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This study aimed to assess, in patients with cardiogenic shock secondary to unprotected left main coronary artery-related myocardial infarction (ULMCA-related AMICS), the incidence and predictors of no recovery of left ventricular function during the admission.This was an observational study conducted at two tertiary care centres (2012-20). The main outcome measured was death or requirement for heart transplantation (HT) or left ventricular assist devices (LVAD) during the admission. A total of 70 patients were included. Percutaneous coronary intervention (PCI) was successful in 53/70 patients (75.7%). The combined endpoint of death or requirement of HT or LVAD during the admission occurred in 41/70 patients (58.6%). The highest incidence of the primary endpoint was observed among patients with profound shock and occluded left main coronary artery (LMCA) (20/23, 87%, P 0.001). Although a successful PCI reduced the incidence of the event in the whole cohort (51.9% vs. 82.4% in failed PCI, P = 0.026), this association was not observed among this last group of complex patients (86.7% vs. 87.5% in failed PCI, P = 0.731). The predictive model included left ventricular ejection fraction, baseline ULMCA Thrombolysis In Myocardial Infarction flow, and severity of shock and showed an optimal ability for predicting death or requirements for HT or LVAD during the admission (area under the curve 0.865, P 0.001).ULMCA-related AMICS was associated with a high in-hospital mortality or need for HT or LVAD. Prognosis was especially poor among patients with profound shock and baseline occluded LMCA, with a low probability of recovery regardless of successful PCI.

Prasugrel and ticagrelor, new P2Y12-ADP receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events in patients with an acute coronary syndrome. However, evidence is lacked about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared to oral aspirin. Recently, we demonstrated in healthy volunteers that the administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin. Loading dose of LA achieves platelet inhibition faster, and with less variability than aspirin. However, there are no data of this issue in patients with an ST-segment elevation myocardial infarction (STEMI). This is a prospective, randomized, multicenter, open platelet function study conducted in STEMI patients. Subjects were randomly assigned to receive a loading dose (LD) of intravenous LA 450 mg plus oral ticagrelor 180 mg, or LD of aspirin 300 mg plus ticagrelor 180 mg orally. Platelet function was evaluated at baseline, 30 min, 1 h, 4 h and 24 h using multiple electrode aggregometry and vasodilator-stimulated phosphoprotein phosphorylation (VASP). The primary endpoint of the study is the inhibition of platelet aggregation (IPA) after arachidonic acid (AA) 0.5 mM at 30 min. Secondary endpoints were the IPA at 1, 4, and 24 h after AA, and non-AA pathways through the sequence (ADP and TRAP). A total of 32 STEMI patients were randomized (16 LA, 16 aspirin). The inhibition of platelet aggregation after AA 0.5 mM at 30 min was greater in subjects treated with LA compared with aspirin: 166 vs. 412 respectively (p = 0.001). This differential effect was observed at 1 h (p = 0.01), but not at 4 and 24 h. Subjects treated with LA presented less variability and faster inhibition of platelet aggregation wit AA compared with aspirin. The administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin on ticagrelor inhibited platelets in patients with STEMI. Loading dose of LA achieves an earlier platelet inhibition, and with less variability than aspirin.Trial Registration: Unique identifier: NCT02929888; URL: http://www.clinicaltrials.gov.

Background The diagnosis of acute myocarditis typically requires either endomyocardial biopsy (which is invasive) or cardiovascular magnetic resonance imaging (which is not universally available). Additional approaches to diagnosis are desirable. We sought to identify a novel microRNA for the diagnosis of acute myocarditis. Methods To identify a microRNA specific for myocarditis, we performed microRNA microarray analyses and quantitative polymerase-chain-reaction (qPCR) assays in sorted CD4+ T cells and type 17 helper T (Th17) cells after inducing experimental autoimmune myocarditis or myocardial infarction in mice. We also performed qPCR in samples from coxsackievirus-induced myocarditis in mice. We then identified the human homologue for this microRNA and compared its expression in plasma obtained from patients with acute myocarditis with the expression in various controls. Results We confirmed that Th17 cells, which are characterized by the production of interleukin-17, are a characteristic feature of myocardial injury in the acute phase of myocarditis. The microRNA mmu-miR-721 was synthesized by Th17 cells and was present in the plasma of mice with acute autoimmune or viral myocarditis but not in those with acute myocardial infarction. The human homologue, designated hsa-miR-Chr8:96, was identified in four independent cohorts of patients with myocarditis. The area under the receiver-operating-characteristic curve for this novel microRNA for distinguishing patients with acute myocarditis from those with myocardial infarction was 0.927 (95% confidence interval, 0.879 to 0.975). The microRNA retained its diagnostic value in models after adjustment for age, sex, ejection fraction, and serum troponin level. Conclusions After identifying a novel microRNA in mice and humans with myocarditis, we found that the human homologue (hsa-miR-Chr8:96) could be used to distinguish patients with myocarditis from those with myocardial infarction. (Funded by the Spanish Ministry of Science and Innovation and others.).

Resumen Han sido numerosos los estudios publicados en el campo de la cardiopatia isquemica y de los cuidados criticos cardiovasculares en este ultimo ano. Por este motivo, esta revision no pretende abarcar todos ellos, sino mas bien una seleccion de algunas publicaciones que a criterio subjetivo de los autores se consideran de interes.

Resumen Durante el pasado ano se han publicado numerosos estudios en el campo de la cardiopatia isquemica y de los cuidados criticos cardiovasculares, por lo que la presente seleccion no pretende ser un repaso exhaustivo sino mas bien una recopilacion de algunas publicaciones destacadas segun el criterio subjetivo de los autores.

Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.

Antithrombotic drug use for acute coronary syndromes (ACS) varies considerably. The number of antithrombotic drugs (excluding oral anticoagulants) used pre- and in-hospital was recorded in ACS survivors enrolled at hospital discharge in the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) registry ( NCT01171404 ), a prospective cohort study. Among 10,568 patients, the number of antithrombotic drugs used early/patient ranged from 0 to 8 (interquartile range = 3-4). Overall, 250 patients (2.4%) experienced ≥ 1 in-hospital ischemic event and 343 (3.2%) ≥ 1 non-fatal bleeding event. While there was no difference in the rate of ischemic events (p = 0.75 for-trend) according to the number of antithrombotic drugs, a significantly higher incidence of non-fatal bleeds was observed (p0.0001 for-trend), with OR = 1.68 (95%CI = 1.51-1.88) per additional antithrombotic drug, which remained after adjustment by patient characteristics. In conclusion, careful balancing of the short-term risks for ischemic and bleeding events should be considered when adding new antithrombotic drugs.

Objectives: This study sought to describe the incidence, determinants, and prognostic impact of cardiogenic shock (CS) in takotsubo syndrome (TTS).Background: TTS can be associated with sev...

The prognosis of patients after acute coronary syndromes is still suboptimal, mainly due to the risk of recurrent adverse coronary events, which is greatest during the first year, but persists over one's lifetime. Meaningful progress in preventing cardiovascular events has been achieved. However, there remains much room for improvement by embracing innovative therapies and investing in multidisciplinary approaches. Pharmacological interventions focused on optimising antithrombotic and lipid-lowering therapies are both pillars of secondary prevention that have seen recent ground-breaking advances. Moreover, new approaches in diabetic patients with cardiovascular disease and new targets for anti-inflammatory treatment may significantly improve prevention strategies in the future. However, pharmacological treatments are expensive and can have significant side effects. Developing better tools in order to identify high-risk patients and promote more personalised strategies for each patient should be an absolute priority. Furthermore, adherence to medication is still low and represents a real challenge; several strategies to improve low adherence to treatment are currently under discussion. Non-pharmacological interventions are also essential. Improving communication with patients and advanced surveillance for those secondary risk factors that may negatively impact prognosis are crucial. Encouraging multidisciplinary teams that work effectively to optimise all aspects of secondary prevention, including a cardiac rehabilitation programme, is the optimal approach. Current secondary prevention strategies and suggestions for areas of improvement are discussed in this manuscript. However, the question remains: will research in secondary prevention continue to focus on stronger and more expensive drugs, or is it time for us to embrace a more patient-centred clinical and research model? The Centro Nacional de Investigaciones Cardiovasculares is supported by the Spanish Ministry of Economy and Competitiveness (MINECO) and the Pro-CNIC Foundation, and is a Severo Ochoa Center of Excellence (MINECO award SEV-2015-0505). Sí

Background: Reperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease. Objectives: This study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI. Methods: Trends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI. Results: Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74). Conclusions: Although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients. Sin financiación 18.639 JCR (2018) Q1, 3/136 Cardiac & Cardiovascular Systems 9.280 SJR (2018) Q1, 1/365 Cardiology and Cardiovascular Medicine No data IDR 2018 UEM

Poisoning by ingestion of ‘Jamaican Stone’, a kind of cardioactive steroid, is extremely rare. However, mortality is very high. For this reason, when it occurs, an early and accurate diagnosis represents a critical challenge for clinicians. We present an unusual case of electrical storm caused by this substance. Resumo: O envenenamento por ingestão de «pedra jamaicana», um tipo de esteroide cardioativo, é extremamente raro. Contudo, dado esta situação se associar a uma mortalidade muito elevada, o diagnóstico precoce e rigoroso desta situação pode ser clinicamente crucial. É retratado um caso pouco comum de tempestade arrítmica causada por esta substância. Keywords: Jamaican Stone, Cardenolides, Bufadienolides, Cardioactive steroids, Palavras-chave: Pedra jamaicana, Cardenolídeos, Bufadienolídeos, Esteroides cardioativos

The mean age of patients presenting with acute coronary syndrome (ACS) has been increasing steadily in the last decades, so managing very old patients has become common practice. The oldest patients are under-represented in clinical trials, so specific evidence is scarce. Still, antithrombotic therapy and invasive strategy are the pillars of appropriate treatment even in the oldest patients. However, the elderly population is a heterogeneous group showing important divergences between chronological and biological age, which needs specific evaluation. Physical, and social function, geriatric syndromes, such as frailty or cognitive decline, and comorbidities must be taken into consideration for clinical decision-making but this requires evaluation beyond the traditional cardiologic approach. In general, elderly patients with ACS who are functional and independent should be treated with the same methods as younger patients although more cautiously. However, specific measures should be put in place to prevent functional decline and delirium, two of the most frequent and devastating specific complications in older patients. Multidisciplinary approaches are needed for that. In general, a new paradigm for the management of very old patients with ACS is warranted, in which evaluation of outcomes traditionally ignored by cardiologists should be considered.

Los avances en la prevencion de eventos cardiovasculares recurrentes en los pacientes que han sufrido un sindrome coronario agudo (SCA) —prevencion secundaria— han sido espectaculares en las ultimas dos decadas. El descubrimiento de sus efectos beneficiosos y el uso generalizado de antiagregantes plaquetarios, bloqueadores beta, estatinas e inhibidores de la enzima de conversion de la angiotensina, asi como el empleo mas selectivo de la rehabilitacion cardiaca, los inhibidores de los receptores de aldosterona y los desfibriladores automaticos implantables, principalmente en pacientes con disfuncion sistolica ventricular izquierda significativa, han reducido sustancialmente la mortalidad y la tasa de eventos cardiovasculares en los pacientes que ya han sufrido un SCA. Pese a ello, el pronostico de los pacientes que sobreviven a un SCA dista de ser benigno. De hecho, es ya bien conocido el hecho de que algunos pacientes con SCA con una mortalidad inicial menor, como aquellos sin elevacion del ST en el ECG, acaban presentando una mortalidad a largo plazo similar a la de aquellos con SCA con elevacion de ST, lo que se produce a expensas del mayor riesgo de recurrencia de eventos coronarios, que aumenta el riesgo de mortalidad tardia. Tradicionalmente se ha hecho enfasis en el riesgo posinfarto de los 12 meses siguientes al episodio agudo. Esto se debe, en primer lugar, a que la tasa de eventos recurrentes es mayor en los primeros meses y la duracion de la doble antiagregacion se recomienda durante 12 meses tras el SCA. Sin embargo, el riesgo persiste posteriormente y, aunque a un ritmo menor, los eventos vasculares y, con menor frecuencia, la muerte de origen cardiovascular siguen produciendose. En el articulo publicado en REVISTA ESPANOLA DE CARDIOLOGIA se presenta el analisis de la recurrencia de eventos cardiovasculares —infarto, ictus o muerte cardiovascular— en una cohorte de 4.858 pacientes tratados en el Complejo Hospitalario Universitario de Santiago de Compostela. En el se encontro una incidencia de 329 eventos durante el primer ano y 616 en los aproximadamente 4 anos de seguimiento posterior, lo que supone

Platypnea-orthodeoxia syndrome (POS) is an uncommon clinical syndrome consisting of dyspnea and deoxygenation accompanying a change from a recumbent to an upright position. The underlying mechanism requires both anatomical and functional features, which result in a right-toleft interatrial shunt. We present a case of POS in an elderly patient with patent foramen ovale (PFO) and aortic root dilatation. A 79-year-old woman, with a history of a healed breast cancer 30 years before, was admitted to the emergency room with increasing dyspnea and shortness of breath last month, especially when moving from supine to the erect position. On physical examination, in a recumbent position, she was eupneic, well perfused and her arterial blood oxygenation was 94 %. When standing up, she referred dyspnea and developed peripheral cyanosis with an arterial blood oxygenation of 63 % despite oxygen administration. On auscultation, a diastolic murmur of aortic regurgitation was heard. A chest X-ray showed dilatation of the aortic root without signs of heart failure. The electrocardiogram did not show abnormalities. An urgent transthoracic echocardiogram was performed revealing normal ventricles, moderate aortic regurgitation and the presence of a dilated ascending aorta and aortic root (48 mm) which compressed extrinsically the right atrium with a significant chamber reduction. Estimated systolic pulmonary pressure was 37 mmHg. An interatrial septum aneurysm was observed, and when agitated saline was injected intravenously in a lying position (Fig. 1a), no microbubbles were identified in left atrium. Nevertheless, when standing up, the aortic root compressed sharply the right atrium, and microbubbles appeared immediately in the left atrium (Fig 1b.), confirming the existence of a right-to-left intracardiac shunt. A CT scan proved dilatation of the aortic root with severe compression of the right atrium without signs of intrapulmonary arteriovenous malformations. The patient underwent closure of the PFO with a percutaneous device (Fig 1c). During the procedure, an aortography was performed showing the ascending aorta and aortic root dilatation and enabling its measurement. There was no evidence of right-to-left residual shunt in the echocardiographic control one week later. The patient was discharged and two years later remains asymptomatic. POS is a rare underdiagnosed clinical entity, first described by Burchell [1], consisting of dyspnea and hypoxemia induced by upright posture that is relieved by recumbency [2]. Its pathophysiology is controverted and has been related to hepatic, pulmonary and cardiac diseases. Nowadays, the most recognized underlying condition is the presence of a right-to-left interatrial shunt in the presence of a PFO or an atrial septal defect (ASD) [3]. In normal circumstances, due to the higher pressure of the left atrium, in the presence of either a PFO or an ASD, there is left-to-right shunt. When conditions that increase right atrial pressure and modify the position of the atrial septum concur, redirection of the flow from the vena cava towards the septum in the upright posture is possible. These conditions can be cardiac (pericardial effusion, constrictive pericarditis), pulmonary (arteriovenous malformations), hepatic (cirrhosis) or vascular (aortic aneurysms) in origin [2–4]. J. M. Montero Cabezas (&) M. de Riva Silva R. Martin Asenjo F. Hernandez Hernandez 12 de Octubre University Hospital, Madrid, Spain e-mail: jmmonterocabezas@hotmail.com

Identification of acute coronary lesions amenable to urgent intervention in survivors of out-of-hospital cardiac arrest is crucial. We aimed to compare the clinical and electrocardiographic characteristics to urgent coronary findings, and to analyze in-hospital prognosis of these patients.From January 2005 to December 2012 we retrospectively identified consecutive patients resuscitated from out-of-hospital cardiac arrest, and analyzed the clinical characteristics, post-resuscitation electrocardiogram and coronary angiogram of those who underwent emergent angiography. Mortality and neurologic status at discharge were also assessed.Patients with ST-elevation more frequently had obstructive coronary artery disease (89% vs. 51%, p0.001) or acute coronary occlusions (83% vs. 8%, p0.001) than patients without ST-elevation. Independent predictors of an acute coronary occlusion were chest pain before arrest (OR 0.16, 95% CI 0.04-0.7, p=0.01), a shockable initial rhythm (OR 0.16, 95% CI 0.03-0.9, p=0.03), and ST-elevation on the post-resuscitation electrocardiogram (OR 0.02, 95% CI 0.004-0.13, p0.001). Survival with favorable neurologic recovery at discharge was 59%. Independent predictors of mortality or unfavorable neurological outcome at discharge were absence of basic life support (OR 0.2, 95% CI 0.06-0.9, p=0.04), prolonged resuscitation time (OR 0.9, 95% CI 0.8-0.9, p=0.01), and necessity of vasopressors (OR 14.8, 95% CI 3.3-65.4, p=0.001).Most patients with ST-elevation on the post-resuscitation electrocardiogram had an acute coronary occlusion, as opposed to patients without ST-elevation. Absence of basic life support, prolonged resuscitation time and use of vasopressors were independent predictors of worse in-hospital outcome.

We describe a patient with a suprarenal pheochromocytoma that had a complex course with electrocardiographic findings characteristic of diffuse myocardial damage, normal findings on coronary angiography, and left intraventricular thrombus complicated by embolic stroke.

Comunicamos el caso de un paciente con un feocromocitoma suprarrenal que curso con una evolucion clinica compleja, alteraciones electrocardiograficas propias de afeccion miocardica difusa, con coronariografia normal y un trombo intraventricular izquierdo complicado con un ictus embolico.

Primary percutaneous intervention of saphenous vein grafts is associated with a high risk of distal embolization and no reflow. We report a case of acute myocardial infarction with a large intragraft thrombus, successfully treated with a technique combining thrombectomy with a 6 Fr guiding catheter and distal protection with the FilterWire EZ.

Anomalous origin of left and right coronary arteries from a single coronary ostium in the right sinus of Valsalva is rare. Accordingly, few reports have described percutaneous coronary interventions in this anomaly. We report a case of a 75-year-old woman with a severe lesion in the anomalous left main coronary artery arising from a single ostium in the right sinus of Valsalva. The patient was successfully treated with direct stenting.