Mortality in low- and very low-risk patients undergoing cardiac surgery: Evaluation according to the EuroSCORE II as a new standard

Background: Only a few reports have analyzed low-risk patient outcomes and in every case, the risk was based on a logistic EuroSCORE ≤ 2. Since this original EuroSCORE overestimates surgical risk, we developed this study to prospectively evaluate the immediate results of cardiac surgery in patients with an expected mortality risk ≤ 2% according to the EuroSCORE II as a new gold standard. We also examined the cause of death and whether it could be considered preventable. Methods: A prospective risk stratification of all cardiac surgical patients treated at the Bue­nos Aires University Hospital of Argentina was performed between 2012 and 2014 using the EuroSCORE II. Causes of death were classified as preventable or not preventable. Results: From a total of 990 patients, 63.2% had EuroSCORE II ≤ 2 (low-risk group) and 32.5% EuroSCORE II < 1 (very low-risk group). In the low-risk group, in-hospital mortal­ity was 1.8%, whereas predicted mortality was 1.04% (AUC 0.765). The observed/expected ratio was 1.73 (95% CI 0.68–4.43) and the observed-expected difference was 0.76 (95% CI –0.68–2.10). Fifty-four percent of deaths were considered preventable. Conclusions: We propose to use and further validate the EuroSCORE II as a new standard for assessing low-risk patients. This model proved to be useful in evaluating the quality standards of local cardiac surgery. The review of cause of death in low-risk patients provided valuable information, which revealed potentially correctable issues. Adoption of a more demanding standard, as the EuroSCORE II to identify low-risk patients, avoids the sense of safety offered by previous versions of the score

Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P = 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without D

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure &lt; 100 mmHg (n = 1127), estimated glomerular filtration rate &lt; 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

La monitorización continua de la calidad de los resultados de la cirugía cardíaca

Propósito del trabajo: Aunque la aplicación de los gráficos variables ajustados por vida (VLAD = variable life-adjusted display) fue propuesta hace una década, existen pocas publicaciones sobre su uso en la monitorización de la mortalidad en cirugía cardíaca, y a nuestro entender, ninguna aplicada a morbilidad u otros parámetros de control de calidad. El objetivo de este estudio fue demostrar la utilidad de un modelo de control de calidad en cirugía cardíaca, basado en la monitorización continua de las complicaciones y muertes con gráficos VLAD. Material y método: Se realizó una monitorización continua de los resultados de morbilidad y mortalidad con VLAD, en una serie prospectiva de 502 cirugías cardíacas. Se confeccionaron curvas VLAD para monitorizar mortalidad, reoperación por sangrado, mediastinitis, accidente cerebrovascular (ACV), infarto de miocardio y necesidad de diálisis postcirugía. La mortalidad se ajustó con el EuroSCORE, mientras que las complicaciones se ajustaron con un puntaje de riesgo de morbilidad, y en base a tasas esperadas fijas de riesgo de complicación. Adicionalmente se gráfico el empleo de arteria mamaria en la serie de coronarios. Resultados: Las curvas VLAD de mortalidad y morbilidad ajustadas por riesgo, permitieron identificar varios conjuntos de resultados adversos (conglomerados) ocurridos en distintos períodos de tiempo, así como también la relación temporal entre ellos. Asimismo se pudo determinar a lo largo de la serie, la vida neta ganada, las complicaciones evitadas y la tasa de uso de arteria mamaria. Conclusiones: La monitorización continua con gráficos VLAD permitió el control en tiempo real de los resultados de la cirugía cardíaca. No sólo fue útil para el seguimiento de la mortalidad, sino que pudo adaptarse para la monitorización de la morbilidad ajustada por riesgo, y para el control de una buena práctica quirúrgica, como es el uso de la arteria mamaria en la cirugía coronaria

Especialista en cardiología: diferentes caminos, ¿iguales resultados?

A medical specialty may be defined as the body of knowledge corresponding to a specific medical field. This knowledge is provided by postgraduate training programs after completing the medical doctor degree. The goal of the present study is to review the different options available in our country to become a specialist in cardiology and, thus, determine if these diverse pathways produce equally trained cardiologists. Training should be understood as a long-term process that shapes professional thinking and social behavior. This process must be permanent and should have core regulations to ensure equal and homogenous training in the specialty. There are many ways of becoming a specialist in cardiology; most of these pathways may be combined and all of them use different tools for selecting, training, supervising, evaluating and controlling trainees. Thus, these differences in training and evaluating specialists might produce professionals with different levels of competencies.Una especialidad médica puede definirse como un conjunto de conocimientos correspondientes a un área específica. Estos conocimientos son adquiridos por medio de estudios de posgrado luego de obtener el título de médico. El propósito de este trabajo es hacer una revisión de las diferentes opciones disponibles en nuestro país para llegar a ser médico especialista en cardiología y, así, tratar de determinar si estos diferentes caminos podrían conducir a formaciones similares y equiparables entre los profesionales. La formación debe entenderse como un proceso de largo alcance a través del cual se modelan el pensamiento y el comportamiento socioprofesional. Este proceso debe ser permanente y debería ser regulado en forma centralizada de modo que permita asegurar la equidad y la homogeneidad en la formación del especialista. Existen diferentes maneras para llegar a ser médico especialista en cardiología, muchas son combinables y todas emplean diversas herramientas de selección, formación, supervisión, evaluación y control. En conclusión, esta heterogeneidad en la forma de instruir y peritar al especialista podría devenir en diferentes niveles de profesionales formados

In-hospital Outcomes of Surgical Aortic Valve Replacement: the Benchmark for Transcatheter Valve Implant

Objective: The aim of this study was to analyze the current in-hospital outcomes of aortic valve replacement (AVR) surgery in order to serve as a benchmark for comparing the local results of transcatheter aortic valve implantation (TAVI). Methods: We retrospectively analyzed the in-hospital outcomes of 422 patients undergoing isolated AVR between 2012 and 2017 in our institutions associated with the University of Buenos Aires. Results: Overall in-hospital mortality was 3.6%, and 3.8% at 30 days; while the in-hospital and 30-days, mortality rate of 71 patients older than 80 years was 4.2%. In the whole series, in-hospital mortality in the low-risk group (EuroSCORE II <4%) was 2.2%, and in the moderate risk group (EuroSCORE II between 4% and 7%) it was 5.0%. Conclusions: This updated information on the local outcomes of AVR surgery stratified by risk could serve as a standard for comparing TAVI results.Objetivo: El objetivo de este estudio fue analizar los resultados hospitalarios actuales de la cirugía del reemplazo valvular aórtico (RVA) a fin de que sirvan como patrón estandarizado para comparar los resultados locales del implante valvular aórtico transcatéter (TAVI). Material y métodos: Se analizaron en forma retrospectiva los resultados hospitalarios de 422 pacientes sometidos a RVA aislado entre 2012 y 2017 en las instituciones asociadas a la Universidad de Buenos Aires. Resultados: La mortalidad hospitalaria global fue 3,6%, y 3,8% a los 30 días, mientras que la mortalidad hospitalaria y a 30 días de 71 pacientes mayores de 80 años, fue 4,2%. En toda la serie la mortalidad hospitalaria en el grupo de bajo riesgo (EuroSCORE II < 4%) fue 2,2%, y en el de riesgo moderado (EuroSCORE II entre 4% y 7%) fue 5,0%. Conclusiones: Esta información actualizada sobre los resultados locales de la cirugía de RVA en todos los estratos de riesgo podría servir como punto de referencia para comparar el TAVI

Evaluation of the Level of Knowledge in Basic Areas in Postgraduate Cardiology Education

Background In our country, training in cardiology is achieved by participating in residency programs, attending a hospital cardiology unit or taking university courses. On the basis of comments from teachers giving classes in the SAC Biennial Course about certain kind of deficit in basic areas of the  specialty among cardiology residents attending the course, we decided to investigate their knowledge in cardiovascular anatomy, physiology, physical diagnosis, pharmacology and clinical cardiology after 1 or 2 years of training in Internal Medicine or Cardiology residency programs, respectively.ObjectiveTo evaluate the knowledge in basic areas in cardiology among residents attending the UBA Biennial Cardiology Course given by the Argentine Society of Cardiology.(full abstract in pdf)Introducción La formación de especialistas en Cardiología en nuestro país se realiza fundamentalmente a través del sistema de Residencias Médicas o de Concurrencia a un servicio de la especialidad y a través de los Cursos Universitarios. Tomando en cuenta la apreciación de docentes invitados para el dictado de las clases del Curso Bienal de la SAC sobre cierto déficit en la formación en áreas básicas de la especialidad que tendrían los residentes, se decidió realizar un estudio para evaluar los conocimientos en anatomía, fisiología, semiología, clínica y farmacología cardiovascular de los residentes que inician su formación teórica sistemática en la Sociedad Argentina de Cardiología después de un año de residencia en Clínica Médica y uno o dos años de residencia en Cardiología.ObjetivoEvaluar el nivel de conocimientos en áreas básicas de Cardiología de los residentes que iniciaban la carrera de Especialista en Cardiología de la UBA y que concurrían al Curso Bienal dictado en la Sociedad Argentina de Cardiología.(resumen completo en pdf