The Art of Prescribing β-Blockers After Myocardial Infarction.

Dr Ibanez is supported by the European Commission (ERC-CoG grant No. 819775), and by the Spanish Ministry of Science and Innovation (MCN; ‘RETOS 2019’ grant No. PID2019-107332RB-I00). The CNIC is supported by the ISCIII, the Ministerio de Ciencia e Innovación, and the Pro CNIC Foundation.S

Evaluation of the Use of Dual Antiplatelet Therapy beyond the First Year after Acute Coronary Syndrome

Acute coronary syndrome; Dual antiplatelet therapy; Ischemic riskSíndrome coronario agudo; Terapia antiplaquetaria dual; Riesgo isquémicoSíndrome coronària aguda; Teràpia antiplaquetària dual; Risc isquèmicClinical practice guidelines recommend extending dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome (ACS) in patients with high ischemic risk and without high bleeding risk. The aim of this study was to identify variables associated with DAPT prolongation in a cohort of 1967 consecutive patients discharged after ACS without thrombotic or hemorrhagic events during the following year. The sample was stratified according to whether DAPT was extended beyond 1 year, and the factors associated with this strategy were analyzed. In 32.2% of the patients, DAPT was extended beyond 1 year. Overall, 770 patients (39.1%) were considered candidates for extended treatment based on PEGASUS criteria and absence of high bleeding risk, and DAPT was extended in 34.4% of them. The presence of a PEGASUS criterion was associated with extended DAPT in the univariate analysis, but not history of bleeding or a high bleeding risk. In the multivariate analysis, a history of percutaneous coronary intervention (odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.4–2.4), stent thrombosis (OR = 3.8, 95% CI 1.7–8.9), coronary artery disease complexity (OR = 1.3, 95% CI 1.1–1.5), reinfarction (OR = 4.1, 95% CI 1.6–10.4), and clopidogrel use (OR = 1.3, 95% CI 1.1–1.6) were significantly associated with extended use. DAPT was extended in 32.2% of patients who survived ACS without thrombotic or hemorrhagic events. This percentage was 34.4% when the candidates were analyzed according to clinical guidelines. Neither the PEGASUS criteria nor the bleeding risk was independently associated with this strategy.This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” [grant numbers JR/21/00041, PI20/00637 and CIBERCV16/11/00486] and by Conselleria de Educación – Generalitat Valenciana (PROMETEO/2021/008)

Prognosis Impact of Diabetes in Elderly Women and Men with Non-ST Elevation Acute Coronary Syndrome

Ancià; Síndromes coronàries agudes; DonesAnciano; Síndromes coronarios agudos; MujeresElderly; Acute coronary syndromes; WomenFew studies have addressed to date the interaction between sex and diabetes mellitus (DM) in the prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Our aim was to address the role of DM in the prognosis of non-selected elderly patients with NSTEACS according to sex. A retrospective analysis from 11 Spanish NSTEACS registries was conducted, including patients aged ≥70 years. The primary end point was one-year all-cause mortality. A total of 7211 patients were included, 2,770 (38.4%) were women, and 39.9% had DM. Compared with the men, the women were older (79.95 ± 5.75 vs. 78.45 ± 5.43 years, p < 0.001) and more often had a history of hypertension (77% vs. 83.1%, p < 0.01). Anemia and chronic kidney disease were both more common in women. On the other hand, they less frequently had a prior history of arteriosclerotic cardiovascular disease or comorbidities such as peripheral artery disease and chronic pulmonary disease. Women showed a worse clinical profile on admission, though an invasive approach and in-hospital revascularization were both more often performed in men (p < 0.001). At a one-year follow-up, 1090 patients (15%) had died, without a difference between sexes. Male sex was an independent predictor of mortality (HR = 1.15, 95% CI 1.01 to 1.32, p = 0.035), and there was a significant interaction between sex and DM (p = 0.002). DM was strongly associated with mortality in women (HR: 1.45, 95% CI = 1.18–1.78; p < 0.001), but not in men (HR: 0.98, 95% CI = 0.84–1.14; p = 0.787). In conclusion, DM is associated with mortality in older women with NSTEACS, but not in men.This work was supported by grants from the Spanish Ministry of Economy and Competitiveness through the Carlos III Health Institute: CIBER-CV 16/11/00420, Madrid, Spain

Post-COVID-19 syndrome and diabetes mellitus: a propensity-matched analysis of the International HOPE-II COVID-19 Registry

SARS-CoV-2; Reinfection; Respiratory complicationsSARS-CoV-2; Reinfección; Complicaciones respiratoriasSARS-CoV-2; Reinfecció; Complicacions respiratòriesBackground: Diabetes mellitus (DM) is one of the most frequent comorbidities in patients suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with a higher rate of severe course of coronavirus disease (COVID-19). However, data about post-COVID-19 syndrome (PCS) in patients with DM are limited. Methods: This multicenter, propensity score-matched study compared long-term follow-up data about cardiovascular, neuropsychiatric, respiratory, gastrointestinal, and other symptoms in 8,719 patients with DM to those without DM. The 1:1 propensity score matching (PSM) according to age and sex resulted in 1,548 matched pairs. Results: Diabetics and nondiabetics had a mean age of 72.6 ± 12.7 years old. At follow-up, cardiovascular symptoms such as dyspnea and increased resting heart rate occurred less in patients with DM (13.2% vs. 16.4%; p = 0.01) than those without DM (2.8% vs. 5.6%; p = 0.05), respectively. The incidence of newly diagnosed arterial hypertension was slightly lower in DM patients as compared to non-DM patients (0.5% vs. 1.6%; p = 0.18). Abnormal spirometry was observed more in patients with DM than those without DM (18.8% vs. 13; p = 0.24). Paranoia was diagnosed more frequently in patients with DM than in non-DM patients at follow-up time (4% vs. 1.2%; p = 0.009). The incidence of newly diagnosed renal insufficiency was higher in patients suffering from DM as compared to patients without DM (4.8% vs. 2.6%; p = 0.09). The rate of readmission was comparable in patients with and without DM (19.7% vs. 18.3%; p = 0.61). The reinfection rate with COVID-19 was comparable in both groups (2.9% in diabetics vs. 2.3% in nondiabetics; p = 0.55). Long-term mortality was higher in DM patients than in non-DM patients (33.9% vs. 29.1%; p = 0.005). Conclusions: The mortality rate was higher in patients with DM type II as compared to those without DM. Readmission and reinfection rates with COVID-19 were comparable in both groups. The incidence of cardiovascular symptoms was higher in patients without DM

Post-COVID-19 Symptoms and Heart Disease: Incidence, Prognostic Factors, Outcomes and Vaccination: Results from a Multi-Center International Prospective Registry (HOPE 2)

COVID-19; Heart disease; PersistentCOVID 19; Malaltia cardíaca; PersistentCOVID-19; Enfermedad cardíaca; PersistenteBackground: Heart disease is linked to worse acute outcomes after coronavirus disease 2019 (COVID-19), although long-term outcomes and prognostic factor data are lacking. We aim to characterize the outcomes and the impact of underlying heart diseases after surviving COVID-19 hospitalization. Methods: We conducted an analysis of the prospective registry HOPE-2 (Health Outcome Predictive Evaluation for COVID-19-2, NCT04778020). We selected patients discharged alive and considered the primary end-point all-cause mortality during follow-up. As secondary main end-points, we included any readmission or any post-COVID-19 symptom. Clinical features and follow-up events are compared between those with and without cardiovascular disease. Factors with p < 0.05 in the univariate analysis were entered into the multivariate analysis to determine independent prognostic factors. Results: HOPE-2 closed on 31 December 2021, with 9299 patients hospitalized with COVID-19, and 1805 died during this acute phase. Finally, 7014 patients with heart disease data were included in the present analysis, from 56 centers in 8 countries. Heart disease (+) patients were older (73 vs. 58 years old), more frequently male (63 vs. 56%), had more comorbidities than their counterparts, and suffered more frequently from post-COVID-19 complications and higher mortality (OR heart disease: 2.63, 95% CI: 1.81–3.84). Vaccination was found to be an independent protector factor (HR all-cause death: 0.09; 95% CI: 0.04–0.19). Conclusions: After surviving the acute phase, patients with underlying heart disease continue to present a more complex clinical profile and worse outcomes including increased mortality. The COVID-19 vaccine could benefit survival in patients with heart disease during follow-up.Non-conditioned grant (Fundación Interhospitalaria para la Investigación cardiovascular, FIC. Madrid, Spain). This nonprofit institution had no role in the study design; collection, analysis, or interpretation of data; in the writing of the report; nor in the decision to submit the paper for publication

Comparative validation of three contemporary bleeding risk scores in acute coronary syndromes

Background: Hemorrhagic complications are strongly linked with subsequent adverse outcomes in acute coronary syndrome (ACS) patients. Various risk scores (RS) are available to estimate the bleeding risk in these patients. Aims: To compare the predictive accuracy of the three contemporary bleeding RS in ACS. Methods: We studied 4500 consecutive patients with ACS. For each patient, the ACTION, CRUSADE, and Mehran et al bleeding RS were calculated. We assessed their performance either for the prediction of their own major bleeding events or to predict the TIMI serious (major and minor) bleeding episodes in the overall population, in patients with non-ST elevation ACS (NSTEACS) and in those with ST-elevation myocardial infarction (STEMI) patients. Calibration (Hosmer-Lemeshow test) and discrimination (c-statistic) for the three RS were computed and compared. We used the concept of net reclassification improvement (NRI) to compare the incremental prognostic value of using a particular RS over the remaining scores in predicting the TIMI serious bleeding. Results: The best predictive accuracy was obtained by the CRUSADE score either for the prediction of its own major bleeding events (c-statistic=0.80, 0.791, and 0.81 for the entire sample, for STEMI, and for NSTEACS patients, respectively) or to predict the TIMI serious bleed occurrence (c-statistic=0.741, 0.738,and 0.745 for the whole population, for STEMI and NSTEACS patients, respectively). The lowest bleeding rates observed in patients classified as low risk corresponded to the CRUSADE RS. All scores performed modestly in patients who did not undergo coronariography (all c-statistic <0.70). The CRUSADE score was significantly superior to the ACTION model in predicting the TIMI serious bleeding occurrence in terms of NRI overall and by ACS subgroups (p<0.05). Overall, the CRUSADE RS exhibited better calibration for predicting the TIMI serious bleeding compared to the ACTION and Mehran et al scores (Hosmer-Lemeshow p-values of 0.26, 0.13, and 0.07, respectively). Conclusion: The CRUSADE score represents, among the more contemporary bleeding RS, the most accurate and reliable quantitative clinical tool in STEACS and STEMI patients. We encourage the utilization of the CRUSADE index for bleeding risk stratification purposes in daily clinical practice and in ACS outcome studies. The performance of the three more contemporary bleeding RS is modest in those patients who received conservative management

Impacto prognóstico a longo prazo do uso de beta-bloqueantes em doentes com síndrome de Takotsubo: resultados do Registo RETAKO

Beta-blocker; Mortality; TakotsuboBloqueador beta; Mortalidad; TakotsuboBloquejador beta; Mortalitat; TakotsuboBackground No evidence-based therapy has yet been established for Takotsubo syndrome (TTS). Given the putative harmful effects of catecholamines in patients with TTS, beta-blockers may potentially decrease the intensity of the detrimental cardiac effects in those patients. Objective The purpose of this study was to assess the impact of beta-blocker therapy on long-term mortality and TTS recurrence. Methods The cohort study used the national Spanish Registry on TakoTsubo Syndrome (RETAKO). A total of 970 TTS post-discharge survivors, without pheochromocytoma, left ventricular outflow tract obstruction, sustained ventricular arrhythmias, and significant bradyarrhythmias, between January 1, 2003, and July 31, 2018, were assessed. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were used to evaluate the association between beta-blocker therapy and survival free of TTS recurrence. Results From 970 TTS patients, 582 (60.0%) received beta-blockers. During a mean follow-up of 2.5 ± 3.3 years, there were 87 deaths (3.6 per 100 patients/year) and 29 TTS recurrences (1.2 per 100 patient/year). There was no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox analysis (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.59–1.27, and 0.95, 95% CI 0.57–1.13, respectively). After weighting and adjusting by IPW, differences in one-year survival free of TTS recurrence between patients treated and untreated with beta-blockers were not found (average treatment effect −0.01, 95% CI −0.07 to 0.04; p=0.621). Conclusions In this observational nationwide study from Spain, there was no significant association between beta-blocker therapy and follow-up survival free of TTS recurrence.The Retako webpage was funded by a non-conditional Astrazeneca scholarship

Clinical Profile and Determinants of Mortality in Patients with Interstitial Lung Disease Admitted for COVID-19

COVID-19; Interstitial lung diseases; MortalityCOVID-19; Malalties pulmonars intersticials; MortalitatCOVID-19; Enfermedades pulmonares intersticiales; MortalidadBackground: Concern has risen about the effects of COVID-19 in interstitial lung disease (ILD) patients. The aim of our study was to determine clinical characteristics and prognostic factors of ILD patients admitted for COVID-19. Methods: Ancillary analysis of an international, multicenter COVID-19 registry (HOPE: Health Outcome Predictive Evaluation) was performed. The subgroup of ILD patients was selected and compared with the rest of the cohort. Results: A total of 114 patients with ILDs were evaluated. Mean ± SD age was 72.4 ± 13.6 years, and 65.8% were men. ILD patients were older, had more comorbidities, received more home oxygen therapy and more frequently had respiratory failure upon admission than non-ILD patients (all p < 0.05). In laboratory findings, ILD patients more frequently had elevated LDH, C-reactive protein, and D-dimer levels (all p < 0.05). A multivariate analysis showed that chronic kidney disease and respiratory insufficiency on admission were predictors of ventilatory support, and that older age, kidney disease and elevated LDH were predictors of death. Conclusions: Our data show that ILD patients admitted for COVID-19 are older, have more comorbidities, more frequently require ventilatory support and have higher mortality than those without ILDs. Older age, kidney disease and LDH were independent predictors of mortality in this population