Cambio en la enolasa neuroespecífica de los supervivientes de parada cardiorrespiratoria extrahospitalaria: herramienta útil para predecir el pronóstico neurológico

Introduction and objectivesNeuron-specific enolase (NSE) is a prognostic marker in out-of-hospital cardiopulmonary arrest (OHCA) survivors treated with mild therapeutic hypothermia (MTH). The objectives were to analyze the correlation between dynamic changes in NSE and outcomes and to determine the measurement timing that best predicts neurological status.MethodsMulticenter cohort study including patients admitted after shockable rhythm OHCA and treated with MTH. Serum NSE was sampled at 2 different times and Δ-NSE (%) was calculated as 100 x (NSE2-NSE1)/NSE1. In-hospital mortality and neurological outcome, as assessed by the Cerebral Performance Category (CPC) scale, were evaluated during admission and after a 6-month follow-up.ResultsWe included 166 patients admitted to 4 hospitals. In-hospital mortality was 31.9%. Almost 60% of patients had a good neurological recovery (CPC 1-2). On univariate and multivariate logistic regression analyses, an increase in NSE levels was associated with higher in-hospital mortality and worse CPC on discharge and after 6-months (P < .001). Positive Δ-NSE showed an OR = 9.28 (95% CI 4.40-19.57) for mortality, OR = 11.23 (95% CI 5.24-24.11) for CPC 3-5 at discharge and OR = 11.14 (95% CI 5.05-24.55) for CPC 3-5 after 6-months’ follow-up (P < .001). The first NSE measurement, conducted at 18 to 24 hours, and the second measurement at 69 to 77 hours after OHCA showed a high area under the curve in predicting CPC at discharge (0.9389 and 0.9909, respectively; 0.8096 for the whole cohort).ConclusionsDynamic changes in NSE serum levels are good markers of hard clinical outcomes after an OHCA due to shockable rhythm in an MTH-treated cohort. NSE measurements at specific intervals after OHCA may predict events even more precisely.     

Cinética de la enolasa neuroespecífica: una herramienta adicional para el pronóstico neurológico después de una parada cardiaca

Introduction and objectivesTo analyze neuron-specific enolase (NSE) kinetics as a prognostic biomarker of neurological outcome in cardiac arrest survivors treated with targeted temperature management.MethodsWe performed a retrospective analysis of patients resuscitated from in- or out-of-hospital cardiac arrest admitted from September 2006 to May 2018 in a single tertiary care center and cooled to 32 °C to 34 °C for 24 hours. Blood samples for measurement of NSE values were drawn at hospital admission and at 24, 48, and 72 hours after return of spontaneous circulation (ROSC). Neurological outcome was evaluated by means of the Cerebral Performance Category (CPC) score at 3 months and was characterized as good (CPC 1-2) or poor (CPC 3-5).ResultsOf 451 patients, 320 fulfilled the inclusion criteria and were analyzed (80.3% male, mean age 61 ± 14.1 years). Among these, 174 patients (54.4%) survived with good neurological status. Poor outcome patients had higher median NSE values at hospital admission and at 24, 48 and 72 hours after ROSC. At 48 and 72 hours after ROSC, NSE predicted poor neurological outcome with areas under the receiver-operating characteristic curves of 0.85 (95%CI, 0.81-0.90) and 0.88 (95%CI, 0.83-0.93), respectively. In addition, delta NSE values between 72 hours after ROSC and hospital admission predicted poor neurological outcome with an area under the receiver-operating characteristic curve of 0.90 (95%CI, 0.85-0.95) and was an independent predictor of unfavorable outcome on multivariate analysis (P < .001).ConclusionsIn cardiac arrest survivors treated with targeted temperature management, delta NSE values between 72 hours after ROSC and hospital admission strongly predicted poor neurological outcome.     

Predictors of mortality in medically treated patients with congestive heart failure of nonrheumatic etiology and reduced systolic function

ObjectiveWe investigated the prognostic value of various parameters on the mortality of patients with nonrheumatic chronic heart failure and left ventricular (LV) systolic dysfunction.MethodsThis study included 132 consecutive patients with congestive heart failure and reduced LV systolic function without rheumatic valve disease. The primary outcome was mortality. Mean follow-up was 38 ± 6 months.ResultsDuring the follow-up period there were 47 deaths (35.6%). The age (64.1 ± 13.5 vs. 58.7 ± 11.8 years, P = 0.019), left bundle branch block (44.7% vs. 18.8%, P = 0.002), urea concentration (11.4 ± 5.3 vs. 8.9 ± 4.6 mmol/L, P = 0.006), LV end-diastolic and end-systolic dimensions (6.7 ± 0.8 vs. 6.4 ± 0.8 cm, P = 0.025 and 5.5 ± 0.8 vs. 4.9 ± 0.8 cm, P < 0.001, respectively), grade 3–4 mitral regurgitation (40.4 vs. 22.4%, P < 0.001), fractional shortening (16.7 ± 5.3% vs. 19.8 ± 5.7%, P = 0.002) and LV ejection fraction (32.9 ± 8.5% vs. 38.7 ± 11.3%, P = 0.003) were different between non-survivors and survivors. Multivariate analysis identified severity of mitral regurgitation (OR = 1.99, 95% CI 1.18–3.34; P = 0.009), age (OR = 1.07, 95% CI 1.02–1.12; P = 0.01) and LV end-systolic dimension (OR = 1.09, 95% CI 1.02–1.16; P = 0.014) as independent correlates of mortality.ConclusionsIn medically treated patients with nonrheumatic chronic heart failure and left ventricular systolic dysfunction, severity of mitral regurgitation, age and enlarged LV end-systolic dimension were independently associated with increased risk of death.     

Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits?

BackgroundImmediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy.MethodsIn this single-centre retrospective study, patients aged ≥ 18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed.ResultsBetween 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P = 0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P < 0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P < 0.001).ConclusionsIn our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.     

Brecha de sexo en la miocardiopatía hipertrófica

Introduction and objectivesKey sex differences have been explored in multiple cardiac conditions. However, sex impact in hypertrophic cardiomyopathy outcome is unclear. We aimed to characterize sex impact in overall and cardiovascular (CV) mortality in a nationwide hypertrophic cardiomyopathy registry.MethodsWe analyzed 1042 adult patients, 429 (41%) women, from a national registry of hypertrophic cardiomyopathy, with mean age at diagnosis 53 ± 16 years and a mean follow-up of 65 ± 75 months. At baseline, women were older (56 ± 16 vs 51 ± 15 years; P < .001), more symptomatic (56.4%, vs 51.7%; P < .001) and had more heart failure (42.0% vs 24.2%. P < .001), diastolic dysfunction (75.2% vs 64.1% P = .001), moderate/severe mitral regurgitation (33.4% vs 21.7%; P = .003), and higher B-type natriuretic peptide levels (920 [366-2412] mg/dL vs 487 [170-1087] mg/dL; P < .001). Women underwent fewer stress tests and cardiac magnetic resonance.ResultsKaplan-Meier survival curves showed higher overall (8.4% vs 5.0%; P = .026) and CV mortality (5.5% vs 2.2%; P = .004) in women. Cox proportional hazard regression showed that female sex was an independent predictor of overall (HR, 2.05; 95%CI, 1.11–3.78; P = .021) and CV mortality (HR, 3.16; 95%CI, 1.25–7.99; P = .015). Women had more heart failure-related death (2.6% vs 0.8%, P = .024). Despite similar sudden cardiac death (SCD) risk, women received fewer implantable cardioverter-defibrillators (10.9% vs 15.6%; P = .032) and, in patients without cardioverter-defibrillators, SCD occurred more commonly in women (1.8% vs 0.4%; P = .031).ConclusionsIn this nationwide registry, female sex was an independent predictor of overall and CV-related death, with more heart failure-related death. Despite similar SCD risk, women were undertreated with implantable cardioverter-defibrillators. These data highlight the need for an improved clinical approach in women with HCM.     

Performance of stent thrombosis and bleeding risk scores in out-of-hospital cardiac arrest due to acute coronary syndromes

BackgroundPatients with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI) are at high risk of bleeding and thrombosis. While predictive bleeding and stent thrombosis risk scores have been established, their performance in patients with OHCA has not been evaluated.MethodsAll consecutive patients admitted for OHCA due to ACS who underwent PCI between January 2007 and December 2019 were included. The ACTION and CRUSADE bleeding risk scores and the Dangas score for early stent thrombosis risk were calculated for each patient. A C-statistic analysis was performed to assess the performance of these scores.ResultsAmong 386 included patients, 82 patients (21.2%) experienced severe bleeding and 30 patients (7.8%) experienced stent thrombosis. The predictive performance of the ACTION and CRUSADE bleeding risk scores for major bleeding was poor, with areas under the curve (AUCs) of 0.596 and 0.548, respectively. Likewise, the predictive performance of the Dangas stent thrombosis risk score was poor (AUC 0.513). Using multivariable analysis, prolonged low-flow (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.05; P = 0.025), reduced haematocrit or fibrinogen at admission (OR 0.93, 95% CI 0.88–0.98; P = 0.010 and OR 0.61; 95% CI 0.41–0.89; P = 0.012, respectively) and the use of glycoprotein IIb/IIIa inhibitors (OR 2.10, 95% CI 1.18–3.73; P = 0.011) were independent risk factors for major bleeding.ConclusionThe classic bleeding and stent thrombosis risk scores have poor performance in a population of patients with ACS complicated by OHCA. Other predictive factors might be more pertinent to determine major bleeding and stent thrombosis risks in this specific population.     

Alteraciones temporomandibulares y odontológicas en pacientes con artritis reumatoide

ObjectiveTo characterize the orofacial abnormalities in patients with rheumatoid arthritis (RA) and compare them with those in a reference population.MethodsThe study included 30 RA patients and 30 consecutive patients in an odontology clinic in whom RA was ruled out. Patients underwent a clinical dental examination which included: 1) clinical and radiographic abnormalities of the temporomandibular joint; 2) biomechanical craniocervical analysis; 3) state of dentition and treatment needs; 4) periodontal status; 5) oral hygiene status; and 6) facial pain, which was compared among study groups. In addition, the association between the variables studied was determined through correlation tests.ResultsPatients with RA showed a higher prevalence of temporomandibular abnormalities, both clinical (100.0% vs. 60.0%, P < .001) and radiographic, including erosions (50.0% vs. 16.0%, P = .010), compared with individuals in the control group. Likewise, patients with RA had a greater number of missing teeth (6.9 ± 5.7 vs. 3.0 ± 2.0, P = .001), more caries (13.4 ± 5.4 vs. 4.9 ± 6.5, P = .001), periodontitis (1.3 ± 0.9 vs. 0.8 ± 0.8, P = .015), poorer oral hygiene (43.3% vs. 13.3%, P = .005) and greater facial pain (66.7% vs. 20.0%, P < .001). The cephalometric analysis of Rocabado showed differences in the craniocervical angle and hyoid triangle between RA and controls. Significant correlations were obtained between oral and temporomandibular abnormalities.ConclusionsPatients with RA showed a greater orofacial deterioration, which reflects the importance of multidisciplinary care, including periodic dental examination.     

Función endotelial y microvascular distal a stents farmacoactivos sin polímero y captadores de células endoteliales. Estudio aleatorizado FUNCOMBO

Introduction and objectivesThe vasomotor function of new-generation drug-eluting stents designed to enhance stent healing and reendothelialization is unknown. This study aimed to compare the endothelial function of the infarct-related artery (IRA) treated with bioactive circulating endothelial progenitor cell-capturing sirolimus-eluting stents (COMBO) vs polymer-free biolimus-eluting stents (BioFreedom) in ST-segment elevation myocardial infarction patients at 6 months. Secondary objectives were to compare the microcirculatory function of the IRA and stent healing at 6 months.MethodsSixty patients were randomized to bioactive sirolimus-eluting stent vs polymer-free biolimus-eluting stents implantation. At 6 months, patients underwent coronary angiography with vasomotor, microcirculatory and optical coherence tomography examinations. Endothelial dysfunction of the distal coronary segment was defined as ≥ 4% vasoconstriction to intracoronary acetylcholine infusion.ResultsEndothelial dysfunction was similarly observed between groups (64.0% vs 62.5%, respectively; P = .913). Mean lumen diameter decreased by 16.0 ± 20.2% vs 16.1 ± 21.6% during acetylcholine infusion (P = .983). Microcirculatory function was similar in the 2 groups: coronary flow reserve was 3.23 ± 1.77 vs 3.23 ± 1.62 (P = .992) and the index of microcirculatory resistance was 24.8 ± 16.8 vs 21.3 ± 12.0 (P = .440). Optical coherence tomography findings were similar: uncovered struts (2.3% vs 3.2%; P = .466), malapposed struts (0.1% vs 0.3%; P = .519) and major evaginations (7.1% vs 5.6%; P = .708) were observed in few cases.ConclusionsEndothelial dysfunction of the IRA was frequent and was similarly observed with new-generation drug-eluting stents designed to enhance stent reendothelialization at 6 months. Endothelial dysfunction was observed despite almost preserved microcirculatory function and complete stent coverage. Larger and clinically powered studies are needed to assess the role of residual endothelial dysfunction in ST-segment elevation myocardial infarction patients.Registered in ClinicalTrials.gov: NCT04202172Full English text available from:www.revespcardiol.org/en     

No inferioridad de la titulación de enfermera de insuficiencia cardiaca en comparación con la de cardiólogo de insuficiencia cardiaca. Ensayo aleatorizado multicéntrico ETIFIC

Introduction and objectivesBeta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin-II-receptor-blockers (ARB), and mineralocorticoid-receptor antagonists decrease mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. The effect is dose-dependent. Careful titration is recommended. However, suboptimal doses are common in clinical practice. This study aimed to compare the safety and efficacy of dose titration of the aforementioned drugs by HF nurses vs HF cardiologists.MethodsETIFIC was a multicenter (n = 20) noninferiority randomized controlled open label trial. A total of 320 hospitalized patients with new-onset HF, reduced ejection fraction and New York Heart Association II-III, without beta-blocker contraindications were randomized 1:1 in blocks of 4 patients each stratified by hospital: 164 to HF nurse titration vs 156 to HF cardiologist titration (144 vs 145 analyzed). The primary endpoint was the beta-blocker mean relative dose (% of target dose) achieved at 4 months. Secondary endpoints included ACE inhibitors, ARB, and mineralocorticoid-receptor antagonists mean relative doses, associated variables, adverse events, and clinical outcomes at 6 months.ResultsThe mean ± standard deviation relative doses achieved by HF nurses vs HF cardiologists were as follows: beta-blockers 71.09% ± 31.49% vs 56.29% ± 31.32%, with a difference of 14.8% (95%CI, 7.5-22.1), P < .001; ACE inhibitors 72.61% ± 29.80% vs 56.13% ± 30.37%, P < .001; ARB 44.48% ± 33.47% vs 43.51% ± 33.69%, P = .93; and mineralocorticoid-receptor antagonists 71% ± 32.12% vs 70.47% ± 29.78%, P = .86; mean ± standard deviation visits were 6.41 ± 2.82 vs 2.81 ± 1.58, P < .001, while the number (%) of adverse events were 34 (23.6) vs 30 (20.7), P = .55; and at 6 months HF hospitalizations were 1 (0.69) vs 9 (5.51), P = .01.ConclusionsETIFIC is the first multicenter randomized trial to demonstrate the noninferiority of HF specialist-nurse titration vs HF cardiologist titration. Moreover, HF nurses achieved higher beta-blocker/ACE inhibitors doses, with more outpatient visits and fewer HF hospitalizations.Trial registry number: NCT02546856.     

Influence of age and intensity of treatment on intra-ICU mortality of patients older than 65 years admitted to the intensive care unit

BackgroundAdvanced age might limit intensive care unit (ICU) admission or aggressive treatments. Outcome comparisons of elderly patients mortality admitted to the ICU have been made with a much younger population, admitted often times for different reasons and in significantly healthier conditions. This could lead to unreliable conclusions. This study assesses mortality in ICU patients age 65 and older who presumably have a closer health status, and the level of aggressiveness of ICU procedures performed on them.ObjectivesTo assess age-related intra-ICU mortality and ICU procedures performed in patients age 65 and older.Materials and methodsPatients admitted to a medical-surgical ICU were divided in two groups: group A, 65 to 74 years old and group B, older than 74. Both groups were compared for APACHE II score, admission group, length of stay, usual ICU procedures (arterial and venous catheters, mechanical ventilation and tracheostomy) and mortality.ResultsA total of 804 patients were included in group A (mean age 69.96 ± 2.8) and 605 in group B (mean age 78.81 ± 3.58). Mean APACHE II scores were 13.86 ± 8.6 for group A and 15.24 ± 8.96 for group B (P = 0.04). There were no differences for ICU procedures between age groups. Mortality was significantly higher in group B (16.5% vs 20.8%, P = 0.04). Mortality was higher only in the cardiac group (5.1% vs 9.7%, P = 0.005).ConclusionsIn this series of ICU patients, cardiac disorders had higher intra-ICU mortality in those older than 74 years old. Once admitted, no restriction for ICU procedures was applied to older patients.     

Eptifibatida y vasodilatadores intracoronarios para prevenir la ausencia de reperfusión en el IAMCEST con diabetes y alta carga de trombos. Un ensayo aleatorizado

Introduction and objectivesTo study the impact of injecting intracoronary eptifibatide plus vasodilators via thrombus aspiration catheter vs thrombus aspiration alone in reducing the risk of no-reflow in acute ST-elevation myocardial infarction (STEMI) with diabetes and high thrombus burden.MethodsThe study involved 413 diabetic STEMI patients with high thrombus burden, randomized to intracoronary injection (distal to the occlusion) of eptifibatide, nitroglycerin and verapamil after thrombus aspiration and prior to balloon inflation (n = 206) vs thrombus aspiration alone (n = 207). The primary endpoint was post procedural myocardial blush grade and corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC). Major adverse cardiovascular events were reported at 6 months.ResultsThe intracoronary eptifibatide and vasodilators arm was superior to thrombus aspiration alone regarding myocardial blush grade-3 (82.1% vs 31.4%; P = .001). The local intracoronary eptifibatide and vasodilators arm had shorter cTFC (18.16 ± 6.54 vs 29.64 ± 5.53, P = .001), and better TIMI 3 flow (91.3% vs 61.65%; P = .001). Intracoronary eptifibatide and vasodilators improved ejection fraction at 6 months (55.2 ± 8.13 vs 43 ± 6.67; P = .005). There was no difference in the rates of major adverse cardiovascular events at 6 months.ConclusionsAmong diabetic patients with STEMI and high thrombus burden, intracoronary eptifibatide plus vasodilators injection was beneficial in preventing no-reflow compared with thrombus aspiration alone. Larger studies are encouraged to investigate the benefit of this strategy in reducing the risk of adverse clinical events.     

Comparación de seguridad y efectividad entre los accesos radiales derecho e izquierdo en la intervención coronaria percutánea

Introduction and objectivesThere is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in “real-world” patients with either stable angina or acute coronary syndrome (ACS).MethodsTo overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry).ResultsThe rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0 ± 947.1 mGy vs 1007.4 ± 983.5 mGy, P = .001; ACS: 1212.7 ± 1005.5 mGy vs 1053.5 ± 1029.7 mGy, P = .001). More contrast was used in LRA procedures but only in ACS patients (174.2 ± 75.4 mL vs 167.2 ± 72.1 mL, P = .001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P = .008), no-reflow phenomenon (0.65% vs 0.49%, P = .005), and puncture site bleeding (0.09% vs 0.05%, P = .04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P = .90).ConclusionsOur finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients.Full English text available from:www.revespcardiol.org/en     

Disección coronaria espontánea en España: un estudio sobre bases administrativas realizado a partir del Conjunto Mínimo Básico de Datos español

Introduction and objectivesSpontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). We sought to compare the results on in-hospital mortality and 30-day readmission rates among patients with AMI-SCAD vs AMI due to other causes (AMI-non-SCAD).MethodsRisk-standardized in-hospital mortality (rIMR) and risk-standardized 30-day readmission ratios (rRAR) were calculated using the minimum dataset of the Spanish National Health System (2016-2019).ResultsA total of 806 episodes of AMI-SCAD were compared with 119 425 episodes of AMI–non-SCAD. Patients with AMI-SCAD were younger and more frequently female than those with AMI–non-SCAD. Crude in-hospital mortality was lower (3% vs 7.6%; P < .001) and rIMR higher (7.6 ± 1.7% vs 7.4 ± 1.7%; P = .019) in AMI-SCAD. However, after propensity score adjustment (806 pairs), the mortality rate was similar in the 2 groups (AdjOR, 1.15; 95%CI, 0.61-2,2; P = .653). Crude 30-day readmission rates were also similar in the 2 groups (4.6% vs 5%, P = .67) whereas rRAR were lower (4.7 ± 1% vs 4.8% ± 1%; P = .015) in patients with AMI-SCAD. Again, after propensity score adjustment (715 pairs) readmission rates were similar in the 2 groups (AdjOR, 1.14; 95%CI, 0.67–1.98; P = .603).ConclusionsIn-hospital mortality and readmission rates are similar in patients with AMI-SCAD and AMI–non-SCAD when adjusted for the differences in baseline characteristics. These findings underscore the need to optimize the management, treatment, and clinical follow-up of patients with SCAD.     

The impact of transoesophageal echocardiography in elderly patients with infective endocarditis

BackgroundInfective endocarditis (IE) increasingly involves older patients. Geriatric status may influence diagnostic and therapeutic decisions.AimTo describe transoesophageal echocardiography (TEE) use in elderly IE patients, and its impact on therapeutic management and mortality.MethodsA multicentre prospective observational study (ELDERL-IE) included 120 patients aged ≥75 years with definite or possible IE: mean age 83.1± 5.0; range 75–101 years; 56 females (46.7%). Patients had an initial comprehensive geriatric assessment, and 3-month and 1-year follow-up. Comparisons were made between patients who did or did not undergo TEE.ResultsTransthoracic echocardiography revealed IE-related abnormalities in 85 patients (70.8%). Only 77 patients (64.2%) had TEE. Patients without TEE were older (85.4 ± 6.0 vs. 81.9 ± 3.9 years; P = 0.0011), had more comorbidities (Cumulative Illness Rating Scale-Geriatric score 17.9 ± 7.8 vs. 12.8 ± 6.7; P = 0.0005), more often had no history of valvular disease (60.5% vs. 37.7%; P = 0.0363), had a trend toward a higher Staphylococcus aureus infection rate (34.9% vs. 22.1%; P = 0.13) and less often an abscess (4.7% vs. 22.1%; P = 0.0122). Regarding the comprehensive geriatric assessment, patients without TEE had poorer functional, nutritional and cognitive statuses. Surgery was performed in 19 (15.8%) patients, all with TEE, was theoretically indicated but not performed in 15 (19.5%) patients with and 6 (14.0%) without TEE, and was not indicated in 43 (55.8%) patients with and 37 (86.0%) without TEE (P = 0.0006). Mortality was significantly higher in patients without TEE.ConclusionsDespite similar IE features, surgical indication was less frequently recognized in patients without TEE, who less often had surgery and had a poorer prognosis. Cardiac lesions might have been underdiagnosed in the absence of TEE, hampering optimal therapeutic management. Advice of geriatricians should help cardiologists to better use TEE in elderly patients with suspected IE.     

Prévalence de l’atteinte des organes cibles chez des patients traités pour une HTA : comparaison homme/femme. Étude ESSENTIELLE

ObjectivesTo compare the percentages of men and women treated for primary arterial hypertension presenting with at least one target organ damage; to identify factors associated with target organ damage and/or blood pressure control.MethodsObservational, transverse study carried out between March 2012 and July 2013 on a representative sample of 2666 outpatients (including 1343 men) consulting general practitioners (n = 469) or cardiologists (n = 250) in routine follow-up.ResultsCharacteristics “men vs. women” were: mean age (62.6 ± 11.6 vs. 57.4 ± 14.7 years; P < 0.0001); ≥ 60 years (61.1% vs. 43.9%; P < 0.0001); waist circumference (98.9 ± 12.2 vs. 89.4 ± 14.3 cm; P < 0.0001); SBP (146.5 ± 16.1 vs. 145.8 ± 17.0 mmHg; NS); DBP (85.1 ± 10.3 vs. 84.2 ± 10.4; P = 0,03). Target organ damage was more frequent in men (37.6% vs. 22.9%; P < 0.0001), whether it was subclinical (20.4% vs. 13.6%; P < 0.0001) or documented (26.3% vs. 13.5%; P < 0.0001); some patients presented with both types of damages. Men developed more often microalbuminuria (6.5% vs. 4.3%; P = 0.01) and LVH (16.3% vs. 10.5%; P < 0.0001); some patients presented with both types of subclinical injuries. Target organ damage was more common in men without regular physical activity than in those exercising regularly (42.1% vs. 32.5%; P = 0.0004). Regular exercises had no effect in women (24.1% vs. 21.3%). For both sexes, other factors associated with target organ damage were: age ≥ 60 years, myocardial infarction/sudden death in family history, LDL-cholesterol ≥ 1.60 g/L, HDL-cholesterol ≤ 0.40 g/L. Stroke before 45 years in family history was a predictive factor in women. Hypertension was controlled in one third of patients without difference between sexes. In women, hypertension was less often controlled in case of excessive alcohol consumption compared to normal alcohol intake (17.9% vs. 36.1%; P = 0.0007); this factor had no effect in men (28.1% vs. 32.6%). Other factors associated with poor blood pressure control were: BMI (P = 0.002), LDL-cholesterol ≥ 1.60 g/L in women. In men, the factors were: tobacco, presence of LVH, absence of physical activity, HDL-cholesterol ≤ 0.40 g/L, absence of diet.ConclusionIn a hypertensive population, target organ damage is more common among men despite similar blood pressure control rates for both sexes.     

Dilatación de la aurícula izquierda en deportistas de alta competición y electrofisiología auricular

Introduction and objectivesThere are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes.MethodsMulticenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34 mL/m². We analyzed its relationship with atrial electrocardiography parameters.ResultsWe included 356 participants, 308 athletes (mean age: 36.4 ± 11.6 years) and 48 controls (mean age: 49.3 ± 16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8 ± 8.6 vs 25.6 ± 8.0 mL/m², P = .006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P < .001), but there were no relevant differences in P-wave duration (106.3 ± 12.5 ms vs 108.2 ± 7.7 ms; P = .31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P = .36), or morphology-voltage-P-wave duration score (1.8 ± 0.84 vs 1.5 ± 0.8; P = .71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P < .001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2).ConclusionsLA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.     

Pilot trial of diabetes self-management education in the hospital setting

AimsDiabetes self-management education (DSME) is recommended for all patients with diabetes. Current estimates indicate that <50% of patients receive DSME, increasing risk for hospitalization which occurs more frequently with diabetes. Hospitalization presents opportunities to provide DSME, potentially decreasing readmissions. To address this, we investigated the feasibility of providing DSME to inpatients with diabetes.MethodsPatients hospitalized on four medicine units were randomized to receive DSME (Education Group) (n = 9) prescribed by a certified diabetes educator and delivered by a registered nurse, or Usual Care (n = 12). Participants completed Diabetes Knowledge Tests (DKT), Medical Outcomes Short Form (SF-36), Diabetes Treatment Satisfaction Questionnaire (DTSQ), and the DTSQ-inpatient (DTSQ-IP). Bedside capillary blood glucoses (CBG) on day of admission, randomization and discharge were compared.ResultsThere were no group differences in demographics, diabetes treatment, admission CBG (186 ± 93 mg/dL vs. 219 ± 84 mg/dL, p = 0.40), DKT scores (Education vs. Usual Care 48 ± 25 vs. 68 ± 19, p = 0.09), SF-36, and DTSQ scores (28 ± 6 vs. 25 ± 7, p = 0.41). Patients receiving education reported more satisfaction with inpatient treatment (83 ± 13 vs. 65 ± 19, p = 0.03), less hyperglycemia prior to (2.7 ± 4.5 vs. 4.5 ± 1.4, p = 0.03) and during hospitalization (3.9 ± 1.9 vs. 5.5 ± 1.2, p = 0.04); and had lower mean discharge CBG (159 ± 38 mg/dL vs. 211 ± 67 mg/dL, p = 0.02).ConclusionsInpatient diabetes education has potential to improve treatment satisfaction, and reduce CBG.     

La técnica de superposición de cúspides en TAVI con dispositivo autoexpandible optimiza la profundidad del implante y reduce la necesidad de marcapasos permanente

Introduction and objectivesThis study aimed to determine the safety and efficacy of modifying the classic implantation technique for aortic transcatheter heart valve (THV) implantation to a cusp-overlap-projection (COP) technique to achieve a higher implantation depth and to reduce the burden of new permanent pacemaker implantation (PPMI) at 30 days. Aortic self-expanding THV carries an elevated risk for PPMI. A higher implantation depth minimizes the damage in the conduction system and may reduce PPMI rates.MethodsFrom March 2017, 226 patients were consecutively included: 113 patients were treated using the COP implantation technique compared with the previous 113 consecutive patients treated using the classic technique. In all patients, implantation depth was assessed by 3 methods (noncoronary cusp to the THV, mean of the noncoronary cusp and the left coronary cusp to the THV, and the deepest edge from the left coronary cusp and the noncoronary cusp to the THV).ResultsThe COP group had a lower implantation depth than the group treated with the classic technique (4.8 mm ± 2.2 vs 5.7 mm ± 3.1; P = .011; 5.8 mm ± 3.1 vs 6.5 mm ± 2.4; P = .095; 7.1 mm ± 2.8 vs 7.4 mm ± 3.2; P = .392). Forty patients (17.7%) required a new PPMI after the 30-day follow-up but this requirement was significantly lower in the COP group (12.4% vs 23%, P = .036). The COP implantation technique consistently protected against the main event (OR, 0.45; 95%CI, 0.21-0.97; P = .043), with similar procedural success rates and complications.ConclusionsThe COP implantation technique is a simple modification of the implantation protocol and provides a higher implantation depth of self-expanding-THV with lower conduction disturbances and PPMI rates.     

Door-to-balloon time in radial versus femoral approach for primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (pPCI) is considered the preferred reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction (STEMI). This study compares the door-to-balloon (D2B) time between transradial vs. the transfemoral approach in patients presenting with STEMI.MethodsA retrospectively collected catheterization laboratory database was reviewed for the consecutive patients presenting with a STEMI. Specific time parameters were recorded, and our composite end points were time to revascularization, angiographic success, short term clinical success, and procedural vascular complications.ResultsRadial PCI (r-PCI) was performed in 33 patients (67.3%) and in 16 patients (32.7%) PCI was done through femoral artery (f-PCI). No significant difference was observed in the pre-catheter and catheter laboratory times. Mean times from emergency room door-to-catheter laboratory time for r-PCI vs. f-PCI were 82.48 ± 37.42 and 76.29 ± 34.32 min, respectively (P = 0.636). The mean time from patient arrival to the cardiac catheter laboratory-to-balloon inflation was 34.56 ± 14.2 in the r-PCI group vs. 33.12 ± 12.56 min with the f-PCI group (P = 0.215). The total D2B time was not significantly different between r-PCI vs. f-PCI groups (100.32 ± 36.3 vs. 97.31 ± 30.37 min, respectively, P = 0.522). Angiographic success rates were observed in 92.1% of the patients for r-PCI, and in 87.5% for f-PCI (P = 0.712). There were no vascular complications in both groups.ConclusionsPatients presenting with STEMI can undergo successful pPCI via radial artery without compromising patient care.     

One year cardiac follow up of young world cup football team compared to nonathletes

IntroductionSudden cardiac death among professional young athletes has become a significant concern mainly attributed to structural heart changes and ECG abnormalities.ObjectivesWe aimed primarily to compare echocardiographic and electrocardiographic changes in young professional athletes versus a control group of sedentary lifestyled nonathletic individuals of the same age group. Secondly, we aimed to follow up echocardiographic and electrocardiographic changes in young professional athletes after one year.MethodsWe conducted the study from May 2008 to May 2009 by clinical examination, transthoraxic echocardiography and 12 lead ECG. Our study group was the national football team candidates for the youth world cup occurring in Cairo 2009. This study group was compared to a control group of randomly picked nonathletic third year medical students after exclusion of anyone with a known medical illness. The study group was classified into Athletes I representing athletes at the beginning of the study and Athletes II representing athletes after one year follow up.ResultsThe Study group comprised 34 males, mean age 18.82 ± 1.56 years while the Control group comprised 28 males, age mean 19.64 ± 2.31 years. There was not a significant difference between the two groups regarding number, age, height or weight (P > 0.05).Athletes I vs controlClinical parameters showed significantly lower Systolic Blood Pressure SBP (athletes 117.79 ± 6.536, control 126.43 ± 17.043, P = 0.008) and Heart Rate HR (athletes 68.88 ± 5.044, control 77.43 ± 6.033, P = 0.001). ECG parameters showed a significantly longer RR interval (athletes 0.88 ± 0.065, control 0.76 ± 0.078, P = 0.001), while Corrected QTc interval was not significantly different (athletes 0.41 ± 0.029, control 0.42 ± 0.022, P > 0.05). Echo parameters showed a significant increase in Ejection fraction EF (athletes 60.94 ± 3.084 vs control 54.14 ± 13.063, P = 0.005) and Left atrial dimension LA (athletes 3.28 ± 0.392 vs control 2.58 ± 1.321, P = 0.005). On the other hand Septal wall in diastole SWD, Right ventricle dimension RV, Left ventricular end systolic dimension LVESD, Left Ventricular End Diastolic Dimension LVEDD, Aortic Root AO, and Posterior wall in diastole PWD were not significantly different (P > 0.05).Athletes II vs controlQTc became significantly longer (athletes 0.43 ± 0.028 vs control 0.42 ± 0.022, P = 0.05). SWD was significantly thicker (athletes 1.21 ± 0.23 vs control 1.07 ± 0.17, P = 0.04). SBP, HR remained significantly lower and RR, EF, LA remained significantly greater (P < 0.05), while RV, LVESD, LVEDD, AO, PWD remained not significantly different both at the beginning and also after 1 year (P > 0.05).Athletes I vs athletes IIECG parameters showed a significant increase in QTc (0.41 ± 0.029 vs 0.43 ± 0.028, P = 0.005) and RR interval (0.81 ± 0.167 vs 0.88 ± 0.065, P = 0.046). Echo parameters showed a significant increase in SWD (1.21 ± 0.232 vs 0.93 ± 0.124, P < 0.001), LA (3.62 ± 0.423 vs 3.28 ± 0.392, P = 0.001), RV (2.37 ± 0.565 vs 2.09 ± 0.234, P = 0.011), PWD (1.00 ± 0.200 vs 0.90 ± 0.200, P = 0.008), and a significant decrease in LVESD (3.19 ± 0.679 vs 3.48 ± 0.190, P = 0.016). Other parameters were not statistically significant (P > 0.05).ConclusionsProfessional football playing in young males results in significant changes compared to their control of sedentary nonathletic medical students of similar age. Clinical parameters showed a significant decrease in systolic blood pressure SBP and heart rate HR, ECG parameters showed significant increase in RR interval and QTc interval, and Echocardiographic parameters showed a significant increase in Left atrium diameter LA, Septal wall in diastole SWD, and ejection fraction EF. One year of professional football playing in young males causes a continuing significant increase in ECG parameters QTc, RR interval, and echocardiographic parameters SWD, LA, Right ventricle dimension RV, Posterior wall in diastole PWD and decrease in Left ventricular end systolic diameter LVESD compared to themselves one year earlier. The international concern of Sudden cardiac death among professional young athletes may be attributed to Structural heart changes and ECG abnormalities acquired with professional training.