Gonzalo Barón-Esquivias

Dual-Chamber Pacing With Closed Loop Stimulation in Recurrent Reflex Vasovagal Syncope: The SPAIN Study

BACKGROUNDnPacing in vasovagal syncope remains controversial.nnnOBJECTIVESnThe authors evaluated dual-chamber pacing with closed loop stimulation (DDD-CLS) in patients with cardioinhibitory vasovagal syncope.nnnMETHODSnThis randomized, double-blind, controlled study included Canadian and Spanish patients agexa0≥40 years, with high burden syncope (≥5 episodes,xa0≥2 episodes in the past year), and a cardioinhibitory head-up tilt test (bradycardiaxa0<40 beats/min for 10xa0s or asystole >3 s). Patients were randomized to either DDD-CLS pacing for 12xa0months followed by sham DDI mode pacing at 30 pulses/min for 12xa0months (group A), or sham DDI mode for 12xa0months followedxa0by DDD-CLS pacing for 12xa0months (group B). Patients in both arms crossed-over after 12xa0months of follow-up orxa0when a maximum of 3 syncopal episodes occurred within 1xa0month.nnnRESULTSnA total of 46 patients completed the protocol; 22 were men (47.8%), and mean age was 56.30 ± 10.63 years. The mean number of previous syncopal episodes was 12 (range 9 to 20). The proportion of patients withxa0≥50% reduction in the number of syncopal episodes was 72% (95% confidence interval [CI]: 47% to 90%) with DDD-CLS compared withxa028% (95% CI: 9.7% to 53.5%) with sham DDI mode (pxa0=xa00.017). A total of 4 patients (8.7%) had events duringxa0DDD-CLS and 21 (45.7%) during sham DDI (hazard ratio: 6.7; 95% CI: 2.3 to 19.8). Kaplan-Meier curve was significantlyxa0different between groups in time to first syncope: 29.2xa0months (95% CI: 15.3 to 29.2xa0months) versusxa09.3xa0months (95% CI: 6.21xa0months, NA; pxa0< 0.016); odds ratio: 0.11 (95% CI: 0.03 to 0.37; pxa0< 0.0001).nnnCONCLUSIONSnDDD-CLS pacing significantly reduced syncope burden and time to first recurrence by 7-fold,xa0prolonging time to first syncope recurrence in patients agexa0≥40 years with head-up tilt test-induced vasovagalxa0syncopexa0compared with sham pacing. (Closed Loop Stimulation for Neuromediated Syncope [SPAINxa0Study];xa0NCT01621464).

Efficacy and safety of rivaroxaban in real-life patients with atrial fibrillation.

Rivaroxaban is a once-daily oral anticoagulant currently marketed for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. This indication is largely based on the results of the ROCKET-AF trial. Although these results are robust, studies performed in clinical practice are necessary to confirm these data in real-life patients. These studies have shown rates of stroke and bleeding similar to that found in ROCKET-AF. As an anticoagulant, attention should be paid to making a correct prescription of rivaroxaban, particularly in fragile patients, to reduce the risk of bleeding. In addition, a number of studies have shown that rivaroxaban is cost-effective in clinical practice. Moreover, rivaroxaban is a good alternative to warfarin in patients undergoing elective cardioversion or atrial fibrillation ablation.

Rivaroxaban in patients with atrial fibrillation: from ROCKET AF to everyday practice

ABSTRACT Introduction: Registries and non-interventional studies offer relevant and complementary information to clinical trials, since they have a high external validity. Areas covered: The information regarding the efficacy and safety of rivaroxaban compared with warfarin, or rivaroxaban alone in clinical practice was reviewed in this manuscript. For this purpose, a search on MEDLINE and EMBASE databases was performed. The MEDLINE and EMBASE search included both medical subject headings (MeSH) and keywords including: atrial fibrillation (AF) OR warfarin OR clinical practice OR ROCKET AF AND rivaroxaban. Case reports were not considered. Expert commentary: In ROCKET AF, rivaroxaban was at least as effective as warfarin for the prevention of stroke in patients with nonvalvular AF at high risk of stroke, but, importantly, with a lesser risk of intracranial, critical and fatal bleedings. A number of observational comparative and non-comparative studies, with more than 60,000 patients included treated with rivaroxaban, have analyzed the efficacy and safety of rivaroxaban in real-life patients with AF in different clinical settings. These studies have shown that in clinical practice, rates of stroke and major bleeding were consistently lower than those reported in ROCKET AF, likely due to the lower thromboembolic and bleeding risk observed in these patients.

Update for 2014 on clinical cardiology, geriatric cardiology, and heart failure and transplantation.

In the present article, we review publications from the previous year in the following 3 areas: clinical cardiology, geriatric cardiology, and heart failure and transplantation. Among the new developments in clinical cardiology are several contributions from Spanish groups on tricuspid and aortic regurgitation, developments in atrial fibrillation, syncope, and the clinical characteristics of heart disease, as well as various studies on familial heart disease and chronic ischemic heart disease. In geriatric cardiology, the most relevant studies published in 2014 involve heart failure, degenerative aortic stenosis, and data on atrial fibrillation in the geriatric population. In heart failure and transplantation, the most noteworthy developments concern the importance of multidisciplinary units and patients with preserved systolic function. Other notable publications were those related to iron deficiency, new drugs, and new devices and biomarkers. Finally, we review studies on acute heart failure and transplantation, such as inotropic drugs and ventricular assist devices.

Care Indicators in Patients With Atrial Fibrillation: Assessment of Sex Differences and Management of Clinical Problems

INTRODUCTION AND OBJECTIVESnTo assess sex differences and the management of clinical problems in patients with atrial fibrillation through the use of care indicators.nnnMETHODSnOver a 5-month period, the study included all consecutive patients attended in the cardiology outpatient clinics of 2 tertiary hospitals with an atrial fibrillation episode or a clinical process due to atrial fibrillation.nnnRESULTSnA total of 533 patients were included (56.5% women; mean age, 70.5 ± 12.2 years), of whom 24.3% were younger than 65 years. Women had significantly more clinical problems and a higher stroke risk: CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) (1.8 ± 1.2 vs 1.5 ± 1.1; P = .001) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled]-vascular disease and sex category [female]) (3.7 ± 1.4 vs 2.2 ± 1.4; P = .0001). Referrals to the cardiology department were appropriate in 94% of the patients, the referral source was primary care or other hospital services in 53.8%, and echocardiography was performed or recommended in 93.4%. Treatment (antiarrhythmics and anticoagulants) was administered according to guideline recommendations. In the previous 3 months, the Rosendaal index was 48.4 ± 37.4.nnnCONCLUSIONSnOne in every 4 patients seeking care for problems associated with atrial fibrillation are young; women have more clinical problems and seek care more frequently than men. Patients are correctly referred to the cardiology department and most are not referred from the emergency department. Echocardiography and antiarrhythmic and anticoagulant therapy were provided according to the recommendations of clinical practice guidelines. Vitamin K antagonists for anticoagulation therapy are underused.

Erratum to: Clinical Experience with Diltiazem in the Treatment of Cardiovascular Diseases

The authors would like to thank Professor Halil Dogan (Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey) for informing them of the following error. The following sentence within the last paragraph of the ‘Diltiazem and Atrial Arrhythmias’ section, ‘‘A retrospective study evaluated 77 patients with supraventricular tachycardia treated with oral adenosine or intravenous diltiazem in the emergency department [21]’’, is incorrect. This sentence should read: ‘‘A retrospective study evaluated 77 patients with supraventricular tachycardia treated with intravenous adenosine or diltiazem in the emergency department [21]’’.

Clinical Experience with Diltiazem in the Treatment of Cardiovascular Diseases

Cardiovascular diseases are the leading cause of death in the world. Coronary artery diseases, atrial fibrillation or hypertensive heart disease, are among the most important cardiovascular disorders. Hypertension represents a significant risk factor for cardiovascular mortality; thus, control of high blood pressure has become a priority to prevent major complications. Although the choice of drugs for treating hypertension remains controversial, extensive clinical evidences point to calcium channel blockers as first-line agents. Diltiazem, a non-dihydropyridine calcium channel blocker, is an effective and safe antihypertensive drug, alone or in combination with other agents. Diltiazem lowers myocardial oxygen demand through a reduction in heart rate, blood pressure, and cardiac contractility, representing also a good alternative for the treatment of stable chronic angina. Furthermore, diltiazem reduces conduction in atrioventricular node, which is also useful for heart rate control in patients with atrial fibrillation. In this review, clinical experts highlight studies on diltiazem effectiveness and safety for the treatment of several cardiovascular diseases and make evidence-based recommendations regarding the management of diltiazem in the clinical practice.FundingLacer Spain.