Miquel Vives-Borrás

Electrophysiological Effects of Selective Atrial Coronary Artery Occlusion in Humans

Background— The arrhythmogenesis of ventricular myocardial ischemia has been extensively studied, but models of atrial ischemia in humans are lacking. This study aimed at describing the electrophysiological alterations induced by acute atrial ischemia secondary to atrial coronary branch occlusion during elective coronary angioplasty. Methods and Results— Clinical data, 12-lead ECG, 12-hour Holter recordings, coronary angiography, and serial plasma levels of high-sensitivity troponin T and midregional proatrial natriuretic peptide were prospectively analyzed in 109 patients undergoing elective angioplasty of right or circumflex coronary arteries. Atrial coronary branches were identified and after the procedure patients were allocated into two groups: atrial branch occlusion (ABO, n=17) and atrial branch patency (non-ABO, n=92). In comparison with the non-ABO, patients with ABO showed: (1) higher incidence of periprocedural myocardial infarction (20% versus 53%, P=0.01); (2) more frequent intra-atrial conduction delay (19% versus 46%, P=0.03); (3) more marked PR segment deviation in the Holter recordings; and (4) higher incidence of atrial tachycardia (15% versus 41%, P=0.02) and atrial fibrillation (0% versus 12%, P=0.03). After adjustment by a propensity score, ABO was an independent predictor of periprocedural infarction (odds ratio, 3.4; 95% confidence interval, 1.01–11.6, P<0.05) and atrial arrhythmias (odds ratio, 5.1; 95% confidence interval, 1.2–20.5, P=0.02). Conclusions— Selective atrial coronary artery occlusion during elective percutaneous transluminal coronary angioplasty is associated with myocardial ischemic damage, atrial arrhythmias, and intra-atrial conduction delay. Our data suggest that atrial ischemic episodes might be considered as a potential cause of atrial fibrillation in patients with chronic coronary artery disease.

Influence of the Extent of Coronary Atherosclerotic Disease on ST-Segment Changes Induced by ST Elevation Myocardial Infarction

The accuracy of the admission electrocardiogram (ECG) in predicting the site of acute coronary artery occlusion in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease is not well known. This study aimed to assess whether the presence of multivessel coronary artery disease (CAD) modifies the artery-related ST-segment changes in patients with acute coronary artery occlusion. We reviewed the admission ECG, clinical records, and coronary angiography of 289 patients with STEMI caused by acute occlusion of left anterior descending (LAD; n = 140), right (n = 118), or left circumflex (LCx; n = 31) coronary arteries. All patients underwent primary percutaneous coronary reperfusion during the first 12 hours. The magnitude and distribution of artery-related ST-segment patterns were comparable in patients with single (n = 149) and multivessel (n = 140) CAD. Occlusion of proximal (n = 55) or mid-distal (n = 85) LAD artery induced ST-segment elevation in leads V1 to V5, but only the proximal occlusion induced reciprocal ST-segment depression in leads II, III, and aVF (p <0.001). Proximal and mid-distal occlusion of right (n = 45 and 73, respectively) or LCx (n = 15 and 16) coronary artery always induced ST-segment elevation in leads II, III, and aVF and reciprocal ST-segment depression in leads V2 and V3. ST-segment elevation in lead V6 >0.1 mV predicted LCx artery occlusion. In conclusion, patients with STEMI with single or multivessel CAD have concordant artery-related ST-segment patterns on the admission ECG; in both groups, reciprocal ST-segment depression in LAD artery occlusion predicts a large infarct. Subendocardial ischemia at a distance is not a requisite for the genesis of reciprocal ST-segment changes.

Atrial coronary artery occlusion during elective percutaneous coronary angioplasty

BACKGROUND Atrial arteries arise from the right and left circumflex coronary arteries and they may be accidentally occluded during percutaneous coronary angioplasty; however, this complication is not well known. The aim of our study was to analyze the incidence and risk factors of accidental atrial branch occlusion (ABO) during elective angioplasty. METHODS AND MATERIALS Clinical records and coronary angiography of 200 patients undergoing elective angioplasty were retrospectively analyzed. Atrial branches were identified and in each vessel we measured the luminal diameter, flow grade, and the location of atherosclerotic plaques. Patients were allocated either into the ABO group if atrial branch flow fell from TIMI grades 2-3 to 0-1 after procedure or in the non-ABO group if TIMI flow was preserved. RESULTS Atrial branch occlusion occurred in 43 (21.5%) patients. The atrial branch diameter was larger in non-ABO than in ABO group (1.29mm, SD 0.33 versus 0.97mm, SD 0.22, p=<0.0001). Plaques at atrial branch origin were present in 93% of ABO group, only in 31.8% of non-ABO (p≤0.0001). Predictors of ABO were a cut-off vessel diameter of 1.00mm (ROC 77% sensitivity and 67.5% specificity, p≤0.0001), the presence of atherosclerotic plaque at the ostium of atrial branch and maximal inflation pressure during stenting. CONCLUSIONS The occurrence of ABO is frequent after elective angioplasty of right or circumflex coronary arteries in an experienced interventional center. Risk factors were the diameter and the presence of ostial plaques in the atrial branches, and the maximal inflation pressure during stenting.

Global Geriatric Assessment and In-Hospital Bleeding Risk in Elderly Patients with Acute Coronary Syndromes: Insights from the LONGEVO-SCA Registry

BACKGROUND Bleeding risk scores have shown a limited predictive ability in elderly patients with acute coronary syndromes (ACS). No study explored the role of a comprehensive geriatric assessment to predict in-hospital bleeding in this clinical setting. METHODS The prospective multicentre LONGEVO-SCA registry included 532 unselected patients with non-ST segment elevation ACS (NSTEACS) aged 80 years or older. Comorbidity (Charlson index), frailty (FRAIL scale), disability (Barthel index and Lawton-Brody index), cognitive status (Pfeiffer test) and nutritional risk (mini nutritional assessment-short form test) were assessed during hospitalization. CRUSADE score was prospectively calculated for each patient. In-hospital major bleeding was defined by the CRUSADE classification. The association between geriatric syndromes and in-hospital major bleeding was assessed by logistic regression method and the area under the receiver operating characteristic curves (AUC). RESULTS Mean age was 84.3 years (SD 4.1), 61.7% male. Most patients had increased troponin levels (84%). Mean CRUSADE bleeding score was 41 (SD 13). A total of 416 patients (78%) underwent an invasive strategy, and major bleeding was observed in 37 cases (7%). The ability of the CRUSADE score for predicting major bleeding was modest (AUC 0.64). From all aging-related variables, only comorbidity (Charlson index) was independently associated with major bleeding (per point, odds ratio: 1.23, p = 0.021). The addition of comorbidity to CRUSADE score slightly improved the ability for predicting major bleeding (AUC: 0.68). CONCLUSION Comorbidity was associated with major bleeding in very elderly patients with NSTEACS. The contribution of frailty, disability or nutritional risk for predicting in-hospital major bleeding was marginal.

Prognostic Impact of Physician Specialty on the Prognosis of Outpatients With Heart Failure: Propensity Matched Analysis of the REDINSCOR and RICA Registries

INTRODUCTION AND OBJECTIVES The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists. METHODS We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n=2150) or by internists (RICA, n=1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome. RESULTS Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P<.001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P=.349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P=.002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P=.695). CONCLUSIONS Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort.

PREVALENCE, CLINICAL PROFILE AND SHORT-TERM PROGNOSIS OF INTERATRIAL BLOCK IN PATIENTS ADMITTED FOR WORSENING OF HEART FAILURE

Interatrial block (IAB) is a poorly recognized cardiac rhythm disorder characterized by a prolonged P wave and associated with supraventricular arrhythmias. Our aim was to describe the prevalence, clinical profile and short-term prognosis of IAB in patients admitted for worsening of heart failure (

Summation and Cancellation Effects on QRS and ST-Segment Changes Induced by Simultaneous Regional Myocardial Ischemia

Simultaneous ischemia in two myocardial regions is a potentially lethal clinical condition often unrecognized whose corresponding electrocardiographic (ECG) patterns have not yet been characterized. Thus, this study aimed to determine the QRS complex and ST-segment changes induced by concurrent ischemia in different myocardial regions elicited by combined double occlusion of the three main coronary arteries. For this purpose, 12 swine were randomized to combination of 5-min single and double coronary artery occlusion: Group 1: left Circumflex (LCX) and right (RCA) coronary arteries (n = 4); Group 2: left anterior descending artery (LAD) and LCX (n = 4) and; Group 3: LAD and RCA (n = 4). QRS duration and ST-segment displacement were measured in 15-lead ECG. As compared with single occlusion, double LCX+RCA blockade induced significant QRS widening of about 40 ms in nearly all ECG leads and magnification of the ST-segment depression in leads V1–V3 (maximal 228% in lead V3, p < 0.05). In contrast, LAD+LCX or LAD+RCA did not induce significant QRS widening and markedly attenuated the ST-segment elevation in precordial leads (maximal attenuation of 60% in lead V3 in LAD+LCX and 86% in lead V5 in LAD+RCA, p < 0.05). ST-segment elevation in leads V7–V9 was a specific sign of single LCX occlusion. In conclusion, concurrent infero-lateral ischemia was associated with a marked summation effect of the ECG changes previously elicited by each single ischemic region. By contrast, a cancellation effect on ST-segment changes with no QRS widening was observed when the left anterior descending artery was involved.

Influence of sex and pregnancy on survival in patients admitted with heart failure: Data from a prospective multicenter registry

Female sex is an independent predictor of better survival in patients with heart failure (HF), but the mechanism of this association is unknown. On the other hand, pregnancies have a strong influence on the cardiovascular system.

Clinical and Prognostic Value of the Electrocardiogram in Patients With Acute Occlusion of the Left Circumflex Coronary Artery.

The utility of the electrocardiogram (ECG) in patients with acute left circumflex (LC) coronary occlusion is not established. This study aimed at determining the clinical, angiographic, and prognostic characteristics associated with the different patterns of ST-segment changes in patients with LC occlusion. A cohort of 314 patients with LC occlusion was categorized according to the admission ECG: (1) ST-segment elevation (ST-E, n=208), (2) isolated ST-segment depression in precordial leads (ST-D, n=62), and (3) negligible ST-segment changes (No-ST, n=44). Clinical variables, coronary angiography, and 30-day major adverse cardiac event (MACE) (in-hospital ventricular fibrillation, 1-month mortality, or heart failure) were compared among the three groups. As compared with No-ST, patients with ST-E or ST-D presented more advanced Killip class, higher troponin peak, lower LV ejection fraction, and were independently associated with MACE (odds ratio 5.43, 95% confidence interval 1.09 to 27.20 and odds ratio 3.39, 95% confidence interval 0.66 to 17.50, respectively). Patients with ST-D were tardily reperfused, had more often mitral regurgitation (23.1% vs 9.3% in ST-E and 3.3% in No-ST, p=0.03), and presented ST-segment elevation in leads V7 to V9 in 12 of 16 cases with available recordings. Culprit proximal LC predominated in ST-D (41.9%), distal LC in ST-E (42.8%), and obtuse marginal in No-ST (59.1%) (all p<0.01). The No-ST had smaller coronary vessels and more collaterals. In conclusion, the three ST-segment patterns of LC occlusion identify patients with different clinical, angiographic, and prognostic characteristics. Patients with ST-depression pattern require a prompt reperfusion therapy and could be better recognized by recording leads V7 to V9.

Response by Álvarez-García et al to Letters Regarding Article, "Electrophysiological Effects of Selective Atrial Coronary Artery Occlusion in Humans".

We thank Drs Ng and Efimov and Dr Baranchuk for their interest in our article1 and for addressing the mechanistic aspects of human atrial pathophysiology. On the basis of their own studies in human left ventricular wedge preparations,2,3 in their letter, Ng and Efimov raise a clinically relevant and plausible hypothesis that atrial ischemia might be more arrhythmogenic in the presence of heart failure. Unfortunately, our study cannot elucidate this assumption because, among our 17 patients with atrial coronary occlusion, only 2 presented with depressed (<45%) left ventricular ejection fraction and only 1 patient with overt heart failure. Therefore, in these circumstances, we could not appreciate an association between the …