Vall d’Hebron Risk Score II for myocardial infarction and cardiac death

Malaltia de l'artèria coronària; Factors de risc; Tomografia per emissió computeritzada de fotó únicEnfermedad arterial coronaria; Factores de riesgo; Tomografía por emisión computarizada de fotón únicoCoronary artery disease; Risk factors; Tomography, emission-computed, single-photonObjectives The aim of this study was to create a new Vall d’Hebron Risk Score-II (VH-RS-II) for non-fatal myocardial infarction (MI) and/or cardiac death (CD), excluding patients with coronary revascularisation (CR) during the follow-up. Methods We analysed 5215 consecutive patients underwent gated single photon emission CT (SPECT); 2960 patients (age 64.2±11, male 58.1%) had no previous MI and/or CR, and 2255 patients (age 63.3±11, male 81.9%) had previous MI and/or CR. During a follow-up of 4.3±2.6 years, the cardiac event (MI and CD) was evaluated. This study was reviewed and approved by the ethics committee of our institution (number form trial register, PR(AG)168.2012). To obtain the predictor model, multivariate Cox regression analysis and multivariate logistic regression analysis were used. RS-VH-II was validated with 679 patients. Results In patients without previous MI and/or CR, age (HR: 1.01; p<0.001), diabetes (HR: 2.1, p=0.001), metabolic equivalent (METs) (HR: 0.89, p=0.038), ST segment depression (HR: 1.4, p=0.011), ejection fraction (EF) (HR: 0.97, p<0.001) and summed stress score (HR: 1.2, p<0.001) were the independent predictors of CE (C-statistic: 0.8). In patients with previous MI and/or CR, age (HR: 1.06, p<0.001), male (HR: 1.9, p=0.047), smoker (HR: 1.5, p=0.047), METs (HR: 0.8, p<0.001), ST segment depression (HR: 1.4, p=0.002), EF (HR: 0.96; p<0.001) and summed difference score (HR: 1.03, p=0.06) were the independent predictors of CE (C-statistic:0.8). Conclusion The VH-RS-II obtained from different clinical exercise and gated SPECT variables allow the risk stratification for MI and CD in patients with or without previous MI and/or CR in due form

Bin-CE: A comprehensive web application to decide upon the best set of outcomes to be combined in a binary composite endpoint

The estimation of the Sample Size Requirement (SSR) when using a binary composite endpoint (i.e. two or more outcomes combined in a unique primary endpoint) is not trivial. Besides information about the rate of events for each outcome, information about the strength of association between the outcomes is crucial, since it can determine an increase or decrease of the SSR. Specifically, the greater the strength of association between outcomes the higher the SSR. We present Bin-CE, a free tool to assist clinicians for computing the SSR for binary composite endpoints. In a first step, the user enters a set of candidate outcomes, the assumed rate of events for each outcome and the assumed effect of therapy on each outcome. Since the strength of the association between outcomes is usually unknown, a semi-parametric approach linking the a priori clinical knowledge of the potential degree of association between outcomes with the exact values of these parameters was programmed with Bin-CE. Bin-CE works with a recursive algorithm to choose the best combination of outcomes that minimizes the SSR. In addition, Bin-CE computes the sample size using different algorithms and shows different figures plotting the magnitude of the sample size reduction, and the effect of different combinations of outcomes on the rate of the primary endpoint. Finally, Bin-CE is programmed to perform sensitivity analyses. This manuscript presents the mathematic bases and introduces the reader to the use of Bin-CE using a real example

Serum Metabolomic Analysis Suggests Impairment of Myocardial Energy Production in Takotsubo Syndrome

Acute coronary syndromes; Takotsubo syndromeSíndromes coronarios agudos; Síndrome de TakotsuboSíndromes coronaris aguts; Síndrome de TakotsuboIntroduction: Takotsubo syndrome is a complex entity that, although it usually has a good prognosis, can be life threatening. While recent advances have improved the knowledge of takotsubo syndrome, many aspects of its etiology still remain uncertain. Metabolomics, a hypothesis generating approach, could provide novel pathophysiology information about this disease. Methods and Results: Serum samples were obtained from takotsubo (n = 19) and acute myocardial infarction patients (n = 8) at the cath lab and, in the case of takotsubo, again once the patient had recovered, 3 months after the main event. 1H NMR spectra of the serum were acquired at 9.4T using a CPMG pulse sequence (32 ms effective delay). Supervised and unsupervised pattern recognition approaches where applied to the data. Pattern recognition was able to differentiate between takotsubo and acute myocardial infarction during the acute phase with 95% accuracy. Myocardial infarction patients showed an increase in lipid signals, a known risk factor for the disease while takotsubo patients showed a relative increase in acetate that could suggest a reduced turnover of the Krebs cycle. When comparing acute and recovered phases, we could detect an increase in alanine and creatine once patients recovered. Conclusions: Our results demonstrate that takotsubo syndrome is metabolically different than AMI, showing limited myocardial energy production capacity during the acute phase. We achieved high classification success against AMI; however, this study should be considered as a proof of concept regarding clinical application of metabolic profiling in takotsubo cardiomyopathy.This work was supported by the Spanish Ministry of Economy and Competitiveness, Instituto de Salud Carlos III (Grants PI14/01431 and PI17/01397, SGR-1807, CIBER-CV, and CIBERESP), co-financed by the European Regional Development Fund (ERDF-FEDER, a way to build Europe)

A Case of a Young Patient with Acute Endocarditis and Challenging Diagnostic and Treatment Decisions

Endocarditis infecciosa; Endocarditis protésicaEndocarditis infecciosa; Endocarditis protèsicaInfective endocarditis; Prosthetic endocarditisDespite advances achieved in recent years, Infective Endocarditis (IE) remains a disease associated with high mortality and morbidity. When it involves multiple locations at the same time, deciding the best treatment can become challenging. In some cases, especially in patients with prosthetic valve endocarditis, a definitive diagnosis can be difficult to achieve and multimodality imaging including Positron Emission Tomography/Computed Tomography Angiography (PET/CTA) has demonstrated improvement in the diagnostic yield. We present a case of a young patient with two previous thoracic surgeries who was admitted due to a severe Staphylococcus aureus IE affecting the mitral valve and presenting a questionable image in an aortic arch graft. This case illustrates the importance of the Endocarditis Team when it comes to difficult decisions regarding diagnosis and management in a disease with poor scientific evidence

Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study

Cardiac imaging; Myocardial injury; Noncardiac surgeryImatge cardíaca; Lesió del miocardi; Cirurgia no cardíacaImagen cardiaca; Lesión miocárdica; Cirugía no cardiacaBackground Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention. Methods Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48–72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality. Results We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%). Conclusion This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes.The study has been supported by research grant from the Instituto de Salud Carlos III, Spain (PI16/01162), partly funded by Fondo Europeo de Desarrollo Regional (FEDER), Unión Europea, “Una manera de hacer Europa” to Ekaterine Popova, by Generalitat de Catalunya (PERIS SLT017/20/000089) to Ekaterine Popova and by a "Marato de TV3" grant (20150110) to Pablo Alonso-Coello

Dynamics of Emergency Cardiovascular Hospital Admissions and In-Hospital Mortality During the COVID-19 Pandemic: Time Series Analysis and Impact of Socioeconomic Factors

COVID-19; Síndrome coronario agudo; Insuficiencia cardiacaCOVID-19; Síndrome coronària aguda; Insuficiència cardíacaCOVID-19; Acute coronary syndrome; Heart failureAims: This study aimed to evaluate the decline in urgent cardiovascular hospital admissions and in-hospital mortality during the COVID pandemic in two successive waves, and to evaluate differences by sex, age, and deprivation index subgroups. Methods and Results: We obtained acute cardiovascular hospital episodes during the years 2019–2020 from region-wide data on public healthcare usage for the population of Catalonia (North-East Spain). We fitted time models to estimate the incidence rate ratios (IRRs) of the acute coronary syndrome (ACS) and acute heart failure (HF) admissions during the first pandemic wave, the between-waves period, and the second wave compared with the corresponding pre-COVID-19 periods and to test for the interaction with sex, age, and area-based socioeconomic level. We evaluated the effect of COVID-19 period on in-hospital mortality. ACS (n = 8,636) and HF (n = 27,566) episodes were defined using primary diagnostic ICD-10 codes. ACS and HF admissions decreased during the first wave (IRR = 0.66, 95%CI: 0.58–0.76 and IRR = 0.61, 95% CI: 0.55–0.68, respectively) and during the second wave (IRR = 0.80, 95%CI: 0.72–0.88 and IRR = 0.76, 95%CI: 0.69–0.84, respectively); acute HF admissions also decreased in the period between waves (IRR: 0.81, 95%CI: 0.74–0.89). The impact was similar in all sex and socioeconomic subgroups and was higher in older patients with ACS. In-hospital mortality was higher than expected only during the first wave. Conclusion: During the first wave of the COVID-19 pandemic, there was a marked decline in urgent cardiovascular hospital admissions that were attenuated during the second wave. Both the decline and the attenuation of the effect have been similar in all subgroups regardless of age, sex, or socioeconomic status. In-hospital mortality for ACS and HF episodes increased during the first wave, but not during the second wave.This study was funded with a grant from Sociedad Española de Cardiología y Fundación Española del Corazón (SEC/FEC-INV-CLI 21/017). The funder had no role in the study development

Registros de cirugía cardíaca: revisión internacional

Registres; Cirurgia cardíaca; Nivell internacionalRegistros; Cirugía cardíaca; Nivel internacionalRecords; Heart surgery; International levelObjective: to assess, in the currently available continuous registries of cardiac surgicalprocedures, features regarding authorship, outcome variables, quality control, their consequences for the quality of care, and bibliometric impact. Methods: 1) A systematic review of the information published on the medical literature or reported in the Internet, and 2) A structured survey addressed to persons identifi ed as representative of the recovered registries. Results: twenty-eight registries fulfi lling the inclusion criteria were identifi ed. Using the survey and the review of web pages additional data were obtained of 9 more registries. Most registries were based on national or regional initiatives or from scientifi c societies and their principal aim was quality of care improvement. Their authors were predominantly cardiac surgeons. Most registries only recorded in-hospital events, and from most of them internal documents that were returned to participants for feedback were generated. Although in most registries some quality control measures were undertaken, these were not comprehensive. Several registries generated articles in high impact journals. Greater impact corresponded to those registries that were associated with intensive and widespread campaigns for quality improvement or with collateral Studies derived from the registry.Objetivo: evaluar, en los registros continuos de cirugía cardíaca actualmente existentes a nivel internacional, sus características de autoría, variables de resultado, control de calidad, infl uencia en la calidad asistencial e impacto bibliométrico. Métodos: 1) Revisión sistemática de la información publicada en la literatura médica y en Internet. 2) Realización de una encuesta estructurada a los responsables de los registros identificados. Resultados: se identifi caron 28 registros que cumplían los criterios de inclusión. Mediante encuesta y revisión de página web se obtuvieron datos adicionales de 9 de ellos. La gran mayoría correspondían a iniciativas nacionales, regionales o de sociedades científicas para mejoría de la calidad asistencial. Los autores predominantes eran cirujanos cardíacos. La mayoría de registros contemplaban sólo resultados intrahospitalarios, y en la mayoría se generaban documentos internos que retornaban la información correspondiente a los participantes. A pesar de que en la mayoría se realizaban actividades de control de calidad, éstas no eran exhaustivas. Varios de los registros generaron publicaciones científi cas de impacto. El mayor de éstos correspondió a registros asociados a campañas intensas y ampliamente difundidas de mejoría de la calidad o a estudios colaterales derivados del propio registro.Objectiu: avaluar, en els registres continus de cirurgia cardíaca actualment existents a nivell internacional, les seves característiques d'autoria, variables de resultat, control de qualitat, influència en la qualitat assistencial i impacte bibliomètric. Mètodes: 1) Revisió sistemàtica de la informació publicada a la literatura mèdica ia Internet. 2) Realització d'una enquesta estructurada als responsables dels registres identificats. Resultats: es identificació car 28 registres que complien els criteris d'inclusió. mitjançant enquesta i revisió de pàgina web es van obtenir dades addicionals de 9 d'ells. La gran majoria corresponien a iniciatives nacionals, regionals o de societats científiques per a millora de la qualitat assistencial. Els autors predominants eren cirurgians cardíacs. La majoria de registres contemplaven només resultats intrahospitalaris, i en la majoria es generaven documents interns que retornaven la informació corresponent als participants. Tot i que en la majoria es realitzaven activitats de control de qualitat, aquestes no eren exhaustives. Diversos dels  registres van generar publicacions científiques ques d'impacte. El major d'aquests va correspondre a registres associats a campanyes intenses i àmpliament difoses de millora de la qualitat o a estudis col·laterals derivats del propi registre

Iron ore sintering. Part 3: Automatic and control systems

The sintering process involves a large number of parameters, more than 500, each of which exerts a greater or lesser influence and needs to be controlled, within the possible limits, in order to optimise productivity, process stability, and standardise the composition and quality of the sinter produced. To comply with environmental legislation, a pollution control system must monitor the particle matter and gases generated and emitted into the atmosphere by the sinter plant. Automation and control systems are vital tools to assist plant operators in the monitoring of each stage of the sinter production process