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The recent Academic Research Consortium for High Bleeding Risk (ARC-HBR) proposal did not consider acute coronary syndrome (ACS), by consensus, a bleeding criterion per se despite being a high bleeding risk (HBR) scenario. We investigated the applicability of the ARC-HBR classification and criteria in ACS patients.Patients with ACS undergoing coronary stenting between 2012 and 2018 at a tertiary hospital were retrospectively classified as being at HBR if they met ≥ 1 major or ≥ 2 minor ARC-HBR criteria. The primary endpoint was the 1-year cumulative incidence of Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding.Among 4412 patients, 29.5% were at HBR. The incidence of bleeding was higher in the HBR group than in the non-HBR group (9.4% vs 1.3%; P.01). The rates of in-hospital periprocedural and postdischarge bleeding were also higher in the HBR group (4.3% vs 0.5% and 5.3% vs 0.9%, respectively; P.01). Bleeding risk gradually increased with increasing ARC-HBR criteria: 1.8%, 5.0%, 9.4%, 16.8%, 25.2%, and 25.9% for 1 isolated minor criterion, ≥ 2 isolated minor criteria, 1 major criterion (isolated or plus 1 minor criterion), 1 major plus ≥ 2 minor criteria, ≥ 2 major criteria (isolated or plus 1 minor criterion), and ≥ 2 major plus ≥ 2 minor criteria, respectively. Sixteen (80%) out of 20 ARC-HBR criteria satisfied the ARC-HBR predefined cutoffs for BARC 3 or 5 bleeding risk.This study supports the use of the ARC-HBR classification and criteria in the ACS setting. The ARC-HBR classification provides an accurate major bleeding risk estimate and it seems suitable for the identification and management of patients at HBR.

Resumen Introduccion y objetivos La reciente propuesta del Academic Research Consortium for High Bleeding Risk (ARC-HBR), por consenso, no considera el sindrome coronario agudo (SCA) un criterio de hemorragia per se a pesar de tratarse de una situacion de alto riesgo hemorragico (ARH). En este articulo, se investiga la aplicabilidad de la clasificacion y los criterios del ARC-HBR a los pacientes con SCA. Metodos Se clasifico retrospectivamente a los pacientes con SCA sometidos a implante de stent coronario entre 2012 y 2018 en un hospital terciario como ARH si cumplian al menos 1 criterio mayor o 2 o mas criterios menores del ARC-HBR. El objetivo primario fue la incidencia acumulada a 1 ano de hemorragias de grado Bleeding Academic Research Consortium (BARC) 3-5. Resultados De los 4.412 pacientes incluidos, el 29,5% estaba en ARH. La incidencia de hemorragias fue mayor en el grupo con ARH que en el de no ARH (el 9,4 frente al 1,3%; p Conclusiones Este estudio respalda la aplicacion de la clasificacion y los criterios del ARC-HBR en el contexto del SCA. La clasificacion ARC-HBR proporciona una estimacion precisa del riesgo de hemorragia mayor y parece adecuada para la identificacion y el tratamiento de los pacientes con ARH.

Resumen Introduccion y objetivos La toma de decisiones clinicas sobre la anticoagulacion de pacientes ancianos con fibrilacion auricular (FA) requiere que se considere no solo la incidencia de eventos embolicos y hemorragicos, sino tambien el riesgo de muerte tras esos efectos adversos. Nuestro objetivo es analizar el balance con respecto a la mortalidad entre los eventos embolicos y hemorragicos en pacientes ancianos con FA. Metodos Se analizo a todos los pacientes de 75 o mas anos de un area de salud espanola diagnosticados de FA entre 2014 y 2017 (n = 9.365). El riesgo de muerte se estimo utilizando modelos de Cox que incluyeron los episodios embolicos y hemorragicos como variables dependientes del tiempo. Resultados Durante una mediana de seguimiento de 4,0 anos, los eventos se asociaron con mayor mortalidad, tanto los embolicos (HR = 2,39; IC95%, 2,12-2,69) como los hemorragicos (HR = 1,79; IC95%, 1,64-1,96). El riesgo de muerte fue un 33% mayor despues de una embolia que despues de una hemorragia (rRR = 1,33; IC95%, 1,15-1,55), aunque con accidente isquemico transitorio el riesgo fue menor que con hemorragia (rRR = 0,79; IC95%, 0,63-0,99). La mortalidad tras una hemorragia intracraneal fue similar que tras una embolia mayor (RR = 1,00; IC95%, 0,75-1,29). Conclusiones En los pacientes de edad avanzada con FA, los eventos embolicos parecen estar asociados con una mayor mortalidad que las hemorragias extracraneales, salvo los accidentes isquemicos transitorios. Con hemorragia intracraneal, el riesgo de muerte es similar al de una embolia mayor.

Despite patients with cancer having a higher incidence of atrial fibrillation (AF), little is known about the predictors of outcomes in this population. This study aimed to assess the incidence and predictors of bleeding in patients with AF and cancer. The study population comprised 16,056 patients from a Spanish health area diagnosed with AF between 2014 and 2018 (1,137 with cancer). Competing risk analysis were used to evaluate the association of cancer and bleeding. Discrimination and calibration of bleeding risk scores were assessed by the concordance statistic and the Brier score, respectively. During a median follow-up of 4.9 years, the incidence of bleeding in patients with cancer was 13.2 per 100 patients/year. After multivariate adjustment, a significant association between cancer and bleeding was detected (subdistribution hazard ratio [sHR] 1.18, 95% CI 1.07 to 1.30, p = 0.001), specifically in patients with active cancer or previous radiotherapy. Early age, male gender, diabetes, and anticoagulation were independent predictors of bleeding. However, only anticoagulation with vitamin K antagonist (sHR 1.36, 95% CI 1.03 to 1.78, p = 0.026), not with direct oral anticoagulants (sHR 1.25, 95% CI 0.84 to 1.85, p = 0.270), was associated with bleeding. Discrimination and calibration of Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, and Drugs/alcohol concomitantly (HAS-BLED), AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), and Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age ≥75 years), Reduced platelet count or function, Rebleeding risk, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR

Background: Patients with previous acute coronary syndrome (ACS) are at high risk of recurrent adverse cardiovascular events. Recently, prolonged dual antiplatelet therapy (DAPT) and oral anticoagulation therapy (OAT) have been shown to reduce recurrent ischemic events to the expense of an increase in bleeding events. The number of patients potentially eligible for these therapies in real life remains to be determined. Methods: Among ACS patients from five registries and one randomized controlled trial, we assessed the proportion of patients eligible for the PEGASUS strategy only and the proportion of patients eligible for the COMPASS strategy only, and set out the proportion of patients with an overlap between the strategies. Findings: Among the 10,048 evaluable patients, we found that 5373 (53.4%) were eligible for the PEGASUS strategy and 3841 (38.2%) were eligible for the COMPASS strategy, with a group of 3444 (34.4%) overlapping between the two strategies. The number of patients eligible for the PEGASUS strategy only was 1929 (19.2%) and the number eligible for the COMPASS strategy only was 397 (4.0%); 4278 (42.6%) were eligible for neither a PEGASUS strategy nor a COMPASS strategy. Interpretation: In a large cohort of ACS patients, one in three patients was eligible for either a prolonged DAPT with ticagrelor 60 mg and low-dose aspirin or a dual pathway inhibition approach with rivaroxaban 2.5 mg and low-dose aspirin.

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.

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.

Background Even when low-density lipoprotein-cholesterol (LDL-C) levels are lower than guideline thresholds, a residual risk of atherosclerosis remains. It is unknown whether triglyceride (TG) levels are associated with subclinical atherosclerosis and vascular inflammation regardless of LDL-C. Objectives This study sought to assess the association between serum TG levels and early atherosclerosis and vascular inflammation in apparently healthy individuals. Methods An observational, longitudinal, and prospective cohort study, including 3,754 middle-aged individuals with low to moderate cardiovascular risk from the PESA (Progression of Early Subclinical Atherosclerosis) study who were consecutively recruited between June 2010 and February 2014, was conducted. Peripheral atherosclerotic plaques were assessed by 2-dimensional vascular ultrasound, and coronary artery calcification (CAC) was assessed by noncontrast computed tomography, whereas vascular inflammation was assessed by fluorine-18 fluorodeoxyglucose uptake on positron emission tomography. Results Atherosclerotic plaques and CAC were observed in 58.0% and 16.8% of participants, respectively, whereas vascular inflammation was evident in 46.7% of evaluated participants. After multivariate adjustment, TG levels ≥150 mg/dl showed an association with subclinical noncoronary atherosclerosis (odds ratio [OR]: 1.35; 95% confidence interval [CI]: 1.08 to 1.68; p = 0.008). This association was significant for groups with high LDL-C (OR: 1.42; 95% CI: 1.11 to 1.80; p = 0.005) and normal LDL-C (OR: 1.85; 95% CI: 1.08 to 3.18; p = 0.008). No association was found between TG level and CAC score. TG levels ≥150 mg/dl were significantly associated with the presence of arterial inflammation (OR: 2.09; 95% CI: 1.29 to 3.40; p = 0.003). Conclusions In individuals with low to moderate cardiovascular risk, hypertriglyceridemia was associated with subclinical atherosclerosis and vascular inflammation, even in participants with normal LDL-C levels. (Progression of Early Subclinical Atherosclerosis [PESA]; NCT01410318), Central Illustration

Data de publicació electrònica: 20-01-2023 Introduction and objectives: Dual antiplatelet therapy (DAPT) duration after ST-segment elevation myocardial infarction (STEMI) remains a matter of debate. Methods: We analyzed the effect of DAPT on 5-year all-cause mortality, cardiovascular mortality, and cardiovascular readmission or mortality in a cohort of 1-year survivor STEMI patients. Results: A total of 3107 patients with the diagnosis of STEMI were included: 93% of them were discharged on DAPT, a therapy that persisted in 275 high-risk patients at 5 years. Cardiovascular mortality in patients on single antiplatelet therapy vs DAPT at 5 years was 1.4% vs 3.6% (P

Advanced heart failure is a growing problem for which the best treatment is cardiac transplantation. However, the shortage of donors’ hearts made left ventricular assist devices as destination therapy (DT-LVAD) a highly recommended alternative: they improved mid-term prognosis as well as patients’ quality of life. Current intracorporeal pumps with a centrifugal continuous flow evolved in the last few years. Since 2003, when first LVAD was approved for long-term support, smaller device sizes with better survival and hemocompatibility profile were reached. The most important difficulty lies in the moment of the implant. Recent indications range from INTERMACS class 2 to 4, with close monitoring in intermediate cases. Moreover, a large multiparametric study is needed for considering the candidacy: basal situation, with a special interest in frailty, comorbidities, including renal and hepatic dysfunction, and medical background, considering every prior cardiac condition, must be evaluated. In addition, some clinical risk scores can be helpful to measure the possibility of right heart failure or morbi-mortality. With this review, we sought to summarize all the device improvements, with their updated clinical results, as well as to focus on all the patient selection criteria.

Introduction and objectives: The presence of comorbidities in elderly patients with non-ST-segment elevation acute coronary syndrome worsens its prognosis. The objective of the study was to analyze the impact of the burden of comorbidities in the decision of using invasive management in these patients. Methods: A total of 7211 patients > 70 years old from 11 Spanish registries were included. Individual data were analyzed in a common database. We assessed the presence of 6 comorbidities and their association with coronary angiography during admission. Results: The mean age was 79 ± 6 years and the mean CRACE score was 150 ± 21 points. A total of 1179 patients (16%) were treated conservatively. The presence of each comorbidity was associated with less invasive management (adjusted for predictive clinical variables): cerebrovascular disease (OR, 0.78; 95%CI, 0.64-0.95; P = .01), anemia (OR, 0.64; 95%CI, 0.54-0.76; P < .0001), chronic kidney disease (OR, 0.65; 95%CI, 0.56-0.75; P < .0001), peripheral arterial disease (OR, 0.79; 95%CI, 0.65-0.96; P = .02), chronic lung disease (OR, 0.85; IC95%, 0.71-0.99; P = .05), and diabetes mellitus (OR, 0.85; 95%CI, 0.74-0.98; P < .03). The increase in the number of comorbidities (comorbidity burden) was associated with a reduction in coronary angiographies after...

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.

There is limited knowledge regarding the efficacy and safety of fixed-dose oral anticoagulants in overweight patients because of the possible increased risk of embolism and hemorrhage. This study aimed to evaluate embolic, hemorrhagic, and mortality events in anticoagulated patients, administered both antivitamin K and direct oral anticoagulants based on the body weight (60 kg, 60 to 100 kg and100 kg). A retrospective registry-based cohort study including all consecutive patients with a diagnosis of atrial fibrillation between January 2014 and January 2018 in the health area of Vigo (Galicia, Spain) was used (CardioCHUVI-AF registry; ClinicalTrials.gov identifier: NCT04364516). The final cohort comprised 11,821 AF patients. The cohort was classified into 3 categories: low body weight ([LBW],60 kg, 924 patients); middle body weight (60 to 100 kg, 9,546 patients); and high body weight ([HBW],100 kg, 958 patients). Outcomes were predicted using the Fine and Gray model and Cox proportional hazards model when appropriate. Middle body weight was the reference group. No association was found between the weight and major bleeding in the univariate analyses: LBW with a sub-distribution hazard ratio (sHR) of 1.13 (95% confidence interval [CI] 0.92 to 1.41), and HBW with an sHR of 1.02 (95% CI 0.83 to 1.26). Stroke/systemic embolism events occurred in 817 patients (6.6%). In the univariate analyses, we found an association between weight and risk of stroke/systemic embolism: LBW sHR 1.37 (95% CI 1.09 to 1.72), and HBW sHR 0.66 (95% CI 0.49 to 0.89) but no association was found in the multivariable model. The same situation was observed with all-cause death: in the univariable model, LBW presented a hazard ratio of 1.48 (95% CI 1.31 to 1.68) and the HBW group presented a hazard ratio of 0.53 (95%CI 0.44 to 0.63) whereas no significant association was found in the multivariable model. We conclude that in our registry, extreme weights were not related to more events during follow-up.

Little is known about the prediction of atrial fibrillation (AF) risk scores in patients with cancer. The aim of this study was to assess the predictive ability of the CHAsub2/subDSsub2/sub-VASc and HAS-BLED scores in patients with AF and cancer. Overall, 16,056 patients with AF diagnosed between 2014 and 2018 from a Spanish health area, including 1,137 patients with cancer, were observed during a median follow-up of 4.9 years. Although discrimination was similar between patients with cancer and patients without cancer who were treated with anticoagulation therapy (0.56 and 0.58), in patients with cancer who were not treated with anticoagulation therapy, c-statistic of CHAsub2/subDSsub2/sub-VASc was poor and significantly lower than in the patients without cancer (0.42 vs 0.65). The overall precision of the CHAsub2/subDSsub2/sub-VASc score was good throughout the follow-up (Brier scorelt; 0.1), in patients with and without cancer. Regarding the HAS-BLED score, calibration and discrimination were poor in patients with cancer (c-statistic 0.51), similar to those in patients without cancer (c-statistic 0.53). In patients with cancer who were not treated with anticoagulation therapy, the embolic risk CHAsub2/subDSsub2/sub-VASc score = 1 was similar to CHAsub2/subDSsub2/sub-VASc score ≥ 2. Only patients with AF and cancer and CHAsub2/subDSsub2/sub-VASc score = 0 presented a low risk of embolic events (negative predictive value 100%). A HAS-BLED scoregt; 3 was not associated with higher bleeding risk in patients with cancer (pgt; 0.05). In summary, in patients with cancer and with AF, neither the CHAsub2/subDSsub2/sub-VASc score nor the HAS-BLED score was useful for predicting embolic and hemorrhagic events, respectively. However, a CHAsub2/subDSsub2/sub-VASc score 0 is useful to identify patients with AF and cancer who are at low embolic risk.

The impact of cancer on clinical outcomes in patients with atrial fibrillation (AF) is unclear. The aim of this study was to assess how cancer influences the prediction and risk of embolic and hemorrhagic events in patients with AF.The study population comprised 16 056 patients from a Spanish health area diagnosed with AF between 2014 and 2018. Of these, 1137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years, we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis, considering death as a competing risk.No association was detected between an increased risk of embolic events and cancer overall (sHR, 0.73; 95%CI, 0.41-1.26), active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding, although only in patients with active cancer (sHR, 1.42; 95%CI, 1.20-1.67) or prior radiotherapy (sHR, 1.40; 95%CI, 1.19-1.65). Both the CHACancer was not associated with an increased risk of embolic events in AF patients, only with an increased risk of bleeding. However, active cancer worsened the ability of the CHA

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 Introduccion y objetivos El envejecimiento de la poblacion se asocia con una prevalencia creciente de fibrilacion auricular (FA) y demencia. Con este estudio se pretende analizar el impacto de la anticoagulacion oral en pacientes ancianos con FA y demencia de grado moderado-grave. Metodos Estudio retrospectivo unicentrico que analiza a pacientes de edad ≥ 85 anos con diagnostico de FA entre 2013 y 2018. El impacto de la anticoagulacion en la mortalidad, las embolias y las hemorragias se evaluo mediante un analisis multivariado de Cox. En los pacientes con demencia, dicho analisis se complemento con un propensity score matching en funcion de que se les prescribiera tratamiento anticoagulante o no. Resultados De los 3.549 pacientes de 85 o mas anos con FA, 221 presentaban demencia de grado moderado-grave (6,1%), de los que 88 (60,2%) fueron anticoagulados. Durante un seguimiento de 2,8 ± 1,7 anos, la anticoagulacion se asocio con menor riesgo embolico y mayor riesgo hemorragico tanto en pacientes con demencia (HRembolias = 0,36; IC95%, 0,15-0,84; HRhemorragias = 2,44; IC95%, 1,04-5,71) como sin demencia (HRembolias = 0,58; IC95%, 0,45-0,74; HRhemorragias = 1,55; IC95%, 1,21-1,98). Sin embargo, la anticoagulacion unicamente se asocio con menor mortalidad en los pacientes sin demencia (HR = 0,63; IC95%, 0,53-0,75), no en pacientes con demencia (HR ajustada = 1,04; IC95%, 0,63-1,72; p = 0,541; HR despues de propensity score matching = 0,91; IC95%, 0,45-1,83; p = 0,785). Conclusiones En pacientes de 85 o mas anos con demencia moderada-grave y FA, la anticoagulacion oral se asocio de manera significativa con menor riesgo de embolias y mayor riesgo hemorragico, sin encontrarse diferencias en cuanto a mortalidad total.

Background: The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Methods: We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003–2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine–Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage. Results: Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7–319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01–1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36–8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors. Conclusion: The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.

Introduction and objectives In de novo heart failure with reduced ejection fraction (HFrEF) current guidelines support, an initial double combination therapy with angiotensin converting enzyme inhibitors/angiotensin-receptor blockers and betablockers, only adding minerocorticoid receptor antagonists if after treatment optimization left ventricular ejection fraction (LVEF) is still under 40%. An initial triple combination therapy could be an attractive initial approach in the stability phase after an acute HF episode in debut HFrEF; which is what we describe in this report and analyze the factors related to the treatment with triple neurohormonal blockade (TNHB). Methods Retrospective study of patients discharged from our centre between January 2009 and January 2016 with de novo HFrEF after an acute HF episode with these criteria: 15–85 year-old, creatinine ≤2.5 mg/dL, potassium Results A total of 280 patients fulfilled the criteria, 58% of them were discharged on TNHB. Mean age was 65.4 ± 12.5 years, LVEF 29.8 ± 7.3% and median NT-ProBNP 2917 pg/mL. After a mean follow-up of 43.4 ± 26.6 months, 72 patients died (25.7%), with a mean survival of 76 months. Patients treated with TNHB had a better risk profile (they were younger, better creatinine and lower pulmonary pressures) but poorer LVEF (28.7 ± 7.4% vs. 31.4 ± 6.7%; P = .002). Mean survival on TNHB was better (months, 82.1 ± 3.0 vs. 68.6 ± 3.8; P = .007). Multivariate analysis showed that TNHB was an independent predictor of better survival (HR, 1.79; 1.05–3.05; P = .03). Conclusions TNHB is commonly used in debut HFrEF, especially in younger patients with worse LVEF. In our cohort TNHB was an independent factor related to better survival.

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 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.

BACKGROUND The risk of recurrent ischemia and bleeding after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) may vary during the first year of follow-up according to clinical presentation, and medical and interventional strategies. METHODS BleeMACS and RENAMI are 2 multicenter registries enrolling patients with ACS treated with PCI and clopidogrel, prasugrel, or ticagrelor. The average daily ischemic and bleeding risks (ADIR and ADBR) in the first year after PCI were the primary end points. The difference between ADBR and ADIR was calculated to estimate the potential excess of bleeding/ischemic events in a given period or specific subgroup. RESULTS A total of 19,826 patients were included. Overall, in the first year after PCI, the ADBR was 0.008085%, whereas ADIR was 0.008017% (P = .886). In the first 2 weeks ADIR was higher than ADBR (P = .013), especially in patients with ST-segment elevation myocardial infarction or incomplete revascularization. ADIR continued to be, albeit non-significantly, greater than ADBR up to the third month, whereas ADBR became higher, although not significantly, afterward. Patients with incomplete revascularization had an excess in ischemic risk (P = .003), whereas non-ST-segment elevation ACS patients and those on ticagrelor had an excess of bleeding (P = .012 and P = .022, respectively). CONCLUSIONS In unselected ACS patients, ADIR and ADBR occurred at similar rates within 1 year after PCI. ADIR was greater than ADBR in the first 2 weeks, especially in ST-segment elevation myocardial infarction patients and those with incomplete revascularization. In the first year, ADIR was higher than ADBR in patients with incomplete revascularization, whereas ADBR was higher in non-ST-segment elevation ACS patients and in those discharged on ticagrelor.

Introduction and objectives To study the incidence, predictors and prognosis of follow-up de novo heart failure (HF) after discharge for acute myocardial infarction (AMI) in patients with left ventricular ejection fraction (LVEF) ≥ 50% and without previous history of HF. Methods Retrospective multicenter registry that includes 2158 consecutive patients discharged for AMI, from January 2011 to December 2015, with LVEF ≥ 50% and without history of HF. The association between clinical variables and the development of de novo HF was assessed by Fine–Gray proportional hazards regression analysis, accounting for death as a competing episode. The adjusted effect of post-discharge HF on subsequent mortality was investigated using extended Cox proportional hazards model. Results During follow-up (20.1 ± 11.8 months), 60 patients (2.8%) had HF admissions, with a cumulative incidence function of 1.7 per 100 patient-year. Age ≥ 70 years, hypertension, atrial fibrillation, and renal dysfunction were independent risk factors for follow-up HF. The HF incidence rate after surviving AMI increased with a higher number of risk factors, from 0.1% in patients with 0, to 1.8%, 3.8%, 15.3%, and 19% in patients with 1, 2, 3, and 4 risk factors, respectively (P Conclusions De novo HF after hospital discharge for ACS in patients with LVEF ≥ 50% is an independent predictor of follow-up death. Fortunately, it is an infrequent post-AMI complication and is easily predictable the combination of 4 clinical risk factors.