Vicente Barriales

Alternate-day dosing of aspirin in atrial fibrillation

BACKGROUND In inhibiting platelet function, aspirin seems to reduce the risk of cerebrovascular accidents, death, and acute coronary events in patients with nonrheumatic atrial fibrillation. Aspirin given on alternate days might have the advantage of not hindering prostacyclin synthesis. Thus a study was performed to evaluate whether aspirin used in this way might improve the results reported with daily treatment. METHODS To test this hypothesis 285 patients (age range 40 to 82 years) with primary atrial fibrillation were randomly allocated in an open multicenter trial to 3 groups: (1) group A1, treated with 125 mg aspirin daily (n = 104); (2) group A2, treated with 125 mg aspirin on alternate days (n = 90), (3) group C (controls), who were not treated with anticoagulants or platelet inhibitors (n = 91). RESULTS Inclusion took place from January 1990 to July 1994, and follow-up ended in May 1996 (range 1 to 62 months). Sudden cardiac death in association with heart failure or angina was the most common final event: 4.8%, 1.1%, and 6.6% in groups A1, A2, and C, respectively. Both cardiovascular mortality rate and the incidence of main events were reduced, in relative terms, by 80% (1. 1% in group A2 vs 6.6% in group C). The differences were smaller between group A1 and C but did not reach statistical significance. The reduction of main cardiovascular events between groups A1 and A2 was statistically significant (7.7% vs 2.2% = 5.5%; 95% confidence limits 1%, 11%; P <.05). The difference did not reach statistical significance when other end points were analyzed. CONCLUSION In this trial low-dose aspirin given on alternate days seemed to be an efficient intervention in preventing major cardiovascular events. Regarding strokes, however, aspirin was less efficient. Mortality rate in the 3 groups as a whole was associated with heart failure and the development of ischemic heart disease.

Primary cardiac tumors: 32 years of experience from a Spanish tertiary surgical center

INTRODUCTION Primary cardiac tumors are rare entities with an autopsy frequency ranging between 0.001% and 0.3%. Our objective was to review 32 years of experience from a Spanish tertiary surgical center. METHOD We collected data on 73 patients with a histopathological diagnosis of a primary cardiac tumor in a retrospective analysis from 1979 to 2012. Tissue samples were obtained either at surgery or from necropsy and subsequently divided into benign and malignant groups. RESULTS Benign neoplasms accounted for 84.9% of cases. The average age at diagnosis was 61 years, and tumors were twice as frequent among women. It was an incidental finding in one quarter of patients. In symptomatic patients, the typical presentation was of cardioembolic stroke or of congestive symptoms. Myxoma (93.5%) was the most common diagnosis, typically affecting the left atrium (74.2%). Surgical resection was curative for 95% of these patients. Malignant tumors represented 15.1% of cases with an average age at diagnosis of 50 years. Over 90% of these patients were symptomatic at presentation with the cardinal symptom being heart failure. Undifferentiated sarcoma was the most frequent malignant tumor (36.4%). Less than 20% of patients were alive 1 year after diagnosis despite the treatment. CONCLUSIONS In our study, primary cardiac tumors were insidious. The most common was left atrial myxoma in which surgical resection was considered curative. Undifferentiated sarcoma was the most frequent malignant tumor. Malignant neoplasms carried a worse prognosis with unsuccessful total excision and the presence of metastatic disease being markers of an adverse outcome.

Floating thrombi on the Eustachian valve as a complication of venous thromboembolic disease

Floating right heart thrombi can occur in 4-18% of patients with pulmonary embolism. Usually, the diagnosis is done by echocardiography and carries an important prognostic significance as thrombi can embolize at any moment and severe pulmonary embolism is the most frequent way of floating right heart thrombi presentation (mortality rate >40%). We present a case report of floating right thrombi in a patient with proven deep venous thrombosis complicated with nonmassive pulmonary embolism that was successfully treated with thrombolysis.

Usefulness of cardiac magnetic resonance imaging in left ventricular non‐compaction cardiomyopathy

We have read with great interest the paper published recently in your journal by Habib et al. about isolated left ventricular non-compaction in adults. As the authors say, the genetic and clinical features, prognosis and characterization of this fascinating entity remain incompletely understood and the subject of interesting debate in the scientific community. As stated by the authors, difficulties commence with the diagnostic criteria, as different timings of measurement, at systole or diastole, have been proposed. In addition even for experts, making a final diagnosis can be difficult; and echocardiography laboratories have contributed to the great increase in noncompaction cardiomyopathy diagnosis or over diagnosis. Certainly, although both 3D and contrast echocardiography can improve the assessment of this cardiomyopathy, we must not forget that cardiac magnetic resonance imaging (MRI) can also play an important role in its diagnosis. The spatial resolution of this technique, its ability for evaluating cardiac function and what is more, the tissue characterization by the late-gadolinium hyperenhancement sequence makes it an excellent tool for the diagnosis of cardiomyopathies, especially in the case of non-compaction in which differential diagnosis from other entities such as hypertrophic cardiomyopathy, can sometimes be difficult. Late gadolinium enhancement is a surrogate of myocardial fibrosis, Nucifora et al. recently published a report in this journal demonstrating correlation of fibrosis with clinical severity and ventricular dysfunction in patients with non-compaction disease. Thus, fibrosis represents a marker of poor prognosis that could be used as a stratification tool in these patients, similar to that proposed for hypertrophic cardiomyopathy. Many questions remain about left ventricular non-compaction disease, but cardiac MRI can provide some of the answers: a more precise diagnosis based on a better endomyocardial definition and tissue characterization that can help to determine patient prognosis.

Management and risk factors for mortality in very elderly patients with acute myocardial infarction

Aim:  Elderly patients often remain underrepresented in clinical trials. The aim of our study was to analyze the treatment, clinical outcome and risk factors for mortality in patients aged ≥85 years with ST‐segment elevation myocardial infarction (STEMI).

Registro del Infarto de Miocardio en Asturias: proyecto RIMAS

BACKGROUND AND OBJECTIVE: Spanish hospital registers of myocardial infarction (MI) are not uniform. The RIMAS project is trying to know the real situation of myocardial infarction in Asturias and to observe possible differences among hospitals and with other registers. PATIENTS AND METHOD: It was a cohorts study using a hospital registry of patients with MI. All cases arriving alive to all public and private-public Asturian hospitals during 1998 were included. Demographic data, cardiovascular risk factors, delays, evolution, treatments and techniques used, were all registered. RESULTS: 875 cases were registered with a coverage rate of 77%. The average age was 66.5 years (45.6% older than 70 years) and women represented 29.1%. Sixty three per cent of the patients had tobacco consumption, 43% had arterial hypertension, and 22.3% were diabetics. The extrahospital delay was 135 min and thrombolysis delay was 180 min. Thrombolytic therapy was administered to 34.1% of patients and 4% were treated with primary angioplasty. Intrahospital mortality was 14.4%. At discharge, antiagregant therapy was administrated to 94%, betablockers to 43.2%, ACE inhibitors to 33.3% and hypolipemiants to 25% of treated patients. CONCLUSIONS: People attended in Asturias with a MI are older and there is a higher percentage of women. There are delays which include the start of thrombolytic therapy. However, there are significant differences with regard to the adhesion to clinical practice guidelines between different hospitals.

Real Structural Valve Deterioration of the Mitroflow Aortic Prosthesis: Competing Risk Analysis

INTRODUCTION AND OBJECTIVES The Mitroflow aortic prosthesis is a bovine pericardial bioprosthesis specially designed to increase the valve area in relation to its size. There is controversy regarding the pattern of structural valve deterioration (SVD). Our aim was to determine the cumulative incidence of SVD, risk factors influencing its occurrence, and its impact on mortality. METHODS A total of 1028 patients were clinically and echocardiographically followed up. Because the study population was elderly and had heart disease, we used a competing risk analysis. RESULTS The percentage of patients with SVD at 5 years was 4.22% (95%CI, 2.96-5.81) and was 15.77% at 8 years (95%CI, 12.46-19.43). The incidence was higher for small valves (19mm and 21mm) reaching 6.43% at 5 years (95%CI, 4.48-8.84) and 20.06% at 8 years (95%CI, 15.53-25.01). Severe patient-prosthesis mismatch (PPM) influenced the incidence of SVD (sHR, 3.53; 95%CI, 2.20-5.66; P < .001) but moderate PPM had no impact. The most powerful predictor of mortality was the presence of SVD (HR, 4.59; 95%CI, 2.91-7.22; P < .001). CONCLUSIONS This study used a definition based on the increase in the transprosthetic gradient and found a higher incidence of SVD of the Mitroflow prosthesis than that reported by other series, especially for sizes 19mm and 21mm and in patients with severe PPM. The incidence of SVD increased exponentially from the fifth year after implantation and its occurrence led to a 4.5-fold increase in the risk of death.

Nonsyndromic thoracic aortic aneurysm and dissection: Finally answers.

a Area del Corazón del Hospital Universitario Central de Asturias, Avda Roma s/n, Oviedo, Spain b Bone andMineral ResearchUnit, IRSIN, Hospital Universitario Central de Asturias, REDinREN from ISCIII, Area del CorazónHospital Universitario Central de Asturias, AvdaRoma s/n, Oviedo, Spain c Cardiac Surgery, Hospital Universitario Central de Asturias, Area del Corazón Hospital Universitario Central de Asturias, Avda Roma s/n, Oviedo, Spain

Insufficient Lipid Control in Patients With Coronary Artery Disease: An Unresolved Problem.

Despite the difficulties in establishing causality due to multiple factors that could be related to drug-eluting or bare-metal stent thrombosis, we think the following considerations should be taken into account. A test formulation is considered bioequivalent to a reference medication if the 90% confidence interval (CI) of the geometric mean for the area under the curve (AUC) and maximum plasma concentration (Cmax) is between 80% and 125%. In the case of the polypill approved in Spain, a bioequivelence trial was conducted. The 90% CI of the geometric means for both AUC and Cmax were within these limits and so bioequivalence was demonstrated according to the accepted criterion. Specifically, in the case of acetylsalicylic acid, the 90% CIs were 96.92%-104.47% for AUC and 84.51%-95.78% for Cmax. 3 These results, which demonstrate bioequivalence for acetylsalicylic acid in the polypill compared to separate pills, suggest the polypill can be used in the same indications as acetylsalicylic acid, in this case, as a strategy for secondary prevention in patients with ischemic heart disease, regardless of the clinical presentation (after acute coronary syndrome or in chronic phase) and treatment (after percutaneous revascularization or surgery or in patients without revascularization). In different clinical trials with polypills in patients with ischemic heart disease, which include the FOCUS study, there was no evidence of increased ischemic complications compared with the separate components, although that study excluded patients with drug-releasing stents. These patients were, however, included in the SECURE (Secondary Prevention of Cardiovascular Disease in the Elderly Trial, NCT 02596126) study that randomized patients over 65 years of age with recent myocardial infarction to the polypill or the individual components.

Biscuspid aortic valve syndrome: diversity and controversy.

We have read with great interest the manuscript recently published in your journal by Allen et al. [1] about the influence of beta-blocker therapy in aortic blood flow in patients with bicuspid aortic valve (BAV). The initiative of this study is really welcome and, considering that BAV is the most frequent congenital disease, it would be interesting to design a prospective and multicentre study about this matter, although still some questions remain in the air. As we all know, BAV is a heterogeneous disease and it can present as an isolated valvulopathy or in association with other congenital diseases and aortic diseases such as dilatation of the ascending aorta and aortic coarctation. A recent publication by Disha et al. opens an interesting debate about the follow-up of patients with BAV and normal aortic size at the moment of valvular surgery. As authors said, there is a lack of data regarding the risk of aortic events in this subgroup of patients and here is a new issue of concern: bicuspid aortopathy represents a spectrum of different proximal aortic phenotypes which are the manifestation of a genetic complexity still unsolved [2]. As it is known, alterations in the aortic media and differences in aortic elastic properties and wall stress are also present in the aortopathy associated to BAV, but further studies are still needed in order to identify not only genes responsible for BAV but also the different phenotypes associated with this entity or syndrome. In this scenario of heterogeneity, diversity and controversy we think that of course, preoperative evaluation of aortic root is mandatory and, until more clear evidence exists, a periodically follow-up after aortic valve surgery should be carried out. About this last issue and, in order to answer questions, prospective and multicentre studies would also be welcome.