Low Performance of a Clinical-Genetic Model in the Estimation of Time in Therapeutic Range in Acenocoumarol-Adherent Patients with Nonvalvular Atrial Fibrillation: The Quality of Anticoagulation Challenge.

BACKGROUND: Anticoagulation with vitamin K antagonists continues to be a challenging task given the difficulty of achieving a correct time in therapeutic range (TTR). The SAMeTT2R2 score has been proposed to identify patients that will be good responders. In this study we aimed to analyse clinical and genetic factors involved in a correct level of anticoagulation in patients with atrial fibrillation and thereby potentially improve the diagnostic performance of SAMeTT2R2 score. METHODS: We prospectively included 212 consecutive patients with nonvalvular atrial fibrillation under treatment with acenocoumarol for at least 6 months that were attended in a cardiology outpatient clinic and were categorized as adherent to medication. We carried out a multivariate regression analysis to detect the independent predictive factors of good control. In all patients VKORC1, CYP2C9⁎2, CYP2C9⁎3, and MIR133A2 genotyping was performed. RESULTS: A total of 128 (60.4%) patients presented TTR <70% (average TTR = 63.2). We identified body mass index (OR 0.94, 95%CI 0.89-0.99, p=0.032) and regular vitamin K intake (OR 0.53, 95%CI 0.28-0.99, p= 0.046) as independent predictors of poor anticoagulation control. The discriminatory power of a clinical-genetic model derived from our cohort was significantly better compared to the SAMeTT2R2 score (C-statistic 0.658 versus 0.524, p<0.001). CONCLUSIONS: In our study the SAMeTT2R2 score revealed a poor ability in the prediction of TTR. Besides SAMeTT2R2, body mass index and possibly vitamin K intake should be taken into account when deciding the optimal anticoagulation strategy. The information provided by the identified genotypes was marginal.

Prognostic Usefulness of the 6-Minute Walk Test in Patients With Severe Aortic Stenosis.

The 6-minute walk test distance (6MWD) has been shown to predict prognosis in selected cohorts of patients with heart failure and outcomes after surgical or transcatheter aortic valve implantation (AVI) in patients with symptomatic severe aortic stenosis (AS). Our objective was to evaluate the association between the 6MWD and outcome in patients with severe AS while remaining under medical treatment. In a prospective observational cohort study, a total of 149 patients diagnosed with severe AS by Doppler echocardiography underwent a 6-minute walk test. The single end point was a composite of all-cause death or hospitalization for heart failure. Patients receiving an AVI were censored from follow-up at the time of their AVI, so that only the events that occurred while the patients remained under medical treatment were included in the analysis. During follow-up (median 12.9 months), the end point occurred in 65 patients (43.6%). Univariate analysis showed an association between the 6MWD and the end point (p <0.001). After adjustment for symptoms, left ventricular ejection fraction, aortic valve area, Charlson co-morbidity score, and anemia, the 6MWD independently predicted the end point (adjusted hazard ratio 0.63; 95% confidence interval 0.45 to 0.89; p = 0.010). The incidence of the composite end point was 12 per 100 patient-years in patients with a 6MWD >331 m compared to 86 per 100 patient-years in those with a 6MWD ≤331 m (p <0.001). In conclusion, although patients with severe AS remain under medical treatment, the 6MWD is independently associated with all-cause death or hospitalization for heart failure.

Trombo sobre la red de Chiari: Thrombus on Chiari Network

El descubrimiento de una masa en la aurícula derecha obliga a realizar un amplio diagnóstico diferencial que incluye tumores, vegetaciones, trombo, válvula de Eustaquio o red de Chiari. Tradicionalmente, estas posibilidades etiológicas se han considerado excluyentes. En esta presentación se describe el caso de un varón con cuadro catarral, dolorimiento generalizado y febrícula, con diagnóstico de fibrilación auricular y, mediante ecocardiograma, de una masa alargada muy móvil en la aurícula derecha. Se plantearon diferentes entidades etiológicas y finalmente se inició tratamiento con heparina, con lo que se produjo la resolución de dicha masa, con persistencia de una estructura filamentosa compatible con la red de Chiari.(AU)

The presence of a mass in the right atrium requires a broad differential diagnosis including tumors, vegetations, thrombus, Eustachian valve, or Chiari network. Traditionally, these etiological possibilities have been considered exclusive. This report describes the case of a male patient with catarrh, generalized tenderness and low-grade fever, diagnosed with atrial fibrillation. An echocardiography revealed a mobile, elongated mass in the right atrium. Different etiological entities were posed, and finally heparin treatment was started which resolved the mass, with a persistent filamentous structure compatible with Chiari network.(AU)

Trombo sobre la red de Chiari: Thrombus on Chiari Network

El descubrimiento de una masa en la aurícula derecha obliga a realizar un amplio diagnóstico diferencial que incluye tumores, vegetaciones, trombo, válvula de Eustaquio o red de Chiari. Tradicionalmente, estas posibilidades etiológicas se han considerado excluyentes. En esta presentación se describe el caso de un varón con cuadro catarral, dolorimiento generalizado y febrícula, con diagnóstico de fibrilación auricular y, mediante ecocardiograma, de una masa alargada muy móvil en la aurícula derecha. Se plantearon diferentes entidades etiológicas y finalmente se inició tratamiento con heparina, con lo que se produjo la resolución de dicha masa, con persistencia de una estructura filamentosa compatible con la red de Chiari.

The presence of a mass in the right atrium requires a broad differential diagnosis including tumors, vegetations, thrombus, Eustachian valve, or Chiari network. Traditionally, these etiological possibilities have been considered exclusive. This report describes the case of a male patient with catarrh, generalized tenderness and low-grade fever, diagnosed with atrial fibrillation. An echocardiography revealed a mobile, elongated mass in the right atrium. Different etiological entities were posed, and finally heparin treatment was started which resolved the mass, with a persistent filamentous structure compatible with Chiari network.

Utilidad de la tomografía computarizada multidetector en pacientes con dolor torácico y sospecha de miocardiopatía hipertrófica apical / Value of multidetector computed tomography in patients with chest pain and suspected apical hypertrophic cardiomyopathy

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[Usefulness of clinical profiling and exercise testing in the prognostic assessment of patients admitted with chest pain but without high-risk criteria]. / Utilidad del perfil clínico y la ergometría en la valoración del pronóstico de los pacientes ingresados por dolor torácico sin criterios de alto riesgo.

INTRODUCTION AND OBJECTIVES: Few data are available on the outcome of patients admitted to hospital with suspected acute coronary syndrome who have no high-risk factors and who undergo exercise testing before discharge. Our objectives were to investigate outcomes in this group of patients and to determine whether clinical history-taking or exercise testing can help to predict outcome. PATIENTS AND METHOD: The study population comprised 449 patients admitted to hospital with chest pain suggestive of acute coronary syndrome. All were judged to be at a low risk of subsequent events (i.e., none had ischemic ECG changes or an elevation in troponin level). They underwent treadmill exercise testing before discharge, after an observation period of at least 12 hours. Exercise testing was performed after clinical evaluation based on an algorithm involving troponin-T level and resting ECG. The median follow-up duration was 479 days. The single combined endpoint was defined as cardiac death, or hospital admission for nonfatal acute myocardial infarction or unstable angina. RESULTS: Adverse events occurred in 44 (10%) of the 449 patients. A high event rate was associated with four clinical features (i.e., age > or =65 years, diabetes, previous acute myocardial infarction, and typical chest pain) and with a positive result on exercise testing. CONCLUSIONS: Adverse events after discharge are not infrequent in patients admitted to hospital with suspected acute coronary syndrome and a low risk profile. Both the patient's clinical characteristics and exercise test results should be taken into account in accurately determining prognosis.

Utilidad del perfil clínico y la ergometría en la valoración del pronóstico de los pacientes ingresados por dolor torácico sin criterios de alto riesgo / Usefulness of clinical profiling and exercise testing in the prognostic assessment of patients admitted with chest pain but without high-risk criteria

Introducción y objetivos. Hay escasa información sobre la evolución de los pacientes hospitalizados por dolor torácico que no presentan criterios de alto riesgo tras su evaluación inicial, a los que se realiza una prueba de esfuerzo para su valoración antes del alta. Nuestro objetivo fue evaluar el pronóstico de este grupo de pacientes y averiguar si hay factores clínicos y derivados de la prueba de esfuerzo que permitan predecir su evolución. Pacientes y método. La población estaba constituida por 449 pacientes hospitalizados por dolor torácico de posible origen isquémico, sin criterios de alto riesgo (sin alteraciones isquémicas en el electrocardiograma ni elevación de la troponina), a los que se realizó una prueba de esfuerzo previa al alta, tras un período de observación de al menos 12 h. La mediana de seguimiento fue 479 días. Se consideraron acontecimientos adversos la muerte cardíaca o el reingreso por infarto agudo de miocardio (IAM) no mortal o angina inestable. Resultados. De los 449 pacientes, 44 (10%) presentaron algún suceso. En el análisis de regresión de Cox se identificaron como predictores independientes de evolución desfavorable cuatro variables clínicas (edad ≥ 65 años, diabetes, IAM previo y carácter típico del dolor torácico) y una prueba de esfuerzo positiva. Conclusiones. Los pacientes hospitalizados por dolor torácico sin criterios de alto riesgo tras su evaluación inicial, a los que se efectúa una prueba de esfuerzo, no están exentos de sucesos adversos tras el alta. El perfil clínico contribuye, junto con el resultado de la ergometría, a la valoración del riesgo de estos pacientes

Introduction and objectives. Few data are available on the outcome of patients admitted to hospital with suspected acute coronary syndrome who have no high-risk factors and who undergo exercise testing before discharge. Our objectives were to investigate outcomes in this group of patients and to determine whether clinical history-taking or exercise testing can help to predict outcome. Patients and method. The study population comprised 449 patients admitted to hospital with chest pain suggestive of acute coronary syndrome. All were judged to be at a low risk of subsequent events (i.e., none had ischemic ECG changes or an elevation in troponin level). They underwent treadmill exercise testing before discharge, after an observation period of at least 12 hours. Exercise testing was performed after clinical evaluation based on an algorithm involving troponin-T level and resting ECG. The median follow-up duration was 479 days. The single combined endpoint was defined as cardiac death, or hospital admission for nonfatal acute myocardial infarction or unstable angina. Results. Adverse events occurred in 44 (10%) of the 449 patients. A high event rate was associated with four clinical features (i.e., age ≥65 years, diabetes, previous acute myocardial infarction, and typical chest pain) and with a positive result on exercise testing. Conclusions. Adverse events after discharge are not infrequent in patients admitted to hospital with suspected acute coronary syndrome and a low risk profile. Both the patient's clinical characteristics and exercise test results should be taken into account in accurately determining prog

[Dobutamine stress echocardiography in patients with stable chronic angina and a low- or medium-risk on exercise testing: usefulness for assessing long-term prognosis]. / Ecocardiografía con dobutamina en pacientes con angina crónica estable y ergometría de riesgo bajo o intermedio: utilidad en la valoración del pronóstico a largo plazo.

INTRODUCTION AND OBJECTIVES: The ability of stress echocardiography to provide prognostic information that supplements that obtainable from clinical data and exercise electrocardiography is still controversial. Our aim was to determine whether dobutamine stress echocardiography provides additional information on long-term prognosis after conventional exercise testing has indicated that a patient with chronic stable angina has a low or intermediate risk of a cardiac event. PATIENTS AND METHOD: The study included consecutive patients with stable angina who were not found to be at high risk on a previous exercise test. All patients underwent dobutamine stress echocardiography. The mean follow- up period was 4.5+/-1.76 years. The single combined end-point was defined as death due to cardiac disease, nonfatal myocardial infarction, or hospitalization for unstable angina. Multivariate analysis was used to identify independent predictors of cardiac events. RESULTS: There were 24 (19%) cardiac events in the 124 participants: four deaths due to cardiac disease, 10 nonfatal myocardial infarctions, and 10 hospitalizations for unstable angina. Associations were found between a higher event rate during follow-up and previous myocardial infarction, Duke treadmill score, and the detection of regional wall motion abnormalities indicative of multivessel disease by stress echocardiography. CONCLUSIONS: In patients with stable angina who have undergone an exercise test that indicates that they have a low or intermediate risk of cardiac events, dobutamine stress echocardiography provides additional prognostic information to that obtainable from clinical data and exercise testing.

Ecocardiografía con dobutamina en pacientes con angina crónica estable y ergometría de riesgo bajo o intermedio: utilidad en la valoración del pronóstico a largo plazo / Dobutamine stress echocardiography in patients with stable chronic angina and a low- or medium-risk on exercise testing: usefulness for assessing long-term prognosis

Introducción y objetivos. La capacidad de la ecocardiografía de estrés para añadir información pronóstica a los datos clínicos y la prueba de esfuerzo convencional cuando ésta es valorable es motivo de debate. Nuestro objetivo fue evaluar si la ecocardiografía con dobutamina aporta información, tras la realización de una prueba de esfuerzo de riesgo bajo o intermedio, en la valoración del pronóstico a largo plazo de la angina estable. Pacientes y método. Se realizó un ecocardiograma con dobutamina en una serie consecutiva de pacientes con angina estable en los que previamente se había efectuado una ergometría que no había mostrado criterios de alto riesgo. El tiempo de seguimiento medio fue de 4,5 ± 1,76 años. Se definió un único criterio de valoración compuesto por la incidencia de muerte cardíaca, infarto de miocardio no mortal u hospitalización por angina inestable. Se realizó un análisis multivariable para determinar los predictores independientes de sucesos. Resultados. De los 124 pacientes incluidos, 24 (19%) presentaron algún suceso (4, muerte cardíaca; 10, infarto de miocardio no mortal, y 10, ingreso hospitalario por angina inestable). El antecedente de infarto de miocardio, la puntuación de Duke de la ergometría y la detección de anomalías de la contractilidad regional correspondientes a enfermedad multivaso mediante el ecocardiograma de estrés se asociaron con una mayor incidencia de acontecimientos en el seguimiento. Conclusiones. En pacientes con angina estable clásica que realizan una prueba de esfuerzo de riesgo bajo o intermedio, la ecocardiografía con dobutamina ofrece información pronóstica adicional a la proporcionada por los datos clínicos y la prueba de esfuerzo

Introduction and objectives. The ability of stress echocardiography to provide prognostic information that supplements that obtainable from clinical data and exercise electrocardiography is still controversial. Our aim was to determine whether dobutamine stress echocardiography provides additional information on long-term prognosis after conventional exercise testing has indicated that a patient with chronic stable angina has a low or intermediate risk of a cardiac event. Patients and method. The study included consecutive patients with stable angina who were not found to be at high risk on a previous exercise test. All patients underwent dobutamine stress echocardiography. The mean follow- up period was 4.5±1.76 years. The single combined end-point was defined as death due to cardiac disease, nonfatal myocardial infarction, or hospitalization for unstable angina. Multivariate analysis was used to identify independent predictors of cardiac events. Results. There were 24 (19%) cardiac events in the 124 participants: four deaths due to cardiac disease, 10 nonfatal myocardial infarctions, and 10 hospitalizations for unstable angina. Associations were found between a higher event rate during follow-up and previous myocardial infarction, Duke treadmill score, and the detection of regional wall motion abnormalities indicative of multivessel disease by stress echocardiography. Conclusions. In patients with stable angina who have undergone an exercise test that indicates that they have a low or intermediate risk of cardiac events, dobutamine stress echocardiography provides additional prognostic information to that obtainable from clinical data and exercise testing

Prognosis of patients with unstable angina and low-risk exercise test: significance of ST-segment depression on the admission ECG.

The presence of ST-segment depression on the admission electrocardiogram (ECG) is an important predictor of poor outcome in patients with unstable angina. On the other hand, patients with unstable angina who undergo a low-risk exercise test are supposed to have a favorable prognosis. The objective of the study was to determine the prognostic significance of ST-segment depression on the admission ECG in patients with unstable angina who undergo an exercise test that indicates a low risk of events. An interpretable exercise test was performed in 257 patients with primary unstable angina. A low-risk exercise test was completed by 156 (60%) patients and medical therapy was planned for all these patients. A multivariate analysis was performed in order to determine the independent predictors of events (cardiac death, nonfatal acute myocardial infarction, or admission for unstable angina) during a 12-month follow-up. Among patients with a low-risk exercise test, there were no significant differences between patients with and without ST-segment depression on the presenting ECG with regard to event rate (34 vs. 29%, P=NS). In multivariate analysis, ST-segment depression was not related to a higher incidence of events. Our findings appear to indicate that the presence of ST-segment depression on the admission ECG loses its prognostic significance in patients with primary unstable angina if they complete a low-risk exercise test.