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BACKGROUND The association between digoxin and mortality is an unclear issue. In older patients with atrial fibrillation (AF), where use of digoxin is frequent, the evidence of its safety is scarce. Our aim is to assess the safety of digoxin in nonagenarian patients with AF. METHODS We evaluated data from 795 nonagenarian patients with non-valvular AF from the Spanish Multicenter Registry. We analyzed the relationship between digoxin and all-cause mortality with the Cox proportional-hazards model. RESULTS Follow-up was 27.7 ± 18.3 months. Mean age was 92.5 ± 3.8 years, and 71% of nonagenarian patients were female. Digoxin was not associated with increased risk of mortality [adjusted hazard ratio (aHR) = 1.16, 95% CI: 0.96-1.41, P = 0.130]. However, we found a significant increase in mortality in the subgroup with estimated glomerular filtration rate (eGFR) < 30 mL/min per 1.73 m2 (aHR = 2.01, 95% CI: 1.13-3.57, P = 0.018), but not in the other subgroups of eGFR (30-59 mL/min per 1.73 m2 and = 60 mL/min per 1.73 m2). When exploring the risk of mortality according to sex, male subgroup was associated with an increase in mortality (aHR = 1.48, 95% CI: 1.02-2.14, P = 0.041). This was not observed in females subgroup (aHR = 1.03, 95% CI: 0.81-1.29, P = 0.829). Based on the presence or absence of heart failure, we did not find significant differences (aHR = 1.20, 95% CI: 0.87-1.65, P = 0.268 vs. aHR = 1.15, 95% CI: 0.90-1.47, P = 0.273, respectively). CONCLUSIONS In our large registry of nonagenarian patients with AF, we did not find an association between digoxin and mortality in the total sample. However, in the subgroup analyses, we found an increase in mortality with the use of digoxin in men and in patients with an eGFR < 30 mL/min per 1.73 m². [ABSTRACT FROM AUTHOR]

Aim: It is well known that angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) prevent left ventricular remodelling and heart failure (HF) admissions after acute myocardial infarction (AMI). This is particularly relevant in patients with reduced left ventricular ejection fraction (LVEF <= 40%). However, this fact is not so clear in post-AMI patients with LVEF > 40%. The aim of this study was to analyze the prognostic impact of ACEI/ARB for reducing HF admissions after AMI discharge according to LVEF. Methods: We analyzed data about 8,169 patients from two university hospital from Spain discharged with diagnosis of AMI between 2010 and 2016. The end-point was follow-up HF admissions. We performed a propensity score matching (PSM) analysis to draw up two paired groups according to the therapy with ACEI/ARB. The prognostic value of ACEI/ARB to reduce HF admissions during follow-up was analyzed using competitive risk analysis with the Fine-Gray model (death = competitive event). Results: During the follow-up (3.3 ± 2.2 years, median 2.9 years, IQR 1.3-4.9 years), 1,211 patients died (14.8%) and 1,296 were admitted to the hospital by HF (14.9%). The cumulative incidence function (CIF) of HF was 5.2 (95% CI 4.9-5.5) per 100 persons/year, higher in patients with LVEF <= 40% (12.4 vs 4.2 per 100 patients/year). In the univariate analysis, ACEI/ARB was not associated with less follow-up HF (subHazard Ratio [sHR] 1.09 (95% CI 0.96-1.23), p=0.183). With the PSM we get two paired groups of 1,786 patients, in order to avoid the bias secondary to the large differences between patients receiving ACEI/ARB and those who did not receive them. After PSM, ACEI/ARB were not associated with less HF readmissions (sHR 1.01; 95% CI 0.85-1.19; p=0.910). However, when we analyzed these results according to LVEF (Figure 1A), we found that ACEI/ARB were associated with less HF readmissions as the LVEF decreased, being these differences significant only in patients with LVEF <=40% (sHR 0.65, 95% CI 0.46-0.92; p=0.014). (Figure 1B). Conclusions: ACEI/ARB reduce HF readmissions after hospital discharge for AMI only in patients with reduced LVEF. [ABSTRACT FROM AUTHOR]

Aims: Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via a pentaspline pulsed field ablation (PFA) catheter in persistent AF sustained beyond 6 months (PerAF > 6 m) and long-standing persistent AF (LSPAF)., Methods and Results: The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia regionalization and ablation (Stage 3). Seventy-two [age:68 ± 10years, 61.1%males; AF history: 25 (18-45) months] patients with PerAF > 6 m (52.8%) and LSPAF (47.2%) underwent their first PFA via the FarapulseTM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The PFA catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit. Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112 ± 25 min and 59 ± 22 min, respectively. Major complications occurred in 2 (2.8%) patients. Single-procedure success rate was 74.6% after 14.9 ± 2.7 months of follow-up; AF-free survival was 89.2%., Conclusion: In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favourable clinical outcomes were observed during >1 year of follow-up., Competing Interests: Conflict of interest: M.L.M. is a consultant for AtriCure. A.N. serves as a consultant for Abbott, Biosense Webster, Biotronik, Boston Scientific, and iRhythm. C.d.A. receives research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips and Acutus and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical and Daiichi Sankyo. G.B.C. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Competing Interests: Conflict of interest: G.C. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, Acutus Medical. C.d.A. receives research grants on behalf of the centre from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus; C.d.A. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, and Acutus Medical Daiichi Sankyo. A.S. is consultant for Biosense Webster and Medtronic and received speaker fees from Biosense Webster, Biotronik, Pfizer, and Microport. The remaining authors have nothing to disclose.

Aims: Nutrition is an important determinant of health above the age of 80 years. Malnutrition in the elderly is often underdiagnosed. The aim of this study was to report the prevalence and prognostic value of malnutrition in patients ≥80 years old with atrial fibrillation (AF) with and without anticoagulant therapy., Methods and Results: We assessed the nutritional status of 4724 octogenarian patients with diagnoses of AF in a single centre from Spain between 2014 and 2017 with the CONUT score. Malnutrition was confirmed in 2036 patients (43.1%). Anticoagulation prescription was more frequent in patients with good nutrition than in those malnourished (79.5% vs. 71.7%, P < 0.001). The impact of malnutrition on mortality was evaluated by Cox regression, whereas its association with ischaemic stroke and major bleeding was studied through competing risk analysis. After multivariate adjusting, malnutrition was associated with mortality [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.24-1.49], stroke [sub-distribution HR (sHR) 1.37, 95% CI 1.10-1.69], and major bleeding (sHR 1.29, 95% CI 1.02-1.64). In anticoagulated patients, the embolic-haemorrhagic trade-off event was virtually neutral for those who had normal nutritional status [average daily rates (ADRs) for stroke and bleeding: 4.70 and 4.69 per 100 000 patients/day, respectively; difference = +0.01 per 100 000 patients/day; P = 0.99] and negative for those with malnutrition (ADR for stroke and bleeding: 5.38 and 7.61 per 100 000 patients/day, respectively; difference = -2.23 per 100 000 patients/day; P = 0.07)., Conclusion: Malnutrition is very common in octogenarian patients with AF, being a clinical predictor for poor prognosis. For anticoagulated patients, malnutrition was associated with a negative embolic-haemorrhagic balance., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: The aim of the present study was to establish the safety and efficacy profile of prasugrel and ticagrelor in real-life acute coronary syndrome (ACS) patients with renal dysfunction., Methods and Results: All consecutive patients from RENAMI (REgistry of New Antiplatelets in patients with Myocardial Infarction) and BLEEMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registries were stratified according to estimated glomerular filtration rate (eGFR) lower or greater than 60 mL/min/1.73 m2. Death and myocardial infarction (MI) were the primary efficacy endpoints. Major bleedings (MBs), defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety endpoint. A total of 19 255 patients were enrolled. Mean age was 63 ± 12; 14 892 (77.3%) were males. A total of 2490 (12.9%) patients had chronic kidney disease (CKD), defined as eGFR <60 mL/min/1.73 m2. Mean follow-up was 13 ± 5 months. Mortality was significantly higher in CKD patients (9.4% vs. 2.6%, P < 0.0001), as well as the incidence of reinfarction (5.8% vs. 2.9%, P < 0.0001) and MB (5.7% vs. 3%, P < 0.0001). At Cox multivariable analysis, potent P2Y12 inhibitors significantly reduced the mortality rate [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.54-0.96; P = 0.006] and the risk of reinfarction (HR 0.53, 95% CI 0.30-0.95; P = 0.033) in CKD patients as compared to clopidogrel. The reduction of risk of reinfarction was confirmed in patients with preserved renal function. Potent P2Y12 inhibitors did not increase the risk of MB in CKD patients (HR 1.00, 95% CI 0.59-1.68; P = 0.985)., Conclusion: In ACS patients with CKD, prasugrel and ticagrelor are associated with lower risk of death and recurrent MI without increasing the risk of MB., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Introduction: The safety and efficacy of prasugrel and ticagrelor in patients with diabetes mellitus presenting with acute coronary syndrome and treated with percutaneous coronary intervention remain to be assessed., Methods: All diabetes patients admitted for acute coronary syndrome and enrolled in the REgistry of New Antiplatelets in patients with Myocardial Infarction (RENAMI) were compared before and after propensity score matching. Net adverse cardiovascular events (composite of death, stroke, myocardial infarction and BARC 3-5 bleedings) and major adverse cardiovascular events (composite of death, stroke and myocardial infarction) were the co-primary endpoints. Single components of primary endpoints were secondary endpoints., Results: Among 4424 patients enrolled in RENAMI, 462 and 862 diabetes patients treated with prasugrel and ticagrelor, respectively, were considered. After propensity score matching, 386 patients from each group were selected. At 19±5 months, major adverse cardiovascular events and net adverse cardiovascular events were similar in the prasugrel and ticagrelor groups (5.4% vs. 3.4%, P =0.16 and 6.7% vs. 4.1%, P =0.11, respectively). Ticagrelor was associated with a lower risk of death and BARC 2-5 bleeding when compared to prasugrel (2.8% vs. 0.8%, P =0.031 and 6.0% vs. 2.6%, P =0.02, respectively) and a clear but not significant trend for a reduction of BARC 3-5 bleeding (2.3% vs. 0.8%, P =0.08). There were no significant differences in myocardial infarction recurrence and stent thrombosis., Conclusion: Diabetes patients admitted for acute coronary syndrome seem to benefit equally in terms of major adverse cardiovascular events from ticagrelor or prasugrel use. Ticagrelor was associated with a significant reduction in all-cause death and bleedings, without differences in recurrent ischaemic events, which should be confirmed in dedicated randomised controlled trials.