Joel Salazar-Mendiguchía

Impacto en tiempos de actuación y perfil de los pacientes tratados con angioplastia primaria en el área metropolitana sur de Barcelona al implantar el programa Código Infarto

INTRODUCTION AND OBJECTIVES A standardized protocol of emergent transfer for primary percutaneous coronary intervention for patients with ST elevation myocardial infarction, defined as the Infarction Code, was implemented in June 2009 in the Catalan regional health system. The objective of this study was to evaluate the impact of the new protocol on delay times, number of procedures and clinical characteristics compared with the previous period in the population of patients referred to our hospital. METHODS All consecutive patients undergoing primary percutaneous coronary intervention in our hospital were prospectively registered. The clinical characteristics, delay times and mortality in the follow-up of the protocol implementation period (June 2009-May 2010) were analyzed and compared with the previous year (June 2008-May 2009). RESULTS During the protocol period, 514 patients were included, compared with 241 in the previous year. Age, cardiovascular risk factors, anterior myocardial infarction and procedure characteristics were similar in the 2 groups. The first medical contact to balloon time was lower in the protocol period (median time 120 min vs 88 min; P<.001). Patients in the protocol period showed a trend toward less severe disease (Killip III, rescue angioplasty). The multivariate regression analysis showed a significant association between 1-year mortality and age, Killip class ≥ III at admission, anterior infarction and 3-vessel disease. CONCLUSIONS The introduction of the Infarction Code program increased the number of patients treated by primary percutaneous coronary intervention with a reduction in delay times and better clinical characteristics at presentation. Full English text available from:www.revespcardiol.org.

CRUSADE bleeding risk score validation for ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention

INTRODUCTION The CRUSADE bleeding risk score (CBRS) accurately predicts major bleeding in non-ST segment elevation myocardial infarction NSTEMI patients. However, little information exists about its application in ST segment elevation myocardial infarction STEMI. We aimed to assess the ability of CBRS to predict in-hospital major bleeding in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). MATERIALS AND METHODS We prospectively analyzed consecutive STEMI patients undergoing PPCI. Baseline characteristics, in-hospital complications and mid term mortality were recorded. Major bleeding was defined by the CRUSADE definition. Predictive ability of the CBRS was assessed by logistic regression method and the area under the ROC curve (AUC). RESULTS We included 1064 patients (mean age 63years). Mean CBRS value was 24. Most of patients (740/1064 (69.6%)) were in the two lowest risk quintiles of CBRS. Incidence of in-hospital major bleeding was 33/1064 (3.1%). The rates of in-hospital bleeding across the quintiles of risk groups were 0.4% (very low risk), 2.6% (low), 4.6% (moderate), 7.2% (high), and 13.4% (very high) (p 0.001). AUC was 0.80 (95% CI 0.73-0.87 p 0.001). In patients with radial access angiography (n=621) AUC was 0.81 (95% CI: 0.65-0.97). Mean follow up was 344days. Patients with bleeding events had higher mortality during follow up (HR 6.91; 95% CI 3.72-12.82; p 0.001). CONCLUSIONS Our patients had a significantly lower bleeding risk as compared to CRUSADE NSTEMI population. CBRS accurately predicted major in-hospital bleeding in this different clinical scenario, including patients with radial artery approach.

Idiopathic Restrictive Cardiomyopathy Is Primarily a Genetic Disease.

Restrictive cardiomyopathy (RCM) is characterized by restrictive ventricular physiology in the presence of normal diastolic volume and normal ventricular wall thickness [(1)][1]. RCM is the least common cardiomyopathy and its prevalence is unknown [(1,2)][1]. Furthermore, its etiology could be

Anthracycline-mediated cardiomyopathy: Basic molecular knowledge for the cardiologist

Anthracyclines are cytostatic antibiotics discovered almost half a century ago exerting their action through inhibition of topoisomerase II. The two most representative drugs are doxorubicin and daunorubicin and they have been proven as useful antineoplastics and are widely prescribed in daily oncology practice; unfortunately, cardiotoxicity has been a limiting factor when it comes to their use. Diverse mechanisms have been involved in anthracycline cardiotoxicity, none of which are capable of causing the whole clinical picture by itself. Traditionally, reactive oxygen species (ROS) have received more attention, although recently basic research has proven other factors to be as important as ROS. These factors mainly involve sarcomeric structure disruption, toxic accumulation of metabolites, iron metabolism, energetic alterations and inflammation. The role of genetics has been studied by some groups, although a clear genotype-response relationship is yet to be elucidated. With the improved survival from different oncologic diseases we are witnessing more cases of chemotherapy-induced cardiotoxicity and the advent of new anticancer drugs poses several challenges for the cardiologist, highlighting the importance of a deep knowledge of the main mechanisms inducing this toxicity.

Impact of Anaemia on Mortality and its Causes in Elderly Patients with Acute Coronary Syndromes

BACKGROUND Prognostic impact of anaemia in the elderly with acute coronary syndromes has not been specifically analysed, and little information exists about causes of mortality in this setting. METHODS We prospectively included consecutive patients with acute coronary syndromes. Anaemia was defined as haemoglobin < 130 g/L in men, and < 120 g/L in women. Primary outcome was mid-term mortality and its causes. Analyses were performed by Cox regression method. RESULTS We included 2128 patients, of whom 394 (18.6%) were aged 75 years or older. Anaemia was more common in the elderly (40.4% vs 19.5%, p <0.001). Mean follow-up was 386 days. Anaemia independently predicted overall mortality (HR 1.47, 95% CI 1.05-2.06), cardiac mortality (HR 1.76, 95% CI 1.06-2.94) and non-cardiac mortality (HR 1.59, 95% CI 1.03-2.45) in the overall cohort. In young patients the association between anaemia and mortality was significant only for non-cardiac causes. The association between anaemia and mortality was not significant in the elderly (HR 1.08, 95% CI 0.71-1.63, p 0.736). CONCLUSIONS The impact of anaemia on cause specific of mortality seem to be different according to age subgroup. The association between anaemia and mortality was not observed in elderly patients from our series.

Renal Function Improvement After Conversion to Proliferation Signal Inhibitors During Long-Term Follow-up in Heart Transplant Recipients

INTRODUCTION The use of proliferation signal inhibitors (PSIs) for calcineurin-inhibitor (CNI) minimization or conversion protocols has been promoted for heart transplantation (HT) in the contexts of renal insufficiency, cardiac allograft vasculopathy (CAV), or malignancy. We evaluated our experience with conversion of patients from a CNI-based to a PSI-based immunosuppressive regimen. We focused on improvement in renal function. METHODS This prospective follow-up included 96 HT patients converted to a PSI-based regimen from 2001 to 2010. We evaluated changes in creatinine clearance (CrCl) prior to at 1 year and at the end of follow-up after conversion. RESULTS Ninety-six patients including 86% men showed a mean age of 62 ± 8 years. They were converted to a PSI-based regimen at 6.3 ± 4 years post-HT due to the following causes: CNI toxicity (45%), CAV (16%), cancer (16%), CNI toxicity + CAV (17%), or CNI toxicity + cancer (6%). CNI withdrawal was achieved in 77 cases (80%) and minimization in 19 (20%). Everolimus was used in 54 (56%) and sirolimus in 42 (44%) cases. Median follow-up time was 3.8 years. PSI discontinuation due to side effects was common (38%). There were 43 deaths mainly due to cancer and CAV. CrCl improved albeit not significantly in the withdrawal group from a median of 51 mL/min preconversion to 59 mL/min at the last follow-up (P = .12). In the minimization group, median CrCl worsened from a median of 61 mL/min preconversion to 51 mL/min at the last follow-up (P = .001). In the 58 cases (61%) of CNI nephrotoxicity, median CrCl improved from a median of 41 mL/min preconversion to 49 mL/min at the last follow-up (P = .04). CONCLUSION Despite high rates of discontinuation of PSIs during long-term follow-up, the conversion regimen seemed to be useful to diminish CNI-related renal insufficiency especially with CNI withdrawal.

Genetic Etiology for Alcohol-Induced Cardiac Toxicity

Background Alcoholic cardiomyopathy (ACM) is defined by a dilated and impaired left ventricle due to chronic excess alcohol consumption. It is largely unknown which factors determine cardiac toxicity on exposure to alcohol. Objectives This study sought to evaluate the role of variation in cardiomyopathy-associated genes in the pathophysiology of ACM, and to examine the effects of alcohol intake and genotype on dilated cardiomyopathy (DCM) severity. Methods The authors characterized 141 ACM cases, 716 DCM cases, and 445 healthy volunteers. The authors compared the prevalence of rare, protein-altering variants in 9 genes associated with inherited DCM. They evaluated the effect of genotype and alcohol consumption on phenotype in DCM. Results Variants in well-characterized DCM-causing genes were more prevalent in patients with ACM than control subjects (13.5% vs. 2.9%; p = 1.2 ×10−5), but similar between patients with ACM and DCM (19.4%; p = 0.12) and with a predominant burden of titin truncating variants (TTNtv) (9.9%). Separately, we identified an interaction between TTN genotype and excess alcohol consumption in a cohort of DCM patients not meeting ACM criteria. On multivariate analysis, DCM patients with a TTNtv who consumed excess alcohol had an 8.7% absolute reduction in ejection fraction (95% confidence interval: −2.3% to −15.1%; p < 0.007) compared with those without TTNtv and excess alcohol consumption. The presence of TTNtv did not predict phenotype, outcome, or functional recovery on treatment in ACM patients. Conclusions TTNtv represent a prevalent genetic predisposition for ACM, and are also associated with a worse left ventricular ejection fraction in DCM patients who consume alcohol above recommended levels. Familial evaluation and genetic testing should be considered in patients presenting with ACM.

Invasive mechanical ventilation in acute coronary syndromes in the era of percutaneous coronary intervention

Background: Percutaneous coronary intervention (PCI) improves prognosis in patients with acute coronary syndromes (ACS) reducing ischaemic complications and the development of heart failure, thus potentially changing invasive mechanical ventilation (IMV) requirements. Little information exists about patients with ACS requiring IMV in the current era. We aimed to analyze IMV requirements and characteristics of ACS patients treated under current recommendations (including a high rate of PCI). Methods: Baseline characteristics, indications for IMV, management and in-hospital and mid-term clinical course were analyzed prospectively in a consecutive series of patients with ACS admitted to a tertiary care hospital. Results: We included 1821 patients, of which 106 (5.8%) required IMV. Mean follow-up was 347 days. PCI was performed in 84% of cases. Patients with IMV had more comorbidities, worse left ventricular function and more unstable hemodynamic parameters on admission. In-hospital mortality in patients requiring IMV was 29%. These patients also had higher mid-term mortality (hazard ratio (HR) 6.58; 95% confidence interval (CI) 4.49−9.64; p 0.001). The most common indication for IMV was cardiopulmonary arrest (CA) (65; 61%), followed by pulmonary oedema (27; 26%) and shock (14; 13.2%). Patients with CA were younger, with better hemodynamic parameters at admission, more favourable coronary anatomy and higher rates of PCI. There were no significant differences in overall mortality between the three groups. The main cause of death in CA patients was persistent vegetative state. Conclusions: Mortality in patients with ACS requiring IMV remained high despite a high rate of PCI. Baseline characteristics, management and clinical course were different according to the reason for IMV. The most common cause for IMV requirement was CA.

Predictive ability of bleeding risk scores in the routine clinical practice

Background: Previous predictive models of bleeding in acute coronary syndromes (ACSs) used different definitions of bleeding and some of them come from populations lacking important predictors of haemorrhagic complications. Our group previously developed a predictive model of bleeding (PMB), including clinically meaningful variables, providing an optimal predictive ability. We aimed to compare the ability of this PMB with the main available bleeding risk scores for predicting major bleeding according to different definitions in non-selected ACS patients from daily clinical practice. Methods: All ACS patients admitted to the Coronary Care Unit were prospectively included. CRUSADE, Mehran and ACTION bleeding risk scores were calculated for each patient. In-hospital bleeding was recorded using the CRUSADE, TIMI, Mehran, ACTION and BARC definitions. For reasons of clinical relevance, BARC 3 and 5 categories were considered severe BARC bleeding for this study. The predictive ability of the PMB and other bleeding risk scores was assessed by binary logistic regression, ROC curves and areas under the curves (AUCs). Results: We included 1976 patients. Mean age was 62.1 years. Almost all patients underwent angiography, 65% of them by the radial approach. The incidence of major bleeding was: CRUSADE bleeding 3.9% (77/1976); Mehran bleeding 4.8% (94/1976); ACTION bleeding 3.9% (78/1976); and BARC 3/5 bleeding 2.4% (48/1976). The PMB showed the best ability for predicting major bleeding regardless of the definition used. The differences were specially significant for predicting BARC 3/5 bleeding (AUC: PMB 0.87, Mehran score 0.68, CRUSADE score 0.70 and ACTION score 0.70). The predictive ability of CRUSADE, ACTION and Mehran scores was similar for all the definitions analysed. Conclusions: Current bleeding risk scores showed a similar predictive ability for major bleeding regardless of the definitions used. Including other clinically meaningful predictors of bleeding into the new PMB significantly improved its predictive ability in the clinical scenario of ACS.

Is it possible to separate ischemic and bleeding risk in patients with non-ST segment elevation acute coronary syndromes?

nade. Color Doppler-flow examination revealed flow within the anterior portion of the pericardial effusion directed toward the right ventricle in systole and toward the right atrium in diastole. No communication with the right atrium or right ventricle was seen [1]. The intrapericardial flow pattern could also be demonstrated by pulsed-wave Doppler examination. The authors hypothesize that in their case, probably secondary to anticoagulation, the viscosity of the pericardial fluid was low enough to demonstrate, by way of fluid shifts within the confines of the pericardium, the changes of volume and pressure of the heart chambers throughout the cardiac cycle. Nevertheless, the small amount of effusion can be commonly seen in post-radiofrequency ablation, which should be general fluid without red blood cells and could not generate Doppler signal. In our case, the patient has only a small amount pericardial effusion. The flow was clearly demonstrated by color and pulse Doppler which might be due to mild injury around the pulmonary vein during radiofrequency ablation operation. The absence of red blood cells prevents the reflection of the ultrasound beam and, therefore, generates a Doppler signal. This case indicated that in patients with pericardial effusion postprocedure, we should pay more attention to find if there is any flow signal by color and pulse Doppler, which can early detect the communication between chambers and pericardium.