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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.

[Abstract] Despite the efforts made to improve the care of cardiogenic shock (CS) patients, including the development of mechanical circulatory support (MCS), the prognosis of these patients continues to be poor. In this context, CS code initiatives arise, based on providing adequate, rapid, and quality care to these patients. In this multidisciplinary document we try to justify the need to implement the SC code, defining its structure/organization, activation criteria, patient flow according to care level, and quality indicators. Our specific purposes are: a) to present the peculiarities of this condition and the lessons of infarction code and previous experiences in CS; b) to detail the structure of the teams, their logistics and the bases for the management of these patients, the choice of the type of MCS, and the moment of its implantation, and c) to address challenges to SC code implementation, including the uniqueness of the pediatric SC code. There is an urgent need to develop protocolized, multidisciplinary, and centralized care in hospitals with a large volume and experience that will minimize inequity in access to the MCS and improve the survival of these patients. Only institutional and structural support from the different administrations will allow optimizing care for CS. [Resumen] Pese a los esfuerzos realizados para mejorar la atención al shock cardiogénico (SC), incluyendo el desarrollo de dispositivos de asistencia circulatoria mecánica (ACM), su pronóstico continúa siendo desfavorable. En este contexto surgen iniciativas de código SC, basadas en proporcionar una asistencia rápida y de calidad a estos pacientes. Este documento multidisciplinario trata de justificar la necesidad de implantar el código SC, definiendo su estructura/organización, criterios de activación, flujo de pacientes según nivel asistencial e indicadores de calidad. Sus propósitos concretos son: a) presentar las peculiaridades de esta enfermedad y el aprendizaje del código infarto y de experiencias previas en SC; b) detallar las bases para el abordaje de estos pacientes, la estructura de los equipos, su logística, la elección del tipo de ACM y el momento de su implante, y c) abordar los desafíos para la implantación del código SC, como la singularidad del código SC pediátrico. Urge desarrollar una asistencia protocolizada, multidisciplinaria y centralizada en hospitales con gran volumen y experiencia que permita minimizar la inequidad en el acceso a la ACM y mejorar la supervivencia de estos enfermos. Solo el apoyo institucional y estructural de las distintas administraciones permitirá optimizar la atención al SC.

Introduction and objectives Temporary pacemaker (TP) is used in patients with high-degree atrioventricular block (HAVB) and ST-segment elevation myocardial infarction (STEMI) to maintain cardiac output and prevent the onset of malignant arrhythmias. Our aim was to characterize the outcomes of patients with STEMI who require TP implantation in the primary angioplasty era. Methods We enrolled all consecutive patients with STEMI who underwent primary angioplasty from 2004 to 2017 in a tertiary care referral center. Patients with STEMI and HAVB who required TP implantation were analyzed. Patients with anterior and inferior STEMI were compared and a multivariate analysis was performed to identify mortality risk factors. All patients completed 30-day and 1-year follow-up. Results Of the 3063 patients in the study cohort, 180 (5.9%) had HAVB at the time of cardiac catheterization, and 114 (3.7%) underwent TP implantation. Thirty-day and 1-year mortality were 25.6% and 31.5%, respectively. Low left ventricle ejection fraction and impaired renal function showed independent association with mortality in this patient population. Patients with anterior STEMI who required TP had a ∼4-fold higher 30-day mortality than those with inferior STEMI (71% vs 18%; P ≤ .001). Only in 7% of patients a definitive pacemaker was finally implanted. Conclusions Patients with STEMI and HAVB who require TP implantation, particularly those with anterior STEMI, are at high risk of adverse outcome. Low left ventricle ejection fraction and impaired renal function are independently associated with mortality. A definitive pacemaker implant is finally required in a small proportion of this patient population.

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.

Background Acute coronary syndrome (ACS) remains one of the leading causes of mortality for women, increasing with age. There is an unmet need regarding this condition in a fast‐growing and predominantly female population, such as nonagenarians. Hypothesis Our aim is to compare sex‐based differences in ACS management and long‐term clinical outcomes between women and men in a cohort of nonagenarians. Methods We included consecutive nonagenarian patients with ACS admitted at four academic centers between 2005 and 2018. The study was approved by the Ethics Committee of each center. Results A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non‐ST‐segment elevation ACS and 307 (45%) with ST‐segment elevation myocardial infarction (STEMI). Men presented a higher disease burden compared to women. Conversely, women were frailer with higher disability and severe cognitive impairment. In the STEMI group, women were less likely than men to undergo percutaneous coronary intervention (PCI) (60% vs. 45%; p = .01). Overall mortality rates were similar in both groups but PCI survival benefit at 1‐year was greater in women compared to their male counterparts (82% vs. 68%; p = .008), persisting after sensitivity analyses using propensity‐score matching (80% vs. 64%; p = .03). Conclusion Sex‐gender disparities have been observed in nonagenarians. Despite receiving less often invasive approaches, women showed better clinical outcomes. Our finding may help increase awareness and reduce the current gender gap in ACS management at any age.

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is the most common arrhythmia in the elderly. Age increases both thromboembolic risk and bleeding complications. However, these patients are not anticoagulated on many occasions. AF in the context of acute coronary syndrome (ACS) increases the complexity of the management of these patients and they are underrepresented in clinical trials. Purpose The objective of the study was to analyze the impact of AF in nonagenarian patients at 12 months. Other objectives were to evaluate the therapeutic strategy for ACS and AF and to compare clinical events according to AF subtype and treatment at discharge. Methods A retrospective, multicenter and observational study was carried out, in which all nonagenarian patients admitted for ACS and AF (prevalent or incident) between 2005 and 2018 were consecutively included. Patients with type 2 myocardial infarction were excluded. Baseline characteristics were analyzed and mortality at 12 months was analyzed in all patients and according to AF subtype (incident AF was considered when occurred during admission and prevalent AF was considered in patients with previous history of AF) Results 680 patients with a mean age of 92.6 ± 2.4 years were analyzed. Patients with AF more frequently presented chronic kidney disease (CKD) and non-ST-segment elevation acute coronary syndrome (Non-STEMI) and arterial hypertension (HBP) (Table 1). Mortality rate was similar in patients with previous AF and those without history of AF (Figure 1 A). 21.6% (147) of the patients had AF at admission, of which only 47.7% of the patients were previously anticoagulated. Treatment at discharge is shown in Figure 1 B. Mortality at 1 year according to discharge treatment and AF subtype are represented in figures 1C and 1D. Conclusions This is the largest registry of ACS and AF in this population. Patients with prevalent AF had more frequent Non-STEMI and comorbidities, with a similar mortality to AF subgroup at 1 year. Previous AF was no related to higher mortality in this cohort. Half of the patients were not anticoagulated at discharge. OAC was not associated with prognostic benefit in our series.

Paravalvular leak (PVL) is a serious complication of surgical valve replacement, often affecting elderly, multimorbid, high-risk patients. The risk of surgical intervention is often prohibitive in these cases, and so percutaneous PVL closure emerged as a feasible and effective management strategy, with a low complication rate. Specific devices for closure of PVL's are currently not widely available, and so PVLs are closed using generic vascular closure devices, which may result in residual paravalvular regurgitation or even closure device displacement. Although rare, late displacement of the closure device with prosthetic impingement can be life threatening, requiring urgent intervention.We present a case of a seventy-year-old gentleman with rheumatic heart disease and multiple previous mechanical aortic and mitral valve replacements. After repeated admissions for decompensated heart failure, secondary to paravalvular mitral regurgitation, a percutaneous paravalvular leak closure was performed with successful reduction of the leak. He represented 30 days later with cardiogenic shock and multiorgan failure secondary to torrential central mitral regurgitation caused by late displacement of the closure device with mitral prosthesis impingement. Due to an excessively high surgical risk, his case was successfully managed percutaneously with retrieval of the displaced device and closure of the PVL using two Amplatzer Vascular Plug III devices. At the six-month review, he remains asymptomatic.Percutaneous PVL closure is an effective strategy for patients with prohibitive surgical risk. Late closure device displacement can be a life-threatening complication. Our case demonstrates that percutaneous management of this complication is feasible even in patients presenting in extremis.

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.

Introduction and objectives Severe pericardial effusion (PE) is a potentially severe clinical entity. Idiopathic PE accounts for one-third of patients with severe PE. However, evidence-based treatments are scarce. The aim of the study was to investigate whether pericardial drainage is associated with prognostic improvement, and to evaluate the influence of anti-inflammatory treatment on prognosis. Methods All severe PE diagnosed between 2003 and 2017 were retrospectively collected. Of them, those classified as idiopathic were selected (N = 153). Patients were divided in 2 groups: those who underwent pericardial drainage (N = 105) and patients who did not (N = 48). In addition, the study population was divided according to the anti-inflammatory drug (AD) administration. Median follow-up was 47.7 months. Results There were no significant differences in 2-year mortality between patients who underwent pericardial drainage and those who did not. There were also no significant differences in the number of hospitalizations for heart failure between the 2 study groups. However, mortality was significantly lower among patients who received AD compared to those who did not receive these agents. Only treatment with AD (HR, 0.24; P = .002) remained independently associated with lower mortality in the multivariate analysis. AD treatment was associated with a 70% reduction in mortality (HR, 0.30; 95%CI, 0.10–0.90; P Conclusions Pericardial drainage was not associated with a better prognosis of patients with severe idiopathic PE, in terms of 2-year mortality, heart failure admissions, or the combined endpoint. AD treatment was found to be an independent protective factor for mortality in this patient population.

Background Our goal was to evaluate whether TAP block offers the same analgesic pain control compared to epidural technique in laparoscopic radical prostatectomy surgery through the morphine consumption in the first 48 hours. Methods In this study, 45 patients were recruited and assigned to either TAP or epidural. The main study outcome was morphine consumption during the first 48 hours after surgery. Other data recorded were pain at rest and upon movement, technique-related complications and adverse effects, surgical and postoperative complications, length of surgery, need for rescue analgesia, postoperative nausea and vomiting, start of intake, sitting and perambulation, first flatus, and length of in-hospital stay. Results From a total of 45 patients, two were excluded due to reconversion to open surgery (TAP group = 20; epidural group = 23). There were no differences in morphine consumption (0.96 vs. 0.8 mg; p = 0.78); mean postoperative VAS pain scores at rest (0.7 vs. 0.5; p = 0.72); or upon movement (1.6 vs. 1.6; p = 0.32); in the TAP vs. epidural group, respectively. Sitting and perambulation began sooner in TAP group (19 vs. 22 hours, p = 0.03; 23 vs. 32 hours, p = 0.01; respectively). The epidural group had more technique-related adverse effects. Conclusion TAP blocks provide the same analgesic quality with optimal pain control than epidural technique, with less adverse effects.

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.

Introduction and objectives: According to the recommendations of the latest clinical practice guidelines, non-ST-elevation acute myocardial infarction (NSTEMI) patients should undergo an invasive coronary angiography. However, the best moment to perform this coronary angiography has not been stablished yet. Our main objective was to see if performing an early angiography (within the first 24 h) in NSTEMI patients was associated with better prognosis compared to delayed angiography (beyond the first 24 h). Methods: From January 2014 to June 2016, 447 consecutive patients were admitted to the acute cardiac care unit of a tertiary hospital with a diagnosis of NSTEMI. They all underwent catheterization. We classified them into 3 groups depending on the moment when the coronary angiography was performed (within the first 24 h after diagnosis, 24 h to 72 h later, and > 72 h after diagnosis). Results: Coronary angiography was performed within the first 24 h in 285 patients (63.8%). There were no differences among the groups regarding gender, distribution of cardiovascular risk factors, past medical history of coronary disease or presence of other comorbidities. We found no differences among the 3 groups in variables with known prognostic impact. The cardiovascular events and 1-year mortality at follow-up were similar among the 3 groups. Conclusions: In our study, in the whole spectrum of NSTEMI, early coronary angiography (within the first 24 h) did not show any clinical benefits regarding survival or fewer major adverse cardiovascular events.

espanolIntroduccion y objetivos: Las guias clinicas recomiendan la realizacion de una coronariografia en los pacientes con infarto agudo de miocardio sin elevacion del segmento ST (IAMSEST). Sin embargo, no esta claramente establecido el mejor momento para hacerla. Por ello, el objetivo del presente trabajo fue analizar si practicar un cateterismo precoz (durante las primeras 24 h) se relaciona con un mejor pronostico, en comparacion con hacerlo de manera diferida (mas alla de las 24 h). Metodos: De enero de 2014 a junio de 2016 ingresaron en la unidad de cuidados agudos cardiologicos de un hospital terciario 447 pacientes consecutivos con diagnostico de IAMSEST a los que se hizo una coronariografia. Se clasifico de forma retrospectiva a los pacientes en 3 grupos en funcion del momento de realizacion del cateterismo: durante las primeras 24 h, entre las 24 y 72 h tras el diagnostico, y despues de las primeras 72 h. Resultados: El cateterismo se llevo a cabo en las primeras 24 h en 285 pacientes (63,8%). No se identificaron diferencias entre los grupos en cuanto a sexo, prevalencia de factores de riesgo cardiovascular ni presencia de comorbilidad. Tampoco se encontraron diferencias en las variables pronosticas analizadas ni en la mortalidad. En el seguimiento a los 12 meses, la incidencia de eventos cardiovasculares y la mortalidad fueron similares entre los grupos. Conclusiones: En el presente estudio, la realizacion de una coronariografia precoz (en las primeras 24 h) a los pacientes ingresados por IAMSEST no mostro beneficio clinico en terminos de supervivencia o reduccion de eventos cardiovasculares. EnglishIntroduction and objectives: According to the recommendations of the latest clinical practice guidelines, non-ST-elevation acute myocardial infarction (NSTEMI) patients should undergo an invasive coronary angiography. However, the best moment to perform this coronary angiography has not been stablished yet. Our main objective was to see if performing an early angiography (within the first 24 h) in NSTEMI patients was associated with better prognosis compared to delayed angiography (beyond the first 24 h). Methods: From January 2014 to June 2016, 447 consecutive patients were admitted to the acute cardiac care unit of a tertiary hospital with a diagnosis of NSTEMI. They all underwent catheterization. We classified them into 3 groups depending on the moment when the coronary angiography was performed (within the first 24 h after diagnosis, 24 h to 72 h later, and > 72 h after diagnosis). Results: Coronary angiography was performed within the first 24 h in 285 patients (63.8%). There were no differences among the groups regarding gender, distribution of cardiovascular risk factors, past medical history of coronary disease or presence of other comorbidities. We found no differences among the 3 groups in variables with known prognostic impact. The cardiovascular events and 1-year mortality at follow-up were similar among the 3 groups. Conclusions: In our study, in the whole spectrum of NSTEMI, early coronary angiography (within the first 24 h) did not show any clinical benefits regarding survival or fewer major adverse cardiovascular events.

Spontaneous coronary artery dissection is associated with several conditions and vascular disorders. We describe the management of 2 patients presenting with spontaneous coronary artery dissection and unruptured ascending aortic aneurysms. Coexistence of spontaneous coronary artery dissection with extracoronary vascular disorders should be considered by clinicians.

OBJECTIVE Female sex has been associated with differences in diagnostic and management of acute coronary syndrome (ACS). Our aim was to analyze sex differences in ACS with interventional management in a tertiary care hospital. METHODS Patients with ACS admitted to a Spanish tertiary care referral center were included prospectively and consecutively. All patients included in the study underwent a coronary angiography. RESULTS From the total cohort of 1214 patients, 290 (24%) were women. Women were older (71 ± 12.8 vs 64 ± 13.4 years, p

Resumen La incorporacion precoz del enfermo al que se ha realizado una angioplastia con stent a su vida habitual, por ausencia de impedimentos propios de la tecnica, ha permitido incluir mas pronto a estos pacientes en la fase II de la rehabilitacion cardiaca. Aunque la rehabilitacion del paciente coronario sigue para todos los pacientes unas pautas generales que pretenden abordar desde un punto de vista de prevencion secundaria la aterosclerosis coronaria, las circunstancias de cada enfermo, entre las que se incluye la tecnica con que ha sido revascularizado, determinan aspectos individuales de la rehabilitacion del enfermo con cardiopatia isquemica. El ejercicio fisico continuado (entrenamiento fisico) produce, por si mismo, grandes beneficios cardiovasculares para la prevencion cardiovascular primaria y secundaria. En pacientes con infarto disminuye la mortalidad y mejora la capacidad funcional, la funcion ventricular y el remodelado ventricular, y hay esperanzas de que pueda mejorar la circulacion colateral. Tambien mejora la funcion endotelial y estimula la circulacion de celulas madre. Se ha demostrado que el entrenamiento fisico tras revascularizacion percutanea disminuye el numero de eventos y que en pacientes con angina estable el entrenamiento fisico produce menos eventos que la revascularizacion percutanea.

Resumen La incorporacion precoz del enfermo al que se ha realizado una angioplastia con stent a su vida habitual, por ausencia de impedimentos propios de la tecnica, ha permitido incluir mas pronto a estos pacientes en la fase II de la rehabilitacion cardiaca. Aunque la rehabilitacion del paciente coronario sigue para todos los pacientes unas pautas generales que pretenden abordar desde un punto de vista de prevencion secundaria la aterosclerosis coronaria, las circunstancias de cada enfermo, entre las que se incluye la tecnica con que ha sido revascularizado, determinan aspectos individuales de la rehabilitacion del enfermo con cardiopatia isquemica. El ejercicio fisico continuado (entrenamiento fisico) produce, por si mismo, grandes beneficios cardiovasculares para la prevencion cardiovascular primaria y secundaria. En pacientes con infarto disminuye la mortalidad y mejora la capacidad funcional, la funcion ventricular y el remodelado ventricular, y hay esperanzas de que pueda mejorar la circulacion colateral. Tambien mejora la funcion endotelial y estimula la circulacion de celulas madre. Se ha demostrado que el entrenamiento fisico tras revascularizacion percutanea disminuye el numero de eventos y que en pacientes con angina estable el entrenamiento fisico produce menos eventos que la revascularizacion percutanea.

Resumen La incorporacion precoz del enfermo al que se ha realizado una angioplastia con stent a su vida habitual, por ausencia de impedimentos propios de la tecnica, ha permitido incluir mas pronto a estos pacientes en la fase II de la rehabilitacion cardiaca. Aunque la rehabilitacion del paciente coronario sigue para todos los pacientes unas pautas generales que pretenden abordar desde un punto de vista de prevencion secundaria la aterosclerosis coronaria, las circunstancias de cada enfermo, entre las que se incluye la tecnica con que ha sido revascularizado, determinan aspectos individuales de la rehabilitacion del enfermo con cardiopatia isquemica. El ejercicio fisico continuado (entrenamiento fisico) produce, por si mismo, grandes beneficios cardiovasculares para la prevencion cardiovascular primaria y secundaria. En pacientes con infarto disminuye la mortalidad y mejora la capacidad funcional, la funcion ventricular y el remodelado ventricular, y hay esperanzas de que pueda mejorar la circulacion colateral. Tambien mejora la funcion endotelial y estimula la circulacion de celulas madre. Se ha demostrado que el entrenamiento fisico tras revascularizacion percutanea disminuye el numero de eventos y que en pacientes con angina estable el entrenamiento fisico produce menos eventos que la revascularizacion percutanea.