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

Desfibrilador automático implantable para prevención primaria de la muerte súbita cardíaca en España: eficacia, seguridad y eficiencia

Desfibrilador automático implantable; Muerte súbita cardíaca; Prevención primariaImplantable cardioverter defibrillator; Sudden cardiac death; Primary preventionDesfibril·lador automàtic implantable; Mort sobtada cardíaca; Prevenció primàriaInforme que té com a objectius analitzar nova evidència disponible i conèixer el valor actual del cost-utilitat del DAI, més el tractament mèdic convencional (TMC) enfront de TMC per a prevenció primària d’arrítmies cardíaques des de la perspectiva del Sistema Nacional de Salut (SNS).Report that report that aims to analyze new available evidence and to know the current value of the cost-utility of the Implantable Cardioverter Defibrillator (ICD) plus Conventional Medical Treatment (CCT) versus CCT for primary prevention of cardiac arrhythmias from the perspective of the Spanish National Health System (SNS).Informe que tiene como objetivo analizar nueva evidencia disponible y conocer el valor actual del coste-utilidad del Desfibrilador Automático Implantable (DAI) más Tratamiento Médico Convencional (TMC) frente a TMC para prevención primaria de arritmias cardiacas desde la perspectiva del Sistema Nacional de Salud (SNS)

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

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

Sample size requirement in trials that use the composite endpoint major adverse cardiovascular events (MACE): new insights

Composite endpoints; Correlation; Sample sizePuntos finales compuestos; Correlación; Tamaño de la muestraPunts finals compostos; Correlació, Grandària de la mostraBackground The real impact of the degree of association (DoA) between endpoint components of a composite endpoint (CE) on sample size requirement (SSR) has not been explored. We estimate the impact of the DoA between death and acute myocardial infarction (AMI) on SSR of trials using use the CE of major adverse cardiac events (MACE). Methods A systematic review and quantitative synthesis of trials that include MACE as the primary outcome through search strategies in MEDLINE and EMBASE electronic databases. We limited to articles published in journals indexed in the first quartile of the Cardiac & Cardiovascular Systems category (Journal Citation Reports, 2015–2020). The authors were contacted to estimate the DoA between death and AMI using joint probability and correlation. We analyzed the SSR variation using the DoA estimated from RCTs. Results Sixty-three of 134 publications that reported event rates and the therapy effect in all component endpoints were included in the quantitative synthesis. The most frequent combination was death, AMI, and revascularization (n = 20; 31.8%). The correlation between death and AMI, estimated from 5 trials¸ oscillated between − 0.02 and 0.31. SSR varied from 14,602 in the scenario with the strongest correlation to 12,259 in the scenario with the weakest correlation; the relative impact was 16%. Conclusions The DoA between death and AMI is highly variable and may lead to a considerable SSR variation in a trial including MACE.Intramural CIBER-ESP PR22 from the Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP)

Association of renin–angiotensin system blockers with COVID-19 diagnosis and prognosis in patients with hypertension: a population-based study

COVID-19; Angiotensin receptor blockers; HypertensionCOVID-19; Bloqueadores de los receptores de angiotensina; HipertensiónCOVID-19; Bloquejadors dels receptors d'angiotensina; HipertensióBackground The effect of renin–angiotensin system (RAS) blockade either by angiotensin-converting enzyme inhibitors (ACEis) or angiotensin-receptor blockers (ARBs) on coronavirus disease 2019 (COVID-19) susceptibility, mortality and severity is inadequately described. We examined the association between RAS blockade and COVID-19 diagnosis and prognosis in a large population-based cohort of patients with hypertension (HTN). Methods This is a cohort study using regional health records. We identified all individuals aged 18–95 years from 87 healthcare reference areas of the main health provider in Catalonia (Spain), with a history of HTN from primary care records. Data were linked to COVID-19 test results, hospital, pharmacy and mortality records from 1 March 2020 to 14 August 2020. We defined exposure to RAS blockers as the dispensation of ACEi/ARBs during the 3 months before COVID-19 diagnosis or 1 March 2020. Primary outcomes were: COVID-19 infection and severe progression in hospitalized patients with COVID-19 (the composite of need for invasive respiratory support or death). For both outcomes and for each exposure of interest (RAS blockade, ACEi or ARB) we estimated associations in age-, sex-, healthcare area- and propensity score-matched samples. Results From a cohort of 1 365 215 inhabitants we identified 305 972 patients with HTN history. Recent use of ACEi/ARBs in patients with HTN was associated with a lower 6-month cumulative incidence of COVID-19 diagnosis {3.78% [95% confidence interval (CI) 3.69–3.86%] versus 4.53% (95% CI 4.40–4.65%); P < 0.001}. In the 12 344 patients with COVID-19 infection, the use of ACEi/ARBs was not associated with a higher risk of hospitalization with need for invasive respiratory support or death [OR = 0.91 (0.71–1.15); P = 0.426]. Conclusions RAS blockade in patients with HTN is not associated with higher risk of COVID-19 infection or with a worse progression of the disease.The study was partially funded by ‘CIBER de Epidemiología y Salud Pública (CIBERESP)’