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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.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.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 fraction40%, 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).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.

This study aimed to assess, in patients with cardiogenic shock secondary to unprotected left main coronary artery-related myocardial infarction (ULMCA-related AMICS), the incidence and predictors of no recovery of left ventricular function during the admission.This was an observational study conducted at two tertiary care centres (2012-20). The main outcome measured was death or requirement for heart transplantation (HT) or left ventricular assist devices (LVAD) during the admission. A total of 70 patients were included. Percutaneous coronary intervention (PCI) was successful in 53/70 patients (75.7%). The combined endpoint of death or requirement of HT or LVAD during the admission occurred in 41/70 patients (58.6%). The highest incidence of the primary endpoint was observed among patients with profound shock and occluded left main coronary artery (LMCA) (20/23, 87%, P 0.001). Although a successful PCI reduced the incidence of the event in the whole cohort (51.9% vs. 82.4% in failed PCI, P = 0.026), this association was not observed among this last group of complex patients (86.7% vs. 87.5% in failed PCI, P = 0.731). The predictive model included left ventricular ejection fraction, baseline ULMCA Thrombolysis In Myocardial Infarction flow, and severity of shock and showed an optimal ability for predicting death or requirements for HT or LVAD during the admission (area under the curve 0.865, P 0.001).ULMCA-related AMICS was associated with a high in-hospital mortality or need for HT or LVAD. Prognosis was especially poor among patients with profound shock and baseline occluded LMCA, with a low probability of recovery regardless of successful PCI.

Introducción y objetivos Los datos respecto a la utilización del oxigenador extracorpóreo de membrana venoarterial (ECMO-VA) en adultos con shock cardiogénico (SC) son escasos. El objetivo del presente estudio fue describir los datos de un registro multicéntrico español, y analizar qué factores tuvieron un impacto en la mortalidad intrahospitalaria. Métodos Registro retrospectivo multicéntrico español de pacientes en situación de SC profundo que recibieron soporte circulatorio con ECMO-VA. Resultados Desde enero de 2012 hasta octubre de 2018, se asistieron 233 pacientes con ECMO-VA. La edad media fue 56,3 ± 12,18 años y 50 eran mujeres (21,5%). Recibieron el alta hospitalaria 109 pacientes (46,8%). Las complicaciones más frecuentes observadas fueron: insuficiencia renal aguda en 131 (59,0%), hemorragia en 70 (31,7%), hipoxemia en 86 (36,9%) e infección en 99 (43,4%). Los predictores independientes de mortalidad intrahospitalaria fueron lactato al implante (OR = 1,05; IC95%, 1,05-1,19), edad (OR = 2,19; IC95%, 1,05-4,58) y canulación intraparada cardiaca (OR = 1,04; IC95%, 1,01-1,06). Un total de 45 pacientes tenían edad > 60 años y lactato al implante > 8 mmol/l, su mortalidad intrahospitalaria fue de 77,8% y llegó al 91,7% en 12 de ellos en los que la canulación fue intraparada cardiaca. Conclusiones La terapia con ECMO-VA es factible en pacientes con SC profundo. La selección adecuada parece fundamental para evitar la futilidad del implante en pacientes con escasas posibilidades de éxito. Introduction and objectives The data regarding the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults in with cardiogenic shock (CS) are scarce. The aim of this study was to describe the data of a Spanish multicenter registry, and to analyze which factors had an impact on in-hospital mortality. Methods Retrospective Spanish multicenter registry of patients with deep CS treated with VA-ECMO circulatory support. Results From January 2012 to October 2018, 233 patients were treated with VA-ECMO. Mean age was 56.3 ± 12.18 years and 50 were female (21.5%). A total of 109 patients were successfully discharged (46.8%). The most frequent complications were acute kidney injury in 131 (59.0%), hypoxemia in 86 (36.9%) major bleeding in 70 (31.7%), and infection in 99 (43.4%). The independent in-hospital mortality risk factors were lactate before implant (OR, 1.05; 95%CI, 1.05-1.19), age (OR, 2.19; 95%CI, 1.05-4.58), and cannulation during cardiac arrest (OR, 1.04; 95%CI, 1.01-1.06). A total of 45 patients > 60 years with lactate before implant > 8 mmol/l had an in-hospital mortality rate of 77.8%, in-hospital mortality and reached 91.7% in 12 of them with cannulation during cardiac arrest. Conclusions VA-ECMO therapy for patients with deep cardiogenic shock is feasibly. Appropriate selection seems critical in order to avoid the futility of using ECMO in those patients with low survival chances. Sin financiación No data JCR (2021) 0.130 SJR (2021) Q4, 317/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEM

Resumen Antecedentes y objetivo La mala adherencia terapeutica tras un infarto agudo de miocardio (IAM) puede conllevar complicaciones graves precoces. La informacion sobre el impacto de la valoracion geriatrica en la adherencia es escasa. El objetivo de este estudio fue analizar, en pacientes mayores con IAM, el impacto de la valoracion geriatrica en la adherencia terapeutica 12 meses tras el ingreso. Materiales y metodos Un estudio previo aleatorizo a pacientes de edad > 75 anos que habian presentado un IAM a un programa de educacion sanitaria de enfermeria o manejo convencional. Se evaluo el impacto de dicha intervencion en la adherencia terapeutica tras 12 meses. Se realizo valoracion geriatrica intrahospitalaria. Para este subestudio se analizaron los predictores de adherencia mediante regresion logistica binaria. Se considero adherentes a aquellos pacientes que lo resultaron en las 4 herramientas: el test de Morisky-Green, Haynes-Sackett, asistencia a visitas y correcta retirada de farmacos de farmacia. Resultados Se incluyo a 119 pacientes, con una edad media de 82,2 anos. Al ano, un total de 42 pacientes (35,3%) fueron adherentes. Los predictores de mala adherencia en el modelo final fueron el sexo masculino, el peor filtrado glomerular, el deterioro cognitivo, el riesgo nutricional, el hecho de no vivir solo y no haber participado en el grupo de intervencion. Conclusiones Los datos de esta serie muestran una baja adherencia terapeutica en las personas mayores despues de un IAM. El deterioro cognitivo o el riesgo nutricional se asociaron de forma significativa con una peor adherencia, de forma contraria a una intervencion de enfermeria, lo que pone de relieve la importancia de la educacion sanitaria y la supervision en pacientes de alto riesgo.

Resumen Durante este ultimo ano se han publicado multiples estudios en el campo de la cardiopatia isquemica y de los cuidados criticos cardiovasculares. Hemos seleccionado las publicaciones mas destacadas segun el criterio de los autores, ordenandolas por bloques tematicos, para hacer mas sencilla su lectura.

Background Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19–associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. Methods A total of 112 patients with suspected AM from 56963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19–associated AM. Results AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19–associated pneumonia. Twenty- one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47; P Conclusions AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.

Resumen Introduccion y objetivos La rotura de septo interventricular tras un infarto es una complicacion rara, pero muy grave, con una alta tasa de mortalidad. Nuestro proposito es analizar que factores han podido influir en la mortalidad por esta afeccion durante la ultima decada, incluyendo los relacionados con la asistencia circulatoria mecanica. Metodos El registro CIVIAM es un estudio retrospectivo, observacional y multicentrico desarrollado en Espana. Se diseno un analisis comparativo, cuyos objetivos primarios son describir el tratamiento de esta afeccion, asi como los cambios en la mortalidad hospitalaria y al ano, dividiendo el periodo de observacion en 2 periodos iguales (enero de 2008 a junio de 2013 y julio de 2013 a diciembre de 2018). Resultados En total se recluto a 120 pacientes consecutivos. La mortalidad total al ano fue del 61,7%. Los pacientes en el segundo periodo del estudio eran significativamente mas jovenes. Se encontro una reduccion significativa de la mortalidad al ano en el segundo periodo del estudio (el 75,6 frente al 52,7%; p = 0,01), confirmada despues de ajustar por factores de confusion (OR = 0,40; IC95%, 0,17-0,98). Se sometio a reparacion quirurgica al 58,7 frente al 70,3% (p = 0,194) y a cierre percutaneo, al 8,7 y el 6,8% respectivamente (p = 0,476). Se realizo trasplante cardiaco a 1 frente a 5 pacientes (el 2,2 frente al 6,8%; p = 0,405). La principal diferencia entre uno y otro periodo del estudio fue el mayor uso de oxigenador extracorporeo de membrana venoarterial en el segundo (el 4,4 frente al 27%; p = 0,001). Conclusiones La comunicacion interventricular posinfarto aun presenta altas tasas de mortalidad. Se observa una tendencia a una mayor utilizacion del oxigenador extracorporeo de membrana venoarterial y mayor acceso a tratamiento correctivos, con mejores tasas de supervivencia.

Resumen Introduccion y objetivos El objetivo es evaluar la interaccion entre carga de comorbilidad y beneficio de la revascularizacion en ancianos con sindrome coronario agudo sin elevacion del ST (SCASEST). Metodos Estudio retrospectivo que incluyo a 7.211 pacientes de edad ≥ 70 anos y procedentes de 11 registros de SCASEST espanoles. Se evaluaron 6 comorbilidades (diabetes mellitus, arteriopatia periferica, enfermedad cerebrovascular, enfermedad pulmonar cronica, insuficiencia renal y anemia). Se calculo una puntuacion de propension para comparar el efecto de la revascularizacion frente al tratamiento conservador. El objetivo fue la mortalidad a 1 ano. Resultados Al ano habian fallecido 1.090 pacientes (15%). La frecuencia de revascularizacion durante la hospitalizacion fue del 60%. La revascularizacion se asocio con menor mortalidad, cuya magnitud no cambio al anadir al modelo las comorbilidades (HR = 0,61; IC95%, 0,53-0,69; p = 0,0001). Sin embargo, los efectos de la revascularizacion se atenuaron en los pacientes con insuficiencia renal, arteriopatia periferica y enfermedad pulmonar cronica (para la interaccion, p = 0,004, p = 0,007 y p = 0,03 respectivamente), mientras que no se modificaron con la diabetes mellitus, la anemia o la enfermedad cerebrovascular (p = 0,74, p = 0,51 y p = 0,28). Los beneficios de la revascularizacion disminuyeron gradualmente segun aumentaba el numero de comorbilidades (de HR = 0,48; IC95%, 0,39-0,61 con 0 comorbilidades hasta HR = 0,83; IC95%, 0,62-1,12 con 5 o mas comorbilidades; omnibus, p = 0,016). Los resultados fueron identicos con el modelo de la puntuacion de propension o cuando se utilizo la intervencion de cateterismo cardiaco como variable de exposicion. Conclusiones La revascularizacion durante el ingreso mejoro independientemente de las comorbilidades la mortalidad a 1 ano de una poblacion anciana con SCASEST. No obstante, el beneficio se redujo de manera progresiva segun aumentaba la carga de comorbilidades. La insuficiencia renal, la arteriopatia periferica y la enfermedad pulmonar cronica son las comorbilidades que mas contrarrestaron los potenciales beneficios de la revascularizacion.

Resumen Introduccion y objetivos Las redes de tratamiento del infarto agudo de miocardio con elevacion del segmento ST (IAMCEST) han incrementado la tasa de reperfusion y reducido los tiempos de isquemia. Nuestro objetivo fue analizar la diferencia en el pronostico entre generos en pacientes con un primer IAMCEST. Metodos Se realizo un estudio de cohorte multicentrico de pacientes con primer IAMCEST durante 2010-2016 para determinar el efecto del genero/sexo ajustado sobre la mortalidad, la combinacion de mortalidad, fibrilacion ventricular, shock cardiogenico o edema agudo de pulmon a 30 dias, y sobre la mortalidad al ano. Resultados Entre 2010 y 2016 se incluyeron 14.690 pacientes, un 24% fueron mujeres. En el periodo de estudio, la mediana [rango intercuartilico] de tiempo entre electrocardiograma y apertura de arteria descendio en ambos sexos (119 min [85-160] frente a 109 min [80-153] en 2010 en mujeres, y 102 min [81-133] frente a 96 min [74-124] en 2016 en mujeres, ambos valores p = 0,001). En el mismo periodo, el porcentaje de angioplastia primaria en Conclusiones Las mujeres con un primer IAMCEST presentan un porcentaje de muerte o complicaciones al mes similar a la de los varones y, en cambio, menos mortalidad al ano tras ajustar por edad y gravedad.

Purpose: Higher risk of bleeding with ticagrelor over clopidogrel in elderly patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) has been suggested. We assessed the incidence of major bleedings (MB), reinfarction (re-MI), and all-cause death to evaluate safety and efficacy of ticagrelor versus clopidogrel in such population. Methods: Real-world registries RENAMI and BleeMACS were merged. The pooled cohort was divided into two groups, clopidogrel versus ticagrelor. Statistical analysis considered patients

Introduction and objectives Despite evidence of a reduction in the incidence and mortality of acute coronary syndrome (ACS), some studies have highlighted differences in outcomes between men and women. We aimed to explore sex differences in the management and treatment of patients with ACS in Spain. Methods This ecological cross-sectional study combined ACS data from 10 Spanish registries (54 centres). Meta-regression analysis was performed using aggregated data of baseline characteristics, interventional procedures, treatments, and events that occurred during hospitalization and one-year follow-up. Results Aggregated data from 34 605 patients (75.1% men) was included. ST-segment elevation myocardial infarction was the most frequent diagnosis (58.9%) and almost 80% of patients were Killip Class I. Compared to men, women were older (mean age: 71.0 vs 63.3 years) and presented higher rates of hypertension (68.1% vs 51.7%) and diabetes (37.7% vs 26.5%). Women were also less likely to undergo percutaneous coronary interventions, revascularization surgery, and to receive drug-eluting stents during hospitalization. Regarding to antiplatelet therapy, even though indicated, 23.1% of women were not treated with P2Y12 inhibitors (vs 14.2% of men; P 60%). Significantly higher in-hospital (5.4% vs 3.7%) and 1-year (8.2% vs 4.9%) mortality was observed among women compared to men, which was mainly attributed to cardiovascular causes. Conclusions Despite older age and unfavourable risk profile, female ACS patients seem to be suboptimally treated with P2Y12 inhibitors. To reduce mortality associated with ACS, improved prevention and optimized therapeutic approaches are needed.

A significant proportion of cases of cardiogenic shock (CS) are due aetiologies other than acute coronary syndromes (non ACS-CS). We assessed differences regarding clinical profile, management, and prognosis according to the cause of CS among nonselected patients with CS from a large nationwide database.We performed an observational study including patients admitted from the hospitals of the Spanish National Health System (SNHS) with a principal or secondary diagnosis code of CS (2016-2019). Data were obtained from the Minimum Basic Data Set (MBDS). Hospitals were classified according to the availability of cardiology related resources, as well as the availability of Intensive Cardiac Care Unit (ICCU).A total of 10,826 episodes of CS were included, of whom 5,495 (50.8%) were non-ACS related. Non ACS-CS patients were younger (71.5 vs. 72.4 years) and had a lower burden of arteriosclerosis-related comorbidities. Non ACS-CS cases underwent less often invasive procedures and presented lower in-hospital mortality (57.1% vs. 61%,p 0.001). The most common main diagnosis among non ACS-CS was acute decompensation of chronic heart failure (ADCHF) (35.4%). A lower risk-adjusted in-hospital mortality rate was observed in high volume hospitals (52.6% vs. 56.7%; p 0.001), as well as in centers with ICCU (OR: 0.71; CI 95%: 0.58-0.87; p 0.001).More than a half of cases of CS were due to non-ACS causes. Non ACS-CS cases are a very heterogeneous group, with different clinical profile and management. Management at high-volume hospitals and availability of ICCU were associated with lower risk adjusted mortality among non ACS-CS patients.

In recent decades, life expectancy has been increasing significantly. In this scenario, health interventions are necessary to improve prognosis and quality of life of elderly with cardiovascular risk factors and cardiovascular disease. However, the number of elderly patients included in clinical trials is low, thus current clinical practice guidelines do not include specific recommendations. This document aims to review prevention recommendations focused in patients ≥ 75 years with high or very high cardiovascular risk, regarding objectives, medical treatment options and also including physical exercise and their inclusion in cardiac rehabilitation programs. Also, we will show why geriatric syndromes such as frailty, dependence, cognitive impairment, and nutritional status, as well as comorbidities, ought to be considered in this population regarding their important prognostic impact.

Summary Background The accuracy of current prediction tools for ischaemic and bleeding events after an acute coronary syndrome (ACS) remains insufficient for individualised patient management strategies. We developed a machine learning-based risk stratification model to predict all-cause death, recurrent acute myocardial infarction, and major bleeding after ACS. Methods Different machine learning models for the prediction of 1-year post-discharge all-cause death, myocardial infarction, and major bleeding (defined as Bleeding Academic Research Consortium type 3 or 5) were trained on a cohort of 19 826 adult patients with ACS (split into a training cohort [80%] and internal validation cohort [20%]) from the BleeMACS and RENAMI registries, which included patients across several continents. 25 clinical features routinely assessed at discharge were used to inform the models. The best-performing model for each study outcome (the PRAISE score) was tested in an external validation cohort of 3444 patients with ACS pooled from a randomised controlled trial and three prospective registries. Model performance was assessed according to a range of learning metrics including area under the receiver operating characteristic curve (AUC). Findings The PRAISE score showed an AUC of 0·82 (95% CI 0·78–0·85) in the internal validation cohort and 0·92 (0·90–0·93) in the external validation cohort for 1-year all-cause death; an AUC of 0·74 (0·70–0·78) in the internal validation cohort and 0·81 (0·76–0·85) in the external validation cohort for 1-year myocardial infarction; and an AUC of 0·70 (0·66–0·75) in the internal validation cohort and 0·86 (0·82–0·89) in the external validation cohort for 1-year major bleeding. Interpretation A machine learning-based approach for the identification of predictors of events after an ACS is feasible and effective. The PRAISE score showed accurate discriminative capabilities for the prediction of all-cause death, myocardial infarction, and major bleeding, and might be useful to guide clinical decision making. Funding None.

Background: Acute myocardial infarction (AMI) recurrence is still high despite great progress in secondary prevention. Patients with recurrent AMI suffer worse prognosis compared to those with first AMI. The objective was to evaluate the effect of optimal medical therapy (OMT) on these patients with recurrent AMI. Methods and results: Sub-analysis was performed including 13,343 patients with AMI from the international multicenter Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) registry. OMT was defined as the combination of aspirin, any P2Y12 inhibitor, statin, angiotensin converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. Among 1285 patients with prior AMI, 56.8% received OMT prescription. Patients receiving OMT suffered from less congestive heart failure, peripheral artery disease, malignancy, and bleeding history. Kaplan-Meier survival estimates revealed that OMT was strongly related to decreased in all-cause death (4.2% vs. 10.1%, p < .001) and the composite endpoint of death/re-AMI (11.1% vs. 16.9%, p = .005) at 1-year follow-up. OMT was the independent protect factor of primary endpoint even after adjusting for multiple possible confounders (HR, 0.46; 95% CI, 0.27–0.78; p = .004). However, no significant difference was observed regarding re-AMI between OMT and non-OMT groups. OMT also reduced all-cause death in patients with recurrent AMI after propensity score matching. Conclusions: The prescription of OMT was seriously insufficient in patients with recurrent AMI, especially high-risk patients, even though OMT was associated with improved prognosis. Further improvements in pharmacological therapy are needed to reduce subsequent recurrent events.

Resumen Objetivo Las guias de practica clinica recomiendan la estrategia invasiva precoz ajustada al riesgo (EIPAR) en pacientes con sindrome coronario agudo sin elevacion del segmento ST (SCASEST). El objetivo fue analizar la aplicacion de la EIPAR, sus condicionantes e impacto sobre el pronostico en pacientes con SCASEST ingresados en Unidades de Cuidados Intensivos Cardiologicos (UCIC). Diseno Estudio de cohortes prospectivo. Ambito UCIC de 8 hospitales en Cataluna. Pacientes Pacientes consecutivos con SCASEST entre octubre del 2017 y marzo del 2018. El perfil de riesgo se definio mediante los criterios de la Sociedad Europea de Cardiologia. Intervenciones Se definio como EIPAR la realizacion de coronariografia en las primeras 6 h en pacientes de muy alto riesgo o en 24 h en pacientes de alto riesgo. Variables de interes Mortalidad/reingreso a los 6 meses. Resultados Se incluyo a 629 pacientes (edad media 66,6 anos), 225 (35,9%) de muy alto riesgo y 392 (62,6%) de alto riesgo. La estrategia invasiva fue mayoritaria (96,2%). La EIPAR se aplico en 284 pacientes (45,6%), especialmente pacientes mas jovenes, con menos comorbilidades. Estos pacientes presentaron menor estancia en UCIC y hospitalaria, asi como menor incidencia de SCA, revascularizaciones y menor incidencia de muerte/reingreso a 6 meses. Tras ajustar por factores de confusion, la asociacion entre adherencia y muerte/reingreso a 6 meses persistio de manera significativa (razon de riesgos: 0,66 [0,45-0,97] p = 0,035). Conclusiones La EIPAR se aplica en una minoria de SCASEST ingresados en UCIC, asociandose con una menor incidencia de eventos.

Resumen Antecedentes y objetivos La prevalencia de fibrilacion auricular (FA) y cardiopatia isquemica ( C I) aumenta con la edad. Coexisten en hasta un 20% de los pacientes octogenarios, situacion que supone un desafio terapeutico. Los ensayos que han abordado este escenario, que incluyeron un porcentaje bajo de octogenarios, demostraron que la doble terapia (antiagregacion simple + anticoagulacion) en comparacion con la triple terapia (doble antiagregacion + anticoagulacion) se asocia menos eventos hemorragicos, especialmente con anticoagulantes orales de accion directa. Estos estudios no tenian potencia suficiente para detectar diferencias en eventos isquemicos. Por otro lado, aspectos prevalentes en la poblacion mayor, como los sindromes geriatricos, no se valoraron en estos estudios, y tampoco en la practica clinica habitual, desconociendose su impacto pronostico en este contexto clinico. Material y metodos Estudio observacional, prospectivo y multicentrico, que incluira pacientes ≥ 80 anos con FA y CI en Espana. Se valoraran las caracteristicas basales y los sindromes geriatricos, asi como la eleccion del tratamiento antitrombotico. El objetivo primario es conocer la mortalidad cardiovascular y por todas las causas a uno y tres anos. Resultados Este estudio permitira conocer las caracteristicas y el pronostico de pacientes octogenarios con FA y CI en nuestro medio, los factores implicados en la eleccion del tratamiento antitrombotico y la incidencia de eventos isquemicos y hemorragicos durante el seguimiento a corto y largo plazo. Conclusiones Nuestro trabajo contribuira a mejorar el conocimiento en terminos de seguridad y eficacia de las distintas opciones terapeuticas en pacientes mayores con FA y CI y su impacto pronostico.

Background: Dexmedetomidine induces cooperative and arousable sedation. Our aim was to analyze dexmedetomidine use in medical cardiac intensive care units (CICU). Methods: Multicenter prospective registry of patients treated with dexmedetomidine in CICU. Consecutive inclusion during a 12-month period. Results: A total of 410 patients were included, mean age was 67.4 ± 13.9 years, and 94 (22.9%) were women. Before using dexmedetomidine, 247 patients (60.2%) had delirium, 48 developed delirium after dexmedetomidine use. In 178 (43.4%) dexmedetomidine was used during weaning from mechanical ventilation, with a reintubation rate of 10.1%, early reintubation rate (

La infección por SARS-CoV-2, denominada COVID-19 (Coronavirus Infectious Disease-19), es una enfermedad desconocida hasta diciembre de 2019 a la que nos enfrentamos en España desde el 31 de enero de 2020 —fecha del primer caso diagnosticado en nuestro país— y que ya ha causado la muerte de 7.340 personas (a 30 de marzo de 2020), sobre todo mayores. Es importante tener en cuenta que, dado que la información evoluciona con extremada rapidez en este campo, lo expuesto en el presente documento puede estar sujeto a modificaciones. La población de mayor edad es especialmente susceptible a la infección por COVID-19, así como a desarrollar criterios de gravedad. Este aumento de morbimortalidad en el paciente mayor se ha asociado tanto con las comorbilidades, especialmente la enfermedad cardiovascular, como con la situación de fragilidad, que conlleva una respuesta inmunológica más pobre. La situación actual, tanto por los países afectados como por el número de casos, constituye una pandemia y supone una emergencia sanitaria de primer nivel. Como España es uno de los países más envejecidos del mundo, la COVID-19 se ha convertido en una emergencia geriátrica. El presente documento se ha elaborado conjuntamente entre la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología y la Sociedad Española de Geriatría y Gerontología. Sin financiación 4.753 JCR (2020) Q2, 45/142 Cardiac & Cardiovascular Systems 0.455 SJR (2020) Q3, 202/349 Cardiology and Cardiovascular Medicine No data IDR 2020 UEM

Objectives Initial data on Covid-19 infection has pointed out a special vulnerability of elderly people. Design we performed a meta-analysis with available national reports at May 7th 2020 from China, Italy, Spain, United Kingdom and New York State. Analyses were performed by a random effects model and sensitivity analyses were performed for the identification of potential sources of heterogeneity. Setting and Participants: covid-19 positive patients reported in literature and national reports. Measures all-cause mortality by age. Results A total of 611,1583 subjects were analyzed and 141,745 (23.2%) had age ≥80. The percentage of octogenarians was different in the 5 registries being the lowest in China (3.2%) and the highest and the highest in UK and New York State. The overall mortality rate was 12.10% and it varied widely between countries being the lowest in China (3.1%) and the highest in UK (20.8%) and New York State (20.99%). Mortality was 50 and, especially, >60. Elderly patients should be priorized in the implementation of preventive measures., fatality of covid-19 increases exponentially with age and octogenarians have more than 6-fold higher risk of death.

Resumen Introduccion y objetivos Las guias recomiendan centralizar la atencion del shock cardiogenico (SC) en centros altamente especializados. El objetivo de este estudio fue evaluar la asociacion entre las caracteristicas de los centros tratantes y la mortalidad en el SC secundario a infarto de miocardio con elevacion del segmento ST (IAMCEST). Metodos Se seleccionaron los episodios de alta con diagnostico de SC-IAMCEST entre 2003-2015 del Conjunto Minimo Basico de Datos del Sistema Nacional de Salud espanol. Los centros se clasificaron segun disponibilidad de servicio de cardiologia, laboratorio de hemodinamica, cirugia cardiaca y disponibilidad de Unidad de Cuidados Intensivos Cardiologicos (UCIC). La variable objetivo principal fue la mortalidad hospitalaria. Resultados Se identificaron 19.963 episodios. La edad media fue de 73,4 ± 11,8 anos. La proporcion de pacientes tratados en hospitales con laboratorio de hemodinamica y cirugia cardiaca aumento del 38,4% en 2005 al 52,9% en 2015; p Conclusiones La proporcion de pacientes con SC-IAMCEST tratados en centros altamente especializados aumento, mientras que la mortalidad disminuyo a lo largo del periodo de estudio. La revascularizacion y el ingreso en UCIC se asociaron con mejores resultados.

Objectives Diabetes mellitus (DM) and frailty are common in older patients with acute coronary syndromes (ACS). No data exists about its prognostic impact on long-term outcomes and their possible interaction in this setting. Design Observational prospective study. Setting Multicenter registry conducted in 44 hospitals in Spain. Participants Consecutive patients with ACS aged 80≥years. Measurements A comprehensive geriatric evaluation was performed during hospitalization, including frailty assessment by the FRAIL score. The impact of DM and frailty on the incidence of mortality/readmission at 24 months was analysed by a Cox regression model. Results A total of 498 patients were included (mean age 84.3 years). Prevalence of previous DM was 199/498 (40.0%). The rate of frail patients was 135/498 (27.1%). The incidence of mortality/readmission was higher frail patients (HR 2.49) (both p

Resumen Han sido numerosos los estudios publicados en el campo de la cardiopatia isquemica y de los cuidados criticos cardiovasculares en este ultimo ano. Por este motivo, esta revision no pretende abarcar todos ellos, sino mas bien una seleccion de algunas publicaciones que a criterio subjetivo de los autores se consideran de interes.

Resumen Durante el ultimo ano se han publicado numerosos trabajos centrados en el paciente mayor con enfermedad cardiovascular. En este texto repasamos algunos de estos trabajos, relacionados todos con el abordaje del paciente mayor en distintos escenarios clinicos. Hemos querido resaltar y prestar especial atencion a aspectos de gran relevancia clinica, dado su impacto pronostico, como la fragilidad, la comorbilidad o la polifarmacia, y centrarnos en como mejorar la atencion que proporcionamos a nuestros pacientes en distintos ambitos (urgencias, hospitalizacion, ambulatorio) y procesos concretos como la fibrilacion auricular, la insuficiencia cardiaca, las valvulopatias y los sindromes coronarios agudos.

Aims To estimate the cost–effectiveness and cost–utility ratios of a restrictive vs. liberal transfusion strategy in acute myocardial infarction (AMI) patients with anaemia. Methods and results Patients (n = 666) with AMI and haemoglobin between 7–8 and 10 g/dL recruited in 35 hospitals in France and Spain were randomly assigned to a restrictive (n = 342) or a liberal (n = 324) transfusion strategy with 1-year prospective collection of resource utilization and quality of life using the EQ5D3L questionnaire. The economic evaluation was based on 648 patients from the per-protocol population. The outcomes were 30-day and 1-year cost-effectiveness, with major adverse cardiovascular events (MACEs) averted as the effectiveness outcome. and a 1-year cost–utility ratio. The 30-day incremental cost–effectiveness ratio was €33 065 saved per additional MACE averted with the restrictive vs. liberal strategy, with an 84% probability for the restrictive strategy to be cost-saving and MACE-reducing (i.e. dominant). At 1 year, the point estimate of the cost–utility ratio was €191 500 saved per quality-adjusted life year gained; however, the cumulated MACE was outside the pre-specified non-inferiority margin, resulting in a decremental cost–effectiveness ratio with a point estimate of €72 000 saved per additional MACE with the restrictive strategy. Conclusion In patients with AMI and anaemia, the restrictive transfusion strategy was dominant (cost-saving and outcome-improving) at 30 days. At 1 year, the restrictive strategy remained cost-saving, but clinical non-inferiority on MACE was no longer maintained. Trial Registration ClinicalTrials.gov Identifier: NCT02648113. One sentence summary The use of a restrictive transfusion strategy in patients with acute myocardial infarction is associated with lower healthcare costs, but more evidence is needed to ascertain its long-term clinical impact.

The Impella pump has emerged as a promising tool in patients with cardiogenic shock (CS). Despite its attractive properties, there are scarce data on the specific clinical setting and the potential role of Impella devices in CS patients from routine clinical practice.This is an observational, retrospective, single center, cohort study. All consecutive patients with diagnosis of CS and undergoing support with Impella 2.5A total of 50 patients were included (median age: 59.3 ± 10 years). The most common cause of CS was acute coronary syndrome (ACS) (68%), followed by decompensation of previous cardiomyopathy (22%). A total of 13 patients (26%) had profound CS. Most patients (54%) improved pulmonary congestion at 48 h after Impella support. A total of 19 patients (38%) presented significant bleeding. In-hospital mortality was 42%. Among patients with profound CS (In this cohort of real-life CS patients, Impella devices were used in different settings, with different clinical profiles and management. Despite a significant rate of complications, mortality was acceptable and lower than those observed in other series.

ImportanceTo our knowledge, no randomized clinical trial has compared the invasive and conservative strategies in frail, older patients with non–ST-segment elevation acute myocardial infarction (NSTEMI).ObjectiveTo compare outcomes of invasive and conservative strategies in frail, older patients with NSTEMI at 1 year.Design, Setting, and ParticipantsThis multicenter randomized clinical trial was conducted at 13 Spanish hospitals between July 7, 2017, and January 9, 2021, and included 167 older adult (≥70 years) patients with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. Data analysis was performed from April 2022 to June 2022.InterventionsPatients were randomized to routine invasive (coronary angiography and revascularization if feasible; n = 84) or conservative (medical treatment with coronary angiography for recurrent ischemia; n = 83) strategy.Main Outcomes and MeasuresThe primary end point was the number of days alive and out of the hospital (DAOH) from discharge to 1 year. The coprimary end point was the composite of cardiac death, reinfarction, or postdischarge revascularization.ResultsThe study was prematurely stopped due to the COVID-19 pandemic when 95% of the calculated sample size had been enrolled. Among the 167 patients included, the mean (SD) age was 86 (5) years, and mean (SD) Clinical Frailty Scale score was 5 (1). While not statistically different, DAOH were about 1 month (28 days; 95% CI, −7 to 62) greater for patients managed conservatively (312 days; 95% CI, 289 to 335) vs patients managed invasively (284 days; 95% CI, 255 to 311; P = .12). A sensitivity analysis stratified by sex did not show differences. In addition, we found no differences in all-cause mortality (hazard ratio, 1.45; 95% CI, 0.74-2.85; P = .28). There was a 28-day shorter survival in the invasive vs conservatively managed group (95% CI, −63 to 7 days; restricted mean survival time analysis). Noncardiac reasons accounted for 56% of the readmissions. There were no differences in the number of readmissions or days spent in the hospital after discharge between groups. Neither were there differences in the coprimary end point of ischemic cardiac events (subdistribution hazard ratio, 0.92; 95% CI, 0.54-1.57; P = .78).Conclusions and RelevanceIn this randomized clinical trial of NSTEMI in frail older patients, there was no benefit to a routine invasive strategy in DAOH during the first year. Based on these findings, a policy of medical management and watchful observation is recommended for older patients with frailty and NSTEMI.Trial RegistrationClinicalTrials.gov Identifier: NCT03208153

International audience; No abstract available

The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest (OHCA) in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. We aimed to assess whether emergency CAG and PCI would improve survival with good neurological outcome in this population.In this multicenter, randomized, open-label, investigator-initiated clinical trial, we randomly assigned 69 survivors of OHCA without STEMI to undergo immediate CAG or deferred CAG. The primary efficacy endpoint was a composite of in-hospital survival free of severe dependence. The safety endpoint was a composite of major adverse cardiac events including death, reinfarction, bleeding, and ventricular arrhythmias.A total of 66 patients were included in the primary analysis (95.7%). In-hospital survival was 62.5% in the immediate CAG group and 58.8% in the delayed CAG group (HR, 0.96; 95%CI, 0.45-2.09; P=.93). In-hospital survival free of severe dependence was 59.4% in the immediate CAG group and 52.9% in the delayed CAG group (HR, 1.29; 95%CI, 0.60-2.73; P=.4986). No differences were found in the secondary endpoints except for the incidence of acute kidney failure, which was more frequent in the immediate CAG group (15.6% vs 0%, P=.002) and infections, which were higher in the delayed CAG group (46.9% vs 73.5%, P=.003).In this underpowered randomized trial involving patients resuscitated after OHCA without STEMI, immediate CAG provided no benefit in terms of survival without neurological impairment compared with delayed CAG.gov Identifier: NCT02641626.

The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management. Instituto de Salud Carlos III / FEDER Founds (JR/21/00041, CIBERCV16/11/00486, PI20/00637) Generalitat Valencia, Conselleria d'Educació (PROMETEO/21/008) 4.242 JCR (2020) Q1, 39/167 Medicine, General & Internal 1.040 SJR (2021) Q1, 438/2489 Medicine (miscellaneous) No data IDR 2020 UEV