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Introduction and objectives Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown. Methods We present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory. Results Between June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non–ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P = .004) and angiographic presentation as intramural hematoma (OR, 4.96; P = .028). Conclusions In Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events. Registered at ClnicalTrials.gov (Identifier: NCT03607981).

Introduction and objectives Severe symptomatic aortic stenosis carries a very poor prognosis. Transcatheter aortic valve replacement has been demonstrated to change the natural history of the disease. However, it is not known whether the probability of survival in older patients receiving this treatment returns to a similar value to that in the general population. Our objective was to determine survival in these patients vs that in the general population. Methods We retrospectively analyzed the survival curves of patients older than 75 years who underwent transcatheter aortic valve implantation (TAVI) at our hospital and compared them with those in the general population of the same age, sex, and geographic region by using data from the Spanish National Institute of Statistics. Results We analyzed 526 patients. Among postoperative survivors, survival curves were similar between the 2 groups during most of the follow-up. In TAVI patients, the probability of survival at 1, 3, 5, and 8 years of follow-up was 90.58% (confidence interval [CI] 95%, 87.54-92.91), 72.51% (95%CI, 67.38-76.97), 53.23% (95%CI, 46.52-59.48), and 35.73% (95%CI, 27.72-43.80). In the reference population, these percentages were 91.93%, 75.63%, 59.6%, and 37.47%. Conclusions Long-term survival in elderly patients undergoing TAVI is influenced by postoperative mortality. In patients surviving the postoperative period, the probability of survival returns to a similar value to that in the general population of the same age, sex, and geographical area.

Resumen La incorporacion precoz del enfermo al que se ha realizado una angioplastia con stent a su vida habitual, por ausencia de impedimentos propios de la tecnica, ha permitido incluir mas pronto a estos pacientes en la fase II de la rehabilitacion cardiaca. Aunque la rehabilitacion del paciente coronario sigue para todos los pacientes unas pautas generales que pretenden abordar desde un punto de vista de prevencion secundaria la aterosclerosis coronaria, las circunstancias de cada enfermo, entre las que se incluye la tecnica con que ha sido revascularizado, determinan aspectos individuales de la rehabilitacion del enfermo con cardiopatia isquemica. El ejercicio fisico continuado (entrenamiento fisico) produce, por si mismo, grandes beneficios cardiovasculares para la prevencion cardiovascular primaria y secundaria. En pacientes con infarto disminuye la mortalidad y mejora la capacidad funcional, la funcion ventricular y el remodelado ventricular, y hay esperanzas de que pueda mejorar la circulacion colateral. Tambien mejora la funcion endotelial y estimula la circulacion de celulas madre. Se ha demostrado que el entrenamiento fisico tras revascularizacion percutanea disminuye el numero de eventos y que en pacientes con angina estable el entrenamiento fisico produce menos eventos que la revascularizacion percutanea.

W Aortic stenosis A B S T R A C T Introduction and objectives: There is little information on the use of transcatheter aortic valve implantation in patients with severe aortic stenosis and porcelain aorta. The primary aim of this study was to analyze death from any cause after CoreValve W implantation in patients with severe aortic stenosis, with and without porcelain aorta. Methods: In this multicenter, observational prospective study, carried out in 3 hospitals, percutaneous aortic valves were implanted in 449 patients with severely calcified aortic stenosis. Of these, 36 (8%) met the criteria for porcelain aorta. The primary end-point was death from any cause at 2 years. Results: Patients with porcelain aorta more frequently had extracardiac vascular disease (11 (30.6%) vs 49 (11.9%); P=.002), prior coronary revascularization (15 (41.7%) vs 98 (23.7%); P=.017), and dyslipidemia (26 (72.2%) vs 186 (45%); P=.02). In these patients, there was greater use of general anesthesia (15 (41.7%) vs 111 (16.9%); P=.058) and axillary access (9 (25%) vs 34 (8.2%); P=.004). The success rate of the procedure (94.4 vs 97.3%; P=.28) and the incidence of complications (7 (19.4%) vs 48 (11.6%); P=.20) were similar in both groups. There were no statistically significant differences in the primary end point at 24 months of follow-up (8 (22.2%) vs 66 (16%); P=.33). The only predictive variable for the primary end point was the presence of complications during implantation (hazard ratio=2.6; 95% confidence interval, 1.5- 4.5; P=.001). Conclusions: In patients with aortic stenosis and porcelain aorta unsuitable for surgery, percutaneous implantation of the CoreValve W self-expanding valve prosthesis is safe and feasible.

Introduction and objectives High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients. Methods A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8 h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event. Results Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P =.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P =.004). N-terminal pro-brain natriuretic peptide elevation (>125 ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P =.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P =.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide. Conclusions In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.

Introduction and objectives Traditionally, the oral glucose tolerance test has been useful to diagnose unknown diabetes. Recently, the American Diabetes Association committee has accepted glycated hemoglobin ≥6.5% as a criterion for unknown diabetes. The aim was to determine the benefit of glycated hemoglobin for diagnosing unknown diabetes and also create a predictive model that adjusts the indication for oral glucose tolerance test in coronary patients. Methods We examined the glycemic profile of 338 coronary patients without previous diagnosis of diabetes, applying 2010 American Diabetes Association criteria. A unknown diabetes risk predictive model was developed using logistic regression analysis, and then validated in another cohort. Results Using the glycated hemoglobin criteria and/or fasting plasma glucose, unknown diabetes was diagnosed in 26 patients. The remaining patients were classified according to oral glucose tolerance test as follows: unknown diabetes 53 (17%), prediabetes 144 (46.2%), and normoglycemic 115 (36.8%). The diagnostic method for unknown diabetes was fasting plasma glucose in 25.3%, glycated hemoglobin in 7.6%, and oral glucose tolerance test in 67.1%. A risk model including fasting plasma glucose, glycated hemoglobin, left ventricular ejection fraction, age, and noncoronary vascular disease was shown to effectively predict unknown diabetes after oral glucose tolerance test: area under the ROC curve 0.8 (95% interval confidence: 0.74-0.87). When the oral glucose tolerance test is restricted to patients with a risk score >6 (31% of our sample) we properly identify 83% of unknown diabetes cases (sensitivity: 75%, specificity: 73%, positive predictive value: 40%, negative predictive value: 93%). The model was adequately validated in another cohort of 115 patients (area under the ROC curve 0.84 [95% interval confidence: 0.74-0.95]). Conclusions In coronary patients, glycated hemoglobin alone failed to detect many cases of unknown diabetes. However, its inclusion in a risk prediction model leads to optimizing the usefulness of oral glucose tolerance test.

Introduction and objectives: Currently air pollution is considered as an emerging risk factor for cardiovascular disease. Our objective was to study the concentrations of particulate matter in ambient air and analyze their relationship with cardiovascular risk factors in patients admitted to a cardiology department of a tertiary hospital with the diagnosis of heart failure or acute coronary syndrome (ACS). Methods: We analyzed 3950 consecutive patients admitted with the diagnosis of heart failure or ACS. We determined the average concentrations of different sizes of particulate matter (

Traditionally, scientific journals present a summary of the previous 12 months’ activity in the final issue of each year. Thus, they keep subscribers and readers in general up to date with results, innovations and actions taken in the year that is ending. Revista Espanola de Cardiologia (REC) has long published reports like this, 1-3 and the new editorial team intends to continue the tradition. In this article we offer the bibliometric data, a summary of various activities, and initial results of the new initiatives we described in our initial presentation. 4 The current report was presented and debated in detail with the Editorial Committee and Editorial Board during their annual meeting, which coincided with the Congress on Cardiovascular Diseases in Valencia. Furthermore, part of the information was distributed to the plenary session of the Spanish Society of Cardiology (SEC), when the Scientific Sections and all members at the General Assembly were informed.

Introduction and objectives Drug-eluting stents (DES) reduce the restenosis rate in native vessels. However, results in saphenous vein grafts (SVG) are less clear. The aim of this study was to compare DES and bare metal stents (BMS) in de novo stenosis in SVG. Methods The study included all percutaneous interventions involving a DES in SVG carried out at five centers up until July 2007. Findings were compared with those in a historical cohort that used conventional stents at 2 centers. The study analyzed in-hospital and long-term outcomes and predictors of survival and revascularization. Results The study included 107 stenoses treated with DESs in 98 patients and 130 stenoses treated with BMS in 113 patients. The DES group was older at baseline and had thrombus less often. There were also procedural differences: in the DES group, stents were longer, direct stenting was used less, and the stent diameter was smaller. The proportion of patients who experienced cardiac death by 12, 24, and 30 months was 95%(2%), 91%(3%), and 89%(3%), respectively, in the DES group and 95%(2%), 90%(3%) and 87%(3%) in the BMS group ( P =.66). The proportion without target vessel revascularization at 12, 24 and 30 months was 90%±3%, 86%±4% and 83%(4%), respectively, in the DES group and 94%±2%, 87%(3%) and 87%(3%) in the BMS group ( P =.49). The only predictor of cardiac death was the ejection fraction. There was no predictor of revascularization. Conclusions In our series, using DESs in SVGs was not associated with a reduction in mortality or target vessel revascularization. The only predictor of cardiac death was the ejection fraction. There was no predictor of revascularization.

Introduction and objectives. Recently we reported that prolongation of the corrected QT (CTc) interval is an independent risk factor in patients with unstable angina and acute ischemic changes. The aim of this study was to determine the prognostic value of this variable in patients with non-ST-segment elevation acute coronary syndrome who do not exhibit acute ischemic changes on admission ECG. Methods. The study included 55 patients with this syndrome. On admission, a standard 12-lead ECG was recorded, the cardiac troponin-T was measured and a TIMI (Thrombolysis in Myocardial Infarction) risk score was calculated. The primary endpoint was the combination of nonfatal acute myocardial infarction, percutaneous or surgical revascularization, and cardiac death up to 30 days after discharge. Two independent investigators measured the QT interval manually and the corrected value was derived using Bazett’s formula. In the statistical analysis, the following cut-off points were used: the median TIMI risk score, a cardiac troponin-T level of 0.04 ng/mL, and a QTc of 0.458 s. Results. Of the 21 patients (38%) who reached the primary endpoint, 17 (81%) had QTc prolongation. Binary logistic regression analysis showed that QTc prolongation was an independent predictor of the combined endpoint. Conclusions. This study shows that QTc prolongation is an independent predictor of cardiovascular risk in patients with non-ST-segment elevation acute coronary syndrome but without acute ischemic changes on admission ECG.

Radial artery access improves the patient's well-being, permits earlier ambulation and diminishes vascular complications after cardiac catheterization. Using the same catheter to study the left and right coronary arteries may facilitate the technique. In a cohort of 100 patients we prospectively analyzed the possibility of studying both coronary arteries with a Judkins left 3.5 catheter. The variables studied were percentage of successful access, complications, and procedural time from insertion of the guiding catheter to the end of ventriculography. It was possible to catheterize both coronary arteries with the same catheter in 94 cases (94%) with a procedural time of 16.7 (6.8) min. In 6 patients a JR4 catheter was required, in one of them due to severe spasm of the right coronary artery ostium and due to impossibility to catheterize the ostium in the other 5. There were no cases of severe radial artery spasm.

Despite advances in basic and clinical cardiovascular research, coronary artery disease remains one of the main causes of death and disability in the western world. Inflammation of the arterial wall is an etiologic and pathogenic mechanism involved in the onset, development and destabilization of the atherogenic process. Indeed, atherosclerosis is currently considered to be an inflammatory disease. Of the many biological markers of this inflammatory process, such as serum amyloid protein A, fibrinogen, white blood cell count, neopterin, endothelial adhesion molecules and cytokines, C-reactive protein (CRP) is the marker which has received most attention over recent years. Accumulated evidence suggests that high-sensitivity CRP is a predictor of cardiovascular risk in patients with established heart disease and in apparently healthy persons. Indeed, it has recently been suggested that CRP is a more powerful predictor of risk than levels of low density lipoprotein cholesterol (LDL-C) and that it provides added prognostic information to the conventional Framingham score. 1 Arterial inflammation and blood levels of CRP are lowered by several drugs, such as aspirin, reductase inhibitor 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA), angiotensin converting enzyme (ACE) inhibitors, thienopyridines, and peroxisome proliferator-activated receptor (PPAR) agonists, which reduce morbidity and mortality in patients with cardiovascular disease and in apparently healthy subjects. However, whether inhibition of the inflammation and the consequent reduc

The Revista Espanola de Cardiologia has traditionally been one of the principal driving forces in the diffusion of scientific knowledge in the area of cardiology. Continuous medical education has been one of the pillars in the development of many of today’s most important scientific associations. Different methods have been employed to achieve this aim, the most important being scientific meetings and conferences, traditional publications and online courses. The ‘‘Update’’ section is one of themain tools of the Revista Espanola de Cardiologia, journal of the Sociedad Espanola de Cardiologia, to achieve this purpose. In previous years, the titles have tackled areas as important as ‘‘Cardiovascular Diseases in Women’’ (2006), ‘‘Non-Coronary Arterial Disease’’ (2007), ‘‘Cardiovascular Prevention’’ (2008), ‘‘Translational Cardiovascular Medicine’’ (2009), and ‘‘The Right Heart and Pulmonary Circulation’’ (2010). All of these efforts have been very popular with the readers of the Journal. In this new edition of ‘‘Update’’, corresponding to 2011, we wanted to tackle a series of subjects that are not strictly cardiovascular, but are nonetheless very important for the cardiologist. Hence the title, ‘‘Systemic diseases and the cardiovascular system’’. The reason for choosing this topic can be summarized as follows: (1) From day to day, the patients that a cardiologist must deal with present greater complexity, due to more associated comorbidities; (2) The patients a cardiologist generally treats are generally the elderly, which contributes to a high prevalence of comorbidities as well as cardiovascular diseases; (3) Our society demands a continued ‘‘fight’’ on behalf of patients with other serious diseases, which increases demand for cardiological care; (4) Cardiologists must interact with other specialist colleagues to coordinate the treatment of complex patients; and (5) The treatment and management of people with non-cardiac diseases change rapidly, forcing cardiologists to be upto-date on everything that may affect the cardiovascular system. Even though the reader of Revista Espanola de Cardiologia will note that some of the subjects, such as those related to pregnancy or aging, do not tackle ‘‘diseases’’ as such, this title was chosen, despite its limitations, for its ability to direct the reader quickly to the content of the 2011 ‘‘Update’’. The main aim of this set of review articles is, in itself, the reason for creating it: to attempt to offer the cardiologist a practical, interesting and up-to-date compendium of the essential knowledge

Dada la importancia que tiene la formacion medica continuada en nuestra especialidad, REVISTA ESPANOLA DE CARDIOLOGIA presenta una nueva seccion de «Puesta al dia». En anos previos se han abordado temas tan interesantes como «Enfermedades cardiovasculares en la mujer» (2006), «Patologia arterial no coronaria» (2007), «Prevencion cardiovascular» (2008), «Medicina cardiovascular traslacional» (2009), «Corazon derecho y circulacion pulmonar» (2010), «Enfermedades sistemicas y corazon» (2011) y «Arritmias» (2012). En esta nueva edicion de «Puesta al dia», correspondiente al ano 2013, abordamos el tema de la «Innovacion en cardiologia». La cardiologia es una especialidad que siempre ha estado a la vanguardia de la innovacion tecnologica. Especialmente en los ultimos anos, la introduccion de nuevas herramientas tecnologicas ha abierto la puerta a una revolucion tanto en el aspecto diagnostico como en el terapeutico. Las tecnicas de imagen cardiaca evolucionan con rapidez (ecocardiograma tridimensional, tomografia computarizada con medicion de reserva fraccional de flujo coronario, etc.) y son un pilar fundamental en el diagnostico de muchas enfermedades cardiovasculares. El desarrollo de nuevos materiales —como cateteres, bioprotesis especificamente disenadas para el implante percutaneo y stents— ha facilitado la aplicacion de soluciones terapeuticas eficaces con una excelente relacion riesgo-beneficio. Ademas, esta innovacion permite potenciar la investigacion basica y clinica mas avanzada, como ocurre en el caso de los stents bioabsorbibles. A lo largo de los distintos capitulos, como ya se hizo en ediciones previas, se ha intentado abordar los temas mas candentes y que van a seguir cambiando la cardiologia. Para ello, y como no podia ser diferente, contamos con autores de gran prestigio y con gran experiencia en los diferentes temas tratados. El primer capitulo (Dr. Ibanez) analiza el futuro de las tecnicas de imagen, poniendo especial atencion en las que se pueden combinar en una unica exploracion por paciente. El Prof. Clemmensen expone el estado actual y futuro de la telemedicina y los nuevos sistemas de monitorizacion electrocardiografica, aplicado a marcapasos, desfibriladores y pacientes con insuficiencia cardiaca. El Prof. Ackerman nos pone al dia en el estado de la medicina personalizada y el diagnostico genetico. La Dra. Galvez analiza el estado actual y futuro de la ingenieria tisular cardiaca y la neoorganogenesis. En el campo de la cardiologia intervencionista, los capitulos siguientes abordan el presente y el futuro de