Rodrigo Estévez-Loureiro

Prognostic Value of Exercise Echocardiography in Patients with Hypertrophic Cardiomyopathy

BACKGROUND Although exercise echocardiography may assess left ventricular (LV) function and LV outflow tract (LVOT) gradients during exercise in patients with hypertrophic cardiomyopathy (HCM), its value for predicting outcomes has not been studied. The aim of this study was to determine whether exercise echocardiography predicts outcomes in patients with HCM. METHODS LV function and LVOT gradients were evaluated during exercise echocardiography in 239 patients with HCM. RESULTS Sixty patients (25.1%) had LVOT obstruction at rest, and 43 (18%) developed exercise-induced LVOT obstruction. The mean resting LV ejection fraction was 69 ± 9%, and the mean resting wall motion score index was 1.00 ± 0.06. Wall motion abnormalities during exercise were seen in 19 patients (7.9%). During follow-up of 4.1 ± 2.6 years, 19 patients had hard events (cardiac death, cardiac transplantation, appropriate discharge of a defibrillator, stroke, myocardial infarction, or hospitalization for heart failure), and 41 patients had composite end points of hard or soft events (including atrial fibrillation and syncope). Exercise wall motion abnormalities occurred in 31.5% of patients with hard events compared with 5.9% of patients without hard events (P < .001). After adjustment, LV wall thickness (hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.05-1.21; P = .002), resting wall motion score index (HR, 21.59; 95% CI, 2.38-196.1, P = .006), and metabolic equivalents (HR, 0.74; 95% CI, 0.63-0.88; P = .001) remained independent predictors of hard events. Change in wall motion score index was also independently associated with hard events (HR, 52.30; 95% CI, 3.81-718.5; P = .003) and with the composite end point (HR, 39.51; 95% CI, 3.79-412.4; P = .002). LVOT obstruction was not associated with either end point. CONCLUSIONS Assessment of exercise capacity and LV systolic function during exercise echocardiography may have a role in risk stratification of patients with HCM.

Local and general anaesthesia do not influence outcome of transfemoral aortic valve implantation.

BACKGROUND There is great variability for the type of anaesthesia used during TAVI, with no clear consensus coming from comparative studies or guidelines. We sought to detect regional differences in the anaesthetic management of patients undergoing transcatheter aortic valve implantation (TAVI) in Europe and to evaluate the relationship between type of anaesthesia and in-hospital and 1 year outcome. METHODS Between January 2011 and May 2012 the Sentinel European TAVI Pilot Registry enrolled 2807 patients treated via a transfemoral approach using either local (LA-group, 1095 patients, 39%) or general anaesthesia (GA-group, 1712 patients, 61%). RESULTS A wide variation in LA use was evident amongst the 10 participating countries. The use of LA has increased over time (from a mean of 37.5% of procedures in the first year, to 57% in last 6 months, p<0.01). MI, major stroke as well as in-hospital death rate (7.0% LA vs 5.3% GA, p=0.053) had a similar incidence between groups, confirmed in multivariate regression analysis after adjusting for confounders. Dividing our population in tertiles according to the Log-EuroSCORE we found similar mortality under LA, whilst mortality was higher in the highest risk tertile under GA. Survival at 1 year, compared by Kaplan-Meier analysis, was similar between groups (log-rank: p=0.1505). CONCLUSIONS Selection of anaesthesia appears to be more influenced by national practice and operator preference than patient characteristics. In the absence of an observed difference in outcomes for either approach, there is no compelling argument to suggest that operators and centres should change their anaesthetic practice.

Seguridad y viabilidad del retorno precoz de pacientes transferidos para angioplastia primaria a sus centros de origen

Introduccion y objetivos. Hasta la fecha existen pocos datos sobre la posibilidad de retornar a los pacientes con sindrome coronario agudo con elevacion del segmento ST (SCACEST) trasladados para angioplastia primaria (AP) a su centro de referencia. El objetivo de este estudio es evaluar la seguridad y viabilidad del retorno precoz de dichos pacientes a sus centros de origen. Metodos. Analisis de cohortes constituido por 200 pacientes consecutivos (edad, 62 ± 13 anos; el 83% varones) devueltos a su centro de origen tras la realizacion de AP, comparandolos con un grupo de 297 pacientes de similares caracteristicas pertenecientes a nuestra area sanitaria. Se analizo el tiempo de estancia en el hospital intervencionista y los eventos cardiovasculares de mas de 30 dias. Resultados. La mediana de permanencia en nuestro hospital fue de 8 h. El grupo retornado no presento ningun evento durante el traslado al hospital de origen. A los 30 dias no se observaron diferencias significativas entre los pacientes retornados y los del grupo control respecto a muerte (el 1 frente al 3,7%; p = 0,064), reingreso (el 5 frente al 4,5%; p = 0,657), complicaciones isquemicas (el 2,5 frente al 2%; p = 0,721), realizacion de nuevo cateterismo (el 5 frente al 2,5%; p = 0,112), accidentes cerebrovasculares (el 1 frente al 1%; p = 0,936) o el evento combinado (el 11 frente al 9,2%; p = 0,540). En un analisis multivariable, el retorno de los pacientes no se asocio con un mayor numero de eventos cardiovasculares (odds ratio = 1,32; intervalo de confianza del 95%, 0,62-2,80). Conclusiones. El retorno precoz de pacientes con IAM de bajo riesgo a su centro de origen tras AP es seguro y viable

Prevalencia, causas y pronóstico de las «falsas alarmas» al laboratorio de hemodinámica en pacientes con sospecha de infarto de miocardio con elevación del segmento ST

Introduccion y objetivos. Determinar prevalencia, causas y pronostico de las «falsas alarmas» al laboratorio de hemodinamica (FALH) en una red regional de angioplastia primaria. Metodos. Registro prospectivo de 1.662 pacientes remitidos para angioplastia primaria entre enero de 2003 y agosto de 2008. Se definio FALH como ausencia de lesion coronaria causal. Resultados. En 120 pacientes (7,2%; intervalo de confianza [IC] del 95%, 5,9-8,5) no se identifico ninguna lesion coronaria causal. De ellos, 104 (6,3%; IC del 95%, 5,1-7,4) recibieron un diagnostico alternativo a IAMCEST, 91 (5,5%; IC del 95%, 4,3-6,6) no presentaron enfermedad coronaria significativa y 64 (3,8%; IC del 95%, 2,9-4,8) presentaron marcadores de dano miocardico negativos. Los diagnosticos alternativos mas frecuentes fueron: infarto con onda Q previo (18 casos), alteraciones inespecificas del segmento ST (11), pericarditis (10) y discinesia apical transitoria (10). La mortalidad a 30 dias fue similar en los pacientes con y sin lesion causal (el 5,8 frente al 5,8%; p = 0,99). La prevalencia de FALH fue discretamente superior entre los pacientes remitidos desde los servicios de urgencias de hospitales no intervencionistas sin evaluacion previa por un cardiologo que entre los remitidos por cardiologos desde el servicio de urgencias del hospital intervencionista (el 9,5 frente al 6,1%; p = 0,02; odds ratio [OR] = 1,64; IC del 95%, 1,08-2,5). No observamos un exceso de FALH entre los pacientes remitidos por medicos de UVI Moviles-061 (7,2%; p = 0,51; OR = 1,37; IC del 95%, 0,79-2,37). Conclusiones. Hemos observado una prevalencia de FALH del 7,2% de acuerdo con el criterio de ausencia de lesion coronaria causal. Nuestros resultados indican que diferentes modelos de activacion del laboratorio de hemodinamica podrian justificar discretas variaciones en la prevalencia de FALH.

Prevalence, etiology, and outcome of catheterization laboratory false alarms in patients with suspected ST-elevation myocardial infarction

INTRODUCTION AND OBJECTIVES To investigate the prevalence, causes and outcome of catheterization laboratory false alarms (CLFAs) in a regional primary angioplasty network. METHODS A prospective registry of 1,662 patients referred for primary angioplasty between January 2003 and August 2008 was reviewed to identify CLFAs (i.e. when no culprit coronary lesion could be found). RESULTS No culprit coronary lesion could be identified in 120 patients (7.2%; 95% confidence interval [CI], 5.9-8.5%). Of these, 104 (6.3%, 95% CI, 5.1-7.4%) had a discharge diagnosis other than ST-elevation myocardial infarction, 91 (5.5%; 95% CI, 4.3-6.6%) had no significant coronary disease, and 64 (3.8%; 95% CI, 2.9-4.8%) tested negative for cardiac biomarkers. The most frequent alternative diagnoses were: previous Q-wave myocardial infarction (18 cases), nonspecific ST-segment abnormalities (11), pericarditis (10) and transient apical dyskinesia (10). The 30-day mortality rate was similar in patients with and without culprit lesions (5.8% vs. 5.8%; P=.99). The prevalence of CLFAs was slightly higher in patients not previously evaluated by a cardiologist and referred from emergency departments in hospitals without catheterization laboratories than in those referred by cardiologists from emergency departments at hospitals with such facilities (9.5% vs. 6.1%; P=.02; odds ratio=1.64; 95% CI, 1.08-2.5). The prevalence of CLFAs was not significantly higher in patients referred by physicians with out-of-hospital emergency medical services (7.2%; P=.51; odds ratio=1.37; 95% CI, 0.79-2.37). CONCLUSIONS The prevalence of CLFAs was 7.2%, with the criterion of no culprit coronary lesion. Our findings suggest that different patterns of referral to catheterization laboratories could account for small variations in the prevalence of CLFAs.

Angioplastia primaria en el Area Norte de Galicia: cambios asistenciales y resultados tras la implantacion del programa PROGALIAM

INTRODUCTION AND OBJECTIVES To analyze changes in healthcare delivery and results for primary angioplasty at Centro Hospitalario Universitario A Coruña following implementation of the PROGALIAM protocol. METHODS Observational registry of 1434 patients referred for primary angioplasty between 2003 and 2007. Results under PROGALIAM (May 2005 - December 2007; n=963) were compared with those from the preceding period (January 2003 - April 2005; n=388). RESULTS After implementing PROGALIAM, there were increases in the number of primary angioplasty procedures (preceding period, 14.4 cases/month; PROGALIAM, 32.2 cases/month), mean patient age (preceding period, 61.3 (11.9) years; PROGALIAM, 64.2 (11.7) years; P<.001), and the percentage of patients referred from peripheral hospitals and treated after normal working hours. Overall median first medical contact-to-balloon time increased (previous period, 106 min; PROGALIAM, 113 min; P=.02), but decreased significantly among patients referred from noninterventional centers (previous period, 171 min; PROGALIAM, 146 min; P<.001). Percentage of cases with an first medical contact-to-balloon time <120 min remained unchanged among interventional-center patients (preceding period, 69%; PROGALIAM, 71%; P=.56) and increased among patients at noninterventional centers, although it remained low in this subgroup (preceding period, 17%; PROGALIAM, 30%; P=.04). Thirty-day mortality (preceding period, 5.2%; PROGALIAM, 6.2%; P=.85) and 1-year mortality (preceding period, 9.5%; PROGALIAM, 10.2%; P=.96) remained unchanged. CONCLUSIONS Implementation of PROGALIAM allowed us to increase the percentage of patients receiving primary angioplasty without jeopardizing the clinical results of this treatment.

Prevalence and prognostic value of cardiac allograft vasculopathy 1 year after heart transplantation according to the ISHLT recommended nomenclature

Although cardiac allograft vasculopathy (CAV) is the major impediment to long-term survival after heart transplantation (HT), it is only recently that standards governing the grading of this entity have been introduced in the form of the International Society for Heart and Lung Transplantation’s recommended nomenclature (ISHLT-RN), which is based on angiographic findings and graft function. The prognostic value of this grading system remains unknown. In this study we evaluated the prevalence and prognostic significance of ISHLT-RN CAV grades assigned 1 year after HT. We retrospectively studied 169 consecutive patients who underwent HT at our center between January 2000 and December 2009, and coronary angiography 1 year after HT (median time 12.3 months, interquartile range 9.7 to 13.7 months). Patients’ baseline characteristics (Table 1) were

Direct transfer of ST-elevation myocardial infarction patients for primary percutaneous coronary intervention from short and long transfer distances decreases temporal delays and improves short-term prognosis: the PROGALIAM Registry

AIMS This study sought to evaluate the impact of a direct transfer strategy on treatment times and prognosis of patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous intervention (PPCI). METHODS AND RESULTS We conducted a cohort study of 1,194 patients who underwent PPCI in our centre between May 2005 and December 2008. We studied the role of direct transfer on time to treatment and door-to-balloon delays and its effect on 30-day mortality adjusted by risk profile on admission. During this period, 255 patients (21%) experienced direct transfer (DT) from the field to the catheterisation laboratory. Patients referred directly for PPCI experienced lower median door-to-balloon delay (102 minutes vs. 125 minutes, p<0.0001) and lower time to treatment (median 189 minutes vs. 259 minutes, p<0.0001) when compared with those referred from emergency departments (ED). These differences were consistent, with respect to door-to-balloon delay and time to treatment interval, in patients from our catchment area: median 88 vs. 98 minutes, (p=0.003) and 174 vs. 219 minutes (p<0.0001) respectively, and from long-distance transfer: 110 vs. 169 minutes (p<0.0001) and 197 minutes vs. 342 minutes (p<0.0001) respectively. Patients in the DT group experienced lower 30-day mortality than patients transferred from the ED (2.7% vs. 6.8%, p=0.017). In a multivariable analysis, DT strategy was independently associated with better short-term prognosis (OR 0.33, CI95% 0.12 - 0.92). CONCLUSIONS Direct transfer reduces time delays and improves prognosis of patients with STEMI undergoing PPCI.

Safety and feasibility of returning patients early to their originating centers after transfer for primary percutaneous coronary intervention.

INTRODUCTION AND OBJECTIVES At present, little information is available on returning patients with ST-elevation myocardial infarction (STEMI) to their originating centers after transfer for primary percutaneous coronary intervention (PPCI). The objective of this study was to evaluate the safety and feasibility of the early return of these patients to their originating centers. METHODS The cohort study involved 200 consecutive STEMI patients (age 62+/-13 years, 83% male) who were returned to their originating centers after PPCI. They were compared with a group of 297 patients with similar characteristics from our healthcare catchment area. The length of stay in the intervention hospital and major adverse cardiovascular events occurring within 30 days were recorded. RESULTS The median length of stay in the intervention hospital was 8 hours. No adverse events occurred during transport in the group who returned to their originating centers. At 30-day follow-up, no significant difference was observed between patients who returned and the control group in either mortality (1.0% vs. 3.7%; P=.064), readmission (5.0% vs. 4.5%; P=.657), ischemic complications (2.5% vs. 2.0%; P=.721), re-catheterization (5.0% vs. 2.5%; P=.112), stroke (1% vs. 1%; P=.936) or the composite end-point (11% vs. 9.2%; P=.540). Multivariate analysis showed that returning patients after PPCI was not associated with a significantly greater number of major adverse cardiovascular events (odds ratio=1.32; 95% confidence interval, 0.62-2.80). CONCLUSIONS The early return of patients with low-risk STEMI to their originating centers after PPCI was safe and feasible.

Comparacion del valor predictivo pronostico de los scores TIMI, PAMI, CADILLAC y GRACE en el SCACEST sometido a ICP primario o de rescate

INTRODUCTION AND OBJECTIVES We sought to compare the predictive value of the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) scores for the outcome of ST-segment elevation acute coronary syndrome undergoing urgent percutaneous coronary intervention. METHODS We performed a retrospective analysis of a cohort composed of all consecutive patients with ST-segment elevation acute coronary syndrome treated by urgent percutaneous coronary intervention between 2006 and 2010 (n=1503). TIMI, PAMI, CADILLAC, and GRACE risk scores were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for death, reinfarction, and target-vessel revascularization at 30 days and 1 year, using the C statistic, which was obtained by means of logistic regression and ROC curves. RESULTS The TIMI, PAMI, CADILLAC and GRACE showed an excellent predictive value for 30-day and 1-year mortality (C statistic range, 0.8-0.9), with superiority of the TIMI, CADILLAC, and GRACE risk models. The performance of these 4 scores was poor for both reinfarction and target-vessel revascularization (C statistic, 0.5-0.6). CONCLUSIONS The TIMI, PAMI, CADILLAC, and GRACE scores provide excellent information to stratify the risk of mortality in patients treated by percutaneous coronary intervention. The TIMI, CADILLAC, and GRACE models have higher predictive accuracy. The usefulness of these models for reinfarction and target-vessel revascularization prediction is questionable.