Ramón Bover

Comentarios a la guía de práctica clínica de la ESC para el manejo del infarto agudo de miocardio en pacientes con elevación del segmento ST

The European Society of Cardiology (ESC) guidelines are endorsed by the Spanish Society of Cardiology (SEC) and translated into Spanish for their publication in the Revista Española de Cardiología. Under the policy introduced in 2011, each new guideline is accompanied by an article that formulates comments in accordance with the objectives and methodology recommended in the article that established the Guidelines Committee of the SEC.1 In the present article, we discuss the new European guidelines for ST-segment elevation acute myocardial infarction (STEMI).2 The Guidelines Committee established a work group composed of members proposed by the Ischemic Heart Disease, Hemodynamics, Clinical Cardiology, Heart Failure, and Geriatric Cardiology work groups. As a general comment, we consider that the present guidelines introduce highly interesting developments and that the topics are dealt with clearly and in detail. However, we should also point out that it contains 157 recommendations, 69 (44%) of which are accompanied by level C evidence (expert consensus), predominantly in the sections on in-hospital management, heart failure, and complications, fields in which there thus remains ample room for individualization and progress in clinical research. In applying them, we should not forget that the guidelines themselves remind us that the level A and B recommendations are based on clinical trials, and that even these results are open to interpretation. The different therapeutic options could be influenced by the available resources. Thus, it will be increasingly necessary to perform cost-efficiency studies that aid us in choosing among the different strategies. For the purpose of making the article more readable and to highlight the most relevant or novel aspects, as well as those that are not made clear or are not addressed, we have summarized them in Tables 1 and 2, respectively.

Nuevas evidencias, nuevas controversias: análisis crítico de la guía de práctica clínica sobre fibrilación auricular 2010 de la Sociedad Europea de Cardiología

Manuel Anguita,* Fernando Worner, Pere Domenech, Francisco Marı́n, Javier Ortigosa, Julián Pérez-Villacastı́n, Antonio Fernández-Ortiz, Angel Alonso, Angel Cequier, Josep Comı́n, Magda Heras, Manuel Pan, Javier Alzueta, Angel Arenal, Gonzalo Barón, Xavier Borrás, Ramón Bover, Mariano de la Figuera, Carlos Escobar, Miguel Fiol, Benito Herreros, José L. Merino, Lluis Mont, Nekane Murga, Alonso Pedrote, Aurelio Quesada, Tomás Ripoll, José Rodrı́guez, Martı́n Ruiz, and Ricardo Ruiz Coordinadores del Grupo de Trabajo sobre Guı́as de Fibrilación Auricular de la Sociedad Española de Cardiologı́a, Madrid, Spain Grupo de Trabajo sobre Guı́as de Fibrilación Auricular de la Sociedad Española de Cardiologı́a, Madrid, Spain Comité de Guı́as de Práctica Clı́nica de la Sociedad Española de Cardiologı́a, Madrid, Spain Grupo de expertos revisores del documento sobre Guı́as de Fibrilación Auricular de la Sociedad Española de Cardiologı́a, Madrid, Spain

Comentarios a la guía de práctica clínica de la ESC para el manejo del síndrome coronario agudo en pacientes sin elevación persistente del segmento ST. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

doi: 10.1016/j.rec.2011.12.004 The new guidelines for the management of acute coronary syndrome in patients without persistent ST-elevation (NSTE-ACS),1 prepared in 2011 by the European Society of Cardiology (ESC), have been accepted by the Spanish Society of Cardiology (SEC) and translated to Spanish for publication in their entirety in the Revista Española de Cardiología2. As a support tool for the implementation of these guidelines, and in accordance with the new SEC policy for clinical practice guidelines,3 this editorial discusses the innovations and new recommendations in these guidelines and evaluates some aspects considered to be controversial, so as to facilitate the implementation of the new guidelines in our field.

Comentarios a la guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica 2012. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

El Comite de Guias de Practica Clinica de la SEC formo un grupo de trabajo integrado por cardiologos clinicos, electrofisiologos, cirujanos cardiacos y personal de enfermeria, expertos en los diversos aparta-dos de la IC que cubre la guia de la ESC, propuestos por la Seccion de Insuficiencia Cardiaca y Trasplante y el Grupo de Trabajo sobre Resin-cronizacion Cardiaca de la SEC y por la Asociacion Espanola de Enfer-meria Cardiovascular, con el objetivo general de revisar las evidencias y recomendaciones aportadas por la guia europea sobre IC antes citada

Estratificación del riesgo y prevención de la muerte súbita en pacientes con insuficiencia cardíaca

Los pacientes con insuficiencia cardiaca (IC) pueden fallecer como consecuencia de un fallo progresivo de bomba o de muerte subita (MS). En este articulo analizaremos los predictores de MS en pacientes con IC secundaria a disfuncion sistolica ventricular izquierda. Aunque en los estudios realizados en estos pacientes se han detectado distintos predictores univariados independientes relacionados con la supervivencia, la mayor parte de ellos ha demostrado tener un valor predictivo positivo muy limitado. El desfibrilador implantable ha confirmado ser el tratamiento mas eficaz en pacientes resucitados de una parada cardiaca debida a fibrilacion ventricular o a una taquicardia ventricular hemodinamicamente mal tolerada. La presencia de una fraccion de eyeccion ventricular izquierda baja, un mal grado funcional, una taquicardia ventricular no sostenida y la inducibilidad de arritmias ventriculares en el estudio electrofisiologico ayudan a identificar a los pacientes candidatos al implante de un desfibrilador. El papel de la amiodarona a la hora de prevenir la MS en pacientes de riesgo elevado con fracaso cardiaco parece pequeno. Se necesitan mas estudios que nos ayuden a conseguir una mejor estratificacion del riesgo en pacientes con IC, con el fin de reconocer mejor a los candidatos a un desfibrilador implantable. Palabras clave: Insuficiencia cardiaca. Muerte subita. Estratificacion del riesgo.

Long-Term Follow-Up of Atrial Fibrillation Patients in the NASPEAF Study. Prospective Evaluation of Different Antiplatelet Treatments

INTRODUCTION AND OBJECTIVES In the NASPEAF (National Study for Prevention of Embolism in Atrial Fibrillation) trial, combination therapy with an anticoagulant and an antiplatelet was more effective than anticoagulation alone in patients with atrial fibrillation. We report long-term follow-up in these patients, including prospective evaluation of different antiplatelet therapies. METHODS This analysis included 574 atrial fibrillation patients. Standard anticoagulation (international normalized ratio [INR] 2.0-3.0) was used as control therapy to compare with anticoagulation (INR 1.9-2.5) plus either triflusal at 600 mg/day, triflusal at 300 mg/day or aspirin at 100 mg/day. The primary endpoint was ischemic or hemorrhagic stroke, a systemic or coronary ischemic event, or cardiovascular death. The mean follow-up was 4.92 years. RESULTS Long-term follow-up confirmed that combination therapy with an anticoagulant plus triflusal at 600 mg/day gave significantly better results than anticoagulation alone (hazard ratio [HR]=0.33; 95% confidence interval [CI], 0.14-0.80; P=.014). There was a significantly higher incidence of ischemic events with triflusal at 300 mg/day (P=.031) and of severe bleeding events with aspirin at 100 mg/day (P=.008). The mean INR was similar in the three combination therapy groups. The incidence of severe nongastric bleeding during combination therapy with triflusal was very low (0.3% of patients/year). CONCLUSIONS Long-term follow-up confirmed that combination antithrombotic therapy with triflusal at 600 mg/day gave significantly better results than anticoagulant monotherapy. The results obtained with combination therapy with triflusal at 300 mg/day and with aspirin at 100 mg/day should be considered provisional because the treatment groups were small and treatment was not randomly assigned.

La nueva cascada de la coagulación y su posible influencia en el difícil equilibrio entre trombosis y hemorragia

The article published by Navarro et al 1 in this issue of Revista Espanola de Cardiologia reports the experience of 4 anticoagulation units located in large referral hospitals in Spain. The article also illustrates the appropriateness of monitoring treatment in specialist units to maintain the level of anticoagulation within the very narrow margin that allows prevention of thrombosis without causing bleeding complications. All thrombotic processes have their origin in the dysfunction or rupture of the vascular endothelium, leading to release of tissue factor, which initiates the process of coagulation, and of collagen and von Willebrand factor, which initiates adhesion and activation of platelets. Alteration of the homeostatic balance between prothrombotic and antithrombotic factors during anticoagulation therapy can result in insufficient inhibition of coagulation (thrombosis) or the occurrence of bleeding due to excessive antithrombotic treatment. The interpretation of the coagulation process described by MacFarlane 2 in 1964 (the “MacFarlane cascade”) has been of use for many years in beginning to understand the complex problem of thrombus formation. According to MacFarlane, there are 2 pathways: the extrinsic pathway, involving tissue factor and factor VII, and the intrinsic pathway, in which factors XII, XI, IX, VIII, and V participate. Both pathways converge to activate factor X and lead to transformation of prothrombin into thrombin and, through the action of thrombin, of fibrinogen into fibrin. The role of platelets in coagulation was considered independent. During the following 3 decades, numerous studies were undertaken, culminating in almost simultaneous publications from groups in Houston (Schafer et al 3 ) and

Comments on the ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012. A Report of the Task Force of the Clinical Practice Guidelines Committee of the Spanish Society of Cardiology

In line with the policy on clinical practice guidelines established by the Executive Committee of the Spanish Society of Cardiology,1 the present article aims to discuss the most salient and novel features of the European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure (HF).2 These guidelines update the recommendations of the prior version published 4 years ago in 20083 and include the new evidence that has emerged since then in the field of HF.

Aortic Root Pseudoaneurysm 1 Year After Transapical Aortic Valve Implantation

An 84-year-old woman was admitted to our institution for transapical aortic valve implantation (TAVI) because of severe aortic stenosis coexisting with high-risk clinical conditions. She had a past history of type 2 diabetes mellitus, hypertension, intrinsic asthma, moderate to severe chronic renal insufficiency (Modification of Diet in Renal Disease glomerular filtration rate, 36 mL/min per 1.73 m2), and peripheral atherosclerotic vascular disease involving both iliofemoral arteries. Eighteen months before, she had suffered a non–ST-segment elevation myocardial infarction and was treated with 2 bare metal stents on the middle segment of the left anterior descending coronary artery and the very proximal or ostial segment of the right coronary artery. Aortic stenosis was evaluated as moderate. After 5 months, she developed advanced Mobitz II–type atrioventricular block, and a permanent sequential atrial synchronous ventricular inhibited pacemarker was indicated. Progression of the aortic valve disease was not noted. More recently, she was admitted to another hospital with severe dyspnea, showing signs of acute heart failure on physical examination. Urgent transthoracic echocardiogram disclosed a normal left ventricle with preserved ejection fraction and progression of the severity of the aortic valve stenosis. Because of the very high operative risk, conventional on-pump aortic valve replacement was dismissed. …

Repetitive use of levosimendan in advanced heart failure: need for stronger evidence in a field in dire need of a useful therapy

Patients in the latest stages of heart failure are severely compromised, with poor quality of life and frequent hospitalizations. Heart transplantation and left ventricular assist device implantation are viable options only for a minority, and intermittent or continuous infusions of positive inotropes may be needed as a bridge therapy or as a symptomatic approach. In these settings, levosimendan has potential advantages over conventional inotropes (catecholamines and phosphodiesterase inhibitors), such as sustained effects after initial infusion, synergy with beta-blockers, and no increase in oxygen consumption. Levosimendan has been suggested as a treatment that reduces re-hospitalization and improves quality of life. However, previous clinical studies of intermittent infusions of levosimendan were not powered to show statistical significance on key outcome parameters. A panel of 45 expert clinicians from 12 European countries met in Rome on November 24-25, 2016 to review the literature and envision an appropriately designed clinical trial addressing these needs. In the earlier FIGHT trial (daily subcutaneous injection of liraglutide in heart failure patients with reduced ejection fraction) a composite Global Rank Score was used as primary end-point where death, re-hospitalization, and change in N-terminal-prohormone-brain natriuretic peptide level were considered in a hierarchical order. In the present study, we tested the same end-point post hoc in the PERSIST and LEVOREP trials on oral and repeated i.v. levosimendan, respectively, and demonstrated superiority of levosimendan treatment vs placebo. The use of the same composite end-point in a properly powered study on repetitive levosimendan in advanced heart failure is strongly advocated.