Comparison between beta-blockers and calcium channel blockers in patients with atrial fibrillation according to renal function.

BACKGROUND: Rate control is the most commonly employed first-line management strategy for atrial fibrillation (AF) in patients with chronic kidney disease (CKD). Principal agents used to control heart rate (HR) include beta-blockers (BB) and nondihydropyridine calcium channel blockers (ND-CCB). However, there is a paucity of published studies of the differences between those drugs in CKD patients. HYPOTHESIS: The present study aimed to investigate the differences, in terms of hospitalizations due to a poor HR control, in patients with AF under a rate-control strategy according to glomerular filtration rate (GFR). METHODS: The study cohort included 2804 AF patients under rate-control regime (BB or ND-CCB) between January 2014 and April 2020. The end point, determined by competing risk regression, was hospitalizations for AF with rapid ventricular response (RVR), slow ventricular response (SVR), and need for pacemaker. RESULTS: On multivariate analysis, there were no statistical differences between ND-CCB and BB for subjects with GFR > 60 mL/min/1.73 m2 (subdistribution heart rate [sHR] 0.850, 95% confidence interval [CI]: 0.61-1.19; p = .442) and GFR 30-59 mL/min/1.73 m2 (sHR 1.242, 95% CI: 0.80-1.63; p = .333), while in patients with GFR < 30 mL/min/1.73 m2, ND-CCB therapy was associated with increased hospitalizations due to poor HR control (sHR 4.53, 95% CI: 1.19-17.18; p = .026). CONCLUSION: In patients with GFR ≥ 30 mL/min/1.73 m2, the choice of ND-CCB or BB had no impact on hospitalizations due to poor HR control, while in GFR < 30 mL/min/1.73 m2, a possible association was detected. The effects of these drugs on GFR < 30 mL/min/1.73 m2 would require further investigation.

Predictive value of bleeding risk scores in elderly patients with atrial fibrillation and oral anticoagulation.

BACKGROUND: The predictive value of bleeding risk scores for atrial fibrillation in older patients is not as well known. The goal of this study was to evaluate the predictive value of HASBLED, ORBIT and ATRIA for major bleeding (MB) and intracranial hemorrhage (ICH) in patients ≥ 75 years with atrial fibrillation and oral anticoagulation (OAC). METHODS: A retrospective unicenter study including patients ≥ 75 years with atrial fibrillation (AF) and OAC. A total of 7613 patients ≥ 75 years with AF and OAC included between 2014 and 2018 (registry: NCT04364516). We analyzed the discriminative value of HASBLED, ATRIA and ORBIT scores for bleeding endpoints (major bleeding as primary endpoint and intracerebral hemorrhage as secondary). Cox regression was used to predict major bleeding with each scale and also for searching other variables potentially predictor of major bleeding. Model discrimination was assessed using Harrell's C-statistic. Calibration was assessed with goodness-of-fit test proposed by Gronnesby and Borgan. RESULTS: During a mean follow up of 4.0 years (IQR: 2.4-5.7 years), 729 patients developed MB (2.61 per 100 patients/year) and 243 patients developed ICH (0.85 per 100 patients/year). Three scores showed a low discrimination for major bleeding, being ORBIT the best (HASBLED C statistic = 0.557; ATRIA C statistic = 0.568; ORBIT C statistic = 0.595) and also a low discrimination for ICH (HASBLED C statistic = 0.509; ATRIA C statistic = 0.522; ORBIT C statistic = 0.526). Among the variables that are part of the scores and other baseline characteristics, after multivariable adjustment only sex (male), dementia, prior admission for bleeding, anemia and liver disease were found as a predictors of MB. CONCLUSIONS: In older patients under oral anticoagulation with atrial fibrillation, the risk scores HASBLED, ATRIA and ORBIT showed a weak discrimination for major bleeding and intracranial hemorrhage. Therefore, other better alternatives should be evaluated for this purpose.

Comparison of Outcomes in Patients With Atrial Fibrillation Under Oral Anticoagulation Therapy Analyzed by Body Weight (<60, 60 to 100, and >100 kg).

There is limited knowledge regarding the efficacy and safety of fixed-dose oral anticoagulants in overweight patients because of the possible increased risk of embolism and hemorrhage. This study aimed to evaluate embolic, hemorrhagic, and mortality events in anticoagulated patients, administered both antivitamin K and direct oral anticoagulants based on the body weight (<60 kg, 60 to 100 kg and >100 kg). A retrospective registry-based cohort study including all consecutive patients with a diagnosis of atrial fibrillation between January 2014 and January 2018 in the health area of Vigo (Galicia, Spain) was used (CardioCHUVI-AF registry; ClinicalTrials.gov identifier: NCT04364516). The final cohort comprised 11,821 AF patients. The cohort was classified into 3 categories: low body weight ([LBW], <60 kg, 924 patients); middle body weight (60 to 100 kg, 9,546 patients); and high body weight ([HBW], >100 kg, 958 patients). Outcomes were predicted using the Fine and Gray model and Cox proportional hazards model when appropriate. Middle body weight was the reference group. No association was found between the weight and major bleeding in the univariate analyses: LBW with a sub-distribution hazard ratio (sHR) of 1.13 (95% confidence interval [CI] 0.92 to 1.41), and HBW with an sHR of 1.02 (95% CI 0.83 to 1.26). Stroke/systemic embolism events occurred in 817 patients (6.6%). In the univariate analyses, we found an association between weight and risk of stroke/systemic embolism: LBW sHR 1.37 (95% CI 1.09 to 1.72), and HBW sHR 0.66 (95% CI 0.49 to 0.89) but no association was found in the multivariable model. The same situation was observed with all-cause death: in the univariable model, LBW presented a hazard ratio of 1.48 (95% CI 1.31 to 1.68) and the HBW group presented a hazard ratio of 0.53 (95%CI 0.44 to 0.63) whereas no significant association was found in the multivariable model. We conclude that in our registry, extreme weights were not related to more events during follow-up.

Effect of mitral regurgitation on stroke risk in patients with non-rheumatic atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) carries a thrombotic risk related to blood stasis in the left atrium. In patients with rheumatic valve disease and AF, the presence of severe mitral regurgitation (MR) has been shown to reduce the risk of atrial thrombosis and stroke. However, in patients without rheumatic disease, the results are controversial. AIM: To analyse the association between MR and the incidence of stroke in patients with non-rheumatic AF. METHODS: We analysed data from the retrospective CardioCHUVI-AF registry, which includes 15,720 patients with AF (without mechanical prostheses or rheumatic valvular disease) in the Vigo area of Spain, during 2014-2018. We grouped the patients according to MR grades: 0-2 (n=15,194) and 3-4 (n=526). We performed univariate and multivariable competitive risk analyses to analyse the association between MR and stroke, with death as the competitive event. RESULTS: During a median (interquartile range [IQR]) follow-up of 4.9 (2.8-4.9) years, 859 patients (5.5%) suffered a stroke. The stroke incidence was 1.3 per 100 person-years (95% confidence interval [95% CI]: 1.2-1.4), with no difference between the MR groups. In univariate analysis, no relationship was observed between MR grade and stroke (subdistribution hazard ratio [sHR]: 1.12, 95% CI: 0.79-1.60; P=0.53); likewise after multivariable analysis (sHR: 0.98, 95% CI: 0.68-1.41; P=0.90). This same relationship was evaluated in subgroups of interest (patients with and without: oral anticoagulation, CHA2DS2-VASc≥2, prior heart failure, aortic valve disease, left ventricular ejection fraction≤40%, and moderate-severe left atrial dilation), with results consistent with the overall population. CONCLUSION: In our large registry of patients with non-rheumatic AF, we did not find a protective effect of grade 3-4 MR on the risk of stroke.

Validation and Psychometric Properties of the Spanish Version of the Fear of Childbirth Questionnaire (CFQ-e).

The fear of childbirth is a topical concern, yet the issue has barely been studied in Spain, and only one fear of childbirth measurement instrument has been validated in the country. The aim of this study was to translate, adapt and validate the Fear of Childbirth Questionnaire (CFQ) for use in Spain, as well as to describe and evaluate the psychometric properties of the Spanish version of this instrument. In a first phase, a methodological study was carried out (translation-backtranslation and cross-cultural adaptation), and pilot study was carried out in the target population. In addition, content validation of the instrument was obtained (CFQ-e) from 10 experts. In the second phase, a cross-sectional study was carried out at several centres in Gran Canaria Island to obtain a validation sample. The evaluation of the psychometric properties of the CFQ-e, including construct validity through exploratory factor analysis and confirmatory factor analysis, the calculation of reliability via factor consistency using the ORION coefficients as well as alpha and omega coefficients were carried out. The CFQ-e showed evidence of content validity, adequate construct validity and reliability. The CFQ-e is composed of 37 items distributed in four subscales or dimensions: "fear of medical interventions"; "fear of harm and dying"; "fear of pain" and "fears relating to sexual aspects and embarrassment". The CFQ-e constitutes a valid and reliable tool to measure the fear of childbirth in the Spanish pregnant population.

Compromiso e intención de abandono en adolescentes de selecciones nacionales argentinas: el papel de los agentes sociales y efectos del género / Engagement and intentions of drop-out in adolescents of Argentinean national teams: The role of social agents and gender effects

Resumen Introducción/objetivo. El objetivo de esta investigación es examinar el poder predictivo de la percepción de los estilos interpersonales de entrenadores/as, padres y madres en el compromiso e intención de abandono de adolescentes deportistas argentinos de alto rendimiento, considerando el papel del género en esta relación. Método. Participaron 234 adolescentes de entre 12 y 16 años (M = 14.48, DT = 1.09) seleccionados para los Juegos Olímpicos de la Juventud -Buenos Aires 2018-, quienes cumplimentaron cuestionarios para la evaluación de las variables de interés. Resultados. Los varones perciben mayores niveles de compromiso que las mujeres y estas perciben mayor apoyo a la autonomía de la madre. El apoyo a la autonomía del entrenador tuvo mayor capacidad predictiva en el compromiso de los varones y en la intención de abandono del deporte de las mujeres. En ambos géneros, el efecto del apoyo a la autonomía del entrenador fue mayor que el de los padres. Conclusiones. Estos resultados muestran la importancia de los otros significativos en la participación deportiva y contribuyen al conocimiento de los factores que pueden favorecer el desarrollo positivo en deportistas adolescentes de alto rendimiento.

Abstract Introduction/Objective. This research aims to examine the predictive power of perceived interpersonal styles of coaches, fathers and mothers on engagement and intentions to drop-out of Argentinean high-performance adolescent athletes considering the role of gender in this relationship. Method. A total of 234 adolescents aged 12-16 years (M = 14.48, SD = 1.09) selected for the Youth Olympic Games -Buenos Aires 2018- participated in the study, who answered questionnaires assessing the variables of interest. Results. Males perceived higher levels of engagement than females, and females perceived higher autonomy support from the mother. Coaches' autonomy support had greater predictive power on males' engagement and females' intentions to drop-out sport. In both genders, the effect of coach autonomy support was greater than parents. Conclusions. These results show the importance of significant others in sport participation and contribute to the knowledge of factors that may foster positive development in high-performance adolescence athletes.

Relationship between early onset severe intrahepatic cholestasis of pregnancy and higher risk of meconium-stained fluid.

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is the commonest gestational liver disease. The risk of adverse fetal outcome has been associated with the severity of maternal hypercholanemia after diagnosis. OBJECTIVE: To investigate whether there is a relationship between the severity and timing of onset of hypercholanemia and the risk of meconium-stained amniotic fluid (MSAF) and adverse neonatal events. STUDY DESIGN: The study included 382 pregnancies complicated by ICP managed at a referral hospital in Buenos Aires (Argentina) between June 2009 and December 2013. The patients were classified into three groups according to the severity of hypercholanemia at diagnosis; mild (10-19.9 µmol/L), moderate (20-39.9 µmol/L) and severe (≥40 µmol/L). Their clinical characteristics and pregnancy outcomes were investigated in a prospective observational study. RESULTS: Higher risk of MSAF was observed when ICP appeared early in gestation or when hypercholanemia was more severe. Taking both parameters into account an MSAF risk factor (MRF) was defined. Based on a model of positive/negative predictive values, a cut-off point of MRF = 3 was selected, which prioritized sensitivity versus specificity. In ICP patients with MRF>3, the probability of MSAF was enhanced 4-fold. An increase in the frequency of MSAF was also associated with higher serum levels at diagnosis of alanine transaminase, alkaline phosphatase and direct bilirubin. CONCLUSIONS: The risk of MSAF is associated not only with the magnitude of hypercholanemia at diagnosis but also with the early gestational onset of raised maternal serum bile acids.

Brief cognitive battery in the diagnosis of mild Alzheimer's disease in subjects with medium and high levels of education.

There has been an increasing trend to utilize short cognitive batteries for the diagnosis of dementia. Most of these batteries have been designed in countries with high standards of education and are less suitable for populations with low levels of education.We developed a battery that has been previously shown to be highly accurate in the diagnosis of dementia in individuals with low levels of education. The accuracy of this battery for patients with higher levels of education is unknown. OBJECTIVES: To evaluate the accuracy of a brief cognitive battery in the diagnosis of Alzheimer's disease (AD) in subjects with medium and high levels of schooling, and to develop a mathematical model that includes the most discriminative tests. METHODS: Seventy-three mildly demented patients with probable AD and 94 control subjects were evaluated. Sixty patients and 60 controls were randomly selected to generate a mathematical model including the most discriminative tests of the battery using logistic regression. The model was back-tested for the remaining sample of patients and controls. RESULTS: Delayed recall, learning and category fluency tests were included in a mathematical model that obtained an area of 0.917 in the ROC curve in the back-testing. Inter-rater reliabilities of these tests were high (kappa>0.8). CONCLUSIONS: This model showed a high accuracy for the diagnosis of mild AD in patients with medium and high educational levels. Future studies with more heterogeneously educated individuals are necessary to investigate whether the educational level (number of years at school) should also be included in the model.

Existe crescente tendência de se utilizarem baterias cognitivas breves no diagnóstico de demência. A maioria destas tem sido idealizada em países com altos níveis de escolaridade e é menos adequada para populações com baixa escolaridade. Desenvolvemos uma bateria que tem demonstrado alta acurácia no diagnóstico de demência em indivíduos com baixa escolaridade, mas a acurácia em indivíduos com escolaridade alta ainda não é conhecida. OBJETIVOS: Avaliar a acurácia de uma bateria cognitiva breve no diagnóstico de doença de Alzheimer (DA) em indivíduos com escolaridade média ou alta, e desenvolver um modelo matemático que inclua os testes mais discriminativos. MÉTODOS: Setenta e três pacientes com demência leve causada por DA provável e 94 controles foram avaliados com a bateria cognitiva breve. Sessenta pacientes e 60 controles foram selecionados aleatoriamente para gerar um modelo matemático com os testes mais discriminativos, empregando regressão logística. Este modelo foi retro-testado na amostra remanescente de pacientes e controles. RESULTADOS: Os testes de memória tardia, aprendizado e fluência verbal foram incluídos no modelo matemático que obteve área sob a curva ROC de 0,917 no retro-teste. A confiabilidade inter-examinadores destes testes foi alta (kappa>0.8). CONCLUSÕES: Este modelo apresentou alta acurácia no diagnóstico de demência leve na DA em sujeitos com escolaridade média ou alta. Novos estudos com população com maior heterogeneidade educacional são necessários para investigar se os anos de escolaridade também devem ser incluídos no modelo.

Mortalidad fetal 2006 en la Maternidad Sardá / Fetal mortality 2006 in the Maternidad Sardá

Objetivos: 1) describir las tasas de mortalidad fetal del año 2006 incluyendo y excluyendo los fetos malformados; 2) describir sus posibles causas y 3) analizar la oportunidad diagnóstica y el manejo de la terminación del parto. Material y métodos: diseño observacional, retrospectivo. Fuente de datos: las historias clínicas de las embarazadas portadoras de un feto muerto nacidos en el Hospital Materno Infantil Ramón Sardá durante el año 2006. Resultados: durante el año 2006 se registraron 7282 nacimientos que incluyen 7220 recién nacidos vivos y 62 muertes fetales. El 35,5 por ciento de los fetos muertos eran malformados que incluyen, según la edad gestacional, 45,8 por ciento entre 20 a 27 semanas y 28,9 por ciento en >= 28 semanas. En los embarazos de termino las causas de muerte más frecuentes fueron los accidentes del cordón (44 por ciento). Excluyendo los fetos malformados la causa más frecuente entre 20 y 27 semanas fueron las infecciones. Sin embargo, en la franja de embarazos de 28 semanas o más, donde las malformaciones representan el 28,9 por ciento de los mismos, no se encontró la causa en el 37 por ciento de los casos. Conclusiones: se observaron altas cifras de pacientes nulíparas y una elevada contribución de las malformaciones y las infecciones.

Mortalidad fetal 2006 en la Maternidad Sardá / Fetal mortality 2006 in the Maternidad Sardá

Objetivos: 1) describir las tasas de mortalidad fetal del año 2006 incluyendo y excluyendo los fetos malformados; 2) describir sus posibles causas y 3) analizar la oportunidad diagnóstica y el manejo de la terminación del parto. Material y métodos: diseño observacional, retrospectivo. Fuente de datos: las historias clínicas de las embarazadas portadoras de un feto muerto nacidos en el Hospital Materno Infantil Ramón Sardá durante el año 2006. Resultados: durante el año 2006 se registraron 7282 nacimientos que incluyen 7220 recién nacidos vivos y 62 muertes fetales. El 35,5 por ciento de los fetos muertos eran malformados que incluyen, según la edad gestacional, 45,8 por ciento entre 20 a 27 semanas y 28,9 por ciento en >= 28 semanas. En los embarazos de termino las causas de muerte más frecuentes fueron los accidentes del cordón (44 por ciento). Excluyendo los fetos malformados la causa más frecuente entre 20 y 27 semanas fueron las infecciones. Sin embargo, en la franja de embarazos de 28 semanas o más, donde las malformaciones representan el 28,9 por ciento de los mismos, no se encontró la causa en el 37 por ciento de los casos. Conclusiones: se observaron altas cifras de pacientes nulíparas y una elevada contribución de las malformaciones y las infecciones. (AU)