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Background: No evidence-based therapy has yet been established for Takotsubo syndrome (TTS). Given the putative harmful effects of catecholamines in patients with TTS, beta-blockers may potentially decrease the intensity of the detrimental cardiac effects in those patients. Objective: The purpose of this study was to assess the impact of beta-blocker therapy on long-term mortality and TTS recurrence. Methods: The cohort study used the national Spanish Registry on TakoTsubo Syndrome (RETAKO). A total of 970 TTS post-discharge survivors, without pheochromocytoma, left ventricular outflow tract obstruction, sustained ventricular arrhythmias, and significant bradyarrhythmias, between January 1, 2003, and July 31, 2018, were assessed. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were used to evaluate the association between beta-blocker therapy and survival free of TTS recurrence. Results: From 970 TTS patients, 582 (60.0%) received beta-blockers. During a mean follow-up of 2.5 ± 3.3 years, there were 87 deaths (3.6 per 100 patients/year) and 29 TTS recurrences (1.2 per 100 patient/year). There was no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox analysis (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.59–1.27, and 0.95, 95% CI 0.57–1.13, respectively). After weighting and adjusting by IPW, differences in one-year survival free of TTS recurrence between patients treated and untreated with beta-blockers were not found (average treatment effect −0.01, 95% CI −0.07 to 0.04; p=0.621). Conclusions: In this observational nationwide study from Spain, there was no significant association between beta-blocker therapy and follow-up survival free of TTS recurrence. Resumo: Introdução: Ainda não foi estabelecido um tratamento baseado na evidência para a síndrome de Takotsubo (STT). Dados os efeitos supostamente nocivos das catecolaminas em doentes com STT, os betabloqueantes podem potencialmente diminuir a intensidade dos seus efeitos prejudiciais nesses doentes. Objetivo: Avaliar o impacto da terapêutica com betabloqueantes na mortalidade a longo prazo e na recidiva da STT. Métodos: O estudo coorte utilizou o registo nacional espanhol da síndrome de Takotsubo (RETAKO). Foram avaliados 970 sobreviventes de STT após a alta, sem feocromocitoma, sem obstrução do trato de saída do ventrículo esquerdo, sem arritmias ventriculares mantidas e sem bradiarritmias significativas, entre 1 de janeiro de 2003 e 31 de julho de 2018. A análise de regressão de Cox e a análise da ponderação de probabilidade inversa (PPI) foram utilizadas para avaliar a associação entre a terapia com betabloqueantes e a sobrevivência sem recidiva de STT. Resultados: Dos 970 doentes com STT, 582 (60,0%) foram tratados com betabloqueantes. Durante um seguimento médio de 2,5 ± 3,3 anos, houve 87 mortes (3,6 por 100 doentes/ano) e 29 recidivas de STT (1,2 por 100 doentes/ano). Não se verificaram diferenças significativas na mortalidade durante o seguimento, nem na recidiva de STT na análise Cox não ajustada e ajustada (Hazard Ratio [HR] 0,86, Intervalo de Confiança [IC] 95%, 0,59-1,27 e IC 95%−0,57-1,13, respetivamente). Após ponderação e ajuste por PPI, não foram também encontradas diferenças na sobrevivência a um ano e na recidiva de STT entre doentes tratados e não tratados com betabloqueantes (efeito médio do tratamento −0,01, IC 95% −0,07 a 0,04; p=0,621). Conclusão: Neste estudo observacional de âmbito nacional em Espanha, não houve associação significativa entre a terapêutica com betabloqueantes e a sobrevivência ou recidivas de STT.

Abstract Aims To describe logistics and outcomes of the accreditation program of centres of excellence in heart failure (HF) developed in Spain by the Spanish Society of Cardiology (SEC) between 2016 and 2021. Methods and results A scientific committee created by the SEC defined three types of HF units (community, specialized, and advanced), depending on the characteristics of the hospital and their portfolio of services and equipment, as well as the quality standards required for the accreditation of excellence. The units were required to submit to the SEC a document certifying compliance with the requirements and quality standards. Once verified these, the unit received accreditation of excellence from the SEC. Between 2017 and October 2021, 78 HF units spread throughout Spain applied for accreditation. This represents 50.6% of all Spanish national health system centres with cardiology departments. Accreditation was definitive in 56.4% of the applicant centres and provisional in the remaining 43.6%. Of the 78 units, 19 were community units, 44 specialized, and 15 advanced. Of the 34 units that received provisional accreditation for failure to meet any of the required quality standards, all resolved these deficits within 6 months of the initial evaluation, subsequently receiving definitive accreditation. Conclusions Our experience indicates that implementation of an accreditation programme for excellence and quality of care of HF units at the national level by a scientific society is feasible and sustainable over time, leading the majority of HF units in the country to apply for accreditation and to meet the required quality standards.

BackgroundNowadays, good clinical practice should be established in human research. Patient’s rights and autonomy must be respected above the interest of the researcher, making mandatory to raise patient’s awareness on the implications of participating in a clinical study. Contrary to popular belief, this is not always the case. This means that, after signing the informed consent form, some patients have difficulties understanding their responsibilities as participants.Materials and methodsThis study is a prospective, multicenter, non-randomized controlled trial comparative survey conducted on patients enrolled in a clinical trial to evaluate and improve their understanding after an educational intervention was applied to the research staff.ResultsFemales were underrepresented in the clinical trials performed in this study, 21.5%. Most of the participants had a low educational level (74.4%). Around 5 and 10% of the research participants were not aware they were part of a clinical study, and more 24% just trusted in the medical decision to be enrolled. After the interventional education, the following items: “given time and resolution of the patient doubts” (p-value = 0.003), “enough written information” (p-value = 0.006), “explanation of the risks of participating in the study,” (p-value = 0.047) and understanding of the information provided to them showed an improvement regarding the study in which they were participating.ConclusionThe research participants understanding of their involvement in clinical trials is limited. An educational intervention on the research team can improve the process of empowerment and transit of information.

Background. The main cause of acute coronary syndrome (ACS) is coronary artery obstruction due to atherosclerotic plaque growth or thrombus formation secondary to plaque rupture or erosion. However, there is a subgroup of patients with signs and symptoms suggestive of ACS but without relevant coronary artery obstruction on coronary angiography. This population is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA). The present study analyzes the clinical features and outcomes of very young patients with a diagnosis of MINOCA. Method. Nested case-control study of ≤40-year-old patients referred for coronary angiography due to clinical suspicion of ACS. Patients were divided into three groups: patients with obstructive coronary artery disease (CAD), patients diagnosed with MINOCA, and controls with non-coronary artery disease. Results. Of 19,321 coronary angiographies performed in our center in a period of 10 years, 408 (2.1%) were in patients ≤40 years old, and MINOCA was identified in 32 (21%) patients. The cardiovascular risk factors for obstructive CAD and MINOCA were very similar. The incidence of major adverse cardiovascular events (MACE) at follow-up was significantly higher in the MINOCA (HR 4.13 (95%CI 1.22–13.89) and obstructive CAD (HR 4.59 (95%CI 1.90–10.99) patients compared to controls. Cocaine use HR 14.58 (95%CI 3.08–69.02), family history of CAD HR 6.20 (95%CI 1.40–27.43), and depression HR 5.16 (95%CI 1.06–25.24) were associated with a poor outcome in the MINOCA population. Conclusion. Very young patients with MINOCA had a poor prognosis at long-term follow-up, similar to patients with obstructive CAD. Focusing efforts on secondary prevention is essential in this population.

Coronary artery disease (CAD) is a common chronic condition in the elderly. However, the earlier CAD begins, the stronger its impact on lifestyle and costs of health and social care. The present study analyzes clinical and angiographic features and the outcome of very young patients undergoing coronary angiography due to suspected CAD, including a nested case-control study of ≤40-year-old patients referred for coronary angiography. Patients were divided into two groups: cases with significant angiographic stenosis, and controls with non-significant stenosis. Of the 19,321 coronary angiographies performed in our center in a period of 10 years, 504 (2.6%) were in patients ≤40 years. The most common cardiovascular risk factors for significant CAD were smoking (OR 2.96; 95% CI 1.65–5.37), dyslipidemia (OR 2.18; 95% CI 1.27–3.82), and family history of CAD (OR 1.95; 95% CI 1.05–3.75). The incidence of major adverse cardiovascular events (MACE) at follow-up was significantly higher in the cases compared to controls (HR 2.71; 95% CI 1.44–5.11). Three conventional coronary risk factors were directly related to the early signs of CAD. MACE in the long-term follow-up is associated to dyslipidaemia and hypertriglyceridemia. Focusing efforts for the adequate control of CAD in young patients is a priority given the high socio-medical cost that this disease entails to society.

Coronary artery disease is a chronic disease with an increased expression in the elderly. However, different studies have shown an increased incidence in young subjects over the last decades. The prediction of major adverse cardiac events (MACE) in very young patients has a significant impact on medical decision-making following coronary angiography and the selection of treatment. Different approaches have been developed to identify patients at a higher risk of adverse outcomes after their coronary anatomy is known. This is a prognostic study of combined data from patients ≤40 years old undergoing coronary angiography (n = 492). We evaluated whether different machine learning (ML) approaches could predict MACE more effectively than traditional statistical methods using logistic regression (LR). Our most effective model for long-term follow-up (60 ± 27 months) was random forest (RF), obtaining an area under the curve (AUC) = 0.79 (95%CI 0.69–0.88), in contrast with LR, obtaining AUC = 0.66 (95%CI 0.53–0.78, p = 0.021). At 1-year follow-up, the RF test found AUC 0.80 (95%CI 0.71–0.89) vs. LR 0.50 (95%CI 0.33–0.66, p < 0.001). The results of our study support the hypothesis that ML methods can improve both the identification of MACE risk patients and the prediction vs. traditional statistical techniques even in a small sample size. The application of ML techniques to focus the efforts on the detection of MACE in very young patients after coronary angiography could help tailor upfront follow-up strategies in such young patients according to their risk of MACE and to be used for proper assignment of health resources.