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In this observational and multicenter study, that included all patients who underwent a heart transplantation (HT) in Spain from 1984 to 2018, we analyzed the incidence, management, and prognosis of colorectal cancer (CRC) after HT. Of 6,244 patients with a HT and a median follow-up of 8.8 years since the procedure, 116 CRC cases (11.5% of noncutaneous solid cancers other than lymphoma registered) were diagnosed, mainly adenocarcinomas, after a mean of 9.3 years post-HT. The incidence of CRC increased with age at HT from 56.6 per 100,000 person-years among under 45 year olds to 436.4 per 100,000 person-years among over 64 year olds. The incidence rates for age-at-diagnosis groups were significantly greater than those estimated for the general Spanish population. Curative surgery, performed for 62 of 74 operable tumors, increased the probability of patient survival since a diagnosis of CRC, from 31.6% to 75.7% at 2 years, and from 15.8% to 48.6% at 5 years, compared to patients with inoperable tumors. Our results suggest that the incidence of CRC among HT patients is greater than in the general population, increasing with age at HT.

Resumen Introduccion y objetivos La amiloidosis cardiaca (AC) es una enfermedad infiltrativa que ha cobrado especial relevancia en los ultimos anos. El objetivo del estudio fue definir el perfil del paciente diagnosticado de AC. Metodos Estudio retrospectivo realizado entre enero de 2013 y febrero de 2020 que recoge las caracteristicas clinicas, electrocardiograficas y de pruebas de imagen de los pacientes con diagnostico de AC. Resultados Se incluyeron 44 pacientes con diagnostico confirmado de AC (17 con AC primaria y 27 con AC por transtirretina), con una edad media de 73 ± 12 anos, el 71% fueron varones. El sintoma principal de inicio fue la insuficiencia cardiaca (IC): 59%. El septo interventricular medio fue de 16 ± 3 mm y la fraccion de eyeccion del ventriculo izquierdo se encontraba preservada en el 50% de los pacientes (22 pacientes). La rentabilidad de la biopsia endomiocardica fue del 100% (n = 14). La gammagrafia con 99mTc-acido 3,3-difosfono-1,2-propanodicarboxilico resulto positiva en el 41% de los pacientes con AC primaria y en el 96% con AC por transtirretina. A los 83,8 ± 14,1 meses de seguimiento, 19 pacientes fallecieron (15,6 por 100 pacientes/ano) y 21 tuvieron al menos un reingreso por IC (24,6 por 100 pacientes/ano). El subtipo de AC primaria y el inicio por insuficiencia cardiaca se asociaron a una mayor mortalidad y mayor tasa de reingresos hospitalarios. El grosor del septo interventricular tambien tuvo asociacion con la mortalidad. Conclusiones En nuestro estudio, la AC es mas prevalente en los varones en la septima decada de la vida, siendo la forma de presentacion mas habitual como IC, con alta prevalencia de fraccion de eyeccion del ventriculo izquierdo reducida en el momento del diagnostico. El pronostico de esta enfermedad es infausto, con una mayor mortalidad en aquellos pacientes con AC primaria.

Resumen Introduccion y objetivos Se presentan las caracteristicas clinicas y los resultados de los trasplantes cardiacos realizados en Espana con la actualizacion correspondiente a 2019. Metodos Se describen las caracteristicas clinicas y los resultados de los trasplantes cardiacos realizados en 2019, asi como las tendencias de estos en el periodo 2010-2018. Resultados En 2019 se realizaron 300 trasplantes (8.794 desde 1984; 2.745 entre 2010 y 2019). Respecto a anos previos, los cambios mas llamativos son el descenso hasta el 38% de los trasplantes realizados en codigo urgente, y la consolidacion en el cambio de asistencia circulatoria pretrasplante, con la practica desaparicion del balon de contrapulsacion (0,7%), la estabilizacion del uso del oxigenador extracorporeo de membrana (9,6%) y el aumento de los dispositivos de asistencia ventricular (29%). La supervivencia en el trienio 2016-2018 es similar a la del trienio 2013-2015 (p = 0,34), y ambas mejores que la del trienio 2010-2012 (p = 0,002 y p = 0,01 respectivamente). Conclusiones Se mantienen estables tanto la actividad del trasplante cardiaco en Espana como los resultados en supervivencia en los ultimos 2 trienios. Hay una tendencia a realizar menos trasplantes urgentes, la mayoria con dispositivos de asistencia ventricular.

[Abstract] Introduction and objectives: The Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score was derived and validated as a predictor of mortality after heart transplantation (HT). The primary objective of this work is to externally validate the IMPACT score in a contemporary Spanish cohort. Methods: Spanish Heart Transplant Registry data were used to identify adult (>16 years) HT patients between January 2000 and December 2015. Retransplantation, multiorgan transplantation and patients in whom at least one of the variables required to calculate the IMPACT score was missing were excluded from the analysis (N = 2810). Results: Median value of the IMPACT score was five points (IQR: 3, 8). Overall, 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score categories (0-2, 3-5, 6-9, 10-14, ≥15) were 84.4%, 81.5%, 79.3%, 77.3%, and 58.5%, respectively (Log-Rank test: p < .001). Performance analysis showed a good calibration (Hosmer-Lemeshow chi-square for 1 year was 7.56; p = .47) and poor discrimination ability (AUC-ROC .59) of the IMPACT score as a predictive model. Conclusions: In a contemporary Spanish cohort, the IMPACT score failed to accurately predict the risk of death after HT.

Introducción y objetivos Se presentan las características clínicas y los resultados de los trasplantes cardiacos realizados en España con la actualización correspondiente a 2019. Métodos Se describen las características clínicas y los resultados de los trasplantes cardiacos realizados en 2019, así como las tendencias de estos en el periodo 2010-2018. Resultados En 2019 se realizaron 300 trasplantes (8.794 desde 1984; 2.745 entre 2010 y 2019). Respecto a años previos, los cambios más llamativos son el descenso hasta el 38% de los trasplantes realizados en código urgente, y la consolidación en el cambio de asistencia circulatoria pretrasplante, con la práctica desaparición del balón de contrapulsación (0, 7%), la estabilización del uso del oxigenador extracorpóreo de membrana (9, 6%) y el aumento de los dispositivos de asistencia ventricular (29%). La supervivencia en el trienio 2016-2018 es similar a la del trienio 2013-2015 (p = 0, 34), y ambas mejores que la del trienio 2010-2012 (p = 0, 002 y p = 0, 01 respectivamente). Conclusiones Se mantienen estables tanto la actividad del trasplante cardiaco en España como los resultados en supervivencia en los últimos 2 trienios. Hay una tendencia a realizar menos trasplantes urgentes, la mayoría con dispositivos de asistencia ventricular. Introduction and objectives: The present report describes the clinical characteristics and outcomes of heart transplants in Spain and updates the data to 2019. Methods: We describe the clinical characteristics and outcomes of heart transplants performed in Spain in 2019, as well as trends in this procedure from 2010 to 2018. Results: In 2019, 300 transplants were performed (8794 since 1984; 2745 between 2010 and 2019). Compared with previous years, the most notable findings were the decreasing rate of urgent transplants (38%), and the consolidation of the type of circulatory support prior to transplant, with an almost complete disappearance of counterpulsation balloon (0.7%), stabilization in the use of extracorporeal membrane oxygenation (9.6%), and an increase in the use of ventricular assist devices (29.0%). Survival from 2016 to 2018 was similar to that from 2013 to 2015 (P = .34). Survival in both these periods was better than that from 2010 to 2012 (P = .002 and P = .01, respectively). Conclusions: Heart transplant activity has remained stable during the last few years, as have outcomes (in terms of survival). There has been a trend to a lower rate of urgent transplants and to a higher use of ventricular assist devices prior to transplant.

To investigate the value of tissue Doppler velocities for ruling out treatment-requiring acute cellular rejection (TR-ACR), in the context of myocardial deformation analysis performed by means of speckle tracking echocardiography. We performed serial echocardiograms in 37 heart transplant recipients in their first year post-transplantation within 3 h of the routine surveillance endomyocardial biopsies (EMB). The association of the sum of lateral mitral annulus systolic (s′) and early diastolic (e′) velocities, in absolute values, measured by tissue Doppler echocardiography (s′+ e′), with TR-ACR (ACR grade ≥ 2R) was investigated by multivariate analysis, including classic echocardiographic parameters and myocardial deformation variables. A total of 251 pairs of EMB and echo exams were performed, 35 (14%) with rejection grade ≥ 2R (TR-ACR). s′ + e′ was independently associated to TR-ACR (OR 0.80, 95%CI 0.72–0.89, p

This report presents the clinical characteristics, outcomes and complications of all consecutive patients implanted with a long-term mechanical circulatory support device in Spain between 2007 and 2020.Analysis of the Spanish Registry of durable ventricular assist devices (REGALAD) including data form Spanish centers with a mechanical circulatory support program.During the study period, 263 ventricular assist devices were implanted in 22 hospitals. The implanted device was an isolated continuous-flow left ventricular assist device in 182 patients (69%), a pulsatile-flow device (58 isolated left ventricular and 21 biventricular) in 79 (30%), and a total artificial heart in 2 patients (1%). The strategy of the implant was as bridge to heart transplant in 78 patients (30%), bridge to candidacy in 110 (42%), bridge to recovery in 3 (1%) and destination therapy in 72 patients (27%). Overall survival at 6, 12 and 24 months was 79%, 74% and 69%, respectively, and was better in continuous-flow left ventricular assist devices (84%, 80%, and 75%). The main adverse events related to this therapy were infections (37% of patients), bleeding (35%), neurological (29%), and device malfunction (17%).Durable ventricular assist devices have emerged in Spain in the last few years as a useful therapy for patients with advanced heart failure. As in other international registries, the current trend is to use continuous-flow intracorporeal left ventricular devices, which are associated with better results. Adverse events continue to be frequent and severe.

Introduction: Non-vitamin-K oral anticoagulants (NOACs) are known to have advantages over vitamin K antagonists (VKAs) for patients with atrial fibrillation (AF). However, more than half of patients are still treated with VKAs. The absence of direct comparisons amongst NOACs and the insufficient evidence in some clinical situations could explain, at least in part, this predominance of VKAs. The aims of our study were: 1) to analyze the opinion of an expert panel on the role of NOACs in different clinical scenarios; 2) to elaborate specific consensus recommendations for the management of NOACs for each one of these situations.Patients and methods: An online survey was created covering distinct aspects of the use of oral anticoagulants in various clinical settings. A two-round modified Delphi approach was used.Results: Forty-eight experts responded to the survey. Consensus was reached on 58% (48/83) of the items. The panelists concluded that the term non-valvular AF should be avoided. In most clinical settings NOACs were preferred over VKAs. Once daily NOACs were preferred in elderly patients to improve therapeutic compliance and, in those over the age of 85, edoxaban could be the best choice. Edoxaban and apixaban were the favorites for patients with AF and moderate chronic kidney disease (CKD). In the case of patients on triple antithrombotic therapy due to AF and acute coronary syndrome (ACS) the lowest effective NOAC dose should be used.Conclusion: Our study emphasizes that there are several clinical circumstances in patients with AF requiring complex decisions about anticoagulation treatment and offers some recommendations based on the consensus reached by an expert panel.

Our aim was to investigate the role of left atrial longitudinal strain (LALS) in the non-invasive diagnosis of acute cellular rejection (ACR) episodes in heart transplant (HTx) recipients. Methods: We performed successive echocardiographic exams in 18 consecutive adult HTx recipients in their first year after HTx within 3 h of the routine surveillance endomyocardial biopsies (EMB) in a single center. LALS parameters were analyzed with two different software. We investigated LALS association with ACR presence, as well as inter-vendor variability in comparable LALS values. Results: A total of 147 pairs of EMB and echo exams were carried out. Lower values of LALS were significantly associated with any grade of ACR presence. Peak atrial longitudinal strain (PALS) offered the best diagnostic value for any grade of ACR, with a C statistic of 0.77 using one software (95% CI 0.68–0.84, p < 0.0005) and 0.64 with the other (95% CI 0.54–0.73, p = 0.013) (p = 0.02 for comparison between both curves). Reproducibility between comparable LALS parameters was poor (intraclass correlation coefficients were 0.60 for PALS, 95% CI 0.42–0.73, p < 0.0005; and 0.42 for PALS rate, 95% CI −0.13–0.68, p < 0.0005). Conclusions: LALS variables might be a sensitive marker of ACR in HTx recipients, principally discriminating between those studies without rejection and those with any grade of ACR. Inter-vendor variability was significant.

Introduction and objectives The present report describes the clinical characteristics and outcomes of heart transplants in Spain and updates the data to 2019. Methods We describe the clinical characteristics and outcomes of heart transplants performed in Spain in 2019, as well as trends in this procedure from 2010 to 2018. Results In 2019, 300 transplants were performed (8794 since 1984; 2745 between 2010 and 2019). Compared with previous years, the most notable findings were the decreasing rate of urgent transplants (38%), and the consolidation of the type of circulatory support prior to transplant, with an almost complete disappearance of counterpulsation balloon (0.7%), stabilization in the use of extracorporeal membrane oxygenation (9.6%), and an increase in the use of ventricular assist devices (29.0%). Survival from 2016 to 2018 was similar to that from 2013 to 2015 (P=.34). Survival in both these periods was better than that from 2010 to 2012 (P=.002 and P=.01, respectively). Conclusions Heart transplant activity has remained stable during the last few years, as have outcomes (in terms of survival). There has been a trend to a lower rate of urgent transplants and to a higher use of ventricular assist devices prior to transplant.

INTRODUCTION AND OBJECTIVES The present report updates the characteristics and results of heart transplantation in Spain, mainly focused in the 2008-2017 period. METHODS We describe the recipient and donor characteristics, surgical procedures, and outcomes of heart transplants performed in 2017. The 2017 data were compared with those obtained from 2008 to 2016. RESULTS A total of 304 cardiac transplants were performed in 2017. Between 1984 and 2017, 8173 procedures were performed, 2689 of them after 2008. Significant temporal trends were observed in recipient characteristics (lower pulmonary vascular resistance, lower use of mechanical ventilation, and a higher percentage of diabetic patients and those with previous cardiac surgery), donor characteristics (older donor age and a higher percentage of female donors and those with a prior cardiac arrest) and procedures (lower ischemia time). In 2017, 27% of patients were transplanted after undergoing mechanical ventricular assistance (P

Background Anticoagulation in heart transplant (HT) recipients increases the risk of hemorrhagic complications, so correct reversal of anticoagulation is needed. Dabigatran, a direct thrombin inhibitor, is increasingly used for anticoagulation in patients with non-valvular atrial fibrillation (NVAF) whose effect can be reversed by idarucizumab. Aim To present a nationwide experience using idarucizumab for the urgent reversal of dabigatran before HT. Methods Multicenter observational study in 12 Spanish centers to analyze the clinical outcomes after using idarucizumab before HT surgery. Results Fifty-three patients were included (81.1% male). 7.5% required re-operation in the immediate postoperative period to control bleeding and 66% transfusion of blood products. Median length of stay in the intensive care unit was 6 days and total hospital stay 24 days. 30-day survival was 92.4%. There were four deaths in the first month, all in the first 5 days post-HT. Only in one patient (transplanted due to a congenital heart disease, after sternotomy) who had surgical problems and right ventricular failure post-HT death was associated with bleeding. Conclusions These results may support the use of dabigatran as an alternative to vitamin K antagonists in patients listed for HT requiring anticoagulation due to NVAF. More studies are needed to reaffirm these observations.

Several studies have identified copy number variants (CNVs) as responsible for cardiac diseases associated with sudden cardiac death (SCD), but very few exhaustive analyses in large cohorts of patients have been performed, and they have been generally focused on a specific SCD-related disease. The aim of the present study was to screen for CNVs the most prevalent genes associated with SCD in a large cohort of patients who suffered sudden unexplained death or had an inherited cardiac disease (cardiomyopathy or channelopathy). A total of 1765 European patients were analyzed with a homemade algorithm for the assessment of CNVs using high-throughput sequencing data. Thirty-six CNVs were identified (2%), and most of them appeared to have a pathogenic role. The frequency of CNVs among cases of sudden unexplained death, patients with a cardiomyopathy or a channelopathy was 1.4% (8/587), 2.3% (20/874), and 2.6% (8/304), respectively. Detection rates were particularly high for arrhythmogenic cardiomyopathy (5.1%), long QT syndrome (4.7%), and dilated cardiomyopathy (4.4%). As such large genomic rearrangements underlie a non-neglectable portion of cases, we consider that their analysis should be performed as part of the routine genetic testing of sudden unexpected death cases and patients with SCD-related diseases. post-print 1349 KB

Lamin A/C gene (LMNA)-related familial dilated cardiomyopathy (fDCM) is an aggressive heart disease that often leads to transplantation and sudden death. The aim of our study was to evaluate the circulating microRNA (miRNA) profiles of patients with LMNA pathogenic mutations. The study population (N = 75) included (i) patients with pathogenic LMNA mutations responsible for fDCM (LMNAMUT), (ii) age- and sex-matched LMNA wild-type controls (LMNAWT control), and (iii) LMNA wild-type idiopathic DCM (iDCM) patients (LMNAWT iDCM). Detailed clinical information was obtained from each participant. A panel of 179 plasma miRNAs was evaluated using RT-qPCR. An initial screening study was performed in LMNAMUT carriers and age-matched LMNAWT controls (N = 16). Forty-four miRNAs were specifically deregulated in LMNAMUT carriers. Ten miRNA candidates were selected for subsequent validation after coexpression analyses and filtered for expression levels and statistical significance. Among the candidates, let-7a-5p, miR-142-3p, miR-145-5p and miR-454-3p levels were significantly increased in LMNAMUT carriers compared to LMNAWT controls and iDCM patients (P, This work was supported by the Fundación Pública Andaluza Progreso y Salud para la Financiación de la I+i Biomédica y en Ciencias de las Salud en Andalucia (PI-0011/2014) and a grant in the framework of the Integrated Territorial Initiative (ITI)2014-2020 for the province of Cádiz by the Ministry of Health and the European Regional Developement Fund (ERDF) PI0048-2017 (project co-finantiated 80% by funds from the ERDF operational program of Andalusia 2014-2020) (ITI 0048-2017). This work was also supported by FIS PI14/01729 from the Instituto Salud Carlos III, co-financed by the European Fund for Regional Development (E.F.R.D.), Fundació Marató TV3 (201521 10), and Fundació BLa Caixa.^ CIBER Cardiovascular (CB16/11/00403) is an Instituto de Salud Carlos III Project. DdG-C was a recipient of a Juan de la Cierva-Incorporación grant from the Ministerio de Economía y Competitividad (IJCI-2016-29393).

BACKGROUND: It's unclear whether pre-transplant T. gondii seropositivity is associated with impaired survival in heart transplant recipients. OBJECTIVES: To test the above-mentioned hypothesis in the Spanish Heart Transplantation Registry. METHODS: Post-transplant outcomes of 4048 patients aged >16years who underwent first, single-organ heart transplantation in 17 Spanish institutions from 1984 to 2014 were studied. Long-term post-transplant survival and survival free of cardiac death or retransplantation of 2434 (60%) T. gondii seropositive recipients and 1614 (40%) T. gondii seronegative recipients were compared. RESULTS: T. gondii seropositive recipients were older, had higher body mass index, and presented higher prevalence of hypertension, hypercholesterolemia, COPD and Cytomegalovirus seropositivity than T. gondii seronegative recipients. In univariable analysis, pre-transplant T. gondii seropositivity was associated with increased post-transplant all-cause mortality (non-adjusted HR 1.15; 95% CI 1.04-1.26). However, this effect was no longer statistically significant after multivariable adjustment by recipient's age and sex (adjusted HR 1.01, 95% CI 0.92-1.11). Extended multivariable adjustment by other potential confounders showed similar results (adjusted HR 0.99, 95% CI 0.89-1.11). T. gondii seropositivity had no significant effect on the composite outcome cardiac death or retransplantation (non-adjusted HR 1.08, 95% CI 0.95-1.24, p=0.235). The distribution of the causes of death was comparable in T. gondii seropositive and T. gondii seronegative recipients. No statistically significant impact of donor's T. gondii serostatus or donor-recipient T. gondii serostatus matching on post-transplant survival was observed. CONCLUSIONS: Our analysis did not show a significant independent effect of preoperative T. gondii serostatus on long-term outcomes after heart transplantation. Sin financiación 3.471 JCR (2018) Q2, 48/136 Cardiac & Cardiovascular Systems 0.990 SJR (2018) Q2, 91/365 Cardiology and Cardiovascular Medicine No data IDR 2018 UEM

Background Our objective was to evaluate the impact of asymptomatic acute cellular rejection (ACR) in left ventricular myocardial strain in heart transplant (HT) recipients by means of two-dimensional speckle tracking echocardiography (2DSTE). Methods From September 1, 2009 to December 15, 2010 a conventional echocardiography and 2DSTE exam was performed on all consecutive HT recipients in their first year posttransplantation within 3 hours of the surveillance endomyocardial biopsies, as well as on 14 healthy controls. The association of strain echocardiographic variables with different grades of ACR was investigated. Results Of the 78 studies performed 4 ± 3 months after HT in 20 patients, 32 studies were coincident with grade 0R rejection, 41 with grade 1R, and 5 with grade 2R. Significantly lower values of average radial strain were found with higher grades of ACR (29.1 ± 7.7%, 23.2 ± 8.5%, and 14.3 ± 8.8% for grades 0R, 1R, and 2R of ACR, P = 0.001). Average deformation was similar for controls versus transplanted patients, in the absence of acute rejection: radial 29.1 ± 10.0% versus 29.1 ± 7.7%, P = 0.98; circumferential −19.3 ± 3.2% versus −20.2 ± 5.9%, P = 0.62; and longitudinal −20.7 ± 4.1% versus −18.5 ± 5.4%, P = 0.19. An average radial strain

El Comite de Guias de Practica Clinica de la SEC formo un grupo de trabajo integrado por cardiologos clinicos, electrofisiologos, cirujanos cardiacos y personal de enfermeria, expertos en los diversos aparta-dos de la IC que cubre la guia de la ESC, propuestos por la Seccion de Insuficiencia Cardiaca y Trasplante y el Grupo de Trabajo sobre Resin-cronizacion Cardiaca de la SEC y por la Asociacion Espanola de Enfer-meria Cardiovascular, con el objetivo general de revisar las evidencias y recomendaciones aportadas por la guia europea sobre IC antes citada

In line with the policy on clinical practice guidelines established by the Executive Committee of the Spanish Society of Cardiology,1 the present article aims to discuss the most salient and novel features of the European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure (HF).2 These guidelines update the recommendations of the prior version published 4 years ago in 20083 and include the new evidence that has emerged since then in the field of HF.

Resumen Introduccion El objetivo del presente estudio es describir las caracteristicas clinicas y el tratamiento antitrombotico de los pacientes octogenarios con FANV atendidos en una consulta general de cardiologia. Pacientes y metodo Desde el 1 de febrero de 2000 hasta el 30 de junio de 2009 todos los pacientes ≥80 anos con fibrilacion auricular no valvular (FANV) atendidos en dos consultas de cardiologia fueron incluidos en un protocolo prospectivo de manejo. Se registraron los factores de riesgo cardioembolicos (FRCE) y las contraindicaciones para anticoagulacion, ofreciendose este tratamiento a todos aquellos sin contraindicacion y con al menos un FRCE ademas de la edad, y dejando la decision al cardiologo responsable en aquellos sin ningun FRCE adicional. Resultados Un total de 269 pacientes fueron incluidos en el estudio (87 varones, edad media 83 ± 3 anos). Los FRCE mas frecuentes fueron: hipertension (73%), diabetes mellitus (25%), insuficiencia cardiaca (17%), embolismo previo (16%) y cardiopatia isquemica (9%). Un total de 65 pacientes (24%) presentaron contraindicaciones absolutas para anticoagulacion. Del resto, fueron anticoagulados 164 pacientes (el 80% de los sin contraindicacion y el 61% del total de la serie). Los pacientes anticoagulados presentaron una menor edad (83 ± 3 anos frente a 84 ± 4 anos, p = 0,001) y una mayor frecuencia de hipertension arterial (77% frente al 66%, p Conclusion Los pacientes octogenarios con FANV presentan una elevada prevalencia de factores de riesgo cardioembolicos, asi como de contraindicaciones absolutas a la anticoagulacion. Tras un estudio protocolizado, el 61% recibio tratamiento anticoagulante.

Introduction and objectives The prevalence of malnutrition among patients with heart failure and the role it might play in prognosis is not currently known. The aim of this study was to analyse the prevalence and risk of malnutrition as well as its possible influence on long-term mortality in patients with heart failure. Methods A prospective analysis was conducted on 208 patients discharged consecutively from our centre between January 2007 and March 2008 after being hospitalised with heart failure. Before discharge, a complete nutritional assessment was performed and diagnosis of malnutrition and risk of malnutrition was done with the Mini Nutritional Assessment. Its possible independent association with mortality was assessed by a Cox multivariate analysis. Results The mean age of the patients was 73 ± 10 years, with 46% women; the most common aetiology of heart failure was ischaemia (41%). In addition, 13% were classified as malnourished, 59.5% at risk of malnutrition and 27.5% were well-nourished. At a median follow-up of 25 months, mortality in the three groups was 76%, 35.9% and 18.9%, respectively (log-rank, P Conclusions Malnutrition and the risk of malnutrition are highly prevalent in patients hospitalised for heart failure. Furthermore, we found that the state of malnutrition as defined by the Mini Nutritional Assessment survey is an independent predictor of mortality in these patients.

Actualmente se desconoce la prevalencia de desnutricion entre los pacientes con insuficiencia cardiaca y el papel que este estado pudiera tener en su pronostico. El objetivo de este estudio es analizar la prevalencia y riesgo de desnutricion y su posible influencia en la mortalidad a largo plazo de los pacientes con insuficiencia cardiaca. Metodos Se analizo prospectivamente a 208 pacientes dados de alta consecutivamente desde nuestro centro entre enero de 2007 y marzo de 2008 tras un ingreso por insuficiencia cardiaca. Antes del alta, se realizo una completa valoracion nutricional y se realizo el diagnostico de desnutricion y riesgo de desnutricion mediante la encuesta Mini Nutritional Assessment. Su posible asociacion independiente con la mortalidad se valoro mediante un analisis multivariable de Cox. Resultados La media de edad fue 73±10 anos, el 46% eran mujeres y la etiologia mas frecuente de la insuficiencia cardiaca fue la isquemica (41%). El 13% de los pacientes fueron clasificados como desnutridos; el 59,5%, en riesgo de desnutricion y el 27,5%, bien nutridos. A los 25 meses (mediana de seguimiento), la mortalidad en los tres grupos fue del 76, el 35,9 y el 18,9% respectivamente (log-rank test, p

Resumen Introduccion y objetivos Estudios observacionales establecen una influencia pronostica positiva de la obesidad en la insuficiencia cardiaca, si bien la relacion de la misma con la composicion corporal no ha sido estudiada. El objetivo del estudio es analizar la influencia que sobre la mortalidad tienen el indice de masa corporal y la composicion corporal. Metodos Se midio el indice de masa corporal, el pliegue tricipital y el perimetro muscular braquial en 208 pacientes ingresados por insuficiencia cardiaca. Los pacientes fueron divididos en 4 grupos segun su indice de masa corporal (bajo peso: Resultados La mortalidad a un ano difirio (p Conclusiones En nuestro estudio el IMC es un factor de riesgo independiente en IC debido al grupo de bajo peso. La pobre supervivencia del mismo esta asociada a una disminucion de la masa grasa corporal.

Introduccion y objetivos Nuestro objetivo es evaluar el valor pronostico de la frecuencia cardiaca en reposo (FCr) en una poblacion general no seleccionada de pacientes con cardiopatia isquemica cronica (CIC). Metodos Del 1 de febrero de 2000 al 31 de enero de 2004, se incluyo prospectivamente a 1.264 pacientes ambulatorios con CIC, y se los siguio para eventos mayores (mortalidad, sindrome coronario agudo, revascularizacion coronaria, ictus e ingreso por insuficiencia cardiaca) para evaluar la asociacion de estos con la FCr (≥ 70 frente a Resultados La mediana [p25–p75] de edad fue 68 [60–74] anos, y 926 pacientes eran varones (73%); 645 pacientes (51%) presentaron una FCr ≥ 70 lat/min y 619 (49%), FCr Conclusiones La FCr no ha sido un factor pronostico adverso en esta muestra no seleccionada de pacientes con CIC. La importancia pronostica de la FCr en la practica clinica habitual podria ser baja en esta poblacion.

Fundamento y objetivos La insuficiencia cardiaca cronica sigue teniendo un mal pronostico, a pesar de los avances en su tratamiento. Es posible que la optimizacion del tratamiento basada en el control clinico de los pacientes no sea la estrategia mas efectiva. El objetivo de nuestro estudio es evaluar la efectividad de una estrategia de adecuacion del tratamiento basada en los valores del peptido natriuretico cerebral (BNP). Pacientes y metodos Se han estudiado 60 pacientes consecutivamente dados de alta en un servicio de cardiologia de un hospital espanol con el diagnostico de insuficiencia cardiaca con clase de la New York Heart Association (NYHA) III o IV, 30 asignados de forma aleatoria a un grupo en el que el ajuste del tratamiento farmacologico se baso en un control clinico (score de Framinghan), y otros 30 a un grupo en el que el ajuste se realizo de acuerdo a los valores plasmaticos de BNP. El tratamiento se ajusto intentando obtener una puntuacion clinica

ResumenObjetivoEstimar la concordancia en el diagnóstico de la hipertrofia ventricular izquierda electrocardiográfica (HVI-ECG) en sujetos hipertensos entre médicos de atención primaria (AP) y un cardiólogo experto.DiseñoEstudio transversal y multicéntrico.EmplazamientoCentros de AP de Andalucía.Participantes120 médicos de AP que mediante muestreo aleatorio seleccionaron a pacientes de 35 o más años con hipertensión arterial de al menos 6 meses de evolución.Mediciones principalesSe recogieron datos demográficos, de factores de riesgo y de enfermedades cardiovasculares. La HVI-ECG se evaluó aplicando los criterios de voltaje de Cornell, producto de Cornell y de Sokolow-Lyon. Los investigadores de AP realizaron una primera lectura y un cardiólogo, una segunda ciega.ResultadosSe estudió a 570 pacientes (media±desviación estándar de edad, 65±11 años; mujeres, 54,5%); la prevalencia de HVI-ECG fue del 13,7% (intervalo de confianza [IC] del 95%, 10,8-16,6; el 12,6% por Cornell y el 1,6% por Sokolow-Lyon). La concordancia en el diagnóstico de HVI-ECG entre el médico de AP y el cardiólogo fue 0,378 (IC del 95%, 0,272-0,486; desacuerdos en el 15,5% de los casos). Los investigadores de AP subestimaron levemente la prevalencia de HVI-ECG por Cornell y la sobreestimaron levemente por el criterio de Sokolow-Lyon; también fue baja la concordancia para cada uno de ellos (Cornell: κ=0,367; IC del 95%, 0,252-0,482; Sokolow-Lyon: κ=0,274; IC del 95%, 0,093-0,454).ConclusionesLa concordancia entre el diagnóstico de los médicos de AP y el cardiólogo es baja. Los resultados de este estudio indican la necesidad de mejorar la medición electrocardiográfica entre los médicos de AP; la utilización de sistemas informatizados podría ser una buena opción.AbstractObjectiveTo assess the agreement between Primary Care (PC) doctors and a cardiology specialist in diagnosing left ventricular hypertrophy in the electrocardiograph (LVH-ECG) in hypertensive patients.DesignCross-sectional, multicentre study.SettingAndalusian Primary Care Centres.ParticipantsA total of 120 PC doctors who using a random sample selected patients of 35 years or more with AHT of at least 6 months of progression.Primary variablesDemographic data, risk factors and cardiovascular diseases were recorded. The LVH-ECG was evaluated by applying Cornell voltage criteria, Cornell and Sokolow-Lyon product. The PC researchers read the ECG first and the cardiologist made a second reading blind.ResultsA total of 570 patients (mean±SD of age, 65±11 years; 54.5% females); the LVH-ECG prevalence was 13.7% (95% CI, 10.8-16.6; 12.6% by Cornell and 1.6% by Sokolow-Lyon). The agreement in the diagnosis between the PC doctors and the cardiologist was 0.378 (95% CI, 0.272-0.486; disagreements in 15.5% of cases). The PC doctors slightly underestimated the LVH-ECG prevalence by Cornell and slightly overestimated it by the Sokolow-Lyon criteria. The agreement was also low for all of them (κ=0.367; 95% CI, 0.252-0.482, for Cornell, and κ=0.274; 95% CI: 0.093-0.454 for Sokolow-Lyon).ConclusionsThe agreement between the diagnosis by the PC doctors and the cardiologist was low. The implications of this study suggest the need to improve the reading of ECG among PC doctors. The use of computerised systems could be a good option.

Resumen Objetivos el objetivo del estudio PREHVIA ha sido estimar la prevalencia de hipertrofia ventricular izquierda evidenciada en el electrocardiograma (HVI-ECG) y de fibrilacion auricular (FA) en pacientes con hipertension arterial (HTA) de Andalucia, y evaluar la relacion de estas variables con la enfermedad cardiovascular (ECV). Pacientes y metodos se realizo un estudio transversal con seleccion de centros de salud segun la distribucion de la poblacion andaluza por provincias y habitat, y seleccion aleatoria de pacientes incluidos en la muestra. Se recogieron los antecedentes y los medicos participantes y un cardiologo experto valoraron la HVI-ECG aplicando los criterios de Cornell (voltaje y producto) y de Sokolow-Lyon. Se valoro la asociacion con la HVI o la ECV mediante modelos de regresion logistica. Resultados en 570 pacientes (edad media de 65 anos, un 54,5% de mujeres, un 50,6% con obesidad y un 28,2% con diabetes), la prevalencia de HVI-ECG fue del 13,7% (intervalo de confianza [IC] del 95%, 10,8–16,6%). El 12,6% cumplio el criterio de Cornell y el 1,6% el de Sokolow-Lyon. Un 5,1% presento FA (IC del 95%, 3,9–7,5%) y el 22,1% (IC del 95%, 18,4–25,4%) tenia antecedente de ECV. En el analisis multivariante, la HVI-ECG se relaciono con el sexo femenino (odds ratio=5,10; IC del 95%, 2,44–10,64) y la presencia de ECV (odds ratio=2,18; IC del 95%, 1,09–4,12). La ECV se relaciono independientemente con la edad avanzada, el sexo masculino y la FA, y con menos fuerza con un filtrado glomerular bajo y la diabetes mellitus. Conclusiones en hipertensos de Andalucia la prevalencia de HVI-ECG es considerablemente inferior a la hallada en otros estudios, mucho mayor en mujeres y a expensas principalmente del criterio de Cornell. La prevalencia de FA es del 5,1% y la de ECV similar a la de estudios previos. Se observa una asociacion independiente entre HVI-ECG y ECV, y entre ECV y FA.

Introduccion y objetivos Para predecir el riesgo cardioembolico en la fibrilacion auricular no valvular (FANV) se ha propuesto un nuevo indice, el CHADS 2 , que se conforma asignando 1 punto por la presencia de insuficiencia cardiaca, hipertension, edad ≥ 75 anos o diabetes y 2 puntos si hay historia de ictus o accidente isquemico transitorio (AIT). Nuestro objetivo es evaluar este indice en una poblacion mediterranea. Metodos Del 1 de febrero de 2000 al 20 de diciembre de 2006, a todos los pacientes con FANV permanente atendidos en dos consultas de cardiologia de un hospital del sur de Espana, se les indico terapia antitrombotica segun las recomendaciones de las sociedades cientificas. Se siguio prospectivamente la aparicion de eventos embolicos (ictus, AIT o embolia periferica). El indice CHADS 2 fue aplicado a los 296 pacientes que no fueron anticoagulados. Resultados El indice CHADS 2 fue 0 en 69 (23,3%) pacientes, 1 en 81 (27,4%), 2 en 99 (33,4%), 3 en 30 (10,1%) y ≥ 4 en 17 (5,7%). Tras 21 ± 17 meses de seguimiento, la tasa de eventos embolicos segun su indice CHADS 2 fuera 0, 1, 2, 3 o ≥ 4 fue de 2,88, 5,80, 5,16, 14,78 y 22,02 cada 100 pacientes/ano, respectivamente (p = 0,0016). Los pacientes con indice CHADS 2 0-2 presentaron una tasa de embolias de 4,63, frente a 17,31/100 pacientes/ano en aquellos con indices ≥ 3 (p = 0,00087). Conclusiones El indice CHADS 2 es valido para cuantificar el riesgo de eventos embolicos en una poblacion mediterranea de pacientes con FANV. En nuestra serie, el riesgo embolico en pacientes con indice bajo no es despreciable.

Introduction and objectives A new index for predicting embolic risk in nonvalvular atrial fibrillation has been proposed, the CHADS 2 score, which is calculated by adding 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes, and by adding 2 points for a history of stroke or transient ischemic attack (TIA). Our objective was to evaluate the use of this score in a Mediterranean population. Methods Between February 1, 2000 and December 20, 2006, all patients with permanent nonvalvular atrial fibrillation being treated at two outpatient cardiology clinics in a university hospital in the south of Spain were offered antithrombotic therapy in accordance with scientific society recommendations and were prospectively monitored for embolic events (ie, stroke, TIA, or peripheral embolism). A CHADS 2 score was derived for each of the 296 patients who did not receive anticoagulation. Results The CHADS 2 score was 0 in 69 (23.3%) patients, 1 in 81 (27.4%), 2 in 99 (33.4%), 3 in 30 (10.1%), and 4 or more in 17 (5.7%). After 21 (17) months of follow-up, the embolic event rates for CHADS 2 scores of 0, 1, 2, 3, and ≥4 were 2.88, 5.80, 5.16, 14.78, and 22.02 per 100 patient-years, respectively (P=.0016). Patients with a CHADS 2 score from 0–2 had an embolic rate of 4.63 per 100 patient-years, compared with 17.31 per 100 patient-years in those with a score ≥3 (P=.00087). Conclusions The CHADS 2 score proved useful for quantifying the risk of an embolic event in Mediterranean patients with nonvalvular atrial fibrillation. In our series, the risk of embolism in patients with a low score was not negligible.

Introduccion y objetivos La insuficiencia cardiaca con funcion sistolica conservada (ICFSC) parece tener un pronostico similar al de la insuficiencia cardiaca con funcion sistolica disminuida. Sin embargo, no se conoce si la ICFSC es una entidad pronostica homogenea o si su morbimortalidad varia segun su etiologia. Metodos Se ha evaluado a una serie de 95 pacientes diagnosticados consecutivamente de ICFSC, con fraccion de eyeccion mayor del 45%, y hemos comparado los grupos de etiologia isquemica (n = 25; 26%) y no isquemica (n = 70; 74%). Resultados La edad media fue de 73 ± 6 anos, el 60% eran mujeres y la fraccion de eyeccion era del 61 ± 7%, con cifras similares en ambos grupos. Tras un seguimiento de 53 ± 8 meses (limites, 4-69; mediana, 46), el grupo isquemico presento mayor mortalidad (17,88 frente a 2,37 muertes/100 pacientes/ano; p Conclusiones La ICFSC no es una entidad homogenea desde el punto de vista pronostico. La morbimortalidad es mas elevada en los casos de etiologia isquemica, y sus mecanismos son tambien distintos.

The objective of the study was to evaluate whether improvements obtained during an intervention programme were maintained after the programme was stopped. 153 patients discharged with a diagnosis of heart failure (HF) were randomized to either usual care or an intervention programme, which included patient education, consultation with the cardiologist and monitoring in the Heart Failure Unit. After an average period of 16±8 months, the intervention programme was stopped. One year later, all the patients were re-examined to assess HF readmissions, all-cause mortality, quality of life, and prescribed medical treatment. During the 16±8-month treatment period, patients in the intervention group had a lower rate of HF readmissions (17% vs. 51%, p

Introduction and objectives. Observational studies have shown that oral anticoagulants (OAC) prescription is suboptimal in patients with nonvalvular atrial fibrillation (NVAF). Our objective was to evaluate the usefulness of a prospective protocol for increasing OAC usage in these patients.

La terapia de resincronizacion cardiaca (TRC) esta actualmente indicada en pacientes con insuficiencia cardiaca en clase funcional avanzada refractaria a tratamiento medico, fraccion de eyeccion severamente deprimida y QRS ancho, como marcador de asincronia interventricular y/o intraventricular1. En esta poblacion se ha demostrado que la TRCmejora los sintomas, la capacidad de ejercicio y la funcion ventricular y reduce las hospitalizaciones por insuficiencia 2 cardiaca y la mortalidad . El criterio clasico para establecer si hay asincronia es la duracion del QRS >120-150ms. Sin embargo, este parametro

Fundamento y objetivo Comparar las caracteristicas clinicas y ecocardiograficas de los hiperrespondedores a la terapia de resincronizacion cardiaca (TRC) frente al resto. Pacientes y metodo Incluimos a 80 pacientes consecutivos tratados con TRC y un seguimiento de 19±14 meses. Definimos hiperrrespondedores a los que al final del seguimiento presentaban una fraccion de eyeccion del ventriculo izquierdo (FEVI) = 50%. Resultados Doce (15%) fueron hiperrespondedores. Sus caracteristicas clinicas basales eran similares a las del resto, excepto en que habia menos varones hiperrespondedores. En estos pacientes, el diametro diastolico basal del ventriculo izquierdo fue de 64 (7) mm y el sistolico de 55 (6) mm frente a 75 (8) mm y 66 (9) mm respectivamente, p

To study whether the presence of the polymorphism in the apolipoprotein E (apo E) gene influences the lipid profile in heart-transplant recipients.A cohort of 103 recipients of heart transplant (93 men and 10 women, with a mean age of 47 +/- 13 years) under triple immunosuppressive therapy were submitted to a genetic study of the apo E gene region. Anthropometric and analytical data, including lipid profile and arterial blood pressure were collected prior to transplantation and 3, 6, 12, and 24 months after it.65 subjects present the genotype E3E3, 27 the genotype E3E4, 6 the genotype E2E3, and 5 the genotype E2E4. Carriers of the E2 allele (that is, genotypes E3E2 and E4E2) had higher total plasma triglyceride (TG) levels after 3 months (3.47 +/- 1.88 mmol/liter p0.001) and after 1 year of transplantation (3.13 +/- 1.77 mmol/liter p0.05) than the other genotypes. There were no differences in the plasma levels of total cholesterol (TC), LDL-cholesterol (LDL-C), and HDL-cholesterol (HDL-C). Multiple regression analysis revealed that the apoprotein E gene polymorphism determines 5% (p = 0.0425) and age 8.7% (p0.009) of the variants in TG levels.The presence of the E2 allele in heart-transplant recipients produces a greater rise in total TG plasma levels than the other genotypes.

El efecto favorable de la administracion de los inhibidores de la enzima de conversion de la angiotensina (IECA) a largo plazo en pacientes con insuficiencia cardiaca cronica y fraccion de eyeccion deprimida esta bien establecido, ero no hay tanta evidencia en pacientes con disfuncion sistolica secundaria a miocarditis aguda que normalizan la contraccion ventricular. Hemos seguido a 35 pacientes con miocarditis aguda y fraccion de eyeccion 50% en los 35 casos. De esos 35, en 15 se suspendieron los IECA, mientras que 20 continuaron tomandolos. A los 3 anos de seguimiento no hubo ninguna muerte, pero los pacientes en los que se suspendieron los IECA tuvieron una mayor incidencia de nuevos episodios de insuficiencia cardiaca con fraccion de eyeccion

Libman-Sacks endocarditis is a classic but rarely symptomatic manifestation of systemic lupus erythematosus, and valvular surgery is needed in a few cases. We present a patient with systemic lupus erythematosus and Libman-Sacks endocarditis that progressed rapidly to severe mitral regurgitation that needed surgery; surgical valve repair was decided upon. The literature on this topic is reviewed.

We sought to determine the incidence, risk factors, and consequences of acute rejection (AR) after conversion from a calcineurin inhibitor (CNI) to a proliferation signal inhibitor (PSI) in maintenance heart transplantation. Relevant clinical data were retrospectively obtained for 284 long-term heart transplant recipients from nine centers in whom CNIs were replaced with a PSI (sirolimus or everolimus) between October 2001 and March 2009. The rejection rate at one yr was 8.3%, stabilizing to 2% per year thereafter. The incidence rate after conversion (4.9 per 100 patient-years) was significantly higher than that observed on CNI therapy in the pre-conversion period (2.2 per 100 patient-years). By multivariate analysis, rejection risk was associated with a history of late AR prior to PSI conversion, early conversion (

Background: In the last decade, mTOR inhibitors (mTOR-is) have become the cornerstone of the calcineurin inhibitor (CNI)-reduced/free regimens aimed to the preservation of post-transplant renal function. We compared utility and safety of the total replacement of calcineurin inhibitors with a mTOR-i with a strategy based on calcineurin inhibitor minimization and concomitant use of m-TOR-i. Methods: In a retrospective multi-center cohort of 394 maintenance cardiac recipients with renal failure (GFR - 60 mL/min/1.73 m(2)), we compared 235 patients in whom CNI was replaced with a mTOR-i (sirolimus or everolimus) with 159 patients in whom mTOR-is were used to minimize CNIs. A propensity score analysis was carried out to balance between group differences. Results: Overall, after a median time of 2 years from mTOR-i initiation, between group differences for the evolution of renal function were not observed. In a multivariate adjusted model, improvement of renal function was limited to patients with mTOR-i usage within 5 years after transplantation, particularly with the conversion strategy, and in those patients who could maintain mTOR-i therapy. Significant differences between strategies were not found for mortality, infection and mTOR-i withdrawal due to drug-related adverse events. However, conversion group tended to have a higher acute rejection incidence than the minimization group (p = 0.07). Conclusion: In terms of renal benefits, our results support an earlier use of mTOR-is, irrespective of the strategy. The selection of either a conversion or a CNI minimization protocol should be based on the clinical characteristics of the patients, particularly their rejection risk. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Una forma muy infrecuente de miocardiopatia congenita, resultado de la interrupcion en el normal desarrollo embrionario endomiocardico, consistente en la no compactacion del miocardio ventricular, es la «miocardiopatia espongiforme». Las caracteristicas ecocardiograficas de esta enfermedad consisten en multiples trabeculaciones y recesos que comunican directamente con la cavidad ventricular. Existe una alta incidencia familiar de esta enfermedad. Presentamos un caso ilustrativo de la forma aislada de esta enfermedad, no asociada a otras anomalias, en un paciente de 16 anos de edad con las manifestaciones clinicas y ecocardiograficas tipicas de este proceso patologico. Revisamos a continuacion la bibliografia de esta afeccion.

The prevalence of malnutrition among patients with heart failure and the role it might play in prognosis is not currently known. The aim of this study was to analyse the prevalence and risk of malnutrition as well as its possible influence on long-term mortality in patients with heart failure.A prospective analysis was conducted on 208 patients discharged consecutively from our centre between January 2007 and March 2008 after being hospitalised with heart failure. Before discharge, a complete nutritional assessment was performed and diagnosis of malnutrition and risk of malnutrition was done with the Mini Nutritional Assessment. Its possible independent association with mortality was assessed by a Cox multivariate analysis.The mean age of the patients was 73 ± 10 years, with 46% women; the most common aetiology of heart failure was ischaemia (41%). In addition, 13% were classified as malnourished, 59.5% at risk of malnutrition and 27.5% were well-nourished. At a median follow-up of 25 months, mortality in the three groups was 76%, 35.9% and 18.9%, respectively (log-rank, P.001). In the Cox multivariate analysis, the malnutrition state was an independent predictor of mortality (hazard ratio 3.75, 95% confidence interval, 1.75-8.02, P=.001).Malnutrition and the risk of malnutrition are highly prevalent in patients hospitalised for heart failure. Furthermore, we found that the state of malnutrition as defined by the Mini Nutritional Assessment survey is an independent predictor of mortality in these patients.

Our aim was to investigate the prognostic value of the resting heart rate (RHR) in a broad unselected population of patients with stable coronary artery disease (sCAD).Between February 1, 2000 and January 31, 2004, 1264 ambulatory patients with sCAD were recruited into the prospective study. Patients were followed up for major events (i.e. death, acute coronary syndrome, coronary revascularization, stroke, and hospitalization for heart failure). Associations between these events and the RHR (i.e. ≥ 70 beats per minute [bpm] versus70 bpm) were evaluated.The patients' median age was 68 years (interquartile range [IQR] 60-74 years) and 926 (73%) were male. The RHR was ≥ 70 bpm in 645 patients (51%) and70 bpm in 619 (49%). After a median follow-up period of 25 months (IQR 12-39 months), with only seven patients lost to follow-up, the probability of an event was 17.48% in patients with an RHR ≥ 70 bpm and 17.67% in those with an RHR70 bpm (P =. 32) and total mortality was 2.32% and 2.5%, respectively (P = .56). After adjustment for age, sex, cardiovascular risk factors, blood pressure, baseline cardiac rhythm, ejection fraction and treatment at first visit, no significant association was found between the RHR and major events (hazard ratio [HR] = 1.04; 95% confidence interval [CI], 0.76-1.43; P = .79) or mortality (HR = 1.24; 95% CI, 0.55-2.81; P=.61).The RHR was not an adverse prognostic factor in this group of unselected patients with sCAD. The prognostic value of the RHR in daily clinical practice could be low in this population.

Chronic heart failure continues to have a poor prognosis, in spite of advances made in its therapy. It is uncertain whether symptom-guided therapy optimization is the most effective strategy in this setting. The aim of our study was to evaluate the usefulness of a brain natriuretic peptide (BNP)-guided therapy for the treatment of patients with heart failure.We carried out a prospective and randomized study including 60 patients consecutively discharged with the diagnosis of heart failure NYHA class III or IV in one cardiology department of a Spanish hospital; 30 patients were randomly assigned to a symptom-guided therapy group based on the clinical Framingham score, and 30 to a BNP-guided therapy group. Therapy was adjusted to obtain a clinical score2 in the symptom-guided group and BNP levels100pg/ml in the BNP-guided group. Follow up was 16±4 months.BNP-guided group had lower BNP levels during follow up than had symptom-guided group: 14(20)pg/ml versus 111±71pg/ml at 18 months, p=0.029. Clinical score was similar in both groups: 0.42(0.33) versus 0.39(0.63) at 18 months. Probability of survival (86% in both groups) and probability of being free of readmissions for heart failure (68 versus 66%) at 18 months were similar in both groups.In our experience, in patients with heart failure, BNP-guided therapy did not improve clinical outcomes compared with symptom-guided therapy.