Revista Espanola de Cardiologia Suplementos最新文献

Atrial fibrillation is the most common arrhythmia seen in clinical practice. Its prevalence has increased substantially in developed countries because of population aging. Atrial fibrillation is the primary cause of cardioembolic stroke and oral anticoagulant therapy can considerably reduce its risk. Moreover, the number of patients with a cardiac implantable electronic device is increasing. Since these devices have the ability to detect heart rhythm alterations and to store electrograms, they are highly effective tools for detecting atrial high rate episodes, which in most patients usually correspond to episodes of atrial fibrillation or, to a lesser extent, to atrial flutter or tachycardia. Numerous studies have shown that episodes of subclinical atrial fibrillation are associated with an increased risk of thromboembolic events, although it has not been possible to demonstrate a temporal relationship between the two. To date, the efficacy of oral anticoagulants in patients with subclinical atrial fibrillation has been assessed in only one clinical trial, with negative results. Therefore, and until more information is available, the clinical decision on whether to start oral anticoagulant therapy in patients with subclinical atrial fibrillation is not straightforward and, at present, such treatment is not supported by solid clinical evidence.

The aim of this review was to provide a practical guide to, and summary of, the imaging techniques currently available for evaluating patients with atrial fibrillation. In addition, the potential diagnostic, prognostic and therapeutic uses of these techniques are also discussed. This is a broad field in constant development. Nevertheless, today imaging is a vital aid to decision-making for patients with atrial fibrillation seen in routine clinical practice.

Edoxaban is a potent, selective, direct, reversible inhibitor of coagulation factor Xa. Because of its mechanism of action, edoxaban prolongs the prothrombin time and the activated partial thromboplastin time and reduces anti-factor-Xa activity. In both in vitro and in vivo models, edoxaban is a more effective antithrombotic than fondaparinux. Given orally, the drug rapidly (i.e. in 1–2 hours) reaches its peak plasma concentration and achieves its maximum effect on various antithrombotic biomarkers (e.g. prothrombin time, activated partial thromboplastin time and anti-factor-Xa activity). Edoxaban (15–150 mg once daily) has a linear pharmacokinetic profile. It is readily absorbed when given orally (the bioavailability is 62%), but, unlike other factor-Xa inhibitors, it exhibits only poor binding to plasma proteins and is not biotransformed via CYP3A4. It is eliminated by biliary and renal routes and has a half-life of 10–14 hours, which enables edoxaban to be administered once daily. Exposure to the drug is independent of age, sex and ethnicity, but increases as the patient's weight and renal function decrease.

Edoxaban has been studied extensively in phase-III trials, for example, for nonvalvular atrial fibrillation (the ENGAGE AF-TIMI 48 study), for the prevention of recurrent venous thromboembolism (the Hokusai-VTE study) and for the prevention of thromboembolism after orthopedic surgery (the STARS study). In addition, a number of recently published, subanalyses of pivotal trials deserve consideration: these concern different subtypes of stroke and peripheral embolism in patients receiving amiodarone and the treatment of elderly patients.

Transcatheter aortic valve implantation is associated with a relatively high rate of complications, which can be serious in some cases. However, the improvements in device design and implantation techniques that have taken place since early experience with the procedure, combined with better understanding of possible complications and their risk factors, have contributed to a substantial reduction in the incidence of most complications. This article reviews recent findings on the most important complications of transcatheter aortic valve implantation.

The joint guidelines of the European Society of Cardiology and the European Atherosclerosis Society on the management of dyslipidemia include a number of interesting clinical features: risk stratification provides the basis for selecting the type and intensity of lipid-lowering treatment; the principal therapeutic target is the low-density lipoprotein cholesterol level; the precise treatment target for this parameter depends on the level of risk (<70 mg/dl for very-high-risk patients and <100 mg/dl for high-risk patients); potent statins, given at a high dose, are the drugs of choice for achieving these goals; and particular recommendations must be followed for a number of common clinical scenarios: e.g. the elderly, women, patients with chronic kidney disease and secondary prevention.

Today heart transplantation is an accepted and established treatment for advanced heart failure. However, since the first procedure in Spain was performed in 1984, there have been substantial, unfavorable changes in donor and recipient profiles, as well as in the circumstances under which patients present for transplantation. These changes have taken place in parallel with medical and surgical advances in heart transplantation, such that, overall, outcomes have not been greatly affected. Nevertheless, it is important that the number of transplantations is either maintained or increased, that the good results obtained so far are sustained, that organs continue to be allocated as fairly as possible and that mortality among patients on the waiting list is reduced. This article considers the changes that have occurred in the field and reviews proposals for future improvements.

Heart transplantation in Spain achieved maturity some time ago in terms of outcomes and the number of procedures performed. The main limitation has been a lack of suitable donors. This article reviews strategies currently under discussion for achieving progress in the field, whether by increasing the number of donors, by more rational selection of transplant candidates or by better planning at the national level. The emergence of mechanical circulatory assist devices, used either as a complement or an alternative to transplantation, is the single factor that will have the greatest influence on heart transplantation in the future. Heart failure is a common, chronic and complex condition, whose treatment requires the cooperation of different tiers within the health-care system at the national level. Formal regional networks that enable such cooperation must be established, beginning with the adoption of common terminology. Of particular relevance is the network established for the integrated treatment of cardiogenic shock. Finally, the ongoing training of specialists in the field should be recognized officially. The Spanish Society of Cardiology should take the first steps on the regulatory path towards establishing certification in this subspecialty – this will help harmonize practice in the field of heart failure in Spain with that in other developed countries.