Cesar Caro

Red blood cell distribution width predicts long-term outcome regardless of anaemia status in acute heart failure patients

To study the long‐term prognostic value of red blood cell distribution width (RDW) in patients hospitalized with acute heart failure (AHF) and to compare the value of this measurement with haemoglobin levels and anaemia status.

Increased Major Bleeding Complications Related to Triple Antithrombotic Therapy Usage in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Artery Stenting

BACKGROUND The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S. METHODS We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [< or = 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded. RESULTS We studied 104 patients (mean age +/- SD, 72 +/- 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53). CONCLUSION A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.

Impact of Chronic Kidney Disease on Major Bleeding Complications and Mortality in Patients With Indication for Oral Anticoagulation Undergoing Coronary Stenting

BACKGROUND Patients with indications for oral anticoagulation (OAC) undergoing percutaneous coronary artery stenting (PCI-S) represent a high-risk population for major bleeding complications. Chronic kidney disease (CKD) is also associated with poor outcome after PCI-S. Limited data are available regarding the impact of CKD on the frequency of major bleeding and mortality in this population. METHODS We investigated the influence of CKD on major bleeding and all-cause mortality in patients with indication for OAC who undergo PCI-S. Patients were grouped according to calculated creatinine clearance (CrCl): CrCl > 60 mL/min, (n = 98) and CrCl < or = 60 mL/min, (n = 68). Major bleeding and major adverse vascular events (all-cause mortality, myocardial infarction, repeat revascularization, stent thrombosis, or stroke) were collected during follow-up. RESULTS We analyzed 166 consecutive patients with indication(s) for OAC (77% men; mean age, 71 years; range, 66 to 76 years) after undergoing PCI-S. CKD was associated with higher risk for major bleeding (hazard ratio [HR], 3.44; 95% confidence interval [CI], 1.50 to 7.93; p = 0.004) and all-cause mortality (HR, 3.50; 95% CI, 1.53 to 7.99; p = 0.003). In multivariate analyses, age > 75 years (HR, 2.75; 95% CI, 1.15 to 6.56; p = 0.023), CKD (HR, 2.59; 95% CI, 1.00 to 6.95; p = 0.049), anemia (HR, 2.36; 95% CI, 1.00 to 5.54; p = 0.049), and triple antithrombotic therapy (HR, 3.29; 95% CI, 1.23 to 8.84; p = 0.018) were independent predictors for major bleeding, whereas age > 75 years (HR, 2.38; 95% CI, 1.03 to 5.59; p = 0.046) and CKD (HR, 2.44; 95% CI, 1.03 to 5.82; p = 0.044) were predictors for all-cause mortality. CONCLUSION In this high-risk population, CKD is independently associated with increased major bleeding and all-cause mortality following PCI-S.

Existe un efecto beneficioso a largo plazo con el tratamiento con marcapasos de la miocardiopatía hipertrófica obstructiva severa

Introduccion y objetivos Alrededor de un 25% de los pacientes con MCH obstructiva permanecen sintomaticos a pesar de una correcta medicacion. Algunos pueden beneficiarse del implante de un marcapasos. El objetivo fue valorar el efecto del marcapasos en la modificacion del gradiente en el tracto de salida del ventriculo izquierdo (TSVI), grosor maximo del ventriculo izquierdo (VI) y en la capacidad funcional. Metodos A 72 pacientes con MCH obstructiva y sintomas incapacitantes se les implanto un marcapasos. Se realizo un examen clinico, una ecocardiografia (61 pacientes) y una ergometria (34 pacientes) antes y despues de la implantacion del marcapasos. Resultados La capacidad funcional subjetiva, estimada segun la clasificacion de la NYHA, mejoro en el 43,1% de los pacientes, aunque no lo hizo la estimada mediante ergometria. Se observo una reduccion significativa del gradiente subaortico (mediana, 87 [intervalo intercuartilico, 61,5-115,2] frente a 30 [18-54,5] mmHg; p Conclusiones La implantacion de marcapasos en pacientes con MCH obstructiva con sintomas incapacitantes disminuye el gradiente obstructivo del TSVI y el grosor maximo del VI, pero solo el 43,1% consigue una mejoria clinica subjetiva, siendo una clase funcional mas avanzada el unico factor predictor de mejoria.

Severe aortic valve stenosis with low-gradient and preserved ejection fraction: a misclassification issue?

INTRODUCTION AND OBJECTIVES Low-gradient severe aortic stenosis with preserved ejection fraction is a controversial entity. Misclassification of valvulopathy severity could explain the inconsistencies reported in the prognosis of these patients. Planimetry of the aortic area using three-dimensional transesophageal echocardiography could clear up these doubts. The objectives were to assess the agreement between measurements of the valvular aortic area by continuity equation in transthoracic echocardiography and that obtained through planimetry with three-dimensional transesophageal echocardiography in low-gradient severe aortic stenosis patients. METHODS Cross-sectional descriptive study of consecutive patients referred due to severe aortic stenosis. Patients underwent transthoracic echocardiography and three-dimensional transesophageal echocardiography. Paradoxical low-gradient severe aortic stenosis was defined by the presence in the transthoracic echocardiography of aortic valve area<1 cm(2), mean ventricular gradient<40 mmHg, and ejection fraction ≥ 50%. Concordance between the two techniques was evaluated. RESULTS Of 212 consecutive severe aortic stenosis patients evaluated, 63 cases (29.7%) fulfilled the paradoxical low-gradient inclusion criteria. We obtained three-dimensional aortic valve planimetry in 61 (96.8%) of those patients. In 52 patients (85.2%), aortic valve area by transesophageal echocardiography was <1 cm(2). The intraclass correlation coefficient between the two methods was 0.505 (95% confidence interval, 0.290-0.671; P<.001). CONCLUSIONS Paradoxical low-gradient severe aortic stenosis is an actual entity, confirmed in 85% of cases evaluated by three-dimensional transesophageal echocardiography.

Comparison of Late Mortality in Hospitalized Patients >70 Years of Age With Systolic Heart Failure Receiving Beta Blockers Versus Those Not Receiving Beta Blockers

Beta blockers are underprescribed to elderly patients with systolic heart failure (HF). We studied whether the prescription of a beta blocker is associated with a survival benefit in a nonselected population of patients >70 years of age hospitalized with acute HF and systolic dysfunction. We studied 272 consecutive patients >70 years (median 77.0, interquartile range 73.4 to 81.1) hospitalized with acute HF (left ventricular ejection fraction 34 +/- 8%) during a 2-year period. At discharge, beta-blocker therapy was prescribed in 139 patients (51.1%). A propensity score for the likelihood of receiving beta-blocker therapy was developed and showed a good performance (c-statistic = 0.825 and Hosmer-Lemeshow p = 0.820). After discharge, 120 patients (44.1%) died during the follow-up (median 31 months, interquartile range 12 to 46). Cox regression analysis showed a lower risk of death associated with beta-blocker prescription (p <0.001, hazard ratio [HR] 0.450, 95% confidence interval [CI] 0.310 to 0.655), which persisted after risk adjusting for the propensity score (HR 0.521, 95% CI 0.325 to 0.836, p = 0.007). In a propensity-matched cohort of 130 patients, there was a significantly lower mortality in patients receiving beta blockers (log rank 0.009, HR 0.415, 95% CI 0.234 to 0.734, p = 0.003). Risk reduction associated with beta blockade was observed with both high doses (HR 0.472, 95% CI 0.300 to 0.742, p = 0.001) and low doses (HR 0.425, 95% CI 0.254 to 0.711, p = 0.001). In conclusion, beta-blocker prescription at discharge in a nonselected population >70 years of age hospitalized with systolic HF is associated with a significantly lower risk of death even at low doses. This benefit remains consistent after adjustment for potential confounders.

Antithrombotic therapy after coronary stenting in patients with indication for oral anticoagulation

not known after discontinuing the drugs. In addition, Urhausen et al. [3] reported that LV changes may not completely recover after stopping the drugs even after several years. Although more studies are required to clarify these findings, including the need for further imaging methods such as magnetic resonance imaging and additional studies due to the limitation of echocardiography for examining the RV, it is possible to say, based on the results of this current study, that AAS negatively affects RV diastolic function more than LV functions.

Does Pacemaker Implantation Provide Long-Term Benefits in Severe Obstructive Hypertrophic Cardiomyopathy?

INTRODUCTION AND OBJECTIVES About 25% of patients with obstructive hypertrophic cardiomyopathy (HCM) remain symptomatic despite optimal medical treatment. Some may benefit from pacemaker implantation. The aim of this study was to determine the effect of pacemaker implantation on the left ventricular outflow tract (LVOT) gradient, the maximum thickness of the left ventricle, and functional capacity. METHODS In total, 72 patients with obstructive HCM and incapacitating symptoms underwent pacemaker implantation. Clinical examination, echocardiography (in 61 patients) and treadmill testing (in 34 patients) were performed before and after implantation. RESULTS Subjective functional capacity, as assessed using the New York Heart Association (NYHA) classification, improved in 43.1% of patients, but treadmill testing showed no change. There were significant reductions in subaortic gradient, from a median of 87.0 mmHg (interquartile range [IQR] 61.5-115.2 mmHg) to 30.0 mmHg (IQR 18.0-54.5 mmHg; P< .001), and maximum left ventricular thickness, from 22.1+/-4.5 mm to 19.8+/-3.6 mm (P=.001). Univariate analysis identified two factors associated with clinical improvement: female sex (odds ratio [OR]=3.43; P=.020) and functional class III/IV (OR=4.17; P=.009). On multivariate analysis, only functional class III/IV remained a significant predictor (OR=3.12; P=.048). CONCLUSIONS In patients with obstructive HCM and incapacitating symptoms, pacemaker implantation reduced the LVOT gradient and the maximum left ventricular thickness, but only 43.1% of patients experienced clinical improvement. The only factor predictive of improvement was advanced NYHA functional class.