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Introduction and Objectives: In patients with established chronic coronary syndrome (CCS), the significance of persistent angina is controversial. We aimed to evaluate the prognostic role of persistent angina in symptomatic CCS patients with abnormal stress cardiovascular magnetic resonance (CMR) and altered angiographic findings undergoing percutaneous revascularization., Methods: We analyzed 334 CCS patients with Canadian Cardiovascular Society angina class ≥2, perfusion deficits on stress CMR and severe lesions in angiography who underwent medical therapy optimization plus CMR-guided percutaneous revascularization. We investigated the association of persistent angina at 6 months postintervention with subsequent cardiac death, myocardial infarction, and hospital admission., Results: All patients had angina class ≥2 (mean: 2.8±0.7), abnormal stress CMR (mean ischemic burden: 5.8±2.7 segments), and severe angiographic lesions. The angina resolution rates were 81% at 6 months, and 81%, 81%, and 77% at 1, 2, and 5 years, respectively. During a median follow-up of 8.9 years, persistent angina was independently associated with higher rates of subsequent cardiac death (13% vs 4%; HR, 3.7; 95%CI, 1.5-9.2; P=.005), myocardial infarction (24% vs 6%; HR, 4.9; 95%CI, 2.4-9.9; P<.001), and hospital admission for heart failure (27% vs 13%; HR, 2.7; 95%CI, 1.5-5.2; P=.001)., Conclusions: In CCS patients with robust diagnostic evidence from symptoms, stress CMR, and angiography, persistent angina after percutaneous revascularization is a strong predictor of subsequent cardiac death, myocardial infarction, and hospital admission for heart failure., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Carbohydrate antigen 125 (CA125), a biomarker associated with fluid overload, has proven useful in managing diuretic therapy in heart failure. We aimed to evaluate the impact of diuretic optimization guided by CA125 before transcatheter aortic valve implantation (TAVI) on outcomes., Methods: This prospective interventional study enrolled patients scheduled for TAVI, in whom baseline CA125 was measured 2 weeks before TAVI. Patients with CA125 ≥ 20 U/mL underwent diuretic up-titration before TAVI. Three groups were included: group I) baseline CA125 <20 U/mL; IIa) CA125 ≥ 20 U/mL that decreased after treatment, and IIb) CA125 ≥ 20 U/mL that did not decrease. The primary outcome was changes in the Kansas City Cardiomyopathy Questionnaire at 3 and 12 months. The secondary endpoint was clinical events., Results: The study included 184 patients (115 group I, 46 IIa, and 23 IIb). Groups I and IIa exhibited early and sustained improvements in the Kansas City Cardiomyopathy Questionnaire (group I: 18.9 points [95%CI, 15.7-22.1; P <.001] at 90 days, and 18.1 [95%CI, 14.9-21.4, P <.001] at 1 year; group IIa: 21.1 points [95%CI, 15.4-26.7; P <.001] and 19.5 [95%CI, 13.9-25.1; P <.001] respectively). In contrast, in group IIb there was no significant improvement at 90 days (P=.12), with improvement being significant only at 1 year (17.8 points, 95%CI, 5.9-29.6; P=.003). Over a median follow-up of 20.7 months, there were 63 (27.83%) deaths or heart failure admissions. Multivariate analysis showed a lower risk of events in group I vs IIb (HR, 0.28; 95%CI, 0.14-0.58; P <.001), and IIa vs IIb (HR, 0.24; 95%CI, 0.11-0.55; P <.001)., Conclusions: Patients with persistently high CA125 despite diuretic therapy pre-TAVI showed slower functional recovery and poorer clinical outcomes after TAVI., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Heart failure (HF) is prevalent in advanced ages. Our objective was to assess the impact of frailty on 1-year mortality in older patients with ambulatory HF., Methods: Our data come from the FRAGIC study (Spanish acronym for "Study of the impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly outpatients with heart failure"), a multicenter prospective registry conducted in 16 Spanish hospitals including outpatients ≥ 75 years with HF followed up by cardiology services in Spain., Results: We included 499 patients with a mean age of 81.4±4.3 years, of whom 193 (38%) were women. A total of 268 (54%) had left ventricular ejection fraction <40%, and 84.6% was in NYHA II functional class. The FRAIL scale identified 244 (49%) pre-frail and 111 (22%) frail patients. Frail patients were significantly older, were more frequently female (both, P <.001), and had higher comorbidity according to the Charlson index (P=.017) and a higher prevalence of geriatric syndromes (P <.001). During a median follow-up of 371 [361-387] days, 58 patients (11.6%) died. On multivariate analysis (Cox regression model), frailty detected with the FRAIL scale was marginally associated with mortality (HR=2.35; 95%CI, 0.96-5.71; P=.059), while frailty identified by the visual mobility scale was an independent predictor of mortality (HR=2.26; 95%CI, 1.16-4.38; P=.015); this association was maintained after adjustment for confounding variables (HR=2.13; 95%CI, 1.08-4.20; P=.02)., Conclusions: In elderly outpatients with HF, frailty is independently associated with mortality at 1 year of follow-up. It is essential to identify frailty as part of the comprehensive approach to elderly patients with HF., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: The management of elderly patients with chronic coronary syndrome (CCS) is challenging. We explored the prognostic value and usefulness for decision-making of ischemic burden determined by vasodilator stress cardiac magnetic resonance (CMR) imaging in elderly patients with known or suspected CCS., Methods: The study group comprised 2496 patients older than 70 years who underwent vasodilator stress CMR for known or suspected CCS. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Subsequently, we retrospectively analyzed its association with all-cause mortality and the effect of CMR-guided revascularization., Results: During a median follow-up of 4.58 years, there were 430 deaths (17.2%). A higher ischemic burden was an independent predictor of mortality (HR, 1.04; 95%CI, 1.01-1.07 for each additional ischemic segment; P=.006). This association was also found in patients older than 80 years and in women (P <.001). An interaction between revascularization and mortality was detected toward deleterious consequences at low ischemic burden and a protective effect in patients with extensive ischemia., Conclusions: Vasodilator stress CMR is a valuable tool to stratify risk in elderly patients with CCS and might be helpful to guide decision-making in this scenario., (Copyright © 2021 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Discordant data have been reported on the prognosis of myocardial infarction with nonobstructive coronary arteries (MINOCA). Moreover, few data are available on the impact of angiographic subtypes. The objectives of this study were to assess the prognostic impact on the long-term follow-up of the diagnosis of MINOCA and its angiographic subtypes., Methods: We included 591 consecutive patients with non-ST-segment elevation myocardial infarction (NSTEMI) who underwent coronary angiography. MINOCA was classified according to angiographic findings as smooth coronary arteries, mild irregularities (< 30% stenosis), and moderate atherosclerosis (30%-49% stenosis). The primary endpoint was a composite of mortality, nonfatal myocardial infarction, and revascularization (MACE) at a median of 5 years of follow-up., Results: A total of 121 patients (20.5%) showed no obstructive lesions. MINOCA was associated with a lower occurrence of MACE (P=.014; HR, 0.63; 95%CI, 0.44-0.91) and was confirmed as an independent factor in the multivariate analysis (P=.018; HR, 0.63; 95%CI, 0.43-0.92). On analysis of the separate components of the main endpoint, MINOCA was significantly associated with a lower rate of myocardial infarction and revascularization, but not with mortality. Analysis of angiographic subtypes among MINOCA patients showed that smooth coronary arteries were a statistically significant protective factor on both univariate and multivariate analysis, while mild irregularities and 30% to 49% plaques were associated with a higher risk of MACE., Conclusions: MINOCA is associated with a lower rate of MACE, driven by fewer reinfarctions and revascularizations. Within the angiographic subtypes of MINOCA, smooth arteries were independently associated with a lower number of MACE., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Angiogenesis helps to reestablish microcirculation after myocardial infarction (MI). In this study, we aimed to further understand the role of the antiangiogenic isoform vascular endothelial growth factor (VEGF)-A 165 b after MI and to explore its potential as a coadjuvant therapy to coronary reperfusion., Methods: Two mice MI models were formed: a) permanent coronary ligation (nonreperfused MI); b) transient 45-minute coronary occlusion followed by reperfusion (reperfused MI); in both models, animals underwent echocardiography before euthanasia at day 21 after MI induction. We determined serum and myocardial VEGF-A 165 b levels. In both experimental MI models, we assessed the functional and structural role of VEGF-A 165 b blockade. In a cohort of 104 ST-segment elevation MI patients, circulating VEGF-A 165 b levels were correlated with cardiovascular magnetic resonance-derived left ventricular ejection fraction at 6 months and with the occurrence of adverse events (death, heart failure, and/or reinfarction)., Results: In both models, circulating and myocardial VEGF-A 165 b levels were increased 21 days after MI induction. Serum VEGF-A 165 b levels inversely correlated with systolic function evaluated by echocardiography. VEGF-A 165 b blockade increased capillary density, reduced infarct size, and enhanced left ventricular function in reperfused, but not in nonreperfused, MI experiments. In patients, higher VEGF-A 165 b levels correlated with depressed ejection fraction and worse outcomes., Conclusions: In experimental and clinical studies, higher serum VEGF-A 165 b levels are associated with worse systolic function. Their blockade enhances neoangiogenesis, reduces infarct size, and increases ejection fraction in reperfused, but not in nonreperfused, MI experiments. Therefore, VEGF-A 165 b neutralization represents a potential coadjuvant therapy to coronary reperfusion., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making., (Copyright © 2019 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient., (Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: The optimal treatment of patients with acute heart failure (AHF) and cardiorenal syndrome type 1 (CRS-1) is far from being well-defined. Arterial hypoperfusion in concert with venous congestion plays a crucial role in the pathophysiology of CRS-I. Plasma carbohydrate antigen 125 (CA125) has emerged as a surrogate of fluid overload in AHF. The aim of this study was to evaluate the clinical usefulness of CA125 for tailoring the intensity of diuretic therapy in patients with CRS-1., Methods: Multicenter, open-label, parallel clinical trial, in which patients with AHF and serum creatinine ≥ 1.4mg/dL on admission will be randomized to: a) standard diuretic strategy: titration-based on conventional clinical and biochemical evaluation, or b) diuretic strategy based on CA125: high dose if CA125 > 35 U/mL, and low doses otherwise. The main endpoint will be renal function changes at 24 and 72hours after therapy initiation. Secondary endpoints will include: a) clinical and biochemical changes at 24 and 72hours, and b) renal function changes and major clinical events at 30 days., Results: The results of this study will add important knowledge on the usefulness of CA125 for guiding diuretic treatment in CRS-1. In addition, it will pave the way toward a better knowledge of the pathophysiology of this challenging situation., Conclusions: We hypothesize that higher levels of CA125 will identify a patient population with CRS-1 who could benefit from the use of a more intense diuretic strategy. Conversely, low levels of this glycoprotein could select those patients who would be harmed by high diuretic doses., (Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Microvascular obstruction exerts deleterious effects after myocardial infarction. To elucidate the role of ischemia-reperfusion injury on the occurrence and dynamics of microvascular obstruction, we performed a preliminary methodological study to accurately define this process in an in vivo model., Methods: Myocardial infarction was induced in swine by means of 90-min of occlusion of the mid left anterior descending coronary artery using angioplasty balloons. Intracoronary infusion of thioflavin-S was applied and compared with traditional intra-aortic or intraventricular instillation. The left anterior descending coronary artery perfused area and microvascular obstruction were quantified in groups with no reperfusion (thioflavin-S administered through the lumen of an inflated over-the-wire balloon) and with 1-min, 1-week, and 1-month reperfusion (thioflavin-S administered from the intracoronary catheter after balloon deflation)., Results: In comparison with intra-aortic and intraventricular administration, intracoronary infusion of thioflavin-S permitted a much clearer assessment of the left anterior descending coronary artery perfused area and of microvascular obstruction. Ischemia-reperfusion injury exerted a decisive role on the occurrence and dynamics of microvascular obstruction. The no-reperfusion group displayed completely preserved perfusion. With the same duration of coronary occlusion, microvascular obstruction was already detected in the 1-min reperfusion group (14%±7%), peaked in the 1-week reperfusion group (21%±7%), and significantly decreased in the 1-month reperfusion group (4%±3%; P<.001)., Conclusions: We present proof-of-concept evidence on the crucial role of ischemia-reperfusion injury on the occurrence and dynamics of microvascular obstruction. The described porcine model using intracoronary injection of thioflavin-S permits accurate characterization of microvascular obstruction after myocardial infarction., (Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: In patients with heart failure and type 2 diabetes, low glycosylated hemoglobin has been related with higher risk of mortality but information regarding morbidity is scarce. We sought to evaluate the association between glycosylated hemoglobin and 30-day readmission in patients with type 2 diabetes and acute heart failure., Methods: Glycosylated hemoglobin was measured before discharge in 835 consecutive patients with acute heart failure and type 2 diabetes. Cox regression analysis adapted for competing events was used., Results: Mean (standard deviation) age was 72.9 (9.6) years and median glycosylated hemoglobin was 7.2% (6.5%-8.0%). Patients treated with insulin or insulin/sulfonylurea/meglitinides were 41.1% and 63.2% of the cohort, respectively. At 30 days post-discharge, 109 (13.1%) patients were readmitted. A multivariate analysis revealed that the effect of glycosylated hemoglobin on the risk of 30-day readmission was differentially affected by the type of treatment (P for interaction<.01). Glycosylated hemoglobin (per 1% decrease) was inversely associated with higher risk in those receiving insulin (hazard ratio = 1.45; 95% confidence interval, 1.13-1.86; P=.003) or insulin/sulfonylurea/meglitinides (hazard ratio = 1.44; 95% confidence interval, 1.16-1.80; P=.001). Conversely, glycosylated hemoglobin (per 1% increase) had no effect in non-insulin dependent diabetes (hazard ratio = 1.01; 95% confidence interval, 0.87-1.17; P=.897) or even a positive effect in patients not receiving insulin/sulfonylurea/meglitinides (hazard ratio = 1.12; 95% confidence interval, 1.03-1.22; P=.011)., Conclusions: In acute heart failure, glycosylated hemoglobin showed to be inversely associated to higher risk of 30-day readmission in insulin-dependent or those treated with insulin/sulfonylurea/meglitinides. A marginal effect was found in the rest. Whether this association reflects a treatment-related effect or a surrogate of more advanced disease should be clarified in further studies., (Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: The incremental prognostic value of inducible myocardial ischemia over necrosis derived by stress cardiac magnetic resonance in depressed left ventricular function is unknown. We determined the prognostic value of necrosis and ischemia in patients with depressed left ventricular function referred for dipyridamole stress perfusion magnetic resonance., Methods: In a multicenter registry using stress magnetic resonance, the presence (≥ 2 segments) of late enhancement and perfusion defects and their association with major events (cardiac death and nonfatal infarction) was determined., Results: In 391 patients, perfusion defect or late enhancement were present in 224 (57%) and 237 (61%). During follow-up (median, 96 weeks), 47 major events (12%) occurred: 25 cardiac deaths and 22 myocardial infarctions. Patients with major events displayed a larger extent of perfusion defects (6 segments vs 3 segments; P <.001) but not late enhancement (5 segments vs 3 segments; P =.1). Major event rate was significantly higher in the presence of perfusion defects (17% vs 5%; P =.0005) but not of late enhancement (14% vs 9%; P =.1). Patients were categorized into 4 groups: absence of perfusion defect and absence of late enhancement (n = 124), presence of late enhancement and absence of perfusion defect (n = 43), presence of perfusion defect and presence of late enhancement (n = 195), absence of late enhancement and presence of perfusion defect (n = 29). Event rate was 5%, 7%, 16%, and 24%, respectively (P for trend = .003). In a multivariate regression model, only perfusion defect (hazard ratio = 2.86; 95% confidence interval, 1.37-5.95]; P = .002) but not late enhancement (hazard ratio = 1.70; 95% confidence interval, 0.90-3.22; P =.105) predicted events., Conclusions: In depressed left ventricular function, the presence of inducible ischemia is the strongest predictor of major events., (Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: A variety of cardiac magnetic resonance indexes predict mid-term prognosis in ST-segment elevation myocardial infarction patients. The extent of transmural necrosis permits simple and accurate prediction of systolic recovery. However, its long-term prognostic value beyond a comprehensive clinical and cardiac magnetic resonance evaluation is unknown. We hypothesized that a simple semiquantitative assessment of the extent of transmural necrosis is the best resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction., Methods: One week after a first ST-segment elevation myocardial infarction we carried out a comprehensive quantification of several resonance parameters in 206 consecutive patients. A semiquantitative assessment (altered number of segments in the 17-segment model) of edema, baseline and post-dobutamine wall motion abnormalities, first pass perfusion, microvascular obstruction, and the extent of transmural necrosis was also performed., Results: During follow-up (median 51 months), 29 patients suffered a major adverse cardiac event (8 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 readmissions for heart failure). Major cardiac events were associated with more severely altered quantitative and semiquantitative resonance indexes. After a comprehensive multivariate adjustment, the extent of transmural necrosis was the only resonance index independently related to the major cardiac event rate (hazard ratio=1.34 [1.19-1.51] per each additional segment displaying>50% transmural necrosis, P<.001)., Conclusions: A simple and non-time consuming semiquantitative analysis of the extent of transmural necrosis is the most powerful cardiac magnetic resonance index to predict long-term outcome soon after a first ST-segment elevation myocardial infarction., (Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: To evaluate by cardiovascular magnetic resonance those factors related to the amount of salvaged myocardium after a myocardial infarction and its value in predicting adverse ventricular remodeling., Methods: One hundred eighteen patients admitted for a first ST elevation myocardial infarction (primary angioplasty, 65 patients; a pharmacoinvasive strategy, 53 patients) underwent magnetic resonance (6 [5-8] days and 6 months; n=83). The myocardial salvage index was quantitatively assessed as the percentage of area at risk (T2-weighted sequences) not showing late enhancement., Results: Myocardial salvage index >31% (median) was associated with a shorter time to reperfusion (153 min vs 258 min), a lower rate of diabetes (12% vs 32%), shorter time to magnetic resonance, and better cardiovascular parameters (P<.05 for all analyses). There were no significant differences depending on the reperfusion method. In a logistic regression analysis, delayed reperfusion (odds ratio=0.42 [0.29-0.63]; P<.0001), diabetes (odds ratio=0.32 [0.11-0.99]; P<.05) and a longer time to the performance of magnetic resonance (odds ratio=0.86 [0.76-0.97]; P<.05) were independently related to a lower probability of a myocardial salvage index >31%. Predictors of increased left ventricular end-systolic volume at 6 months were the number of segments showing an extent of transmural necrosis >50% (odds ratio =1.51 [1.21-1.90]; P<.0001) and left ventricular end-systolic volume at one week (odds ratio=1.12 [1.06-1.18]; P<.0001)., Conclusions: Cardiovascular magnetic resonance enables the quantification of the salvaged myocardium after myocardial infarction. The celerity with which reperfusion therapy is administered constitutes its most important predictor. The possible effect of a delay in the performance of magnetic resonance on myocardial salvage needs to be confirmed. Salvaged myocardium does not improve the value of magnetic resonance for predicting adverse remodeling., (Copyright © 2012 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)