Impacto de la edad del donante-receptor en la supervivencia al trasplante cardiaco. Subanálisis del Registro Español de Trasplante Cardiaco

[Abstract] Introduction and objectives. The age of heart transplant recipients and donors is progressively increasing. It is likely that not all donor-recipient age combinations have the same impact on mortality. The objective of this work was to compare survival in transplant recipients according to donor-recipient age combinations. Methods. We performed a retrospective analysis of transplants performed between 1 January 1993 and 31 December 2017 in the Spanish Heart Transplant Registry. Pediatric transplants, retransplants and combined transplants were excluded (6505 transplants included). Four groups were considered: a) donor < 50 years for recipient < 65 years; b) donor < 50 years for recipient ≥ 65 years; c) donor ≥ 50 years for recipient ≥ 65 years, and d) donor ≥ 50 years for recipient < 65 years. Results. The most frequent group was young donor for young recipient (73%). There were differences in the median survival between the groups (P < .001): a) younger-younger: 12.1 years, 95%CI, 11.5-12.6; b) younger-older: 9.1 years, 95%CI, 8.0-10.5; c) older-older: 7.5 years, 95%CI, 2.8-11.0; d) older-younger: 10.5 years, 95%CI, 9.6-12.1. On multivariate analysis, independent predictors of mortality were the age of the donor and the recipient (0.008 and 0.001, respectively). The worst combinations were older-older vs younger-younger (HR, 1.57; 95%CI, 1.22-2.01; P < .001) and younger-older vs younger-younger (HR, 1.33; 95%CI, 1.12-1.58; P = .001). Conclusions. Age (of the donor and recipient) is a relevant prognostic factor in heart transplant. The donor-recipient age combination has prognostic implications that should be identified when accepting an organ for transplant.[Resumen] Introducción y objetivos. La edad de receptores y donantes cardiacos se está incrementando progresivamente. Es probable que no todas las combinaciones tengan el mismo impacto en la mortalidad. El objetivo de este trabajo es comparar la supervivencia de los pacientes trasplantados según la combinación de edades de donante y receptor. Métodos. Análisis retrospectivo del Registro Español de Trasplante Cardiaco de los trasplantes realizados entre el 1 de enero de 1993 y el 31 de diciembre de 2017. Se excluyeron los pediátricos, los retrasplantes y los trasplantes combinados (se incluyeron 6.505 trasplantes). Se consideraron 4 grupos: a) donante menor de 50 años para receptor menor de 65 años; b) donante menor de 50 años para receptor de edad ≥ 65 años; c) donante de edad ≥ 50 años para receptor de 65 o más, y d) donante de edad ≥ 50 años para receptor menor de 65. Resultados. El grupo más frecuente fue el de donante joven para receptor joven (73%). Hubo diferencias en la mediana de supervivencia entre los grupos (p < 0,001): a) joven-joven: 12,1 años (IC95%, 11,5-12,6); b) joven-mayor: 9,1 años (IC95%, 8,0-10,5); c) mayor-mayor: 7,5 años (IC95%, 2,8-11,0), y d) mayor-joven: 10,5 años (IC95%, 9,6-12,1). En el análisis multivariante, las edades del donante y del receptor resultaron predictoras independientes de la mortalidad (0,008 y 0,001 respectivamente). Las peores combinaciones fueron mayor-mayor frente a joven-joven (HR = 1,57; IC95%, 1,22-2,01; p < 0,001) y joven-mayor frente a joven-joven (HR = 1,33; IC95%, 1,12-1,58; p = 0,001). Conclusiones. La edad (del donante y del receptor) es un factor pronóstico relevante en el trasplante cardiaco. La combinación de edades de donante y receptor posee implicaciones pronósticas que se debe conocer a la hora de aceptar un órgano para trasplante

Relationship of adverse events to quality of anticoagulation control in atrial fibrillation patients with diabetes: Real-world data from the FANTASIIA registry.

BACKGROUND:Atrial fibrillation (AF) patients with diabetes (DM) are at increased risk of cardiovascular events and have higher related morbidity and mortality. PURPOSE:To compare clinical characteristics, cardiovascular adverse outcomes and quality of anticoagulation in AF patients with and without DM. METHODS:AF patients from the Spanish national, multicentric, prospective FANTASIIA registry were included. Patients received oral anticoagulation (vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC)) for at least 6 months before inclusion. Baseline clinical characteristics and comorbidities were recorded. After 2-years follow-up, the association between adverse events and the presence of DM was evaluated. RESULTS:1956 individuals (mean age 73.8 ± 9.5 years, 56% male) were analysed; of these, 574 (29.3%) had DM. Diabetic patients had increased prevalence of other risk factors such as hypertension (90.6% vs 76.1%; p < 0.001), renal disease (21.4% vs 15.9%; p < 0.001) and heart failure (39.1% vs 24.7%; p < 0.001). A rhythm control strategy was applied less often in diabetic patients vs non-diabetics (33.6% vs 40.1%; p = 0.007).After a median follow-up of 1077 days (IQR 766-1113 days), diabetic patients had higher risk of total mortality (16.9%/year vs 11.4%/year; p < 0.001), cardiovascular mortality (9.1%/year vs 3.9%/year; p < 0.001) and MACE (12.9%/year vs 6.8%/year; p < 0.001). Patients with DM had increased total mortality risk [HR 1.58 (95IC% 1.20-2.07); p < 0,001], cardiovascular mortality [HR 2.40 (95IC% 1.17-3.53); p < 0.001] and MACE [HR 2.03 (IC95% 1.47-2.80); p < 0.001]. DM patients had poorer anticoagulation control (time in therapeutic range: 58.52 ± 24.37% vs 62.68 ± 25.31%; p = 0.002). Among diabetic individuals, those with lower TTR showed higher risk of cardiovascular death [(14.12 vs 4.89%;p = 0.001 for TTR <65 vs ≥65%);(13.36 vs 4.55%;p = 0.003 for TTR <70 vs ≥70%)] and MACE [(16.79 vs 9.78%;p = 0.03 for TTR <65 vs ≥65%);(16.44 vs 9.09%;p = 0.03 for TTR <70 vs ≥70%)]. Multivariate analysis showed an independent association between the presence of DM and cardiovascular mortality [HR 1.73 (IC95% 1.07-2.80); p = 0.024]. CONCLUSION:Diabetic patients with AF have more associated comorbidities. Quality of anticoagulation control with vitamin K antagonists in these subjects was poorer than in non-diabetic patients. Lower TTR was associated with cardiovascular death and MACE in diabetic patients. The risk of cardiovascular outcomes (total mortality, cardiovascular mortality and MACE events) was higher, with an independent association between DM and increased mortality risk

Impact of Integrated Care Management on Clinical Outcomes in Atrial Fibrillation Patients: A Report From the FANTASIIA Registry

BackgroundAn integrated and holistic approach is increasingly advocated in patients with atrial fibrillation (AF), based on the Atrial fibrillation Better Care (ABC) pathway: A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management. The aim of this study was to examine the prevalence of adherence to each component of the ABC pathway and to analyze its impact on long-term prognosis in the real-world cohort of AF patients from the FANTASIIA registry. MethodsThis prospective study included consecutive AF outpatients anticoagulated with direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) from June 2013 to October 2014. From the ABC pathway, adherence to the A criterion was defined by a time in the therapeutic range (TTR) >= 70% or correct dose with DOAC; B criterion adherence was defined by a European Heart Rhythm Association (EHRA) Symptom Scale I-II; and C criterion adherence was defined as optimized risk factors and comorbidity management. Baseline features and embolic events, severe bleeding, and all-cause and cardiovascular mortality rates up to 3 years of follow-up were analyzed, and a Cox multivariate analysis was performed to investigate the role of each component of the ABC pathway in predicting major events. ResultsA total of 1,955 AF patients (age: 74.4 +/- 9.4 years; 43.2% female patients) were included in this study: adherence to A criterion was observed in 920 (47.1%) patients; adherence to B criterion was observed in 1,791 (91.6%) patients; and adherence to C criterion was observed in 682 (34.8%) patients. Only 394 (20.2%) of the whole population had good control of AF according to the ABC pathway. After a median follow-up of 1,078 days (IQR: 766-1,113), adherence to A criterion was independently associated with reduced cardiovascular mortality [HR: 0.67, 95%CI (0.45-0.99); p = 0.048] compared with non-adherence. Adherence to the B criterion was independently associated with reduced stroke [HR: 0.28, 95%CI (0.14-0.59); p < 0.001], all-cause mortality [HR: 0.49, 95%CI (0.35-0.69); p < 0.001], cardiovascular mortality [HR: 0.39, 95%CI (0.25-0.62); p < 0.001], and major adverse cardiovascular events (MACE) [HR: 0.41, 95%CI (0.28-0.62); p < 0.001] compared with non-adherence. AF patients with C criterion adherence had a significantly lower risk of myocardial infarction [HR: 0.31, 95%CI (0.15-0.66); p < 0.001]. Fully adherent ABC patients had a significant reduction in MACE [HR: 0.64, 95%CI (0.42-0.99); p = 0.042]. ConclusionIn real-world anticoagulated AF patients from FANTASIIA registry, we observed a lack of adherence to integrated care management of AF following the ABC pathway. AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management

A comparison of front-line oral anticoagulants for the treatment of non-valvular atrial fibrillation: effectiveness and safety of direct oral anticoagulants in the FANTASIIA registry

For a long time, vitamin K antagonists (VKA) were the only oral anticoagulation therapy available to reduce adverse events in atrial fibrillation (AF) patients. Direct-acting oral anticoagulants (DOAC) are at least as effective and safe as VKA with few drug interactions, rapid onset, and short half-life. Four DOACs, dabigatran, apixaban, rivaroxaban, and edoxaban, have demonstrated efficacy and safety for treatment in AF patients. The purpose of this review article is to analyze the current evidence in clinical trials and in real-world populations and performed a new analysis with the estimated effect of those DOACs over the VKA population from the FANTASIIA registry. In the absence of randomized, controlled head-to-head comparisons between DOACs, high-quality observational data can provide useful information on the comparative effectiveness of DOACs. Current clinical guidelines recommend the management of oral anticoagulation in AF patients with DOACs over VKA for stroke prevention; however, many guidelines generally do not suggest a specific DOAC choice in clinical practice. The revised evidence in this manuscript and our real experience reflects that apixaban and dabigatran show the best efficacy and safety profile