Incidence and Predictors of Progression in Asymptomatic Patients With Stable Heart Failure.

Data from previous heart failure (HF) trials suggest that patients with mild symptoms (NYHA II) actually have a poor clinical outcome. However, these studies did not assess clinical stability and rarely included patients in NYHA I. We sought to determine the incidence of short-term clinical progression in supposedly stable HF patients in NYHA I. In addition, we aimed to investigate the predictive value of widely available electrocardiographic and echocardiographic parameters for short-term disease progression. This is a retrospective study including 153 consecutive patients with HF with reduced and mid-range ejection fraction (HFrEF: LVEF<40%; HFmrEF: LVEF 40-49%) in NYHA I with no history of decompensation within the previous 6 months. All patients underwent comprehensive baseline echocardiographic and electrocardiographic assessment. The primary endpoint was the composite of cardiovascular death, hospitalization and need for intensification of HF treatment within a 12 month follow-up period. The cumulative incidence of HF progression was 17.8%, with a median time to event of 193 days. Death and hospitalization due to HF accounted for three-quarters of the events. QRS duration ≥120ms and mitral regurgitation grade >1 showed to be significant predictors of HF progression (HR: 8.92, p<0.001; and HR: 4.10, p<0.001, respectively). Patients without these risk factors had a low incidence of clinical events (3.8%). In conclusion, almost one in five supposedly stable HF patients in NYHA I experience clinical progression in short-term follow-up. Simple electrocardiographic and echocardiographic predictors may be useful for risk stratification and could help to improve individual HF patient management and outcomes.

Ventricular tachycardia secondary to thyrotoxic periodic paralysis: A case report.

Thyrotoxic periodic paralysis (TPP) is a rare but potentially life-threatening entity, which is characterized by sudden onset of muscle weakness and can in exceptional cases be associated with more severe symptoms, such as severe hypokalemia. We present the rare case of a young patient presenting with monomorphic ventricular tachycardia secondary to hypokalemia due to TPP. This case report highlights the importance of recognition of TPP as a rare cause of VT. A high index of suspicion is needed since signs of hyperthyroidism may be subtle. However, early diagnosis is crucial in order to avoid cardiovascular complications and improve outcomes.

Atrial cholangiocarcinoma diagnosed by cardiac magnetic resonance imaging.

In this rare case of intrahepatic cholangiocarcinoma (ICC) tumor thrombus with right atrial (RA) invasion, we describe its diagnostic workup based on cardiac magnetic resonance imaging (cMRI). An 85-year-old man underwent transthoracic echocardiography due to dyspnea, revealing a RA mass. Comprehensive cMRI evaluation, including cine bright blood, T1- and T2-weighed, fat-suppressed, and contrast-enhanced imaging, was performed and diagnosis of ICC tumor thrombus with RA invasion was made. This first description of cMRI-guided diagnosis of RA invasion by ICC tumor thrombus points out the usefulness of cMRI for the diagnostic approach of RA masses suggestive of tumor thrombus.

[Antiplatelet therapy: resistance to traditional antiaggregation drugs and role of new antiplatelet agents]. / Antiagregación: resistencia a fármacos tradicionales y papel de los nuevos antiplaquetarios.

Platelet aggregation plays a key role in the development of major cardiovascular events (MACE) related to atherothrombosis. Since the appearance of coronary stenting, the importance of measuring and modulating platelet activity has considerably increased in the scientific literature during the last decade. Double antiplatelet therapy with aspirin and clopidogrel administrated to stent carriers has widely demonstrated its efficacy in the prevention of MACE compared with aspirin alone. These benefits are also present when a conservatory approach is chosen for acute coronary syndrome management. However, there are an important number of patients who develop MACE despite optimal dual antiplatelet therapy, most likely related to an incomplete platelet activity inhibition. Many studies suggest an important inter-individual variability in the response to the drugs, maybe related, at least in part, to the use of different assessment techniques of platelet aggregation. Other authors suggest an incomplete platelet inhibition as a possible explanation for the presence of MACE in patients under optimal antiplatelet therapy. Resistance to usual drugs has become a clinically relevant issue that requires an individual approach where new antiplatelet agents, such as prasugrel or ticagrelor, could play an important role as stated in current consensus documents.

Poor response to antiplatelet drugs. An important issue in drug-eluting stents.

Platelet aggregation activity is the cornerstone of the pathogenesis of atherothrombosis and plays a main role in the appearance of major adverse cardiac events (MACE). This aspect has become even more important nowadays due to the use of drug-eluting stents (DES), where a proper platelet inhibition is required. Dual antiplatelet therapy with aspirin and clopidogrel in patients undergoing percutaneous coronary intervention (PCI) has widely demonstrated its beneficial effect in reducing MACE compared with aspirin alone. These benefits had also been established in short and long term treatment in patients with coronary artery disease managed with a conservative strategy. However, despite dual antiplatelet therapy an important number of patients experience new MACE related to an incomplete platelet inhibition that can be caused by the interaction of different mechanisms, not fully known at the moment. Several clinical studies suggested the significant variability in individual patient response to antiplatelet drugs to be due to the use of different laboratory tests. Moreover, other studies associated the low responsiveness status with an increased risk of recurrent cardiovascular events. Notably, resistance or reduced response to antiplatelet therapy with aspirin and clopidogrel is a clinically relevant entity that needs to be taken into account in order to perform a proper and individualized treatment strategy. Recent antiplatelet drugs such as prasugrel and ticagrelor have appeared to be an attractive option for patients with resistance or low response to traditional therapy. In this article we review aspirin and clopidogrel resistance as a clinical entity, the different mechanisms that could be linked to treatment failure, its relation with special situations and future perspectives in this area.