Carlos Peña-Gil

Do GRACE (Global Registry of Acute Coronary events) risk scores still maintain their performance for predicting mortality in the era of contemporary management of acute coronary syndromes

BACKGROUND Although the GRACE risk scores (RS) are the preferred scoring system for risk stratification in acute coronary syndromes (ACS), little is known whether these RS still maintain their performance in the current era. We aimed to investigate this issue in a contemporary population with ACS. METHODS The study population composed of patients enrolled in the MASCARA national registry. The GRACE RS were calculated for each patient. Discrimination and calibration were evaluated with the C statistic and the Hosmer-Lemeshow test, in the whole population and according to the type of ACS, risk strata, and whether the patient had a history of diabetes and/or chronic renal failure. We determined if left ventricular ejection fraction (LVEF) provides incremental prognostic information above that established by the RS and whether percutaneous coronary intervention (PCI) during admission affects the performance of the score for predicting 6-month mortality. RESULTS The 5,985 patients constituted the validation cohort for the in-hospital mortality RS and 5,635 the validation cohort for the 6-month mortality RS. Overall, both GRACE RS demonstrated excellent discrimination (C > 0.80) and calibration (all P values in Hosmer-Lemeshow >.1). Although similar results were seen in all subgroups, the 6-month mortality RS performed significantly less well in patients undergoing PCI compared to those patients who did not (C = 0.73 vs 0.76, P < .004). Adding LVEF to the RS did not convey significant prognostic information. CONCLUSIONS The GRACE RS for predicting in-hospital and 6-month mortality still maintain their excellent performance in a contemporary cohort of patients with ACS. Further studies are needed to investigate the performance of the 6-month mortality GRACE score in patients undergoing in-hospital PCI. Left ventricular ejection fraction did not convey significant information over that provided by the RS.

Evaluation of SAMe-TT2R2 risk score for predicting the quality of anticoagulation control in a real-world cohort of patients with non-valvular atrial fibrillation on vitamin-K antagonists

AIMS Clinicians need to get better at identifying patients who would have poor quality of anticoagulation control with vitamin-K antagonists (VKAs). We assessed the predictive ability of SAMe-TT2R2 score, recently conceived for the prior purpose, and examined its relationship with major bleeding, thromboembolic (TE) complications, and death. METHODS AND RESULTS Retrospectively, 911 consecutive patients with non-valvular atrial fibrillation (NVAF) started on VKAs within 8 months were studied. The percentage of international normalized ratios in therapeutic range (PINRR) at different levels was used as a metric of anticoagulation quality. We also tested the SAMe-TT2R2 predictability for major bleeding, TE complications, and death throughout 10 ± 3 months. The PINRR decreased from 62% at zero point to 53% at ≥4 points of SAMe-TT2R2. 82.1% of patients who achieved PINRR ≥ 70% had 0 or 1 point of SAMe-TT2R2. SAMe-TT2R2 performed significantly better at PINRR 70% than at 65 and 60% (c-statistic = 0.60 vs. c-statistic = 0.56). The calibration of SAMe-TT2R2 was excellent (Hosmer-Lemeshow test P-values ≥ 0.6). SAMe-TT2R2 showed significant association with the composite outcome of major bleeding, TE complications, and death [n = 98; hazard ratio (HR) = 1.32; 95% confidence interval (CI) 1.08-1.60]; the c-statistic was 0.57 (95% CI: 0.51-0.62) and P = 0.03. As individual outcomes, SAMe-TT2R2 was significantly associated with death (n = 60; HR = 1.3; 95% CI: 1.03-1.69), but not with either major bleeding (n = 30; HR = 1.2; 95% CI: 0.85-1.76) or TE complications (n = 15; HR = 1.01; 95% CI: 0.58-1.77). CONCLUSION Among NVAF patients, SAMe-TT2R2 could represent a useful clinical tool to identify patients who would have poor quality of anticoagulation control with VKAs. SAMe-TT2R2 successfully predicts the composite outcome of major bleeding, TE complications, and death.

Validación en una cohorte contemporánea de pacientes con síndrome coronario agudo del score GRACE predictor de mortalidad a los 6 meses de seguimiento

Introduccion y objetivos El score GRACE permite estimar la probabilidad de muerte a los 6 meses del alta hospitalaria en los pacientes con sindrome coronario agudo (SCA). Nuestro objetivo fue validar este score en una cohorte contemporanea de pacientes ingresados en un hospital de Espana. Metodos Desde febrero de 2004 a febrero de 2009, se evaluo a 1.183 pacientes consecutivos con SCA. Se determino el estado vital a los 6 meses del alta y se realizo un estudio de validacion del mencionado score a partir de su capacidad de calibracion (prueba de Hosmer- Lemeshow) y de discriminacion (area bajo la curva receiver operating characteristic [ROC]). Resultados Ingresaron 459 (38,8%) pacientes por infarto agudo de miocardio con elevacion del ST (IAMCEST) y 724 (61,2%) por SCA sin elevacion del ST (SCASEST); 846 (71,5%) fueron revascularizados por via percutanea. La mediana del score GRACE fue de 121 [96-144] puntos. La mortalidad a 6 meses fue del 4,4%. El score GRACE mostro adecuada calibracion y excelente discriminacion en el conjunto de la poblacion, en el IAMCEST y en el SCASEST (Hosmer-Lemeshow, p > 0,2; area bajo la curva ROC, 0,86 [0,807-0,916], 0,9 [0,829- 0,975] y 0,86 [0,783-0,927], respectivamente). Conclusiones El score GRACE de prediccion de mortalidad a los 6 meses del alta tras sufrir un SCA ha sido validado adecuadamente y puede utilizarse para estimar el riesgo de muerte a 6 meses en estos pacientes. En nuestra poblacion tiene sentido incluir en los informes de atencion por SCA el score GRACE.

Participation and adherence to cardiac rehabilitation programs. A systematic review

Acute myocardial infarction (AMI) is an important health problem. Cardiac rehabilitation (CR) programs following AMI have shown to be effective in reducing mortality. We aim to systematically review the existing literature that analyzes the factors that affect participation and adherence to cardiac rehabilitation programs. We reviewed Medline, EMBASE and Cochrane databases from 01/01/2004 to June 2016 using predefined inclusion and exclusion criteria. We classified the results into factors affecting participation and factors influencing adherence to CR programs. We included 29 studies, and there was a general agreement in those factors predicting participation and adherence to CR programs. These factors can be classified into person-related factors and aspects related to CR programs. Older participants, women, patients with comorbidities, unemployed and uncoupled persons, less educated people and those with lower income had a lower participation. A similar pattern was observed for CR adherence. Also, those potential participants who live farther from CR facilities, do not have transportation, or do not drive, attended less to CR programs. These factors were very similar when analyzing adherence to CR programs. These aspects were similar in Europe and the USA. These results clearly show that participation in CR programs follows a determined pattern that is very homogeneous in different settings. Health professionals should also be aware of patients reluctant to participate in CR programs and adapt their messages and redesign CR programs, to promote participation and adherence.

Cystatin C provides more information than other renal function parameters for stratifying risk in patients with acute coronary syndrome.

INTRODUCTION AND OBJECTIVES The protein cystatin C has a stable plasma concentration and is eliminated exclusively by the kidneys. The aim of this study was to determine the prognostic value of cystatin C in patients with acute coronary syndrome (ACS). METHODS The prospective study included 203 hospitalized ACS patients. Clinical evaluation during the first 24 hours of hospitalization included a hemogram and measurement of creatinine, cystatin C, total and fractionated cholesterol and markers of myocardial necrosis. The glomerular filtration rate (GFR) was estimated using the MDRD (Modification of Diet in Renal Disease) equation. A comparison was made between two groups of patients divided according to a serum cystatin-C level above or below 0.95 mg/L. The mean follow-up period was 151 days. RESULTS In total, 90 patients (44.3%) had a cystatin-C level < or =0.95 mg/L and 113 (55.7%) had a level >0.95 mg/L. Those with a cystatin-C level >0.95 mg/L had poorer in-hospital outcomes, including more frequent heart failure (51.3% vs. 13.3%; P=.001) and higher in-hospital mortality (17.6% vs. 3.3%; P=.001), as well as higher mortality throughout follow-up (22.0% vs. 5.6%; P=.001). Multivariate analysis adjusted for age, ejection fraction and troponin-I and high-sensitivity C-reactive protein concentrations showed that cystatin C was the most powerful independent predictor of a cardiovascular event (relative risk=1.91; 95% confidence interval, 1.03-3.53). Patients with a GFR >60 mL/1.73 m(2) and a cystatin-C level >0.95 mg/L had higher in-hospital mortality (10.2% vs. 3.9%; P=.001). CONCLUSIONS Measurement of cystatin C in high-risk ACS patients may be clinically useful for risk stratification during hospitalization, particularly in those with a normal GFR.

Validation of the GRACE Risk Score for Predicting Death Within 6 Months of Follow-Up in a Contemporary Cohort of Patients With Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES The Global Registry of Acute Coronary Events (GRACE) risk score provides an estimate of the probability of death within 6 months of hospital discharge in patients with acute coronary syndrome (ACS). Our aim was to assess the validity of this risk score in a contemporary cohort of patients admitted to a Spanish hospital. METHODS The study involved 1,183 consecutive patients with ACS evaluated between February 2004 and February 2009. Their vital status was determined 6 months after hospital discharge and the validity of the GRACE risk score was evaluated by assessing its calibration (Hosmer-Lemeshow test) and its discriminatory capacity (area under the receiver operating characteristic [ROC] curve). RESULTS In total, 459 (38.8%) patients were admitted for ST-elevation myocardial infarction (STEMI) and 724 (61.2%) for non-ST-elevation myocardial infarction (NSTEMI). Percutaneous revascularization was performed in 846 (71.5%). The median GRACE risk score was 121 [interquartile range, 96-144]. Mortality 6 months after discharge was 4.4%. The calibration of the GRACE risk score was acceptable (Hosmer-Lemeshow, P>.2) and its discriminatory capacity was excellent: the area under the ROC curve was 0.86 (95% confidence interval [CI], 0.807-0.916) for all patients, 0.9 (95% CI, 0.829-0.975) for those with STEMI and 0.86 (95% CI, 0.783-0.927) for those with NSTEMI. CONCLUSIONS The GRACE risk score for predicting death within 6 months of hospital discharge was validated and can be used in patients with ACS. It would be wise to include the GRACE risk score in the medical records of these patients.

Very brief training for laypeople in hands-only cardiopulmonary resuscitation. Effect of real-time feedback.

BACKGROUND Bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest, but rates and performance quality remain low. Although training laypeople is a primary educational goal, the optimal strategy is not well defined. This study aimed to determine whether a short training with real-time feedback was able to improve hands-only CPR among untrained citizens. METHODS On the occasion of the 2015 World Heart Day and the European Restart a Heart Day, a pilot study involving 155 participants (81 laypeople, 74 health care professionals) was conducted. Participants were invited to briefly practice hands-only CPR on a manikin and were after evaluated during a 2-minute chest compression (CC) test. During training brief instructions regarding hand position, compression rate and depth according to the current guidelines were given and real-time feedback was provided by a Laerdal SkillReporting System. RESULTS Mean CC rate was significantly higher among health care professionals than among laypeople (119.07 ± 12.85 vs 113.02 ± 13.90 min(-1); P = .006), although both met the 100-120 CC min(-1) criterion. Laypeople achieved noninferior results regarding % of CC at adequate rate (51.46% ± 35.32% vs health care staff (55.97% ± 36.36%; P = .43) and depth (49.88% ± 38.58% vs 50.46% ± 37.17%; P = .92), % of CC with full-chest recoil (92.77% ± 17.17% vs 0.91% ± 18.84; P = .52), and adequate hand position (96.94% ± 14.78% vs 99.74 ± 1.98%; P = .11). The overall quality performance was greater than 70%, noninferior for citizens (81.23% ± 20.10%) vs health care staff (85.95% ± 14.78%; P = .10). CONCLUSION With a very brief training supported by hands-on instructor-led advice and visual feedback, naïve laypeople are able to perform good-quality CC-CPR. Simple instructions, feedback, and motivation were the key elements of this strategy, which could make feasible to train big numbers of citizens.

Mehran contrast nephropathy risk score: Is it still useful 10 years later?

BACKGROUND Nowadays, contrast-induced nephropathy (CIN) is the third cause of acquired acute renal impairment in hospital. CIN is related to increased in-hospital morbidity, mortality, costs of medical care, and long admissions. Because of this, we hypothesized it would be useful to determine the risk of CIN with scores such as the Mehran score. The aim of this study was to validate the Mehran score in a contemporary cohort of Spanish patients with acute coronary syndrome (ACS). METHODS We assessed the calibration and discriminatory capacity of Mehran score to predict CIN in a cohort of 1520 patients with a definitive diagnosis of ACS and who underwent coronary angiography between March 2008 and June 2012. We excluded patients on chronic dialysis and those without data of contrast volume. The calibration of the model was assessed with the Hosmer-Lemeshow goodness-of-fit test and discriminatory capacity was assessed by C-statistic, which is equivalent to the area under the receiver-operating characteristic curve. RESULTS From the total group, 118 patients (7.8%) developed CIN. They were older, with higher rates of diabetes (DM) and hypertension and worse renal function and anemia (p<0.001). The odds ratios for different score components in Mehrans population versus our study were similar except for DM, hypotension, and intra-aortic balloon pump (1.6%, 2.68%, 2.55% vs 0.9%, 1.89%, and 2.86%, respectively). Calibration and discriminatory capacity of Mehran score were excellent with a Hosmer-Lemeshow p=0.7, C-statistic value >0.8. CONCLUSIONS Mehran risk score has been validated in our study as a good score for predicting CIN in patients with ACS who underwent coronary angiography. According to this, we support its use in patients hospitalized for ACS in order to identify the ones at risk, and to optimize CIN prophylactic therapy prior to and after catheterization.

Comparison Between 3 Bleeding Scoring Systems in Nonvalvular Atrial Fibrillation Patients. What Can the New ORBIT Score Provide

Atrial fibrillation (AF) is a health problem of increasing concern at the national level in Spain. Bleeding risk assessment is a key step in AF patient management for a safer use of oral anticoagulants. Current European Society of Cardiology guidelines recommend the use of the HAS-BLED classification system for bleeding risk assessment in nonvalvular AF (NVAF) patients. However, HAS-BLED has been criticized for the requirement of data on INR (international normalized ratio) monitoring, which are not usually available at the moment of decision-making for anticoagulant-naı̈ve NVAF patients. The new ORBIT bleeding risk score (Table 1 of the supplementary material) was found to have the advantage of providing similar discrimination and even better calibration than the HASBLED and ATRIA bleeding scores (Table 2 of the supplementary material), despite not requiring information on the time in therapeutic range (ie, labile INR) for its calculation. However, in a recent validation study, the new ORBIT score did not outperform HAS-BLED, albeit that study was a clinical trial excluding patients with a history of major bleeding. In this study, we aimed to explore in a real word cohort of outpatients, whether, as recently suggested, there is an incremental prognostic value of the new ORBIT score over HAS-BLED and ATRIA. The details of this study have been published elsewhere. Briefly, between January 2011 and February 2013, we studied 911 consecutive NVAF patients recently started on vitamin K antagonists (VKA). Major bleeding was defined using the definition of the International Society on Thrombosis and Haemostasis (ISHT) 2005. We had insufficient data on the INR values before patient enrollment in the study. However, given the major importance of the labile INR variable, we used each patient’s INR measurements during the follow-up to calculate the time in therapeutic range (after excluding the INR values registered during the first month after VKA initiation). According to the study design, we excluded patients with interrupted VKA > 3 days (n = 73 patients) and, in a group of these patients, the reason for VKA interruption was nonmajor bleeding. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution’s human research committee. The median age was 75 years (interquartile range [IQR]: 66-81 years); 34.6% were female. A total of 84.7% had a CHA2DS2-VASc 2 points, and 12.6% had prior bleeding. The median number of INR controls was 15 [14-15]. Time in therapeutic range by Roosendaal was 66% [54-77%]. The median HAS-BLED, ATRIA, and ORBIT scores was 2 [2-3] points, 3 [1-3] points, and 1 [0-2] point.

Clinical profile and outcomes in octogenarians with atrial fibrillation: A community-based study in a specific European health care area

BACKGROUND Age increases risk of stroke and bleeding. Clinical trial data have had relatively low proportions of elderly subjects. We sought to study a Spanish population of octogenarians with atrial fibrillation (AF) by combining different sources of electronic clinical records from an area where all medical centres utilized electronic health record systems. METHODS Data was derived from the Galician Healthcare Service information system. RESULTS From 383,000 subjects, AF was coded in 7990 (2.08%), 3640 (45.6%) of whom were ≥80 and 4350 (54.4%)<80. All CHA2DS2-VAScs components were more prevalent in the elderly except for diabetes. Of those ≥80, 2178 (59.8%) were women. Mean CHA2DS2-VASc was 4.2±1.1. Distribution of CHA2DS2-VASc components varied between genders. 2600 (71.4%) were on oral anticoagulant (OA). During a median follow up of 696days (124.23), all-cause mortality was higher in ≥80 (1011/3640 (27.8%) vs 350/4350 (8.05%) (p<0.001). There were differences in rate of thromboembolic (TE) and haemorrhagic events (2.3% vs 0.9%, p<0.01 and 2.5% vs 1.7%, p=0.01 respectively). In octogenarian, differences between genders were observed with regard to TE, but not in haemorrhagic or all-cause mortality rates. Age, heart failure, non-valvular AF, dementia, and OA were independent predictors of all-cause mortality. In regard to TE, female gender, hypertension, previous TE and OA were independent predictive factors. CONCLUSIONS Octogenarians with AF had very different characteristics and outcomes from their younger counterparts. These results also provide reassurance about the effectiveness of OA in preventing TE events and maintaining a reasonable haemorrhagic event rate in the extremely elderly.