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Recent studies showed that an early strategy for ventricular tachycardia (VT) ablation resulted in reduction of VT episodes or mortality. Cardiac magnetic resonance (CMR)-derived border zone channel (BZC) mass has proved to be a strong non-invasive predictor of VT in post-myocardial infarction (MI). CMR-guided VT substrate ablation proved to be safe and effective for reducing sudden cardiac death (SCD) and VA occurrence.PREVENT-VT is a prospective, randomized, multicenter, and controlled trial designed to evaluate the safety and efficacy of prophylactic CMR-guided VT substrate ablation in chronic post-MI patients with CMR-derived arrhythmogenic scar characteristics. Chronic post-MI patients with late gadolinium enhancement (LGE) CMR will be evaluated. CMR images will be post-processed and the BZC mass measured: patients with a BZC mass 5.15 g will be eligible. Consecutive patients will be enrolled at 3 centers and randomized on a 1:1 basis to undergo a VT substrate ablation (ABLATE arm) or optimal medical treatment (OMT arm). Primary prevention ICD will be implanted following guideline recommendations, while non-ICD candidates will be implanted with an implantable cardiac monitor (ICM). The primary endpoint is a composite outcome of sudden cardiac death (SCD) or sustained monomorphic VT, either treated by an ICD or documented with ICM. Secondary endpoints are procedural safety and efficiency outcomes of CMR-guided ablation.In some patients, the first VA episode causes SCD or severe neurological damage. The aim of the PREVENT-VT is to evaluate whether primary preventive substrate ablation may be a safe and effective prophylactic therapy for reducing SCD and VA occurrence in patients with previous MI and high-risk scar characteristics based on CMR.ClinicalTrials.gov, NCT04675073, registered on January 1, 2021.

Identifying biomarkers of subclinical atrial fibrillation (AF) is of most interest in patients with cryptogenic stroke (CrS). We sought to evaluate the circulating microRNA (miRNA) profile of patients with CrS and AF compared with those in persistent sinus rhythm.Among 64 consecutive patients with CrS under continuous monitoring by a predischarge insertable monitor, 18 patients (9 with AF and 9 in persistent sinus rhythm) were selected for high-throughput determination of 754 miRNAs. Nine patients with concomitant stroke and AF were also screened to improve the yield of miRNA selection. Differentially expressed miRNAs were replicated in an independent cohort (n=46). Biological markers were stratified by the median and included in logistic regression analyses to evaluate their association with AF at 6 and 12 months.Eight miRNAs were differentially expressed between patients with and without AF. In the replication cohort, miR-1-3p, a gene regulator involved in cardiac arrhythmogenesis, was the only miRNA to remain significantly higher in patients with CrS and AF vs those in sinus rhythm and showed a modest association with AF burden. High (= above the median) miR-1-3p plasma values, together with a low left atrial ejection fraction, were independently associated with the presence of AF at 6 and 12 months.In this cohort, plasma levels of miR-1-3p were elevated in CrS patients with subsequent AF. Our results preliminarily suggest that miR-1-3p could be a novel biomarker that, together with clinical parameters, could help identify patients with CrS and a high risk of occult AF.

Objectives To evaluate at 1.5 and 3 T MRI the safety and performance of trademarked ENO®, TEO®, or OTO® pacing systems with automated MRI Mode and the image quality of non-enhanced MR examinations. Methods A total of 267 implanted patients underwent MRI examination (brain, cardiac, shoulder, cervical spine) at 1.5 (n = 126) or 3 T (n = 141). MRI-related device complications, lead electrical performances stability at 1-month post-MRI, proper functioning of the automated MRI mode and image quality were evaluated. Results Freedom from MRI-related complications at 1 month post-MRI was 100% in both 1.5 and 3 T arms (both p p = 0.001) and 100% (p p p = 0.0001) and 96.9% (p = 0.01); ventricular: 100% (p p = 0.0001)). All devices switched automatically to the programmed asynchronous mode in the MRI environment and to initially programmed mode after the MRI exam. While all MR examinations were assessed as interpretable, artifacts deteriorated a subset of examinations including mostly cardiac and shoulder ones. Conclusion This study demonstrates the safety and electrical stability of ENO®, TEO®, or OTO® pacing systems at 1 month post-MRI at 1.5 and 3 T. Even if artifacts were noticed in a subset of examinations, overall interpretability was preserved. Clinical relevance statement ENO®, TEO®, and OTO® pacing systems switch to MR-mode when detecting magnetic field and switch back on conventional mode after MRI. Their safety and electrical stability at 1 month post MRI were shown at 1.5 and 3 T. Overall interpretability was preserved. Key Points • Patients implanted with an MRI conditional cardiac pacemaker can be safely scanned under 1.5 or 3 Tesla MRI with preserved interpretability. • Electrical parameters of the MRI conditional pacing system remain stable after a 1.5 or 3 Tesla MRI scan. • The automated MRI mode enabled the automatic switch to asynchronous mode in the MRI environment and to initial settings after the MRI scan in all patients.

Aims Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF. Methods and results Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50–67), fluoroscopy time was 43 s (IQR 20–71), and radiofrequency (RF) time was 16.5 min (IQR 14.3–18.4). The median AI tailored to the local LAWT was 387 (IQR 360–410) for the anterior wall and 335 (IQR 300–375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up. Conclusion In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

Resumen Introduccion y objetivos Las redes de tratamiento del infarto agudo de miocardio con elevacion del segmento ST (IAMCEST) han incrementado la tasa de reperfusion y reducido los tiempos de isquemia. Nuestro objetivo fue analizar la diferencia en el pronostico entre generos en pacientes con un primer IAMCEST. Metodos Se realizo un estudio de cohorte multicentrico de pacientes con primer IAMCEST durante 2010-2016 para determinar el efecto del genero/sexo ajustado sobre la mortalidad, la combinacion de mortalidad, fibrilacion ventricular, shock cardiogenico o edema agudo de pulmon a 30 dias, y sobre la mortalidad al ano. Resultados Entre 2010 y 2016 se incluyeron 14.690 pacientes, un 24% fueron mujeres. En el periodo de estudio, la mediana [rango intercuartilico] de tiempo entre electrocardiograma y apertura de arteria descendio en ambos sexos (119 min [85-160] frente a 109 min [80-153] en 2010 en mujeres, y 102 min [81-133] frente a 96 min [74-124] en 2016 en mujeres, ambos valores p = 0,001). En el mismo periodo, el porcentaje de angioplastia primaria en Conclusiones Las mujeres con un primer IAMCEST presentan un porcentaje de muerte o complicaciones al mes similar a la de los varones y, en cambio, menos mortalidad al ano tras ajustar por edad y gravedad.

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

Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation.Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol.Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise ( 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4).The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).

Background Patients with atrial fibrillation (AF) often have sleep apnea (SA), but diagnosis of SA with polysomnography is costly. SA monitoring is a pacemaker feature that measures respiratory disturbance index, the sum of abnormal respiratory events divided by sleep duration. Objective The purpose of this study was to evaluate the incidence and severity of SA and its association with AF in an unselected population fitted with pacemakers. Methods RESPIRE (REgistry of Sleep APnea monItoring and Atrial Fibrillation in pacemakeR patients) was a multicenter, international, observational, open-label study following adult subjects for 18 months after implantation with an SA monitoring–enabled dual-chamber pacemaker. Severe SA was defined as average respiratory disturbance index ≥20 from implantation to follow-up visit. The first co-primary end point was the difference in significant AF (cumulative AF episodes lasting ≥24 hours over 2 consecutive days) between subjects with severe and those nonsevere SA at 12 months in the full analysis set (N = 553). The second co-primary end point was the rate of major serious adverse events at 18 months in the modified intention-to-treat set (N = 1024). Results Severe SA was detected in 31.1% (172 of 553). A higher incidence of significant AF was reported in patients with severe SA than in patients with nonsevere SA (25.0% vs 13.9%; difference 11.1%; 95% confidence interval 3.7%–18.4%; P = .002). Significant AF increased with time in both groups, but at a faster rate in the severe SA group. No intergroup difference in the overall rate of major serious adverse events was observed (P = .065). Conclusion SA screening over 12 months identified severe SA in almost one-third of unselected patients fitted with pacemakers. Severe SA was associated with a higher incidence of significant AF.

Resumen El objetivo principal en el abordaje del paciente con fibrilacion auricular es la reduccion del riesgo de ictus mediante el tratamiento antitrombotico adecuado. Sin embargo, a pesar de una adecuada anticoagulacion, sigue habiendo un importante riesgo residual de eventos isquemicos, particularmente infarto de miocardio y muerte de origen cardiovascular, que exige una proteccion mas completa. Por lo tanto, en el paciente con fibrilacion auricular, el tratamiento anticoagulante deberia perseguir este doble objetivo, la reduccion tanto del riesgo de ictus como de las complicaciones isquemicas. Diferentes estudios han demostrado que los antagonistas de la vitamina K solo disminuyen el riesgo de ictus y de eventos isquemicos cuando el control de la anticoagulacion es optimo, cosa que ocurre en un pequeno numero de pacientes. Con respecto a los anticoagulantes orales de accion directa, aunque en general muestran un perfil de eficacia y seguridad mejor que los antagonistas de la vitamina K, parece que no todos ofrecerian la misma proteccion en cuanto a la reduccion de los eventos isquemicos. Esta demostrado que el rivaroxaban reduce de manera significativa (18%) el riesgo de infarto de miocardio. De hecho, los estudios muestran que el rivaroxaban proporciona una proteccion vascular mas completa en diferentes contextos clinicos, no solo en el paciente con fibrilacion auricular, sino tambien en el paciente con enfermedad vascular ateroesclerotica.

Background: Pulmonary veins isolation (PVI) is a standard treatment for recurrent atrial fibrillation (AF). Uninterrupted anticoagulation for minimum 3 weeks before the ablation and exclusion of left atrial (LA) thrombus with transesophageal echography (TEE) immediately before or during the procedure minimize peri-procedural risk. We aimed to demonstrate the utility of cardiac tomography (CT) and cardiac magnetic resonance (CMR) to rule out LA thrombus prior to PVI. Methods: Patients undergoing PVI for recurrent AF were retrospectively evaluated. Only patients that started anticoagulation at least 3 weeks prior to the CT/CMR and subsequently uninterrupted until the ablation procedure were selected. An intracardiac echo (ICE) catheter was used in all patients to evaluate LA thrombus. The results of CT/CMR were compared to ICE imaging. Results: We included 272 consecutive patients averaging 54.5 years (71% male; 30% persistent AF). Average CHA2DS2VASC Score was 0.9 and mean LA diameter was 43 mm, 111 patients on Acenocumarol and 161 on direct oral anticoagulants. Anticoagulation was started 227±392 days before the CT/CMR, and 291±416 days before the ablation procedure. CT/CMR diagnosed intracardiac thrombus in 2 cases, both in the LA appendage. A new CT/CMR revealed resolution of thrombus after 6 additional months of uninterrupted anticoagulation. No macroscopic thrombus was observed in any patients with ICE (negative predictive value of 100%; pConclusions: CT and MRI are excellent surrogates to TEE and ICE to rule out intracardiac thrombus in patients adequately anticoagulated prior AF ablation. This is true even for delayed procedures as long as anticoagulation is uninterrupted.

Background Catheter ablation of accessory pathways (AP) with bidirectional conduction may be challenging due to issues related to anatomical course or location. Objective We describe an alternative electro-anatomical mapping technique which aims at depicting the entire anatomic course of the AP from the atrial toward the ventricular insertion in order to guide catheter ablation. Methods Twenty consecutive patients with confirmed bidirectional AP conduction and at least one previous ablation procedure or para-Hisian location were included. 3-D electro-anatomical mapping was used to depict the merged 10-ms isochrone area of maximum early activation of both the ventricular and atrial signals during sinus rhythm and ventricular pacing/orthodromic tachycardia, respectively. Catheter ablation was performed within the depicted earliest isochrone area. Results Acute bidirectional AP conduction block was achieved in all patients 4.2 +/- 1.7 s after the first radiofrequency energy pulse was delivered, without reconnection during a 30 +/- 10 min post-ablation observation time. No procedural complications were seen. After a mean follow-up period of 9 +/- 7 months (range 3 to 16), no recurrences were documented. Conclusion This merged two-way mapping technique is a safe, efficient, and effective technique for ablation of APs with bidirectional conduction.

HL-1 cells; L-type calcium channels; Calcium regulation Células HL-1; Canales de calcio tipo L; Regulación del calcio Cel·lules HL-1; Canals de calci tipus L; Regulació del calci MicroRNAs (miRNAs) participate in atrial remodeling and atrial fibrillation (AF) promotion. We determined the circulating miRNA profile in patients with AF and heart failure with reduced ejection fraction (HFrEF), and its potential role in promoting the arrhythmia. In plasma of 98 patients with HFrEF (49 with AF and 49 in sinus rhythm, SR), differential miRNA expression was determined by high-throughput microarray analysis followed by replication of selected candidates. Validated miRNAs were determined in human atrial samples, and potential arrhythmogenic mechanisms studied in HL-1 cells. Circulating miR-199a-5p and miR-22-5p were significantly increased in HFrEF patients with AF versus those with HFrEF in SR. Both miRNAs, but particularly miR-199a-5p, were increased in atrial samples of patients with AF. Overexpression of both miRNAs in HL-1 cells resulted in decreased protein levels of L-type Ca2+ channel, NCX and connexin-40, leading to lower basal intracellular Ca2+ levels, fewer inward currents, a moderate reduction in Ca2+ buffering post-caffeine exposure, and a deficient cell-to-cell communication. In conclusion, circulating miR-199a-5p and miR-22-5p are higher in HFrEF patients with AF, with similar findings in human atrial samples of AF patients. Cells exposed to both miRNAs exhibited altered Ca2+ handling and defective cell-to-cell communication, both findings being potential arrhythmogenic mechanisms. This work was funded by the following grants, awarded to B.B.: Sociedad Española de Cardiología, Sección de Arritmias y Electrofisiología 2012; Sociedad Española de Cardiología, Sección de Insuficiencia Cardíaca 2013; Fondo Investigación Sanitaria (FIS)—Instituto Carlos III 2013 (PI13/01830); and Societat Catalana de Cardiologia 2016. Awarded to K.W.A-A. and S.R.: British Heart Foundation (BHF) Intermediate Research Fellowship. Awarded to J.M.F.F.: grant from the Spanish Ministry of Science and Innovation (RTI2018-094809-B-I00). “María de Maeztu” Programme for Units of Excellence in R&D to the Departament de Ciències Experimentals i de la Salut (MDM-2014-0370) and FEDER (Fondo Europeo de Desarrollo Regional) also contributed to this work.

Background: Pulmonary Veins Isolation (PVI) is the cornerstone in the treatment of atrial fibrillation. Recurrence rate is common in the long-term followup (FU); nevertheless, some patients maintain Sinus Rhythm (SR) for more than 5 years after the index ablation. The aim of this study is characterize this kind of patients so called “super-responders”. Methods: This is a retrospective single-center study including all patients summited for cryo-balloon ablation in our hospital from January 2011 to September 2020. We investigated clinical, electrocardiographic, echocardiographic variables and those linked to the ablation procedure. A univariate and multivariate logistic regression was performed. Results: During this period, 422 patients underwent PVI; however, 193 were excluded: 21 lost in the FU, 30 got radiofrequency ablation and 142 did not reach a minimum 5 years FU. Of the 229 finally included, 85 (group 1) did not have any recurrence during the follow-up, in front of 144 (group 2) with AF recurrences. In the multivariate analysis the p wave duration: OR: 0.92; 95% CI (0.89-0.94); p

Purpose Patients undergoing cavotricuspid isthmus (CTI) ablation for typical flutter (AFL) have a high incidence of new onset atrial fibrillation (AF). We aimed to analyze the influence of PACE score to predict new onset AF in this subset of patients to stratify thromboembolic risk. Methods Between 2017 and 2019, patients undergoing CTI ablation for AFL and without history of AF were prospectively included. All patients were monitored continuously by implantable loop recorder and followed by remote monitoring. Results Overall 48 patients were included. New onset AF rate at 12 months was 56.3%. We observed two very strong independent predictors for new onset AF: a PACE score ≥ 30 (HR:6.9; 95% CI:1.71–27.91; p = 0.007) and an HV interval ≥ 55 (HR:11.86; 95% CI:2.57–54.8; p = 0.002). Conclusions The incidence of newly diagnosed AF is high in patients with AFL after CTI ablation, and can occur early. A high PACE score and/or long HV interval predict even higher risk, and may be useful in the decision for empiric long-term anticoagulation.

Silent atrial fibrillation (AF) may be the cause of some cryptogenic strokes (CrS). The aim of the study was to analyse atrial size and function by speckle tracking echocardiography in CrS patients to detect atrial disease. Patients admitted to the hospital due to CrS were included prospectively. Echocardiogram analysis included left atrial ejection fraction (LAEF) and atrial strain. Insertable cardiac monitor was implanted, and AF was defined as an episode of ≥1 min in the first year after stroke. Left atrial enlargement was defined as indexed volume &gt, 34 mL/m2. Seventy-five consecutive patients were included, aged 76 ± 9 years (arterial hypertension 75%). AF was diagnosed in 49% of cases. The AF group had higher atrial volume and worse atrial function: peak atrial longitudinal strain (PALs) 19.6 ± 5.7% vs. 29.5 ± 7.2%, peak atrial contraction strain (PACs) 8.9 ± 3.9% vs. 16.5 ± 6%, LAEF 46.8 ± 11.5% vs. 60.6 ± 5.2%, p &lt, 0.001. AF was diagnosed in 20 of 53 patients with non-enlarged atrium, and in 18 of them, atrial dysfunction was present. The multivariate logistic regression analysis demonstrated an independent association between detection of AF and atrial volume, LAEF, and strain. Cut-off values were obtained: LAEF &lt, 55%, PALs &lt, 21.4%, and PACs &lt, 12.9%. In conclusion, speckle tracking echocardiography in CrS patients improves silent atrial disease diagnosis, with or without atrial enlargement.

Purpose: Patients undergoing cavotricuspid isthmus (CTI) ablation for typical flutter (AFL) have a high incidence of new onset atrial fibrillation (AF). We aimed to analyze the incidence and predictors for new onset AF in this subset of patients to stratify thromboembolic risk. Methods: Between 2016 and 2019, 70 patients without history of AF but with high-risk for developing AF, based on a recent AFL ablation or a high PACE score for AF risk, were prospectively included. All patients were monitored continuously by implantable loop recorder and followed by remote monitoring.Results: Overall 48 patients were included after CTI ablation and 22 patients were included based on a high PACE score. New onset AF rate at 12 months was significantly higher in the AFL group compared to PACE group (56.3% vs 22.7%, p=0.011). History of AFL was the only independent predictor for new onset AF (HR:3.82; 95% CI:1.46-10.03; p=0.006) at a median follow-up of 12 months (Q1-Q3:4-19 months). In the AFL group, two very strong independent predictors for new onset AF were a PACE score ³30 (HR:6.9; 95% CI:1.71-27.91; p=0.007) and HV interval ³55 (HR:11.86; 95% CI:2.57-54.8; p=0.002).Conclusions: AFL is the most important predictor for new onset AF. In patients undergoing AFL ablation, a high PACE score and/or long HV interval predict even higher risk, and may be useful in decision for empiric long-term anticoagulation.

Background: Pulmonary veins isolation (PVI) is a standard treatment for recurrent atrial fibrillation (AF). Uninterrupted anticoagulation for minimum 3 weeks before the ablation and exclusion of left atrial (LA) thrombus with transesophageal echography (TEE) immediately before or during the procedure minimize peri-procedural risk. We aimed to demonstrate the utility of cardiac tomography (CT) and cardiac magnetic resonance (CMR) to rule out LA thrombus prior to PVI.Methods: Patients undergoing PVI for recurrent AF were retrospectively evaluated. Only patients that started anticoagulation at least 3 weeks prior to the CT/CMR and subsequently uninterrupted until the ablation procedure were selected. An intracardiac echo (ICE) catheter was used in all patients to evaluate LA thrombus. The results of CT/CMR were compared to ICE imaging.Results: We included 272 consecutive patients averaging 54.5 years (71% male; 30% persistent AF). Average CHA2DS2VASC Score was 0.9 and mean LA diameter was 43 mm, 111 patients on Acenocumarol and 161 on direct oral anticoagulants. Anticoagulation was started 227±392 days before the CT/CMR, and 291±416 days before the ablation procedure. CT/CMR diagnosed intracardiac thrombus in 2 cases, both in the LA appendage. A new CT/CMR revealed resolution of thrombus after 6 additional months of uninterrupted anticoagulation. No macroscopic thrombus was observed in any patients with ICE (negative predictive value of 100%; p

Resumen Introduccion y objetivos El adecuado control lipidico tras un sindrome coronario agudo (SCA) es una estrategia de prevencion secundaria crucial para disminuir el riesgo de reinfarto y muerte cardiovascular. Existen tablas que predicen la dosificacion necesaria del tratamiento hipolipidemiante segun el colesterol LDL (cLDL) inicial pero no han sido probadas en el SCA. Analizamos los factores asociados al control del cLDL tras un SCA y la utilidad de las tablas de Masana y Plana en este contexto. Metodos Entre enero de 2015 y mayo de 2016 se incluyeron 326 pacientes con SCA. Se registraron las concentraciones basales de cLDL y el tratamiento hipolipidemiante al alta. Se analizaron las variables asociadas a un adecuado control del cLDL ( Resultados La edad media fue 66 ± 13 anos, el 72% varones. El tratamiento hipolipidemiante al alta se ajusto a las recomendaciones de Masana en 196 (60%) pacientes. Tras 122 [66-184] dias, en 148 (45%) se alcanzo el objetivo de cLDL, siendo este porcentaje mayor (109/196 –56%– vs. 39/130 –30%– pacientes) cuando el tratamiento fue planificado segun las tablas de Masana y Plana (p Conclusiones El control lipidico adecuado tras un SCA se alcanza en menos de la mitad de casos. La dosificacion de la terapia hipolipidemiante segun las tablas de Masana y Plana mejora la consecucion de este crucial objetivo terapeutico.

Adequate LDL cholesterol (LDLc) control after an acute coronary syndrome (ACS) is a crucial secondary prevention strategy to minimize the incidence of recurrent myocardial infarction and cardiovascular death. There are tables that predict the necessary dosage of lipid-lowering treatment from the initial LDLc but have not been tested in ACS. Variables associated with optimal LDLc after an ACS were analyzed and the therapeutic yield of the use of Masana's recommendations in this setting.A total number of 326 ACS-patients were included between January-2015 and May-2016. Baseline LDLc concentration and prescribed hypolipemiant treatment at hospital discharge were registered. We analyzed the variables associated with optimal LDLc levels (70mg/dL) control during follow-up.Among our patient population (72% male, age 66±13 years), the hypolipemiant treatment at hospital discharge fulfilled the Masana's recommendations in 196 (60%) patients. After a follow-up period of 122 [66-184] days the targeted LDLc levels were achieved in 148 (45%) patients, being this percentage greater among those in whom the Masana's recommendations were fulfilled (109/196, 56%), as compared with the remaining (39/130, 30%; P.001). The male gender (P.001), the absence of prior history of dyslipemia (P.001) and the adherence to Masana's recommendations (P=.007) were independent predictors for the achievement of targeted LDLc levels during follow-up.In less than half of ACS-patients adequate mid-term LDLc control is obtained. The dosage of the lipid-lowering therapy according to Masana's recommendations helps to achieve this important therapeutic goal.

Resumen Introduccion y objetivos Determinar la efectividad de los anticoagulantes orales directos frente a los antagonistas de la vitamina K en pacientes con fibrilacion auricular de la practica clinica. Metodos Se realizo una revision sistematica acorde con los estandares metodologicos de Cochrane. Los resultados de la revision se publicaron segun la declaracion PRISMA. Se empleo la herramienta ROBINS-I para determinar el riesgo de sesgos. Resultados Se incluyeron datos de 27 estudios diferentes provenientes de 30 publicaciones. En los estudios con seguimiento hasta 1 ano, el apixaban (HR = 0,93; IC95%, 0,71-1,20) y dabigatran (HR = 0,95; IC95%, 0,80-1,13) no se redujo significativamente el riesgo de ictus isquemico frente a la warfarina, pero si el rivaroxaban (HR = 0,83; IC95%, 0,73-0,94). Con respecto al riesgo de hemorragias mayores, el apixaban (HR = 0,66; IC95%, 0,55-0,80) y el dabigatran (HR = 0,83; IC95%, 0,70-0,97) lo redujeron significativamente frente a la warfarina, pero no el rivaroxaban (HR = 1,02, IC95%, 0,95-1,10), aunque con heterogeneidad entre los estudios. El apixaban (HR = 0,56; IC95%, 0,42-0,73), el dabigatran (HR = 0,45; IC95%, 0,39-0,51) y el rivaroxaban (HR = 0,66; IC95%, 0,49-0,88) redujeron significativamente el riesgo de hemorragia intracraneal frente a la warfarina. El empleo de dosis bajas de anticoagulantes orales directos se asocio con una ligera mejoria del perfil de seguridad, pero con una marcada reduccion de la efectividad en la prevencion de ictus. Conclusiones Los resultados de este metanalisis indican que, en comparacion con la warfarina, la efectividad para prevenir el riesgo de ictus y de hemorragias de los anticoagulantes orales directos en los pacientes con fibrilacion auricular de la practica clinica real puede ser diferente.

Introduction and objectives To assess the effectiveness of direct oral anticoagulants vs vitamin K antagonists in real-life patients with atrial fibrillation. Methods A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA statement. The ROBINS-I tool was used to assess risk of bias. Results A total of 27 different studies publishing data in 30 publications were included. In the studies with a follow-up up to 1 year, apixaban (HR, 0.93; 95%CI, 0.71-1.20) and dabigatran (HR, 0.95; 95%CI, 0.80-1.13) did not significantly reduce the risk of ischemic stroke vs warfarin, whereas rivaroxaban significantly reduced this risk (HR, 0.83; 95%CI, 0.73-0.94). Apixaban (HR, 0.66; 95%CI, 0.55-0.80) and dabigatran (HR, 0.83; 95%CI, 0.70-0.97) significantly reduced the major bleeding risk vs warfarin, but not rivaroxaban (HR, 1.02; 95%CI, 0.95-1.10), although with a high statistical heterogeneity among studies. Apixaban (HR, 0.56; 95%CI, 0.42-0.73), dabigatran (HR, 0.45; 95%CI, 0.39-0.51), and rivaroxaban (HR, 0.66; 95%CI, 0.49-0.88) significantly reduced the risk of intracranial bleeding vs warfarin. Reduced doses of direct oral anticoagulants were associated with a slightly better safety profile, but with a marked reduction in stroke prevention effectiveness. Conclusions Data from this meta-analysis suggest that, vs warfarin, the stroke prevention effectiveness and bleeding risk of direct oral anticoagulants may differ in real-life patients with atrial fibrillation.

Introduction and objectives The epidemiology of heart failure (HF) that complicates ST-segment elevation myocardial infarction (STEMI) is not well defined. Our aim was to analyze the epidemiology and prognosis of HF that complicates STEMI treated with primary percutaneous coronary intervention (PCI). Methods Multicentre registry of 14 070 patients with STEMI treated with primary PCI from January 2010 to December 2015. Results Patients with HF were older, more frequently female, and diabetic and had chronic ischaemic heart disease. Only 10.3% of patients with STEMI treated with primary PCI had HF on admission and the majority of them had the mildest form (Killip–Kimball II 77.8%). HF was associated with high mortality (30-day mortality was 2.9% of patients in Killip–Kimball I, 9.5% of Killip–Kimball II and 17.4% in Killip–Kimball III, P Conclusions HF complicates 10.3% of patients with STEMI treated with primary PCI and it was associated with a higher risk of developing cardiogenic shock and with 30-day and 1-year mortality in 30-day survivors. In this high-risk population, primary PCI and posterior medical treatment should be prioritized to avoid worsening of HF.

Obstructive sleep apnea syndrome (OSAS) has a high prevalence in western countries. Many papers have been published with the purpose of demonstrating that OSAS acts as an arrhythmia trigger and is responsible for an increase in cardiovascular morbidity and mortality. The aim of this study was to review our knowledge on this topic. There is a lot of evidence demonstrating the relationship between OSAS and arrhythmias, but there remains a lack of an interventional randomized trial to demonstrate that by treating OSAS we can reduce arrhythmia burden. OSAS is a highly prevalent illness in western countries and is clearly related to an increase in cardiovascular mortality and morbidity. Cardiac arrhythmias are triggered by a repetitive hypoxemia, hypercapnia, acidosis, intrathoracic pressure fluctuations, reoxygenation, and arousals during apnea and hypopnea episodes. Early diagnosis and treatment of these patients can reduce further cardiovascular morbidity and mortality.

AimsDuring the COVID-19 pandemic, concern regarding its effect on the management of non-communicable diseases has been raised. However, there are no data on the impact on cardiac implantable electronic devices (CIED) implantation rates. We aimed to determine the impact of SARS-CoV2 on the monthly incidence rates and type of pacemaker (PM) and implantable cardiac defibrillator (ICD) implantations in Catalonia before and after the declaration of the state of alarm in Spain on 14 March 2020.Methods and resultsData on new CIED implantations for 2017–20 were prospectively collected by nine hospitals in Catalonia. A mixed model with random intercepts corrected for time was used to estimate the change in monthly CIED implantations. Compared to the pre-COVID-19 period, an absolute decrease of 56.5% was observed (54.7% in PM and 63.7% in ICD) in CIED implantation rates. Total CIED implantations for 2017–19 and January and February 2020 was 250/month (>195 PM and >55 ICD), decreasing to 207 (161 PM and 46 ICD) in March and 131 (108 PM and 23 ICD) in April 2020. In April 2020, there was a significant fall of 185.25 CIED implantations compared to 2018 [95% confidence interval (CI) 129.6–240.9; P ConclusionsDuring the first wave of the COVID-19 pandemic, a substantial decrease in CIED implantations was observed in Catalonia. Our findings call for measures to avoid long-term social impact.

Current European guidelines on chronic coronary syndromes recommend the use of low-dose aspirin (or clopidogrel if intolerance or contraindication occurs) throughout life. However, as the risk of recurrent vascular events is high, particularly in some patients (i.e. diffuse multivessel coronary artery disease, diabetes, recurrent myocardial infarction, peripheral artery disease, or chronic kidney disease,…), these guidelines also consider that in those patients at moderate or high risk of ischemic events, but without a high bleeding risk, dual antithrombotic therapy should be considered. According to these guidelines, treatment options for dual antithrombotic therapy in combination with aspirin may include clopidogrel 75 mg/daily, prasugrel 10 mg/daily, ticagrelor 60 mg bid or rivaroxaban 2.5 mg bid. Remarkably, despite the results of the clinical trials that sustain these recommendations clearly diverge, guidelines do not differentiate between them. However, although all these drugs have demonstrated a significant reduction in major cardiovascular events in patients with stable atherosclerotic disease, only the addition of rivaroxaban has been associated with a reduction in cardiovascular and overall mortality in the secondary analysis. This may be related to the fact that the activation of platelets and factor X plays a key role in the development of atherothrombosis, and, consequently, both targets should be considered for the appropriate management of these patients.

Introduction and objectives: Dyspnea is the most common symptom among hospitalized patients with heart failure (HF) but besides dyspnea questionnaires (which reflect the subjective patient sensation and are not fully validated in HF) there are no measurable physiological variables providing objective assessment of dyspnea in a setting of acute HF patients. Studies performed in respiratory patients suggest that the measurement of electromyographic (EMG) activity of the respiratory muscles with surface electrodes correlates well with dyspnea. Our aim was to test the hypothesis that respiratory muscles EMG activity is a potential marker of dyspnea severity in acute HF patients. Methods: Prospective and descriptive pilot study carried out in 25 adult patients admitted for acute HF. Measurements were carried out with a cardio-respiratory portable polygraph including EMG surface electrodes for measuring the activity of main (diaphragm) and accessory (scalene and pectoralis minor) respiratory muscles. Dyspnea sensation was assessed by means of the Likert 5 questionnaire. Data were recorded during 3 min of spontaneous breathing and after breathing at maximum effort for several cycles for normalizing data. An index to quantify the activity of each respiratory muscle was computed. This assessment was carried out within the first 24 h of admission, and at day 2 and 5. Results: Dyspnea score decreased along the three measured days. Diaphragm and scalene EMG index showed a positive and significant direct relationship with dyspnea score (p

Aims Frequent premature ventricular complexes (PVCs) can induce or worsen left ventricular systolic dysfunction. We aimed to investigate the influence of the baseline QRS in the response after PVC ablation in patients with depressed left ventricular ejection fraction (LVEF). Methods and results Two hundred and fifteen [59 ± 13 years old, 152 (71%) men] consecutive patients with left ventricular (LV) systolic dysfunction and frequent PVCs referred for ablation were included and followed-up for 12 months. Echocardiographic response was defined as an improvement of at least five absolute points in LVEF. Clinical, electrocardiogram, and electrophysiological characteristics were analysed. Mean baseline QRS duration was 110 ms [97–140]. Premature ventricular complex burden significantly decreased after ablation from 23% [16–33] at baseline to 1% [0–8] at 12 months, P 130 ms. Conclusions In patients with LV systolic dysfunction, intrinsic QRS duration is inversely related to the probability and the degree of echocardiographic response after frequent PVC ablation. Patients with a QRS duration >130 ms at baseline have the poorer response after ablation.

Cryoballoon ablation (CBA) has become a standard treatment for recurrent atrial fibrillation (AF). There is need for improved CBA protocols. We aimed to demonstrate that a new protocol including minimum temperature (minT) reached could reduce procedure times and complications. A new double factor protocol (DFP), based on the performance of one single shot per vein with variable duration, and conditional bonus shot, determined by time-to-effect (TTE) and minT, was compared with the conventional protocol (CP), with at least two shots per vein. Procedure parameters, complications, and efficacy were compared. We prospectively included 88 consecutive patients treated with the DFP. These were compared to the previous consecutive 69 patients treated with CP. All procedures were performed with 28-mm second-generation balloon. Acute pulmonary vein (PV) isolation was similar (98.6% vs. 98.9% in CP vs. DFP, p = 0.687). Procedure and ablation times favored DFP over CP (120 vs. 134 min, p = 0.003; and 1051 vs. 1475 s, p

Background The diagnostic accuracy of incremental atrial pacing (IP) to determine complete cavo-tricuspid isthmus (CTI) block during typical atrial flutter (AFL) ablation is limited by both an extensive/nonlinear ablation and/or the presence of intra-atrial conduction delay elsewhere in the right atrium. We examined the diagnostic performance of an IP variant based on the assessment of the atrial potentials adjacent to the ablation line which aims at overcoming both limitations. Methods From a prospective population of 108 consecutive patients, 15 were excluded due to observation of inconclusive CTI ablation potentials precluding for a straight comparison between the IP maneuver and its variant. In the remaining 93, IP was performed from the low lateral right atrium and the coronary sinus ostium, with the ablation catheter positioned both at the CTI line and adjacent (

Aims Sudden cardiac death (SCD) risk estimation in patients referred for cardiac resynchronization therapy (CRT) remains a challenge. By CRT-mediated improvement of left ventricular ejection fraction (LVEF), many patients loose indication for primary prevention implantable cardioverter-defibrillator (ICD). Increasing evidence shows the importance of myocardial scar for risk prediction. The aim of this study was to investigate the prognostic impact of myocardial scar depending on the echocardiographic response in patients undergoing CRT. Methods and results Patients with indication for CRT were prospectively enrolled. Decision about ICD or pacemaker implantation was based on clinical criteria. All patients underwent delayed-enhancement cardiac magnetic resonance imaging. Median follow-up duration was 45 (24–75) months. Primary outcome was a composite of sustained ventricular arrhythmia, appropriate ICD therapy, or SCD. A total of 218 patients with LVEF 25.5 ± 6.6% were analysed [158 (73%) male, 64.9 ± 10.7 years]. Myocardial scar was observed in 73 patients with ischaemic cardiomyopathy (ICM) (95% of ICM patients); in 62 with non-ischaemic cardiomyopathy (45% of these patients); and in all but 1 of 36 (17%) patients who reached the primary outcome. Myocardial scar was the only significant predictor of primary outcome [odds ratio 27.7 (3.8–202.7)], independent of echocardiographic CRT response. A total of 55 (25%) patients died from any cause or received heart transplant. For overall survival, only a combination of the absence of myocardial scar with CRT response was associated with favourable outcome. Conclusion Malignant arrhythmic events and SCD depend on the presence of myocardial scar but not on CRT response. All-cause mortality improved only with the combined absence of myocardial scar and CRT response.

The present article provides an update on anticoagulant treatment in patients with atrial fibrillation in distinct clinical scenarios requiring particular considerations, such as ischaemic heart disease, electrical cardioversion, pulmonary vein ablation, the presence of valvular disease with or without prosthetic valves, and renal insufficiency, as well as old age and frailty. In patients with non-valvular atrial fibrillation, the presence of renal insufficiency increases both thrombotic and haemorrhagic risk. In mild and moderate stages, direct-acting anticoagulants confer a greater benefit than warfarin, although they usually require dose adjustment. In renal failure/dialysis, there is no solid evidence that warfarin is beneficial and the use of direct-acting anticoagulants is not recommended. Because of its pathophysiology, oral anticoagulation could have a beneficial effect in patients with heart disease. However, vitamin K antagonists have not shown a satisfactory risk-benefit ratio. In contrast, direct-acting anticoagulants, at reduced doses, could have a beneficial effect in this scenario in association with antiplatelet agents. The use of direct-acting anticoagulants prior to electrical cardioversion in patients with non-valvular atrial fibrillation seems to be associated with a risk of cardioembolic events that is at least comparable to that of vitamin K antagonists. Their use avoids delay in the application of electrical cardioversion in patients without adequate INR levels. In the context of their use before and after atrial fibrillation ablation, dabiga-tran and rivaroxaban have demonstrated at least non-inferiority with vitamin K antagonists in terms of safety. In patients with any type or grade of valvular disease and atrial fibrillation, the indication of antithrombo-tic treatment must be evaluated in the same way as in patients with atrial fibrillation and no valvular di-sease. Whenever anticoagulation is required, direct-acting anticoagulants are the treatment of choice in nearly all situations, except in patients with mechanical valves or who have significant rheumatic mitral disease, who should be treated with vitamin K antagonists. The choice of appropriate antithrombotic stra-tegy in frail elderly patients is complex and involves multiple factors beyond assessment of embolic and haemorrhagic risk. Comprehensive geriatric assessment is essential for an individualised final decision. Moreover, any such decision should be consensus-based and periodically reviewed. Direct-acting anticoa-gulants could be the most beneficial alternative in most elderly patients with non-valvular atrial fibrillation.

Objectives The aim of this study was to analyze whether scar characterization could improve the risk stratification for life-threatening ventricular arrhythmias and sudden cardiac death (SCD). Background Among patients with a cardiac resynchronization therapy (CRT) indication, appropriate defibrillator (CRT-D) therapy rates are low. Methods Primary prevention patients with a class I indication for CRT were prospectively enrolled and assigned to CRT-D or CRT pacemaker according to physician’s criteria. Pre-procedure contrast-enhanced cardiac magnetic resonance was obtained and analyzed to identify scar presence or absence, quantify the amount of core and border zone (BZ), and depict BZ distribution. The presence, mass, and characteristics of BZ channels in the scar were recorded. The primary endpoint was appropriate defibrillator therapy or SCD. Results 217 patients (39.6% ischemic) were included. During a median follow-up of 35.5 months (12 to 62 months), the primary endpoint occurred in 25 patients (11.5%) and did not occur in patients without myocardial scar. Among patients with scar (n = 125, 57.6%), those with implantable cardioverter-defibrillator (ICD) therapies or SCD exhibited greater scar mass (38.7 ± 34.2 g vs. 17.9 ± 17.2 g; p Conclusions The presence, extension, heterogeneity, and qualitative distribution of BZ tissue of myocardial scar independently predict appropriate ICD therapies and SCD in CRT patients.