Javier García-Seara

Clinical characteristics and prognosis of hospitalised inpatients with heart failure and preserved or reduced left ventricular ejection fraction.

Objective: To determine the clinical and prognostic differences between patients with heart failure who had preserved or deteriorated systolic function, defined as a left ventricular ejection fraction of > 50% or < 50%, respectively, within two weeks of admission to hospital. Methods: The records of 229 patients with congestive heart failure were studied. There were 95 women and 134 men, mean (SD) age 66.7 (11.7) years, who had been admitted to a cardiology department for congestive heart failure in the period 1991 to 1994, and whose left ventricular systolic function had been evaluated echocardiographically within two weeks of admission. Data were collected on the main clinical findings, supplementary investigations, treatment, and duration of hospital admission. Follow up information was obtained in the spring of 1998 by searching the general archives of the hospital and by a telephone survey. Results: Left ventricular systolic function was preserved in 29% of the patients. The preserved and deteriorated groups differed significantly in the sex ratio (more women in the preserved group) and in the presence of a third heart sound, cardiomegaly, alveolar oedema, ischaemic cardiomyopathy, and treatment with angiotensin converting enzyme (ACE) inhibitors (all more in the deteriorated group). There were no significant differences in age, New York Heart Association functional class, rhythm disturbances, left ventricular hypertrophy, treatment with drugs other than ACE inhibitors, or survival. In the group as a whole, the survival rates after three months, one year, and five years were 92.6%, 80%, and 48.4%, respectively. Conclusions: In view of the unexpectedly poor prognosis of patients with congestive heart failure and preserved left ventricular systolic function, controlled clinical trials should be carried out to optimise their treatment.

Prognostic impact of atrial fibrillation progression in a community study: AFBAR Study (Atrial Fibrillation in the Barbanza Area Study).

INTRODUCTION The aim of the study is to describe the natural history of an unselected population of patients with atrial fibrillation (AF) currently attending primary care services in a single health-service area in Galicia, north-western Spain. METHODS AFBAR is a transverse prospective study in which 35 general practitioners within one health-service area have enrolled patients diagnosed with AF who presented at their clinics during a three-month recruiting period. Primary endpoints are mortality or hospital admission. Here we report the results of the first 7-month follow-up period. RESULTS 798 patients (421 male) were recruited; mean age of cohort was 75 years old. Hypertension was the most prevalent risk factor (77%). 87% of the patients were both overweight and obese. Permanent AF was diagnosed in 549 patients (69%). In the follow-up period, 16.4% of the patients underwent a primary endpoint and the overall survival was 98%. The following independent determinants of primary endpoint were identified: change in AF status (Hazard Ratio (HR) 2.89 (95% confidence interval (CI) 1.28-6.55); p=0.011); ischemic heart disease (IHD) (HR 2.78 (95% CI 1.51-5.13); p=0.001); pre-recruitment hospital admission (HR 2.22 (95% CI 1.18-4.19); p=0.013); left ventricular systolic dysfunction (HR 2.19 (95% CI 1.11-4.32); p=0.023); or AF-related complications (HR 1.98 (95% CI 1.10-3.56); p=0.022). CONCLUSIONS In the first 7-month follow-up period of patients with AF in a primary care setting the study identified several independent risk factors for mortality or hospital admission, i.e. change in AF status, ischemic heart disease, left ventricular systolic dysfunction, previous AF-related complications and hospital admission.

Monomorphic ventricular tachycardia in patients with Brugada syndrome: A multicenter retrospective study

BACKGROUND Isolated cases of monomorphic ventricular tachycardia (MVT) in patients with Brugada syndrome (BrS) have been reported. OBJECTIVE We aimed to describe the incidence and characteristics of MVT in a cohort of patients with BrS who had received an implantable cardioverter-defibrillator (ICD). METHODS Data from 834 patients with BrS implanted with an ICD in 15 tertiary hospitals between 1993 and 2014 were included. RESULTS The mean age of enrolled patients was 45.3 ± 13.9 years; 200 patients (24%) were women. During a mean follow-up of 69.4 ± 54.3 months, 114 patients (13.7%) experienced at least 1 appropriate ICD intervention, with MVT recorded in 35 patients (4.2%) (sensitive to antitachycardia pacing in 15 [42.8%]). Only QRS width was an independent predictor of MVT in the overall population. Specifically, 6 (17.1%) patients presented with right ventricular outflow tract tachycardia (successfully ablated from the endocardium in 4 and epicardial and endocardial ablation in 1), 2 patients with MVT arising from the left ventricle (1 successfully ablated in the supra lateral mitral annulus), and 2 (5.7%) patients with bundle branch reentry ventricular tachycardia. Significant structural heart disease was ruled out by echocardiography and/or cardiac magnetic resonance imaging. CONCLUSION In this retrospective study, 4.2% of patients with BrS implanted with an ICD presented with MVT confirmed as arising from the right ventricular outflow tract tachycardia in 6, patients with MVT arising from the left ventricle in 2, and patients with bundle branch reentry ventricular tachycardia in 2. Endocardial and/or epicardial ablation was successful in 80% of these cases. These data imply that the occurrence of MVT should not rule out the possibility of BrS. This finding may also be relevant for ICD model selection and programming.

Outcomes of a Contemporary Sample of Patients With Atrial Fibrillation Taking Digoxin: Results From the AFBAR Study

INTRODUCTION AND OBJECTIVES We aimed to assess and compare the effect of digoxin on clinical outcomes in patients with atrial fibrillation vs those under beta-blockers or none of these drugs. METHODS AFBAR is a prospective registry study carried out by a team of primary care physicians (n=777 patients). Primary endpoints were survival, survival free of admission due to any cause, and survival free of admission due to cardiovascular causes. The mean follow up was 2.9 years. Four groups were analyzed: patients receiving digoxin, beta-blockers, or digoxin plus beta-blockers, and patients receiving none of these drugs. RESULTS Overall, 212 patients (27.28%) received digoxin as the only heart control strategy, 184 received beta-blockers (23.68%), 58 (7.46%) were administered both, and 323 (41.57%) received none of these drugs. Digoxin was not associated with all-cause mortality (estimated hazard ratio=1.42; 95% confidence interval, 0.77-2.60; P=.2), admission due to any cause (estimated hazard ratio=1.03; 95% confidence interval, 0.710-1.498; P=.8), or admission due to cardiovascular causes (estimated hazard ratio=1.193; 95% confidence interval, 0.725-1.965; P=.4). No association was found between digoxin use and all-cause mortality, admission due to any cause, or admission due to cardiovascular causes in patients without heart failure. There was no interaction between digoxin use and sex in all-cause mortality or in survival free of admission due to any cause. However, an association was found between sex and admission due to cardiovascular causes. CONCLUSIONS Digoxin was not associated with increased all-cause mortality, survival free of admission due to any cause, or admission due to cardiovascular causes, regardless of underlying heart failure.

Influencia del eje eléctrico QRS preimplante en la respuesta a la terapia de resincronización cardiaca

Introduccion y objetivos El objetivo del estudio es evaluar si el eje QRS puede ayudar a predecir el resultado en pacientes sometidos a terapia de resincronizacion cardiaca. Metodos Se ha incluido a 78 pacientes a los que se implanto con exito un dispositivo de resincronizacion. Los pacientes se clasificaron en eje normal (QRS entre −30° y +120°) y eje izquierdo (QRS entre −30° y −90°). Se considero respondedores a los pacientes que cumplian todos los criterios siguientes: mejorar al menos un grado en su clase funcional, aumentar al menos un 5% la fraccion de eyeccion del ventriculo izquierdo, no requerir hospitalizacion por insuficiencia cardiaca y seguir vivos a los 12 meses de seguimiento. Resultados Tras ajustar por edad, fraccion de eyeccion preimplante, etiologia e insuficiencia mitral, hemos encontrado una interaccion estadisticamente significativa (p = 0,026) entre el eje electrico y la localizacion del electrodo, con mejor respuesta en la localizacion anterior cuando el eje QRS era izquierdo. Conclusiones Se objetiva una interaccion entre la localizacion del electrodo y el eje electrico QRS preimplante, de tal forma que se observa una mejor respuesta a la terapia de resincronizacion en pacientes a quienes se implanta el electrodo en la vena interventricular anterior y el eje esta desviado a la izquierda.

Epidemiología de la fibrilación auricular y comorbilidades asociadas

If we leave to one side patients with atrial fibrillation due predominantly to an electrical mechanism, such as those with Wolff-Parkinson-White syndrome or atrial fibrillation induced by another tachycardia (e.g. tachycardia-induced tachycardia), in the majority of cases, atrial fibrillation is the final outcome of cardiovascular disease and cardiovascular risk factors that eventually lead to atrial fibrosis. The problem is that atrial fibrillation itself becomes established as an independent risk factor for morbidity and mortality. We need to increase our understanding of the epidemiology of atrial fibrillation, improve noninvasive techniques for identifying factors involved in the cardiovascular remodeling that promotes atrial fibrillation, and develop new animal models that will increase our knowledge of the pathophysiology of the condition in humans. Once atrial fibrillation has occurred, efforts should be aimed at preventing both its progression to a more persistent form and the development of its principal sequelae (i.e. heart failure and stroke). Although preventive strategies have a fundamental role to play in atrial fibrillation, and here atherosclerosis could provide a model, there is also scope for substantial improvements in the treatment of patients with clinically significant atrial fibrillation, especially those with heart failure or a high risk of thromboembolic disease. This article contains a review of the epidemiology of atrial fibrillation, its associated comorbid conditions and preventive strategies and treatment.

Initial experience and treatment of atrial fibrillation using a novel irrigated multielectrode catheter: Results from a prospective two-center study

PV electrical isolation has become the cornerstone of catheter ablation for the treatment of atrial fibrillation (AF). Several strategies have been proposed to achieve this goal. The aim of this study was to assess the efficacy and safety of AF ablation using a new circular irrigated multielectrode ablation catheter designed to achieve single‐delivery pulmonary vein (PV) isolation.

Long-term prognosis of patients with life-threatening ventricular arrhythmias induced by coronary artery spasm

Aims Coronary artery spasm (CAS) is associated with ventricular arrhythmias (VA). Much controversy remains regarding the best therapeutic interventions for this specific patient subset. We aimed to evaluate the clinical outcomes of patients with a history of life-threatening VA due to CAS with various medical interventions, as well as the need for ICD placement in the setting of optimal medical therapy. Methods and results A multicentre European retrospective survey of patients with VA in the setting of CAS was aggregated and relevant clinical and demographic data was analysed. Forty-nine appropriate patients were identified: 43 (87.8%) presented with VF and 6 (12.2%) with rapid VT. ICD implantation was performed in 44 (89.8%). During follow-up [59 (17-117) months], appropriate ICD shocks were documented in 12. In 8/12 (66.6%) no more ICD therapies were recorded after optimizing calcium channel blocker (CCB) therapy. SCD occurred in one patient without ICD. Treatment with beta-blockers was predictive of appropriate device discharge. Conversely, non-dihydropyridine CCB therapy was significantly protective against VAs. Conclusion Patients with life-threatening VAs secondary to CAS are at particularly high-risk for recurrence, especially when insufficient medical therapy is administered. Non-dihydropyridine CCBs are capable of suppressing episodes, whereas beta-blocker treatment is predictive of VAs. Ultimately, in spite of medical intervention, some patients exhibited arrhythmogenic events in the long-term, suggesting that ICD implantation may still be indicated for all.

Influence of the Preimplantation QRS Axis on Responses to Cardiac Resynchronization Therapy

INTRODUCTION AND OBJECTIVES The aim of this study was to determine whether measurement of the QRS axis can help to predict outcome in patients undergoing cardiac resynchronization therapy. METHODS The study included 78 patients who had undergone successful cardiac resynchronization device implantation. Patients were classified as having either a normal QRS axis (i.e., between -30 degrees and +120 degrees) or a left QRS axis deviation (i.e., between -30 degrees and -90 degrees). Patients were regarded as responders if they fulfilled all of the following criteria: their functional class improved by at least one grade, their left ventricular ejection fraction increased by at least 5%, they did not need hospitalization for worsening heart failure, and they were still alive at 12-month follow-up. RESULTS After adjustment for age, preimplantation left ventricular ejection fraction, etiology and mitral regurgitation, a statistically significant interaction was found between the QRS axis and lead location (P=.026). There was a better response with an anterior lead location if the patient had a left QRS axis deviation. CONCLUSIONS A significant interaction was found between the lead location and the preimplantation QRS electrical axis, such that there was a better response to resynchronization therapy when the lead was implanted in the anterior interventricular vein if the patient had a left QRS axis deviation.

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.