Rut Andrea

Consulta inmediata ambulatoria de alta resolución en cardiología: 10 años de experiencia

En 1996 se implemento en el Hospital General de Vic la consulta inmediata ambulatoria de alta resolucion en cardiologia, con el objetivo de dar respuesta rapida a los pacientes y realizar el mismo dia la visita especializada y las exploraciones complementarias indicadas, fundamentalmente ecocardiograma, prueba de esfuerzo o Holter. Se expone la experiencia de 10 anos de seguimiento, con un total de 19.515 visitas. La media de espera para la visita fue de 3 dias. Se analizan los motivos de consulta, las exploraciones efectuadas y la disminucion de visitas sucesivas e ingresos hospitalarios. La satisfaccion de la atencion primaria aumento con este modelo asistencial. La consulta de alta resolucion resulto aplicable en la practica real y perdurable en el seguimiento. El modelo es beneficioso para el paciente y satisfactorio para la atencion primaria, reduce los contactos paciente-hospital y posiblemente evita ingresos hospitalarios.

Left atrial dysfunction relates to symptom onset in patients with heart failure and preserved left ventricular ejection fraction

AIMS Pathophysiology of heart failure (HF) with preserved ejection fraction (HFPEF) remains unclear. Left atrial (LA) function has been related to HF symptoms. Our purpose is to analyse LA function in outpatients with new onset symptoms of HF. METHODS AND RESULTS An observational study was performed including 138 consecutive outpatients with suspected HF referred to a one-stop clinic. Final diagnosis [HF with reduced EF (HFREF), HFPEF, or non-HF] was established according to current recommendations. Echocardiography was performed in all patients. LA function was analysed using strain derived from speckle tracking in sinus rhythm patients (n = 83). Results were analysed with ANOVA and Bonferroni statistical tests. Receiver operating characteristic (ROC) curves were constructed to investigate the predictive ability of LA parameters for the final diagnosis of HF. Patients were 75 ± 9 years and 63% women. Final diagnosis was 23.2% HFREF, 45.7% HFPEF, and 31.2% non-HF. Left ventricular strain rate showed no differences between non-HF and HFPEF groups, but both groups showed differences with the HFREF group. LA strain rate (A- and S-waves) was significantly reduced in both HF groups (without differences among them) when compared with the non-HF group. LA strain rate and indexed volume showed significant accuracy for HF diagnosis in ROC curves. CONCLUSIONS In outpatients with new-onset symptoms of HF, LA dysfunction was observed. It might be the initial mechanism in the development of symptoms in HFPEF patients. These findings support the relationship of LA dysfunction with HFPEF, suggesting that the analysis of LA function may be useful in sinus rhythm patients with new-onset dyspnoea.

Lung Function Abnormalities are Highly Frequent in Patients with Heart Failure and Preserved Ejection Fraction

BACKGROUND Heart failure with preserved ejection fraction (HFPEF) is the most prevalent form of heart failure in outpatients. Yet, the pathophysiology of this syndrome is unclear and pharmacological treatment does not improve prognosis. Because breathlessness during activities of daily living is the most frequent complaint of patients with HFPEF, we hypothesised that lung function may be often abnormal in these patients due to either a direct effect of HFPEF and/or shared risk factors. In this study we explore the frequency, type and severity of lung function abnormalities in HFPEF. METHODS We measured forced spirometry, static lung volumes, pulmonary diffusing capacity (DL(CO)) and arterial blood gases in 69 outpatients with newly diagnosed symptomatic HFPEF. RESULTS We found that 94% of the patients showed abnormalities in at least one of the lung function measurements obtained: spirometry was abnormal in 59%, DL(CO) in 83% and arterial hypoxaemia was present in 62%. Their severity varied between patients, they were more prevalent in patients with NYHA functional class III/IV, and most often they were undiagnosed and untreated. CONCLUSIONS Lung function abnormalities are very frequent in HFPEF patients. A greater awareness among clinicians may contribute to improve their management and health status.

Transfemoral transcatheter aortic valve replacement compared with surgical replacement in patients with severe aortic stenosis and comparable risk: cost-utility and its determinants.

OBJECTIVE To evaluate cost-effectiveness of transfemoral TAVR vs surgical replacement (SAVR) and its determinants in patients with severe symptomatic aortic stenosis and comparable risk. METHODS Patients were prospectively recruited in 6 Spanish hospitals and followed up over one year. We estimated adjusted incremental cost-effectiveness ratio (ICER) (Euros per quality-adjusted life-year [QALY] gained) using a net-benefit approach and assessed the determinants of incremental net-benefit of TAVR vs SAVR. RESULTS We analyzed data on 207 patients: 58, 87 and 62 in the Edwards SAPIEN (ES) TAVR, Medtronic-CoreValve (MC) TAVR and SAVR groups respectively. Average cost per patient of ES-TAVR was €8800 higher than SAVR and the gain in QALY was 0.036. The ICER was €148,525/QALY. The cost of MC-TAVR was €9729 higher than SAVR and the QALY difference was -0.011 (dominated). Results substantially changed in the following conditions: 1) in patients with high preoperative serum creatinine the ICERs were €18,302/QALY and €179,618/QALY for ES and MC-TAVR respectively; 2) a 30% reduction in the cost of TAVR devices decreased the ICER for ES-TAVR to €32,955/QALY; and 3) imputing hospitalization costs from other European countries leads to TAVR being dominant. CONCLUSIONS In countries with relatively low health care costs TAVR is not likely to be cost-effective compared to SAVR in patients with intermediate risk for surgery, mainly because of the high cost of the valve compared to the cost of hospitalization. TAVR could be cost-effective in specific subgroups and in countries with higher hospitalization costs.

Diagnóstico de la insuficiencia cardíaca con fracción de eyección preservada o reducida mediante una consulta de alta resolución

Resumen Objetivos a) Valorar la aplicabilidad de una consulta de alta resolución (CAR) para el diagnóstico de pacientes ambulatorios con insuficiencia cardíaca (IC) de inicio; b) caracterizar a los pacientes con IC y fracción de eyección preservada (ICFE-P) comparados con los de fracción de eyección reducida (ICFE-R), y c) determinar el nivel de péptido natriurético tipo B (PNB) para identificar la IC en esta población. Diseño Estudio longitudinal observacional descriptivo. Emplazamiento Atención primaria especializada. Participantes y mediciones Ciento cuarenta y tres pacientes con síntomas iniciales de IC fueron incluidos en una CAR-IC con evaluación clínica, electrocardiograma, radiografía de tórax, PNB y ecocardiograma. Resultados Se diagnosticó IC en 65,7% de los pacientes: 67% ICFE-P y 33% ICFE-R. La mayoría de pacientes con ICFE-P eran mujeres (71,4 versus 38,7%; p = 0,002), con más edemas maleolares (61,9% versus 35,5%; p = 0,016) e índice de masa corporal (29,8 ± 5,1 versus 27,2 ± 5,0; p = 0,021). Ambos presentaron signos ecocardiográficos de disfunción diastólica e hipertensión pulmonar, con PNB (153,3 ± 123,1 versus 400,8 ± 579,8; p = 0,025) y troponina I (0,024 ± 0,019 versus 0,071 ± 0,12; p = 0,037) más elevados en ICFE-R. Resultaron predictores de ICFE-P el sexo femenino y los edemas maleolares, mientras que la onda Q, los valores elevados de PNB y la frecuencia cardíaca lo fueron de ICFE-R. El punto de corte de PNB = 60,12 pg/ml identificó IC con sensibilidad del 83% y especificidad del 84% (ABC = 0,898; IC 95% [0,848-0,948]; p < 0,001). Conclusiones La CAR-IC permitió el diagnóstico rápido y la caracterización de la IC de inicio, con mayor prevalencia de ICFE-P, en pacientes ambulatorios. El valor de PNB 60,12 pg/ml ofreció una sensibilidad y especificidad elevadas para identificar la IC en esta población.OBJECTIVES a) To assess the usefulness of a one-stop clinic for the diagnosis of outpatients with new onset heart failure; b) to characterize these patients comparing preserved (HF-PEF) versus reduced ejection fraction (HF-REF), and c) to determine brain natriuretic peptide (BNP) cut-off limit to identify HF in outpatients. DESIGN Observational descriptive study. SETTING Primary care. PARTICIPANTS AND MEASUREMENTS A total of 143 outpatients with new onset HF were assessed in a one-stop clinic. A cardiologist evaluation, electrocardiogram, chest X-ray, BNP, and echocardiography (diastolic and systolic study) were performed. RESULTS Almost two-thirds (65.7%) were diagnosed with HF: 67% with HF-PEF and 33% HF-REF. Women (71.4% versus 38.7%, P=.002), presence of swelling ankles (61.9% versus 35.5%, P=.016) and higher body mass index (29.8±5.1 versus 27.2±5.0 P=.021) were more frequent in the first group of patients. Echocardiographic signs of diastolic dysfunction and pulmonary hypertension were found in both groups, with higher values of BNP (153.3±123.1 versus 400.8±579.8 P=.025) and troponin I (0.024±0.019 versus 0.071±0.12, P=.037) in HF-REF patients. Female gender and swelling ankles were predictors of HF-PEF in the multivariate analysis, while Q waves and higher values of BNP and heart rate were predictors of HF-REF. A cut-off value of 60.12 pg/ml for BNP provided 83% sensitivity, 84% specificity (AUC=0.898; 95% CI; 0.848-0.948; P <.001). CONCLUSIONS The one-stop HF clinic has diagnosed and characterized outpatients with new onset HF and high prevalence of HF-PEF. The cut-off value of 60.12 pg/ml for BNP provides high sensitivity and specificity to identify HF in this population.

Infective endocarditis in patients with an implanted transcatheter aortic valve: Clinical characteristics and outcome of a new entity

AIMS This study reports one case and review the literature on TAVI-associated endocarditis (TAVIE), to describe its clinical picture and to perform an analysis on prognostic factors. METHODS AND RESULTS A MEDLINE search from January 2002 to October 2014 revealed 31 cases of TAVIE, including 1 from our hospital. Median age was 81 years (IQR, 78-85), 53% of patients were males and the median age-adjusted Charlson score was 7 (IQR, 5-8). Heart failure was recorded in 42%, embolic events in 19%, and periannular complications in 45%. The most common causative agent was Enterococcus spp (36%). Ten patients (32%) underwent surgery and nine patients died (29%). The prognostic factors for 6-month mortality were heart failure (HR, 9.97 [3.7-24.5]; p = 0.001), periannular complications (HR, 11.82 [3.3-41.3]; p = 0.004), and nonenterococcal/streptococcal etiology (HR, 4.76 [2.1-11.1]; p = 0.03). In patients with heart failure who did not undergo surgery, mortality was 89% (8 out of 9); in those who did undergo surgery, mortality was 0% (p < 0.001). CONCLUSIONS TAVIE is an emerging entity with high mortality. Patients with heart failure who did not undergo surgery had a higher probability of dying. Surgical treatment provided better outcomes even in patients in whom surgery had previously been ruled out.

Prognosis of new-onset heart failure outpatients and collagen biomarkers

Prognosis of heart failure patients has been defined in hospital‐based or retrospective studies. This study aimed to characterize prognosis of outpatients with new‐onset preserved or reduced ejection fraction heart failure; to explore the role of collagen turnover biomarkers (MMP2, MMP9, TIMP1) in predicting prognosis; and to analyse their relationship with echocardiographic parameters and final diagnosis.

Out-of-hospital cardiac arrest and stent thrombosis: Ticagrelor versus clopidogrel in patients with primary percutaneous coronary intervention under mild therapeutic hypothermia☆

BACKGROUND Out-of-Hospital Cardiac Arrest (OHCA) and mild therapeutic hypothermia (MTH) have been linked to increased risk of Stent Thrombosis (ST) in comatose survivors who undergo percutaneous coronary intervention (PCI). In this sense, there is no formal recommendation about which antiplatelet regimen should be used in patients with acute coronary syndromes (ACS) after OHCA. AIMS To compare the incidence of probable/definite ST and bleeding events between ticagrelor and clopidogrel, in patients with ACS under MTH after an OHCA. METHODS AND RESULTS From January 2010 to August 2016, 144 patients underwent MTH after an OHCA. Overall, 114 had an ACS (79%) and 98 (67,3%) were treated with primary PCI and stent implantation. Among them, 61 (62,2%) were treated with clopidogrel, and 32 (32,6%) with ticagrelor. During hospitalization, the incidence of probable or definite ST was significantly higher in patients receiving clopidogrel compared to ticagrelor (11,4% vs. 0%; p: 0.04), and no significant differences in any (28,6% vs. 25%; p: 0.645) or major bleeding (BARC 3 or 5) (11,4% vs. 12,5%; p: 0.685) were found. Hospital mortality did not differ between groups (26,2% vs. 25%; p: 0.862). CONCLUSIONS In this study, as compared to clopidogrel, ticagrelor was associated with a lower rate of ST, without differences in haemorrhagic events in patients with OHCA for an ACS under MTH. Similarly to other settings, ticagrelor might be a valid alternative to clopidogrel in these patients.

Safety issues of adjunctive clopidogrel in patients discharged after percutaneous coronary intervention with stent placement and requiring oral anticoagulation

Indications for percutaneous coronary intervention with stent placement are increasing; some candidates already require oral anticoagulation. Safety of triple antithrombotic therapy--aspirin (ASA), clopidogrel and oral anticoagulation (OAC)--remains largely unknown. In order to study hemorrhagic complications in those patients, we identified thirty-three patients from our anticoagulation clinic registry who were prescribed triple antithrombotic therapy. All hemorrhagic events were collected and classified as non-severe (NSH) or severe (SH). The same population provided a control to determine increased risk from addition of a second antiplatelet drug. Overall, patients were followed for 53 patient-months while on triple therapy (TT) and 869 patient-months on double therapy. Patients in TT group had more hemorrhages (90.6% patient-years vs 8.29% patient-years, p<0.01) due to an increase in NSH (90.6% patient-years vs 5.52% patient-years, p<0.01), without changes in SH. Mean international normalized ratio (INR) was similar in both groups and INR at bleeding time was not uniformly increased. We conclude that in patients with an AAS and OAC based regimen, addition of clopidogrel because of a stent placement results in a significant increase in NSH but no increase in SH.

Interatrial Dyssynchrony May Contribute to Heart Failure Symptoms in Patients with Preserved Ejection Fraction.

Heart failure (HF) with preserved ejection fraction (HFPEF) is the most prevalent type of HF in nonhospitalized patients, but its pathophysiology remains poorly understood. The aim of our study was to assess the existence of interatrial dyssynchrony (IAD), a potentially treatable condition, in the development of HF symptoms.