrahospitalaria. El estudio concluyó que los pacientes hospitalizados con COVID-19 y que tomaban previamente anticoagulación presentaron menor supervivencia y muchas más comorbilidades. Background The coronavirus disease 2019 (COVID-19) shows high morbidity and mortality, particularly in patients with concomitant cardiovascular diseases. Some of these patients are under oral anticoagulation (OAC) at admission, but to date, there are no data on the clinical profile, prognosis and risk factors of such patients during hospitalization for COVID-19. Design Subanalysis of the international ‘real-world’ HOPE COVID-19 registry. All patients with prior OAC at hospital admission for COVID-19 were suitable for the study. All-cause mortality was the primary endpoint. Results From 1002 patients included, 110 (60.9% male, median age of 81.5 [IQR 75-87] years, median Short-Form Charlson Comorbidity Index [CCI] of 1 [IQR 1-3]) were on OAC at admission, mainly for atrial fibrillation and venous thromboembolism. After propensity score matching, 67.9% of these patients died during hospitalization, which translated into a significantly higher mortality risk compared to patients without prior OAC (HR 1.53, 95% CI 1.08-2.16). After multivariate Cox regression analysis, respiratory insufficiency during hospitalization (HR 6.02, 95% CI 2.18-16.62), systemic inflammatory response syndrome (SIRS) during hospitalization (HR 2.29, 95% CI 1.34-3.91) and the Short-Form CCI (HR 1.24, 95% CI 1.03-1.49) were the main risk factors for mortality in patients on prior OAC. Conclusions Compared to patients without prior OAC, COVID-19 patients on OAC therapy at hospital admission showed lower survival and higher mortality risk. In these patients on OAC therapy, the prevalence of several comorbidities is high. Respiratory insufficiency and SIRS during hospitalization, as well as higher comorbidity, pointed out those anticoagulated patients with increased mortality risk.Depto. de MedicinaFac. de MedicinaTRUEpu