Prognostic stratification of older patients with multivessel coronary artery disease treated with percutaneous transluminal coronary angioplasty based on clinical and biochemical measures: protocol for a prospective cohort study.

INTRODUCTION: The incidence of acute coronary syndrome is rising in step with the growth of life expectancy. An increase in the age of patients with coronary artery disease has been related to in-hospital mortality, which has seen an upsurge over a short period of time. However, there is no consensus about the percutaneous coronary angioplasty strategy to follow for older patients with multivessel coronary artery disease (MVCAD). Complete revascularisation (CR) or incomplete revascularisation (ICR) strategy depends on prognosis but this has not yet been accurately described because of geriatric conditions and comorbidities. The aim of this study is to evaluate changes of clinical and biochemical parameters in older patients with MVCAD undergoing revascularisation and to establish a prognostic stratification model for CR and ICR. METHODS AND ANALYSIS: This observational, longitudinal, prospective study will include 150 patients with MVCAD and subsequent revascularisation who attend the Hospital Universitario Virgen de la Victoria (Málaga, Spain). Because of the dropout rates, 180 patients will be recruited at the beginning. Sociodemographic characteristics, clinical and angiographic parameters, and biochemical variables, such as cardiovascular, metabolic, inflammatory, stress oxidative biomarkers, will be collected in the admission for coronary revascularisation and three follow-ups at 6, 12 and 18 months. Statistical analyses will be conducted with these data using CR and ICR as the primary exposure variable. Relevant explanatory variables will be selected from a predictive model for their inclusion in a prognostic stratification model. The primary outcome measures will be major adverse cardiovascular events. ETHICS AND DISSEMINATION: Protocols and patient information have been approved by the regional research ethics committee (CEIm Provincial de Málaga-PEIBA (PI0131/2020). The results will be disseminated in international peer-reviewed journals, presented at conferences in Cardiology and Gerontology, and sent to participants, medical and health service managers, clinicians and other researchers.

Improving Familial Hypercholesterolemia Index Case Detection: Sequential Active Screening from Centralized Analytical Data.

The majority of familial hypercholesterolemia index cases (FH-IC) remain underdiagnosed and undertreated because there are no well-defined strategies for the universal detection of FH. The aim of this study was to evaluate the diagnostic yield of an active screening for FH-IC based on centralized analytical data. From 2016 to 2019, a clinical screening of FH was performed on 469 subjects with severe hypercholesterolemia (low-density lipoprotein cholesterol ≥220 mg/dL), applying the Dutch Lipid Clinic Network (DLCN) criteria. All patients with a DLCN ≥ 6 were genetically tested, as were 10 patients with a DLCN of 3-5 points to compare the diagnostic yield between the two groups. FH was genetically confirmed in 57 of the 84 patients with DLCN ≥ 6, with a genetic diagnosis rate of 67.9% and an overall prevalence of 12.2% (95% confidence interval: 9.3% to 15.5%). Before inclusion in the study, only 36.8% (n = 21) of the patients with the FH mutation had been clinically diagnosed with FH; after genetic screening, FH detection increased 2.3-fold (p < 0.001). The sequential, active screening strategy for FH-IC increases the diagnostic yield for FH with a rational use of the available resources, which may facilitate the implementation of FH universal and family-based cascade screening strategies.

Randomized Trial of Empagliflozin in Nondiabetic Patients With Heart Failure and Reduced Ejection Fraction.

BACKGROUND: Large clinical trials established the benefits of sodium-glucose cotransporter 2 inhibitors in patients with diabetes and with heart failure with reduced ejection fraction (HFrEF). The early and significant improvement in clinical outcomes is likely explained by effects beyond a reduction in hyperglycemia. OBJECTIVES: The purpose of this study was to assess the effect of empagliflozin on left ventricular (LV) function and volumes, functional capacity, and quality of life (QoL) in nondiabetic HFrEF patients. METHODS: In this double-blind, placebo-controlled trial, nondiabetic HFrEF patients (n = 84) were randomized to empagliflozin 10 mg daily or placebo for 6 months. The primary endpoint was change in LV end-diastolic and -systolic volume assessed by cardiac magnetic resonance. Secondary endpoints included changes in LV mass, LV ejection fraction, peak oxygen consumption in the cardiopulmonary exercise test, 6-min walk test, and quality of life. RESULTS: Empagliflozin was associated with a significant reduction of LV end-diastolic volume (-25.1 ± 26.0 ml vs. -1.5 ± 25.4 ml for empagliflozin vs. placebo, respectively; p < 0.001) and LV end-systolic volume (-26.6 ± 20.5 ml vs. -0.5 ± 21.9 ml for empagliflozin vs. placebo; p < 0.001). Empagliflozin was associated with reductions in LV mass (-17.8 ± 31.9 g vs. 4.1 ± 13.4 g, for empagliflozin vs. placebo, respectively; p < 0.001) and LV sphericity, and improvements in LV ejection fraction (6.0 ± 4.2 vs. -0.1 ± 3.9; p < 0.001). Patients who received empagliflozin had significant improvements in peak O2 consumption (1.1 ± 2.6 ml/min/kg vs. -0.5 ± 1.9 ml/min/kg for empagliflozin vs. placebo, respectively; p = 0.017), oxygen uptake efficiency slope (111 ± 267 vs. -145 ± 318; p < 0.001), as well as in 6-min walk test (81 ± 64 m vs. -35 ± 68 m; p < 0.001) and quality of life (Kansas City Cardiomyopathy Questionnaire-12: 21 ± 18 vs. 2 ± 15; p < 0.001). CONCLUSIONS: Empagliflozin administration to nondiabetic HFrEF patients significantly improves LV volumes, LV mass, LV systolic function, functional capacity, and quality of life when compared with placebo. Our observations strongly support a role for sodium-glucose cotransporter 2 inhibitors in the treatment of HFrEF patients independently of their glycemic status. (Are the "Cardiac Benefits" of Empagliflozin Independent of Its Hypoglycemic Activity? [ATRU-4] [EMPA-TROPISM]; NCT03485222).

Anticoagulantes orales en pacientes con fibrilación auricular no valvular y con bajo riesgo / Oral anticoagulants in non-valvular atrial fibrillation and low-risk patients

Los pacientes con fibrilación auricular no valvular y puntuación CHA2D2-VASc 1 (un único factor clínico de riesgo) suponen un grupo significativo de pacientes en la práctica clínica, que plantean cierta dificultad en cuanto a la toma de decisiones sobre si iniciar y mantener de forma crónica un tratamiento anticoagulante oral. La dificultad deriva en que, clásicamente, se ha tenido la idea de que son pacientes de bajo riesgo tromboembólico, cuando parece tratarse de un grupo heterogéneo con un riesgo tromboembólico no despreciable. Por ello, es fundamental individualizar la decisión y tener presente que, pese a discrepancias entre distintas sociedades científicas, las guías de práctica clínica de la European Society of Cardiology recomiendan tratar con anticoagulante oral. Además, hay ciertos factores de la escala CHA2D2-VASc que conllevan un mayor riesgo tromboembólico y algunos pacientes pueden presentar otros factores de riesgo no incluidos en dicha escala, que contribuyen también a incrementar el riesgo tromboembólico. A la hora de iniciar un anticoagulante oral, su elección debe individualizarse atendiendo a las características propias de cada paciente, valorando el balance riesgo-beneficio de iniciar dicho tratamiento, resaltando que los anticoagulantes orales de acción directa presentan un perfil de riesgo más favorable que los antagonistas de la vitamina K, lo cual es especialmente interesante en estos pacientes de menor riesgo. En caso de pautar un anticoagulante oral de acción directa, se ha de tener presente cuándo deben realizarse ajustes de dosis en función del perfil renal, la edad o el peso, pues un inadecuado ajuste de la pauta se asocia con un aumento de los eventos isquémicos y hemorrágicos

Patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1, with only one clinical risk factor, are a significant group in daily clinical practice, who represent a challenge in therapeutic decision making, especially with regard to whether to start or maintain chronic oral anticoagulant therapy. The main difficulty stems from the fact that these patients were previously believed to have a low thromboembolic risk, whereas currently they seem to be a heterogeneous group with a significant thromboembolic risk. Therefore, it is very important to individualise treatment decisions in each patient and base the selected treatment option on the European Society of Cardiology clinical practice guidelines, which recommend oral anticoagulant therapy, despite discrepancies with other scientific societies. In addition, some risk factors in the CHA2DS2-VASc score involve greater thromboembolic risk than others and some patients have other risk factors not included in CHA2DS2-VASc score, which increase their risk. When starting an oral anticoagulant treatment, the choice of agent should be individualised, bearing in mind the characteristics of each patient, and assessing the benefit-risk profile of the treatment, given that direct-acting oral anticoagulants have a more favourable profile than vitamin K antagonists, which is particularly important in lower risk patients. Finally, an important key point with direct-acting oral anticoagulants is dose adjustment according to renal function, age or weight, because an inadequate dose substantially increases the bleeding and ischaemic event rate

Una historia resumida. Impacto de los avances en el control lipídico / A brief history. Impact of advances in lipid control

El colesterol es un factor de riesgo modificable fundamental en el desarrollo de la enfermedad ateroesclerótica. Numerosos estudios han demostrado que las estatinas son capaces de reducir el colesterol plasmático y disminuir la aparición de complicaciones ateroescleróticas en prevención tanto primaria como secundaria. De hecho, las guías de práctica clínica recomiendan el uso de estatinas como fármacos esenciales en el control de la hipercolesterolemia, y se recomiendan cifras de colesterol unido a lipoproteínas de baja densidad más estrictas para los pacientes con alto riesgo cardiovascular y en prevención secundaria. A pesar de ello, son numerosos los pacientes que no están adecuadamente controlados, lo que se debe a diversos factores dependientes de los fármacos, del médico y de los pacientes. Por ello, existe un importante margen para mejorar el grado de control de los pacientes con hipercolesterolemia (AU)

Cholesterol is a key modifiable risk factor for the development of atherosclerosis. Numerous studies have shown that statins can reduce plasma cholesterol levels and decrease the development of atherosclerotic complications, both in primary and secondary prevention. In fact, clinical practice guidelines recommend the use of statins as essential drugs in the control of hypercholesterolaemia, recommending stricter levels of low-density lipoprotein cholesterol in patients at high cardiovascular risk and in secondary prevention. Despite this, numerous patients are not adequately controlled, which is due to various factors depending on the drugs, the doctor and the patients. Therefore, there is a substantial margin for improvement in the degree of control of patients with hypercholesterolaemia (AU)