El análisis del flujo aórtico por ecocardiografía Doppler es útil en la estratificación pronóstica de los pacientes con estenosis aórtica grave con fracción de eyección normal

Introduction and objectives

The prognosis of patients with severe aortic stenosis, low aortic gradient and preserved ejection fraction is controversial. Our study analyzed the prognosis of these patients and its relation to pressure gradient and aortic valve flow.

Methods

We performed a retrospective cohort study of 363 consecutive patients with severe aortic stenosis and preserved ejection fraction, divided into 4 groups, based on the presence of a systolic volume index greater or lower than 35 mL/m² and the presence of a mean aortic gradient greater or lower than 40 mmHg. Group I: normal flow, high gradient (n=169, 47%); group II: normal flow, low gradient (n=98, 27%); group III: low flow, high gradient (n=54, 15%), and group IV: low flow, low gradient (n=42, 12%). The primary endpoint was overall mortality.

Results

Independent risk factors for mortality were age (hazard ratio=1.04; 95% confidence interval, 1.01-1.08) and atrial fibrillation (hazard ratio=2.21; 95% confidence interval, 1.24-3.94). Surgical treatment was associated with longer survival in all groups (hazard ratio=0.25; 95% confidence interval, 0.13-0.49). Mortality was higher in patients with low flow than in those with with normal flow (26.6% vs 13.6%; P=.004). The most favorable mean prognosis was found in group II (hazard ratio=0.4; 95% confidence interval, 0.2-0.9).

Conclusions

Patients with severe aortic stenosis, normal ejection fraction and low aortic flow have a worse prognosis. Analysis of aortic flow by Doppler echocardiography is useful in risk stratification and therapeutic decision-making in patients with aortic stenosis.Full English text available from:www.revespcardiol.org/en.     

Tratamiento anticoagulante en pacientes con insuficiencia cardiaca por disfunción sistólica y ritmo sinusal: análisis del registro REDINSCOR

Introduction and objectives

In patients with heart failure, left ventricular ejection fraction ≤35% and sinus rhythm without conditions such as atrial fibrillation, thrombus or history of thromboembolic events, the use of anticoagulation is controversial. Our objective was to evaluate the anticoagulation strategy in these patients, variables associated with its use, and its effects on various cardiovascular events.

Methods

Of the patients included in the REDINSCOR registry with left ventricular ejection fraction ≤35% and sinus rhythm without other anticoagulation indications (including patients with heart failure from 19 Spanish centres), we compared those who received this treatment with the remaining patients.

Results

Between 2007 and 2010, 2263 patients were included, of whom 902 had left ventricular ejection fraction ≤35% and sinus rhythm. Of these, 237 (26%) were receiving anticoagulation therapy. Variables associated with this treatment were a lower left ventricular ejection fraction, ischemic etiology, advanced functional class, wider QRS, larger left atrial diameter, and hospitalization. After 21(11-32) months of median follow-up, there were no significant differences in total mortality (14% versus 12.5%) or stroke (0.8% versus 0.9%). A propensity score adjusted multivariate analysis showed a reduction in a combined end-point including cardiac death, heart transplantation, coronary revascularization, and cardiovascular hospitalization (hazard ratio: 0.74; 95% confidence interval, 0.56-0.97; P=.03) in patients receiving anticoagulation therapy. No information regarding bleeding was collected in the follow-up.

Conclusions

In a large and contemporary series of patients with heart failure, left ventricular ejection fraction ≤35% and sinus rhythm, 26% received anticoagulation therapy. This was not associated with lower mortality or stroke incidence, although there was a reduction in major cardiac events.Full English text available from:www.revespcardiol.org     

Supervivencia de pacientes ambulatorios con insuficiencia cardiaca crónica del área mediterránea. Un estudio de base poblacional

Introduction and objectives

Scarce research has been performed in ambulatory patients with chronic heart failure in the Mediterranean area. Our aim was to describe survival trends in our target population and the impact of prognostic factors.

Methods

We carried out a population-based retrospective cohort study in Catalonia (north-east Spain) of 5659 ambulatory patients (60% women; mean age 77 [10] years) with incident chronic heart failure. Eligible patients were selected from the electronic patient records of primary care practices from 2005 and were followed-up until 2007.

Results

During the follow-up period deaths occurred in 950 patients (16.8%). Survival after the onset of chronic heart failure at 1, 2, and 3 years was 90%, 80%, 69%, respectively. No significant differences in survival were found between men and women (P=.13). Cox proportional hazard modelling confirmed an increased risk of death with older age (hazard ratio=1.06; 95% confidence interval, 1.06-1.07), diabetes mellitus (hazard ratio=1.53; 95% confidence interval, 1.33-1.76), chronic kidney disease (hazard ratio=1.73; 95% confidence interval, 1.45-2.05), and ischemic heart disease (hazard ratio=1.18; 95% confidence interval, 1.02-1.36). Hypertension (hazard ratio=0,73; 95% confidence interval, 0,64-0,84) had a protective effect.

Conclusions

Service planning and prevention programs should take into consideration the relatively high survival rates found in our area and the effect of prognostic factors that can help to identify high risk patients.Full English text available from:www.revespcardiol.org/en     

Beneficio clínico de la terapia de resincronización cardiaca con desfibrilador para pacientes con fracción de eyección > 35% por resonancia magnética

Introduction and objectives

Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35% estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance.

Methods

We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n = 103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance.

Results

The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups.

Conclusions

We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis.Full English text available from:www.revespcardiol.org/en     

Diferencias en función del sexo en las características clínicas,tratamiento y mortalidad a 28 días y 7 años de un primer infarto agudo de miocardio. Estudio RESCATE II

Introduction and objectives

To analyze sex-based differences in clinical characteristics, management, and 28-day and 7-year prognosis after a first myocardial infarction.

Methods

Between 2001 and 2003, 2042 first myocardial infarction patients were consecutively registered in 6 Spanish hospitals. Clinical characteristics, management, and 28-day case-fatality were prospectively recorded. Seven-year vital status was also ascertained by data linkage with the National Mortality Index.

Results

The registry included 449 women and 1593 men with a first myocardial infarction. Compared with men, women were older, had a higher prevalence of hypertension and diabetes, and were more likely to receive angiotensin-converting enzyme inhibitors but were less likely to receive beta-blockers or thrombolysis. No differences were observed in use of invasive procedures. More women had non-ST-segment elevation and unclassified myocardial infarction than men (37.9% vs 31.3% and 9.8% vs 6.1%, respectively; both P<.001). Case-fatality at 28 days was similar in women and men (5.57% vs 4.46%; P=.39). After multivariate adjustment, the odds ratio of 28-day mortality for men was 1.06 (95% confidence interval: 0.49-2.27; P=.883) compared with women. After multivariate adjustment, men had higher 7-year mortality than women, hazard ratio 1.93 (95% confidence interval: 1.46-2.56; P<.001).

Conclusions

There are demographic and clinical differences between men and women with a first myocardial infarction. The short-term prognosis of a first myocardial infarction in this century is similar in both sexes. However, the long-term vital prognosis after a first myocardial infarction is worse in men than in women. These results are observed in both ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction events.Full English text available from:www.revespcardiol.org/en     

Remodelado cardiaco inverso estructural y funcional en pacientes con aleteo auricular típico sometidos a ablación del istmo cavotricuspídeo

Introduction and objectives

The purpose of the present study is to determine the structural and functional cardiac changes that occur in patients at 1-year follow-up after ablation of typical atrial flutter.

Methods

We enrolled 95 consecutive patients referred for cavotricuspid isthmus ablation. Echocardiography was performed at ≤6 h post-procedure and 1-year follow-up.

Results

Of 95 patients initially included, 89 completed 1-year follow-up. Hypertensive cardiopathy was the most frequently associated condition (39%); 24% of patients presented low baseline left ventricular systolic dysfunction. We observed a significant reduction in right and left atrial areas, end-diastolic and end-systolic left ventricular diameters, and interventricular septum. We observed substantial improvement in right atrium contraction fraction and left ventricular ejection fraction, and a reduction in pulmonary hypertension. Changes in diastolic dysfunction pattern were observed: 60% of patients progressed from baseline grade III to grade I; at 1-year follow-up, this improvement was found in 81%. We found no structural differences between paroxysmal and persistent atrial flutter at baseline and 1-year follow-up, exception for basal diastolic function.

Conclusions

In patients with typical atrial flutter undergoing cavotricuspid isthmus catheter ablation, we found inverse structural and functional cardiac remodeling at 1-year follow-up with much improved left ventricular ejection fraction, right atrium contraction fraction, and diastolic dysfunction pattern.Full English text available from:www.revespcardiol.org     

Morbilidad y mortalidad de los pacientes con transposición completa de grandes arterias intervenidos mediante cirugía de corrección arterial

Introduction and objectives

The arterial switch operation is currently the preferred surgical approach for complete transposition of the great arteries. We sought to determine the mid-term results of this intervention.

Methods

A single-institution retrospective review of clinical records of all consecutive patients who underwent the arterial switch surgery between 1985 and 2010.

Results

Overall, the operation was performed on 155 patients (68% boys) at a median age of 13 days: 64% with an intact septum, 46% with a ventricular septal defect, and 4.5% with associated aortic arch anomaly. The usual coronary pattern was found in 63%. Palliative surgery was performed prior to arterial switch in 6.5%. In all, 137 perioperative survivors were followed for a median of 6 years. Late mortality was 2.9%, of which 50% was due to coronary complications. Eighteen percent required surgical and/or percutaneous reintervention: 95.6% for right-sided obstruction and 4.3% for aortic regurgitation. At last follow-up, 92% had functional class I symptoms and 95% were free of arrhythmias. The left ventricular ejection fraction was greater than 55% in 95%, 28% had neoaortic regurgitation (78% mild regurgitation), and 31% had right ventricular outflow tract obstruction with a mean gradient according to echocardiography greater than 25 mmHg.

Conclusions

Mid-term survival of patients after arterial switch operation is excellent and their functional status is good. However, a few patients have residual lesions and a need for further intervention during follow-up, mostly for right-sided obstructions. Late mortality was uncommon and was related to coronary complications. Neoaortic root dilation and regurgitation are not major issues in early adulthood, but the long-term course of these lesions is still unknown.Full English text available from:www.revespcardiol.org/en     

Enfermedad pulmonar obstructiva crónica en pacientes con tromboembolia de pulmón aguda sintomática

Background

The diagnosis of pulmonary embolism (PE) is often complicated by the presence of chronic obstructive pulmonary disease (COPD). Some studies have suggested that patients with PE and concomitant COPD have a worse prognosis than patients without COPD.

Patients and methods

Outpatients diagnosed with acute symptomatic PE at a university tertiary care hospital were prospectively included in the study. Clinical characteristics, time between onset of symptoms and diagnosis, and outcome were analyzed according to presence or absence of COPD. The primary endpoint was all-cause deaths at 3 months.

Results

Of 882 patients with a confirmed diagnosis of acute symptomatic PE, 8% (95% confidence interval [CI], 6%–9%) had COPD. Patients with COPD were significantly more likely to have a delay in diagnosis of more than 3 days and to have a low pretest probability of pulmonary embolism according to a standardized clinical score. The total number of deaths during 3 months of follow-up was 128 (14%; 95% CI, 12%–17%). Factors significantly associated with mortality from all causes were a history of cancer or immobilization, systolic blood pressure less than 100 mm Hg, and arterial oxyhemoglobin saturation less than 90%. COPD was significantly associated with PE-related death in the logistic regression analysis (relative risk, 2.2; 95% CI, 1.0–5.1).

Conclusions

Patients with COPD and PE more often have a lower pretest probability and a longer delay in diagnosis of PE. COPD is significantly associated with PE-related death in the 3 months following diagnosis.     

Interleucina 6 y proteína C reactiva ultrasensible para la predicción de la evolución clínica en síndromes coronarios agudos sin elevación del segmento ST

Introduction and objectives

High baseline levels of interleukin-6 and C-reactive protein confer an increased risk of mortality in non-ST-segment elevation acute coronary syndrome. The aim of the study was to determine whether serial measurements of interleukin-6 and high-sensitivity C-reactive protein provide additional information to baseline measurements for risk stratification of non-ST-segment elevation acute coronary syndrome.

Methods

Two hundred and sixteen consecutive patients with non-ST-segment elevation acute coronary syndrome were prospectively included. Blood samples were obtained within 24 h of hospital admission and at 30 days of follow-up. The endpoint was a composite of all-cause death, nonfatal myocardial infarction, or acute decompensated heart failure.

Results

Both interleukin-6 and high-sensitivity C-reactive protein levels decreased from day 1 to day 30, regardless of adverse events (both P<.001). Interleukin-6 levels at 2 time points (interleukin-6 day 1, per pg/mL; hazard ratio=1.006, 95% confidence interval, 1.002-1.010; P=.002 and interleukin-6 day 30, per pg/mL; hazard ratio=1.047, 95% confidence interval, 1.021-1.075; P<.001) were independent predictors of adverse events, whereas high-sensitivity C-reactive protein day 1 and high-sensitivity C-reactive protein day 30 levels were not. Patients with interleukin-6 day 1≤8.24 pg/mL and interleukin-6 day 30≤4.45 pg/mL had the lowest event rates (4.7%), whereas those with both above the median values had the highest event rates (35%). After addition of interleukin-6 day 30 to the multivariate model, C-index increased from 0.71 (95% confidence interval, 0.63-0.78) to 0.80 (95% confidence interval, 0.72-0.86), P=.042, and net reclassification improvement was 0.39 (95% confidence interval, 0.14-0.64; P=.002).

Conclusions

In this population, both interleukin-6 and high-sensitivity C-reactive protein concentrations decreased after the acute phase. Serial samples of interleukin-6 concentrations improved the prognostic risk stratification of these patients.Full English text available from:www.revespcardiol.org/en     

Validez y aplicabilidad de un nuevo método de registro para la hipertensión arterial

Introduction and objectives

Blood pressure measurement methods and conditions are determinants of hypertension diagnosis. A recent British guideline recommends systematic 24-h ambulatory blood pressure monitoring. However, these devices are not available at all health centers and they can only be used by 1 patient per day. The aim of this study was to test a new blood pressure recording method to see if it gave the same diagnostic results as 24-h blood pressure monitoring.

Methods

One-hour blood pressure monitoring under routine clinical practice conditions was compared with standard method of day time recording by analyzing the coefficient of correlation and Bland-Altman plots. The Kappa index was used to calculate degree of agreement. Method sensitivity and specificity were also analyzed.

Results

Of the 102 participants, 89 (87.3%) obtained the same diagnosis regardless of method, with high between-method agreement (κ= 0.81; 95% confidence interval, 0.71-0.91). We observed robust correlations between diastolic (r = 0.85) and systolic blood pressure (r = 0.76) readings. Sensitivity and specificity for the new method for diagnosing white coat hypertension were 85.2% (95% confidence interval 67.5%-94.1%) and 92% (95% confidence interval, 83.6%-96.3%), respectively.

Conclusions

One-hour blood pressure monitoring is a valid and reliable method for diagnosing hypertension and for classifying hypertension subpopulations, especially in white coat hypertension and refractory hypertension. This also leads to a more productive use of monitoring instruments.Full English text available from:www.revespcardiol.org/en     

Retraso diagnóstico de la hipertensión arterial en pacientes diabéticos atendidos en atención primaria

Introduction and objectives

Delayed diagnosis of hypertension may result in inadequate blood pressure control and increased cardiovascular risk. The aim of this study was to estimate the delay in hypertension diagnosis in patients with type 2 diabetes and the likelihood of a diagnosis within a suitable period (first 6 months), and to analyze the patient and physician characteristics associated with delayed diagnosis.

Methods

Retrospective dynamic cohort study, with a 7-year follow-up in primary care, of 8074 adult patients with diabetes who met the diagnostic criteria for hypertension. Two thresholds were considered: 140/90 mmHg and 130/80 mmHg. The time elapsed between meeting these criteria and recording the diagnosis was estimated; the time course of the likelihood of a missed diagnosis and the variables associated with correct diagnosis were assessed by Kaplan-Meier survival analysis and logistic regression analysis, respectively.

Results

The mean diagnostic delay was 8.9 (15.4) months in patients with blood pressure≥140/90 mmHg compared to 15.2 (19.6) months for those with <140/90 mmHg (P<.001). The main variables associated with correct diagnosis were baseline blood pressure ≥140/90 mmHg (odds ratio=2.77; 95% confidence interval, 2.44-3.15), no history of acute myocardial infarction (odds ratio=2.23; 95% confidence interval, 1.67-2.99), obesity (odds ratio=1.70; 95% confidence interval, 1.44-1.99), absence of depression (odds ratio=1.63; 95% confidence interval, 1.27-2.08), female sex (odds ratio=1.29; 95% confidence interval, 1.14-1.46), older age, and taking more intensive antidiabetic therapy. There was an inverse relationship with the age of physicians and a direct relationship with their professional stability.

Conclusions

The mean diagnostic delay in hypertension among diabetic patients was greater than 6 months and varied according to the diagnostic threshold used. Patients with baseline blood pressure≥140/90 mmHg were more likely to receive a timely diagnosis.Full English text available from:www.revespcardiol.org/en     

Factores asociados y análisis descriptivo de la endocarditis infecciosa adquirida en el entorno hospitalario de un centro terciario de referencia

Introduction and objectives

The primary aim of this study was to evaluate associated factors, clinical features and prognosis of healthcare-related infective endocarditis cases compared with community-acquired and intravenous drug user-related episodes. Changes in the distribution of healthcare-related infective endocarditis were also analysed over time in our setting.

Methods

A prospective, observational, comparative study was performed. We included all the cases of infective endocarditis from January 2003 to June 2010, which were then classified into 2 groups: group 1: community-acquired and intravenous drug user origin, and group 2: nosocomial and non-nosocomial healthcare-related cases. The episodes were classified into 2 periods: period I: January/2003-June/2006 and period II: July/2006-June 2010. Univariate and multivariate analyses were performed.

Results

A total of 212 cases were included (group 1: 138, group 2: 74). The variables of age (risk ratio 1.026; 95% CI, 1.003 to 1.049), Charlson index (risk radio 1.242; 95% CI, 1.067 to 1.445), and previous heart surgery (risk ratio 2.522; 95% CI, 1.353 to 4.701) were independently associated with healthcare-related infective endocarditis on multivariate analysis. A non-significant increase was observed in healthcare-related cases of infective endocarditis in period II (40/104; 38.4% vs. 34/108; 31.4%).

Conclusions

The recent increase in healthcare-related infective endocarditis seems to be associated with the use of invasive procedures in elderly patients with prosthetic cardiac valve, and those with a greater number of underlying diseases, especially patients with chronic renal failure on haemodialysis.     

Red blood cell distribution width adds prognostic value for outpatients with chronic heart failure

Introduction and objectives

Red blood cell distribution width has emerged as a new prognostic biomarker in cardiovascular diseases. Its additional value in risk stratification of patients with chronic heart failure has not yet been established.

Methods

A total of 698 consecutive outpatients with chronic heart failure were studied (median age 71 years [interquartile range, 62-77], 63% male, left ventricular ejection fraction 40 [14]%). On inclusion, the red cell distribution width was measured and clinical, biochemical, and echocardiographic variables were recorded. The median follow-up period was 2.5 years [interquartile range 1.2-3.7].

Results

A total of 211 patients died and 206 required hospitalization for decompensated heart failure. Kaplan-Meier analysis showed an increase in the probability of death and hospitalization for heart failure with red cell distribution width quartiles (log rank, P<.001). A ROC analysis identified a red cell distribution width of 15.4% as the optimal cut-off point for a significantly higher risk of death (P<.001; hazard ratio=2.63; 95% confidence interval, 2.01-3.45) and hospitalization for heart failure (P<.001; hazard ratio=2.37; 95% confidence interval, 1.80-3.13). This predictive value was independent of other covariates, and regardless of the presence or not of anaemia. Importantly, the addition of red cell distribution width to the clinical risk model for the prediction of death or hospitalization for heart failure at 1 year had a significant integrated discrimination improvement of 33% (P<.001) and a net reclassification improvement of 10.3% (P=.001).

Conclusions

Red cell distribution width is an independent risk marker and adds prognostic information in outpatients with chronic heart failure. These findings suggest that this biological measurement should be included in the management of these patients.Full English text available from:www.revespcardiol.org     

Efecto en los resultados de la intervención y los resultados clínicos a largo plazo de la predilatación de la rama lateral para lesiones coronarias en bifurcación tratadas con la técnica de stent condicional

Introduction and objectives

It is uncertain whether side branch predilatation before main vessel stenting is necessary. We evaluated the effect of side branch predilatation on outcomes in percutaneous coronary intervention for true nonleft main bifurcation determined by the Medina classification using the provisional approach.

Methods

Target vessel failures (composite of cardiac death, myocardial infarction, or target vessel revascularization) were compared between patients who underwent side branch predilatation (predilatation group, n = 175) and those who did not (nonpredilatation group, n = 662).

Results

Final kissing-balloon inflation (57.1% vs 35.8%; P < .001) was performed more frequently and the cross-over rate to a 2-stent technique (14.9% vs 5.1%; P < .001) was higher in the predilatation group. During a median follow-up of 21 months, the predilatation group had a higher incidence of target vessel failures (14.3% vs 6.8%; P = .002) and target vessel revascularization (12.0% vs 5.6%; P = .003), but not of cardiac death or myocardial infarction compared with the nonpredilatation group. On multivariate analysis, side branch predilatation was associated with a higher occurrence of target vessel failures (adjusted hazard ratio = 2.11; 95% confidence interval, 1.27-3.50; P = .004). These results remained consistent after a propensity score-matched population analysis (for target vessel failures, adjusted hazard ratio = 2.63; 95% confidence interval, 1.09-6.34; P = .0031) and they were also constant among the various subgroups, according to the bifurcation angle, calcification, and diameter stenosis of the side branch.

Conclusions

Side branch predilatation before main vessel stenting may be associated with an increased risk of repeat revascularization in patients with true nonleft main bifurcation treated by the provisional approach.Trial registration: ClinicalTrials.gov number: NCT00851526.Full English text available from: www.revespcardiol.org/en     

Importancia clínica de la insuficiencia cardiaca congestiva en la endocarditis protésica. Estudio multicéntrico de 257 pacientes

Introduction and objectives

There have been no studies conducted in the past that focus on the significance of congestive heart failure in patients with prosthetic valve endocarditis. We studied the incidence of congestive heart failure in patients with prosthetic valve endocarditis and analyzed its profile. In this study, we addressed the prognostic significance of heart failure in patients with prosthetic valve endocarditis and analyzed its outcome based on chosen therapeutic strategies.

Methods

A total of 639 episodes of definite left-sided endocarditis were prospectively enrolled. Of them, 257 were prosthetic. Of the 257 episodes, 145 (56%) were diagnosed with heart failure. We compared the profiles of patients with prosthetic valve endocarditis based on the presence of heart failure, and performed a multivariate logistic regression model to establish the prognostic significance of heart failure in patients with prosthetic valve endocarditis and identified the prognostic factors of in-hospital mortality in these patients.

Results

Persistent infection (odds ratio=3.6; 95% confidence interval, 1.9-6.9) and heart failure (odds ratio=3; 95% confidence interval, 1.5-5.8) are the strongest predictive factors of in-hospital mortality in patients with prosthetic valve endocarditis. The short-term determinants of prognosis in patients with prosthetic valve endocarditis and heart failure are persistent infection (odds ratio=2.8; 95% confidence interval, 1.2-6.5), aortic involvement (odds ratio=2.5; 95% confidence interval, 1.1-5.8), abscess (odds ratio=3.6; 95% confidence interval, 1.4-9.5), diabetes mellitus (odds ratio=2.9; 95% confidence interval, 1.1-7.7), and cardiac surgery (odds ratio=0,2; 95% confidence interval, 0,1-0,5).

Conclusions

The incidence of heart failure in patients with prosthetic valve endocarditis is very high. Heart failure increases the risk of in-hospital mortality by threefold in patients with prosthetic valve endocarditis. Persistent infection, aortic involvement, abscess, and diabetes mellitus are the independent risk factors associated with mortality in patients with prosthetic valve endocarditis and heart failure; however, cardiac surgery is shown to decrease mortality in these patients.Full English text available from:www.revespcardiol.org/en     

Análisis combinado de dos ensayos aleatorizados de comparación de stents con recubrimiento de titanio-óxido nítrico con stents liberadores de fármacos en el IAMCEST

Introduction and objectives

We performed a pooled analysis based on patient-level data from the TITAX-AMI and BASE-ACS trials to evaluate the outcome of titanium-nitride-oxide-coated bioactive stents vs drug-eluting stents in patients with ST-segment elevation myocardial infarction at 2-year follow-up.

Methods

The TITAX-AMI trial compared bioactive stents with paclitaxel-eluting stents in 425 patients with acute myocardial infarction. The BASE-ACS trial compared bioactive stents with everolimus-eluting stents in 827 patients with acute coronary syndrome. The primary endpoint for the pooled analysis was major adverse cardiac events: a composite of cardiac death, recurrent myocardial infarction, or ischemia-driven target lesion revascularization at 2-year follow-up.

Results

The pooled analysis included 501 patients; 245 received bioactive stents, and 256 received drug-eluting stents. The pooled bioactive stent group was associated with a risk ratio of 0.85 for major adverse cardiac events (95% confidence interval, 0.53-1.35; P = .49) compared to the pooled drug-eluting stent group. Similarly, the pooled bioactive stent group was associated with a risk ratio of 0.71 for cardiac death (95% confidence interval, 0.26-1.95; P = .51), 0.44 for recurrent myocardial infarction (95% confidence interval, 0.20-0.97; P = .04), and 1.39 for ischemia-driven target lesion revascularization (95% confidence interval, 0.74-2.59; P = .30), compared to the pooled drug-eluting stent group. These results were confirmed by propensity-score adjusted analysis of the combined datasets.

Conclusions

In patients with ST-segment elevation myocardial infarction, bioactive stents were associated with lower rates of recurrent myocardial infarction compared to drug-eluting stents at 2-year follow-up; yet, the rates of cardiac death and ischemia-driven target lesion revascularization were similar.Full English text available from: www.revespcardiol.org/en     

Predictors of Mortality in Patients With an Implantable Cardiac Defibrillator: A Systematic Review and Meta-analysis

Background

Many current predictors of mortality in heart failure (HF) were evaluated before the use of implantable cardioverter defibrillators (ICDs). We conducted a meta-analysis to identify factors associated with mortality in ICD-HF patients.

Methods

We searched in MedLine, EMBASE, and CINAHL in May 2012. Two reviewers selected citations that included ambulatory ICD patients and addressed the association between any predictor and mortality using multivariable regression. We meta-analyzed mortality using random-effects models.

Results

Of 10,420 studies reviewed, 72 studies evaluating 63 predictors on 257,692 ICD patients proved eligible. High confidence in estimates was found for age (hazard ratio [HR], 1.45 for 10-year increase; 95% confidence interval [CI], 1.35-1.56), baseline glomerular filtration rate (HR, 1.25 for 15-mL/min decrease; 95% CI, 1.15-1.35), chronic obstructive pulmonary disease (HR, 1.54; 95% CI, 1.38-1.71), diabetes (HR, 1.56; 95% CI, 1.37-1.79), peripheral vascular disease (HR, 1.43; 95% CI, 1.2-1.72), left ventricular ejection fraction (HR, 0.77 for 10% increase; 95% CI, 0.73-0.83), and appropriate or inappropriate ICD shocks (HR, 2.34; 95% CI 1.59-3.44) New York Heart Association class, atrial fibrillation, and congestive HF were strongly associated with mortality but the confidence in estimates was low. Ischemic cardiomyopathy and male sex were not independent predictors of mortality.

Conclusions

This meta-analysis identified strong reliable mortality predictors in ICD-HF patients. Age, renal dysfunction, chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, decreased left ventricular ejection fraction, and ICD shocks during follow-up were strong predictors of mortality; ischemic cardiomyopathy and male sex were not. Further research is needed to study other potential predictors, particularly biomarkers.     

El polimorfismo de un solo nucleótido PLAU P141L se asocia con el grado de circulación colateral en pacientes con enfermedad arterial coronaria

Introduction and objectives

Urokinase-type plasminogen activator, which is encoded by the PLAU gene, plays a prominent role during collateral arterial growth. We investigated whether the PLAU P141L (C > T) polymorphism, which causes a mutation in the kringle domain of the protein, is associated with coronary collateral circulation in a cohort of 676 patients with coronary artery disease.

Methods

The polymorphism was genotyped in blood samples using a TaqMan-based genotyping assay, and collateral circulation was assessed by the Rentrop method. Multivariate logistic regression models adjusted by clinically relevant variables to estimate odds ratios were used to examine associations of PLAU P141L allelic variants and genotypes with collateral circulation.

Results

Patients with poor collateral circulation (Rentrop 0-1; n = 547) showed a higher frequency of the TT genotype than those with good collateral circulation (Rentrop 2-3; n = 129; P = .020). The T allele variant was also more common in patients with poor collateral circulation (P = .006). The odds ratio of having poorly developed collaterals in patients bearing the T allele (adjusted for clinically relevant variables) was statistically significant under the dominant model (odds ratio =1.83 [95% confidence interval, 1.16-2.90]; P = .010) and the additive model (odds ratio =1.73 [95% confidence interval, 1.14-2.62]; P = .009).

Conclusions

An association was found between coronary collateral circulation and the PLAU P141L polymorphism. Patients with the 141L variant are at greater risk of developing poor coronary collateral circulation.Full English text available from: www.revespcardiol.org/en