Domingo Pascual

Malignancy After Heart Transplantation: Incidence, Prognosis and Risk Factors

The Spanish Post‐Heart‐Transplant Tumour Registry comprises data on neoplasia following heart transplantation (HT) for all Spanish HT patients (1984–2003). This retrospective analysis of 3393 patients investigated the incidence and prognosis of neoplasia, and the influence of antiviral prophylaxis. About 50% of post‐HT neoplasias were cutaneous, and 10% lymphomas. The cumulative incidence of skin cancers and other nonlymphoma cancers increased with age at HT and with time post‐HT (from respectively 5.2 and 8.9 per 1000 person‐years in the first year to 14.8 and 12.6 after 10 years), and was greater among men than women. None of these trends held for lymphomas. Induction therapy other than with IL2R‐blockers generally increased the risk of neoplasia except when acyclovir was administered prophylactically during the first 3 months post‐HT; prophylactic acyclovir halved the risk of lymphoma, regardless of other therapies. Institution of MMF during the first 3 months post‐HT reduced the incidence of skin cancer independently of the effects of sex, age group, pre‐HT smoking, use of tacrolimus in the first 3 months, induction treatment and antiviral treatment. Five‐year survival rates after first tumor diagnosis were 74% for skin cancer, 20% for lymphoma and 32% for other tumors.

Brugada-like electrocardiographic pattern induced by fever.

SAURA, D., et al.: Brugada‐Like Electrocardiographic Pattern Induced by Fever. The Brugada syndrome is characterized by a peculiar ST‐segment elevation in the right precordial leads and the propensity to develop ventricular arrhythmias. Mutations in a cardiac sodium channel gene have been linked to this syndrome and some experimental data suggest that the dysfunction of the mutated channel can be temperature sensitive. This report describes a patient in whom a typical Brugada ECG pattern developed in relation to fever but could not be reproduced at normal temperature on administration of flecainide. This case suggests that in some patients a Brugada‐like ECG may only manifest during a febrile state.

Risk Stratification of Mortality in Patients With Heart Failure and Left Ventricular Ejection Fraction >35%

The population of patients with heart failure (HF) and mild to moderate left ventricular (LV) dysfunction is growing, and mortality remains high. There is a need for better risk stratification of patients who might benefit from primary prevention of mortality. This study aimed to evaluate the prognostic value of Holter-based parameters for predicting mortality in patients with HF with LV ejection fraction (EF) >35%. The study involved 294 patients (199 men, mean age 66 years) with HF of ischemic and nonischemic causes, New York Heart Association classes II to III, and LVEF >35%. Surface electrocardiogram and 24-hour Holter monitoring were performed at enrollment to assess traditional electrocardiographic variables, as well as heart rate variability, heart rate turbulence, and repolarization dynamics (QT/RR). Total mortality and sudden death were the primary and secondary end points. During a median 44-month follow-up, there were 43 deaths (15%). None of the traditional electrocardiographic risk parameters significantly predicted mortality. A standard deviation of all normal-to-normal RR intervals < or =86 ms, turbulence slope < or =2.5 ms/RR, and QT end/RR >0.21 at daytime were found to be independent risk predictors of mortality in multivariate analyses. The predictive score based on these 3 variables showed that patients with > or =2 abnormal risk markers were at risk of death (30% 3-year mortality rate) and sudden death (12%), similar to death rates observed in patients with LVEF < or =35%. In conclusion, increased risk of mortality and sudden death could be predicted in patients with HF with LVEF >35% by evaluating the combination of standard deviation of all normal-to-normal RR intervals, turbulence slope, and QT/RR, parameters reflecting autonomic control of the heart, baroreflex sensitivity, and repolarization dynamics.

Incidence and risk factors for nonmelanoma skin cancer after heart transplantation

INTRODUCTION The incidence of skin cancer in heart transplant (HT) patients is higher than in the general population, reversing the proportion of cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) with a predominance of the former. The etiologic role of new immunosuppressants is not well known. We sought to ascertain the incidence of SCC and BCC in HT patients and the risk factors for its occurrence. PATIENTS AND METHODS We report the incidence of all types of post-HT skin cancer, SCC, and BCC among adult HT patients in Spain (4089 subjects) as well as the influence of gender, age at heart transplant, immunosuppression, and sunlight exposure. RESULTS The incidence rates of SCC and BCC, per 1000 persons/year, were 8.5 and 5.2, respectively. Males had a higher risk of SCC but not BCC. Induction therapy increased the risk of SCC and BCC. The relative risk of mycophenolate mofetil (MMF) was 0.3 (0.2-0.6; P<.0005) and azathioprine (AZA) 1.8 (1.2-2.7; P<.0032) for SCC, whereas tacrolimus and cyclosporine showed no difference. The relative risk of BCC was not affected by any immunosuppressant. CONCLUSION Age at transplantation>45 years, induction therapy use, and high sunshine zone were risk factors for both SCC and BCC. Different immunosuppressive agents have different risks of nonmelanoma skin cancer, as AZA increases the risk of SCC and MMF is a protective factor. The relative risk of BCC was not affected by any immunosuppressor.

Primary graft failure after heart transplantation: Characteristics in a contemporary cohort and performance of the RADIAL risk score

BACKGROUND Primary graft failure (PGF) is the leading cause of early heart transplantation (HT) mortality. Our aim was to analyze PGF currently and explore the ability of a dedicated score for PGF risk stratification. METHODS After applying a dedicated PGF definition, we analyzed its incidence, mortality, and associated factors in a multicenter cohort of 857 HTs performed in 2006 to 2009. We used the following criteria: recipient right (R) atrial pressure ≥ 10 mm Hg; age (A) ≥ 60 years; diabetes (D) mellitus, and inotrope (I) dependence; donor age (A) ≥ 30 years, and length (L) of ischemia ≥ 240 minutes to calculate the RADIAL score for PGF risk prediction. RESULTS PGF incidence was 22%. The right ventricle was almost always affected, alone (45%) or as part of biventricular failure (47%). Mechanical circulatory support was used in 55%. Mortality attributable to PGF was 53% and extended through the third month after HT, but thereafter, PGF had little influence in long-term outcome. The RADIAL score was higher in PGF patients (2.78 ± 1.1 vs. 2.42 ± 1.1, p = 0.001) and stratified 3 groups with incremental PGF incidence: low risk (12.1%), intermediate risk (19.4%), and high risk (27.5%, p = 0.001). CONCLUSIONS PGF had a strong impact, with an incidence of 22% and a mortality exceeding 50% that extends through the third post-HT month. The RADIAL score classified patients into 3 groups with incremental risk for PGF and may be useful for its prevention and early therapy.

Comentarios a la guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica 2012. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

El Comite de Guias de Practica Clinica de la SEC formo un grupo de trabajo integrado por cardiologos clinicos, electrofisiologos, cirujanos cardiacos y personal de enfermeria, expertos en los diversos aparta-dos de la IC que cubre la guia de la ESC, propuestos por la Seccion de Insuficiencia Cardiaca y Trasplante y el Grupo de Trabajo sobre Resin-cronizacion Cardiaca de la SEC y por la Asociacion Espanola de Enfer-meria Cardiovascular, con el objetivo general de revisar las evidencias y recomendaciones aportadas por la guia europea sobre IC antes citada

Risk factors associated with cytomegalovirus infection in heart transplant patients: a prospective, epidemiological study

J.F. Delgado, N. Manito, L. Almenar, M. Crespo‐Leiro, E. Roig, J. Segovia, J.A. Vázquez de Prada, E. Lage, J. Palomo, M. Campreciós, J.M. Arizón, J.L. Rodríguez‐Lambert, T. Blasco, L. de la Fuente, D. Pascual, G. Rábago. Risk factors associated with cytomegalovirus infection in heart transplant patients: a prospective, epidemiological study
Transpl Infect Dis 2011: 13: 136–144. All rights reserved

Comentarios a las guías de práctica clínica sobre manejo de las dislipemias de la Sociedad Europea de Cardiología y la Sociedad Europea de Aterosclerosis 2011. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

In line with the new philosophy on clinical practice guidelines adopted by the executive committee of the Sociedad Española de Cardiología (SEC: Spanish Society of Cardiology), which was explained and justifi ed in a recent document published in the Revista Española de Cardiología (REC),1 this article has the objective of discussing the most important and novel aspects of the guidelines on the management of dyslipidemias but without attempting to replace them. A joint effort by the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS),2 these guidelines updated the old protocols for treating dyslipidemias developed by the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATP III) and published in 2001 (summary) and 2002 (complete text),3 with a minor update in 2004.4 In Spain, recommendations from the Comité Español Interdisciplinario para la Prevención Cardiovascular (CEIPC) have been used more recently,5 with the approval of the Spain’s Health Ministry and the participation of the SEC, although in this Spanish guideline dyslipidemia is just one section of the general recommendations on cardiovascular prevention.

Aplicación de una puntuación de riesgo coronario (TIMI Risk Score) en una población no seleccionada de pacientes que consultan por dolor torácico en un servicio de urgencias

Introduccion y objetivos Diferentes algoritmos de estratificacion del sindrome coronario agudo (SCA) permiten identificar a los individuos con un mayor riesgo que pueden beneficiarse de tratamientos mas agresivos. Se ha demostrado que el TIMI Risk Score (TRS) es util en pacientes con un riesgo intermedio y alto, pero faltan evidencias acerca de su aplicabilidad clinica en pacientes no seleccionados. El objetivo es comprobar la eficacia del TRS en la estratificacion del riesgo en una poblacion con dolor toracico no seleccionada. Pacientes y metodo Se incluyo a 1.254 pacientes consecutivos que acudieron a urgencias por dolor toracico no traumatico sin ascenso del segmento ST (edad 54 ± 19 anos, 57% varones). Se ingreso a 343 (27%) y se dio de alta a 911 (73%). Se registro la aparicion de eventos cardiacos a los 6 meses. Resultados En el grupo dado de alta desde urgencias, 45 (5,3%) pacientes fueron ingresados durante el seguimiento, 9 (1,1%) recibieron tratamiento de revascularizacion, 5 (0,6%) presentaron un infarto agudo miocardico (IAM) y 2 (0,2%) fallecieron por causa cardiovascular. Los que obtuvieron una mayor puntuacion en el TRS presentaron mas riesgo de presentar el evento combinado muerte, infarto o revascularizacion (riesgo relativo por incremento de unidad = 3,63; intervalo de confianza [IC] del 95%, 2,20-6,00; p Conclusiones El TRS es una herramienta eficaz para la estratificacion pronostica de pacientes no seleccionados que consultan por dolor toracico. Permite identificar a los individuos de alto riesgo que se beneficiarian de ingreso hospitalario y tratamiento agresivo precoz.

Association of Blood Pressure and Its Evolving Changes With the Survival of Patients With Heart Failure

OBJECTIVE The association between low blood pressure (BP) levels and increased mortality has been established in several studies of heart failure (HF). Although many drugs administered to these patients decrease BP, the relationship between changes in BP and survival has not been investigated. Nor have previous analyses distinguished among different forms of death. We investigated the influence of baseline BP and changes in BP during a 1-year period on the survival of patients with HF, distinguishing among sudden cardiac death, nonsudden cardiac death, and noncardiac death. We also identified the possible relationship with the baseline values of and changes in other clinical and treatment variables, including pharmacologic treatments. METHOD AND RESULTS A total of 1062 patients with chronic HF included in the Spanish National Registry of Sudden Death (mean age of 64.5 +/- 11.8 years, 72% were men, and 21% were in New York Heart Association class III with a mean left ventricular ejection fraction of 36.7% +/- 14.2%) were prospectively investigated for a mean of 1.9 +/- 0.6 years. A multivariable Cox proportional hazards model adjusting for clinical and therapeutic variables showed an independent association between low baseline systolic blood pressure (SBP) and nonsudden cardiac death (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.93-0.98), but changes in SBP during the following year did not influence survival, regardless of the baseline SBP level (P = .55). Contrariwise, baseline diastolic BP was not associated with mortality, but an increase in diastolic BP during the following year showed a borderline independent significant association with lower nonsudden cardiac death (HR 0.90, 95% CI 0.82-1.00). Treatment with angiotensin-converting enzyme inhibitors or beta-blockers at baseline was also associated with lower nonsudden cardiac mortality, as was an increase in left ventricular ejection fraction during the following year (HR 0.69, 95% CI 0.51-0.93; P = .015). CONCLUSION Among patients with stable HF, low SBP is associated with a greater risk of nonsudden cardiac death. The change in SBP during a 1-year period has no prognostic value. Because the beneficial effects of drugs associated with increased survival (in this study, angiotensin-converting enzyme inhibitors and beta-blockers) thus seem to be independent of their effects on BP, changes in BP should probably not influence the decision to use such drugs or continue their administration.