Disfunción microvascular coronaria e inflamación crónica

La disfunción microvascular coronaria asociada a disfunción endotelial está presente en diferentes contextos de la enfermedad cardiovascular, incluyendo los factores de riesgo cardiovascular clásicos, y la inflamación podría jugar un papel esencial en todo este epifenómeno. De hecho, actualmente la aterosclerosis es vista como un proceso inflamatorio activo e inmuno-mediado en el cual leucocitos y factores solubles (anticuerpos, factores de complemento activados, citoquinas) participan en el progreso de la enfermedad. Los pacientes con enfermedades inflamatorias sistémicas autoinmunes, como la artritis reumatoide y el lupus eritematoso sistémico presentan una elevada morbilidad y mortalidad de origen cardiovascular secundaria a aterosclerosis acelerada y enfermedad coronaria prematura. El exceso de riesgo observado en estos pacientes parece estar relacionado con los efectos deletéreos de la inflamación sistémica en la vasculatura. Por otro lado se especula que un estado inflamatorio de bajo grado podría ser relevante en la patogénesis del síndrome X cardiaco, enfermedad caracterizada por episodios anginosos típicos con isquemia miocárdica transitoria a pesar de no presentar lesiones angiográficas en la coronariografía, en los cuales la disfunción microvascular se ha mostrado como causante de la isquemia miocárdica. El objetivo de la presente tesis es demostrar la posible relación entre inflamación crónica y disfunción microvascular coronaria. Especulamos con que el grado de disfunción de la microcirculación está directamente relacionado con el tiempo de exposición a la inflamación e incluso contemplamos el potencial papel de la inflamación en la modulación de la respuesta microvascular coronaria en algunos pacientes.Background. Coronary microvascular dysfunction associated with endothelial dysfunction is often found in many cardiac conditions, including cardiovascular risk factors, and inflammation would be playing a key role in all this epiphenomenon. Actually, atherosclerosis is seen as an active inflammatory and immune-mediated process in which leukocytes and soluble factors (antibodies, activated complement, cytokines) play a role in accelerating vessel pathology. Patients with systemic inflammatory, autoimmune disease, such as rheumatoid arthritis (AR) and systemic lupus erythematosus (SLE), suffer from increased cardiovascular morbidity and mortality owing to accelerated atherosclerosis and premature coronary disease. The excess risk observed in these patients appears to be driven by the damaging effects of systemic inflammation on the vasculature. A low grade of inflammation could also play a role in the pathogenesis of cardiac syndrome X (ie typical angina and transient myocardial ischemia despite normal coronary arteries) in which coronary microvascular dysfunction has been show to lead myocardial ischemia. Aims. To demonstrate that exposure to chronic inflammation results in coronary microvascular dysfunction (CMD). We speculate that the degree of CMD is directly related to time exposed to inflammation and also hypothesise a potential role of inflammation in the modulation of coronary microvascular responses in some patients. Methods. We carried out 2 separated studies in which systemic inflammatory (AR and LES) patients and CSX patients were analyzed by using positron emission tomography. Resting and hyperaemic (adenosine, 140 μg/Kg/min) myocardial blood flow (MBF) was measured in both groups of patients and in matched healthy volunteers as controls. Results. Although resting MBF was similar in patients (AR/LES and CSX) and controls, abnormalities of the coronary microvascular function were found in both studies, with reduced coronary flow reserve (CFR). CSX patients with C reactive protein levels higher of 3 mg/L at study entry had more severe impairment of CFR. In AR/SLE patients, CFR was inversely related to disease duration (r=-0.65; p<0.001). In both groups of patients, we also found that patients showing ischaemic electrocardiographic changes during adenosine induced hyperaemia, had lower CFR and longer disease duration (AR/LES patients) or higher CRP levels (CSX patients) when compared with patients without changes. Conclusions. Chronic inflammation in the absence of significant coronary disease and traditional cardiovascular risk factors is associated with severe abnormalities of coronary microcirculation, and the degree of this CMD is related with the exposure time to inflammation. We suggest a role for inflammation in the modulation of coronary responses in patients with CSX. This may represent an early marker of cardiovascular disease which precedes and contributes to accelerated atherogenesis

Outcomes and factors associated with mortality in patients with atrial fibrillation and heart failure: FARAONIC study

Background: Heart failure (HF) and atrial fibrillation (AF) are common and coexistent conditions. Hypothesis: To investigate the adverse events and mortality risk factors in patients with AF and HF treated with rivaroxaban in Spain. Methods: Multicenter, prospective and observational study with a follow-up of 2 years, that included adults, with a diagnosis of nonvalvular AF and chronic HF, anticoagulated with rivaroxaban at least 4 months before being enrolled. Results: A total of 672 patients from 71 Spanish centers were recruited, of whom 658 (97.9%) were included in the safety analysis and 552 (82.1%) in the per protocol analysis. At baseline, the mean age was 73.7 +/- 10.9 years, 65.9% were male, 51.3% had HF with preserved ejection fraction and 58.7% were on New York Heart Association functional class II. CHA2DS2-VASc was 4.1 +/- 1.5. During the follow-up, 11.6% of patients died and around one-quarter of patients were hospitalized or visited the emergency department, being HF worsening/progression the main cause (51.1%), with a 2.9% of thromboembolic events and 2.0% of acute coronary syndromes. Major bleeding occurred in 3.1% of patients, with 0.5% experiencing intracranial bleeding but no fatalities. Compliance with HF treatment was associated with a lower risk of death (hazard ratio: 0.092; 95% confidence interval: 0.03-0.31). Conclusions: Among patients with HF and AF anticoagulated with rivaroxaban, incidences of thromboembolic or hemorrhagic complications were low. The most important factor for improving survival was compliance with HF drugs, what strengths the need for early treatment with HF disease-modifying therapy and anticoagulation

Haemodynamic Balance in Acute and Advanced Heart Failure: An Expert Perspective on the Role of Levosimendan

Acute and advanced heart failure are associated with substantial adverse short- and longer-term prognosis. Both conditions necessitate complex treatment choices to restore haemodynamic stability and organ perfusion, relieve congestion, improve symptoms and allow the patient to leave the hospital and achieve an adequate quality of life. Among the available intravenous vasoactive therapies, inotropes constitute an option when an increase in cardiac contractility is needed to reverse a low output state. Within the inotrope category, levosimendan is well suited to the needs of both sets of patients since, in contrast to conventional adrenergic inotropes, it has not been linked in clinical trials or wider clinical usage with increased mortality risk and retains its efficacy in the presence of beta-adrenergic receptor blockade; it is further believed to possess beneficial renal effects. The overall haemodynamic profile and clinical tolerability of levosimendan, combined with its extended duration of action, have encouraged its intermittent use in patients with advanced heart failure. This paper summarises the key messages derived from a series of 12 tutorials held at the Heart Failure 2019 congress organised in Athens, Greece, by the Heart Failure Association of the European Society of Cardiology

The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion

Peer reviewe

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

¿Cuándo se debe plantear no realizar recambio electivo de generador de un desfibrilador automático implantable?

Sin financiación5.9 Q1 JCR 20221.1991 Q1 SJR 2023No data IDR 2022UE

Selection of the best of 2022 in heart failure

Durante este último año se han publicado múltiples estudios de máximo interés en el campo de la insuficiencia cardiaca. Hemos realizado una revisión sistemática de las publicaciones más relevantes, desde el 5 de septiembre de 2021 hasta la misma fecha de 2022, seleccionando aquellas publicaciones más destacadas y ordenándolas por bloques temáticos. Se incluyen referencias a la guía norteamericana sobre insuficiencia cardiaca y a las guías conjuntas de las sociedades europeas de cardiología y respiratorio en hipertensión pulmonar, ambas publicadas en este periodo.Multiple studies of maximum interest have been published in the field of heart failure during the last year. We have carried out a systematic review of the most relevant publications (from 05-09-2021 to 05-09-2022), selecting the most outstanding publications, ordering them by thematic blocks. References to the American guidelines on heart failure and the joint guidelines of the European societies of cardiology and respiration in pulmonary hypertension, both published in this period, are included.Sin financiaciónNo data JCR 20220.138 Q4 SJR 2022No data IDR 2022UE

The Reno-Protective Effect of Hydration With Sodium Bicarbonate Plus N-Acetylcysteine in Patients Undergoing Emergency Percutaneous Coronary Intervention The RENO Study

ObjectivesThis study was designed to determine the effectiveness of a protocol for rapid intravenous hydration to prevent contrast-induced nephropathy (CIN) in patients undergoing emergency percutaneous coronary intervention (PCI).BackgroundContrast-induced nephropathy frequently complicates PCI, resulting in prolonged hospitalization and increased in-hospital and long-term morbidity and mortality. Little is known regarding prevention of CIN in patients undergoing urgent PCI.MethodsWe conducted a prospective, controlled, randomized, single-center trial in 111 consecutive patients with acute coronary syndrome undergoing emergency PCI. As part of the hydration therapy, 56 patients (group A) received an infusion of sodium bicarbonate plus N-acetylcysteine (N-AC) started just before contrast injection and continued for 12 h after PCI. The remaining 55 patients (group B) received the standard hydration protocol consisting of intravenous isotonic saline for 12 h after PCI. In both groups, 2 doses of oral N-AC were administered the next day.ResultsThe 2 groups were similar with respect to age, gender, diabetes mellitus, and baseline serum creatinine. A serum creatinine concentration >0.5 mg/dl from baseline after emergency PCI was observed in 1 patient in group A (1.8%) and in 12 patients in group B (21.8%; p < 0.001). Acute anuric renal failure was observed in 1 patient (1.8%) in group A and in 7 patients (12.7%) in group B (p = 0.032).ConclusionsRapid intravenous hydration with sodium bicarbonate plus N-AC before contrast injection is effective and safe in the prevention of CIN in patients undergoing emergency PCI

Experience with the potassium binder patiromer in hyperkalaemia management in heart failure patients in real life

Abstract Aims Hyperkalaemia (HK) is common in heart failure (HF) patients, related to renal dysfunction and medical treatment. It limits medical therapy optimization, which impacts prognosis. New potassium (K) binders help control HK, allowing better medical management of HF. Methods and results A retrospective multicentre register included all outpatients with HF and HK (K ≥ 5.1 mEq/L) treated with patiromer according to current recommendations. We evaluated analytic and clinical parameters before starting the treatment and at 7, 30 and 90 days, as well as adverse events related to patiromer and treatment optimization. We included 74 patients (71.6% male) with a mean age of 70.8 years (SD 9.2). Sixty‐seven patients (90.5%) presented HK in the previous year. Forty patients (54.1%) underwent down‐titration of a renin–angiotensin–aldosterone inhibitor (RAASi) or a mineralocorticoid receptor antagonist (MRA), and 27 (36.5%) stopped any of them due to HK. Initial K was 5.5 mEq/L (SD 0.6), with a significantly reduction at 7 days (4.9 mEq/L (SD 0.8); P < 0.001), maintained at 90 days (4.9 mEq/L (SD 0.8); P < 0.001). There were no other electrolyte disturbances, with a slight improvement in renal function [glomerular filtration rate 39.6 mL/min (SD 20.4) to 42.7 mL/min (SD 23.2); P = 0.005]. Adverse events were reported in 33.9% of patients, the most common being hypomagnesaemia (16.3%), gastrointestinal disturbances (14.9%) and HK (2.8%). Withdrawal of patiromer was uncommon (12.2%) due to gastrointestinal disturbances in 66.7% of cases. Nine patients (12.2%) started on a RAASi, and 15 patients (20.3%) on an MRA during the follow‐up. Forty‐five patients (60.8%) increased the dose of RAASi or MRA, increasing to target doses in 5.4 and 10.8% of patients, respectively. At 90 days, NTproBNP values were reduced from 2509.5 pg/mL [IQR 1311–4,249] to 1396.0 pg/mL [IQR 804–4263]; P = 0.003, but the reduction was only observed in those who optimized HF medical treatment [NTproBNP from 1950.5 pg/mL (IQR 1208–3403) to 1349.0 pg/mL (IQR 804–2609); P < 0.01]. NYHA functional class only improved in 7.5% of patients, corresponding with those who optimized HF medical treatment. Compared with the previous 3 months before patiromer treatment, the rate of hospitalization was reduced from 28.4 to 10.9% (P < 0.01), and the emergency room visits from 18.9 to 5.4% (P < 0.01). Conclusions In a real‐life cohort of patients with HF, patiromer reduced and maintained K levels during 3 months of follow‐up. The most common adverse events were hypomagnesaemia and gastrointestinal disturbances. Patiromer helps optimize medical treatment, increasing the percentage of patients treated with RAASi and MRA at target doses. At the end of follow‐up, natriuretic peptides values and hospital visits were reduced, suggesting the benefit of optimizing HF medical treatment