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Optimal medical therapy decreases mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. Women have been underrepresented in clinical trials and not specifically evaluated. This study aimed to compare the safety and effectiveness of drug titration in women vs men.This post hoc gender study of the ETIFIC multicenter randomized trial included hospitalized patients with new-onset HF with reduced ejection fraction and New York Heart Association II-III and no contraindications to beta-blockers. A structured 4-month titration process was implemented in HF clinics. The primary endpoint was the mean relative dose (% of target dose) of beta-blockers achieved by women vs men. Secondary endpoints included the mean relative doses of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists, adverse events, and other clinical outcomes at 6 months.A total of 320 patients were included, 83 (25.93%) women and 237 (74.06%) men (76 vs 213 analyzed). The mean±standard deviation of the relative doses achieved by women vs men were as follows: beta-blockers 62.08%±30.72% vs 64.4%±32.77%, with a difference of-2.32% (95%CI,-10.58-5.94), P = .580; and mineralocorticoid receptor antagonists 79.85%±27.72% vs 67.29%±31.43%, P =.003. No other differences in drug dosage were found. Multivariate analysis showed nonsignificant differences. CV mortality was 1 (1.20%) vs 3 (1.26%), P=1, and HF hospitalizations 0 (0.00%) vs 10 (4.22%), P=.125.In a post hoc analysis from the HF-titration ETIFIC trial, we found nonsignificant gender differences in drug dosage, cardiovascular mortality, and HF hospitalizations. Trial registry number: NCT02546856.

Cardiorenal clinics; Cardiorenal disease; Cardiorenal program Clínicas cardiorrenales; Enfermedad cardiorrenal; Programa cardiorrenal Clíniques cardiorenals; Malaltia cardiorenal; Programa cardiorenal The population with concomitant heart and kidney disease (often termed ‘cardiorenal’ disease) is expected to grow, significantly impacting public health and healthcare utilization. Moreover, the cardiorenal nexus encompasses a bidirectional relationship that worsens prognosis and may complicate pharmacological management in often elderly and frail patients. Therefore, a more cohesive multidisciplinary team approach aiming to provide holistic, coordinated and specialized care would be a positive shift towards improving patient outcomes and optimizing healthcare resources. This article aims to define the organizational aspects and key elements for setting up a multidisciplinary cardiorenal clinical program as a potential healthcare model adapted to the particular characteristics of patients with cardiorenal disease.

Instituto de Salud Carlos III (ISCIII), European Regional Development Fund/European Social Fund "A way to make Europe"/" Investing in your future" [PI18/0004, PI20/0320, PT17/0015/0043]; ISCIII; MCIN; Pro-CNIC Foundation; Severo Ochoa Centers of Excellence program [CEX2020-001041-S]; ISCIII [CM20/00101], Frutos F. de, Ochoa JP, Navarro-Peñalver M, Baas A, Bjerre JV, Zorio E, Méndez I, Lorca R, Verdonschot JAJ, García-Granja PE, Bilinska Z, Fatkin D, Fuentes-Cañamero ME, García-Pinilla JM, García-Álvarez MI, Girolami F, Barriales-Villa R, Díez-López C, Lopes LR, Wahbi K, García-Álvarez A, Rodríguez-Sánchez I, Rekondo-Olaetxea J, Rodríguez-Palomares JF, Gallego-Delgado M, Meder B, Kubanek M, Hansen FG, Restrepo-Córdoba MA, Palomino-Doza J, Ruiz-Guerrero L, Sarquella-Brugada G, Perez-Perez AJ, Bermúdez-Jiménez FJ, Ripoll-Vera T, Rasmussen TB, Jansen M, Sabater-Molina M, Elliot PM, Garcia-Pavia P; European Genetic Cardiomyopathies Initiative Investigators

AIMS: Although acute heart failure (AHF) with volume overload is treated with loop diuretics, their dosing and type of administration are mainly based upon expert opinion. A recent position paper from the Heart Failure Association (HFA) proposed a step-wise pharmacologic diuretic strategy to increase the diuretic response and to achieve rapid decongestion. However, no study has evaluated this protocol prospectively. METHODS AND RESULTS: The Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure (ENACT-HF) study is an international, multicentre, non-randomized, open-label, pragmatic study in AHF patients on chronic loop diuretic therapy, admitted to the hospital for intravenous loop diuretic therapy, aiming to enrol 500 patients. Inclusion criteria are as follows: at least one sign of volume overload (oedema, ascites, or pleural effusion), use=40mg of furosemide or equivalent for >1month, and a BNP>250ng/L or an N-terminal pro-B-type natriuretic peptide>1000pg/L. The study is designed in two sequential phases. During Phase 1, all centres will treat consecutive patients according to the local standard of care. In the Phase 2 of the study, all centres will implement a standardized diuretic protocol in the next cohort of consecutive patients. The protocol is based upon the recently published HFA algorithm on diuretic use and starts with intravenous administration of two times the oral home dose. It includes early assessment of diuretic response with a spot urinary sodium measurement after 2h and urine output after 6h. Diuretics will be tailored further based upon these measurements. The study is powered for its primary endpoint of natriuresis after 1day and will be able to detect a 15% difference with 80% power. Secondary endpoints are natriuresis and diuresis after 2days, change in congestion score, change in weight, in-hospital mortality, and length of hospitalization. CONCLUSIONS: The ENACT-HF study will investigate whether a step-wise diuretic approach, based upon early assessment of urinary sodium and urine output as proposed by the HFA, is feasible and able to improve decongestion in AHF with volume overload.

Resumen La hipomagnesemia, definida como cifras de magnesio (Mg) por debajo de 1,5 mg/dl, es un trastorno electrolitico infradiagnosticado en pacientes con insuficiencia cardiaca (IC), que se asocia con la aparicion de arritmias ventriculares y el desarrollo de IC, siendo su relacion con la mortalidad mas controvertida. Su aparicion se relaciona con el uso de algunos farmacos, como los inhibidores de la bomba de protones, diureticos o quelantes del potasio, asi como con otras situaciones como el alcoholismo, trastornos malabsortivos o desnutricion. La deteccion de la hipomagnesemia en pacientes con IC requiere de la monitorizacion periodica del Mg junto con la funcion renal y el resto de los iones, para valorar su gravedad y plantear la correccion mediante suplementos orales y, menos frecuentemente, intravenosos. En esta revision se abordan algunos de los principales aspectos fisiopatologicos, de diagnostico y tratamiento de la hipomagnesemia en los pacientes con IC.

espanolLas valvulopatias derechas han ocupado tradicionalmente un lugar secundario en el manejo de la patologia valvular, por presentar un mayor tiempo de latencia asintomatico y ser consideradas «benignas». Los avances recientes, especialmente en el caso de la insuficiencia tricuspide, han aumentado el interes en un diagnostico mas temprano y un tratamiento eficaz que permita modificar la historia natural de la enfermedad. La etiologia puede ser congenita o adquirida. En el caso de las insuficiencias (pulmonar y tricuspide), la causa mas frecuente es la funcional, secundaria a la dilatacion del ventriculo derecho o de la arteria pulmonar, respectivamente. En la estenosis tricuspide, la etiologia mas prevalente es la reumatica y en la estenosis pulmonar la congenita. Predomina la clinica de insuficiencia cardiaca derecha retrograda, caracterizada por la congestion sistemica venosa (edema en miembros inferiores, ascitis, hepatoesplenomegalia) y la anterograda en forma de bajo gasto (disnea fundamentalmente). La congestion pulmonar no es frecuente y aparece en casos de afectacion concomitante izquierda. El diagnostico se basa en el ecocardiograma, que permite analizar la anatomia valvular y el grado de severidad. El tratamiento quirurgico se reserva para casos resistentes al tratamiento medico (diureticos), siendo el tratamiento percutaneo una alternativa en casos seleccionados. EnglishRight-sided valve diseases have traditionally taken a secondary place in the management of valve disease, as they have a longer asymptomatic latency time and are considered “benign”. Recent advances, especially in tricuspid valve regurgitation, have increased the interest in earlier diagnosis and effective treatment to change the natural history of the disease. The aetiology can be congenital or acquired. The most common cause of pulmonary and tricuspid valve regurgitation is functional, secondary to dilatation of the right ventricle or pulmonary artery, respectively. The most prevalent aetiology is rheumatic in tricuspid valve stenosis, and congenital in pulmonary valve stenosis. Retrograde right heart failure symptoms predominate, characterised by systemic venous congestion (oedema in the lower limbs, ascites, hepatosplenomegaly) and anterograde congestion in the form of low output (fundamentally dyspnoea). Pulmonary congestion is rare and appears in cases of concomitant left-sided involvement. Diagnosis is based on echocardiography, which enables study of the valve anatomy and degree of severity. Surgical treatment is reserved for cases that are resistant to medical treatment (diuretics), and percutaneous treatment is an alternative in selected cases.

Resumen Introduccion y objetivos Las infecciones relacionadas con dispositivos intracardiacos (i-DIC) son potencialmente graves y requieren un diagnostico precoz y certero. Los objetivos del estudio son analizar el rendimiento de la tomografia por emision de positrones con tomografia computarizada (PET/TC) ante sospecha de i-DIC y los cambios que induce sobre el diagnostico inicial e identificar el escenario con mayor beneficio de uso. Metodos Estudio retrospectivo de pacientes valorados mediante PET/TC por sospecha de i-DIC desde 2011 a 2018. Se calcularon valores de rendimiento diagnostico de la PET/TC y la concordancia entre diagnostico inicial y post-PET y el diagnostico definitivo. Se analizaron los cambios diagnosticos considerando la sospecha clinica inicial para identificar a los pacientes con mayor beneficio. Resultados Se incluyo a 44 pacientes. La prevalencia de endocarditis fue del 57%. La sensibilidad y la especificidad de la 18F-FDG-PET/TC para el diagnostico de endocarditis fueron 0,84 y 0,95. El diagnostico tras la PET mejoro el inicial un 45%. De los pacientes con sospecha de infeccion local, la PET/TC reclasifico adecuadamente al 57% por deteccion de infeccion profunda. Conclusiones La PET/TC muestra elevado rendimiento diagnostico ante la sospecha de i-DIC y mejora significativamente el diagnostico convencional, sobre todo en el grupo de pacientes con sospecha de infeccion limitada al bolsillo.

Introduction and objectives Cardiac device-related infections (CDRI) may be life-threatening and require early and accurate diagnosis. The aims of this study were to analyze the performance of positron emission tomography-computed tomography (PET/CT) in suspected CDRI, to assess changes to the initial diagnosis, and to identify a clinical subgroup deriving the greatest benefit from this imaging modality. Methods Retrospective study including patients evaluated by PET/CT for suspected CDRI from 2011 to 2018. We assessed PET/CT performance and the agreement between the initial, post-PET and definitive diagnoses. We also assessed changes in the diagnosis, depending on initial clinical suspicion, to identify patients deriving the greatest benefit from PET/CT. Results We included 44 patients. The prevalence of endocarditis was 57%. The sensitivity and specificity of PET/CT for the diagnosis of infective endocarditis were 0.84 and 0.95, respectively. Post-PET diagnosis improved the initial diagnosis by 45%. PET/CT correctly reclassified 57% of patients with initial suspicion of generator pocket infection by detecting lead infection. Conclusions PET/CT showed high diagnostic performance in suspected of CDRI and significantly improved the conventional diagnostic approach, especially in patients with initial suspicion of focal infection.

Cardiac amyloidosis (CA) is produced by amyloid fiber deposition in the myocardium. The most frequent forms are those caused by light chains (AL) and transthyretin (ATTR). Our objective was to describe the diagnosis, treatment and outcomes of CA in a specialized Spanish center.We included all patients diagnosed with CA in Hospital Universitario Puerta de Hierro Majadahonda from May 2008 to September 2018. We analyzed their clinical characteristics, outcomes, and survival.We included 180 patients with CA, of whom 64 (36%) had AL (50% men; mean age, 65±11 years) and 116 had ATTR (72% men; mean age 79±11 years; 18 with hereditary ATTR). The most common presentation was heart failure in both groups (81% in AL and 45% in ATTR, P.01). Other forms of presentation in ATTR patients were atrial arrhythmias (16%), conduction disorders (6%), and incidental finding (6%); 70 patients (40%), had a previous alternative cardiac diagnosis. Diagnosis was noninvasive in 75% of ATTR patients. Diagnostic delay was higher in ATTR (2.8±4.3 vs 0.6±0.7 years, P.001), but mortality was greater in AL patients (48% vs 32%, P=.028). Independent predictors of mortality were AL subtype (HR, 6.16; 95%CI, 1.56-24.30; P=.01), female sex (HR, 2.35; 95%CI, 1.24-4.46; P=.01), and NYHA functional class III-IV (HR, 2.07; 95%CI, 1.11-3.89; P=.02).CA is a clinical challenge, with wide variability in its presentation depending on the subtype, leading to diagnostic delay and high mortality. Improvements are needed in the early diagnosis and treatment of these patients.

Novel pharmacologic treatment options reduce mortality and morbidity in a cost-effective manner in patients with heart failure (HF). Undisputedly, the effective implementation of these agents is an essential element of good clinical practice, which is endorsed by the European Society of Cardiology (ESC) guidelines on acute and chronic HF. Yet, physicians struggle to implement these therapies as they have to balance the true and/or perceived risks versus their substantial benefits in clinical practice. Any worsening of biomarkers of renal function is often perceived as being disadvantageous and is in clinical practice one of the most common reasons for ineffective drug implementation. However, even in this context, they clearly reduce mortality and morbidity in HF with reduced ejection fraction (HFrEF) patients, even in patients with poor renal function. Furthermore these agents are also beneficial in HF with mildly reduced ejection fraction (HFmrEF) and sodium-glucose cotransporter 2 (SGLT2) inhibitors more recently demonstrated a beneficial effect in HF with preserved ejection fraction (HFpEF). The emerge of several new classes (angiotensin receptor-neprilysin inhibitor [ARNI], SGLT2 inhibitors, vericiguat, omecamtiv mecarbil) and the recommendation by the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic HF of early initiation and titration of quadruple disease-modifying therapies (ARNI/angiotensin-converting enzyme inhibitor + beta-blocker + mineralocorticoid receptor antagonist and SGLT2 inhibitor) in HFrEF increases the likelihood of treatment-induced changes in renal function. This may be (incorrectly) perceived as deleterious, resulting in inertia of starting and uptitrating these lifesaving therapies. Therefore, the objective of this consensus document is to provide advice of the effect HF drugs on renal function.

Resumen Introduccion y objetivos La endocarditis infecciosa (EI) es una enfermedad compleja con elevada mortalidad. La evaluacion pronostica es esencial en el tratamiento de la enfermedad; sin embargo, las guias internacionales no aportan una evaluacion objetiva del riesgo individual. Se desarrollo un modelo predictivo de mortalidad hospitalaria en EI izquierda combinando las variables pronosticas propuestas por la guia europea. Metodos Se utilizaron 2 cohortes prospectivas de pacientes con EI izquierda. La cohorte 1 (n = 1.002) se aleatorizo 2:1 para obtener 2 muestras: muestra de derivacion (n = 688) y muestra de validacion interna (n = 314). La cohorte 2 (n = 133) se utilizo para la validacion externa. Resultados El modelo incluyo edad, endocarditis protesica, comorbilidades, insuficiencia cardiaca, insuficiencia renal, shock septico, Estafilococo aureus, hongos, complicaciones perianulares, disfuncion ventricular y vegetaciones como predictores independientes de mortalidad hospitalaria. El modelo mostro buena capacidad discriminativa (area bajo la curva ROC = 0,855; IC95%, 0,825-0,885) y calibracion (p valor test Hosmer-Lemeshow = 0,409) que se ratificaron en la validacion interna (area bajo curva ROC = 0,823; IC95%, 0,774-0,873) y externa (area bajo curva ROC = 0,753; IC95%, 0,659-0,847). Para la muestra de validacion interna (mortalidad 29,9%) el modelo predijo una mortalidad de 30,7% (IC95%, 27,7-33,7) y para la muestra de validacion externa (mortalidad 27,1%) 26,4% (IC95%, 22,2-30,5). Conclusiones Se presenta un modelo predictivo de mortalidad hospitalaria en EII basado en las variables pronosticas propuestas por la guia europea de EI y con alta capacidad discriminativa.

Resumen: Introducción: en los procedimientos de extracción de electrodos, la vía femoral se usa cuando la vía superior ha fracasado. Objetivo: describir la incidencia, el éxito, las complicaciones y los predictores de uso de la vía femoral. Métodos: se realizó un análisis de la incidencia del uso de la vía femoral y los factores predictores en pacientes a quienes se les realizó extracción de electrodos entre noviembre de 2011 y noviembre de 2017. Resultados: se incluyeron 85 pacientes, con edad media de 62,36 ± 11,15 años. El 38,9% de los dispositivos eran marcapasos. Se extrajeron 135 electrodos, 59,3% de fijación pasiva. La mediana de tiempo desde el implante fue de 102 (60-174) meses. Se empleó la ruta femoral en el 25,9% de los procedimientos. Se obtuvo éxito clínico en el 92,9% de los pacientes. La extracción no fue exitosa en el 22,7% de los procedimientos cuando se usó la vía femoral, en comparación con el 1,6% cuando se usó la vía superior (p 0,004). La extracción no fue completa en el 36,4% de los procedimientos cuando se empleó la vía femoral en comparación con el 9,5% por vía superior (p 0,007).Los factores que predijeron el empleo de la ruta femoral fueron la presencia de electrodos de fijación pasiva [OR IC 95% 13,69 (3,06-62,5) p 0,001] y el tiempo desde el implante del electrodo [OR IC 95% por cada 10 meses 1,04 (1,00-1,09) p 0,044]. Conclusiones: se empleó la ruta femoral en el 25,9% de los procedimientos. No fue eficaz en el 22,7% de las intervenciones. Los factores que predijeron su utilización fueron la presencia de electrodos de fijación pasiva y el tiempo desde el implante del electrodo. Abstract: Introduction: The femoral route is used in electrode removal procedures when the upper route has failed. Objective: To describe the incidence, success rate, complications and predictive factors for the use of the femoral route. Methods: An analysis was performed on the incidence of use of the femoral route and the predictive factors in patients in whom electrode removal was carried out between November 2011 and November 2017. Results: The study included 85 patients with a mean age of 62.36 ± 11.5 years. Pacemakers made up 38.9% of the devices. A total of 135 electrodes, 59.3% of passive fixation, were removed. The median time since the implant was 102 (60-174) months. The femoral route was used in 25.9% of the procedures. Clinical success was achieved in 92.9% of the patients. The removal was not successful in 22.7% of the procedures when the femoral route was used, compared to 1.6% when the upper route was used (P = .004). The removal was not completed in 36.4% of the procedures when the femoral route was used, compared to 9.5% with the upper route (P = .007).The factors that predicted the use of the femoral route were the presence of passive-fixation electrodes (OR = 13.69: 95% CI; 3.06 – 62.5, P = .001), and the time since the electrodes were implanted (OR = 1.04, 95% CI; 1.00 – 1.09, P = .044, for every 10 months). Conclusions: The femoral route was employed in 25.9% of the procedures. It was not effective in 22.7% of the interventions. The factors that predicted its use were the presence of passive-fixation electrodes and the time since the electrode implant.

Resumen La insuficiencia cardiaca es una entidad compleja, que conlleva elevada morbilidad y mortalidad y cuyo curso y evolucion son inciertos y dificiles de predecir. Este trabajo, impulsado por las Secciones de Insuficiencia Cardiaca y Cardiologia Geriatrica de la Sociedad Espanola de Cardiologia, aborda los diferentes aspectos relacionados con los cuidados paliativos en el campo de la insuficiencia cardiaca, via final comun de la mayoria de las enfermedades cardiovasculares. Tambien establece un consenso y una serie de recomendaciones con el objetivo de reconocer y comprender la necesidad de implementar y aplicar, de modo progresivo, este tipo de cuidados a lo largo del curso de la enfermedad, y no unicamente en sus estadios avanzados, para mejorar la atencion que reciben los pacientes y su calidad de vida. La finalidad es mejorar y adecuar los tratamientos a las necesidades y los deseos de cada paciente, que debe contar con informacion adecuada y ser participe de la toma de decisiones.

Mortality and re-admission rates for decompensated acute heart failure (AHF) is increasing overall and risk stratification might be challenging. We sought to evaluate the prognostic role of systemic venous ultrasonography in patients hospitalized for AHF. We prospectively recruited 74 AHF patients with a NT-proBNP level above 500 pg/mL. Then, multi-organ ultrasound assessments (lung, inferior vena cava (IVC), pulsed-wave Doppler (PW-Doppler) of hepatic, portal, intra-renal and femoral veins) were performed at admission, discharge, and follow-up (for 90 days). We also calculated the Venous Excess Ultrasound System (VExUS), a new score of systemic congestion based on IVC dilatation and pulsed-wave Doppler morphology of hepatic, portal and intra-renal veins. An intra-renal monophasic pattern (area under the curve (AUC) 0.923, sensitivity (Sn) 90%, specificity (Sp) 81%, positive predictive value (PPV) 43%, and negative predictive value (NPV) 98%), a portal pulsatility > 50% (AUC 0.749, Sn 80%, Sp 69%, PPV 30%, NPV 96%) and a VExUS score of 3 corresponding to severe congestion (AUC 0.885, Sn 80%, Sp 75%, PPV 33%, and NPV 96%) predicted death during hospitalization. An IVC above 2 cm (AUC 0.758, Sn 93.l% and Sp 58.3) and the presence of an intra-renal monophasic pattern (AUC 0. 834, sensitivity 0.917, specificity 67.4%) in the follow-up visit predicted AHF-related re-admission. Additional scans during hospitalization or the calculation of a VExUS score probably adds unnecessary complexity to the assessment of AHF patients. In conclusion, VExUS score does not contribute to the guidance of therapy or the prediction of complications, compared with the presence of an IVC greater than 2 cm, a venous monophasic intra-renal pattern or a pulsatility > 50% of the portal vein in AHF patients. Early and multidisciplinary follow-up visits remain necessary for the improvement of the prognosis of this highly prevalent disease.

Endomyocardial biopsy (EMB) is the only technique able to establish an etiological diagnosis of myocarditis or inflammatory cardiomyopathy (ICM). The aim of this study was to analyze the clinical profile, outcomes, and prognostic factors of patients with suspected myocarditis/ICM undergoing EMB.We retrospectively analyzed the clinical characteristics, histological findings, and follow-up data of all patients with suspected myocarditis or ICM who underwent EMB between 1997 and 2019 in a Spanish tertiary hospital. The diagnostic yield was compared using the Dallas criteria vs immunohistochemical criteria (IHC).A total of 99 patients underwent EMB (67% male; mean age, 42±15 years; mean left ventricular ejection fraction [LVEF], 34%±14%). Myocarditis or ICM was confirmed in 28% with application of the Dallas criteria and in 54% with the IHC criteria (P.01). Lymphocytic myocarditis was diagnosed in 47 patients, eosinophilic myocarditis in 6, sarcoidosis in 3, and giant cell myocarditis in 1 patient. After a median follow-up of 18 months, 23 patients (23%) required heart transplant (HTx), a left ventricular assist device (LVAD), and/or died. Among the patients with IHC-confirmed myocarditis, 21% required HTx/LVAD or died vs 7% of those without inflammation (P=.056). The factors associated with a worse prognosis were baseline LVEF ≤ 30%, left ventricular end-diastolic diameter ≥ 60mm, and NYHA III-IV, especially in the presence of inflammation.EMB allows an etiological diagnosis in more than half of patients with suspected myocarditis/ICM when IHC techniques are used. IHC-confirmed inflammation adds prognostic value and helps to identify patients with a higher probability of developing complications.

Despite the lack of specific guidelines, surgery has been considered mandatory to treat infective endocarditis (IE) in patients with an ascending aortic prosthetic graft (AAPG), especially when periprosthetic complications are present ([1][1],[2][2]). The indication for surgical treatment contained

Objective: Cardiac amyloid infiltration can lead to systolic heart failure (HF) or to conduction disorders (CD). Patients with transthyretin (ATTR) amyloidosis are particularly exposed. We ...

Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.

Introducción y objetivos La amiloidosis cardiaca (AC) se produce por depósito de fibras de amiloide en el miocardio. Las formas más frecuentes son la amiloidosis por cadenas ligeras (AL) y por transtiretina (ATTR). Nuestro objetivo es describir la experiencia en el diagnóstico, tratamiento y pronóstico en un centro especializado español. Métodos Se incluyeron todos los pacientes diagnosticados de AC en el XXXX1 desde mayo de 2008 a septiembre de 2018 y se analizaron sus características clínicas, evolución y supervivencia. Resultados Se incluyeron 180 pacientes con AC, de los cuales, 64 (36%) eran AL (50% varones;65±11 años) y 116 ATTR (72% varones;79±11 años, 19 con ATTR hereditaria). La forma de presentación más frecuente fue la insuficiencia cardiaca en ambos grupos (81% AL y 45% ATTR;p

[Abstract] Background. Available information about prognostic implications of potassium levels alteration in the setting of acute heart failure (AHF) is scarce. Objectives. We aim to describe the prevalence of dyskalemia (hypo or hyperkalemia), its dynamic changes during AHF-hospitalization, and its long-term clinical impact after hospitalization. Methods. We analyzed 1779 patients hospitalized with AHF who were included in the REDINSCOR II registry. Patients were classified in three groups, according to potassium levels both on admission and discharge: hypokalemia (potassium 5 mEq/L). Results. The prevalence of hypokalemia and hyperkalemia on admission was 8.2 and 4.6%, respectively, and 6.4 and 2.7% at discharge. Hyperkalemia on admission was associated with higher in-hospital mortality (OR = 2.32 [95% CI: 1.04–5.21] p = 0.045). Among patients with hypokalemia on admission, 79% had normalized potassium levels at discharge. In the case of patients with hyperkalemia on admission, 89% normalized kalemia before discharge. In multivariate Cox regression, dyskalemia was associated with higher 12-month mortality, (HR = 1.48 [95% CI, 1.12–1.96], p = 0.005). Among all patterns of dyskalemia persistent hypokalemia (HR = 3.17 [95% CI: 1.71–5.88]; p

The protein titin determines cardiomyocyte contraction and truncating variants in the titin gene (TTN) are the most common cause of dilated cardiomyopathy (DCM). Different to truncations, missense variants inTTNare currently classified as variants of uncertain significance due to their high frequency in the population and the absence of functional annotation. Here, we report the regulatory role of conserved, mechanically active titin cysteines, which, contrary to current views, we uncover to be reversibly oxidized in basal conditions leading to isoform- and force-dependent modulation of titin stiffness and dynamics. Building on our functional studies, we demonstrate that missense mutations targeting a conserved titin cysteine alter myocyte contractile function and cause DCM in humans. Our findings have a direct impact on genetic counselling in clinical practice.One sentence summaryMutations targeting cysteines key to the mechanoredox control of titin cause human dilated cardiomyopathy

Background: Urinary sodium excretion predicts long-term adverse events after discharge in patients with acute heart failure (AHF). The role of natriuresis as an early marker of poor diuretic response during an AHF episode has been scarcely investigated. We sought to evaluate whether early natriuresis or its change during heart failure hospitalization is associated with the development of in-hospital diuretic resistance (DR). Methods: This was a prospective, observational single center study of consecutive patients with AHF. Urine electrolytes were estimated from a spot urine sample within the first 6 hours following the first diuretic dose and 48 hours after admission. In-hospital DR was defined as poor diuretic response based on diuretic efficiency metrics and persistent congestion despite an intensive diuretic protocol. Results: Between January and December 2018, 143 patients were admitted for AHF. Of these, 102 fulfilled the inclusion criteria (60% males, median age 77 years [interquartile range [IQR]: 69-83), and 20 patients (19.6%) met the definition of DR. Early natriuresis was lower in patients with DR than in non-resistant patients (46 mEq/L [IQR: 38.5-80.0] vs 97.5 mEq/L [IQR: 70.5-113.5], P

Introduction and objectives Infective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines. Methods Two prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n = 1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n = 688), and a validation sample for internal validation (n = 314). Cohort 2 (n = 133) was used for external validation. Results The model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve = 0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test = 0.409), which were ratified in the internal (area under the ROC curve = 0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve = 0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5). Conclusions A predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability.

Cardiac device-related infections (CDRI) may be life-threatening and require early and accurate diagnosis. The aims of this study were to analyze the performance of positron emission tomography-computed tomography (PET/CT) in suspected CDRI, to assess changes to the initial diagnosis, and to identify a clinical subgroup deriving the greatest benefit from this imaging modality.Retrospective study including patients evaluated by PET/CT for suspected CDRI from 2011 to 2018. We assessed PET/CT performance and the agreement between the initial, post-PET and definitive diagnoses. We also assessed changes in the diagnosis, depending on initial clinical suspicion, to identify patients deriving the greatest benefit from PET/CT.We included 44 patients. The prevalence of endocarditis was 57%. The sensitivity and specificity of PET/CT for the diagnosis of infective endocarditis were 0.84 and 0.95, respectively. Post-PET diagnosis improved the initial diagnosis by 45%. PET/CT correctly reclassified 57% of patients with initial suspicion of generator pocket infection by detecting lead infection.PET/CT showed high diagnostic performance in suspected of CDRI and significantly improved the conventional diagnostic approach, especially in patients with initial suspicion of focal infection.

The name of author M. Alejandra Restrepo-Cordoba was parsed incorrectly (in such a way as to suggest that her surname is "Alejandra Restrepo-Cordoba") in this article as published.

Review [Abstract] Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making. [Resumen] La insuficiencia cardiaca es una entidad compleja, que conlleva elevada morbilidad y mortalidad y cuyo curso y evolución son inciertos y difíciles de predecir. Este trabajo, impulsado por las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología, aborda los diferentes aspectos relacionados con los cuidados paliativos en el campo de la insuficiencia cardiaca, vía final común de la mayoría de las enfermedades cardiovasculares. También establece un consenso y una serie de recomendaciones con el objetivo de reconocer y comprender la necesidad de implementar y aplicar, de modo progresivo, este tipo de cuidados a lo largo del curso de la enfermedad, y no únicamente en sus estadios avanzados, para mejorar la atención que reciben los pacientes y su calidad de vida. La finalidad es mejorar y adecuar los tratamientos a las necesidades y los deseos de cada paciente, que debe contar con información adecuada y ser partícipe de la toma de decisiones.