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Introduction and objectives Intrapatient blood level variability (IPV) of calcineurin inhibitors has been associated with poor outcomes in solid-organ transplant, but data for heart transplant are scarce. Our purpose was to ascertain the clinical impact of IPV in a multi-institutional cohort of heart transplant recipients. Methods We retrospectively studied patients aged ≥ 18 years, with a first heart transplant performed between 2000 and 2014 and surviving ≥ 1 year. IPV was assessed by the coefficient of variation of trough levels from posttransplant months 4 to 12. A composite of rejection or mortality/graft loss or rejection and all-cause mortality/graft loss between years 1 to 5 posttransplant were analyzed by Cox regression analysis. Results The study group consisted of 1581 recipients (median age, 56 years; women, 21%). Cyclosporine immediate-release tacrolimus and prolonged-release tacrolimus were used in 790, 527 and 264 patients, respectively. On multivariable analysis, coefficient of variation > 27.8% showed a nonsignificant trend to association with 5-year rejection-free survival (HR, 1.298; 95%CI, 0.993-1.695; P = .056) and with 5-year mortality (HR, 1.387; 95%CI, 0.979-1.963; P = .065). Association with rejection became significant on analysis of only those patients without rejection episodes during the first year posttransplant (HR, 1.609; 95%CI, 1.129-2.295; P = .011). The tacrolimus-based formulation had less IPV than cyclosporine and better results with less influence of IPV. Conclusions IPV of calcineurin inhibitors is only marginally associated with mid-term outcomes after heart transplant, particularly with the tacrolimus-based immunosuppression, although it could play a role in the most stable recipients. Introducción y objetivos El objetivo es estudiar el impacto clínico de la variabilidad intrapaciente (VIP) de la concentración sanguínea de los anticalcineurínicos en el trasplante cardiaco, pues la información actual es escasa. Métodos Se analizó retrospectivamente a pacientes de edad ≥ 18 años con un trasplante cardiaco realizado entre 2000 y 2014 y con supervivencia ≥ 1 año. La VIP se valoró mediante el coeficiente de variación de concentraciones entre los meses 4 a 12 postrasplante. El compuesto de rechazo, mortalidad o pérdida del injerto y la mortalidad o pérdida del injerto 1-5 años tras el trasplante se analizaron mediante regresión de Cox. Resultados Se estudió a 1.581 receptores (edad, 56 años; mujeres, 21%), tratados con ciclosporina (790 pacientes) o tacrolimus (791 pacientes). En el análisis multivariable, un coeficiente de variación > 27,8% tendió a asociarse con el compuesto de rechazo/mortalidad (HR = 1,298; IC95%, 0,993-1,695; p = 0,056) y con la mortalidad (HR = 1,387; IC95%, 0,979-1,963; p = 0,065) a los 5 años. La asociación con el rechazo fue significativa al analizar a la población sin rechazos durante el primer año del trasplante (HR = 1,609; IC95%, 1,129-2,295; p = 0,011). El tacrolimus tuvo menos VIP que la ciclosporina, junto con unos mejores resultados por la menor influencia de la VIP. Conclusiones La VIP de los anticalcineurínicos, especialmente con la inmunosupresión basada en el tacrolimus, se asocia solo marginalmente con los resultados a medio plazo del trasplante cardiaco, aunque puede tener influencia en los pacientes más estables durante el primer año tras el trasplante. Astellas Pharma (Spain) Heart Failure Association of the Spanish Society of Cardiology No data JCR 2021 0.385 SJR (2021) Q3, 1499/2489 Medicine (miscellaneous) No data IDR 2021 UEM

Resumen Introduccion y objetivos Se presentan las caracteristicas clinicas y los resultados de los trasplantes cardiacos realizados en Espana con la actualizacion correspondiente a 2019. Metodos Se describen las caracteristicas clinicas y los resultados de los trasplantes cardiacos realizados en 2019, asi como las tendencias de estos en el periodo 2010-2018. Resultados En 2019 se realizaron 300 trasplantes (8.794 desde 1984; 2.745 entre 2010 y 2019). Respecto a anos previos, los cambios mas llamativos son el descenso hasta el 38% de los trasplantes realizados en codigo urgente, y la consolidacion en el cambio de asistencia circulatoria pretrasplante, con la practica desaparicion del balon de contrapulsacion (0,7%), la estabilizacion del uso del oxigenador extracorporeo de membrana (9,6%) y el aumento de los dispositivos de asistencia ventricular (29%). La supervivencia en el trienio 2016-2018 es similar a la del trienio 2013-2015 (p = 0,34), y ambas mejores que la del trienio 2010-2012 (p = 0,002 y p = 0,01 respectivamente). Conclusiones Se mantienen estables tanto la actividad del trasplante cardiaco en Espana como los resultados en supervivencia en los ultimos 2 trienios. Hay una tendencia a realizar menos trasplantes urgentes, la mayoria con dispositivos de asistencia ventricular.

Truncating TTN variants (TTNtv) are the main cause of dilated cardiomyopathy (DCM). The dynamic nature of this entity has previously been described. Based on own empirical observations and previous evidences, this study assessed repolarisation patterns and the possible association with morphological and functional status of TTNtv-DCM patients.Electrocardiograms (ECGs) of index patients with TTNtv-DCM and their relatives were included and matched in time with an echocardiogram. All individuals were classified into five phenotype groups: 1) Reduced left ventricular ejection fraction (LVEF50%); 2) Recovered LVEF: at least 10% increase and LVEF30% after optimal medical treatment; 3) Borderline phenotype (mildly enlarged ventricle and/or hyper-trabeculation); 4) Genotype positive, phenotype negative; and 5) Non-carriers. All electrocardiograms were evaluated by two blinded observers in qualitative and quantitative terms [T index (mm)=Σ T-wave amplitude (V5, V6, II, aVF)] and these data were compared with demographic and clinical information. The Δ T-index was calculated in those individuals with more than one electrocardiogram.Seventy-eight (78) electrocardiograms were included (46% female, mean age 50 years). T-index and prevalence of an abnormal T-wave had significantly different results among the groups (p0.0001). Age and haemodynamic factors were shown to be ECG-modifiers, especially in phenotype-negative patients. T-index enabled individuals with reduced LVEF (2.5) to be identified and to differentiate patients with favourable and unfavourable responses to treatment (Δ T index3.5 and ≤2, respectively).Repolarisation changes enabled characterisation of the spectrum of TTNtv-DCM. The T-index identified potential carriers and patients with the worst profiles of the spectrum of the disease.

Introducción y objetivos Se presentan las características clínicas y los resultados de los trasplantes cardiacos realizados en España con la actualización correspondiente a 2019. Métodos Se describen las características clínicas y los resultados de los trasplantes cardiacos realizados en 2019, así como las tendencias de estos en el periodo 2010-2018. Resultados En 2019 se realizaron 300 trasplantes (8.794 desde 1984; 2.745 entre 2010 y 2019). Respecto a años previos, los cambios más llamativos son el descenso hasta el 38% de los trasplantes realizados en código urgente, y la consolidación en el cambio de asistencia circulatoria pretrasplante, con la práctica desaparición del balón de contrapulsación (0, 7%), la estabilización del uso del oxigenador extracorpóreo de membrana (9, 6%) y el aumento de los dispositivos de asistencia ventricular (29%). La supervivencia en el trienio 2016-2018 es similar a la del trienio 2013-2015 (p = 0, 34), y ambas mejores que la del trienio 2010-2012 (p = 0, 002 y p = 0, 01 respectivamente). Conclusiones Se mantienen estables tanto la actividad del trasplante cardiaco en España como los resultados en supervivencia en los últimos 2 trienios. Hay una tendencia a realizar menos trasplantes urgentes, la mayoría con dispositivos de asistencia ventricular. Introduction and objectives: The present report describes the clinical characteristics and outcomes of heart transplants in Spain and updates the data to 2019. Methods: We describe the clinical characteristics and outcomes of heart transplants performed in Spain in 2019, as well as trends in this procedure from 2010 to 2018. Results: In 2019, 300 transplants were performed (8794 since 1984; 2745 between 2010 and 2019). Compared with previous years, the most notable findings were the decreasing rate of urgent transplants (38%), and the consolidation of the type of circulatory support prior to transplant, with an almost complete disappearance of counterpulsation balloon (0.7%), stabilization in the use of extracorporeal membrane oxygenation (9.6%), and an increase in the use of ventricular assist devices (29.0%). Survival from 2016 to 2018 was similar to that from 2013 to 2015 (P = .34). Survival in both these periods was better than that from 2010 to 2012 (P = .002 and P = .01, respectively). Conclusions: Heart transplant activity has remained stable during the last few years, as have outcomes (in terms of survival). There has been a trend to a lower rate of urgent transplants and to a higher use of ventricular assist devices prior to transplant.

Resumen Introduccion y objetivos La insuficiencia cardiaca (IC) es un problema creciente de salud y una carga importante para la sociedad. Pese a ello, con frecuencia se minusvalora globalmente la gravedad del pronostico. Este estudio estima el pronostico al ano en pacientes con IC aguda y cronica en Espana y resto de Europa. Metodos Un total de 2.829 pacientes con IC (589 IC aguda y 2.240 IC cronica) seleccionados en 27 centros hospitalarios en Espana, atendidos por cardiologos y que participan en el registro ESC-EORP-HFA Heart Failure Long-Term, con 211 centros y 12.440 pacientes en total, se siguieron un ano para monitorizar la mortalidad y el ingreso hospitalario. Resultados La mortalidad al ano en IC aguda fue del 29,3% en Espana (IC95%, 25,6-33,2) y 27,7% en el resto de Europa (p = 0,4303). En IC cronica, las cifras correspondientes fueron 6,4% (IC95%, 5,4-7,5) y 9,5% (p Conclusiones Se confirma la gravedad de la IC, en particular cuando ya necesita ingreso, incluso en centros con buen seguimiento de guias clinicas. En pacientes ingresados por IC en Espana casi un tercio fallecera en el primer ano tras ese ingreso indice (incluyendo el 5,9% que fallece durante el mismo) y casi la mitad fallecera o necesitara reingresar por IC. La comparacion favorable con Europa en hospitalizaciones y mortalidad en IC cronica se debe interpretar con cautela por insuficiente ajuste por potenciales variables de confusion.

Introduction and objectives In patients with heart failure and reduced ejection fraction (HFrEF), several therapies have been proven to reduce mortality in clinical trials. However, there are few data on the effect of the use of evidence-based therapies on causes of death in clinical practice. Methods This study included 2351 outpatients with HFrEF ( Results Patients in REDINSCOR I more frequently received beta-blockers (85% vs 71%; P Conclusions In ambulatory patients with HFrEF, implementation of evidence-based therapies was associated with a lower risk of death, mainly due to a significant reduction in sudden cardiac death.

Introduction and objectives In patients with heart failure and reduced ejection fraction (HFrEF), several therapies have been proven to reduce mortality in clinical trials. However, there are few data on the effect of the use of evidence-based therapies on causes of death in clinical practice. Methods This study included 2351 outpatients with HFrEF (< 40%) from 2 multicenter prospective registries: MUSIC (n=641, period: 2003-2004) and REDINSCOR I (n=1710, period: 2007-2011). Variables were recorded at inclusion and all patients were followed-up for 4 years. Causes of death were validated by an independent committee. Results Patients in REDINSCOR I more frequently received beta-blockers (85% vs 71%; P

Resumen Introduccion y objetivos La hiperpotasemia es una preocupacion creciente en el tratamiento de los pacientes con insuficiencia cardiaca y fraccion de eyeccion reducida, pues limita el uso de farmacos eficaces. Este trabajo ofrece estimaciones de la magnitud de este problema en la practica clinica habitual en Espana, los cambios en las concentraciones de potasio en el seguimiento y los factores asociados. Metodos Pacientes con insuficiencia cardiaca aguda (n = 881) y cronica (n = 3.587) seleccionados en 28 hospitales espanoles del registro europeo de insuficiencia cardiaca de la European Society of Cardiology y seguidos 1 ano para diferentes desenlaces, incluidos cambios en las cifras de potasio y su impacto en el tratamiento. Resultados La hiperpotasemia (K+ > 5,4 mEq/l) esta presente en el 4,3% (IC95%, 3,7-5,0%) y el 8,2% (6,5-10,2%) de los pacientes con insuficiencia cardiaca cronica y aguda; causa el 28,9% de todos los casos en que se contraindica el uso de antagonistas del receptor de mineralocorticoides y el 10,8% de los que no alcanzan la dosis objetivo. Del total de 2.693 pacientes ambulatorios con fraccion de eyeccion reducida, 291 (10,8%) no tenian registrada medicion de potasio. Durante el seguimiento, 179 de 1.431 (12,5%, IC95%, 10,8-14,3%) aumentaron su concentracion de potasio, aumento relacionado directamente con la edad, la diabetes mellitus y los antecedentes de ictus e inversamente con los antecedentes de hiperpotasemia. Conclusiones Este trabajo destaca el problema de la hiperpotasemia en pacientes con insuficiencia cardiaca de la practica clinica habitual y la necesidad de continuar y mejorar la vigilancia de este factor en estos pacientes por su interferencia en el tratamiento optimo.

Introducción y objetivos El objetivo es estudiar el impacto clínico de la variabilidad intrapaciente (VIP) de la concentración sanguínea de los anticalcineurínicos en el trasplante cardiaco, pues la información actual es escasa. Métodos Se analizó retrospectivamente a pacientes de edad ≥ 18 años con un trasplante cardiaco realizado entre 2000 y 2014 y con supervivencia ≥ 1 año. La VIP se valoró mediante el coeficiente de variación de concentraciones entre los meses 4 a 12 postrasplante. El compuesto de rechazo, mortalidad o pérdida del injerto y la mortalidad o pérdida del injerto 1-5 años tras el trasplante se analizaron mediante regresión de Cox. Resultados Se estudió a 1.581 receptores (edad, 56 años; mujeres, 21%), tratados con ciclosporina (790 pacientes) o tacrolimus (791 pacientes). En el análisis multivariable, un coeficiente de variación > 27,8% tendió a asociarse con el compuesto de rechazo/mortalidad (HR = 1,298; IC95%, 0,993-1,695; p = 0,056) y con la mortalidad (HR = 1,387; IC95%, 0,979-1,963; p = 0,065) a los 5 años. La asociación con el rechazo fue significativa al analizar a la población sin rechazos durante el primer año del trasplante (HR = 1,609; IC95%, 1,129-2,295; p = 0,011). El tacrolimus tuvo menos VIP que la ciclosporina, junto con unos mejores resultados por la menor influencia de la VIP. Conclusiones La VIP de los anticalcineurínicos, especialmente con la inmunosupresión basada en el tacrolimus, se asocia solo marginalmente con los resultados a medio plazo del trasplante cardiaco, aunque puede tener influencia en los pacientes más estables durante el primer año tras el trasplante. Introduction and objectives Intrapatient blood level variability (IPV) of calcineurin inhibitors has been associated with poor outcomes in solid-organ transplant, but data for heart transplant are scarce. Our purpose was to ascertain the clinical impact of IPV in a multi-institutional cohort of heart transplant recipients. Methods We retrospectively studied patients aged ≥ 18 years, with a first heart transplant performed between 2000 and 2014 and surviving ≥ 1 year. IPV was assessed by the coefficient of variation of trough levels from posttransplant months 4 to 12. A composite of rejection or mortality/graft loss or rejection and all-cause mortality/graft loss between years 1 to 5 posttransplant were analyzed by Cox regression analysis. Results The study group consisted of 1581 recipients (median age, 56 years; women, 21%). Cyclosporine immediate-release tacrolimus and prolonged-release tacrolimus were used in 790, 527 and 264 patients, respectively. On multivariable analysis, coefficient of variation > 27.8% showed a nonsignificant trend to association with 5-year rejection-free survival (HR, 1.298; 95% C I, 0.993-1.695; P = . 056) and with 5-year mortality (HR, 1.387; 95%CI, 0.979-1.963; P = . 065). Association with rejection became significant on analysis of only those patients without rejection episodes during the first year posttransplant (HR, 1.609; 95%CI, 1.129-2.295; P = . 011). The tacrolimus-based formulation had less IPV than cyclosporine and better results with less influence of IPV. Conclusions IPV of calcineurin inhibitors is only marginally associated with mid-term outcomes after heart transplant, particularly with the tacrolimus-based immunosuppression, although it could play a role in the most stable recipients. Becas de Astellas Pharma (España) y la Asociación de Insuficiencia Cardíaca de la Sociedad Española de Cardiología. 6.975 JCR (2021) Q1, 33/143 Cardiac & Cardiovascular Systems 0.407 SJR (2021) Q3, 205/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEM

Spain is a world leader in donation and transplantation. This model has been exported to other countries with favorable results. The objective of this study was to compare the actual donation intention rate with the effective donation figures, and analyze the main reasons why families decline organ donation. To estimate the current donation intention, we conducted 1065 surveys in March 2019, and to calculate effective donation figures in our hospital, we analyzed 1158 interviews conducted with relatives of potential organ donors between 1996 and 2018. Regarding the surveys to estimate donation intention, the mean (standard deviation) age was 51.6 (17-91) years. A total of 58% were women, 26% were health care professionals, and 5.1% were transplant recipients; 89.4% would donate their organs. In the multivariate analysis, having expressed the desire to donate to their family was independently related to the intention to donate (odds ratio, 3.4; 95% confidence interval, 2.2-5.2; P.001). Regarding the interviews with relatives of potential donors, 79.4% were finally effective donors. The belief that the possible donor would have rejected the organ donation stands out among the causes of decline. However, only one-half of those surveyed expressed the wish to be a donor to their relatives. In the temporal evolution, a greater acceptance of donation is observed in the first period with a reduction over the last years (P.001). It is our responsibility to improve transplantation rates because our model has shown to save lives and it is a role model for other nations, promoting information activities that encourage greater discussion of organ donation within families.

Background and objective Several trials have evaluated the effect of disease management programs in heart failure (HF) with diverse results. The aim of this study was to develop a simple nurse-led clinic intervention program for patients with HF and assess whether this intervention positively affects the prognosis of patients, their care costs and perceived quality of life (QoL). Methods Between 2011 and 2013, 127 patients with reduced ejection fraction were prospectively randomly allocated (1:2) to standard care or intervention program. Primary composite endpoint was all-cause mortality and hospital readmissions. Secondary endpoints were all-cause mortality, all-cause hospital readmissions, readmissions for HF, time to first readmission and QoL improvements assessed by “Minnesota Living with Heart Failure Questionnaire” (MLHFQ). An intention-to-treat analysis was performed. Results After a median follow-up of 2-years, no differences were found in the primary composite endpoint. Likewise, there were no differences between groups in the predefined secondary endpoints of mortality and readmissions from any cause. However, in the intervention group, readmissions for HF were significantly reduced (35% vs. 18%; p = 0.04) and QoL significantly improved (MLHFQ ± SD: 2.29 ± 14 vs. 10.9 ± 14.75; p = 0.04). Conclusions In patients with HF, the use of a nurse-led intervention program significantly improves perceived QoL and reduce HF hospital readmissions.

Introducción y objetivos: Analizar el impacto del lactato sérico en receptores de trasplante cardiaco urgente en asistencia circulatoria mecánica de corta duración preoperatoria. Métodos: Se realizó un subanálisis de un registro multicéntrico español basado en pacientes incluidos en «urgencia grado 0» para trasplante cardiaco con asistencia circulatoria mecánica preoperatoria de corta duración entre 2010 y 2015. Se seleccionó a los receptores de trasplante con cifras preoperatorias de lactato conocidas. El desenlace principal fue la supervivencia 1 año tras el trasplante. Resultados: Se estudió a 177 receptores de trasplante cardiaco urgente, de los que 90 necesitaron asistencia preoperatoria con oxigenador extracorpóreo de membrana venoarterial, 51 con asistencia ventricular izquierda y 36 con asistencia biventricular. De ellos, 44 (25%) presentaban hiperlactatemia antes del trasplante (≥ 2 mmol/l). En el análisis multivariable, la cifra de lactato sérico resultó predictora independiente de mortalidad tras el trasplante (cada 0,1 mmol/l, HR ajustada = 1,02; IC95%, 1,01-1,03; p = 0,007). La supervivencia estimada al año del trasplante cardiaco fue del 53,1% (IC95%, 45,3-60,9) en los pacientes con hiperlactactemia preoperatoria y el 75,6% (IC95%, 71,8-79,4) en los pacientes sin hiperlactatemia (HR ajustada = 1,94; IC95%, 1,04-3,63; p = 0,039). El impacto pronóstico de la hiperlactatemia fue significativo en los pacientes asistidos con oxigenador extracorpóreo de membrana venoarterial, pero no en aquellos con dispositivos de asistencia ventricular. Conclusiones: Los valores preoperatorios de ácido láctico son un potente factor pronóstico independiente en receptores de trasplante cardiaco urgente. Introduction and objectives: To study the prognostic value of serum lactate in patients under temporary preoperative mechanical circulatory support who underwent urgent heart transplant. Methods: We conducted a subanalysis of a Spanish multicenter registry recording data on patients under temporary mechanical circulatory support listed for highly urgent heart transplant from 2010 to 2015. Participants selected for the present study were those who received a transplant and who had known preoperative serum lactate levels. The main study outcome was 1-year survival after transplant. Results: A total of 177 heart transplant recipients were studied; preoperatively, 90 were supported on venoarterial extracorporeal membrane oxygenation, 51 on temporary left ventricular assist devices, and 36 on temporary biventricular assist devices. Preoperative hyperlactatemia (≥ 2 mmol/L) was present in 44 (25%) patients. On multivariable analysis, pretransplant serum lactate was identified as an independent predictor of 1-year posttransplant survival (adjusted HR per 0.1 mmol/L, 1.02; 95%CI, 1.01-1.03; P = .007). One-year posttransplant survival was 53.1% (95%CI, 45.3-60.9) in patients with preoperative hyperlactatemia and 75.6% (95%CI, 71.8-79.4) in those without preoperative hyperlactatemia (adjusted HR, 1.94; 95%CI, 1.04-3.63; P = .039). Preoperative hyperlactatemia correlated with adverse outcomes in patients supported with extracorporeal membrane oxygenation, but not in patients supported on ventricular assist devices. Conclusions: Preoperative serum lactate is a strong independent predictor of worse outcomes in patients undergoing urgent heart transplant on short-term mechanical circulatory support. Sin financiación 4.642 JCR (2019) Q1, 30/138 Cardiac & Cardiovascular Systems 0.473 SJR (2019) Q3, 196/362 Cardiology and Cardiovascular Medicine No data IDR 2019 UEM

Model for End-Stage Liver Disease scoring system excluding international normalized ratio (MELD-XI) has been related with worse outcomes after heart transplantation (HT). However, according to standards in prognostic models research, before implementing a risk score for daily clinical decision-making, its performance and impact on clinical practice/outcomes should be evaluated. The aim of this study was to evaluate the ability of the MELD-XI score to predict outcomes in daily clinical practice.We retrospectively reviewed 190 consecutive adults undergoing HT between 2005-2015. Patients were stratified into low (MELD-XI 12) and high (MELD-XI ≥12) risk cohorts. Mortality rates at 30 days and 1 year were compared between MELD-XI groups. MELD-XI ability to predict 1-year mortality was assessed by the area under the receiver operating curve (AUC) and compared to that of bilirubin, creatinine, and pulmonary vascular resistance (PVR).Mortality rates at 30 days and 1 year were similar between groups (8% vs 13%; P = .28 and 21% vs 29%; P = .21, respectively). MELD-XI ability to predict 1-year mortality was poor and similar to that of bilirubin, creatinine, and PVR (0.51 vs 0.47 vs 0.50 vs 0.50, respectively).MELD-XI score utility in HT clinical decision-making is scarce since its discrimination ability is poor and similar to other simple prognostic variables.

Heart failure (HF) is one of the main causes of morbidity, mortality, and high healthcare costs. Dapagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, reduced cardiovascular mortality and hospitalization for HF compared to placebo in patients with chronic HF, and reduced ejection fraction (EF) in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) study. Our aim was to estimate the number of patients with DAPA-HF characteristics in Spain. Our literature review identified epidemiological studies whose objective was to quantify the prevalence of HF and its comorbidities in Spain. We estimated the prevalence of HF with reduced EF, of New York Heart Association (NYHA) functional class II&ndash, IV, and with a glomerular filtration rate (GFR) &ge, 30 mL/min/1.73 m&sup2, In this population, we analysed the prevalence of diabetes using data from the REDINSCOR (Spanish Network for Heart Failure) registry. Our estimations indicate there are 594,684 patients &ge, 45 years old with HF in Spain (2.6% of this population age group), of which 52.4%, 84.0%, and 93.9% have reduced EF, are NYHA II&ndash, IV, and have a GFR &ge, respectively. By our calculations, approximately 245,789 Spanish patients would meet the DAPA-HF patient profile, and therefore could benefit from the protective cardiovascular effects of dapagliflozin.

Introduction and objectives The present report describes the clinical characteristics and outcomes of heart transplants in Spain and updates the data to 2019. Methods We describe the clinical characteristics and outcomes of heart transplants performed in Spain in 2019, as well as trends in this procedure from 2010 to 2018. Results In 2019, 300 transplants were performed (8794 since 1984; 2745 between 2010 and 2019). Compared with previous years, the most notable findings were the decreasing rate of urgent transplants (38%), and the consolidation of the type of circulatory support prior to transplant, with an almost complete disappearance of counterpulsation balloon (0.7%), stabilization in the use of extracorporeal membrane oxygenation (9.6%), and an increase in the use of ventricular assist devices (29.0%). Survival from 2016 to 2018 was similar to that from 2013 to 2015 (P=.34). Survival in both these periods was better than that from 2010 to 2012 (P=.002 and P=.01, respectively). Conclusions Heart transplant activity has remained stable during the last few years, as have outcomes (in terms of survival). There has been a trend to a lower rate of urgent transplants and to a higher use of ventricular assist devices prior to transplant.

Introducción y objetivos La edad de receptores y donantes cardíacos se está incrementando progresivamente. Es probable que no todas las combinaciones tengan el mismo impacto en la mortalidad. El objetivo de este trabajo es comparar la supervivencia de los pacientes trasplantados según la combinación de edades de donante y receptor. Métodos Análisis retrospectivo del Registro Español de Trasplante Cardiaco de los trasplantes realizados entre el 1 de enero de 1993 y el 31 de diciembre de 2017. Se excluyeron los pediátricos, los retrasplantes y los trasplantes combinados (se incluyeron 6.505 trasplantes). Se consideraron 4 grupos: a) donante menor de 50 años para receptor menor de 65 años; b) donante menor de 50 años para receptor de edad ≥ 65 años; c) donante de edad ≥ 50 años para receptor de 65 o más, y d) donante de edad ≥ 50 años para receptor menor de 65. Resultados El grupo más frecuente fue el de donante joven para receptor joven (73%). Hubo diferencias en la mediana de supervivencia entre los grupos (p

Background – The development of an optimized assessment of operability in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is crucial. This study aimed to evaluate the feasibility of a noninvasive operability assessment of CTEPH based on multidetector computed tomographic angiography (MCTA). Methods –176 patients with CTEPH were evaluated from January 2016 to April 2018. Throughout the first phase, operability was assessed with MCTA and pulmonary angiography (PA): initial surgical decision was made based on MCTA with further analysis of PA to evaluate which cases initial decision was not modified by PA. During the second phase, PA was limited to patients judged inoperable based on MCTA or in those whose assessment was not possible. Results – Patients deemed operable (50%) based on MCTAalong the first phase, had been adequately classified, as PA did not modify the initial decision in all but one patient. Comparable results were obtained throughout the implementation phase, in which decision of operability was based on MCTA in 49% of the patients. Regarding operated patients, decision of operability had been based solely on MCTA in 94% of those with level I disease regarding intraoperative CTEPH classification; in 75% with level II disease and 54% with level III. This approach enabled shorter time periods to complete surgical assessment and the avoidance of PA-related morbidity. Baseline parameters, postoperative measures and survival rates at 1 year after surgerywere comparable in both phases. Conclusions - Noninvasive operability assessment is feasible in a subset of CTEPH patients and optimizessurgical candidacy evaluation.

[Abstract] Introduction and objectives. The age of heart transplant recipients and donors is progressively increasing. It is likely that not all donor-recipient age combinations have the same impact on mortality. The objective of this work was to compare survival in transplant recipients according to donor-recipient age combinations. Methods. We performed a retrospective analysis of transplants performed between 1 January 1993 and 31 December 2017 in the Spanish Heart Transplant Registry. Pediatric transplants, retransplants and combined transplants were excluded (6505 transplants included). Four groups were considered: a) donor < 50 years for recipient < 65 years; b) donor < 50 years for recipient ≥ 65 years; c) donor ≥ 50 years for recipient ≥ 65 years, and d) donor ≥ 50 years for recipient < 65 years. Results. The most frequent group was young donor for young recipient (73%). There were differences in the median survival between the groups (P < .001): a) younger-younger: 12.1 years, 95%CI, 11.5-12.6; b) younger-older: 9.1 years, 95%CI, 8.0-10.5; c) older-older: 7.5 years, 95%CI, 2.8-11.0; d) older-younger: 10.5 years, 95%CI, 9.6-12.1. On multivariate analysis, independent predictors of mortality were the age of the donor and the recipient (0.008 and 0.001, respectively). The worst combinations were older-older vs younger-younger (HR, 1.57; 95%CI, 1.22-2.01; P < .001) and younger-older vs younger-younger (HR, 1.33; 95%CI, 1.12-1.58; P = .001). Conclusions. Age (of the donor and recipient) is a relevant prognostic factor in heart transplant. The donor-recipient age combination has prognostic implications that should be identified when accepting an organ for transplant. [Resumen] Introducción y objetivos. La edad de receptores y donantes cardiacos se está incrementando progresivamente. Es probable que no todas las combinaciones tengan el mismo impacto en la mortalidad. El objetivo de este trabajo es comparar la supervivencia de los pacientes trasplantados según la combinación de edades de donante y receptor. Métodos. Análisis retrospectivo del Registro Español de Trasplante Cardiaco de los trasplantes realizados entre el 1 de enero de 1993 y el 31 de diciembre de 2017. Se excluyeron los pediátricos, los retrasplantes y los trasplantes combinados (se incluyeron 6.505 trasplantes). Se consideraron 4 grupos: a) donante menor de 50 años para receptor menor de 65 años; b) donante menor de 50 años para receptor de edad ≥ 65 años; c) donante de edad ≥ 50 años para receptor de 65 o más, y d) donante de edad ≥ 50 años para receptor menor de 65. Resultados. El grupo más frecuente fue el de donante joven para receptor joven (73%). Hubo diferencias en la mediana de supervivencia entre los grupos (p < 0,001): a) joven-joven: 12,1 años (IC95%, 11,5-12,6); b) joven-mayor: 9,1 años (IC95%, 8,0-10,5); c) mayor-mayor: 7,5 años (IC95%, 2,8-11,0), y d) mayor-joven: 10,5 años (IC95%, 9,6-12,1). En el análisis multivariante, las edades del donante y del receptor resultaron predictoras independientes de la mortalidad (0,008 y 0,001 respectivamente). Las peores combinaciones fueron mayor-mayor frente a joven-joven (HR = 1,57; IC95%, 1,22-2,01; p < 0,001) y joven-mayor frente a joven-joven (HR = 1,33; IC95%, 1,12-1,58; p = 0,001). Conclusiones. La edad (del donante y del receptor) es un factor pronóstico relevante en el trasplante cardiaco. La combinación de edades de donante y receptor posee implicaciones pronósticas que se debe conocer a la hora de aceptar un órgano para trasplante.

INTRODUCTION AND OBJECTIVES The present report updates the characteristics and results of heart transplantation in Spain, mainly focused in the 2008-2017 period. METHODS We describe the recipient and donor characteristics, surgical procedures, and outcomes of heart transplants performed in 2017. The 2017 data were compared with those obtained from 2008 to 2016. RESULTS A total of 304 cardiac transplants were performed in 2017. Between 1984 and 2017, 8173 procedures were performed, 2689 of them after 2008. Significant temporal trends were observed in recipient characteristics (lower pulmonary vascular resistance, lower use of mechanical ventilation, and a higher percentage of diabetic patients and those with previous cardiac surgery), donor characteristics (older donor age and a higher percentage of female donors and those with a prior cardiac arrest) and procedures (lower ischemia time). In 2017, 27% of patients were transplanted after undergoing mechanical ventricular assistance (P

Resumen Introduccion y objetivos El presente articulo presenta las caracteristicas y resultados del trasplante cardiaco en Espana, desde que empezo su actividad en mayo de 1984. Metodos Se realiza un analisis descriptivo de las caracteristicas de los receptores, donantes, procedimiento quirurgico y resultados de los trasplantes cardiacos realizados en Espana hasta el 31 de diciembre de 2016. Resultados Durante 2016 se han realizado 281 procedimientos, con lo que la serie historica consta de 7.869 trasplantes. Las caracteristicas generales del procedimiento son similares a las observadas en los ultimos anos y destacan el alto porcentaje de procedimientos realizados en codigo urgente y, sobre todo, la extension del uso de dispositivos de asistencia circulatoria, particularmente de asistencia ventricular de flujo continuo (el 19,1% del total de trasplantes). La supervivencia ha aumentado significativamente en la ultima decada con respecto a periodos anteriores. Conclusiones La actividad de trasplante cardiaco en Espana permanece estable en los ultimos anos, con alrededor de 250-300 procedimientos al ano. A pesar de la mayor complejidad del contexto clinico, se observa una mejoria de la supervivencia en los ultimos anos.

Resumen Introduccion y objetivos La hipertension arterial pulmonar (HAP) se caracteriza por aumento de resistencias vasculares pulmonares, disfuncion progresiva del ventriculo derecho y muerte. A pesar de los avances, sigue asociada a alta morbimortalidad. El objetivo del estudio es describir el tratamiento de esta enfermedad y determinar factores pronosticos de pacientes con HAP tratados en un centro de referencia nacional a lo largo de 30 anos. Metodos Se estudio a 379 pacientes consecutivos diagnosticados de HAP (enero de 1984-diciembre de 2014). Se los distribuyo en 3 intervalos de tiempo: previo a 2004, 2004-2009 y 2010-2014, y se analizaron los factores pronosticos de deterioro clinico. Resultados La mediana de edad de los pacientes es 44 anos (el 68,6% eran mujeres) y estaban en clase funcional III - IV el 72%. Se observo un incremento en etiologias mas complejas: enfermedad venooclusiva e hipertension portopulmonar en el ultimo periodo. La terapia combinada de inicio aumento (el 5% previo a 2004 frente al 27% posterior a 2010; p Conclusiones La HAP es una enfermedad heterogenea y compleja. La mediana de supervivencia libre de muerte o trasplante en nuestra serie es 9 anos. La estructura de una unidad multidisciplinaria de HAP debe adaptarse con rapidez a los cambios que se producen en el tiempo incorporando nuevas tecnicas diagnosticas y terapeuticas.

INTRODUCTION AND OBJECTIVES Pulmonary arterial hypertension (PAH) is characterized by increased pulmonary vascular resistance, right ventricular dysfunction and death. Despite scientific advances, is still associated with high morbidity and mortality. The aim is to describe the clinical approach and determine the prognostic factors of patients with PAH treated in a national reference center over 30 years. METHODS Three hundred and seventy nine consecutive patients with PAH (January 1984 to December 2014) were studied. Were divided into 3 periods of time: before 2004, 2004-2009 and 2010-2014. Prognostic factors (multivariate analysis) were analyzed for clinical deterioration. RESULTS Median age was 44 years (68.6% women), functional class III-IV: 72%. An increase was observed in more complex etiologies in the last period of time: Pulmonary venooclusive disease and portopulmonary hypertension. Upfront combination therapy significantly increased (5% before 2004 vs 27% after 2010; P

Background In Spain, listing for high-urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T-MCS). We sought to analyse the clinical outcomes of this strategy. Methods and results We conducted a case-by-case, retrospective review of clinical records of 291 adult patients listed for high-urgent heart transplantation under temporary devices from 2010 to 2015 in 16 Spanish institutions. Survival after listing and adverse clinical events were studied. At the time of listing, 169 (58%) patients were supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO), 70 (24%) on temporary left ventricular assist devices (T-LVAD) and 52 (18%) on temporary biventricular assist devices (T-BiVAD). Seven patients transitioned from VA-ECMO to temporary ventricular assist devices while on the waiting list. Mean time on T-MCS was 13.1 ± 12.6 days. Mean time from listing to transplantation was 7.6 ± 8.5 days. Overall, 230 (79%) patients were transplanted and 54 (18.6%) died during MCS. In-hospital postoperative mortality after transplantation was 33.3%, 11.9% and 26.2% for patients bridged on VA-ECMO, T-LVAD and T-BiVAD, respectively (P = 0.008). Overall survival from listing to hospital discharge was 54.4%, 78.6% and 55.8%, respectively (P = 0.002). T-LVAD support was independently associated with a lower risk of death over the first year after listing (hazard ratio 0.52, 95% confidence interval 0.30–0.92). Patients treated with VA-ECMO showed the highest incidence rate of adverse clinical events associated with T-MCS. Conclusion Temporary devices may be used to bridge critically ill candidates directly to heart transplantation in a setting of short waiting list times, as is the case of Spain. In our series, bridging with T-LVAD was associated with more favourable outcomes than bridging with T-BiVAD or VA-ECMO.

Resumen Introduccion y objetivos La guia de insuficiencia cardiaca de la Sociedad Europea de Cardiologia define un nuevo grupo de pacientes con fraccion de eyeccion del ventriculo izquierdo intermedia (40-49%) (ICFEi) cuyas caracteristicas y pronostico no estan bien definidos. Nuestro objetivo es analizar este grupo en pacientes hospitalizados por insuficiencia cardiaca (Registro REDINSCOR II ). Metodos Estudio observacional prospectivo de 1.420 pacientes clasificados segun la fraccion de eyeccion: deprimida (ICFEd), Resultados La distribucion de pacientes fue: 583 (41%) con ICFEd, 227 (16%) con ICFEi y 610 (43%) con ICFEc. El grupo con ICFEi se parece mas al de ICFEc en cuanto a edad, prevalencia de hipertension arterial y fibrilacion auricular, aunque comparte con la ICFEd el predominio de varones, la etiologia isquemica y el mayor uso de farmacos clase I para ICFEd. Las demas caracteristicas fueron intermedias. No se detectaron diferencias entre los 3 grupos en la mortalidad total, las causas de muerte y los reingresos por insufiencia cardiaca. Esta similitud en el pronostico se confirmo en el analisis ajustado por puntuacion de propension. Conclusiones El grupo de pacientes con ICFEi comparte caracteristicas con los de ICFEc e ICFEd, aunque esta mas proximo al de ICFEc. La mortalidad total, las causas de muerte o las rehospitalizaciones por insuficiencia cardiaca eran similares en los 3 grupos.

Background Medical therapy could improve the prognosis of real-life patients discharged after a heart failure (HF) hospitalization. Purpose We aimed to determine the impact of discharge HF treatment on mortality and readmissions in different left ventricular ejection fraction (LVEF) groups. Methods Multicentre prospective registry in 20 Spanish hospitals. Patients were enrolled after a HF hospitalization. Results A total of 1831 patients were included (583 [31.8%] HF with reduced ejection fraction [HFrEF]; 227 [12.4%] HF with midrange ejection fraction [HFmrEF]; 610 [33.3%] HF with preserved ejection fraction [HFpEF], and 411 [22.4%] with unknown LVEF. Angiotensin-converting enzyme (ACE) inhibitors/Angiotensin II receptor blockers (ARB) at discharge were independently associated with a reduction in: i) all-cause mortality: hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.41–0.74, P Events according to the number of drugs – HFrEF (n=583) 0 (n=14) 1 (n=98) 2 (n=160) 3 (n=294) P Death or heart failure readmissions 10 (71.4) 58 (59.2) 66 (41.3) 106 (36.1) Kaplan-Meier Curves for study outcomes Conclusions Discharge treatment with ACE inhibitor/ARB after a HF hospitalization is associated with a reduction in all-cause and refractory HF mortality, irrespectively of LVEF.

Introduction and objectives The present report updates the clinical characteristics and outcomes of heart transplant in Spain to 2018. Methods Prospective registry of all the heart transplants performed between 1984 and 2018 in Spain. Specifically, temporal trends in clinical characteristics and outcomes are described for the period from 2009 to 2017. Results In 2018, 321 transplants were performed (8494 since 1984; 2719 between 2009 and 2018). Compared with the previous year, the number of transplants performed in 2018 rose by 52% in recipients younger than 16 years and by 42% in those older than 60 years. In the last decade, significant temporal trends were observed in recipient characteristics (better pretransplant renal function, higher rates of diabetes, more urgent transplants, and greater use of pretrasplant circulatory support, particularly ventricular assist devices), donor characteristics (higher donor age, more female donors, and higher frequencies of cerebrovascular cause of death and predonation cardiac arrest and lower ischemia time). Survival significantly improved in the last decade, mainly due to lower mortality due to primary graft failure. Conclusions The number of heart transplants is increasing in Spain, with a progressive improvement in survival.

[EN] Introduction and objectives: To study the prognostic value of serum lactate in patients under temporary preoperative mechanical circulatory support who underwent urgent heart transplant. Methods: We conducted a subanalysis of a Spanish multicenter registry recording data on patients under temporary mechanical circulatory support listed for highly urgent heart transplant from 2010 to 2015. Participants selected for the present study were those who received a transplant and who had known preoperative serum lactate levels. The main study outcome was 1-year survival after transplant. Results: A total of 177 heart transplant recipients were studied; preoperatively, 90 were supported on venoarterial extracorporeal membrane oxygenation, 51 on temporary left ventricular assist devices, and 36 on temporary biventricular assist devices. Preoperative hyperlactatemia (≥ 2 mmol/L) was present in 44 (25%) patients. On multivariable analysis, pretransplant serum lactate was identified as an independent predictor of 1-year posttransplant survival (adjusted HR per 0.1 mmol/L, 1.02; 95%CI, 1.01-1.03; P = .007). One-year posttransplant survival was 53.1% (95%CI, 45.3-60.9) in patients with preoperative hyperlactatemia and 75.6% (95%CI, 71.8-79.4) in those without preoperative hyperlactatemia (adjusted HR, 1.94; 95%CI, 1.04-3.63; P = .039). Preoperative hyperlactatemia correlated with adverse outcomes in patients supported with extracorporeal membrane oxygenation, but not in patients supported on ventricular assist devices. Conclusions: Preoperative serum lactate is a strong independent predictor of worse outcomes in patients undergoing urgent heart transplant on short-term mechanical circulatory support., [ES] Introducción y objetivos: Analizar el impacto del lactato sérico en receptores de trasplante cardiaco urgente en asistencia circulatoria mecánica de corta duración preoperatoria. Métodos: Se realizó un subanálisis de un registro multicéntrico español basado en pacientes incluidos en «urgencia grado 0» para trasplante cardiaco con asistencia circulatoria mecánica preoperatoria de corta duración entre 2010 y 2015. Se seleccionó a los receptores de trasplante con cifras preoperatorias de lactato conocidas. El desenlace principal fue la supervivencia 1 año tras el trasplante. Resultados: Se estudió a 177 receptores de trasplante cardiaco urgente, de los que 90 necesitaron asistencia preoperatoria con oxigenador extracorpóreo de membrana venoarterial, 51 con asistencia ventricular izquierda y 36 con asistencia biventricular. De ellos, 44 (25%) presentaban hiperlactatemia antes del trasplante (≥ 2 mmol/l). En el análisis multivariable, la cifra de lactato sérico resultó predictora independiente de mortalidad tras el trasplante (cada 0,1 mmol/l, HR ajustada = 1,02; IC95%, 1,01-1,03; p = 0,007). La supervivencia estimada al año del trasplante cardiaco fue del 53,1% (IC95%, 45,3-60,9) en los pacientes con hiperlactactemia preoperatoria y el 75,6% (IC95%, 71,8-79,4) en los pacientes sin hiperlactatemia (HR ajustada = 1,94; IC95%, 1,04-3,63; p = 0,039). El impacto pronóstico de la hiperlactatemia fue significativo en los pacientes asistidos con oxigenador extracorpóreo de membrana venoarterial, pero no en aquellos con dispositivos de asistencia ventricular. Conclusiones: Los valores preoperatorios de ácido láctico son un potente factor pronóstico independiente en receptores de trasplante cardiaco urgente., The ASIS-TC registry was funded by a health research grant from the Fundación Mutua Madrileña (10th edition, 2014).

Background Medical therapy could improve the prognosis of real‐life patients discharged after a heart failure (HF) hospitalisation. Aim To determine the impact of discharge HF treatment on mortality and readmissions in different left ventricular ejection fraction (LVEF) groups. Methods Multicentre prospective registry in 20 Spanish hospitals. Patients were enrolled after a HF hospitalisation. Results A total of 1831 patients was included (583 (31.8%) HF with reduced ejection fraction (HFrEF); 227 (12.4%) HF with midrange ejection fraction (HFmrEF); 610 (33.3%) HF with preserved ejection fraction (HFpEF), and 411 (22.4%) with unknown LVEF). Angiotensin‐converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB) at discharge were independently associated with a reduction in: (i) all‐cause mortality: hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.41–0.74, P < 0.001, with a similar effect in the four groups; (ii) mortality due to refractory HF HR 0.45, 95% CI 0.29–0.64, P < 0.001, with a similar effect in the three groups with known LVEF; (iii) mortality/HF admissions (HR 0.61; 95% CI: 0.50–0.74), more evident in HFrEF (HR 0.54; 95% CI: 0.38–0.78) compared with HRmEF (HR 0.64; 95% CI 0.40–1.02), or HFpEF (HR 0.70; 95% CI 0.53–0.92). In patients with HFrEF triple therapy (ACE inhibitor/ARB + beta blocker + mineralocorticoid receptor antagonist) was associated with the lowest mortality risk (HR 0.21; 95% CI: 0.08–0.57, P = 0.002) compared with patients that received none of these drugs. Conclusions Discharge treatment with ACE inhibitor/ARB after a HF hospitalisation is associated with a reduction in all‐cause and refractory HF mortality, irrespective of LVEF. CIBERCV - Instituto de Salud Carlos III 1.677 JCR (2019) Q3, 86/165 Medicine, General & Internal 0.573 SJR (2019) Q2, 66/139 Internal Medicine No data IDR 2019 UEM

[Abstract] Introduction and objectives: Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors. Methods: This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment. Results: Hyperkalemia (K+> 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia. Conclusions: This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment. [Resumen] Introducción y objetivos. La hiperpotasemia es una preocupación creciente en el tratamiento de los pacientes con insuficiencia cardiaca y fracción de eyección reducida, pues limita el uso de fármacos eficaces. Este trabajo ofrece estimaciones de la magnitud de este problema en la práctica clínica habitual en España, los cambios en las concentraciones de potasio en el seguimiento y los factores asociados. Métodos. Pacientes con insuficiencia cardiaca aguda (n = 881) y crónica (n = 3.587) seleccionados en 28 hospitales españoles del registro europeo de insuficiencia cardiaca de la European Society of Cardiology y seguidos 1 año para diferentes desenlaces, incluidos cambios en las cifras de potasio y su impacto en el tratamiento. Resultados. La hiperpotasemia (K+ > 5,4 mEq/l) está presente en el 4,3% (IC95%, 3,7-5,0%) y el 8,2% (6,5-10,2%) de los pacientes con insuficiencia cardiaca crónica y aguda; causa el 28,9% de todos los casos en que se contraindica el uso de antagonistas del receptor de mineralocorticoides y el 10,8% de los que no alcanzan la dosis objetivo. Del total de 2.693 pacientes ambulatorios con fracción de eyección reducida, 291 (10,8%) no tenían registrada medición de potasio. Durante el seguimiento, 179 de 1.431 (12,5%, IC95%, 10,8-14,3%) aumentaron su concentración de potasio, aumento relacionado directamente con la edad, la diabetes mellitus y los antecedentes de ictus e inversamente con los antecedentes de hiperpotasemia. Conclusiones. Este trabajo destaca el problema de la hiperpotasemia en pacientes con insuficiencia cardiaca de la práctica clínica habitual y la necesidad de continuar y mejorar la vigilancia de este factor en estos pacientes por su interferencia en el tratamiento óptimo.

[Abstract] Introduction and objectives. To estimate the percentage of heart failure patients in Spain that received the European Society of Cardiology recommended treatments, and in those that did not, to determine the reasons why. Methods. The study included 2834 consecutive ambulatory patients with heart failure from 27 Spanish hospitals. We recorded general information, the treatment indicated, and the reasons why it was not prescribed in some cases. In patients who met the criteria to receive a certain drug, true undertreatment was defined as the percentage of patients who, without justification, did not receive the drug. Results. In total, 92.6% of ambulatory patients with low ejection fraction received angiotensin converting enzyme inhibitors or angiotensin receptor blockers, 93.3% beta-blockers, and 74.5% mineralocorticoid receptor antagonists. The true undertreatment rates were 3.4%, 1.8%, and 19.0%, respectively. Target doses were reached in 16.2% of patients receiving angiotensin converting enzyme inhibitors, 23.3% of those with angiotensin receptor blockers, 13.2% of those prescribed beta-blockers, and 23.5% of those with mineralocorticoid receptor antagonists. Among patients who could benefit from ivabradine, 29.1% received this drug. In total, 36% of patients met the criteria for defibrillator implantation and 90% of them had received the device or were scheduled for implantation, whereas 19.6% fulfilled the criteria for resynchronization therapy and 88.0% already had or would soon have the device. In patients who met the criteria, but did not undergo device implantation, the reasons were not cost-related. Conclusions. When justified reasons for not administering heart failure drugs were taken into account, adherence to the guideline recommendations was excellent. Exclusive use of the percentage of treated patients is a poor indicator of the quality of healthcare in heart failure. Measures should be taken to improve the attainment of optimal dosing in each patient. [Resumen] Introducción y objetivos. Estimar la proporción de pacientes con insuficiencia cardiaca atendidos en España que reciben los tratamientos recomendados por la Sociedad Europea de Cardiología y razones de que no los reciban, en su caso. Métodos. Se incluyó a 2.834 pacientes ambulatorios consecutivos con insuficiencia cardiaca de 27 hospitales españoles. Se recogió información general, tratamiento indicado y causas de que no lo recibiera, en su caso. De los pacientes que cumplen criterios para recibir tratamiento, infratratamiento real es la proporción que, sin justificación, no lo recibe. Resultados. El 92,6% de los pacientes ambulatorios con fracción de eyección reducida recibieron inhibidores de la enzima de conversión de la angiotensina o antagonistas del receptor de la angiotensina II; el 93,3%, bloqueadores beta y el 74,5%, antagonistas del receptor mineralocorticoideo. El infratratamiento real es del 3,4, el 1,8 y el 19,0% respectivamente. Alcanzan dosis objetivo de inhibidores de la enzima de conversión de la angiotensina el 16,2% de los pacientes; de antagonistas de los receptores de la angiotensina II, el 23,3%; de bloqueadores beta, el 13,2% y de antagonistas del receptor mineralocorticoideo, el 23,5%. El 29,1% de los pacientes que podrían beneficiarse de ivabradina la reciben; el 36% cumple criterios para implantar desfibrilador; de ellos, el 90% lo tienen ya implantado o programado; las cifras correspondientes en resincronización son el 19,6 y el 88,0%; el porcentaje restante no se debe a causas económicas. Conclusiones. Considerando razones justificadas para no administrar fármacos a estos pacientes, el cumplimiento de las guías es excelente. Utilizar solo la proporción de pacientes tratados es un mal indicador de calidad de la asistencia en insuficiencia cardiaca. Es necesario introducir medidas que mejoren el logro de la dosis óptima para cada paciente.

Resumen Introduccion y objetivos Estimar la proporcion de pacientes con insuficiencia cardiaca atendidos en Espana que reciben los tratamientos recomendados por la Sociedad Europea de Cardiologia y razones de que no los reciban, en su caso. Metodos Se incluyo a 2.834 pacientes ambulatorios consecutivos con insuficiencia cardiaca de 27 hospitales espanoles. Se recogio informacion general, tratamiento indicado y causas de que no lo recibiera, en su caso. De los pacientes que cumplen criterios para recibir tratamiento, infratratamiento real es la proporcion que, sin justificacion, no lo recibe. Resultados El 92,6% de los pacientes ambulatorios con fraccion de eyeccion reducida recibieron inhibidores de la enzima de conversion de la angiotensina o antagonistas del receptor de la angiotensina II ; el 93,3%, bloqueadores beta y el 74,5%, antagonistas del receptor mineralocorticoideo. El infratratamiento real es del 3,4, el 1,8 y el 19,0% respectivamente. Alcanzan dosis objetivo de inhibidores de la enzima de conversion de la angiotensina el 16,2% de los pacientes; de antagonistas de los receptores de la angiotensina II , el 23,3%; de bloqueadores beta, el 13,2% y de antagonistas del receptor mineralocorticoideo, el 23,5%. El 29,1% de los pacientes que podrian beneficiarse de ivabradina la reciben; el 36% cumple criterios para implantar desfibrilador; de ellos, el 90% lo tienen ya implantado o programado; las cifras correspondientes en resincronizacion son el 19,6 y el 88,0%; el porcentaje restante no se debe a causas economicas. Conclusiones Considerando razones justificadas para no administrar farmacos a estos pacientes, el cumplimiento de las guias es excelente. Utilizar solo la proporcion de pacientes tratados es un mal indicador de calidad de la asistencia en insuficiencia cardiaca. Es necesario introducir medidas que mejoren el logro de la dosis optima para cada paciente.

Acute heart failure (AHF) requires considerable use of resources, is an economic burden, and is associated with high complication and mortality rates in emergency departments, on hospital wards, or outpatient care settings. Diagnosis, treatment, and continuity of care are variable at present, leading 3 medical associations (for cardiology, internal medicine, and emergency medicine) to undertake discussions and arrive at a consensus on clinical practice guidelines to support those who manage AHF and encourage standardized decision making. These guidelines, based on a review of the literature and clinical experience with AHF, focus on critical points in the care pathway. Regarding emergency care, the expert participants considered the initial evaluation of patients with signs and symptoms that suggest AHF, the initial diagnosis, first decisions about therapy, monitoring, assessment of prognosis, and referral criteria. For care of the hospitalized patient, the group developed a protocol for essential treatment. Objectives for the management and treatment of AHF on discharge were also covered through the creation or improvement of multidisciplinary care systems to provide continuity of care.La insuficiencia cardiaca aguda (ICA) supone un elevado uso de recursos, carga económica y morbimortalidad, tanto en los servicios de urgencias como durante la hospitalización o durante su control ambulatorio. La variabilidad actual existente en el diagnóstico, tratamiento y la continuidad asistencial ha inducido que diferentes sociedades científicas (cardiología, medicina interna y urgencias) redacten este documento de consenso sobre recomendaciones prácticas que den soporte a todos los profesionales intervinientes en el manejo de la ICA y permita homogeneizar la toma de decisiones. El enfoque de estas recomendaciones, basadas en la revisión de la literatura y la experiencia clínica, se ha realizado abarcando diferentes puntos críticos del proceso asistencial de los pacientes con ICA: en el servicio de urgencias, en cuanto a la evaluación inicial del paciente con clínica sugestiva de ICA, orientación diagnóstica, primeras decisiones terapéuticas, monitorización, evaluación del pronóstico y criterios de derivación; durante la hospitalización, con el desarrollo de un protocolo básico terapéutico; tras el alta, con la definición de objetivos de manejo y tratamiento de la ICA al alta del paciente; y de forma global, mediante la mejora o creación de una organización en la atención multidisciplinar y la continuidad asistencial en la ICA.

Introduction and objectives: The present article reports the characteristics and results of heart transplants in Spain since this therapeutic modality was first used in May 1984. Methods: We summarize the main features of recipients, donors, surgical procedures, and outcomes of all cardiac transplants performed in Spain up to December 31, 2016. Results: A total of 281 cardiac transplants were performed in 2016. The whole historical series consisted of 7869 procedures. The main features of transplant procedures in 2016 were similar to those observed in recent years. A high percentage of procedures were urgent, particularly those with use of pretransplant continuous-flow left ventricular assist devices (19.1% of all transplants). Survival significantly improved in the last decade compared with previous periods. Conclusions: During the last few years, transplant activity in Spain has remained steady, with approximately 250-300 transplants/year. Despite a more complex clinical context, survival has improved in recent years. (C) 2017 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

In Spain, listing for high-urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T-MCS). We sought to analyse the clinical outcomes of this strategy.We conducted a case-by-case, retrospective review of clinical records of 291 adult patients listed for high-urgent heart transplantation under temporary devices from 2010 to 2015 in 16 Spanish institutions. Survival after listing and adverse clinical events were studied. At the time of listing, 169 (58%) patients were supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO), 70 (24%) on temporary left ventricular assist devices (T-LVAD) and 52 (18%) on temporary biventricular assist devices (T-BiVAD). Seven patients transitioned from VA-ECMO to temporary ventricular assist devices while on the waiting list. Mean time on T-MCS was 13.1 ± 12.6 days. Mean time from listing to transplantation was 7.6 ± 8.5 days. Overall, 230 (79%) patients were transplanted and 54 (18.6%) died during MCS. In-hospital postoperative mortality after transplantation was 33.3%, 11.9% and 26.2% for patients bridged on VA-ECMO, T-LVAD and T-BiVAD, respectively (P = 0.008). Overall survival from listing to hospital discharge was 54.4%, 78.6% and 55.8%, respectively (P = 0.002). T-LVAD support was independently associated with a lower risk of death over the first year after listing (hazard ratio 0.52, 95% confidence interval 0.30-0.92). Patients treated with VA-ECMO showed the highest incidence rate of adverse clinical events associated with T-MCS.Temporary devices may be used to bridge critically ill candidates directly to heart transplantation in a setting of short waiting list times, as is the case of Spain. In our series, bridging with T-LVAD was associated with more favourable outcomes than bridging with T-BiVAD or VA-ECMO.

Background: The intermediate group of patients with heart failure (HF) and mid-range left ventricular ejection fraction (HFmrEF) may constitute a specific phenotype, but a direct evidence is lacking. This study aimed to know whether this HF category is accompanied by a particular clinical phenotype and prognosis. Methods and results: This study includes 3446 ambulatory patients with chronic HF from two national registries. According to EF at enrollment, patients were classified as reduced (HFrEF, = 50%). Patients were followed-up for a median of 41 months and the specific cause of death was prospectively registered. Patients with HFmrEF represented 13% of population and they exhibited a phenotype closer to HFrEF, except for a higher rate of coronary revascularization and diabetes, and a less advanced HF syndrome. The observed all-cause mortality was higher among HFrEF (33.0%), and similar between HFmrEF (27.8%) and HFpEF (28.0%) (p = 0.012); however, the contribution of each cause of death differed significantly between categories (p < 0.001). After propensity score matching, the risk of cardiovascular death, HF death or sudden cardiac death did not differ between HFmrEF and HFrEF in paired samples; however, patients with HFmrEF were at higher risk of cardiovascular death (sHR 1.71, 95% CI 1.13-2.57, p = 0.011) and sudden cardiac death (sHR 2.73, 95% CI 1.07-6.98, p = 0.036) than patients with HFpEF. Conclusions: Patients in the intermediate category of HFmrEF conform a phenotype closer to the clinical profile of HFrEF, and associated to higher risk of sudden cardiac death and cardiovascular death than patients with HFpEF. (C) 2017 Elsevier B.V. All rights reserved.

BACKGROUND: It's unclear whether pre-transplant T. gondii seropositivity is associated with impaired survival in heart transplant recipients. OBJECTIVES: To test the above-mentioned hypothesis in the Spanish Heart Transplantation Registry. METHODS: Post-transplant outcomes of 4048 patients aged >16years who underwent first, single-organ heart transplantation in 17 Spanish institutions from 1984 to 2014 were studied. Long-term post-transplant survival and survival free of cardiac death or retransplantation of 2434 (60%) T. gondii seropositive recipients and 1614 (40%) T. gondii seronegative recipients were compared. RESULTS: T. gondii seropositive recipients were older, had higher body mass index, and presented higher prevalence of hypertension, hypercholesterolemia, COPD and Cytomegalovirus seropositivity than T. gondii seronegative recipients. In univariable analysis, pre-transplant T. gondii seropositivity was associated with increased post-transplant all-cause mortality (non-adjusted HR 1.15; 95% CI 1.04-1.26). However, this effect was no longer statistically significant after multivariable adjustment by recipient's age and sex (adjusted HR 1.01, 95% CI 0.92-1.11). Extended multivariable adjustment by other potential confounders showed similar results (adjusted HR 0.99, 95% CI 0.89-1.11). T. gondii seropositivity had no significant effect on the composite outcome cardiac death or retransplantation (non-adjusted HR 1.08, 95% CI 0.95-1.24, p=0.235). The distribution of the causes of death was comparable in T. gondii seropositive and T. gondii seronegative recipients. No statistically significant impact of donor's T. gondii serostatus or donor-recipient T. gondii serostatus matching on post-transplant survival was observed. CONCLUSIONS: Our analysis did not show a significant independent effect of preoperative T. gondii serostatus on long-term outcomes after heart transplantation. Sin financiación 3.471 JCR (2018) Q2, 48/136 Cardiac & Cardiovascular Systems 0.990 SJR (2018) Q2, 91/365 Cardiology and Cardiovascular Medicine No data IDR 2018 UEM

European Society of Cardiology heart failure guidelines include a new patient category with mid-range (40%-49%) left ventricular ejection fraction (HFmrEF). HFmrEF patient characteristics and prognosis are poorly defined. The aim of this study was to analyze the HFmrEF category in a cohort of hospitalized heart failure patients (REDINSCOR II Registry).A prospective observational study was conducted with 1420 patients classified according to ejection fraction as follows: HFrEF,40%; HFmrEF, 40%-49%; and HFpEF, ≥ 50%. Baseline patient characteristics were examined, and outcome measures were mortality and readmission for heart failure at 1-, 6-, and 12-month follow-up. Propensity score matching was used to compare the HFmrEF group with the other ejection fraction groups.Among the study participants, 583 (41%) had HFrEF, 227 (16%) HFmrEF, and 610 (43%) HFpEF. HFmrEF patients had a clinical profile similar to that of HFpEF patients in terms of age, blood pressure, and atrial fibrillation prevalence, but shared with HFrEF patients a higher proportion of male participants and ischemic etiology, and use of class I drugs targeting HFrEF. All other features were intermediate, and comorbidities were similar among the 3 groups. There were no significant differences in all-cause mortality, cause of death, or heart failure readmission. The similar outcomes were confirmed in the propensity score matched cohorts.The HFmrEF patient group has characteristics between the HFrEF and HFpEF groups, with more similarities to the HFpEF group. No between-group differences were observed in total mortality, cause of death, or heart failure readmission.

Pulmonary hypertension (PH) is associated with a greater mortality rate in patients with heart failure (HF) and it is a risk factor for right ventricular failure after heart transplantation. This study was designed to explore risk factors for PH development in patients with advanced heart failure and left ventricular dysfunction. In a retrospective observational study of 419 patients evaluated for heart transplantation due to end stage HF, different variables were analyzed to find predictors of PH (defined as a mean pulmonary pressure >25 mmHg), reactive PH (defined as a transpulmonary gradient >12 mmHg) and severe PH (defined as a mean pulmonary pressure >40 mmHg and/or pulmonary vascular ressistance >3 WU) using a multivariate stepwise logistic regression analysis. Prevalence of PH, out of proportion and severe PH was 62.2%, 23.8%, and 18.8% respectively. The presence of moderate-severe mitral regurgitation [2.1 (1.2–3.7); P=0.006], moderate-severe tricuspid regurgitation [OR 2.9 (1.3–6.4); P=0.005] and a duration of disease >3 years [OR 1.7 (1.1–2.7); P=0.03] were independent risk factors associated with PH. Moreover, the presence of a moderate-severe mitral regurgitation and a duration of disease greater than 3 years, were independent predictors of out of proportion and severe PH.