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Background During COVID-19 pandemic, elective invasive cardiac procedures (ICP) have been frequently cancelled or postponed. Consequences may be more evident in patients with diabetes. Objectives The objective was to identify the peculiarities of patients with DM among those in whom ICP were cancelled or postponed due to the COVID-19 pandemic, as well as to identify subgroups in which the influence of DM has higher impact on the clinical outcome. Methods We included 2,158 patients in whom an elective ICP was cancelled or postponed during COVID-19 pandemic in 37 hospitals in Spain. Among them, 700 (32.4%) were diabetics. Patients with and without diabetes were compared. Results Patients with diabetes were older and had a higher prevalence of other cardiovascular risk factors, previous cardiovascular history and co-morbidities. Diabetics had a higher mortality (3.0% vs. 1.0%; p = 0.001) and cardiovascular mortality (1.9% vs. 0.4%; p = 0.001). Differences were especially important in patients with valvular heart disease (mortality 6.9% vs 1.7% [p Conclusion Among patients in whom an elective invasive cardiac procedure is cancelled or postponed during COVID-19 pandemic, mortality and cardiovascular mortality is higher in patients with diabetes, irrespectively on other clinical conditions. These procedures should not be cancelled in patients with diabetes.

BACKGROUND: During COVID-19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming. OBJECTIVE: The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID-19 outbreak in Spain. METHODS: The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID-19 pandemic. These patients were followed-up until April 31th. RESULTS: Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year-old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p-values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality. CONCLUSION: Mortality at 45 days during COVID-19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.

Introduction and objectives The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. Methods Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. Results Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P

Aim Patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) remain at high risk of cardiovascular events despite the use of contemporary drug-eluting stents (DES). This trial aim to compare the clinical efficacy of 2 novel second-generation DES in patients with DM. Methods and results The Second-Generation Drug-Eluting Stents in Diabetes (SUGAR) trial (ClinicalTrials.gov NCT03321032) is an investigator-initiated, prospective, randomized, controlled, multicenter study conducted exclusively in patients with DM. This study allows inclusion of the entire spectrum of patients with DM undergoing PCI, and the only exclusion criteria are shock at presentation, inability to consent or a life expectancy

Resumen Introduccion y objetivos Las neoplasias malignas son la segunda causa de muerte en los paises desarrollados, por detras de las enfermedades cardiovasculares, y ambas entidades tienen factores en comun. Metodos Estudio prospectivo de todos los pacientes ingresados por un sindrome coronario agudo en el que se evaluo la prevalencia de neoplasias y la incidencia tras el alta. Resultados La prevalencia de neoplasias en los 1.819 pacientes incluidos fue del 3,4% y el 41,9% de los casos se consideraron libres de enfermedad. Entre los 1.731 pacientes dados de alta, la incidencia fue 3,1% (53 casos) y las localizaciones mas frecuentes fueron colon, pulmon, vejiga y pancreas. Los pacientes con neoplasias prevalentes presentaron mas edad, comorbilidades y complicaciones. No se observaron diferencias en el porcentaje de revascularizacion, pero si menor uso de stents farmacoactivos en los pacientes con neoplasias prevalentes. Durante el seguimiento, la mediana de tiempo hasta el diagnostico de nuevas neoplasias fue de 25 meses y el analisis multivariante identifico como factores independientes la edad y el ser fumador o exfumador. La mortalidad por cualquier causa tras el alta fue muy superior en los pacientes con neoplasias incidentes (64,2%) o prevalentes (40,0%). El analisis multivariante mostro que en las neoplasias prevalentes e incidentes se multiplicaba por 4 el riesgo de mortalidad por cualquier causa. Conclusiones El 3,8% de los pacientes tuvieron neoplasias prevalentes y menos del 50% se consideraban curadas en el momento del ingreso. La incidencia de nuevas neoplasias fue del 3,4% y ambas formas de neoplasias empeoraron mucho el pronostico a largo plazo.

Introduction and objectives Malignancies are the second cause of death in developed countries after cardiovascular disease and both share common risk factors. Methods This prospective study assessed the prevalence and postdischarge incidence of malignancies in all consecutive patients admitted for an acute coronary syndrome. Results A total of 1819 patients were included. On admission, the prevalence of malignancies was 3.4%, and 41.9% of the patients were considered disease-free; of the 1731 discharged patients, the incidence was 3.1% (53 cases) and the most common locations were the colon, lung, bladder, and pancreas. Patients with prevalent malignancies were older and had more comorbidities and complications. There were no differences in the revascularization rate, but implantation of drug-eluting stents was less frequent in patients with prevalent malignancies. During follow-up, the median time to diagnosis of incident malignancies was 25 months. On multivariate analysis, independent risk factors were age and current or former smoking. All-cause mortality was much higher in patients with incident (64.2%) or prevalent (40.0%) malignancies. Multivariate analysis showed that prevalent and incident malignancies increased the risk of all-cause mortality by 4-fold. Conclusions Among patients admitted for an acute coronary syndrome, 3.8% had a history of malignancy, with less than 50% considered cured. The incidence of new malignancies was 3.4% and both types of malignancies substantially impaired the long-term prognosis.

Introduction and objectives Emergency care systems have been created to improve treatment and revascularization in myocardial infarction but they may also improve the management of all patients with acute coronary syndrome. Methods A comparative study of all patients admitted with acute coronary syndrome before and after implementation of an infarction protocol. Results The study included 1210 patients. While the mean age was the same in both periods, the patient group admitted after implementation of the protocol had a lower prevalence of diabetes mellitus and hypertension but more active smokers and higher GRACE scores. The percentage of ST-segment elevation acute coronary syndrome (29.8%-39.5%) and coronary revascularizations (82.1%-90.1%) significantly increased among patients admitted with acute coronary syndrome, and primary angioplasty became routine (51.9%-94.9%); there was also a reduction in time to catheterization and an increase in early revascularization. The mean hospital stay was significantly shorter after implementation of the infarction protocol. In-hospital mortality was unchanged, except in high-risk patients (38.8%-22.4%). After discharge, no differences were observed between the 2 periods in cardiovascular mortality, all-cause mortality, reinfarction, or major cardiovascular complications. Conclusions After implementation of the infarction protocol, the percentage of patients admitted with ST-segment elevation acute coronary syndrome and the mean GRACE score increased among patients admitted with acute coronary syndrome. Hospital stay was reduced, and primary angioplasty use increased. In-hospital mortality was reduced in high-risk patients, and prognosis after discharge was the same in both periods.

Resumen Introduccion y objetivos Los sistemas de atencion urgente del infarto se han creado para mejorar su tratamiento y la revascularizacion, pero pueden mejorar el manejo de todos los pacientes con sindrome coronario agudo. Metodos Estudio comparativo de todos los pacientes ingresados por sindrome coronario agudo antes y tras la implantacion de un codigo infarto. Resultados Se incluyo a 1.210 pacientes, y aunque la media de edad fue igual en ambos periodos, los pacientes ingresados tras la implantacion del codigo infarto presentaron menor prevalencia de diabetes mellitus e hipertension pero mas tabaquismo activo y mayor GRACE. Se observo un incremento significativo en el porcentaje de pacientes ingresados por sindrome coronario agudo con elevacion del segmento ST (29,8-39,5%) y de revascularizaciones coronarias (82,1-90,1%), asi como la generalizacion de la angioplastia primaria (51,9-94,9%), ademas de una reduccion en el tiempo hasta el cateterismo e incremento de la revascularizacion precoz. La estancia hospitalaria media fue significativamente mas corta tras la implantacion del codigo infarto. No se observaron diferencias en la mortalidad hospitalaria, salvo entre los pacientes de alto riesgo (38,8-22,4%). Tras el alta no se observan diferencias entre ambos periodos en mortalidad cardiovascular, mortalidad por cualquier causa, reinfarto o complicaciones cardiovasculares mayores. Conclusiones La implantacion del codigo infarto conllevo un incremento de pacientes ingresados por sindrome coronario agudo con elevacion del segmento ST y mayor GRACE. Se redujo la estancia hospitalaria, se generalizo la angioplastia primaria y se redujo la mortalidad hospitalaria de los pacientes de alto riesgo. El pronostico tras el alta fue igual en ambos periodos.

Resumen Introduccion y objetivos La valoracion angiografica visual sigue utilizandose para decidir la revascularizacion de lesiones coronarias dudosas. Multiples factores, distintos del grado de estenosis, se han asociado con la repercusion funcional de una lesion coronaria. El objetivo de este estudio es analizar la capacidad de predecir visualmente la repercusion funcional de una lesion coronaria y los condicionantes clinicos y angiograficos asociados con el error en la prediccion. Metodos Estudio de concordancia entre la prediccion de repercusion funcional realizada por intervencionistas expertos y el valor de reserva fraccional de flujo obtenido mediante guia intracoronaria de presion en 665 lesiones intermedias (estenosis del 40–70% del diametro) en 587 pacientes. Se determinaron los factores independientemente asociados a un error en la prediccion. Resultados Se observo una discordancia del 30,1% (sobrestimacion, 11,3%; subestimacion, 18,8%) entre el valor de reserva fraccional de flujo predicho ≤ 0,80 y el observado. La localizacion en el stent, en una arteria distinta de la descendente anterior y en una bifurcacion se asocio a sobrestimacion. El sexo masculino, la calcificacion grave y el mayor territorio miocardico distal a la lesion se asociaron significativamente con importancia funcional de la lesion subestimada. Conclusiones Incluso integrando caracteristicas angiograficas y clinicas, la estimacion visual de la importancia funcional de estenosis coronarias intermedias se asocia a una alta tasa de discrepancias respecto a su determinacion real. Determinadas caracteristicas angiograficas y clinicas se asocian especificamente con mayor tendencia a sobrestimar o subestimar la importancia de la lesion.

Objective Functional assessment of coronary artery stenosis is performed by measuring the fractional flow reserve (FFR) under hyperemic conditions (Adenosine). However, the use of adenosine portends limitations. Objective We sought to investigate the relationship and correlation between FFR and the Pd/Pa value obtained just after the intracoronary infusion (acute drop) of nitroglycerin (Pd/Pa-NTG) and if this parameter enhances diagnostic accuracy for FFR prediction compared to the resting baseline Pd/Pa. Methods We conducted a multicenter study including prospectively patients presenting intermediate coronary artery stenosis (30–70%) evaluated with pressure wire. Resting baseline Pd/Pa, Pd/Pa-NTG and FFR were measured. Results 283 patients (335 lesions) were included. Resting baseline Pd/Pa value was 0.72 to 1.0 (0.93 ± 0.04), Pd/Pa-NTG was 0.60 to 1.0 (0.87 ± 0.07) and FFR 0.55 to 1.0 (0.83 ± 0.08). The ROC curves for resting baseline Pd/Pa and for Pd/Pa-NTG, using a FFR ≤ 0.80 showed an AUC of 0.88 (95% CI: 0.84–0.92, P 0.80, were >0.96 and >0.88, respectively. These values were present in a 29.8% (n = 100) and a 47.1% (n = 158), of the total lesions. Scatter plots showed a better correlation and agreement points with Pd/Pa-NTG than resting baseline Pd/Pa. The cutoff value of Pd/Pa-NTG > 0.88 showed an excellent NPV (96.2% for FFR > 0.8 and 100% for FFR > 0.75) and sensitivity (95% for FFR > 0.8 and 100% for FFR > 0.75) which were consistently high across all the subgroups analysis. Conclusion The cutoff value of acute Pd/Pa-NTG > 0.88 has a high NPV meaning adenosine-FFR can be avoided in almost half of lesions. © 2015 Wiley Periodicals, Inc.

Assessment of intermediate coronary lesions can be done with fractional flow reserve (FFR) and intravascular ultrasound (IVUS). There are no randomised trials and only a small registry from one centre is available but this is subject to important bias. We sought to evaluate the clinical outcomes of an FFR strategy compared with an IVUS strategy for intermediate lesion assessment.We compared the outcome of patients assessed with FFR and IVUS in two centres with a differential approach. After propensity score matching 400 pairs of patients were included. Revascularisation was done when FFR was0.75 or minimum lumen area was4 mm2 in vessels3 mm, and3.5 mm2 in vessels 2.5-3 mm, along with plaque burden50%. After FFR and IVUS, 72% and 51.2% of lesions, respectively, were left untreated (p0.001). At one and two years no significant differences in MACE-free survival were observed in overall groups (97.7% at one year and 93.1% at two years in the FFR group and 97.7% at one year and 95.6% at two years in the IVUS group; p=0.35) and among those with deferred intervention (97.9% at one year and 94.2% at two years in the FFR group and 96.5% at one year and 93.6% at two years in the IVUS group; p=0.7).IVUS and FFR may be safely used to defer revascularisation of intermediate lesions. IVUS induces a higher degree of revascularisation but much lower than previously reported and does not affect the clinical outcome.

ResumenIntroduccion y objetivos La estimacion mediante ecografia intracoronaria de la repercusion funcional de lesiones angiograficas intermedias se ha basado principalmente en la medicion del area luminal minima. Estas estimaciones no han tenido en cuenta la longitud de la lesion y no han sido estudiadas suficientemente en lesiones coronarias largas. Metodos Se incluyen 61 lesiones con un 40-70% de estenosis angiografica visual y necesidad de stent ≥ 20 mm para su tratamiento, que se estudiaron con ecografia y reserva fraccional de flujo. Se realizo un analisis tridimensional offline del estudio de ecografia, ciego al valor de reserva fraccional. Se correlacionaron los parametros angiograficos y ecograficos con la reserva fraccional obtenida. Resultados Se obtuvieron por angiografia valores medios de diametro de referencia (2,87 ± 0,57 mm; longitud, 29,8 ± 10,01 mm) y grado de estenosis (50,3 ± 8,7%). El valor medio de reserva fraccional de flujo fue 0,78 ± 0,09. Se obtuvo una pobre correlacion lineal (R) entre la reserva fraccional y los parametros de ecografia que no incluian la longitud de la lesion: reserva fraccional-area luminal minima (R = 0,4; p = 0,003); y mejor cuando se la tenia en cuenta: reserva fraccional − volumen de la placa (R = –0,65; p

Coronary angioplasty Intracoronary ultrasound Fractional flow reserve A B S T R A C T Introduction and objectives: Intracoronary ultrasound estimation of the functional significance of intermediate angiographic lesions has mainly been based on measuring the minimal lumen area. These estimates take no account of lesion length and pay insufficient attention to long coronary lesions. Methods: We included 61 lesions with visual angiographic stenosis of 40% to 70% that required treatment with a � 20 mm stent, studied with ultrasound and fractional flow reserve. Three-dimensional analysis of the ultrasound study was conducted offline and blinded to fractional reserve values. Angiographic and ultrasound parameters were correlated with fractional reserve. Results: From the angiography we obtained data on mean reference diameter (2.87 (0.57) mm), length (29.8 (10.01) mm), and severity of stenosis (50.3% (8.7)%). Mean fractional flow reserve was 0.78 (0.09). We found a weak linear correlation (R) between fractional reserve and the ultrasound parameters that did not include lesion length: fractional reserve-minimal luminal area (R=0.4; P=.003). The correlation was stronger when lesion length was included: fractional reserve-volume of plaque (R=-0.65; P

Objective: To assess the relationship between lesion length and other angiographic parameters on the functional significance of long coronary lesions with moderate stenosis. Background: Coronary revascularization is usually based on angiographic percent stenosis. Coronary stenosis length is not usually considered in daily clinical practice for revascularization decision-making. The relevance of lesion length might be greater in longer lesions with intermediate stenosis. Methods: All coronary lesions >20 mm and of 40–70% percent stenosis assessed by intracoronary pressure wire between 2007 and 2009 were included. Interventionists performing digital quantification of lesion stenosis were blinded to the result of fractional flow reserve (FFR). Correlations between angiographic data and FFR were analyzed. Results: One hundred and six lesions from 103 patients were included. Reference diameter: 2.9 6 0.56 mm; maximal stenosis: 49.0 6 8.7%; minimal luminal diameter (MinimalLD): 1.48 6 0.4 mm; mean luminal diameter (MeanLD): 2.3 6 0.5 mm; mean lesion length: 28.7 6 10.6 mm. Lesions with FFR 20 mm) with moderate angiographic stenosis, lesion length might be the strongest determinant of functional repercussion. Lesion length should be considered when judging the benefit of revascularization or perform functional functional measures that overcome the limitations of simple stenosis quantification. V C 2012 Wiley Periodicals, Inc.

Resumen Introduccion y objetivos Casi la mitad de los pacientes con sindrome coronario agudo presentan enfermedad multivaso. En ocasiones la angiografia no es suficiente para decidir la revascularizacion de lesiones distintas de la que causa el sindrome coronario agudo. La validez de la reserva fraccional de flujo medida con guia intracoronaria de presion es controvertida en el sindrome coronario agudo. Analizamos los resultados de basar la decision de revascularizacion de lesiones angiograficamente dudosas en la reserva fraccional de flujo obtenida mediante guia de presion en pacientes con sindrome coronario agudo y enfermedad multivaso. Metodos Estudio observacional de una serie consecutiva de pacientes cateterizados en dos centros por sindrome coronario agudo, en los se utilizo la reserva fraccional de flujo para decidir el tratamiento de lesiones angiograficamente moderadas distintas de la causal. Resultados Se incluyo a 107 pacientes. Tras tratar la lesion causal, en 81 pacientes (75,7%) alguna de las lesiones no fue tratada segun la reserva fraccional de flujo obtenida (grupo no tratado); en 26 (24,3%) se revascularizaron todas las lesiones estudiadas (grupo tratado). Caracteristicas (grupo no tratado/grupo tratado): vasos enfermos, 1,3 ± 0,7/1,4 ± 0,6 (p = 0,4); lesiones estudiadas, 1,2 ± 0,5/1,1 ± 0,4 (p = 0,3); porcentaje de estenosis, 46,1 ± 8,3%/47,9 ± 10,3% (p = 0,4); reserva fraccional de flujo, 0,86 ± 0,1/0,70 ± 0,1 (p Conclusiones La reserva fraccional de flujo obtenida con guia intracoronaria de presion permite decidir la revascularizacion de lesiones angiograficamente dudosas en el paciente con sindrome coronario agudo y enfermedad multivaso.

Introduccion y objetivos A diferencia de lo que ocurre con la cardiopatia isquemica estable, en el sindrome coronario agudo (SCA), la reserva fraccional de flujo (RFF) medida con guia intracoronaria de presion no ha demostrado utilidad para evaluar lesiones coronarias angiograficamente dudosas. El objetivo de este estudio es analizar el pronostico a 1 ano de los pacientes con SCA y lesiones intermedias en la coronariografia no revascularizados con base en las cifras de RFF obtenida con guia intracoronaria de presion. Metodos Estudio observacional de una cohorte de pacientes ingresados por SCA con lesiones coronarias de gravedad angiografica intermedia no revascularizadas por presentar una RFF > 0,75. El estudio funcional no se realizo en presencia de evidencia angiografica de inestabilidad. Se evaluaron los eventos muerte, infarto no fatal, revascularizacion de la lesion estudiada y el reingreso por causa cardiaca durante el primer ano tras el estudio. Resultados Se incluyo a 106 pacientes con 127 lesiones no revascularizados por obtenerse una RFF > 0,75. Edad, 69,9 ± 10 anos; SCA sin elevacion del segmento ST, 92 (86,8%); estenosis angiografica media, 40,5% ± 7,81%; RFF media, 0,88 ± 0,06. No se observaron complicaciones durante los procedimientos. Se obtuvo un seguimiento al ano del 95,1%. Los eventos observados al ano fueron: mortalidad total, 2 (1,9%); infarto no fatal, 0; revascularizacion de la lesion estudiada, 1 (0,9%); reingreso por causa cardiaca, 5 (4,7%). Conclusiones Excluyendo las lesiones con evidentes signos angiograficos de inestabilidad, la guia intracoronaria de presion puede ser una herramienta util en el SCA para evitar revascularizaciones innecesarias de lesiones coronarias angiograficamente moderadas.

Introduccion y objetivos Los resultados de los stents coronarios farmacoactivos no han sido suficientemente estudiados en los pacientes muy ancianos, quienes poseen caracteristicas clinicas que pueden hacerles presentar mas efectos secundarios y mas eventos clinicos a largo plazo. Metodos Se analiza la seguridad y eficacia del empleo de stents farmacoactivos en una cohorte historica de pacientes octogenarios consecutivos sometidos a intervencionismo coronario percutaneo. Resultados Entre 2002 y 2006 se trataron con stent intracoronario 176 octogenarios (90 con algun stent farmacoactivo y 86 solo con stents convencionales). Los pacientes tratados con stent farmacoactivo presentaron significativamente mayor numero de vasos enfermos (2,28 ± 0,85 frente a 1,87 ± 0,87; p = 0,002), enfermedad multivaso (el 79 frente al 59%; p = 0,005), tratamiento del tronco comun (el 20 frente al 1%; p Conclusiones Con una adecuada seleccion clinica de los pacientes, el empleo de stents farmacoactivos en pacientes octogenarios con un perfil angiografico muy desfavorable puede ser tan seguro y eficaz como el del stent convencional en pacientes con lesiones coronarias de menor riesgo.

Diabetes mellitus confers the highest mortality risk in primary and secondary cardiovascular prevention, but long-term prognosis differences between different forms of cardiovascular disease have not been assessed. We hypothesized that acute heart failure (HF) could have poorer outcomes than acute coronary heart disease (CHD) in patients with diabetes. We performed a prospective study of all consecutive patients admitted in a single year. Patients were categorized according to main cardiologic diagnosis: acute HF, acute CHD, rhythm disorders, or noncardiac disease. A total of 1,293 patients were included, 31.8% had diabetes and had higher mean age, more risk factors, previous cardiovascular disease, and co-morbidities. Hospital mortality (5.6% vs 1.7%; p0.01) was higher in patients with diabetes. During follow-up (median 58.0 months; interquartile range 31.0 to 60.0), diabetic patients had higher cardiovascular mortality (27.2% vs 9.6%; p0.01) and all-cause mortality (35.8% vs 14.5%; p0.01); cardiovascular disease accounted for 75% of deaths. According to discharge diagnosis, patients with diabetes only had higher mortality rates in the subgroup of acute CHD. Acute HF was the diagnosis with higher cardiovascular (36.9%) and all-cause mortality (44.1%), followed by acute CHD (16.8% and 24.4%) and rhythm disorders (5.8% and 8.8%). Multivariate analysis identified an independent association with higher long-term mortality of acute HF and acute CHD in patients with and without diabetes. In conclusion, 1/3 of cardiology-admitted patients have diabetes and have poorer long-term prognosis, especially when discharged with the diagnosis of acute HF or acute CHD.

Introduction and objectives Visual angiographic assessment continues to be used when decisions are made on whether to revascularize ambiguous coronary lesions. Multiple factors, other than the degree of stenosis, have been associated with the functional significance of a coronary lesion. The aim of this study was to investigate the ability of interventionists to visually predict the functional significance of a coronary lesion and the clinical and angiographic characteristics associated with errors in prediction. Methods We conducted a concordance study of the functional significance of coronary lesions predicted by experienced interventionists and fractional flow reserve values measured by intracoronary pressure wire in 665 intermediate lesions (40%-70% diameter stenosis) in 587 patients. We determined which factors were independently associated with errors in prediction. Results There was disagreement between the predicted fractional flow reserve value of ≤ 0.80 and the observed value in 30.1% of the lesions (overestimation: 11.3%; underestimation, 18.8%). Stent location in an artery other than the anterior descending artery or in a bifurcation was associated with overestimation. Male sex, severe calcification, and a greater myocardial territory distal to the lesion were significantly associated with the functional significance of the underestimated lesion. Conclusions Even when taking into account angiographic and clinical characteristics, there is a high rate of disagreement between visual estimation and direct measurement of intermediate coronary stenosis in relation to its functional significance. Specific angiographic and clinical characteristics are associated with an increased tendency to overestimate or underestimate the significance of lesions.

Introduccion y objetivos La diabetes avanzada se puede asociar con una enfermedad coronaria difusa de dificil revascularizacion. Se estudiaron los hallazgos angiograficos y la evolucion clinica de pacientes con diabetes avanzada (insulinodependencia o mas de 5 anos con farmacos) y sindrome coronario agudo sin elevacion del segmento ST tratados con estrategia invasiva. Metodos Se incluyo a 141 pacientes. En la coronariografia se cuantifico la extension de la enfermedad coronaria mediante un sistema de puntuacion sobre 29 segmentos. Durante 1 ano se recogio el evento combinado de muerte, infarto o reingreso por angina. Resultados La extension de la enfermedad coronaria se asocio con 4 variables: grado Killip > 1 en el momento del ingreso (p = 0,02), cirugia coronaria previa (p = 0,003), descenso del segmento ST (p = 0,01) y peor fraccion de eyeccion (p = 0,0001). La presencia de un mayor numero de estas variables (0, 1, 2 o ≥ 3 variables) implicaba un incremento en la extension de la enfermedad coronaria (12 ± 7, 15 ± 7, 21 ± 6 y 23 ± 7 puntos; p = 0,0001), y las diferencias eran significativas entre los pacientes con 2 o mas variables frente a los que tenian menos de 2. Durante el ingreso se revascularizo a 85 pacientes (60%) y durante el seguimiento se produjeron eventos en 39 (28%). La revascularizacion fue la unica variable relacionada con los eventos ( hazard ratio [HR] = 0,43; intervalo de confianza [IC] del 95%, 0,20-0,90; p = 0,02), incluso tras ajustar por un propensity score (indice C = 0,80) para revascularizacion. Conclusiones En pacientes con diabetes avanzada y sindrome coronario agudo sin elevacion del segmento ST tratados con estrategia invasiva, los antecedentes de ci rugia coronaria, el descenso del segmento ST y la depression de la funcion ventricular se asocian con enfermedad coronaria difusa. Los resultados del seguimiento clinico indican que la revascularizacion durante el ingreso mejora el pronostico.

Introduction and objectives Advanced diabetes can be associated with diffuse coronary artery disease that is difficult to treat by revascularization. We studied angiographic findings and disease progression in patients with advanced diabetes (either insulin-dependent or taking antidiabetic drugs for >5 years) and non-ST-elevation acute coronary syndrome who were being treated using an invasive strategy. Methods The study included 141 patients. The extent of the coronary artery disease was quantified using a score derived from a 29-segment coronary angiogram. The composite endpoint was death, myocardial infarction, or readmission for unstable angina within one year of follow-up. Results The extent of coronary disease was associated with Killip class >1 at admission ( P =.02), previous coronary surgery ( P =.003), ST-segment depression ( P =.01), and a poor ejection fraction ( P =.0001). The more of these factors present (i.e., 0, 1, 2, or 3 factors), the greater the extent of the coronary disease (i.e., 12 [7], 15 [7], 21 [6], and 23 [7] points, respectively; P =.0001). There was a significant difference between patients with 2 factors and those with P =.02), even after adjustment using a revascularization propensity score (C-index, 0.80). Conclusions In patients with non-ST-elevation acute coronary syndrome and advanced diabetes being managed using an invasive strategy, a history of coronary surgery, ST-segment depression and poor left ventricular function were all associated with the presence of diffuse coronary artery disease. Clinical follow-up indicated that revascularization during hospital admission improved prognosis.

The study's objective was to analyze the acute complications and prognosis of acute myocardial infarction (AMI) in hypertensive patients in Spain.Complications and early mortality were recorded among the patients with AMI admitted to the coronary care units of the 17 hospitals in the Valencia Community (Spain) between 1995 and 2000.A total of 12.071 patients were registered, of whom 46% were hypertensive (5.550 cases). Atrial fibrillation was more frequent in the hypertensive group, whereas ventricular fibrillation was more common among normotensive patients. We found higher mortality rates in the hypertensive group (14.4% vs 12.4%; P.001). However, after multivariate adjustment, hypertension was not independently associated with mortality (odds ratio: .95; P=.46), and remained independently associated with a lower risk of primary ventricular fibrillation (odds ratio: .83; P.05).Hypertensive patients do not present comparatively greater mortality during AMI, although primary ventricular fibrillation is less common in such subjects.

Introduction and objectives. The RAVEL and SIRIUS studies have demonstrated important reductions in clinical and angiographic restenosis in lesions treated with sirolimus-eluting stents. However, inclusion criteria in both studies excluded complex lesions. We studied immediate and long-term results with this stent in these complex lesions. Patients and method. Prospective, observational study with clinical and angiographic follow-up of patients who met the exclusion criteria used in the RAVEL and SIRIUS studies. All patients were treated in our catheterization laboratory between June 2002 and April 2003 with the Cypher stent, and 57 patients (68 lesions) were studied in all. The most frequent lesion characteristics were excessive length 26.5%; ostial lesions 25%, bifurcations 23.5%, and severe calcifications 22.1%. Almost half (47%) of the patients had diabetes

Introduccion y objetivos Los estudios RAVEL y SIRIUS han demostrado una importante reduccion de la reestenosis clinica y angiografica en lesiones tratadas con stent recubierto de rapamicina. Sin embargo, los criterios de seleccion de ambos ensayos clinicos excluyeron lesiones complejas. Estudiamos los resultados inmediatos y a medio plazo del stent de rapamicina en este tipo de lesiones complejas. Pacientes y metodo Estudio prospectivo y observacional con seguimiento clinico y angiografico de pacientes tratados en nuestro servicio entre junio de 2002 y abril de 2003 con el stent Cypher que cumplian criterios de exclusion en los estudios RAVEL y SIRIUS. Se estudio a 57 pacientes (68 lesiones). Las caracteristicas mas frecuentes fueron: longitud excesiva en el 26,5%, lesiones ostiales en el 25%, bifurcaciones en el 23,5% y calcificacion severa en el 22,1%. El 47% de los pacientes era diabetico y el 68% presentaba enfermedad multivaso. Resultados La angioplastia coronaria transluminal percutanea se llevo a cabo con exito en todos los casos. Hubo un evento cardiaco mayor durante el ingreso hospitalario (un infarto agudo de miocardio con onda Q) y 2 trombosis subagudas en la primera semana. Se realizo seguimiento clinico a medio plazo (8,7 ± 3,1 meses) en el 100% de los pacientes y acontecieron 4 eventos cardiacos mayores (7%): una muerte cardiaca, un infarto agudo de miocardio y 2 revascularizaciones del vaso diana. Se objetivo reestenosis angiografica intrasegmentaria en 4 lesiones (8%). Conclusiones El implante del stent Cypher en lesiones complejas es seguro y se acompana de una baja incidencia de eventos clinicos y muy bajo porcentaje de reestenosis angiografica en el seguimiento a los 6 meses.

Introduction and objectives. NT-proBNP is useful in the diagnosis of heart failure and ventricular dysfunction. Left atrioventricular plane displacement (AVPD) is a consolidated index of ventricular function. Our objective was to carry out a multicenter population-based study to establish the relationship between plasma NT-proBNP levels with AVPD values. Patients and method. We studied 215 subjects (age 66 ± 9 years; 57.7% women) chosen from a random sample of 432 people from the Community of Valencia, who previously reported suffering from some degree of dyspnea. Doppler echocardiography was done, AVPD was calculated and plasma NT-proBNP concentrations were determined. All studies were completed in 194 patients. Results. For the whole population NT-proBNP was 88 (02,586) pg/ml and AVPD was 11.9 ± 1.6 mm. NT-proBNP concentration correlated well with AVPD (r = 0.44; p < 0.00001), and higher peptide levels were obtained in AVPD quartiles that indicated less displacement (p < 0.05). When NT-proBNP values were grouped according to their association with AVPD lower or higher than the 50th percentile AVPD, the difference was significant at p < 0.01. When AVPD values lower and higher than 10 mm were compared, NT-proBNP values were higher in persons with AVPD lower than 10 mm (p < 0.05). Conclusions. This population study found higher NTproBNP concentrations in subjects with lower AVPD, and illustrates the potential diagnostic usefulness of NTproBNP in clinical practice.

Fundamento El objetivo del presente trabajo es conocer el grado real de anticoagulacion y antiagregacionde la fibrilacion auricular cronica en los pacientes hipertensos en la practica diariaen Espana y analizar si existen diferencias entre el medico de atencion primaria y el especialistaen cardiologia. Pacientes y metodo Se ha realizado un estudio transversal de ambito estatal en el que se hanregistrado de forma prospectiva en un cuestionario uniformado los datos demograficos, clinicosy terapeuticos de todos los pacientes atendidos en un mismo dia concreto entre junio y septiembrede 1999 por 1.159 medicos (el 21%, cardiologos). El analisis estadistico se ha realizadomediante el test de la χ2. Resultados La muestra esta formada por 32.501 pacientes, de los cuales 10.555 eran hipertensosy de ellos 999 presentaban fibrilacion auricular (prevalencia del 9,46%), distribuidos en435 varones (44%) y 564 mujeres (56%). El 53% provenia de la consulta de atencion primaria(532 pacientes) y el resto de la consulta de cardiologia (467). El porcentaje global de usode anticoagulantes fue del 33%, distribuidos en un 41% en los pacientes atendidos por el cardiologoy un 26% en los atendidos por el medico de atencion primaria (p Conclusiones La prevalencia de fibrilacion auricular en el paciente con HTA esta cercana al10%. El grado de utilizacion de anticoagulantes en estos pacientes es suboptimo, mas evidenteen el grupo atendido por atencion primaria. La edad mayor de 80 anos condiciona una menorutilizacion de anticoagulantes y un mayor uso de antiagregantes, tanto en la consulta decardiologia como en atencion primaria.

El sindrome de Carney es una enfermedad multisistemica, de transmision autosomica dominante, caracterizada por la asociacion de multiples neoplasias, que incluyen el mixoma de varias localizaciones (cardiaco, cutaneo, mamario), manchas pigmentadas cutaneas, hiperactividad endocrina (sindrome de Cushing, acromegalia), tumores testiculares y schwannomas. Este trabajo recoge el caso de una mujer de 43 anos que presentaba criterios diagnosticos de esta asociacion que se inicio con un infarto agudo de miocardio inferior, probablemente secundario a una embolizacion del mixoma auricular. A partir de este raro caso se realiza una breve revision del sindrome de Carney, en el que el cribado familiar representa un punto esencial

La incidencia de anomalias congenitas de las arterias coronarias oscila, en las distintas series coronariograficas publicadas, entre el 0,3 y el 1,3%. Inicialmente, estas anomalias se consideraron simples hallazgos, sin que se les asignara ninguna significacion clinica. Esta creencia se deshizo posteriormente al describirse casos de sincope, angina, infarto agudo de miocardio y muerte subita asociados a su presencia. Se conoce que las complicaciones clinicas pueden estar en relacion con el trayecto que sigue la arteria coronaria anomala. Presentamos un caso de anomalia congenita de la arteria coronaria izquierda con nacimiento en el seno coronario derecho, en una mujer de 74 anos con angina inestable prolongada, en el que la resonancia magnetica demostro ser definitiva en la determinacion del trayecto exacto de dicha coronaria anomala.

Assessment of intermediate coronary lesions can be done with IVUS and FFR. There are not randomized trials comparing these strategies. There are small registries from the same center but subjected to important biases. :ln two institutions the strategy for intermediate lesion evaluation has been

Intravenous adenosine is considered the drug of choice to obtain maximum hyperemia in the measurement of the fractional flow reserve (FFR). However, comparative studies performed between intravenous and intracoronary administration have not used high doses of intracoronary adenosine. The present study compared the efficacy and safety of high doses of intracoronary adenosine to intravenous administration when calculating the FFR. Intracoronary bolus doses of 60, 180, 300, and 600 μg adenosine were compared to an intravenous administration of 140 μg/kg/min, 200 μg/kg/min, and 140 μg/kg/min plus an intracoronary bolus of 120 μg. All the cases were performed using the radial approach. FFR was assessed in 102 patients with 108 intermediate lesions by an intracoronary pressure wire. The intracoronary dose of 60 μg was associated with a significantly greater FFR compared to the intravenous infusion (0.02 ± 0.03, p = 0.001). The intracoronary doses of 300 (-0.01 ± 0.00; p = 0.006) and 600 μg (-0.02 ± 0.00; p0.0005) were significantly associated with a smaller FFR compared to the intravenous infusion. An intracoronary dose of 600 μg revealed a significantly greater percentage of lesions with an FFR0.80 compared to intravenous infusion at 140 μg/kg/min (37.6 vs 31.5%; p0.05) and 200 μg/kg/min (37.6 vs 32.4%; p0.05) and compared to intracoronary doses of 60 (26.9%) and 180 μg (31.5%). In conclusion, an intracoronary bolus dose300 μg can be equal to or more effective than an intravenous infusion of adenosine in achieving maximum hyperemia when calculating the FFR. Its use could simplify these procedures without having an effect on safety.

To assess the relationship between lesion length and other angiographic parameters on the functional significance of long coronary lesions with moderate stenosis.Coronary revascularization is usually based on angiographic percent stenosis. Coronary stenosis length is not usually considered in daily clinical practice for revascularization decision-making. The relevance of lesion length might be greater in longer lesions with intermediate stenosis.All coronary lesions20 mm and of 40-70% percent stenosis assessed by intracoronary pressure wire between 2007 and 2009 were included. Interventionists performing digital quantification of lesion stenosis were blinded to the result of fractional flow reserve (FFR). Correlations between angiographic data and FFR were analyzed.One hundred and six lesions from 103 patients were included. Reference diameter: 2.9 ± 0.56 mm; maximal stenosis: 49.0 ± 8.7%; minimal luminal diameter (MinimalLD): 1.48 ± 0.4 mm; mean luminal diameter (MeanLD): 2.3 ± 0.5 mm; mean lesion length: 28.7 ± 10.6 mm. Lesions with FFR0.75 accounted for 33% (n = 35). Weak correlations were obtained between FFR and MinimalLD (r = 0.36; P0.0005), MeanLD (r = 0.24; P = 0.014), maximal stenosis (r = 0.31; P = 0.001), and mean stenosis (r = 0.018; P = 0.85); strong correlations were observed between FFR and lesion length (r = 0.63; P0.0005), lesion length/MinimalLD (r = 0.67; P0.0005), and lesion length/MeanLD (0.72; P0.0005). The predictive values of lesion length, lesion length/MinimalLD, and lesion length/MeanLD for FFR0.75 were 0.86, 0.91, and 0.92, respectively.In long lesions (20 mm) with moderate angiographic stenosis, lesion length might be the strongest determinant of functional repercussion. Lesion length should be considered when judging the benefit of revascularization or perform functional functional measures that overcome the limitations of simple stenosis quantification.

Multivessel disease is usually present in almost half of patients with acute coronary syndromes. Angiography is insufficiently accurate to decide on coronary revascularization in moderate nonculprit lesions. There is some debate about the usefulness of fractional flow reserve assessed by intracoronary pressure wire in acute coronary syndromes. We studied the results of using fractional flow reserve values to decide whether to perform coronary revascularization of nonculprit angiographically moderate lesions in patients with acute coronary syndrome and multivessel disease.The fractional flow reserve was used to decide whether to revascularize angiographically moderate nonculprit lesions in a cohort of consecutive patients with acute coronary syndromes recruited in 2 centers.One hundred and seven patients were included. Based on fractional flow reserve values, 81 patients (75.7%) were not revascularized. All lesions studied were revascularized in 26 patients (24.3%). Patient characteristics of the nontreated group and treated group were, respectively, diseased vessels, 1.3 (0.7) vs 1.4 (0.6) (P.4); fractional flow reserve-studied lesions, 1.2 (0.5) vs 1.1 (0.4) (P=.3); stenosis, 46.1 (8.3)% vs 47.9 (10.3)% (P=.4); fractional flow reserve, 0.86 (0.1) vs 0.70 (0.1) (P.005). After 1 year of follow-up, no significant differences in major cardiovascular events were observed between groups. There no deaths or nonfatal myocardial infarctions attributable to fractional flow reserve -deferred lesions. Coronary revascularization of the studied lesions was performed in 3 nontreated group patients (3.7%) due to disease progression.Fractional flow reserve assessed by intracoronary pressure wire is useful in deciding whether to revascularize angiographically moderate nonculprit lesions in patients with acute coronary syndrome and multivessel disease.

Introduction and objectives. The effectiveness of coronary drug-eluting stents has not been fully studied in very elderly patients who have clinical features that predispose them to side effects and long-term adverse events. Methods. The safety and efficacy of drug-eluting stents were studied in a historical cohort of consecutive octogenarian patients who underwent percutaneous coronary intervention. Results. Between 2002 and 2006, 176 octogenarian patients were treated using coronary stents: ninety with drug-eluting stents and 86 with bare-metal stents only. Patients treated using drug-eluting stents had a greater number of diseased vessels (2.28 [0.85] vs 1.87 [0.87]; P=.002), had more vessels treated (1.74 [0.79] vs 1.17 [0.47]; P

We describe four cases of acute myocardial infarction in young patients, secondary to blunt chest trauma. One case was treated with intracoronary thrombolysis and angioplasty, two cases received systemic thrombolysis, and the last one did not have any reperfusion therapy. The coronary angiograms of the left anterior descending artery showed thrombosis in two cases, coronary dissection in one case, and no morphological lesions in the other. We encourage the early performance of angiographic studies in these patients, adjusting the therapy to their pathophysiologic mechanism.

NT-proBNP is useful in the diagnosis of heart failure and ventricular dysfunction. Left atrioventricular plane displacement (AVPD) is a consolidated index of ventricular function. Our objective was to carry out a multicenter population-based study to establish the relationship between plasma NT-proBNP levels with AVPD values.We studied 215 subjects (age 66 9 years; 57.7% women) chosen from a random sample of 432 people from the Community of Valencia, who previously reported suffering from some degree of dyspnea. Doppler echocardiography was done, AVPD was calculated and plasma NT-proBNP concentrations were determined. All studies were completed in 194 patients.For the whole population NT-proBNP was 88 (0-2,586) pg/ml and AVPD was 11.9 1.6 mm. NT-proBNP concentration correlated well with AVPD (r = 0.44; p0.00001), and higher peptide levels were obtained in AVPD quartiles that indicated less displacement (p0.05). When NT-proBNP values were grouped according to their association with AVPD lower or higher than the 50th percentile AVPD, the difference was significant at p0.01. When AVPD values lower and higher than 10 mm were compared, NT-proBNP values were higher in persons with AVPD lower than 10 mm (p0.05).This population study found higher NT-proBNP concentrations in subjects with lower AVPD, and illustrates the potential diagnostic usefulness of NT-proBNP in clinical practice.