Martín Ruiz Ortiz

Oral Anticoagulation in Nonvalvular Atrial Fibrillation in Clinical Practice: Impact of CHADS2 Score on Outcome

Objectives: CHADS2 score predicts embolic risk in patients with nonvalvular atrial fibrillation (NVAF), but also bleeding risk in patients receiving oral anticoagulation (OAC). Our objective is to analyze the effectiveness and safety of OAC in patients with NVAF in daily clinical practice, according to embolic risk evaluated by means of CHADS2 score. Methods: All consecutive outpatients with permanent NVAF seen at 2 cardiology clinics were prospectively followed for embolic events (transient ischemic attack, ischemic stroke, peripheral embolism) and severe bleedings. OAC was prescribed according to the recommendations of scientific associations. CHADS2 score was obtained for each patient. Results: From February 1, 2000 to July 31, 2003, 796 outpatients fulfilled the inclusion criteria. OAC was prescribed to 564 (71%) patients. After 2.4 ± 1.9 years of follow-up, the embolic event rates (per 100 patient-years) for each stratum of the CHADS2 score for patients with/without OAC were: 1/4.1, p = 0.23 (CHADS2 = 0); 0.6/7.1, p = 0.0018 (CHADS2 = 1); 0.5/5.1, p = 0.0014 (CHADS2 = 2); 2.4/12.5, p = 0.0017 (CHADS2 = 3) and 2.9/20, p = 0.013 (CHADS2 ≧4). The severe bleeding rates for the same CHADS2 score strata were 3/0.8, 0.8/0.7, 1.3/0.7, 0.4/0, and 2.9/5 in patients with/without OAC (n.s.). Conclusion: OAC is effective and safe in daily clinical practice in patients with NVAF and CHADS2 score ≧1.

Measurement of Aortic Valve Annulus Using Different Cardiac Imaging Techniques in Transcatheter Aortic Valve Implantation: Agreement with Finally Implanted Prosthesis Size

Aims: To compare the measurements of the aortic annulus obtained with various imaging techniques in patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation, and to determine the grade of agreement between the predicted size of the prosthesis for each technique, and the size of the finally implanted valve. Methods and results: The aortic annulus was measured in 40 patients treated by transcatheter aortic valve implantation (CoreValve aortic valve) with transthoracic (TTE) and transesophageal echocardiography (TEE), 64‐slice tomography, and angiography. A large valve was implanted when annulus was >23 mm and a small one if it was ≤23 mm. If the size of the prosthesis predicted by several techniques was not the same in one case, we selected the size in which more techniques presented agreement. Forty aortic valves, 26 small and 14 large, were implanted percutaneously. The best correlation was obtained with TTE and TEE (r = 0.93, P < 0.001). The correlation of TTE and TEE with angiography also was good (r = 0.58, P < 0.001 and r = 0.53, P < 0.001, respectively). Correlations between these techniques and computed tomography were poor (P = NS for all comparisons). The best agreement between estimated aortic annulus and implanted valve size was obtained with transtoracic and TEE (κ= 0.88 and 0.76). Conclusions: The aortic annulus measurements obtained by TTE, TEE, and angiography correlated well, while tomography correlated poorly with other techniques. The imaging techniques that showed the best agreement between estimated aortic annulus size and implanted aortic valve size were TTE and TEE. (Echocardiography 2011;28:388‐396)

Comparison of 1-Year Outcome in Patients With Severe Aorta Stenosis Treated Conservatively or by Aortic Valve Replacement or by Percutaneous Transcatheter Aortic Valve Implantation (Data from a Multicenter Spanish Registry)

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p <0.001). The 2 main reasons to choose conservative management were the absence of significant symptoms (136% to 29.1%) and the presence of co-morbidity (128% to 27.4%). During 1-year follow-up, 132 patients died (18.2%). The main causes of death were heart failure (60% to 45.5%) and noncardiac diseases (46% to 34.9%). One-year survival for patients treated conservatively, with TAVI, and with AVR was 76.3%, 94.9%, and 92.5%, respectively, p <0.001. One-year survival of patients treated conservatively in the absence of significant symptoms was 97.1%. In conclusion, most patients with severe AS are treated conservatively. The outcome in asymptomatic patients managed conservatively was acceptable. Management in tertiary hospitals is associated with valve intervention. One-year survival was similar with both interventional strategies.

Valor pronóstico de la frecuencia cardiaca en reposo en una población general de pacientes con cardiopatía isquémica crónica: un estudio prospectivo, monocéntrico de cohortes

Introduccion y objetivos Nuestro objetivo es evaluar el valor pronostico de la frecuencia cardiaca en reposo (FCr) en una poblacion general no seleccionada de pacientes con cardiopatia isquemica cronica (CIC). Metodos Del 1 de febrero de 2000 al 31 de enero de 2004, se incluyo prospectivamente a 1.264 pacientes ambulatorios con CIC, y se los siguio para eventos mayores (mortalidad, sindrome coronario agudo, revascularizacion coronaria, ictus e ingreso por insuficiencia cardiaca) para evaluar la asociacion de estos con la FCr (≥ 70 frente a Resultados La mediana [p25–p75] de edad fue 68 [60–74] anos, y 926 pacientes eran varones (73%); 645 pacientes (51%) presentaron una FCr ≥ 70 lat/min y 619 (49%), FCr Conclusiones La FCr no ha sido un factor pronostico adverso en esta muestra no seleccionada de pacientes con CIC. La importancia pronostica de la FCr en la practica clinica habitual podria ser baja en esta poblacion.

Predicting Embolic Events in Patients With Nonvalvular Atrial Fibrillation: Evaluation of the CHADS2 Score in a Mediterranean Population

INTRODUCTION AND OBJECTIVES A new index for predicting embolic risk in nonvalvular atrial fibrillation has been proposed, the CHADS2 score, which is calculated by adding 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes, and by adding 2 points for a history of stroke or transient ischemic attack (TIA). Our objective was to evaluate the use of this score in a Mediterranean population. METHODS Between February 1st, 2000 and December 20th, 2006, all patients with permanent nonvalvular atrial fibrillation being treated at two outpatient cardiology clinics in a university hospital in the south of Spain were offered antithrombotic therapy in accordance with scientific society recommendations and were prospectively monitored for embolic events (i.e., stroke, TIA or peripheral embolism). A CHADS2 score was derived for each of the 296 patients who did not receive anticoagulation. RESULTS The CHADS2 score was 0 in 69 (23.3%) patients, 1 in 81 (27.4%), 2 in 99 (33.4%), 3 in 30 (10.1%), and 4 or more in 17 (5.7%). After 21 (17) months of follow-up, the embolic event rates for CHADS2 scores of 0, 1, 2, 3, and > or =4 were 2.88, 5.80, 5.16, 14.78 and 22.02 per 100 patient-years, respectively (P=.0016). Patients with a CHADS2 score from 0-2 had an embolic rate of 4.63 per 100 patient-years, compared with 17.31 per 100 patient-years in those with a score > or =3 (P=.00087). CONCLUSIONS The CHADS2 score proved useful for quantifying the risk of an embolic event in Mediterranean patients with nonvalvular atrial fibrillation. In our series, the risk of embolism in patients with a low score was not negligible.

Short- and Long-Term Prognosis of Infective Endocarditis in Non-Injection Drug Users: Improved Results Over 15 Years (1987­2001)

Introduction and objectives The treatment of infective endocarditis has undergone significant change within the last few years. The aim of this study was to evaluate the clinical features and prognosis of infective endocarditis over both the short and long term in patients who are not intravenous drug users. Patients and method We carried out a prospective study of 222 consecutive patients who were diagnosed with infective endocarditis between 1987 and June 2001 at two centers. Results Their mean age was 48 (19) years, with 145 (65%) being male. Overall, 154 (69%) had native valve endocarditis and 68 (31%) had prosthetic valve endocarditis. In 61 patients (27%), no predisposing heart disease was found. Staphylococci were the causal microorganisms in 37% of cases (81 patients), and streptococci , in 35% (78 patients). Some 48% of patients underwent surgery during the active disease phase. Overall, inpatient mortality was 17% (39 cases); a significant decrease had occurred in recent years, from 25% in 1989–1995 to 12% in 1996–2001 (P Conclusions Short-and long-term prognoses for patients with infective endocarditis appear to have improved over recent years at our hospitals.

Impact of Asymptomatic Acute Cellular Rejection on Left Ventricle Myocardial Function Evaluated by Means of Two‐Dimensional Speckle Tracking Echocardiography in Heart Transplant Recipients

Our objective was to evaluate the impact of asymptomatic acute cellular rejection (ACR) in left ventricular myocardial strain in heart transplant (HT) recipients by means of two‐dimensional speckle tracking echocardiography (2DSTE).

Evolución clínica y reversibilidad de la disfunción sistólica en pacientes con miocardiopatía dilatada hipertensiva e insuficiencia cardíaca crónica

Introduccion y objetivos Hay poca informacion sobre la evolucion clinica y funcional de los pacientes con insuficiencia cardiaca secundaria a miocardiopatia dilatada de origen hipertensivo. Los objetivos de nuestro trabajo son estudiar la evolucion clinica y funcional de estos pacientes, asi como identificar los posibles factores predictores de esta evolucion. Pacientes y metodo Para ello, hemos evaluado a una serie de 57 pacientes diagnosticados en nuestro centro entre 1994 y 2003 con dicho problema. La edad media de los pacientes fue de 63 ± 11 anos, y el 40% eran mujeres. La fraccion de eyeccion ventricular izquierda era del 30,1 ± 4,8%. El tiempo de seguimiento fue de 45 ± 23 meses (mediana, 41 meses). Resultados La supervivencia a los 4 anos fue 0,84, la tasa de reingresos por insuficiencia cardiaca, 0,12 y la supervivencia libre de reingresos, 0,80. La fraccion de eyeccion aumento desde el 30,1 ± 4,8% hasta el 57,6 ± 13,5% (p Conclusiones La evolucion de los pacientes con miocardiopatia dilatada hipertensiva severa es buena en el 60% de los casos. El control de la presion arterial fue el unico predictor independiente de buena evolucion clinica.

Long-term survival in elderly patients with stable coronary disease

This study aimed to assess long‐term prognosis of stable coronary artery disease (sCAD) in patients aged ≥ 75 years and to identify clinical predictors of cardiovascular and overall mortality.

Clinical Outcome and Reversibility of Systolic Dysfunction in Patients With Dilated Cardiomyopathy Due to Hypertension and Chronic Heart Failure

Introduction and objectives. There is little information on the clinical and functional course of patients with heart failure secondary to dilated cardiomyopathy due to hypertension. The objectives of our study were to assess the clinical and functional course of these patients, and to identify possible predictors of prognosis. Patiens and method. We evaluated a series of 49 patients with this condition diagnosed in our hospital from 1994 to 2003. Mean age was 63 (11) years, and 40% were women. Left ventricular ejection fraction was 30.1 (4.8)%. Follow-up was 45 (23) months (median, 41 months). Results. Four-year survival was 0.84, the 4-year rate of hospitalization due to heart failure was 0.12, and likelihood of readmission-free survival was 0.80 at 4 years. Left ventricular ejection fraction increased from 30.1 (4.8)% to 57.6 (13.5)% (P<.001). An unfavorable clinical and functional outcome at 4 years (death, readmission for heart failure or persistence of dilated cardiomyopathy) was recorded in only in 40% of the patients. Multivariate analysis with the Cox model showed appropriate control of blood pressure to be the only independent predictor of a favorable clinical outcome (absence of death or readmission for heart failure) (hazard ratio = 4.58; 95% CI, 1.32-9.83; P=.032). Conclusions. The course of patients with severe dilated cardiomyopathy due to hypertension was favorable in 60% of cases. Adequate control of blood pressure was the only independent predictor of a favorable clinical outcome.