Estenosis aórtica severa en la vida real. Determinantes del manejo y pronóstico

La estenosis aórtica (EAo) es la enfermedad valvular cardíaca más común en los países desarrollados y tiene un mal pronóstico cuando aparecen los síntomas. Según las guías de práctica clínica la sustitución valvular aórtica (SVAo) es el tratamiento de elección para la EAo severa sintomática. La implantación de válvula aórtica transcatéter (TAVI), presenta buenos resultados a corto y mediano plazo de seguimiento, por lo que cada vez más juega un papel preponderante como opción de tratamiento en los pacientes con EAo severa sintomática. A pesar de las opciones actuales, muchos de los pacientes con EAo severa sintomática son manejados con medicamentos. Nuestro objetivo fue evaluar los determinantes en el manejo y pronóstico de la EAo severa en la vida real. Métodos: Registro multicéntrico (en 48 centros españoles) que incluyó a todos los adultos con EAo severa (gradiente medio≥40 mmHg o área valvular aórtica (AVA) <1 cm2 estimada por ecuación de continuidad, sin intervención valvular previa) diagnosticados por ecocardiograma transtorácico durante el mes de enero de 2014. Se registraron las características clínicas, datos ecocardiográficos, índice de comorbilidad de Charlson, así como el European System for Cardiac Operative Risk Evaluation (EuroSCORE-II). Se realizó seguimiento clínico mediante revisión de historias clínicas o contacto telefónico a los 12 meses en todos los pacientes, incluyendo estado vital y realización de intervención valvular (quirúrgica o percutánea). Se consideraron muertes de causa cardíaca las debidas a insuficiencia cardíaca, muerte súbita o infarto de miocardio..

Baseline ECG and prognosis after transcatheter aortic valve implantation: the role of interatrial block

Background: The clinical significance of conduction disturbances after transcatheter aortic valve implantation has been described; however, little is known about the influence of baseline ECGs in the prognosis of these patients. Our aim was to study the influence of baseline ECG parameters, including interatrial block (IAB), in the prognosis of patients treated with transcatheter aortic valve implantation. Methods and Results: The BIT (Baseline Interatrial Block and Transcatheter Aortic Valve Implantation) registry included 2527 patients with aortic stenosis treated with transcatheter aortic valve implantation. A centralized analysis of baseline ECGs was performed. Patients were divided into 4 groups: normal P wave duration (<120 ms); partial IAB (P wave duration ≥120 ms, positive in the inferior leads); advanced IAB (P wave duration ≥120 ms, biphasic [+/-] morphology in the inferior leads); and nonsinus rhythm (atrial fibrillation/flutter and paced rhythm). The mean age of patients was 82.6±9.8 years and 1397 (55.3%) were women. A total of 960 patients (38.0%) had a normal P wave, 582 (23.0%) had partial IAB, 300 (11.9%) had advanced IAB, and 685 (27.1%) presented with nonsinus rhythm. Mean follow‐up duration was 465±171 days. Advanced IAB was the only independent predictor of all‐cause mortality (hazard ratio [HR], 1.48; 95% CI, 1.10-1.98 [P=0.010]) and of the composite end point (death/stroke/new atrial fibrillation) (HR, 1.51; 95% CI, 1.17-1.94 [P=0.001]). Conclusions: Baseline ECG characteristics influence the prognosis of patients with aortic stenosis treated with transcatheter aortic valve implantation. Advanced IAB is present in about an eighth of patients and is associated with all‐cause death and the composite end point of death, stroke, and new atrial fibrillation during follow‐up

The role of echocardiography as a risk-stratification tool in infective endocarditis

Sin financiación3.660 JCR (2018) Q1, 27/160 Medicine, General & Internal1.076 SJR (2018) Q1, 33/141 Internal MedicineNo data IDR 2018UE

A reversible cause of acute right ventricular failure after heart transplant

Sin financiación5.166 JCR (2017) Q1, 26/128 Cardiac & Cardiovacular SystemsUE

Management of Nonagenarian Patients With Severe Aortic Stenosis: The Role of Comorbidity

Background: The number of nonagenarian patients with aortic stenosis will likely increase due to the ageing population. We assessed the clinical characteristics, management, and outcomes of nonagenarian patients with severe aortic stenosis. Methods: A total of 177 (117 females and 60 males) consecutive nonagenarian patients from two large contemporary registries were included in this study. Clinical characteristics, comorbidity as assessed by the Charlson Index, clinical management, and outcomes were recorded. The main outcome measure was one-year mortality. Results: The mean patient age was 91.1 years, and 56 patients (31.6%) had a Charlson Index <3. A strong association between comorbidity and one-year overall mortality was observed, with higher one-year mortality in patients with Charlson Index ≥3 (66.4% vs. 32.1%, p < 0.001). A total of 150 patients (84.7%) were managed conservatively, and 27 (15.3%) underwent transcatheter aortic valve implantation (TAVI). Predictors of a conservative management were treatment out of TAVI centres, lower mean aortic gradient and better functional class. Clinical management was not significantly different with different degrees of comorbidity. A trend toward higher mortality in patients undergoing conservative management was observed (58% vs. 40.7%, p = 0.097). Independent predictors of mortality were higher Charlson Index, lower creatinine clearance, lower mean aortic gradient, poorer left ventricular ejection fraction, significant mitral regurgitation and conservative management. Conclusions: About one third of nonagenarians with severe aortic stenosis have few comorbidities. The clinical management was similar irrespective of the Charlson Index. Both higher Charlson Index values and a conservative management were independently associated with a higher mortality.Sin financiación2.078 JCR (2018) Q3, 78/136 Cardiac & Cardiovascular Systems0.720 SJR (2018) Q2, 136/365 Cardiology and Cardiovascular Medicine, 66/152 Pulmonary and Respiratory MedicineNo data IDR 2018UE

Prognostic implications of a negative echocardiography in patients with infective endocarditis

Background: Echocardiography plays an important role in infective endocarditis (IE) diagnosis according with the modified Duke criteria. We evaluated the implications of a positive echocardiography in the prognosis of a cohort of patients with IE. Methods: Prospective multicentre study in 31 Spanish centres. From January 2008 to September 2016, 3467 patients were included (2765 definite IE, 702 possible IE). The main outcome was in-hospital mortality. Echocardiography diagnosis was based on modified Duke criteria for the diagnosis of IE. Results: Median age was 69 years (interquartile range: 57–77 years). Comorbidity was high (mean Charlson index 4.7 ± 2.8). Transoesophageal echocardiography was performed in 2680 (77.3%). The overall inhospital mortality rate was 26.7%. Univariate analysis showed that, in patients with definite IE, inhospital mortality was similar in patients with positive and negative echocardiography (27.7% vs. 24.6%, respectively, p = 0.121). In possible IE these figures were 27.5% vs. 16.7%, respectively, p < 0.001. Complications (cardiac and extracardiac [embolic, immunological, and septic shock]) were more frequent with positive than with negative echocardiography, regardless of clinical suspicion (definite IE 35.5% vs. 16.8%, respectively, p < 0.001; possible IE 20.8% vs. 7.6%, respectively, p < 0.001). Positive echocardiography was a predictor of inhospital death by logistic regression modelling, after adjusting for confounders, definite IE (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.02–1.76, p = 0.036), possible IE (OR 1.59, 95% CI 1.02–2.45, p = 0.036). Conclusions: A positive echocardiography in patients with IE is associated with increased inhospital mortality, in addition to other clinical factors and comorbidities.Sin financiación3.660 JCR (2018) Q1, 27/160 Medicine, General & Internal1.076 SJR (2018) Q1, 33/141 Internal MedicineNo data IDR 2018UE

Young athletes' ECG: Incomplete right bundle branch block vs crista supraventricularis pattern

Background: Incomplete right bundle branch block (IRBBB) is prevalent among athletes, but its etiology remains to be clearly elucidated and the commonly advocated mechanism, an intraventricular conduction delay, does not explain all cases. In the general population, an apparently similar phenomenon but with different pathophysiology and potential consequences, "crista supraventricularis pattern" (CSP, defined as QRS ≤ 100 ms, S wave <40 ms in I or V6 together with an RSR´ pattern in lead-V1) has been described. Yet, this manifestation has not been studied in athletes. Given that IRBBB can be associated with some serious conditions (including Brugada syndrome, arrhythmogenic cardiomyopathy, or atrial septal defects) the differentiation between IRBB and CSP could enhance the accuracy of the pre-participation screening (PPS). We thus aimed to determine the prevalence of CSP in young athletes. Methods: Observational study of standard 12-lead resting ECG in a cohort of children (5-16 years) attending a PPS program (August 2018-May 2019). Results: 6,401 children (mean ± SD age 11.2 ± 2.9 years, 99.2% Caucasian, 93.8% male, 97.2% soccer players) were studied. We found CSP in 850 participants (prevalence = 13.3% [95% confidence interval 12.5-14.1]) whereas 553 (8.6%) had IRBBB. The proportion of athletes showing an S1S2S3 pattern was higher in those with CSP compared with the other QRS morphologies (P < .05). Conclusions: CSP might have been overlooked in previous reports of sports PPS for children and misdiagnosed as IRBBB, as the proportion of the former condition was higher. Our findings might add useful information to improve the interpretation of the young athletes' ECG and thus the diagnostic value of PPS.Sin financiación4.221 JCR (2020) Q1, 18/88 Sport Sciences1.575 SJR (2020) Q1, 27/288 Orthopedics and Sports MedicineNo data IDR 2019UE

The “V1 continuum” in the athletes’ ECG

Sin financiación4.221 JCR (2020) Q1, 18/88 Sport Sciences1.575 SJR (2020) Q1, 27/288 Orthopedics and Sports MedicineNo data IDR 2019UE

Oral anticoagulation in octogenarians with atrial fibrillation

Vitamin K antagonists (VKAs) are still largely employed, even in nonvalvular atrial fibrillation (AF). Our aim was to study the clinical profile of octogenarians treated with oral anticoagulation and to study the effect of age on the quality of VKAs anticoagulation. Data are from a prospective national registry in an adult Spanish population of nonvalvular AF. We included 1637 patients who had been receiving VKAs for at least 6 months before enrolment. Mean age was 73.8 ± 9.4 years. Patients aged > 80 years (N = 429) had a high risk profile with higher risk of stroke and bleeding than younger patients; CHA2DS2-VASc (Cardiac failure, Hypertension, Age > 74, Diabetes, Stroke, Vascular disease, Age 65–74 years, and Sex category) 4.5 ± 1.3 vs. 3.5 ± 1.6, p 64 years), Drugs/alcohol concomitantly) 2.4 ± 0.9 vs. 1.9 ± 1.1, p < 0.001. Creatinine clearance was lower in octogenarians than in younger patients (54.3 ± 16.1 ml/min vs. 69.5 ± 23.7 ml/min, p < 0.001) and severe renal disease with creatinine clearance < 30 ml/min was more frequent in octogenarians (5.2% vs. 2.2%, p < 0.001). In patients treated with VKAs (N = 1637), the international normalized ratio values of the 6 months previous to enrollment were similar in all age quartiles, as was the time in the therapeutic range. In this large registry octogenarians with nonvalvular AF had high risk of stroke and bleeding and frequent renal disease. VKAs anticoagulation quality was similar in octogenarians and in younger patients.Sin financiación6.189 JCR (2016) Q1, 16/126 Cardiac and Cardiovascular SystemsUE

Clinical profile of a nonselected population treated with sacubitril/valsartan is different from PARADIGM-HF trial

Our aim is to describe the characteristics of the patients receiving sacubitril/valsartan (SV) in daily clinical practice. This is a prospective registry in 10 hospitals including all patients who started SV in everyday clinical practice. From October 2016 to March 2017, 427 patients started treatment with SV. The mean age was 68.1 ± 12.4 years, and 30.5% were women (22.0% in PARADIGM-HF, P < 0.001). Comparing our cohort with patients included in PARADIGM-HF, baseline treatment was different, with a lower ratio of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (2.7 vs. 3.5, P < 0.001), and a higher proportion of patients with implantable cardioverter defibrillator (53.8% vs. 15%, P < 0.001), and cardiac resynchronization therapy (25.8% vs. 5%, P < 0.001). Treatment with mineralocorticoid receptor antagonists was more frequent (76.7% vs. 60.0%, P < 0.001), and the use of beta-blockers was similar (94.6% vs. 93.0%, P = 0.43). We observed more patients in functional class III-IV (30.4 vs. 24.8, P = 0.015), higher levels of Nt pro-BNP [3421 (904-4161) vs. 1631 (885-3154) pg/mL] and worse renal function (creatinine level 1.3 ± 0.7 vs. 1.1 ± 0.3 mg/dL, P < 0.001). In real life, patients receiving SV have a higher risk profile than in the pivotal trial, poorer functional class, higher levels of natriuretic peptides, and worse renal function.Sin financiación2.371 JCR (2018) Q3, 69/136 Cardiac & Cardiovascular Systems, 151/267 Pharmacology & Pharmacy0.837 SJR (2018) Q2, 111/365 Cardiology and Cardiovascular Medicine, 114/365 PharmacologyNo data IDR 2018UE