Pilar Cabanas-Grandío

Comparing the predictive validity of three contemporary bleeding risk scores in acute coronary syndrome

Aims: Haemorrhagic complications are strongly linked with adverse outcomes in acute coronary syndrome (ACS) patients. Various risk scores (RS) are available to predict bleeding risk in these patients. We compared the performance of three contemporary bleeding RS in ACS. Methods: We studied 4500 consecutive patients with ACS. We calculated the ACTION, CRUSADE, and Mehran et al. (2010) bleeding RS, and evaluated their performance for predicting their own major bleeding events and TIMI serious (major or minor) bleeding episodes, in patients with either non-ST-elevation ACS (NSTEACS) or ST-elevation myocardial infarction (STEMI). Calibration (Hosmer–Lemeshow test, HL) and discrimination (c-statistic) for the three RS were computed and compared. Results: For RS-specific major bleeding, ACTION and CRUSADE showed the best prognostic discrimination in STEMI (c=0.734 and 0.791, respectively; p=0.04), and in NSTEACS (c=0.791 and 0.810; p=0.4); being CRUSADE significantly superior to Mehran et al. in both ACS types (p<0.05). All RS performed well in patients undergoing coronary arteriography using either a radial or femoral approach (all c≥0.718); however, their discriminative capacity was modest in patients not undergoing coronary arteriography and in those previously on oral anticoagulant (all c<0.70). For TIMI serious bleeding, ACTION and CRUSADE displayed the highest c-index values in both STEMI (0.724 and 0.703, respectively; p=0.3) and NSTEACS (c=0.733 and 0.744, respectively; p=0.6); however, calibration of ACTION was poor in both ACS types (HL p<0.05). Conclusions: Of contemporary bleeding RS, the CRUSADE score was found to be the most accurate quantitative tool for NSTEACS and STEMI patients undergoing coronary arteriography.

Relative performance of three formulas to assess renal function at predicting in-hospital hemorrhagic complications in an acute coronary syndrome population. What does the new CKD-EPI formula provide?

Aims: Assessment of renal function is important for bleeding risk stratification in acute coronary syndrome (ACS). There are three formulas routinely used to assess renal function: the Cockroft-Gault (C-G) formula, the MDRD-4 formula and the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Our aim was to compare the ability of these formulas to predict the risk of in-hospital bleeding in patients with ACS. Methods: The study included 3270 patients with ACS. The performance of each formula with respect to in-hospital TIMI (Thrombolysis In Myocardial Infarction) major or TIMI minor bleeding were assessed using continuous data and by dividing patients into four subgroups according to the estimated glomerular filtration rate (eGFR): ≥90, 89–60, 30–59 and <30 ml/min/1.73m2. Results: Bleeding predictive ability was significantly higher for the C-G formula than for MDRD-4 and CKD-EPI formulas, as evaluated by the area under the curve (AUC); continuous eGFR AUCs: 0.73, 0.69 and 0.71, respectively; categorical eGFR AUCs: 0.71, 0.66 and 0.68, respectively. Net reclassification improvement based on the eGFR categories was significantly positively favored C-G: 9.5% (95% confidence interval (CI) 1.8–17.2%) and 19.1% (95% CI 11.3–26.9%) compared with CKD-EPI and MDRD-4, respectively. After multivariable adjustment, the C-G formula predicted in-hospital bleeding better than MDRD-4 formula (severe renal dysfunction vs. normal renal function: odds ratio 7.98, 95% CI 2.61–24.38 with C-G; odds ratio 3.76, 95% CI 1.63–8.69 with MDRD-4; and odds ratio 5.77, 95% CI 2.18–15.24 with CKD-EPI. Conclusions: Our findings suggest that the C-G eGFR may improve risk prediction of in-hospital bleeding more than the MDRD-4 equation and the new CKD-EPI equation in patients with ACS.

Creatinine-or cystatin C-based equations to estimate glomerular filtration rate in acute myocardial infarction: A disparity in estimating renal function and in mortality risk prediction

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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.

Remodelado cardiaco inverso estructural y funcional en pacientes con aleteo auricular típico sometidos a ablación del istmo cavotricuspídeo

INTRODUCTION AND OBJECTIVES The purpose of the present study is to determine the structural and functional cardiac changes that occur in patients at 1-year follow-up after ablation of typical atrial flutter. METHODS We enrolled 95 consecutive patients referred for cavotricuspid isthmus ablation. Echocardiography was performed at ≤6h post-procedure and 1-year follow-up. RESULTS Of 95 patients initially included, 89 completed 1-year follow-up. Hypertensive cardiopathy was the most frequently associated condition (39%); 24% of patients presented low baseline left ventricular systolic dysfunction. We observed a significant reduction in right and left atrial areas, end-diastolic and end-systolic left ventricular diameters, and interventricular septum. We observed substantial improvement in right atrium contraction fraction and left ventricular ejection fraction, and a reduction in pulmonary hypertension. Changes in diastolic dysfunction pattern were observed: 60% of patients progressed from baseline grade III to grade I; at 1-year follow-up, this improvement was found in 81%. We found no structural differences between paroxysmal and persistent atrial flutter at baseline and 1-year follow-up, exception for basal diastolic function. CONCLUSIONS In patients with typical atrial flutter undergoing cavotricuspid isthmus catheter ablation, we found inverse structural and functional cardiac remodeling at 1-year follow-up with much improved left ventricular ejection fraction, right atrium contraction fraction, and diastolic dysfunction pattern. Full English text available from:www.revespcardiol.org.

La enfermedad polivascular aterotrombótica: un enemigo común y distintos frentes

La aterotrombosis es un proceso sistemico, progresivo, con una etiopatogenia comun que afecta a diferentes lechos vasculares y cuyas principales manifestaciones clinicas dependen del territorio mas gravemente afectado. Sin embargo, la practica clinica confirma el caracter multisistemico de la enfermedad, y es frecuente encontrar en el mismo sujeto (sintomatico o no) manifestaciones clinicas o subclinicas de enfermedad vascular en otro territorio. La cardiopatia isquemica, la enfermedad cerebrovascular y la enfermedad arterial periferica representan los tres frentes de presentacion principales y la importante relevancia pronostica de su coexistencia justifica la valoracion vascular integral del paciente. Al tratarse de una enfermedad sistemica con factores de riesgo comunes, el tratamiento con antiagregantes plaquetarios, inhibidores de la enzima de conversion de angiotensina, antagonistas de los receptores de angiotensina II y estatinas ha confirmado sus ventajas pronosticas con independencia del territorio afecto.

Primary Prevention of Sudden Death in Patients With Valvular Cardiomyopathy

INTRODUCTION AND OBJECTIVES Few data exist on the outcomes of valvular cardiomyopathy patients referred for defibrillator implantation for primary prevention. The aim of the present study was to describe the outcomes of this cardiomyopathy subgroup. METHODS This multicenter retrospective study included consecutive patients referred for defibrillator implantation to 15 Spanish centers in 2010 and 2011, and to 3 centers after 1 January 2008. RESULTS Of 1174 patients, 73 (6.2%) had valvular cardiomyopathy. These patients had worse functional class, wider QRS, and a history of atrial fibrillation vs patients with ischemic (n=659; 56.1%) or dilated (n=442; 37.6%) cardiomyopathy. During a follow-up of 38.1 ± 21.3 months, 197 patients (16.7%) died, without significant differences among the groups (19.2% in the valvular cardiomyopathy group, 15.8% in the ischemic cardiomyopathy group, and 17.9% in the dilated cardiomyopathy group; P=.2); 136 died of cardiovascular causes (11.6%), without significant differences among the groups (12.3%, 10.5%, and 13.1%, respectively; P=.1). Although there were no differences in the proportion of appropriate defibrillator interventions (13.7%, 17.9%, and 18.8%; P=.4), there was a difference in inappropriate interventions (8.2%, 7.1%, and 12.0%, respectively; P=.03). CONCLUSIONS All-cause and cardiovascular mortality in patients with valvular cardiomyopathy were similar to those in other patients referred for defibrillator implantation. They also had similar rates of appropriate interventions. These data suggest that defibrillator implantation in this patient group confers a similar benefit to that obtained by patients with ischemic or dilated cardiomyopathy.

Spanish Catheter Ablation Registry. 17th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2017)

INTRODUCTION AND OBJECTIVES This report describes the findings of the 2017 Spanish Catheter Ablation Registry. METHODS Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. RESULTS A total of 15 284 ablation procedures were performed by 98 institutions (the highest number of ablations and institutions historically reported in this registry), with a mean of 156±126 and a median of 136 procedures per center. For the first time, the most frequently treated ablation target was atrial fibrillation (n=3457; 22.6%), followed by cavotricuspid isthmus (n=3449; 22.5%) and atrioventricular nodal re-entrant tachycardia (n=3429; 22.4%). The overall success rate was 87%. The rate of major complications was 2.6%, and the mortality rate was 0.09%. The percentage of procedures performed without fluoroscopic support increased to 6% of all ablations, and 2.3% of all ablations were performed in pediatric patients. CONCLUSIONS The Spanish Ablation Catheter Registry systematically and uninterruptedly collects data on the ablation procedures performed in Spain, revealing that both the number of ablations and the number of centers performing them has progressively increased, while maintaining a high success rate and a low percentage of complications.

Left atrial geometry and outcome of atrial fibrillation ablation: results from the multicentre LAGO-AF study

Aims Left atrial (LA) remodelling is a key determinant of atrial fibrillation (AF) ablation outcome. Optimal methods to assess this process are scarce. LA sphericity is a shape-based parameter shown to be independently associated to procedural success. In a multicentre study, we aimed to test the feasibility of assessing LA sphericity and evaluate its capability to predict procedural outcomes. Methods and results This study included consecutive patients undergoing first AF ablation during 2013. A 3D model of the LA chamber, excluding pulmonary veins and LA appendage, was used to quantify LA volume (LAV) and LA sphericity (≥82.1% was considered spherical LA). In total, 243 patients were included across 9 centres (71% men, aged 56 ± 10 years, 44% with hypertension and 76% CHA2DS2-VASc ≤ 1). Most patients had paroxysmal AF (66%) and underwent radiofrequency ablation (60%). Mean LA diameter (LAD), LAV, and LA sphericity were 42 ± 6 mm, 100 ± 33 mL, and 82.6 ± 3.5%, respectively. Adjusted Cox models identified paroxysmal AF [hazard ratio (HR 0.54, P = 0.032)] and LA sphericity (HR 1.87, P = 0.035) as independent predictors for AF recurrence. A combined clinical-imaging score [Left Atrial Geometry and Outcome (LAGO)] including five items (AF phenotype, structural heart disease, CHA2DS2-VASc ≤ 1, LAD, and LA sphericity) classified patients at low (≤2 points) and high risk (≥3 points) of procedural failure (35% vs. 82% recurrence at 3-year follow-up, respectively; HR 3.10, P < 0.001). Conclusion In this multicentre, real-life cohort, LA sphericity and AF phenotype were the strongest predictors of AF ablation outcome after adjustment for covariates. The LAGO score was easy to implement, identified high risk of procedural failure, and could help select optimal candidates. Clinical Trial Registration Information NCT02373982 (http://clinicaltrials.gov/ct2/show/NCT02373982).

Echocardiographic Biatrial Remodelling and Diastolic Function Assessment in Long-Term Follow-Up after Typical Atrial Flutter Ablation

Background: A reverse left atrial (LA) remodelling after atrial fibrillation (AF) ablation has been reported and a relationship between diastolic function and AF is well known. However, there is little information about atrial remodelling and diastolic function after cavotricuspid isthmus (CTI) ablation. We aimed to evaluate long-term biatrial remodelling and diastolic function in patients undergoing CTI ablation.