Tendencias actuales en el tratamiento antitrombótico Current trends on antithrombotic therapy

Los fármacos antitrombóticos son un pilar fundamental en el tratamiento y prevención de las enfermedades cardiovasculares. A pesar de la amplia experiencia previa, en los últimos años se han producido importantes novedades en la práctica clínica que han modificado estrategias terapéuticas en diferentes escenarios como en el campo de la fibrilación auricular, la cardiopatía isquémica o el intervencionismo coronario percutáneo. A todo esto se debe que añadir el papel fundamental del tratamiento antitrombótico durante la reciente pandemia de COVID-19 y sus implicaciones dado el estado protrombótico que produce la infección por el virus SARS-CoV-2. Desde el Grupo de Trabajo de Trombosis Cardiovascular de la Sociedad Española de Cardiología, se ha sintetizado la evidencia científica reciente en el presente documento.

Tendencias actuales en el tratamiento antitrombótico

Resumen Los fármacos antitrombóticos son un pilar fundamental en el tratamiento y prevención de las enfermedades cardiovasculares. A pesar de la amplia experiencia previa, en los últimos años se han producido importantes novedades en la práctica clínica que han modificado estrategias terapéuticas en diferentes escenarios como en el campo de la fibrilación auricular, la cardiopatía isquémica o el intervencionismo coronario percutáneo. A todo esto se debe que añadir el papel fundamental del tratamiento antitrombótico durante la reciente pandemia de COVID-19 y sus implicaciones dado el estado protrombótico que produce la infección por el virus SARS-CoV-2. Desde el Grupo de Trabajo de Trombosis Cardiovascular de la Sociedad Española de Cardiología, se ha sintetizado la evidencia científica reciente en el presente documento. Antithrombotic drugs play a key role in the treatment and prevention of cardiovascular diseases. Despite the previous knowledge, important developments in clinical practice have been reported in the last few years, especially in the field of atrial fibrillation, coronary heart disease and percutaneous coronary intervention. Moreover, it is important to highlight the role of antithrombotic therapy in the current COVID-19 pandemic, since the infection caused by the new coronavirus SARS-Cov-2 has been associated with a prothrombotic state. This paper by the Working Group on Cardiovascular Thrombosis of the Spanish Society of Cardiology aims at summarizing the current information available in this complex scenario.

Myocarditis after RNA-based vaccines for coronavirus.

BACKGROUND: The incidence of myocarditis after RNA-based vaccines for coronavirus has gained social and medical interest. METHODS: We performed an intention-to-treat meta-analysis, following the PRISMA statement. After a systematic search, without language restriction, 9 publications were selected. Two were excluded (one was only in subjects with age 12-17 and other might had included subjects from a larger publication). We followed the PRISMA guidelines for abstracting data and assessing data quality and validity. Data was verified by 2 investigators. RESULTS: We analyzed 17,704,413 subjects, from 7 studies, that included 627 cases of confirmed myocarditis). The incidence of myocarditis was 0.0035% (95% CI 0.0034-0.0035). Mean incidence rate was 10.69 per 100.000 persons-year. Cases reported from Israel represented 45.14% from total (283 out of the 627). Only 1 case of fatal myocarditis or death was reported. There was significant heterogeneity between results. The meta-regression analysis excluded mean age, region, number of cases or number of people included as sources of heterogeneity. No small-study effect was observed (p = 0.19). CONCLUSIONS AND RELEVANCE: Myocarditis incidence after RNA vaccines is very rare (0.0035%) and has a very favorable clinical course.

Selección de lo mejor del año 2020 en cardiología geriátrica

Resumen Durante el último año se han publicado numerosos trabajos centrados en el paciente mayor con enfermedad cardiovascular. En este texto repasamos algunos de los principales trabajos relacionados con el abordaje del paciente mayor con cardiopatía, incluyendo escenarios clínicos tan complejos como la situación de la pandemia de enfermedad por coronavirus de 2019 (COVID-19) que vivimos. Hemos querido resaltar y prestar especial atención a aspectos de gran relevancia clínica, dado su impacto pronóstico, como son los síndromes geriátricos y la comorbilidad, entidades prevalentes en el paciente mayor con cardiopatía, y que conviene conocer para mejorar la atención que proporcionamos a nuestros pacientes en distintos ámbitos (urgencias, hospitalización, ambulatorio). Analizamos también algunos de los principales estudios y trabajos impulsados desde la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología. During last year several papers focusing on elderly patients with cardiovascular disease have been published. In this article, we review some of the most important studies focused on the management of elderly patients with heart disease, also including complex clinical scenarios such as the COVID-19 pandemic. We highlight some aspects of great clinical relevance, given their prognostic impact, such as geriatric syndromes and comorbidity, all of them prevalent in the elderly. We also emphasize on how to improve the care we provide to our patients in different scenarios (emergency, hospitalization, outpatients). Finally, we analyze some of the main studies promoted by the Geriatric Cardiology Section of the Spanish Society of Cardiology.

Mortality associated with cardiovascular disease in patients with COVID-19

Introduction and objectives: Cardiovascular disease (CVD) has been outlined as a possible risk factor for poorer outcomes in patients with COVID-19 infection. Methods: A meta-analysis was performed with currently available studies that report the prevalence of CVD in survivors vs non-survivors in patients with COVID-19 infection using reports available at 16 July 2020. Analyses were performed by a random effects model and sensitivity analyses were performed for the identification of potential sources of heterogeneity or assess the small-study effects. Results: A total of 307 596 patients from 16 reports were included and 46 321 (15.1%) had CVD. Globally, mortality rate was 8.2% (20 534 patients) and mortality rates were higher in hospital registries (48.7%) compared to national reports (23.1%). A total of 11 213 (24.2%) patients with CVD died and mortality rates were also higher in hospital registries (48.7%) compared to national reports (23.1%). CVD was associated to 4-fold higher risk of mortality (OR, 4.33;95%CI, 3.16-5.94). Data from 28 048 patients with diabetes was available. Diabetes was associated to higher mortality risk (OR, 2.41;95%CI, 1.79-3.26;P < .001). From 40 173 subjects with hypertension it could also be proven a risk factor for higher mortality (OR, 2.60;95%CI, 2.10-3.21;P < .001). Conclusions: patients with CVD and COVID-19 infection have 4-fold higher risk of death. Diabetes or hypertension are also associated with higher mortality risk. Resumen Introducción y objetivos: Las enfermedades cardiovasculares (ECV) se han identificado como un factor de riesgo de mal pronóstico en pacientes con infección por COVID-19. Métodos: Se realizó un metanálisis de estudios actualmente disponibles con la prevalencia de ECV en supervivientes frente a no supervivientes en pacientes con infección por COVID-19 hasta el 16 de julio de 2020. Los análisis se realizaron mediante un modelo de efectos aleatorios y sensibilidad. Se realizaron análisis para identificar posibles fuentes de heterogeneidad o evaluar los efectos de los estudios pequeños. Resultados: Se incluyó a 307.596 pacientes de 16 estudios, de los que 46.321 (15,1%) tenían ECV. La tasa de mortalidad fue del 8,2% (20.534 pacientes) y fue superior en los registros hospitalarios (48,7%) en comparación con los informes nacionales (23,1%). Un total de 11.213 (24,2%) pacientes con ECV fallecieron y las tasas de mortalidad también fueron más altas en los registros hospitalarios (48,7%) en comparación con los informes nacionales (23,1%). La ECV se asoció con un riesgo de mortalidad 4 veces mayor (OR, 4,33;IC95%, 3,16-5,94). Se disponía de datos de 28.048 pacientes con diabetes que también se asoció a un mayor riesgo de mortalidad (OR, 2,41;IC95%, 1,79-3,26;p < 0,001). De 40.173 pacientes con hipertensión, también se concluyó que era un factor de riesgo de mayor mortalidad (OR, 2,60, IC95%, 2,10-3,21;p < 0,001). Conclusiones: Los pacientes con ECV e infección por COVID-19 tienen un riesgo 4 veces mayor de muerte. La diabetes y la hipertensión arterial también son factores de mayor riesgo en los pacientes con COVID-19.

The Effect of Age on Mortality in Patients With COVID-19: A Meta-Analysis With 611,583 Subjects.

OBJECTIVES: Initial data on COVID-19 infection has pointed out a special vulnerability of older adults. DESIGN: We performed a meta-analysis with available national reports on May 7, 2020 from China, Italy, Spain, United Kingdom, and New York State. Analyses were performed by a random effects model, and sensitivity analyses were performed for the identification of potential sources of heterogeneity. SETTING AND PARTICIPANTS: COVID-19-positive patients reported in literature and national reports. MEASURES: All-cause mortality by age. RESULTS: A total of 611,1583 subjects were analyzed and 141,745 (23.2%) were aged ≥80 years. The percentage of octogenarians was different in the 5 registries, the lowest being in China (3.2%) and the highest in the United Kingdom and New York State. The overall mortality rate was 12.10% and it varied widely between countries, the lowest being in China (3.1%) and the highest in the United Kingdom (20.8%) and New York State (20.99%). Mortality was <1.1% in patients aged <50 years and it increased exponentially after that age in the 5 national registries. As expected, the highest mortality rate was observed in patients aged ≥80 years. All age groups had significantly higher mortality compared with the immediately younger age group. The largest increase in mortality risk was observed in patients aged 60 to 69 years compared with those aged 50 to 59 years (odds ratio 3.13, 95% confidence interval 2.61-3.76). CONCLUSIONS AND IMPLICATIONS: This meta-analysis with more than half million of COVID-19 patients from different countries highlights the determinant effect of age on mortality with the relevant thresholds on age >50 years and, especially, >60 years. Older adult patients should be prioritized in the implementation of preventive measures.