[Show abstract][Hide abstract] ABSTRACT: Severe symptomatic aortic stenosis is a serious condition of elderly, mostly geriatric patients with a poor prognosis if the valve is not replaced. Since geriatricians are able to provide major expertise in the prognostic assessment as well in the clinical management of these patients, they need to be more closely involved in the decision making process. For this reason the European Union Geriatric Medicine Society (EUGMS) represented by the authors phrased three propositions: (1) geriatricians need to be aware of the impact of severe aortic stenosis on patients’ outcomes and should be encouraged to take an active role in aortic stenosis management; (2) they need to be aware of treatment options and are required to support multidisciplinary teams with their expertise in assessing geriatric patients; (3) they should routinely perform a comprehensive geriatric assessment in patients with severe aortic stenosis scheduled to undergo surgical or transcatheter aortic valve replacement and during long-term follow-up.
European geriatric medicine 03/2015; 6(3). DOI:10.1016/j.eurger.2014.12.011 · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims: To describe the characteristics of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). Methods and results: This study was performed using the GAMES database, a national prospective registry of consecutive patients with IE in 26 Spanish hospitals. Of the 739 cases of IE diagnosed during the study, 1.3% were post-TAVI IE, and these 10 cases, contributed by five centres, represented 1.1% of the 952 TAVIs performed. Mean age was 80 years. All valves were implanted transfemorally. IE appeared a median of 139 days after implantation. The mean age-adjusted Charlson comorbidity index was 5.45. Chronic kidney disease was frequent (five patients), as were atrial fibrillation (five patients), chronic obstructive pulmonary disease (four patients), and ischaemic heart disease (four patients). Six patients presented aortic valve involvement, and four only mitral valve involvement; the latter group had a higher percentage of prosthetic mitral valves (0% vs. 50%). Vegetations were found in seven cases, and four presented embolism. One patient underwent surgery. Five patients died during follow-up: two of these patients died during the admission in which the valve was implanted. Conclusions: IE is a rare but severe complication after TAVI which affects about 1% of patients and entails a relatively high mortality rate. IE occurred during the first year in nine of the 10 patients.
EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 02/2015; DOI:10.4244/EIJY15M02_05. · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As in other fields, understanding of vascular risk and rehabilitation is constantly improving. The present review of recent epidemiological update shows how far we are from achieving good risk factor control: in diet and nutrition, where unhealthy and excessive societal consumption is clearly increasing the prevalence of obesity; in exercise, where it is difficult to find a balance between benefit and risk, despite systemization efforts; in smoking, where developments center on programs and policies, with the electronic cigarette seeming more like a problem than a solution; in lipids, where the transatlantic debate between guidelines is becoming a paradigm of the divergence of views in this extensively studied area; in hypertension, where a nonpharmacological alternative (renal denervation) has been undermined by the SYMPLICITY HTN-3 setback, forcing a deep reassessment; in diabetes mellitus, where the new dipeptidyl peptidase-4 and sodium-glucose cotransporter type 2 inhibitors and glucagon like peptide 1 analogues have contributed much new information and a glimpse of the future of diabetes treatment, and in cardiac rehabilitation, which continues to benefit from new information and communication technologies and where clinical benefit is not hindered by advanced diseases, such as heart failure. Our summary concludes with the update in elderly patients, whose treatment criteria are extrapolated from those of younger patients, with the present review clearly indicating that should not be the case.
Revista Espa de Cardiologia 01/2015; 68(2). DOI:10.1016/j.recesp.2014.10.006 · 3.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: -Clinical trials in heart failure have focused on the improvement in symptoms or decreases in the risk of death and other cardiovascular events. Little is known about the effect of drugs on the risk of clinical deterioration in surviving patients.
-We compared the angiotensin-neprilysin inhibitor LCZ696 (400 mg daily) with the angiotensinconverting enzyme inhibitor enalapril (20 mg daily) in 8399 patients with heart failure and reduced ejection fraction in a double-blind trial. The analyses focused on prespecified measures of nonfatal clinical deterioration. In comparison with the enalapril group, fewer LCZ696-treated patients required intensification of medical treatment for heart failure (520 versus 604; hazard ratio, 0.84; 95% confidence interval, 0.74-0.94; P=0.003) or an emergency department visit for worsening heart failure (hazard ratio, 0.66; 95% confidence interval, 0.52-0.85; P=0.001). The patients in the LCZ696 group had 23% fewer hospitalizations for worsening heart failure (851 versus 1079; P<0.001) and were less likely to require intensive care (768 versus 879; 18% rate reduction, P=0.005), to receive intravenous positive inotropic agents (31% risk reduction, P<0.001), and to have implantation of a heart failure device or cardiac transplantation (22% risk reduction, P=0.07). The reduction in heart failure hospitalization with LCZ696 was evident within the first 30 days after randomization. Worsening of symptom scores in surviving patients was consistently more common in the enalapril group. LCZ696 led to an early and sustained reduction in biomarkers of myocardial wall stress and injury (N-terminal pro-Btype natriuretic peptide and troponin) versus enalapril.
-Angiotensin-neprilysin inhibition prevents the clinical progression of surviving patients with heart failure more effectively than angiotensin-converting enzyme inhibition. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
[Show abstract][Hide abstract] ABSTRACT: Background
Based on computed tomography (CT) findings, invasive pulmonary aspergillosis (IPA) can be classified in two patterns: airway-invasive (AIR) or angio-invasive (ANG).
AIR-IPA was considered when the CT revealed peribronchial consolidation or a tree in-bud pattern and ANG-IPA when a nodule, cavity, halo sign, infarct shaped or mass like consolidation was found. We evaluated the correlation among IPA CT-pattern and outcome in heart transplant (HT) recipients.
From 1988 to 2011, 27 HT recipients with a CT scan performed at the time of IPA diagnosis were included in the study. AIR- patients (10, 37.1%) were compared with ANG-patients (17, 62.9%). During the post-transplantation period before developing IPA, AIR-patients required more frequently hemodialysis (40% vs 5.9%, p=0.04). AIR patients also had more intercurrent bacterial pneumonia (23.5% vs70%, p<0.001), and IPA was diagnosed later after symptoms onset (2.7 vs 8.5 d, p=0.09). After diagnosis, AIR-IPA patients required more mechanical ventilation (23.5% vs 90%, p<0.01) and had a higher related mortality rate (23.5% vs 70%, p=0.04).
Our study shows that AIR-pattern represents 37% of IPA episodes in HT recipients and that it is associated with a more protracted clinical presentation, later diagnosis and higher mortality rate.
The Journal of Heart and Lung Transplantation 10/2014; 33(10). DOI:10.1016/j.healun.2014.05.003 · 5.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The number of patients older than 80 years is steadily increasing and it represents the main basis for increasing population figures in developed countries. Cardiovascular diseases are the leading causes of mortality and disability causes result in a huge burden of disease in elderly people. However, available scientific evidence to support decision-making on cardiovascular prevention in elderly patients is scarce. Currently available risk assessment scales cannot be applied to elderly people. They are focused on cardiovascular mortality risk and do not provide information on factors with a proven prognostic value in the very old (functioning disability, dementia). Elderly people are a highly heterogeneous population, with a variety of co-morbidities, as well as several functional and cognitive impairment degrees. Furthermore, aging-associated physiological changes and common use of multiple drugs result in an increased risk of adverse drug reactions. Thus, drug use should always be based on a risk/benefit assessment in the elderly. Therefore, therapeutic decision-making in the very old must be an individually tailored and based on an appropriate clinical judgement and a comprehensive geriatric assessment. The current consensus report aims to present a proposal for clinical practices in the primary and secondary cardiovascular prevention in the very old and to provide a number of recommendations on lifestyle changes and drug therapy for the management of major cardiovascular risk factors.
[Show abstract][Hide abstract] ABSTRACT: The occurrence of new conduction abnormalities that lead to the requirement for new permanent pacemaker implantation (PPI) has been reported to be the most frequent complication following transcatheter aortic valve implantation (TAVI). However, the reasons and clinical significance of TAVI-induced conduction disturbances and PPI are yet to be fully delineated. This review aims to evaluate the procedure- and patient-related factors that may contribute to the development of aberrant atrioventricular conduction following TAVI as well as its clinical consequences.
Clinical Research in Cardiology 07/2014; 104(1). DOI:10.1007/s00392-014-0739-6 · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims
Surgery for infective endocarditis (IE) is associated with high mortality. Our objectives were to describe the experience with surgical treatment for IE in Spain, and to identify predictors of in-hospital mortality.
Prospective cohort of 1000 consecutive patients with IE. Data were collected in 26 Spanish hospitals.
Surgery was performed in 437 patients (43.7%). Patients treated with surgery were younger and predominantly male. They presented fewer comorbid conditions and more often had negative blood cultures and heart failure. In-hospital mortality after surgery was lower than in the medical therapy group (24.3 vs 30.7%, p = 0.02). In patients treated with surgery, endocarditis involved a native valve in 267 patients (61.1%), a prosthetic valve in 122 (27.9%), and a pacemaker lead with no clear further valve involvement in 48 (11.0%). The most common aetiologies were Staphylococcus (186, 42.6%), Streptococcus (97, 22.2%), and Enterococcus (49, 11.2%). The main indications for surgery were heart failure and severe valve regurgitation. A risk score for in-hospital mortality was developed using 7 prognostic variables with a similar predictive value (OR between 1.7 and 2.3): PALSUSE: prosthetic valve, age ≥ 70, large intracardiac destruction, Staphylococcus spp, urgent surgery, sex [female], EuroSCORE ≥ 10. In-hospital mortality ranged from 0% in patients with a PALSUSE score of 0 to 45.4% in patients with PALSUSE score >3.
The prognosis of IE surgery is highly variable. The PALSUSE score could help to identify patients with higher in-hospital mortality.
International Journal of Cardiology 07/2014; DOI:10.1016/j.ijcard.2014.04.266 · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article summarizes the main developments reported in 2013 on ischemic heart disease, together with the most important innovations in the management of acute cardiac patients.
Revista Espanola de Cardiologia 02/2014; 67(2):120-6. DOI:10.1016/j.rec.2013.11.001 · 3.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS).
Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index.
Transnational registry in Spain.
We included 928 patients aged ≥80 years with severe symptomatic AS.
Aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI) or conservative therapy.
Mean age was 84.2±3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%), and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk (322 [47.1%]), other medical motives (193 [28.2%]), patient refusal (134 [19.6%]), and family refusal in the case of incompetent patients (35 [5.1%]). The mean time from treatment decision to AVR was 4.8±4.6 months and to TAVI 2.1±3.2 months, p<0.001. During follow-up (11.2 to 38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18, and 24 months were 81.8%, 72.6%, 64.1%, and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49 to 0.93; p=0.016), AVR HR 0.56 (95% CI 0.39 to 0.8; p=0.002).
Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis. This article is protected by copyright. All rights reserved.
Journal of Internal Medicine 12/2013; 275(6). DOI:10.1111/joim.12174 · 5.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Advanced heart failure (HF) is associated with high morbidity and mortality; it represents a major burden for the health system. Episodes of acute decompensation requiring frequent and prolonged hospitalizations account for most HF-related expenditure. Inotropic drugs are frequently used during hospitalization, but rarely in out-patients. The LAICA clinical trial aims to evaluate the effectiveness and safety of monthly levosimendan infusion in patients with advanced HF to reduce the incidence of hospital admissions for acute HF decompensation.
The LAICA study is a multicenter, prospective, randomized, double-blind, placebo-controlled, parallel group trial. It aims to recruit 213 out-patients, randomized to receive either a 24-h infusion of levosimendan at 0.1 μg/kg/min dose, without a loading dose, every 30 days, or placebo.
The main objective is to assess the incidence of admission for acute HF worsening during 12 months. Secondarily, the trial will assess the effect of intermittent levosimendan on other variables, including the time in days from randomization to first admission for acute HF worsening, mortality and serious adverse events.
The LAICA trial results could allow confirmation of the usefulness of intermittent levosimendan infusion in reducing the rate of hospitalization for HF worsening in advanced HF outpatients.
[Show abstract][Hide abstract] ABSTRACT: This article is a joint document of the Spanish Society of Geriatrics and Gerontology, the Spanish Society of Palliative Care and the Section of Geriatric Cardiology of the Spanish Society of Cardiology. Its aim is to address the huge gap that exists in Spain with regard to the management of implantable cardioverter defibrillators (ICDs) in the final stages of life. It is increasingly common to find patients carrying these devices that are in the terminal stage of an advanced disease. This occurs in patients with advanced heart disease and subsequent heart failure refractory to treatment but also in a patient with an ICD who develops cancer disease, organ failure or other neurodegenerative diseases with poor short-term prognosis. The vast majority of these patients are over 65, so the paper focuses particularly on the elderly who are in this situation, but the decision-making process is similar in younger patients with ICDs who are in the final phase of their life.
Revista Clínica Española 10/2013; 214(1). DOI:10.1016/j.rceng.2013.10.002 · 1.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
In patients with acute myocardial infarction treated with primary angioplasty, the inability to achieve successful coronary reperfusion is associated with higher mortality. The objective of the study was to identify which characteristics may predict a lower angiographic success rate in patients with acute myocardial infarction treated with coronary angioplasty.
Patients and methods
The study population is constituted by the 790 patients with acute myocardial infarction that were treated with angioplasty within the 12 hours after the onset of symptoms from 1991 to 1999 at our institution. A successful angiographic result was considered in presence of a residual stenosis < 50% and a TIMI flow 2 or 3 after the procedure.
A successful angiographic result and a final TIMI 3 flow were achieved in 736 (93.2%) and 652 (82.5%) patients, respectively. In-hospital mortality was higher in patients with angiographic failure than in those with angiographic successful result (48 vs. 10%; p < 0.01). Age under 65 (91 vs. 95%; p = 0.02), non smoking (90 vs. 96%; p < 0,01), previous infarction (87 vs. 94%; p < 0.01), angioplasty after failed thrombolysis (83 vs. 94%; p = 0.02), cardiogenic shock (80 vs. 95%; p < 0.01), undetermined location (67 vs. 93%; p < 0.01), non-inferior location (92 vs. 96%; p = 0.04), left bundle branch block (64 vs. 94%; p < 0.01), multivessel disease (91 vs. 95%; p = 0.02), left ventricular ejection fraction < 0.40 (89 vs. 97%; p < 0.01), no utilization of coronary stenting (90 vs. 96%; p < 0.01), and use of intraaortic balloon counterpulsation pump (82 vs. 95%; p < 0.01) were associated with a lower angiographic success rate. In the multivariable analysis, the following were independent predictors for angiographic failure: left bundle branch block (odds ratio [OR], 12.95; CI 95%, 3.00-53.90), cardiogenic shock (OR, 4.20; CI 95%, 1.95-8.75), no utilization of coronary stent (OR, 3.44; CI 95%, 1.71-7.37), and previous infarction (OR, 2.82; CI 95%, 1.29-5.90).
Coronary angioplasty allows a successful coronary recanalization in most patients with acute myocardial infarction. Some basic characteristics, however, may identify some subsets in which a successful angiographic result may be more difficult to obtain.
Revista Espa de Cardiologia 07/2013; 53(9):1169–1176. DOI:10.1016/S0300-8932(00)75221-3 · 3.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The influence of new-onset atrial fibrillation (AF) on the long-term prognosis of nonagenarians who survive acute myocardial infarction (AMI) has not been demonstrated.
Our aim was to study the association between new-onset AF and long-term prognosis of nonagenarians who survive AMI.
From a total of 96 patients aged ≥89 years admitted during a 5-year period, 64 (67 %) were discharged alive and are the focus of this study.
Mean age was 91.0 ± 2.0 years, and 39 patients (61 %) were women. During admission, 9 patients (14 %) presented new-onset AF, 51 (80 %) did not present AF, and 4 (6 %) had chronic AF. During follow-up (mean 2.3 ± 2.6 years; 6.6 ± 3.6 years in survivors), 58 patients (91 %) died, including the 9 patients with new-onset AF. Cumulative survival at 6, 12, 18, 24, and 30 months was 68.3 %, 57.2 %, 49.2 %, 47.6 %, and 31.8 %, respectively. The only two independent predictors of mortality in the multivariate analysis were age (hazard ratio [HR] 1.14; 95 % confidence interval [CI] 1.01-1.28; p = 0.04) and new-onset AF (HR 2.3; 95 % CI 1.1-4.8; p = 0.02).
New-onset AF is a marker of poor prognosis in nonagenarians who survive AMI.
Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 07/2013; 21(11). DOI:10.1007/s12471-013-0439-2 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article summarizes the main developments reported during the year 2012 concerning ischemic heart disease, together with the most relevant innovations in the management of acute cardiac patients.Full English text available from:www.revespcardiol.org/en.
Revista Espa de Cardiologia 03/2013; 66(3):198–204. DOI:10.1016/j.recesp.2012.10.019 · 3.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article summarizes the main developments reported during the year 2012 concerning ischemic heart disease, together with the most relevant innovations in the management of acute cardiac patients. Full English text available from:www.revespcardiol.org/en.
Revista Espa de Cardiologia 01/2013; 66(3). DOI:10.1016/j.rec.2012.10.015 · 3.34 Impact Factor