Value of cardiac magnetic resonance on the risk stratification of cardiomyopathies

Cardiomyopathies represent a diverse group of heart muscle diseases with varying etiologies, presenting a diagnostic challenge due to their heterogeneous manifestations. Regular evaluation using cardiac imaging techniques is imperative as symptoms can evolve over time. These imaging approaches are pivotal for accurate diagnosis, treatment planning, and optimizing prognostic outcomes. Among these, cardiovascular magnetic resonance (CMR) stands out for its ability to provide precise anatomical and functional assessments. This manuscript explores the significant contributions of CMR in the diagnosis and management of patients with cardiomyopathies, with special attention to risk stratification. CMR's high spatial resolution and tissue characterization capabilities enable early detection and differentiation of various cardiomyopathy subtypes. Additionally, it offers valuable insights into myocardial fibrosis, tissue viability, and left ventricular function, crucial parameters for risk stratification and predicting adverse cardiac events. By integrating CMR into clinical practice, clinicians can tailor patient-specific treatment plans, implement timely interventions, and optimize long-term prognosis. The non-invasive nature of CMR reduces the need for invasive procedures, minimizing patient discomfort. This review highlights the vital role of CMR in monitoring disease progression, guiding treatment decisions, and identifying potential complications in patients with cardiomyopathies. The utilization of CMR has significantly advanced our understanding and management of these complex cardiac conditions, leading to improved patient outcomes and a more personalized approach to care.

Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology

Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.

Current role and future perspectives of artificial intelligence in echocardiography

Echocardiography is an essential tool in diagnostic cardiology and is fundamental to clinical care. Artificial intelligence (AI) can help health care providers serving as a valuable diagnostic tool for physicians in the field of echocardiography specially on the automation of measurements and interpretation of results. In addition, it can help expand the capabilities of research and discover alternative pathways in medical management specially on prognostication. In this review article, we describe the current role and future perspectives of AI in echocardiography.

Role of artificial intelligence in cardiology

Artificial intelligence (AI) is the process of having a computational program that can perform tasks of human intelligence by mimicking human thought processes. AI is a rapidly evolving transdisciplinary field which integrates many elements to develop algorithms that aim to simulate human intuition, decision-making, and object recognition. The overarching aims of AI in cardiovascular medicine are threefold: To optimize patient care, improve efficiency, and improve clinical outcomes. In cardiology, there has been a growth in the potential sources of new patient data, as well as advances in investigations and therapies, which position the field well to uniquely benefit from AI. In this editorial, we highlight some of the main research priorities currently and where the next steps are heading us.

Healthcare Provider’s Perspectives on Home Blood Pressure Management in Peru and Cameroon: Findings from the BPMONITOR Study

Home blood pressure management, including self-monitoring and medication self-titration, is an efficient and cost-effective tool. Although its use is increasing globally, little is known about the feasibility of such interventions in low and middle-income countries. Further, the perspectives and experiences of healthcare providers who play a big role in ensuring the success of home blood pressure management interventions have not been documented. This qualitative study was conducted with a total of 35 healthcare providers (60% female, mean [SD] age = 37.3 [6.9 years] years), through 4 in-depth interviews from Peru, and 8 in-depth interviews and 4 focus groups from Cameroon. Study participants (healthcare providers) include physicians (primary care physicians), specialists (cardiologists and geriatricians), and nurses that were purposively recruited from two hospitals in two of the largest cities in both countries. Results were thematically analyzed by two researchers. Themes derived were related to feasibility and acceptability, and largely reflected providers in both countries endorsing home blood pressure management. Providers' concerns were in three main areas; 1) safety of patients when they self-titrate medications, 2) resources such as healthcare financing, local hospital policies that support communications with patients for home blood pressure management, and 3) sustainability through patient adherence, incorporating home blood pressure management within clinical guidelines and hospital policies, and complementing with continued health education and lifestyle modifications. According to providers, home blood pressure management may be feasible and acceptable if tailored multi-faceted protocols were introduced bearing in mind local contexts.

Cardiovascular disease and COVID-19, a deadly combination: A review about direct and indirect impact of a pandemic

Coronavirus disease 2019 (COVID-19) is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular manifestations. The cardiovascular manifestations reported comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. There is also an indirect impact of the pandemic on the management of cardiovascular care that has been shown clearly in multiple publications. In this review, we summarize the deadly relation of COVID-19 with cardiovascular events and the wider impact on several cardiovascular care areas by the pandemic situation

Twitter promotion is associated with higher citation rates of cardiovascular articles: the ESC Journals Randomized Study

The association between the dissemination of scientific articles on Twitter and online visibility (as assessed by the Altmetric Score) is still controversial, and the impact on citation rates has never been rigorously addressed for cardiovascular medicine journals using a randomized design. The ESC Journals Study randomized 695 papers published in the ESC Journal Family (March 2018-May 2019) for promotion on Twitter or to a control arm (with no active tweeting from ESC channels) and aimed to assess whether Twitter promotion was associated with an increase in citation rates (primary endpoint) and of the Altmetric Score. This is the final analysis including 694 articles (one paper excluded due to retraction). After a median follow-up of 994 days (interquartile range: 936-1063 days), Twitter promotion of articles was associated with a 1.12 (95% confidence interval: 1.08-1.15) higher rate of citations, and this effect was independent of the type of article. Altmetric Attention Score and number of users tweeting were positive predictors for the number of citations. A social media strategy of Twitter promotion for cardiovascular medicine papers seems to be associated with increased online visibility and higher numbers of citations.

ISCHEMIA trial: How to apply the results to clinical practice

During the last years two questions have been continuously asked in chronic coronary syndromes: (1) Do revascularization procedures (coronary artery bypass grafting or percutaneous coronary intervention) really improve symptoms of angina? and (2) Do these techniques improve outcomes, i.e. do they prevent new myocardial infarction events and cardiovascular death? Therefore, there was a need for a large definitive trial. This study was the ISCHEMIA trial, a large, multicentric trial sponsored by the National Heart, Lung, and Blood Institute. The main trial compared coronary revascularization and optimal medical treatment (OMT) vs OMT alone in 5179 patients enrolled after a stress test. During a median 3.2-year follow-up, 318 primary outcome events occurred; the adjusted hazard ratio for the invasive strategy as compared with the conservative strategy was 0.93 (95% confidence interval 0.80-1.08, P = 0.34). The ISCHEMIA trial deeply disrupted many of our prior attitudes regarding management strategies for patients with stable coronary artery disease. The findings underscore the benefits of disease-modifying OMT for stable coronary artery disease patients. The main purposes of ischemia assessment before this trial were: Diagnostic purposes, assessment of outcome, and adding to decision-making processes. Obviously, this changed after the trial results. The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial. In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.

Improvement in Atrial Fibrillation-Related Symptoms After Cardioversion: Role of NYHA Functional Class and Maintenance of Sinus Rhythm

Background

The European Heart Rhythm Association (EHRA) score is a proven and validated tool for assessing the symptoms of atrial fibrillation (AF). Little is known about the variables related to this score and how it changes after cardioversion.

Methods

We analyzed 744 patients undergoing elective cardioversion in whom AF-related symptoms were assessed at baseline and after 6 months of follow-up using the EHRA score. We assessed the association between the EHRA score and other clinical and echocardiographic variables at baseline and after 6 months of follow-up.

Results

At 6 months of follow-up, we observed a reduction in the EHRA score in 50% and worsening in 2.8% of patients who remained in sinus rhythm (SR) compared with 34.6% and 11.3%, respectively, of patients with AF episodes (p<0.0001). Patients who maintained SR at 6 months were less symptomatic than those with AF (EHRA score 1.13 ± 0.35 vs 1.42 ± 0.59; p<0.0001). The independent predictors for reduction in the EHRA score after cardioversion were NYHA ≥II at baseline and maintenance of SR (p<0.0001).

Conclusion

The greatest improvement in AF-related symptoms was in patients who remained in SR at 6 months after cardioversion and in patients with worse NYHA functional class at baseline.

Diagnostic and prognostic value of cardiac imaging in amyloidosis

Amyloidosis is an infiltrative disease caused by extracellular protein deposition that has accumulated a lot of scientific production in recent years. Different types of amyloidosis can affect the heart. Transthyretin amyloidosis and light chain amyloidosis are the two most common types of cardiac amyloidosis. These entities have a poor prognosis, so accurate diagnostic techniques are imperative for determining an early therapeutic approach. Recent advances in cardiac imaging and diagnostic strategies show that these tools are safe and can avoid the use of invasive diagnostic techniques to histological confirmation, such as endomyocardial biopsy. We performed a review on the diagnostic and prognostic implications of different cardiac imaging techniques in cardiac amyloidosis. We mainly focus on reviewing echocardiography, cardiac magnetic resonance, computed tomography and nuclear imaging techniques and the different safety measurements that can be done with each of them.

Social media in cardiovascular medicine: a contemporary review

Social media increasingly impact both the private and professional lives of the majority of the population, including individuals engaged in cardiovascular healthcare and research. Healthcare providers across the world use social media platforms such as Twitter or Facebook to find medical and scientific information, to follow scientific meetings, to discuss individual clinical cases with colleagues, and to engage with patients. While social media provide a means for fast, interactive and accessible communication without geographic boundaries, their use to obtain and disseminate information has limitations and the potential threats are not always clearly understood. Governance concerns include a lack of rigorous quality control, bias due to the pre-selection of presented content by filter algorithms, and the risk of inadvertent breach of patient confidentiality. This article provides information and guidance regarding the role and use of social media platforms in cardiovascular medicine, with an emphasis on the new opportunities for the dissemination of scientific information and continuing education that arise from their responsible use.

Twitter promotion predicts citation rates of cardiovascular articles: a preliminary analysis from the ESC Journals Randomized Study

AIMS

The association between the dissemination of scientific articles on Twitter and online visibility (including Altmetric score) is still controversial and the impact on citation rates has never been addressed for cardiovascular medicine journals.

METHODS AND RESULTS

The ESC Journals Study randomized 696 papers published in the ESC Journals family (March 2018-May 2019) for promotion on Twitter or to a control arm (with no active tweeting from ESC channels) and aimed to assess if Twitter promotion was associated with an increase in citation rate (primary endpoint) and Altmetric score. This is a preliminary analysis of 536 articles (77% of total) published until December 2018 (therefore, papers published at least 6 months before collecting citation and Altmetrics data). In the analysis of the primary endpoint, Twitter promotion of articles was associated with a 1.43 (95% confidence interval 1.29-1.58) higher rate of citations, and this effect was independent of the type of article. Both Altmetric score and number of users tweeting were positively associated with the number of citations in both arms, with evidence of a stronger association (interaction) in the Twitter arm.

CONCLUSION

Therefore, a social media strategy of Twitter promotion for cardiovascular medicine papers seems to be associated with increased online visibility and higher number of citations. The final analysis will include 696 papers and 2-year scientific citation rate and is estimated to be concluded in March 2021.

Patients' perceptions of self-management of high blood pressure in three low- and middle-income countries: findings from the BPMONITOR study

Hypertension is the leading risk factor for global disease burden. Self-management of high blood pressure (BP) through self-monitoring and self-titration of medications, has proved to be one successful and cost-effective tool to achieve better BP control in many high-income countries but not much is known about its potential in low- and middle-income countries (LMICs). We used semi-structured questionnaires and focus groups in three LMICs; Peru, Cameroon and Malawi to examine perceptions and attitudes of patients diagnosed with essential hypertension towards living with hypertension, BP measurement and treatment, patient-physician relationship and opinions about self-management of high blood pressure. Results in all three countries were comparable. Patients showed varied levels of health literacy related to hypertension. BP measurement habits were mostly affected by resources available and caregiver support. Treatment and adherence to it were primarily affected by cost. Most patients were welcoming of the idea of self-management but skeptical about the ability to do self-monitoring accurately and the safety involving self-titration of medications.

Prognostic Value of Late Gadolinium Enhancement for the Prediction of Cardiovascular Outcomes in Dilated Cardiomyopathy: An International, Multi-Institutional Study of the MINICOR Group

BACKGROUND

Dilated cardiomyopathy is associated with increased risk of major cardiovascular events. Late gadolinium enhancement (LGE) cardiac magnetic resonance imaging is a unique tissue-based marker that, in single-center studies, suggests strong prognostic value. We retrospectively studied associations between LGE presence and adverse cardiovascular events in patients with dilated cardiomyopathy in a multicenter setting as part of an emerging global consortium (MINICOR [Multi-Modal International Cardiovascular Outcomes Registry]).

METHODS

Consecutive patients with dilated cardiomyopathy referred for cardiac magnetic resonance (2000-2017) at 12 institutions in 4 countries were studied. Using multivariable Cox proportional hazard and semiparametric Fine and Gray models, we evaluated the association between LGE and the composite primary end point of all-cause mortality, heart transplantation, or left ventricular assist device implant and a secondary arrhythmic end point of sudden cardiac death or appropriate implantable cardioverter-defibrillator shock.

RESULTS

We studied 1672 patients, mean age 56±14 years (29% female), left ventricular ejection fraction 33±11%, and 25% having New York Heart Association class III to IV; 650 patients (39%) had LGE. During 2.3 years (interquartile range, 1.0-4.3) follow-up, 160 patients experienced the primary end point, and 88 experienced the arrhythmic end point. In multivariable analyses, LGE was associated with 1.5-fold (hazard ratio, 1.45 [95% CI, 1.03-2.04]) risk of the primary end point and 1.8-fold (hazard ratio, 1.82 [95% CI, 1.20-3.06]) risk of the arrhythmic end point. Primary end point risk was increased in patients with multiple LGE patterns, although arrhythmic risk was higher among patients receiving primary prevention implantable cardioverter-defibrillator and widening QRS.

CONCLUSIONS

In this large multinational study of patients with dilated cardiomyopathy, the presence of LGE showed strong prognostic value for identification of high-risk patients. Randomized controlled trials evaluating LGE-based care management strategies are warranted.

Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions

Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA). This acute coronary syndrome differs from type 1 myocardial infarction (MI) regarding patient characteristics, presentation, physiopathology, management, treatment, and prognosis. Two-thirds of MINOCA subjects present ST-segment elevation; MINOCA patients are younger, are more often female and tend to have fewer cardiovascular risk factors. Moreover, MINOCA is a working diagnosis, and defining the aetiologic mechanism is relevant because it affects patient care and prognosis. In the absence of relevant coronary artery disease, myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries, coronary microcirculation, or both. Epicardial causes of MINOCA include coronary plaque disruption, coronary dissection, and coronary spasm. Microvascular MINOCA mechanisms involve microvascular coronary spasm, takotsubo syndrome (TTS), myocarditis, and coronary thromboembolism. Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients. The diagnostic arsenal includes invasive and non-invasive techniques. Medical history and echocardiography can help indicate vasospasm or thrombosis, if one finite coronary territory is affected, or specify TTS if apical ballooning is present. Intravascular ultrasound, optical coherence tomography, and provocative testing are encouraged. Cardiac magnetic resonance is a cornerstone in myocarditis diagnosis. MINOCA is not a benign diagnosis, and its polymorphic forms differ in prognosis. MINOCA care varies across centres, and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.

Social media in cardiology: Reasons to learn how to use it

Social media has changed the way we learn, educate, and interact with our peers. The dynamic nature of social media and their immediate availability through our portable devices (smartphones, tablets, smartwatches, etc.) is quickly transforming the way we participate in society. The scope of these digital tools is broad as they deal with many different aspects: Teaching and learning, case discussion, congresses coverage, peer to peer interaction, research are examples worth mentioning. The scientific societies considered more innovative, are promoting these tools between their members. These new concepts need to be known by the cardiologists to stay updated, as countless information is moving rapidly through these channels. We summarize the main reasons why learning how to use these tools to be part of the conversation is essential for the cardiologist in training or fully stablished.

P2620PIONEER-HF criteria ready for the prime time? Data from REDINSCOR II registry

Background

New treatment strategies are needed to improve the prognosis in acute heart failure (AHF), recently PIONEER-HF results have been published showing in a selected group of patients a potential use of sacubitril/valsartan with safety in this scenario

Purpose

To evaluate the impact of PIONEER-HF potential indication in daily practice after AHF hospitalization at discharge

Methods

We included a subgroup of 909 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry with the complete data for this analysis. In the trial left ventricular ejection fraction (LVEF) ≤40% and natriuretic peptides at admission with values of NT-ProBNP≥1600 pg/ml were needed to be included. The clinical and analytic stability at discharge to safely start sacubitril/valsartan was considered as MDRD estimated Glomerular Filtration Rate≥30 mL/min/1.73 m2, Systolic Blood Pressure ≥100 mmHg and Potassium ≤5.2 mmol/L.

Results

The mean age was 72.1±12.01 years. Of these, 373 (38.8%) were female, 734 (76,6%) were hypertensive, 462 (48.2%) had diabetes and 282 (29.9%) coronary artery disease. At admission atrial fibrillation was found in 403 patients (40.1%) and 409 (45%) had reduced LVEF. The mean levels of NT-ProBNP 7259.4±9437.1 pg/ml. In this group of patients, the in-hospital mortality was 28 (2.9%) and the 1 year follow up mortality was 197 (20.5%) and the heart failure rehospitalizations in 1 year were 303 (31,5%). In table 1 the percentage of patients that fulfil the needed criteria for the application of PIONEER HF is shown. In our registry 235 patients (25.9%) could be potential users of sacubitril/valsartan after the acute phase of hospitalization

Table 1 Elements to stablish indication Number of patients (%) NT-ProBNP ≥1600 pg/ml at admission 730 (80.3%) MDRD estimated GFR ≥30 mL/min/1.73 m2 at discharge 798 (87.8%) Systolic Blood Pressure ≥100 mmHg at discharge 755 (83.1%) Serum Potassium ≤5.2 mmol/L at discharge 856 (94.2%) Clinical and analytic stability at discharge 636 (70%) Left ventricular ejection fraction ≤40% 409 (45%) PIONEER HF Criteria 235 (25.9%) GFR: Glomerular Filtration Rate.

Conclusions

In our cohort of AHF patients around 1 out 4 could be treated with sacubitril/valsartan at discharge if we apply the PIONEER HF criteria in a contemporary setting, this finding could have potential implications in the prognosis and current costs of care in a population with high morbidity and mortality.

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and FEDER

P6361Prognostic value of discharge heart rate in acute heart failure patients: more relevant in atrial fibrillation?

Background

The prognostic impact of heart rate (HR) in acute heart failure (AHF) patients is not well known especially in atrial fibrillation (AF) patients.

Purpose

The aim of the study was to evaluate the impact of admission HR, discharge HR, HR difference (HRD) (admission- discharge) in AHF patients with sinus rhythm (SR) or AF on long- term outcomes.

Methods

We included 1398 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentric, prospective registry. Logistic regression models were used to estimate the association between admission HR, discharge HR and HR difference and one- year all-cause mortality and HF readmission.

Results

The mean age of the study population was 72±12 years. Of these, 594 (42.4%) were female, 655 (77.8%) were hypertensive and 655 (46.8%) had diabetes. Among all included patients, 745 (53.2%) had sinus rhythm and 653 (46.7%) had atrial fibrillation. Only discharge HR was associated with one-year all-cause mortality (Relative risk (RR)= 1.182, confidence interval (CI) 95% 1.024–1.366, p=0.022) in SR. In AF patients discharge HR was associated with one-year all-cause mortality (RR= 1.276, CI 95% 1.115–1.459, p≤0.001). We did not observe a prognostic effect of admission HR or HRD on long-term outcomes in both groups. This relationship is not dependent on left ventricular ejection fraction (Figure 1)

Effect of post-discharge heart rate

Conclusions

In AHF patients lower discharge HR, neither the admission nor the difference, is associated with better long-term outcomes especially in AF patients

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and the Fondo Europeo de

Subclinical carotid atherosclerosis predicts all-cause mortality and cardiovascular events in obese patients with negative exercise echocardiography

BACKGROUND

Obesity is a major health problem due to its high prevalence. The relationship between obesity and cardiovascular disease is unclear. Some studies agree that certain conditions associated with obesity, such as physical inactivity or cardiovascular risk factors, are responsible for cardiovascular risk excess among obese people. Carotid intima-media thickness and carotid plaques (CP) have been associated with cardiovascular adverse events in healthy populations, and recent data suggest a higher prevalence of subclinical carotid atherosclerosis in obese and metabolically unhealthy patients. However, there are no studies correlating subclinical atherosclerosis and adverse events (AE) in obese subjects.

AIM

To determine the association between carotid disease and AE in obese patients with negative exercise echocardiography (EE).

METHODS

From January 1, 2006 to December 31, 2010, 2000 consecutive patients with a suspicion of coronary artery disease were submitted for EE and carotid ultrasonography. Exclusion criteria included previous vascular disease, left ventricular ejection fraction < 50%, positive EE, significant valvular heart disease and inferior to submaximal EE. An AE was defined as all-cause mortality, myocardial infarction and cerebrovascular accident. Subclinical atherosclerosis was defined as CP presence according to Manheim and the American Society of Echocardiography Consensus.

RESULTS

Of the 652 patients who fulfilled the inclusion criteria, 226 (34.7%) had body mass indexes ≥ 30 kg/m², and 76 of them (33.6%) had CP. During a mean follow-up time of 8.2 (2.1) years, 27 AE were found (11.9%). Mean event-free survival at 1, 5 and 10 years was 99.1% (0.6), 95.1% (1.4) and 86.5% (2.7), respectively. In univariate analysis, CP predicted AE [hazard ratio (HR) 2.52, 95% confidence interval (CI) 1.17-5.46; P = 0.019]. In multivariable analysis, the presence of CP remained a predictor of AE (HR 2.26, 95%CI 1.04-4.95, P = 0.041). Other predictors identified were glomerular filtration rate (HR 0.98, 95%CI 0.96-0.99; P = 0.023), peak metabolic equivalents (HR 0.83, 95%CI 0.70–0.99, P = 0.034) and moderate mitral regurgitation (HR 5.02, 95%CI 1.42–17.75, P = 0.012).

CONCLUSION

Subclinical atherosclerosis defined by CP predicts AE in obese patients with negative EE. These patients could benefit from aggressive prevention measures.

Home Blood Pressure Management Intervention in Low- to Middle-Income Countries: Protocol for a Mixed Methods Study

Background

Control of hypertension in low- and middle-income countries (LMICs) is poor, often less than 10%. A strong body of evidence demonstrates that home blood pressure management lowers blood pressure, and recent guidelines from the National Institute for Clinical Health and Excellence recommends home blood pressure monitoring. However, the preponderance of data on the benefits of home blood pressure management comes from studies in high-income countries.

Objective

The objective of the study is to examine whether an intervention of home blood pressure management is feasible in LMICs. Home blood pressure management is defined as self-monitoring of blood pressure and self-titration of antihypertensive medications. We will identify barriers and facilitators of home blood pressure management and explore unique contextual factors in LMICs that influence implementation of home blood pressure management.

Methods

Participants will be recruited from 6 sites from 2015 to 2018. Patients and health care workers will be included. We will use mixed methods including focus groups, interviews, and standardized checklists. When possible, we will adapt materials from prior successful studies so that they are culturally and contextually appropriate.

Results

This ongoing study is funded by the World Heart Federation. The information that is obtained will be used to develop a randomized clinical trial of home blood pressure management in LMICs.

Conclusions

The data generated from this qualitative study will provide much needed information from patients and health care workers about barriers and facilitators of home blood pressure management and unique contextual factors that might influence implementation of home blood pressure management in LMICs.

Secondary forms of Takotsubo cardiomyopathy: A whole different prognosis

BACKGROUND

Takotsubo syndrome (TKS) usually mimics an acute coronary syndrome. However, several clinical forms have been reported. Our aim was to assess if different stressful triggers had prognostic influence on TKS, and to establish a working classification.

METHODS

We performed an analysis including patients with TKS between 2003-2013 from our prospective local database and the RETAKO National Registry, fulfilling Mayo criteria. Patients were divided in two groups regarding their potential triggers: (a) none/psychic stress as 'primary forms' and (b) physical factors (asthma, surgery, trauma, etc.) as 'secondary forms'.

RESULTS

Finally, 328 patients were included, 90.2% women, with a mean age of 69.7 years. Patients were divided into primary TKS (n=265) and 63 secondary TKS groups. Age, gender, previous functional class and cardiovascular risk profile displayed no differences between groups before admission. However, primary-TKS patients suffered a main complaint of chest pain (89.4% vs 50.7%, p<0.0001) with frequent vegetative symptoms. Regarding treatment before admission, there were no differences either. During admission, differences were related to more intensive antithrombotic and anxiolytic drug use in the primary TKS group. Inotropic and mechanical ventilation use was higher in the secondary cohort. After discharge, a more frequent prescription of beta-blockers and statins in primary-TKS patients was seen. Secondary forms displayed more in-hospital stay and evolutive complications: death (hazard ratio (HR): 3.41; 95% confidence interval (CI): 1.14-10.16, p=0.02), combined event variable (MACE) (HR: 1.61; 95% CI: 1.01-2.6, p=0.04) and recurrences (HR: 1.85; 95% CI: 1.06-3.22, p=0.02).

CONCLUSION

Secondary TKS could present or mark worse short and long-term prognoses in terms of mortality, recurrences and readmissions. We propose a simple working nomenclature for TKS.

Determinants of cardiovascular mortality in a cohort of primary care patients with chronic ischemic heart disease. BARBANZA Ischemic Heart Disease (BARIHD) study

BACKGROUND

Prognosis of chronic patients with established ischemic heart disease (IHD) is not fully understood. The objective was to determine which factors are related to cardiovascular death and hospitalizations in patients with IHD within a primary care network.

MATERIALS AND METHODS

A cohort study was carried out by 69 primary care providers in Spain in 2007. Participants were followed up for a mean of 2.2 ± 0.3 years. 1095 patients were recruited if they had established (at least 1 year of known disease) IHD (myocardial infarction or and stable or unstable angina). Several hypothesized determinants of cardiovascular mortality were studied, using Cox proportional hazard regression models. Subgroup analysis was also performed for participants without cardiovascular admissions within the last year.

RESULTS

Mean time since first IHD diagnosis was 7.6 ± 6.0 years. Annual all-cause mortality rate was 3.25%, with 44 cardiovascular deaths and 119 cardiovascular admissions. The main prognostic factor for cardiovascular death was previous heart failure (hazard ratio [HR] 4.32, 95% confidence interval [CI] 2.30 to 8.11, p<0.001). Recent cardiovascular admission doubled the risk for death (HR 2.01, CI 1.06 to 3.81, p=0.031). Results showed that use of beta blockers and increased physical activity were the main protective factors. Patients without a recent cardiovascular admission showed previous heart failure as the main significant factor for cardiovascular death.

CONCLUSIONS

Patients with chronic IHD in a primary care setting may need a closer follow-up in the presence of previous conditions such as heart failure. Physical activity and treatment with beta blockers were the factors giving these patients the greatest protection.