José Moreno-Arribas

Quality of Anticoagulation With Vitamin K Antagonists

Vitamin K antagonists (VKA) have a narrow therapeutic range, and literature analysis reveals poor quality of anticoagulation control. We sought to assess the prevalence of poor anticoagulant control in patients under VKA treatment in the prevention of stroke for atrial fibrillation (AF).

Las concentraciones bajas de colesterol unido a las lipoproteínas de alta densidad se asocian de manera independiente a enfermedad coronaria aguda en pacientes que ingresan por dolor torácico

INTRODUCTION AND OBJECTIVES The role of high-density lipoproteins in the context of acute chest pain has not been well characterized. The objective of this study was to determine the relative contribution of lipid profile to the risk of acute coronary syndrome in patients admitted to a cardiology ward for chest pain. METHODS We included all consecutive admissions in a single cardiology department over a period of 10 months and 1-year follow-up was performed. RESULTS In total, 959 patients were included: 457 (47.7%) were diagnosed with non-ischemic chest pain, 355 (37%) with non-ST-elevation acute coronary syndrome, and 147 (15.3%) with ST-elevation acute coronary syndrome. Prevalence of high-density lipoproteins <40 mg/dL was 54.6%, and was higher in patients with acute coronary syndrome (69.4% vs 30.6%; P<.01). The prevalence of acute coronary syndrome increased with reductions in mean high-density lipoproteins. Age, active smoking, diabetes, fasting glucose >100 mg/dL, and high-density lipoproteins <40 mg/dL were independently associated with acute coronary syndrome, and low high-density lipoproteins was the main associated factor (odds ratio, 4.11; 95% confidence interval, 2.87-5.96). Survival analysis determined that, compared with non-ischemic chest pain, the presence of acute coronary syndrome was associated with significantly greater risk of all-cause and cardiovascular mortality. CONCLUSIONS Low levels of high-density lipoproteins cholesterol (≤40 mg/dL) were independently associated with a diagnosis of acute coronary syndrome in patients hospitalized for chest pain, with an inverse relationship between lower levels of high-density lipoproteins and prevalence of acute coronary syndrome.

Choice of New Oral Anticoagulant Agents Versus Vitamin K Antagonists in Atrial Fibrillation FANTASIIA Study

Introduction: Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. Many patients with AF receive chronic anticoagulation, either with vitamin K antagonists (VKAs) or with non-VKA oral anticoagulants (NOACs). We sought to analyze variables associated with prescription of NOAC. Methods: Patients with AF under anticoagulation treatment were prospectively recruited in this observational registry. The sample comprised 1290 patients under chronic anticoagulation for AF, 994 received VKA (77.1%) and 296 NOAC (22.9%). Univariate and multivariate analyses were performed to identify variables associated with use of NOAC. Results: Mean age was 73.8 ± 9.4 years, and 42.5% of the patients were women. The CHA2DS2-VASc score was 0 in 4.9% of the population, 1 in 24.1%, and ≥2 in 71% (median = 4, interquartile range = 2). Variables associated with NOAC treatment were major bleeding (odds ratio [OR] = 3.36; confidence interval [CI] 95%: 1.73-6.51; P < .001), hemorrhagic stroke (OR = 3.19; CI 95% 1.00-10.15, P = .049), university education (OR = 2.44; CI 95%: 1.55-3.84; P < .001), high diastolic blood pressure (OR = 1.02; CI 95%: 1.00-1.03; P = .006), and higher glomerular filtration rate (OR 1.01, CI 95% 1.00-1.01; P = .01). And variables associated with VKA use were history of cancer (OR = 0.46; CI 95%: 0.25-0.85; P = .013) and bradyarrhythmia (OR = 0.40; CI 95% 0.19-0.85; P = .020). Conclusion: Medical and social variables were associated with prescription of NOAC. Major bleeding, hemorrhagic stroke, university education, and higher glomerular filtration rate were more frequent among patients under NOAC. On the contrary, patients with history of cancer or bradyarrhythmias more frequently received VKA.

Anticoagulation prescription in atrial fibrillation

Aims: We seek to assess the factors associated with the anticoagulation prescription in a cohort of patients with atrial fibrillation (AF) collected from out-patient clinics. Methods: A total of 1524 patients with a history of AF were collected from out-patients clinics. CHADS2, CHA2DS2-VASc and HAS-BLED scores were calculated in every patient. Variables associated with anticoagulant treatment prescription were analyzed in univariant and multivariant models. Results: Most patients received either anticoagulant (62%) or antiplatelet treatment (37%). Anticoagulation rates increased among higher CHADS2 and CHA2DS2-VASc score values. A logistic regression model was performed to assess the variables associated with the prescription of anticoagulant treatment; the variables with stronger association were the presence of arrhythmia at the current visit (odds ratio (OR) 33, 95% CI 27 – 40, p < 0.001) and lack of concomitant antiplatelet treatment (OR 0.17, 95% CI 0.14 – 0.21, p < 0.001). Conclusions: Although prognosis of patients with AF is mainly determined by the long-term thrombotic risk, the prescription of antithrombotic therapy depends more on the bleeding risk and the immediate thrombotic risk perception.

Burden of systemic hypertension in patients admitted to cardiology hospitalization units.

Hypertension is 1 of the most prevalent cardiovascular risk factors; nevertheless, some studies have reported that the antecedent of hypertension does not impair prognosis in patients with established cardiovascular disease. The objective of this study was to describe the impact of hypertension on readmission and 1-year mortality in patients admitted to a single cardiology hospitalization unit. All consecutive hospitalizations in a single cardiology department through 10 months were included, and 1-year follow-up was performed. Clinical antecedents, risk factors, and main discharge diagnoses were collected. A total of 1,007 patients were included (mean age 71.1 ± 13.5 years). The antecedent of hypertension was present in 69.0%, and these patients had older mean age and higher prevalence of risk factors and previous cardiovascular disease. No differences in hospital discharge main diagnoses were observed according to the antecedent of hypertension. During a mean follow-up period of 404.82 ± 122.2 days, patients with hypertension had higher rates of rehospitalization for cardiac causes (31.1% vs 17.9%, p = 0.01) and of total (17.4% vs 9.3%, p <0.01) and cardiovascular (13.9% vs 5.9%, p <0.01) mortality. Multivariate analysis identified the antecedent of hypertension as an independent risk factor for cardiovascular readmission (hazard ratio 1.46, 95% confidence interval 1.10 to 1.98) and the combined end point of readmission or mortality (hazard ratio 1.45, 95% confidence interval 1.12 to 1.88); no independent association was observed for total mortality. In conclusion, hypertension was present in most patients admitted to a cardiology unit, and they had higher rates of rehospitalization and mortality at 1-year follow-up.

Trends in clinical profile and medical treatments of atrial fibrillation patients over the last 10 years

AIM We sought to define trends in AF prevalence and its medical management using recent data based on data from two cross-sectional studies performed in a European country in 1999 and 2009. METHODS CARDIOTENS 1999 and CARDIOTENS 2009 were two observational, cross-sectional, multicenter studies. Patients were recruited in from primary care and cardiology outpatient clinics. A total of 32 051 and 25 137 subjects were analyzed in the two studies, 1540 and 1524 of them, respectively, diagnosed with AF. RESULTS Over the course of the study period there was an increase in the prevalence of AF (from 4.8% to 6.1%), mainly due to the higher prevalence of AF in patients aged over 70 years (24.7% vs. 37.1%). Furthermore, patients with AF had a higher prevalence of hypertension (64.9% vs. 87.0%), diabetes (19.0% vs. 37.4%), heart failure (30.8% vs. 34.8%), coronary artery disease (23.0% vs. 25.8%) and previous stroke (1.5% vs. 8.9%). An overall increase in prescription of antithrombotic/antiplatelet therapy was observed (33.0% vs. 62.7% and 31.0% vs. 38.2% respectively); the difference observed in 1999 between prescription of oral anticoagulation by general practitioners and cardiologists was not seen in the later study. Differences in prescription of angiotensin-converting enzyme inhibitors (28.0% vs. 40.7%), angiotensin receptor blockers (10.0% vs. 40.0%), beta-blockers (14.0% vs. 41.5%) and calcium channel blockers (21.0% vs. 34.9%) were also identified. CONCLUSIONS The number of patients with AF and a higher risk for thromboembolic events increased over the last 10 years. More aggressive antithrombotic treatment has been observed, especially in older patients.

Comparison of Long-Term Mortality for Cardiac Diseases in Patients With Versus Without Diabetes Mellitus

Diabetes mellitus confers the highest mortality risk in primary and secondary cardiovascular prevention, but long-term prognosis differences between different forms of cardiovascular disease have not been assessed. We hypothesized that acute heart failure (HF) could have poorer outcomes than acute coronary heart disease (CHD) in patients with diabetes. We performed a prospective study of all consecutive patients admitted in a single year. Patients were categorized according to main cardiologic diagnosis: acute HF, acute CHD, rhythm disorders, or noncardiac disease. A total of 1,293 patients were included, 31.8% had diabetes and had higher mean age, more risk factors, previous cardiovascular disease, and co-morbidities. Hospital mortality (5.6% vs 1.7%; p <0.01) was higher in patients with diabetes. During follow-up (median 58.0 months; interquartile range 31.0 to 60.0), diabetic patients had higher cardiovascular mortality (27.2% vs 9.6%; p <0.01) and all-cause mortality (35.8% vs 14.5%; p <0.01); cardiovascular disease accounted for 75% of deaths. According to discharge diagnosis, patients with diabetes only had higher mortality rates in the subgroup of acute CHD. Acute HF was the diagnosis with higher cardiovascular (36.9%) and all-cause mortality (44.1%), followed by acute CHD (16.8% and 24.4%) and rhythm disorders (5.8% and 8.8%). Multivariate analysis identified an independent association with higher long-term mortality of acute HF and acute CHD in patients with and without diabetes. In conclusion, 1/3 of cardiology-admitted patients have diabetes and have poorer long-term prognosis, especially when discharged with the diagnosis of acute HF or acute CHD.

Analyses of inappropriate shocks in a Spanish ICD primary prevention population: Predictors and prognoses

BACKGROUND ICDs have been demonstrated to be highly effective in the primary prevention of sudden death, but inappropriate shocks (IS) occur frequently and represent one of the most important adverse effects of ICDs. The aim of this study was to analyze IS and identify the clinical predictors and prognostic implications of ISs in a real-world primary prevention ICD population. METHODS This multicenter retrospective study was performed in 13 centers with experience in the field of ICD implantation (at least 30 per year) and ICD follow-up in Spain. All consecutive patients who underwent ICD implantation for primary prevention between January 2008 and May 2014 were included. RESULTS One-thousand-sixteen patients were included, and 4 (0.39%) were lost to follow-up. Two-hundred-seventeen (21.4%) patients suffered from shock; 69 (6.8%) of these patients experienced IS, and 154 (15.4%) experienced appropriate shocks (AS). Age (<65 years, hazard ratio (HR) 2.588 [95% CI 1.282-5.225]; p=0.008), history of atrial fibrillation (HR 2.252 [95% CI 1.230-4.115]; p=0.009), non-ischemic myocardiopathy (HR 2.258 [95% CI 1.090-4.479]; p=0.028), and cardiac resynchronization therapy (HR 0.385 [95% CI 0.200-0.740]; p=0.004) were identified as IS predictors in a multivariate analysis. IS was not associated with rehospitalization due to heart failure, myocardial infarction, cardiovascular mortality or all-cause mortality. CONCLUSIONS This analysis of our national registry identified the independent IS predictors of age, atrial fibrillation history and cardiac resynchronization therapy and suggests that ISs are not linked to poorer clinical endpoints.

Differential Effect of β‐Blockers for Heart Rate Control in Coronary Artery Disease

Resting heart rate is an independent risk factor for cardiovascular disease and is mainly controlled by β‐blockers (BBs). BBs are part of the optimal medical treatment for coronary artery disease (CAD), and their benefit correlates with resting heart rate (RHR) reduction.

Time-to-Effect–Based Dosing Strategy for Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation: Results of the plusONE Multicenter Randomized Controlled Noninferiority Trial

Background The optimal dosage of cryotherapy during cryoballoon ablation of pulmonary veins is still unclear. This trial tested the noninferiority of a novel, individualized, cryotherapy-dosing strategy for each vein. Methods and Results This prospective, randomized, multicenter, noninferiority study included 140 patients with paroxysmal atrial fibrillation, which was refractory to antiarrhythmic drugs. Patients were randomly assigned to a conventional strategy of 180-second cryoballoon applications per vein with a bonus freeze (control group, n=70) or to a shorter-time application protocol, with 1 application that lasted the time required for electric block time to effect plus 60- and a 120-second freeze bonus (study group, n=70). Patients were followed with a long-term monitoring system of 30 days. At 1-year follow-up, no difference was observed in terms of free atrial fibrillation-recurrence rates: 79.4% in control versus 78.3% in study group (&Dgr;=1.15%; 90% confidence interval, −10.33% to 12.63%; P=0.869). Time to effect was detected in 72.1% of veins. The control and study groups had similar mean number of applications per patient (9.6±2 versus 9.9±2.4; P=0.76). Compared with controls, the study group had a significantly shorter cryotherapy time (28.3±7 versus 19.4±4.3 minutes; P<0.001), left atrium time (104±25 versus 92±23 minutes; P<0.01), and total procedure time (135±35 versus 119±31 minutes; P<0.01). No differences were observed in complications or acute reconnections. Conclusions The new time-to-effect–based cryotherapy dosage protocol led to shorter cryotherapy and procedure times, with equal safety, and similar acute and 1-year follow-up results, compared with the conventional approach. Clinical Trial Registration URL: https://clinicaltrials.gov. Unique identifier: NCT02789358.