Revista española de cardiología (English ed.)最新文献

Introduction and objectives: Stent implantation is an established treatment for aortic coarctation (CoA) in adults. In pediatric patients, however, ongoing somatic growth necessitates repeated stent redilations, and the optimal timing of these procedures remains undefined. This retrospective study aimed to identify an objective association between stent diameter and body growth parameters, thereby providing a basis for prognostic assessment and structured planning of redilation strategies.

Methods: In the derivation cohort, all stent implantations and redilations performed in 155 patients younger than 20 years with CoA at a tertiary center were analyzed (218 interventions; median age 10.1 years, IQR, 3.4-14.4). The findings were subsequently validated in an independent validation cohort from another tertiary center, comprising 198 patients (323 interventions; median age 7.5 years, IQR, 1.3-14.6).

Results: To assess the association between stent diameter and body growth parameters, correlation analyses were performed. Despite interindividual variability, a significant linear correlation between stent diameter and body height was identified (ꞇ: 0.737, P ≤ .001) and this finding was confirmed in the validation cohort. Based on this relationship, a formula, f(x) = 0.0831•x+1.86, where x represents body height, was derived to estimate the appropriate stent diameter. This formula yields minimum and maximum reference body heights for each stent diameter, which are reached at different ages depending on individual growth velocity. These results were subsequently translated into sex-specific reference tables.

Conclusions: The derived formula enables prediction of the required stent diameter and the anticipated number of subsequent catheter-based procedures, thereby supporting rapid estimation of intervention timing throughout somatic growth.

Introduction and objectives: Gatekeeper strategies using risk factor-weighted clinical likelihood (RF-CL), alone or combined with coronary artery calcium score-weighted clinical likelihood (CACS-CL), may reduce the number of normal scans, radiation exposure, and health care costs.

Methods: Three diagnostic algorithms based on RF-CL and CACS-CL were evaluated in 1792 patients (mean age 65± 11 years; 43% female) referred for rubidium-82 (⁸²Rb) positron emission tomography (PET). Algorithm 1 deferred testing if RF-CL ≤ 5%. Algorithm 2 reclassified patients with RF-CL >5%-15% using CACS-CL and deferred testing if either RF-CL or CACS-CL was ≤ 5%. Algorithm 3 deferred testing if CACS-CL ≤ 5%. Missed diagnoses, normal scans, radiation exposure, and costs were compared with the current reference standard (CACS+PET). Endpoints were defined as small ischemia (summed difference score [SDS] ≥ 2) and relevant ischemia (≥ 10% of the myocardium).

Results: Median RF-CL and CACS-CL were 11% [6-19] and 12% [3-28], respectively. Algorithm 1 reduced radiation exposure and costs by 22.0% while maintaining high gatekeeper performance (sensitivity/negative predictive value [NPV]: 92.7%/98.2%). Algorithm 2 deferred the largest proportion of patients (36.4%) but missed small ischemia in 2.0%. Algorithm 3 demonstrated the best overall gatekeeper performance, reducing radiation exposure by 28.7% and costs by 29.7% without compromising diagnostic accuracy (sensitivity/NPV: 93.2%/98.4% for small ischemia and 97.0%/99.7% for relevant ischemia).

Conclusions: Refining RF-CL in all patients and deferring testing when CACS-CL ≤ 5% provided the most effective gatekeeper strategy in patients with suspected chronic coronary syndromes.

Introduction and objectives: Left atrial remodeling is common in hypertrophic cardiomyopathy (HCM) and is associated with atrial fibrillation (AF) and thromboembolic events. However, currently available AF risk prediction models perform poorly in patients with HCM. The left atrioventricular coupling index (LACI) is a novel imaging marker that integrates left atrial size and left ventricular filling properties and has emerged as a potential indicator of atrial remodeling and AF risk. This study aimed to evaluate the association between LACI and new-onset AF, transient ischemic attack, or ischemic stroke in patients with HCM.

Methods: We retrospectively analyzed 287 patients with HCM without a prior history of AF, transient ischemic attack, or ischemic stroke who underwent cardiac magnetic resonance imaging between 2014 and 2022. Left atrial and left ventricular volumes were measured, and LACI was calculated as the ratio of minimum left atrial volume to left ventricular end-diastolic volume. Patients were categorized into tertiles according to LACI. Left atrial strain analysis was performed. Cox proportional hazards models assessed the association between LACI and a composite endpoint including AF, transient ischemic attack, or ischemic stroke.

Results: During a median follow-up of 60 months, 51 patients (17.9%) reached the composite endpoint. Patients in the highest LACI tertile (≥ 36%) had a significantly higher risk of AF or thromboembolic events (adjusted HR, 2.88; 95%CI, 1.27-6.51; P <.001). Left atrial booster strain was also independently associated with adverse outcomes.

Conclusions: LACI and left atrial booster strain are independently associated with new-onset AF and thromboembolic events in patients with HCM.

Introduction and objectives: Hereditary transthyretin amyloidosis (hATTR) is a rare, multisystemic, autosomal dominant disease. Cardiac involvement worsens prognosis. We aimed to characterize Spanish patients with hATTR cardiac amyloidosis (hATTR-CA) and to identify predictors of poor prognosis.

Methods: We conducted a retrospective, multicenter study in 39 Spanish hospitals, including adults with genetically confirmed hATTR and cardiac involvement (January 2000-September 2022). Independent predictors of poor prognosis (death, heart transplantation, heart failure, or cardiovascular hospitalization) were identified using multivariate logistic regression. Data were also collected on clinical and genetic characteristics, management patterns, and event-free survival.

Results: A total of 442 patients were included (67.6% male; median age at diagnosis, 65 years). Fifteen TTR variants were identified, with p.Val30Met being the most frequent (64.9%). The most common extracardiac manifestation was neuropathy (64.6%). At baseline, most patients were in New York Heart Association class I-II, with progressive worsening during follow-up. Overall, 48.9% of patients were hospitalized, and 21.9% died; 25.3% of deaths were heart failure-related. Five-year event-free survival was 80.2% from symptom onset and 66.9% from diagnosis. Disease-specific treatments (tafamidis, patisiran, inotersen, or liver transplant) were associated with improved survival (P < .001). In an exploratory analysis stratified by diagnosis before vs after 2018, event-free survival did not differ significantly (HR, 1.04; 95%CI, 0.63-1.72; P = .88). Independent predictors of poor prognosis included New York Heart Association class II-IV, lower left ventricular ejection fraction, elevated N-terminal pro-B-type natriuretic peptide, and the presence of neurological involvement.

Conclusions: This national cohort-the largest reported to date-highlights the clinical and genetic heterogeneity of hATTR -CA in Spain. Early diagnosis and disease-specific therapies are essential to improving prognosis.

Introduction and objectives: Clinical practice guidelines for heart failure (HF) recommend advance care planning and assessment of patients' end-of-life preferences. However, very few studies have captured these preferences or their relationship with prognosis.

Methods: Observational, multicenter, survey-style study of patients aged 75 or older admitted for HF to internal medicine department of 60 Spanish hospitals. Patients were followed for 6 months and mortality, emergency room visits and readmissions were recorded.

Results: A total of 673 patients were included. The median age was 86 years, and they had significant comorbidity, frailty (59%), and a predominance of HF with preserved left ventricular ejection fraction (75%). A total of 92% of patients prioritized quality of life over living longer. A total of 9% had spoken with their physician about cardiopulmonary resuscitation; 29% did not want cardiopulmonary resuscitation, and 37% had not yet decided. About 15% of patients were considering requesting euthanasia. Adequate symptom control, particularly dyspnea and pain, was the patients' major priority. None of the end-of-life preferences expressed by patients were shown to be an independent prognostic factor at 6 months of follow-up.

Conclusions: Elderly patients with multiple pathologies admitted for HF prioritize quality of life and symptom control over living longer. Advance care planning for them should be systematic and proactive.