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Introduction and objectives: This report presents the findings of the 2018 Spanish Catheter Ablation Registry. Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers. Results: Data sent by 100 centers were analyzed, with a total number of 16,566 ablation procedures performed (the highest historically reported in this registry) for a mean of 165.5 ± 127.9 and a median of 119 procedures per center. The ablation targets most frequently treated were atrial fibrillation (n = 4234; 25.6%), atrioventricular nodal re-entrant tachycardia (n = 3525; 21.3%) and cavotricuspid isthmus (n = 3425; 20.7%). A new peak was observed in the ablation of atrial fibrillation, increasing the distance from the other substrates. The overall success rate was 91%. The rate of major complications was 2.2%, and the mortality rate was 0.04%. A total of 2.1% of the ablations were performed in pediatric patients. Conclusions: The Spanish Catheter Ablation Registry systematically and continuously enrolls the ablation procedures performed in Spain, showing a progressive increase in the number of ablations over the years, with a high success rate and low percentage of complications.

Resumen La significacion clinica que tiene un bloqueo de rama derecha (BRD) en los pacientes asintomaticos sin evidencia de patologia cardiovascular conocida es fuente de controversia. Para establecer la relacion entre la aparicion del BRD y el aumento de morbimortalidad cardiovascular en pacientes sanos se realizo una revision bibliografica de los articulos existentes hasta septiembre de 2017, a traves de la busqueda sistematica en PubMed, Cochrane y busqueda manual de la bibliografia citada y articulos relacionados. De las 29 publicaciones que cumplian los criterios de inclusion, 8 mostraron resultados de mortalidad y 16 de morbilidad. En 8 articulos se observo un aumento de riesgo de muerte y en 11 de eventos cardiovasculares. Las publicaciones revisadas sugieren que la presencia de BRD en pacientes sanos no es irrelevante. Se necesitan mas estudios que analicen que tipo de seguimiento se deberia realizar en estos pacientes.

Resumen Introduccion y objetivos La taquicardia ventricular polimorfica catecolaminergica (TVPC) es una enfermedad hereditaria caracterizada por arritmias ventriculares (AV) polimorficas o bidireccionales desencadenadas por estres fisico o emocional en jovenes con corazon estructuralmente normal. El pilar del tratamiento son los bloqueadores beta y recientemente se ha incorporado la flecainida al arsenal terapeutico. El objetivo de este trabajo es exponer nuestra experiencia con su uso. Metodos De un total de 174 pacientes pertenecientes a 7 familias afectadas de TVPC con genotipo positivo, se analizo a los que tomaron flecainida. Se valoraron la indicacion, los efectos secundarios, la dosificacion, los eventos clinicos, las AV y la ventana arritmica en las pruebas de esfuerzo y las descargas del desfibrilador automatico (DAI). Resultados Recibieron flecainida 18 pacientes (10,4%); 17 en combinacion con bloqueadores beta y 1 como tratamiento unico por intolerancia al bloqueador beta. Ningun paciente sufrio efectos secundarios. La indicacion fue la persistencia de AV complejas en la prueba de esfuerzo en 13 pacientes (72,2%) y descargas frecuentes del DAI en los otros 5 (27,8%). En el 66,7% de la familia 1, la puntuacion cuantitativa de AV en la prueba de esfuerzo se redujo mas de un 50% (32,76 ± 84,06 frente a 74,38 ± 153,86 lpm; p = 0,018). La ventana arritmica fue menor (5,8 ± 11,9 frente a 19,69 ± 21,27 lpm; p = 0,007) y 4 de los 5 pacientes con descargas apropiadas del DAI no sufrieron mas descargas. Conclusiones En pacientes con TVPC, la flecainida reduce los eventos clinicos, las AV, la ventana arritmica y las descargas del DAI y los pacientes la toleran bien.

Introduction and objectives Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited disease characterized by polymorphic or bidirectional ventricular arrhythmias (VA) triggered by physical or emotional stress in young people with a structurally normal heart. Beta-blockers are the cornerstone of treatment, while flecainide has recently been incorporated into the therapeutic arsenal. The aim of this study was to report our experience with this drug. Methods The cohort included 174 genotype-positive CPVT-patients from 7 families. We collected data from patients who were receiving flecainide and analyzed the indications, adverse effects and dosage, clinical events, VA and arrhythmic window during exercise testing, and implantable cardioverter-defibrillator (ICD) shocks during follow-up. Results Eighteen patients (10.4%) received flecainide; 17 patients in combination with beta-blockers, and 1 patient as monotherapy due to beta-blocker intolerance. None of the patients presented side effects. In 13 patients (72.2%) the indication was the persistence of exercise-induced VA and in 5 patients (27.7%) persistent ICD-shocks, despite on beta-blockers. After flecainide initiation, the exercise-induced VA quantitative score was reduced by more than 50% in 66.7% of the members of family 1 (32.76 ± 84.06 vs 74.38 ± 153.86; P = .018). The arrhythmic window was reduced (5.8 ± 11.9 bpm vs 19.69 ± 21.27 bpm; P = .007), and 4 of 5 patients with appropriate ICD shocks experienced no further shocks in the follow-up. Conclusions In CPVT-patients flecainide reduces clinical events, exercise-induced VA, the arrhythmic window, and ICD shocks, with good tolerance.

Introduction and objectives In Spain, 0.3% of patients with hypertension are refractory to conventional treatment. The complications resulting from deficient control of this condition can lead to poor quality of life for the patient and considerable health care costs. Barostim is an implantable device designed to lower blood pressure in these patients. The aim of this study was to analyze the cost-effectiveness of Barostim compared with drug therapy in hypertensive patients refractory to conventional treatment (at least 3 antihypertensive drugs, including 1 diuretic agent). Methods We used a Markov model adapted to the epidemiology of the Spanish population to simulate the natural history of a cohort of patients with refractory hypertension over their lifetime. Data on the effectiveness of the treatments studied were obtained from the literature, and data on costs were taken from hospital administrative databases and official sources. Deterministic and probabilistic sensitivity analyses were conducted. Results Barostim increased the number of quality-adjusted life years by 0.78 and reduced the number of hypertension-associated clinical events. The incremental cost-effectiveness ratio in a cohort of men reached 68 726 euros per year of quality-adjusted life. One of the main elements that makes this technology costly is the need for battery replacement. The results were robust. Conclusions Barostim is not a cost-effective strategy for the treatment of refractory hypertension in Spain. The cost-effectiveness ratio could be improved by future reductions in the cost of the battery.

Resumen Introduccion y objetivos En Espana, el 0,3% de los pacientes hipertensos son refractarios al tratamiento convencional. Las complicaciones derivadas de un control deficiente se traducen en mala calidad de vida para el paciente y un coste importante para el sistema sanitario. Barostim es un dispositivo implantable que busca reducir la presion arterial de estos pacientes. El objetivo del presente estudio es analizar el coste-efectividad de Barostim comparado con terapia farmacologica en pacientes hipertensos refractarios al tratamiento convencional (al menos tres farmacos antihipertensivos, siendo uno de ellos un diuretico). Metodos Modelo de Markov adaptado a la epidemiologia de la poblacion espanola que simula la historia natural de una cohorte de pacientes con hipertension arterial refractaria a lo largo de su vida. Los datos sobre efectividad de los tratamientos se obtuvieron de la literatura y los de costes, de bases de datos administrativas hospitalarias y de fuentes oficiales. Se realizaron analisis de sensibilidad deterministico y probabilistico. Resultados Barostim redujo los eventos clinicos asociados a la hipertension y aumento en 0,78 el numero de anos de vida ajustados por calidad. El cociente de coste-efectividad incremental para una cohorte de varones alcanzo los 68.726 euros por ano de vida ajustado por calidad. Uno de los principales elementos que encarece la tecnologia es el coste del recambio de la bateria. Los resultados fueron robustos. Conclusiones Barostim no es una estrategia coste-efectiva para el tratamiento de la hipertension refractaria en Espana. Reducciones futuras en el precio de la bateria mejorarian su cociente de coste-efectividad.

The clinical significance of a right bundle branch block (RBBB) in an asymptomatic adult without evidence of cardiovascular disease is controversial. To establish the relationship between the appearance of the RBBB and the increase of cardiovascular morbidity and mortality in healthy patients, we have carried out a literature review of documents available until September 2017 through a systematic search on the Pubmed database, Cochrane library and a manual search of the mentioned literature and related articles. From the 29 articles included in the study sample, eight showed mortality and 16 morbidity outcomes. An increase of risk of death is observed is eight articles and an increase of cardiovascular events is observed in 11 articles. The most recent publications suggest that the appearance of an RBBB in healthy individuals should not be underestimated, thus further studies are needed to analyse the type of follow-up that should be carried out in these patients.

AMI : acute myocardial infarction ARVC : arrhythmogenic right ventricular cardiomyopathy BrS : Brugada syndrome CACS : coronary artery calcium score CAD : coronary artery disease ChD : Chagas heart disease CMR : cardiac magnetic resonance CPVT : catecholaminergic polymorphic ventricular tachycardia CTCA : computed tomography coronary angiography CV : cardiovascular DCM : dilated cardiomyopathy EAPCR : European Association for Cardiovascular Prevention and Rehabilitation HCM : hypertrophic cardiomyopathy LGE : late gadolinium enhancement LQTS : long QT syndrome LV/RV : left/right ventricle LVH : left ventricle hypertrophy NSVT : non-sustained ventricular tachycardia PPE : preparticipation evaluation PVC : premature ventricular contractions SCA/SCD : sudden cardiac arrest/death TTE : transthoracic echocardiography VF : ventricular fibrillation VT : ventricular tachycardia Sudden cardiac death (SCD) associated with athletic activity is a rare but devastating event. Victims are usually young and apparently healthy, and while many of these deaths remain unexplained, a substantial number of victims harbour an underlying and potentially detectable cardiovascular (CV) disease.1–4 The vast majority of these events are due to malignant tachyarrhythmias, usually ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into ventricular fibrillation (VF), occurring in individuals with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, channelopathies). Intensive exercise training and competitive sport participation is a trigger that may favour insurgence of ominous ventricular tachyarrhythmias in predisposed individuals.5 Consequently, there is a great interest in early identification of at-risk individuals for whom appropriate treatment, followed or not by physical activity adjustment, may be implemented to minimize the risk of SCD. However, the role of pre-participation evaluation (PPE) in athletes as a feasible and efficient strategy to identify individuals at risk has remained controversial. …

Introduction and objectives: The aim of the study was to assess and measure health-related quality of life (HRQoL) changes in patients with typical atrial flutter following catheter ablation. The outcome was standardized and normalized to the Spanish population adjusted by age and sex. Methods: Ninety-five consecutive patients who had undergone cavotricuspid isthmus ablation were included. The SF-36 questionnaire was self-administered before the procedure and at 1-year follow-up. We used the effect size and the standardized response mean as measures of responsiveness to quantify the change in HRQoL and the minimum clinically important difference to assess the smallest difference in score that patients perceived as beneficial. Results: Of the 95 patients initially included, 88 completed the 1-year follow-up. We observed a large improvement (effect size � 0.8) on the physical functioning, role-physical, general health, and vitality scales and on the physical component summary. We detected a moderate improvement (effect size � 0.5) on the role-emotional, social functioning, and mental health scales and on the mental component summary. On all scales except bodily pain and social activity, the improvement was clinically perceived by patients. Conclusions: A clinically significant improvement in HRQoL measures was found in patients with typical atrial flutter who underwent cavotricuspid isthmus catheter ablation.

Resumen Introduccion y objetivos El proposito de nuestro trabajo es evaluar y cuantificar los cambios en la calidad de vida (CVRS) en pacientes con flutter auricular tipico sometidos a ablacion con cateter de radiofrecuencia, estandarizados y normalizados para la poblacion espanola ajustada por edad y sexo. Metodos Hemos analizado a 95 pacientes consecutivos sometidos a ablacion del istmo cavotricuspideo que se han autoaplicado el cuestionario SF-36 antes del procedimiento y al cabo de 1 ano de seguimiento. Hemos utilizado nuevas herramientas de medida de CVRS como son el tamano de efecto y la media de respuesta estandarizada para cuantificar la magnitud del cambio y las diferencias minimas clinicamente importantes para valorar si los cambios en la CVRS han sido percibidos clinicamente por el paciente. Resultados De los 95 pacientes inicialmente incluidos, 88 completaron el estudio. Se observo una magnitud de cambio grande (tamano del efecto ≥ 0,8) en las dimensiones funcion fisica, rol fisico, salud general, vitalidad y componente sumario fisico, y una magnitud de cambio moderada (tamano del efecto ≥ 0,5), en las dimensiones rol emocional, actividad social, salud mental y componente sumario mental. En el analisis de las diferencias minimas clinicamente importantes, se observo que en todas las dimensiones, excepto dolor corporal y actividad social, se supera el minimo exigido para que la magnitud del cambio sea percibida clinicamente por el paciente. Conclusiones Se observa una mejora en la CVRS de un grupo de pacientes con flutter auricular tipico sometidos a ablacion del istmo cavotricuspideo despues de 1 ano del procedimiento.

Brugada Syndrome (BrS) is a channelopathy that predisposes to sudden death (SD) in the absence of structural heart disease. The diagnostic pattern, known as coved-type or type 1, consists of a concave ST segment elevation ≥2 mm followed by a negative T wave, and it must be distinguished from other conditions that also present with ST-segment elevation in the precordial leads, including Brugada phenocopies (BrS type 1 pattern triggered by an environmental cause such as RV ischemia, acute pulmonary embolism, etc.) and other causes of Brugada-like ECG patterns, as acute ischemia of the left anterior descendent artery, right bundle branch block, early repolarization, arrhythmogenic right ventricular dysplasia, etc. Other modulating factors, such as fever, hormones or certain drugs, can unmask or exacerbate the typical BrS pattern.

La Sociedad Espanola de Cardiologia (SEC) ha elaborado su «marco etico». Este documento se estructura en 2 partes diferenciadas que tratan sobre la responsabilidad de la SEC como organizacion y de los profesionales en tanto que socios. La SEC propone a sus miembros unas pautas de actuacion en su practica diaria, establece un horizonte de compromiso civico como asociacion cientifica, y desea que las reflexiones, las recomendaciones y los consejos reflejados sirvan para debatir responsablemente sobre los problemas eticos de nuestro quehacer.

Dentro del arsenal terapeutico de la insuficiencia cardiaca, la resincronizacion cardiaca cada vez esta adquiriendo un papel mas importante como coadyuvante del tratamiento medico. Se ha demostrado ampliamente que en los pacientes con insuficiencia cardiaca avanzada y bloqueo de rama izquierda, la estimulacion biventricular produce una mejoria hemodinamica y clinica, asi como un remodelado inverso del ventriculo izquierdo. Algunos estudios sugieren tambien una disminucion de la mortalidad. Sin embargo, es una terapia costosa y compleja que no esta libre de complicaciones y con un porcentaje de pacientes que no mejoran. Por ello, para su correcta aplicacion es necesaria una colaboracion multidisciplinaria. El Grupo de Trabajo de Resincronizacion Cardiaca de la Sociedad Espanola de Cardiologia ha redactado el presente documento de consenso con especial interes por exponer las indicaciones de esta terapia, asi como la correcta seleccion de los dispositivos y su adecuada tecnica de implante y seguimiento.

La terapia de resincronizacion cardiaca ha demostrado un claro beneficio en pacientes con insuficiencia cardiaca avanzada, disfuncion sistolica del ventriculo izquierdo y un trastorno electrico en la activacion ventricular. Sin embargo, pese a la evidencia de su eficacia, la terapia de resincronizacion se incorpora de manera lenta y desigual a nuestro arsenal terapeutico. La tasa de implantes en Europa tiene una distribucion muy heterogenea. En algunos paises, como Italia o Belgica, se alcanzaron en el ano 2002 cifras superiores a los 30 implantes por millon de habitante y ano, mientras que en Suiza, Espana, Portugal, Suecia y Francia no se alcanzan los 10 implantes por millon y ano. El analisis por comunidades ofrece datos muy heterogeneos. Algunas comunidades, como Navarra o Canarias, estan muy por encima de la media nacional e incluso europea, con cifras superiores a los 30 implantes por millon. La mayoria de las comunidades grandes de nuestro pais implantaron entre 10 y 15 unidades por millon en el ano 2003. Afortunadamente, se ha producido un ligero incremento con el tiempo. En nuestro pais, la tasa de implantes ha aumentado de 8,7 durante 2002 a un esperanzador 12,54 en 2003. Sin embargo, en Europa, la tasa de implante crece mas rapidamente, pues ha pasado de 14,5 a 22 implantes por millon durante el ano 2003. Necesitamos que nuestro sistema sanitario destine mas recursos a esta tecnica si queremos que el beneficio de la terapia alcance de manera efectiva a la poblacion a la que va destinada.

It is known that myocardial ischaemia and infarction leads to severe metabolic and electrophysiological changes that induce silent or symptomatic life-threatening arrhythmias. Sudden cardiac death is most often attributed to this pathophysiology, but many patients survive the early stage of an acute coronary syndrome (ACS) reaching a medical facility where the management of ischaemia and infarction must include continuous electrocardiographic (ECG) and hemodynamic monitoring, and a prompt therapeutic response to incident sustained arrhythmias. During the last decade, the hospital locations in which arrhythmias are most relevant have changed to include the cardiac catheterization laboratory, since the preferred management of early acute ACS is generally interventional in nature. However, a large proportion of patients are still managed medically. Both atrial and ventricular arrhythmias may occur in the setting of ACS and sustained ventricular tachyarrhythmias (VAs) may be associated with circulatory collapse and require immediate treatment. Atrial fibrillation (AF) may also warrant urgent treatment when a fast ventricular rate is associated with hemodynamic deterioration. The management of other arrhythmias is also based largely on symptoms rather than to avert progression to more serious arrhythmias. Prophylactic antiarrhythmic management strategies have largely been discouraged. Although the mainstay of antiarrhythmic therapy used to rely on antiarrhythmic drugs (AADs), particularly sodium channel blockers and amiodarone, their use has now declined, since clinical evidence to support such treatment has never been convincing. Therapy for acute coronary syndrome and arrhythmia management are now based increasingly on invasive approaches. The changes in the clinical approach to arrhythmia management in ACS have been so substantial that the European Heart Rhythm Association, the Acute Cardiovascular Care Association and the European Association of Percutaneous Cardiovascular Interventions established a task force to define the current position. Generation of the ventricular action potential by voltage and substrate dependent ion currents is the basis for …

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including the assessment of the risk/benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified …

The Spanish Society of Cardiology (SEC) has produced an Ethical Framework Document. This document is divided into two distinct parts that deal, respectively, with the responsibilities of the SEC as an organization and the responsibilities of its professional members. The SEC makes recommendations on how its members should carry out their daily clinical practice, provides a professional perspective on public commitments as a scientific association, and aims to ensure that any views, recommendations, and advice expressed provide the basis for an informed debate on ethical problems in our field of work.