Current heart failure disease management and treatment in accredited units from Cardiology and Internal Medicine in Spain

BACKGROUND AND OBJECTIVES

Heart failure (HF) is a complex disease with high prevalence, incidence and mortality rates leading to high healthcare burden. In Spain, there are multidisciplinary HF units coordinated by Cardiology and Internal Medicine. Our objective is to describe its current organizational model and their adherence to the latest scientific recommendations.

MATERIALS AND METHODS

In late 2021, a scientific committee (with cardiology and internal medicine specialists) developed a questionnaire that was sent as an online survey to 110 H F units. 73 from cardiology (accredited by SEC-Excelente) and 37 from internal medicine, (integrated in UMIPIC program).

RESULTS

83 answers were received (75.5% total: 49 from cardiology and 34 from internal medicine). HF units are mostly integrated by specialists from cardiology, internal medicine and specialized nurse practitioners (34.9%). Patient characteristics from HF units are widely different when comparing those in cardiology to UMIPIC, being the latter older, more frequently with preserved ejection fraction and higher comorbidity burden. Most HF units (73.5%) currently use a hybrid face-to-face/virtual model to perform patient follow-up. Natriuretic peptides are the biomarkers most commonly used (90%). All four disease-modifying drug classes are mainly implemented at the same time (85%). Only 24% of HF units hold fluent communication with primary care.

CONCLUSIONS

Both models from Cardiology and Internal Medicine HF units are complementary, they include specialized nursing, they use hybrid approach for patient follow-up and they display a high adherence to the latest guideline recommendations. Coordination with primary care remains as the major improvement area.

1-year hospital readmissions due to cardiovascular causes after a heart failure episode in elderly patients in Spain

Background

The prevalence of heart failure (HF) increases with age, one of the leading causes of hospitalization and death in the elderly. However, there are little data about the long-term readmission rate of elderly patients after an episode of HF admission in Spain.

Purpose

Study 1-year hospital readmissions due to cardiovascular causes in patients ≥75 years discharged to a hospital due to HF in Spain.

Methods

We performed a retrospective analysis of the Minumum basic dataset of Spain, including all episodes of HF discharged from public hospitals in Spain between 2016 and 2019. The codification was made with ICD-10. We selected patients ≥75 years with HF as the principal diagnosis. We analyzed predictors of readmissions 365 days after the index episode of HF hospitalization with Poisson regression.

Results

236,463 index episodes of HF in>75 years were included. 59.1% were female, and the mean age was 85 (SD 5.6) years. 35.0% had HF-pef, 4.3% HF-ref, and 60.7% had unknown LVEF HF.

39.6% of patients had at least one readmission (mean 1.7 readmissions by year for these patients), with no differences in sex or age. Patients with non-cardiovascular comorbidities (renal failure, chronic lung disorders, and severe hematological disorders) as well as coronary atherosclerosis and diabetes were more likely to be readmitted (Table 1).

Conclusions

After a hospital discharge for HF in patients ≥75 years, the crude ratio of readmission due to cardiovascular causes at 1-year was 39.6%. Readmissions were more likely in patients with non-cardiovascular comorbidities, predominantly renal, hematological, and chronic respiratory disorders, and those with diabetes and coronary atherosclerosis.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

2MACE score predicts cardiovascular adverse events in real-world atrial fibrillation patients under rivaroxaban therapy. Data from EMIR study

Background

Atrial Fibrillation (AF) patients have higher risk of major adverse cardiovascular events (MACEs). In 2015, the 2MACE score (2 points for metabolic syndrome and age ≥75, and 1 point for myocardial infarction [MI] or revascularization, congestive heart failure [ejection fraction ≤40%] and thromboembolism [stroke or transient ischemic attack]) was described to stratify cardiovascular risk and 2MACE≥3 was related with high risk of MACE in AF patients but a long-term validation in prospective patients under direct anticoagulants has not been performed yet.

The aim of this study was to analyse the incidence of cardiovascular events and to validate the 2MACE score as predictor of MACEs.

Methods

EMIR study [acronym from 'Estudio observacional para la identificaciόn de los factores de riesgo asociados a eventos cardiovasculares Mayores en pacientes con fIbrilaciόn auricular no valvular tratados con un anticoagulante oral directo (Rivaroxaban)'] was an observational, multicenter, post-authorization and prospective study that involved AF patients under oral anticoagulation with rivaroxaban at least 6 months before enrolment. We analyzed baseline clinical characteristics and adverse events after 2.5 years of follow up: annual incidence of thromboembolic events, MACE (composite of nonfatal MI, coronary revascularization and cardiac death) and cardiovascular mortality were analyzed.

Results

We analyzed 1,433 patients (55.5% women, mean 74.2±9.7 years). 385 (26.9%) patients had 2MACE score ≥3 and of those high-risk patients, 42.1% had previous coronary disease, 12.5% had previous peripheral artery disease, 40.7% had diabetes mellitus, 39% heart failure and 50% had chronic kidney disease (GFR<60 ml/min). After 2.5 (2.2–2.6) years of follow-up, we observed patients with 2MACE score ≥3 had higher rate of adverse events (Table), specially of higher rate of cardiovascular mortality and MACE. Patients with 2MACE score ≥3 had RR 4.09 (2.59–6.45; p<0.001) for MACE. Indeed, patients with 2MACE score ≥3 had around 6-fold risk of cardiovascular death due heart failure than patients with 2MACE score <3 (0.17%/year vs 1.09%/year; p=0.003). 2MACE score had suitable predictive performance for MACE (AUC 0.638 [(0.534–0.742); p=0.010).

Conclusion

In a Real-world AF patients under rivaroxaban therapy from EMIR registry, the 2MACE score is a good predictor of long-term cardiovascular events, MACE and major bleeding. A 2MACE score ≥3 categorize patients at “high-risk” with almost 4-fold risk of MACE in a long-term follow-up.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania S.L. Table 1. Adverse events according to 2MACE

Impact of canagliflozin in natriuretic peptides in patients with type 2 diabetes after hospitalization for acute heart failure

Background

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated to reduce the risk of hospitalization for heart failure (HF) in patients with type 2 diabetes mellitus (T2D). We aimed to assess the changes in N-terminal pro-B-type natriuretic peptide (NT-ProBNP) concentrations in a cohort of patients hospitalized for HF according to whether or not they received canagliflozin at discharge.

Methods

This cohort study included all patients with T2D admitted for HF from January 2017 to December 2019 in a single center. We excluded patients whose treatment with SGLT2 inhibitors were contraindicated (eGFR ≤45 ml/min/1.73 m2) and those who had other SGLT2 inhibitors than canagliflozin in their treatment at discharged. All patients had received a primary diagnosis of acute decompensated heart failure, including signs and symptoms of fluid overload and a concentration of NT-ProBNP of 1400 pg/mL at least. NT-ProBNP concentrations were collected at 3 months, 6 months, and 1 year after hospitalization with laboratory records if available. The aim of this study is to compare mean NT-ProBNP levels at hospital discharge and 3, 6 and 12 moths of follow-up in patients treated with and without canagliflozin.

Results

We included a total of 102 patients, 45 patients (44.1%) were prescribed canagliflozin and the remaining 57 (55.9%) were not prescribed any SGLT2 inhibitors (control group). There were no significant differences in clinical and comorbidities in both groups, except for age; slightly younger in the canagliflozin group (69,2±10,3 vs 73,2±11,1; p=0,04). Treatment at discharge was also similar, patients in the control group received more dipeptidyl peptidase-4 (DPP-4) inhibitors (21.1% vs 6.7%; p=0.04). Low rate of patients received sacubitril-valsartan (15,6%) in the canagliflozin group and 14% in the control group. More than a half of patients in both groups have HF with reduced ejection fraction. Mean levels of peptides were similar in both groups at hospital admission and discharge. During the first period of 3 months, we observed a decreased of NT-ProBNP concentration in both groups, but significantly inferior in canagliflozin group (p<0,001). At 6 and 12 months, NT-ProBNP levels were practically maintained in patients treated with canagliflozin, whereas levels in patients in the control group were increased. Difference in both groups at a 12 month-period was significantly superior (p=0,004), with a median reduction of concentration levels at discharge of 64.3% in the canagliflozin group and 15,8% in control group. There were no differences in patients with HF from those with reduced ejection fraction and preserved.

Conclusions

Canagliflozin therapy at discharge was associated with a significant reduction in NT-ProBNP concentration in patients with diabetes after hospitalization for HF.

Funding Acknowledgement

Type of funding sources: None. NT-ProBNP according to canagliflozin

Oral anticoagulation therapy with rivaroxaban in elderly patients with atrial fibrillation. Results from EMIR study

Background

Atrial fibrillation (AF) in elderly patients increases both bleeding and thromboembolic risks. Elderly patients benefit as much from anticoagulation therapy with positive net clinical benefit. However, there have been few studies that focused on the efficacy and safety of direct oral anticoagulants in elderly patients.

The aim of this subanalysis from EMIR study was to assess the effectiveness of rivaroxaban in patients older than 75 years old.

Methods

EMIR Study (acronym from 'Estudio observacional para la identificaciόn de los factores de riesgo asociados a eventos cardiovasculares Mayores en pacientes con fIbrilaciόn auricular no valvular tratados con un anticoagulante oral directo (Rivaroxaban)') was an observational, multicenter, post-authorization and prospective study that involved AF patients under oral anticoagulation with rivaroxaban at least 6 months before enrolment. We analyzed baseline clinical characteristics and adverse events after 2.5 years of follow up.

Results

We analyzed 1,433 patients with median age of 74.7 (67.7–81.6). Of them 691 (48.2%) were ≥75 years. Elderly patients had higher prevalence of cardiovascular risk factors such previous stroke (16.8% vs 8.5%; p<0.001), heart failure (25.0% vs 20.6%; p<0.001), higher CHA2DS2-VASc (4.4±1.3 vs 2.7±1.2; p<0.001) and HAS-BLED (1.9±1.0 vs 1.2±1.0; p<0.001) scores. After 2.5 (2.2–2.6) years of follow-up, we observed low rate of adverse events in patients under rivaroxaban therapy. We observed higher rate of adverse events in elderly population for thromboembolic events (1.13%/year vs 0.36%/year; p=0.017) and major bleeding events (1.80%/year vs 0.36%/year; p<0.001) but those adverse rates were lower than expected according to previous studies (i.e. ROCKET-AF trial, rivaroxaban group had 4.86%/year of major bleeding or in XANTUS study was 3.2%/year of major bleeding in patients >75 years). We did not observe differences between groups from MACE (1.13%/year vs 1.01%/year; p=0.875) or cardiovascular death (0.86%/year vs 0.42%/year; p=0.170).

Conclusion

In real-world elderly population, rivaroxaban showed higher rates of thromboembolic and major bleeding events in elderly patients but with annual rates lower than expected according to previous studies like ROCKET-AF or XANTUS. Similar annual rates in elderly were observed for MACE and cardiovascular mortality than in younger patients, being rivaroxaban a good therapeutic alternative even for the elderly.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania S.L.

Impact of COVID-19 on heart failure hospitalizations: one year after

Background

Coronavirus disease 2019 (COVID-19) rapidly spread worldwide since it first emerged in December 2019, with more than 100 million cases reported to date, causing a great impact on healthcare systems. Heart failure (HF) is a major health problem. It affects about 10 million people in Europe and is the leading cause of hospitalization for patients older than 65 years. During the first wave of COVID-19 there was an important decrease in HF hospitalizations. Data regarding HF admissions during the second and third waves and inter-waves periods is scarce.

Purpose

To examine the impact of COVID-19 on HF hospitalizations during the first year of the pandemic and to compare the clinical characteristics and in-hospital outcomes of patients admitted during the three pandemic waves with those admitted the previous year during the same periods.

Methods

Data from a tertiary Heart Failure Unit in Southern Spain between 1 March 2020 and 28 February 2021 were compared to the corresponding time period in the previous year. The impact of the pandemic on weekly hospitalizations was assessed using a Poisson Regression model, with year, season and pandemic wave as covariates. Clinical characteristics and in-hospital outcomes of patients admitted during the three waves were compared to those admitted during the same periods one year after.

Results

A significantly lower weekly number of admissions for HF was observed during the three pandemic wave periods compared to all other included periods (inter-wave periods and same periods in the previous year) (p=0.002, IRR 0.81, 0.77–0.86). Figure 1 shows monthly HF admissions between 1 March 2020 and 28 February 2021 (pandemic year) and the previous year, as well as COVID-19 hospitalized cases in our area. Clinical characteristics and in-hospital outcomes of patients admitted during the COVID-19 waves and the same periods in the previous year are shown in Figure 2. Patients admitted during the COVID-19 waves were younger, and fewer had diabetes mellitus (DM), atrial fibrillation (AF) and valvular heart disease (VHD). There were no differences in clinical outcomes (intensive care unit admission, in-hospital mortality).

Conclusion

There was decline in HF hospitalization during the three waves of the pandemic year, but not during the inter-wave periods. Patients admitted during the wave periods had some clinical differences but similar in-hospital outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Spanish cohort profile, antithrombotic therapy and clinical outcomes at 1 year in the EORP atrial fibrillation long-term registry

Background

Atrial fibrillation (AF) is associated with a high risk of stroke and mortality. Some years ago, the EURObservational Research Programme launched the General Long-Term Registry with the aim to evaluate contemporary management of AF patients in Europe, the current use of vitamin K antagonists (VKAs), direct-acting oral anticoagulants (DOACs) and other AF treatments, in relation to guideline recommendations.

Purpose

The present report aims to describe the characteristics of a large database on the management of AF in Spain, using the Spanish cohort included in the EORP-AF Long-Term Registry.

Methods

The EORP-AF Long-Term General Registry is a prospective, observational, large-scale multicentre registry sponsored and conducted by the ESC, enrolling AF patients in current cardiology practices in 250 centres from 27 participating ESC countries. Patients were enrolled consecutively when presenting with AF as primary or secondary diagnosis to inpatients and outpatient cardiology services from October 2013 to September 2016. The first Spanish patient in the EORP-AF Long-Term Registry was included in 2014. Initially, the aim was to carry out a follow-up up to 3 years but this was reduced to 2 years by the Executive Committee. To date, only data from the first year of follow-up is available for the Spanish cohort.

Results

A cohort of 729 AF Spanish patients was included (57.1% male, median age 75 [IQR 67–81] years, median CHA2DS2-VASc and HAS-BLED of 3 [IQR 2–5] and 2 [IQR 1–2], respectively). A relatively low proportion of patients (634, 87%) received oral anticoagulants (OACs), of which 389 (53.4%) were on VKAs and 245 (33.6%) were on DOACs (rate ratio = 1.59 [95% CI 1.35–1.87], p<0.001). Importantly, there were 98 (13.4%) patients taking concomitantly antiplatelet therapy and OACs; as well as 5.5% of patients were taking parenteral anticoagulation or antiplatelets alone. After 1 year, the proportion of patients on OACs increased from 87.0% to 88.1%. The proportion of DOACs users increased from 33.6% at baseline to 39.9%, partly due to switches from VKA to DOACs in relation to poor time in therapeutic range. At the same time, 34 (4.7%) patients withdrew OACs. During the first year of follow-up, 48 patients (6.6%) died, 7 (1.0%) suffered ischemic strokes and 6 (0.8%) transient ischemic attacks. Of note, there was a substantial rate of major bleeds (ISTH criteria) (57, 7.8%), of which 10 (1.4%) were intracranial haemorrhages.

Conclusions

Baseline data of the Spanish cohort are similar to that reported for the whole EORP cohort, including similar stroke and bleeding risks. OAC use slightly increased at 1-year, with low discontinuation rates which could be related with a low incidence of thromboembolic events. However, despite the ∼8% rate of major bleeding in overall, the use of a safer therapy such as DOACs is still low compared to VKAs, being the antiplatelets commonly used concomitantly with OACs

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unconditional grant by Boehringer-Ingelheim

P1515Female sex is an independent predictor of mortality in patients with STEMI in Spain: a study in 325,017 episodes over 11 years (2005–2015)

Background

Recent studies reported a decrease in the mortality of ST-elevation myocardial infarction (STEMI) patients. This favorable evolution could not extend to women. The interaction between gender and mortality in STEMI remains controversial.

Purpose

To assess the impact of female sex on mortality of patients with STEMI through of period of 11 years.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system of the Spanish National Health System to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015.

Results

A total of 325,017 STEMI were identified. Of them, 273,182 were included, and 106,277 (38.8%) were women. Women were older than men and had more comorbidities. Through the study period 53% men vs 37.2% underwent PTCA; women presented more frequently heart failure, shock and stroke than men (p<0.001, respectively). The mean crude in-hospital mortality rate for the whole study period was higher in women (OR: 2.18; 95% CI: 2.12.-2.23, p<0.0001). Female sex was independently associated with higher in-hospital mortality (adjusted OR: 1.18; 95% CI: 1.14–1.22, p<0.001) (Table 1). The risk was maintained through the whole study period (lower OR: 1.14 in 2014; higher OR: 1.28 in 2006).

Table 1. Variables independently associated with in-hospital mortality adjusted by risk in a multilevel logistic regression model, 2005–2015 STEMI In-hospital mortality Odds Ratio P 95% CI Woman 1.18 <0.001 1.14 1.22 Age 1.06 <0.001 1.06 1.06 History of PTCA 1.58 <0.001 1.40 1.77 Congestive heart failure 1.26 <0.001 1.22 1.30 Acute Myocardial Infarction 1.84 <0.001 1.54 2.20 Anterior myocardial infarction 1.47 <0.001 1.23 1.76 Cardio-respiratory failure or shock 15.25 <0.001 14.78 15.75 Hypertension 0.81 <0.001 0.79 0.84 Stroke 5.76 <0.001 5.18 6.42 Cerebrovascular disease 0.86 <0.001 0.79 0.93 Renal failure 1.95 <0.001 1.88 2.02 Vascular disease and complications 7.03 <0.001 5.72 8.63 CI, Confidence Interval.

Conclusions

Female sex is an independent predictor of mortality in patients with STEMI in Spain, maintaining through a period of the 11 years.

P3605Lower benefit of women than men with ST-elevation myocardial infarction networks system in Spain: a study of 325,017 episodes over 10 years (2005–2015)

Background

Sex differences are known to exist in the management of women presenting with ST elevation myocardial infarction (STEMI).Few studies have examined whether the clinical management and prognosis differs by sex when the STEMI network system is applied.

Purpose

To assess whether the STEMI network system improves management and prognosis both in men and women in Spain and to analyze possible differences according to sex.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system (MDBS) of the Spanish National Health System (SNHS) to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality and expected mortality, multiplied by the crude rate of mortality. The RSMR was calculated using multilevel risk adjustment models developed by the Medicare and Medicaid Services. The year of the development of organized systems of care for STEMI patients in the different Autonomous Communities was double-checked using data from the National Cardiac Catheterization and Interventional Cardiology Annual Registry. RSMR was used to compare outcomes related with gender and with the presence of regional AMI networks and the performance of PCI. Temporal trends for in-hospital mortality during the observed period were modeled using Poisson regression analysis with year as the only independent variable. In all models, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were calculated.

Results

A total of 325,017 STEMI were identified among patients aged 35–94 years old. Of them 273,182 were selected after exclusions, and 106,277 (38.8%) were women. Women were on average 10 years older than men and had more comorbidities burden. The overall proportion of STEMI patients underwent to PCI increased, when a regional STEMI network was present from 2005–2015: (63.7% vs 48.2% in men; and 47.4% vs 32.9% in women; p<0.001). Differences in crude mortality between sexes was 15%, maintaining through 10 years, despite a higher increased of PCI (figure 1).However, women were less likely to be treated with PCI even though when STEMI network was stablished (63.7% vs 48.2% in men, 47.4% vs 32.9% in women, p<0.001) (figure 1).The mean crude in-hospital mortality rate for the whole study period was higher in women (9.3% vs 18.3%; unadjusted OR: 2.18, 95% CI: 2.12.-2.23, p<0.0001). RSMR was lower for women when STEMI network were working (17.7% vs. 19.7%; p<0.001).PCI and the presence of STEMI network were associated with a lower in-hospital mortality in STEMI women (adjusted OR, 0.48; 95% CI 0.41–0.52 and OR, 0.84; 95% CI 0.79–0.89, p<0.001, respectively).

Conclusions

Women were less likely to be treated with PCI and had higher in-hospital risk-adjusted mortality than men, despite the existence of STEMI network system.

P4800Estimated effect of NOACs compared to Vitamin K Antagonists in real-world atrial fibrillation patients: Data from FANTASIA Registry

Background

Despite of the effectiveness and safety profile of Non-vitamin K Antagonists Oral Anticoagulants (NOACs) even in real-world (RW) Atrial Fibrillation (AF) patients, Vitamin K Antagonists (VKAs) have remained widely used in clinical practice worldwide but the comparison with acenocoumarol therapy in RW is unknown.

Purpose

To estimate the potential absolute benefit in clinical adverse events if the AF patients anticoagulated with VKA therapy had been treated with NOACs.

Methods

We analyzed anticoagulated AF patients who were prospectively recruited into the multicentre FANTASIIA registry. Patients were treated with VKAs for at least 6 months prior to inclusion. The estimation of clinical adverse events avoided was calculated applying absolute risk reductions, relative risk reductions and hazard ratios from the meta-analysis of RW use of NOACs relative to VKAs.

Results

We analyzed 1,470 patients under VKA therapy (mean age 74.1±9.5 years; 56.4% male). Stroke rate with acenocoumarol treatment was 0.88%/year. The estimated rates for stroke using NOACs would be 0.80%/year for Dabigatran 150 mg; 0.76%/year for Rivaroxaban and 0.74%/year for Apixaban instead of VKA. No significant differences were observed between the different NOACs and VKA in stroke rate. Major bleeding with acenocoumarol was 3.40%/year. The estimated rates for major bleeding using NOACs would be 2.75%/year for Dabigatran 150 mg; 3.37%/year for Rivaroxaban and 2.18%/year for Apixaban instead of VKA. Apixaban was the only NOAC that showed a significant estimated reduction rates (p=0.046). Finally, the all-cause mortality rate with acenocoumarol was 4.69%/year. The estimated rates of all-cause mortality using NOACs would be 3.28%/year for Dabigatran 150mg; 4.88%/year for Rivaroxaban and 2.67%/year for Apixaban. Dabigatran and Apixaban showed significant estimated reduction rates with the highest reduction with Apixaban (Table).

Annual Rate reduction of adverse events

Conclusion

The absolute estimated effect of NOACs in the AF patients anticoagulated with VKA showed a significant reduction in adverse clinical events. Apixaban performed the highest estimated reduction in major bleeding and all-cause mortality in comparison with acenocoumarol.

The clinical profile of women with stable ischaemic heart disease in Spain. More effort is needed in secondary prevention. SIRENA study

OBJECTIVES

Cardiovascular diseases are the leading cause of death for women, especially ischaemic heart disease, which is still considered a man's disease. In Spain, there are various registries on ischaemic heart disease, although none are exclusively for women. The objectives of the SIRENA study were to describe the clinical profile of women with ischaemic heart disease treated in cardiology consultations, to estimate its prevalence of cardiovascular risk factors and understand its clinical management.

PATIENTS AND METHODS

A multicentre observational study was conducted with a sample of 631 women with stable ischaemic heart disease, consecutively included during cardiology consultations. Forty-one researchers from all over Spain participated in the study.

RESULTS

The mean age was 68.5 years. The clinical presentation was in the form of acute coronary syndrome in up to 67.2% of the patients. The prevalence of cardiovascular risk factors was high (77.7% of the patients had hypertension, 40.7% had diabetes and 68% had dyslipidaemia), with 30.7% having uncontrolled hypertension, 78.4% having LDL-cholesterol levels higher than 70mg/dL and 49.2% having HbA1c levels greater than 7%. The considerable majority of the patients underwent optimal medical treatment with antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone system blockers and hypolipidaemic agents. Coronary angiography was performed for 88.3% of the patients, and 63.4% underwent percutaneous coronary intervention.

CONCLUSIONS

Women with stable ischaemic heart disease in Spain initially present some form of acute coronary syndrome and a high prevalence of inadequately controlled cardiovascular risk factors, despite undergoing optimal medical therapy. A high percentage of these women undergo coronary revascularisation. Increased efforts are required for secondary prevention in women with stable ischaemic heart disease.

Distribution and biokinetic analysis of 210Pb and 210Po in poultry due to ingestion of dicalcium phosphate

Dicalcium phosphate (DCP) is used as a calcium supplement for food producing animals (i.e., cattle, poultry and pig). When DCP is produced via wet acid digestion of the phosphate rock and depending on the acid used in the industrial process, the final product can result in enhanced (210)Pb and (210)Po specific activities (approximately 2000 Bq.kg(-1)). Both (210)Pb and (210)Po are of great interest because their contribution to the dose received by ingestion is potentially large. The aims of this work are to examine the accumulation of (210)Pb and (210)Po in chicken tissues during the first 42 days of life and to build a suitable single-compartment biokinetic model to understand the behavior of both radionuclides within the entire animal using the experimental results. Three commercial corn-soybean-based diets containing different amounts and sources of DCP were fed to broilers during a period of 42 days. The results show that diets containing enhanced concentrations of (210)Pb and (210)Po lead to larger specific accumulation in broiler tissues compared to the blank diet. Radionuclides do not accumulate homogeneously within the animal body: (210)Pb follows the calcium pathways to some extent and accumulates largely in bones, while (210)Po accumulates to a large extent in liver and kidneys. However, the total amount of radionuclide accumulation in tissues is small compared to the amounts excreted in feces. The single-compartment non-linear biokinetic model proposed here for (210)Pb and (210)Po in the whole animal takes into account the size evolution and is self-consistent in that no fitting parameterization of intake and excretions rates is required.

Radioactivity contents in dicalcium phosphate and the potential radiological risk to human populations

Potentially harmful phosphate-based products derived from the wet acid digestion of phosphate rock represent one of the most serious problems facing the phosphate industry. This is particularly true for dicalcium phosphate (DCP), a food additive produced from either sulphuric acid or hydrochloric acid digestion of raw rock material. This study determined the natural occurring radionuclide concentrations of 12 DCP samples and 4 tricalcium phosphate (TCP) samples used for animal and human consumption, respectively. Metal concentrations (Al, Fe, Zn, Cd, Cr, As, Hg, Pb and Mg) were also determined. Samples were grouped into three different clusters (A, B, C) based on their radionuclide content. Whereas group A is characterized by high activities of 238U, 234U (approximately 10(3) Bq kg(-1)), 210Pb (2 x 10(3) Bq kg(-1)) and (210)Po ( approximately 800 Bq kg(-1)); group B presents high activities of (238)U, (234)U and (230)Th (approximately 10(3) Bq kg(-1)). Group C was characterized by very low activities of all radionuclides (< 50 Bq kg(-1)). Differences between the two groups of DCP samples for animal consumption (groups A and B) were related to the wet acid digestion method used, with group A samples produced from hydrochloric acid digestion, and group B samples produced using sulphuric acid. Group C includes more purified samples required for human consumption. High radionuclide concentrations in some DCP samples (reaching 2 x 10(3) and 10(3) Bq kg(-1) of 210Pb and 210Po, respectively) may be of concern due to direct or indirect radiological exposure via ingestion. Our experimental results based on 210Pb and 210Po within poultry consumed by humans, suggest that the maximum radiological doses are 11 +/- 2 microSv y(-1). While these results suggest that human health risks are small, additional testing should be conducted.

Evaluation of a dynamic in vitro model to simulate the porcine ileal digestion of diets differing in carbohydrate composition

The aim of the study was to assess the ability of a dynamic in vitro model to determine the digestibility of OM, CP, and starch compared with a validated, static, in vitro method and in vivo ileal digestibility obtained from growing pigs fitted with a T-cannula. Five experimental diets with different carbohydrate types and level were assessed: a standard corn-based diet (ST) or the same diet with coarse ground corn (CC), 8% sugar beet pulp (BP), 10% wheat bran (WB), or 8% sugar beet pulp and 10% wheat bran (HF). In the in vivo experiment, diets CC and HF reduced (P = 0.015) ileal digestibility of OM compared with the ST diet. The inclusion of sugar beet pulp reduced (P = 0.049) ileal CP digestibility of the BP diet. This reduction was not statistically significant when sugar beet pulp was combined with the wheat bran in the HF diet. No differences were shown for in vivo starch digestibility among diets. With the static in vitro method, the OM disappearance was greater than that observed in the in vivo experiment. In this static method, the BP and HF diets reduced (P = 0.004 and < 0.001, respectively) the disappearance of the OM compared with the ST diet. The coarse grinding of corn did not alter OM digestibility but decreased (P = 0.005) the starch digestibility. The R(2) between the in vivo results and the static in vitro methods for OM and starch digestibility was 0.99 when the CC diet was not considered. The dynamic in vitro model yielded OM and CP digestibility coefficients comparable with those obtained in vivo for the ST and CC diets. However, the values were considerably affected by the incorporation of the fibrous ingredients. Diets BP, WB, and HF had decreased (P = 0.009, 0.058, and 0.004, respectively) OM digestibility compared with the ST diet. Protein digestibility was also decreased (P < 0.001, P = 0.019, and P = 0.003, respectively) with the BP, WB, and HF diets compared with the ST diet. However, digestibility was decreased to a greater extent in the BP diet than in the WB and HF diets, both of which contained wheat bran. The R(2) between the dynamic in vitro model and the in vivo results for CP digestibility was 0.99 when the CC diet was not considered. No differences were detected for starch digestibility among the diets with the dynamic in vitro model. This dynamic in vitro model yielded ileal digestibility results comparable with those obtained in vivo for CP and OM with a corn-soybean diet, or with a diet including coarse corn, but it underestimated digestibility when fibrous ingredients were included in the diet.

Influence of the amount of dietary fiber on the available energy from hindgut fermentation in growing pigs: Use of cannulated pigs and in vitro fermentation1

Available energy from hindgut fermentation to pigs fed various amounts of dietary fiber was investigated using an in vivo-in vitro methodology. Six growing pigs fitted with a simple T-shaped cannula at the terminal ileum, and following a Latin-square design, were fed 3 diets differing in the content of non-starch polysaccharides (NSP): a low fiber diet (LFD, 77 g/kg of DM), a standard fiber diet (SFD, 160 g/kg of DM), and a high fiber diet (HFD, 240 g/kg of DM). After adaptation to the diet for 10 d, samples from feces and ileum were collected and analyzed for DM, energy, NSP, and chromic oxide; feces were also analyzed for short chain fatty acids (SCFA). Freeze-dried ileal samples (10 g/L) were fermented in vitro in a fecal slurry consisting of an anaerobic mineral salt medium and feces (50 g/L) from cannulated pigs fed the same diets. Available energy was calculated from the amount of SCFA produced in vitro after 48 h of incubation. Nonstarch polysaccharide content in the fermented material was measured to assess the in vitro degradation of this fraction. Increasing dietary NSP from 77 to 240 g/kg of feed DM increased (P < 0.001) ileal flow from 199 to 468 g/kg of feed, leading to a reduction in the energy digested at the terminal ileum, from 15 to 11 MJ/kg of feed DM and an increment in energy digested in the hindgut, from 1.6 to 3.5 MJ/kg of feed DM. Total in vitro production of SCFA/kg of feed DM was dependent on the amount of ileal substrate available for fermentation; that is, increased concentrations of NSP in the diet led to an increase in the SCFA that may be available to the animal (P < 0.001). The molar ratio of SCFA produced in vitro was affected by diet; the high fiber diet showed the greatest (P = 0.004) proportion of acetic acid, and the low fiber diet showed a tendency (P = 0.081) to an increased butyric acid proportion compared with the other 2 diets. Net disappearance of NSP during fermentation in vivo and in vitro were compared and showed a close relationship (P < 0.001, slope = 0.906, r = 0.960). In our experimental conditions, available energy as SCFA to the animal from hindgut fermentation increased with the concentration of dietary NSP (P < 0.001) and provided between 7.1 and 17.6% of the total available energy.

Effects of butyrate, avilamycin, and a plant extract combination on the intestinal equilibrium of early-weaned pigs1

We evaluated the effects of 3 additives, sodium butyrate (AC), avilamycin (AB), and a combination of plant extracts (XT), on the productive performance and the intestinal environment of the early-weaned pig. The XT was a standardized mixture with 5% (wt/wt) carvacrol (from Origanum spp.), 3% cinnamaldehyde (from Cinnamonum spp.), and 2% capsicum oleoresin (from Capsicum annum). Pigs (n = 32) weaned at 18 to 22 d of age with an initial BW of 6.0 +/- 0.10 kg were allocated to 8 pens that, in turn, were allocated to 4 treatments. The treatments included a basal diet (CT) or the basal diet supplemented with 0.3% of AC, 0.04% of AB, or 0.03% of XT. Productive performance was determined during the initial 14 d postweaning. On d 19 and 21 of the experiment, the pigs were killed to allow collection of digesta and intestinal tissue to evaluate variables indicative of aspects of the gastrointestinal environment. Treatments AB and AC improved G:F (P = 0.012 and 0.003, respectively) compared with the CT. Butyrate included in the diet was only detected in the stomach but not in cranial jejunum. When compared with CT, AC produced a lower ileal starch digestibility (P = 0.002) and a lower whole-tract OM and starch digestibility (P = 0.001 and 0.003, respectively), related to a lower VFA concentration in the cranial colon (P = 0.082) and a numerically reduced branched VFA percentage in the rectum. The AB treatment diminished propionate production in caudal colon (P = 0.002) and rectum (P = 0.012) compared with CT. The AC group exhibited deeper crypt depth in the jejunum without variations in villus height compared with CT (P = 0.042). The AC and AB groups also increased goblet cell presence in the colon (P = 0.001 and 0.032, respectively). On the other hand, AB and XT diminished intraepithelial lymphocytes in the jejunum (P = 0.003 and 0.034, respectively). The XT increased lymphocyte presence in the colon (P = 0.003). These results show the important influence of AB and AC on productive performance and on pig gut dynamics. The intestinal modifications observed for AB and AC compared with CT suggest distinct modes of action for each additive.