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Gonzalez-Del-Hoyo M, Mas-Llado C, Blaya-Peña L, Siquier-Padilla J, Coughlan JJ, Peral V, Rossello X. Type of evidence supporting ACC/AHA and ESC clinical practice guidelines for acute coronary syndrome. Clin Res Cardiol 2024; 113:546-560. [PMID: 37436514 DOI: 10.1007/s00392-023-02262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
AIM The aim of clinical practice guidelines for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) is to assist healthcare professionals in clinical decision-making. We evaluated the type of studies supporting these guidelines and their recommendations. METHODS All references and recommendations in the 2013 and 2014 ACC/AHA and 2017 and 2020 (ESC clinical guidelines for STEMI and NSTE-ACS were reviewed. References were classified into meta-analyses, randomised, non-randomised, and other types (e.g., position papers, reviews). Recommendations were classified according to class and their level of evidence (LOE). RESULTS We retrieved 2128 non-duplicated references: 8.4% were meta-analyses, 26.2% randomised studies, 44.7% non-randomised studies, and 20.7% 'other' papers. Meta-analyses were based on randomised data in 78% of cases and used individual-patient data in 20.2%. Compared to non-randomised studies, randomised studies were more frequently multicentre (85.5% vs. 65.5%) and international (58.2% vs. 28.5%). The type of studies supporting recommendations varied as per the LOE of the recommendation. For LOE-A recommendations, the breakdown of supporting recommendations was: 18.5% meta-analyses, 56.6% randomised studies, 16.6% non-randomised studies and 8.3% 'other' papers; for LOE-B this breakdown was 9%, 39.8%, 38.2%, and 12.9%; and for LOE-C; 4.6%, 19.3%, 30.3%, and 45.9%. CONCLUSIONS The references supporting the ACC/AHA and ESC guidelines on STEMI and NSTE-ACS consisted of non-randomised studies in ~ 45% of cases, with less than a third of the references consisting of meta-analyses and randomised studies. The type of studies supporting guideline recommendations varied widely by the LOE of the recommendation.
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Affiliation(s)
- Maribel Gonzalez-Del-Hoyo
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
| | - Caterina Mas-Llado
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital de Manacor, Manacor, Spain
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Laura Blaya-Peña
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
| | | | - J J Coughlan
- Deutsches Herzzentrum München und Technische Universität München, Munich, Germany
- Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland
| | - Vicente Peral
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain.
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain.
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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Gonzalez-Del-Hoyo M, Mas-Llado C, Siquier-Padilla J, Blaya-Peña L, Coughlan JJ, Peral V, Rossello X. A systematic assessment of the characteristics of randomized controlled trials cited by acute coronary syndrome clinical practice guidelines. Eur Heart J Qual Care Clin Outcomes 2024; 10:176-188. [PMID: 37296213 DOI: 10.1093/ehjqcco/qcad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 06/12/2023]
Abstract
AIMS The aim of this study was to describe the methodological features of the randomized controlled trials (RCTs) cited in American and European clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS AND RESULTS Out of 2128 non-duplicated references cited in the 2013 and 2014 American College of Cardiology/American Heart Association and 2017 and 2020 European Society of Cardiology CPGs for STEMI and NSTE-ACS, we extracted data for 407 RCTs (19.1% of total references). The majority were multicenter studies (81.8%), evaluated pharmacological interventions (63.1%), had a 2-arm (82.6%), and superiority (90.4%) design. Most RCTs (60.2%) had an active comparator, and 46.2% were funded by industry. The median observed sample size was 1001 patients (84.2% of RCTs achieved ≥80% of the intended sample size). Most RCTs had a single primary outcome (90.9%), which was a composite in just over half (51.9%). Among the RCTs testing for superiority, 44.0% reported a P-value of ≥0.05 for the primary outcome and 61.9% observed a risk reduction of >15%. The observed treatment effect was lower-than-expected in 67.6% of RCTs, with 34.4% having at least a 20% lower-than-expected treatment effect. The calculated post hoc statistical power was ≥80% for 33.9% of cited RCTs. CONCLUSIONS This analysis demonstrates that RCTs cited by CPGs can still have significant methodological issues and limitations, highlighting that a better understanding of the methodological aspects of RCTs is crucial in order to formulate recommendations relevant to clinical practice.
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Affiliation(s)
- Maribel Gonzalez-Del-Hoyo
- Health Research Institute of the Balearic Islands (IdISBa), Carretera de Valldemossa, 79, 07120 Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, 07120 Palma, Spain
| | - Caterina Mas-Llado
- Health Research Institute of the Balearic Islands (IdISBa), Carretera de Valldemossa, 79, 07120 Palma, Spain
- Cardiology Department, Hospital de Manacor, Carretera Manacor-Alcudia, 07500 Manacor, Spain
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Carretera de Valldemossa, 79, 07120 Palma, Spain
| | - Joan Siquier-Padilla
- Cardiology Department, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, 07120 Palma, Spain
| | - Laura Blaya-Peña
- Cardiology Department, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, 07120 Palma, Spain
| | - J J Coughlan
- Cardiovascular Research Institute, Universtiy of Medicine and Health Sciences, Mater Private Network, D07 KWR1 Dublin, Ireland
| | - Vicente Peral
- Health Research Institute of the Balearic Islands (IdISBa), Carretera de Valldemossa, 79, 07120 Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, 07120 Palma, Spain
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Carretera de Valldemossa, 79, 07120 Palma, Spain
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), Carretera de Valldemossa, 79, 07120 Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, 07120 Palma, Spain
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Carretera de Valldemossa, 79, 07120 Palma, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Calle Melchor Fernández Almagro, 3, 28029 Madrid, Spain
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Mas-Llado C, Gonzalez-Del-Hoyo M, Siquier-Padilla J, Blaya-Peña L, Coughlan JJ, García de la Villa B, Peral V, Rossello X. Representativeness in randomised clinical trials supporting acute coronary syndrome guidelines. Eur Heart J Qual Care Clin Outcomes 2023; 9:796-805. [PMID: 36702530 PMCID: PMC10745262 DOI: 10.1093/ehjqcco/qcad007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023]
Abstract
AIMS Clinical practice guidelines (CPGs) are published to guide the management of acute coronary syndrome (ACS). We aimed to critically appraise the representativeness and standard of care of randomised clinical trials (RCTs) supporting CPGs for ACS. METHODS AND RESULTS American and European CPGs for ST- and non-ST-elevation ACS were screened to extract all references (n = 2128) and recommendations (n = 600). Among the 407 primary publications of RCTs (19.1%), there were 52.6 and 73.2% recruiting patients in North America and Europe, respectively, whereas other regions were largely under-represented (e.g. 25.3% RCTs recruited in Asia). There was 68.6% RCTs enrolling patient with ACS, whereas the remaining 31.4% did not enrol any patient with ACS. There was under-representation of some important subgroups, including elderly, female (29.9%), and non-white patients (<20%). The incidence and type of reperfusion reported in these RCTs were not reflective of current clinical practice (the percentage of patients who underwent percutaneous coronary intervention (PCI) among all RCTs was 42.7%; whereas for ST-Elevation Myocardial Infarction patients, the number of participants who underwent fibrinolysis was 3.3-fold higher than those who underwent primary PCI). All-cause mortality in these RCTs was 11.9% in RCTs with a follow-up ≤ 1 year. CONCLUSION Randomised clinical trials supporting CPGs for ACS are not fully representative of the diversity of the ACS population and their current standard of care. While some of these issues with representativeness may be explained by how evidence has been accrued over time, efforts should be made by trialists to ensure that the evidence supporting CPGs is representative of the wider ACS population.
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Affiliation(s)
- Caterina Mas-Llado
- Cardiology Department, Hospital de Manacor, 07500 Manacor, Spain
- Fisiopatología y Terapéutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Maribel Gonzalez-Del-Hoyo
- Fisiopatología y Terapéutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
| | - Joan Siquier-Padilla
- Cardiology Department, Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
| | - Laura Blaya-Peña
- Cardiology Department, Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
| | - J J Coughlan
- Cardiology Department, Deutsches Herzzentrum München und Technische Universität München, 80636 Munich, Germany
- Cardiology Department, Cardiovascular Research Institute, Mater Private Network, D07 KWR1 Dublin, Ireland
| | - Bernardo García de la Villa
- Cardiology Department, Hospital de Manacor, 07500 Manacor, Spain
- Fisiopatología y Terapéutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
| | - Vicente Peral
- Fisiopatología y Terapéutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
| | - Xavier Rossello
- Fisiopatología y Terapéutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands (IdISBa), 07122 Palma, Spain
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
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García-Touchard A, Sabaté M, Gonzalo N, Peral V, Vaquerizo B, Ruiz-Salmerón R, García del Blanco B, Jiménez-Mazuecos J, Molina E, Martínez-Romero P, Hernandez-García JM, Ruiz-Quevedo V, Urbano C, Fernández-Portales J, Rumoroso JR, Casanova-Sandoval J, Pinar E, Lopez-Pais J, Oteo JF, Alfonso F. Very long-term efficacy and safety of paclitaxel-eluting balloon after a bare-metal stent for the treatment of ST-elevation myocardial infarction: 8-year results of a randomized clinical trial (PEBSI study). Cardiovasc Diagn Ther 2023; 13:792-804. [PMID: 37941845 PMCID: PMC10628420 DOI: 10.21037/cdt-22-623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 09/08/2023] [Indexed: 11/10/2023]
Abstract
Background Drug-eluting stents (DES) are considered the therapy of choice in ST-segment elevation myocardial infarction (STEMI); however, a low persistent rate of revascularizations and stent thrombosis exist over the time. We have previously shown that a paclitaxel (PTX)-drug-coated balloon (DCB) after a bare-metal stent (BMS) implantation (DCB-combined strategy) yields superior angiographic and clinical results compared to BMS in the short term. However, the long-term safety and efficacy of this approach remain uncertain. Methods An 8-year clinical follow-up was conducted on patients enrolled in the randomized PEBSI-1 trial (NCT01839890). The original trial included patients who suffered a STEMI, patients were randomly assigned to receive a DCB-combined strategy or BMS only and the primary endpoint was in-stent late luminal loss (LLL) at 9-month follow-up. After the completion of this study, death, myocardial re-infarction, ischemia-driven repeated revascularizations included target lesion revascularization (TLR) and target vessel revascularization (TVR), and stent thrombosis, were assessed by yearly contact by a clinical visit, telephone or by electronic records. These outcomes were adhered to ARC-2 criteria. Results The rate of incomplete follow-up was very low, with only 3 out of 111 patients (2.7%) in the DCB-combined strategy group and 1 out of 112 patients (0.9%) in the BMS group. At 8 years there were a lower rate of TVR [3.7% vs. 14.3%; hazard ratio (HR): 0.243; 95% confidence interval (CI): 0.081-0.727; P=0.006], and a trend towards lower TLR (2.8% vs. 8.9%; HR: 0.300; 95% CI: 0.083-1.090; P=0.052) in the DCB-combined strategy group. No statistical difference between the DCB-combined strategy and BMS groups were found for all causes of death, deaths from cardiovascular disease, reinfarctions or stent thrombosis. Notably in the DCB-combined strategy group, no episode of stent thrombosis occurred after the first year. Similarly, there were no cardiovascular deaths, TVR and TLR in the DCB-combined strategy group after 5 years. In contrast, during the period from year 5 to 8, the BMS group experienced an additional cardiovascular death, as well as one case of TVR, one case of TLR, and one case of stent thrombosis. Conclusions In STEMI patients, the DCB-combined strategy maintains its safety and clinical efficacy over time. Our rates of TVR, TLR, and very late stent thrombosis (VLST) at very long-term are the lowest ever found in a STEMI trial. Further studies are warranted to assess the potential superiority of this novel strategy as compared with new-generation DES to prevent very late events in these patients. Trial Registration ClinicalTrials.gov; identifier: NCT01839890.
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Affiliation(s)
- Arturo García-Touchard
- Department of Interventional Cardiology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
| | - Manel Sabaté
- Department of Interventional Cardiology, Hospital Clinic i Provincial, Barcelona, Spain
| | - Nieves Gonzalo
- Department of Interventional Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Vicente Peral
- Department of Interventional Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma de Mayorca, Spain
| | - Beatriz Vaquerizo
- Department of Interventional Cardiology, Hospital Del Mar, Barcelona, Spain
| | - Rafael Ruiz-Salmerón
- Department of Interventional Cardiology, Hospital Virgen Macarena, Sevilla, Spain
| | - Bruno García del Blanco
- Department of Interventional Cardiology, Hospital Universitari Vall D’Hebron, Barcelona, Spain
| | - Jesús Jiménez-Mazuecos
- Department of Interventional Cardiology, Complejo Hospitalario Universitario De Albacete, Albacete, Spain
| | - Eduardo Molina
- Department of Interventional Cardiology, Hospital Universitario Virgen De Las Nieves, Granada, Spain
| | | | | | - Valeriano Ruiz-Quevedo
- Department of Interventional Cardiology, Hospital Universitario De Navarra, Pamplona, Spain
| | - Cristóbal Urbano
- Department of Interventional Cardiology, Hospital Carlos Haya, Málaga, Spain
| | | | - José Ramón Rumoroso
- Department of Interventional Cardiology, Hospital De Galdakao, Bizkaia, Spain
| | | | - Eduardo Pinar
- Department of Interventional Cardiology, Hospital Virgen De La Arrixaca, Murcia, Spain
| | - Javier Lopez-Pais
- Department of Interventional Cardiology, Hospital Clínico Universitario De Santiago, La Coruña, Spain
| | - Juan Francisco Oteo
- Department of Interventional Cardiology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
| | - Fernando Alfonso
- Department of Interventional Cardiology, Hospital Universitario de La Princesa, Madrid, Spain
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González-Del-Hoyo M, Rossello X, Peral V, Pocock S, Van de Werf F, Chin CT, Danchin N, Lee SWL, Medina J, Huo Y, Bueno H. Impact of standard modifiable cardiovascular risk factors on 2-year all-cause mortality: Insights from an international cohort of 23,489 patients with acute coronary syndrome. Am Heart J 2023; 264:20-30. [PMID: 37279841 DOI: 10.1016/j.ahj.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/20/2023] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Controversial findings have been reported in the literature regarding the impact of the absence of standard modifiable cardiovascular risk factors (SMuRFs) on long-term mortality risk in patients with acute coronary syndrome (ACS). While the prognostic additive value of SMuRFs has been well described, the prognostic role of prior cardiovascular disease (CVD) by sex is less well-known in patients with and without SMuRFs. METHODS EPICOR and EPICOR Asia are prospective, observational registries conducted between 2010 and 2014, which enrolled ACS patients in 28 countries across Europe, Latin America, and Asia. Association between SMuRFs (diabetes, dyslipidaemia, hypertension, and smoking) and 2-year postdischarge mortality was evaluated using adjusted Cox models stratified by geographical region. RESULTS Among 23,489 patients, the mean age was 60.9 ± 11.9 years, 24.3% were women, 4,582 (20.1%) presented without SMuRFs, and 16,055 (69.5%) without prior CVD. Patients with SMuRFs had a higher crude 2-year postdischarge mortality (HR 1.86; 95% CI, 1.56-2.22; P < .001), compared to those without SMuRFs. After adjustment for potential confounding, the association between SMuRFs and 2-year mortality risk was substantially attenuated (HR 1.17, 95% CI 0.98-1.41; P = .087), regardless of the type of ACS. The risk conferred by prior CVD was added to the underlying risk of SMuRFs to provide risk-specific phenotypes (eg, women with SMuRFs and with prior CVD were at higher risk of dying than women without SMuRFs and without CVD; HR 1.67, 95% CI 1.34-2.06). CONCLUSIONS In this large-scale international ACS cohort the absence of SMuRFs was not associated with a lower adjusted 2-year postdischarge mortality risk. Patients with both SMuRFs and prior CVD had a higher mortality irrespective of their sex.
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Affiliation(s)
- Maribel González-Del-Hoyo
- Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain.
| | - Vicente Peral
- Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain; Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Stuart Pocock
- Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain; London School of Hygiene and Tropical Medicine, London, UK
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - Nicolas Danchin
- Hôpital Européen Georges Pompidou & René Descartes University, Paris, France
| | | | - Jesús Medina
- BioPharmaceuticals Medical, AstraZeneca, Madrid, Spain
| | - Yong Huo
- Beijing University First Hospital, Beijing, China
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Cardiology Department, Hospital Universitario 12 de Octubre, and Instituto de investigación i+12, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Gonzalez-Del-Hoyo M, Mas-Llado C, Blaya-Peña L, Siquier-Padilla J, Peral V, Rossello X. The Fragility Index in randomised clinical trials supporting clinical practice guidelines for acute coronary syndrome: measuring robustness from a different perspective. Eur Heart J Acute Cardiovasc Care 2023:7071514. [PMID: 36882068 DOI: 10.1093/ehjacc/zuad021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND In randomised clinical trials (RCTs) rejecting the null hypothesis, the fragility index (FI) yields the minimum number of participants who would need to have had a different outcome for the results of the trial to become non-significant. We evaluated the robustness of RCTs supporting ACC/AHA and ESC clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) using the FI. METHODS There were 407 RCTs among the 2128 studies cited in the 2013 and 2014 ACC/AHA and 2017 and 2020 ESC CPGs for STEMI and NSTE-ACS, respectively. The FI could be calculated in 132 RCTs (32.4%) meeting the needed criteria for its estimation (2-arm RCT, 1:1 allocation, binary outcome, p < 0.05). RESULTS The median FI was 12 (interquartile range: 4-29). Hence, a change in the outcome status of 12 patients would be needed to reverse the statistical significance of the primary endpoint in 50% of the RCTs. The FI was ≤1% than their sample size in 55.7% RCTs, whereas in 47% of RCTs, the FI was lower than the number of patients lost to follow-up. Some study design features were associated with higher FI (international, multicentre, private funding; all p < 0.05), whilst baseline patient characteristics were not substantially different by FI (e.g., age, female sex, white study participants; all p > 0.05), except for geographic enrolment (p = 0.042). CONCLUSIONS FI might be useful to evaluate the robustness of those RCTs with statistically significant findings for the primary endpoint that have an impact on key guideline recommendations.
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Affiliation(s)
- Maribel Gonzalez-Del-Hoyo
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.,Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
| | - Caterina Mas-Llado
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.,Cardiology Department, Hospital de Manacor, Manacor, Spain.,Department of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Laura Blaya-Peña
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
| | | | - Vicente Peral
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.,Cardiology Department, Hospital Universitari Son Espases, Palma, Spain.,Department of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.,Cardiology Department, Hospital Universitari Son Espases, Palma, Spain.,Department of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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Antúnez-Muiños P, Vicente-Palacios V, Pérez-Sánchez P, Sampedro-Gómez J, Sánchez-Puente A, Dorado-Díaz PI, Nombela-Franco L, Salinas P, Gutiérrez-García H, Amat-Santos I, Peral V, Morcuende A, Asmarats L, Freixa X, Regueiro A, Caneiro-Queija B, Estevez-Loureiro R, Rodés-Cabau J, Sánchez PL, Cruz-González I. Predictive Power for Thrombus Detection after Atrial Appendage Closure: Machine Learning vs. Classical Methods. J Pers Med 2022; 12:jpm12091413. [PMID: 36143197 PMCID: PMC9503612 DOI: 10.3390/jpm12091413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/12/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Device-related thrombus (DRT) after left atrial appendage (LAA) closure is infrequent but correlates with an increased risk of thromboembolism. Therefore, the search for DRT predictors is a topic of interest. In the literature, multivariable methods have been used achieving non-consistent results, and to the best of our knowledge, machine learning techniques have not been used yet for thrombus detection after LAA occlusion. Our aim is to compare both methodologies with respect to predictive power and the search for predictors of DRT. To this end, a multicenter study including 1150 patients who underwent LAA closure was analyzed. Two lines of experiments were performed: with and without resampling. Multivariate and machine learning methodologies were applied to both lines. Predictive power and the extracted predictors for all experiments were gathered. ROC curves of 0.5446 and 0.7974 were obtained for multivariate analysis and machine learning without resampling, respectively. However, the resampling experiment showed no significant difference between them (0.52 vs. 0.53 ROC AUC). A difference between the predictors selected was observed, with the multivariable methodology being more stable. These results question the validity of predictors reported in previous studies and demonstrate their disparity. Furthermore, none of the techniques analyzed is superior to the other for these data.
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Affiliation(s)
- Pablo Antúnez-Muiños
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
- Correspondence: ; Tel.: +34-923291100
| | | | - Pablo Pérez-Sánchez
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
| | | | | | - Pedro Ignacio Dorado-Díaz
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
| | - Pablo Salinas
- Instituto Cardiovascular, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
| | - Hipólito Gutiérrez-García
- CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Ignacio Amat-Santos
- CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Vicente Peral
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, 07120 Palma, Spain
| | - Antonio Morcuende
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, 07120 Palma, Spain
| | - Lluis Asmarats
- Quebec Heart and Kung Institute, Laval University, Quebec City, QC G1V 0A6, Canada
| | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | | | | | - Josep Rodés-Cabau
- Quebec Heart and Kung Institute, Laval University, Quebec City, QC G1V 0A6, Canada
| | - Pedro Luis Sánchez
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
| | - Ignacio Cruz-González
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
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8
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Mesnier J, Cruz-González I, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Regueiro A, McInerney A, Mas-Lladó C, Estevez-Loureiro R, Laricchia A, O'Hara G, Rodés-Cabau J. Early Discontinuation of Antithrombotic Treatment Following Left Atrial Appendage Closure. Am J Cardiol 2022; 171:91-98. [PMID: 35317927 DOI: 10.1016/j.amjcard.2022.01.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 01/04/2023]
Abstract
Although antithrombotic treatment is recommended after left atrial appendage closure (LAAC), some patients require discontinuation of antithrombotic treatment after LAAC without evidence on the safety of such a strategy. We sought to evaluate outcomes of patients who had early antithrombotic treatment discontinuation after LAAC. This is a multicenter study including 1,082 patients who underwent successful LAAC. Early discontinuation of antithrombotic treatment was defined as discontinuation of all antiplatelet/anticoagulant treatment within 6 months following the procedure. A propensity-matched analysis was used to compare outcomes of patients with and without early antithrombotic treatment discontinuation. A total of 148 patients (13.7%) had early antithrombotic treatment discontinuation. In the entire population, antithrombotic treatment discontinuation patients exhibited a lower CHA2DS2-VASc score (p <0.001) and a higher rate of previous gastrointestinal bleeding episodes (p = 0.01) compared with patients without discontinuation. After a median follow-up of 2.1 (1,1-3.1) years after antithrombotic treatment discontinuation, the rates of death, ischemic stroke, and major bleeding were 12.1, 0.6, and 3.3 per 100 patient-years. In 119 matched pairs with similar baseline characteristics, antithrombotic treatment discontinuation patients had a similar risk of death (hazard ratio [HR] 1.06, 95% confidence interval [CI] 0.65 to 1.71, p = 0.82), ischemic stroke (HR 0.39, 95% CI 0.04 to 3.79, p = 0.42) and major bleeding (HR 1.48, 95% CI 0.56 to 3.88, p = 0.43) compared with those without discontinuation. In conclusion, antithrombotic treatment was discontinued in 1 of 7 selected patients within 6 months after LAAC, and this was not associated with an increased risk of death or thromboembolic events after a median follow-up of 2 years. These data support the safety of shorter periods of antithrombotic therapy after LAAC in high bleeding risk patients based on clinician judgment. Further trials are warranted.
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9
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de Prado AP, Ocaranza-Sánchez R, Ruiz-Poveda FL, Moreu Burgos J, Álvarez Ramos R, Rodrigues A, Fernández González L, Aguar P, del Blanco BG, Pinar E, Peral V, Sainz Laso F, Ramón Rumoroso J, Torres A, Sabaté y M, Trillo Nouche R. Registro prospectivo del stent liberador de sirolimus con pol�mero estable de fluoroacrilato Angiolite: estudio EPIC02 � RANGO. RECIC 2022. [DOI: 10.24875/recic.m21000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Massot M, Itier R, Rico Ramirez Y, Rollin A, Fournier P, Ramis Barcelo M, Fortuny E, Torres L, Pons J, Barde L, Deney A, Roncalli J, Heine D, Peral V, Galinier M, Ripoll T, Maury P. The benefit of genetic testing using next-generation sequencing in patients with dilated cardiomyopathies: A multicentric international study. Archives of Cardiovascular Diseases Supplements 2022. [DOI: 10.1016/j.acvdsp.2021.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Rico Y, Ramis MF, Massot M, Torres-Juan L, Pons J, Fortuny E, Ripoll-Vera T, González R, Peral V, Rossello X, Heine Suñer D. Familial Dilated Cardiomyopathy and Sudden Cardiac Arrest: New Association with a SCN5A Mutation. Genes (Basel) 2021; 12:genes12121889. [PMID: 34946838 PMCID: PMC8701882 DOI: 10.3390/genes12121889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 12/19/2022] Open
Abstract
Dilated cardiomyopathy (DCM) has significant morbidity and mortality. Familial transmission is reported in 20–35% of cases, highlighting the role of genetics in this disorder. We present an interesting family in which the index case is a 64-year-old woman who survived a sudden cardiac arrest. She presented left ventricular dilatation and dysfunction, which indicated the presence of DCM, as well as a history of DCM and sudden arrest in her family (mother and sister). Genetic testing identified a heterozygous mutation c.74A > G missense change that causes an amino acid, p.Glu25Gly, change in the N-terminal domain of the SCN5A protein. After performing an exhaustive family medical history, we found that this previously not described mutation segregated within the family. All relatives with the DCM phenotype were carriers, whereas none of the noncarriers showed signs of heart disease, so this mutation is the most likely cause of the disease. This is the first time that a variant in the N-terminal domain of SCN5A has been associated with DCM.
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Affiliation(s)
- Yolanda Rico
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
- Correspondence:
| | - Maria Francisca Ramis
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
| | - Montse Massot
- Centre Hospitalier Universitaire de Toulouse, Hôpital de Rangueil, 31400 Toulouse, France;
| | - Laura Torres-Juan
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
- Unit of Molecular Diagnostics and Clinical Genetics, Hospital Universitari Son Espases, 07120 Palma, Spain
| | - Jaume Pons
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
| | - Elena Fortuny
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
| | - Tomas Ripoll-Vera
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
- Cardiology Department, Hospital Universitari Son Llatzer, 07198 Palma, Spain
| | - Rosa González
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
| | - Vicente Peral
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
| | - Xavier Rossello
- Cardiology Department, Hospital Universitari Son Espases, 07120 Palma, Spain; (M.F.R.); (J.P.); (E.F.); (R.G.); (V.P.); (X.R.)
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
| | - Damià Heine Suñer
- Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain; (L.T.-J.); (T.R.-V.); (D.H.S.)
- Unit of Molecular Diagnostics and Clinical Genetics, Hospital Universitari Son Espases, 07120 Palma, Spain
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12
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Marroquin L, Tirado-Conte G, Pracoń R, Streb W, Gutierrez H, Boccuzzi G, Arzamendi-Aizpurua D, Cruz-González I, Ruiz-Nodar JM, Kim JS, Freixa X, Lopez-Minguez JR, De Backer O, Ruiz-Salmeron R, Dominguez A, McInerney A, Peral V, Estevez-Loureiro R, Fernandez-Nofrerias E, Freitas-Ferraz AB, Saia F, Huczek Z, Gheorghe L, Salinas P, Demkow M, Delgado-Arana JR, Fernandez Peregrina E, Kalarus Z, Elvira Laffond A, Jang Y, Fernandez Camacho JC, Lee OH, Hernández-Garcia JM, Mas-Llado C, Caneiro Queija B, Amat-Santos IJ, Dabrowski M, Rodés-Cabau J, Nombela Franco L. Management and outcomes of patients with left atrial appendage thrombus prior to percutaneous closure. Heart 2021; 108:1098-1106. [PMID: 34686564 PMCID: PMC9240333 DOI: 10.1136/heartjnl-2021-319811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/27/2021] [Indexed: 12/03/2022] Open
Abstract
Objective Left atrial appendage (LAA) thrombus has heretofore been considered a contraindication to percutaneous LAA closure (LAAC). Data regarding its management are very limited. The aim of this study was to analyse the medical and invasive treatment of patients referred for LAAC in the presence of LAA thrombus. Methods This multicentre observational registry included 126 consecutive patients referred for LAAC with LAA thrombus on preprocedural imaging. Treatment strategies included intensification of antithrombotic therapy (IAT) or direct LAAC. The primary and secondary endpoints were a composite of bleeding, stroke and death at 18 months, and procedural success, respectively. Results IAT was the preferred strategy in 57.9% of patients, with total thrombus resolution observed in 60.3% and 75.3% after initial and subsequent IAT, respectively. Bleeding complications and stroke during IAT occurred in 9.6% and 2.9%, respectively, compared with 3.8% bleeding and no embolic events in the direct LAAC group before the procedure. Procedural success was 90.5% (96.2% vs 86.3% in direct LAAC and IAT group, respectively, p=0.072), without cases of in-hospital thromboembolic complications. The primary endpoint occurred in 29.3% and device-related thrombosis was found in 12.8%, without significant difference according to treatment strategy. Bleeding complications at 18 months occurred in 22.5% vs 10.5% in the IAT and direct LAAC group, respectively (p=0.102). Conclusion In the presence of LAA thrombus, IAT was the initial management strategy in half of our cohort, with initial thrombus resolution in 60% of these, but with a relatively high bleeding rate (~10%). Direct LAAC was feasible, with high procedural success and absence of periprocedural embolic complications. However, a high rate of device-related thrombosis was detected during follow-up.
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Affiliation(s)
- Luis Marroquin
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Gabriela Tirado-Conte
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Witold Streb
- Silesian Centre for Heart Disease, Zabrze, Poland
| | | | | | | | | | | | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei, Korea (the Republic of)
| | - Xavier Freixa
- Cardiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | | | | | - Antonio Dominguez
- Cardiology, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - Angela McInerney
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Vicente Peral
- Cardiology, Hospital Universitario Son Espases, Health Research Institute of the Balearic Islands (IdISBa), Palma de Mallorca, Spain
| | | | | | | | - Francesco Saia
- Cardiology, University Hospital of Bologna, Bologna, Italy
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Livia Gheorghe
- Cardiology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Pablo Salinas
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | | | | | | | - Ana Elvira Laffond
- Cardiology, Hospital Universitario de Salamanca, IBSAL, CIBER CV, Salamanca, Spain
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei, Korea (the Republic of)
| | | | - Oh-Hyun Lee
- Severance Cardiovascular Hospital, Yonsei, Korea (the Republic of)
| | | | - Caterina Mas-Llado
- Cardiology, Hospital Universitario Son Espases, Health Research Institute of the Balearic Islands (IdISBa), Palma de Mallorca, Spain
| | | | | | - Maciej Dabrowski
- Interventional Cardiology and Angiology Clinic, National Institute of Cardiology, Warsaw, Poland
| | - Josep Rodés-Cabau
- Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec, Ontario, Canada
| | - Luis Nombela Franco
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
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13
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Masso Van Roessel A, Perello Bordoy A, Mas Llado C, Ramis Barcelo M, Vives Borras M, Pons J, Peral V, Rossello X. Assessment of the ESC quality indicators in patients with acute myocardial infarction: a systematic review. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Quality indicators (QIs) provide a mechanism for measuring opportunities to improve cardiovascular care and outcomes. To help improving quality of care in patients with acute myocardial infarction (AMI), the European Society of Cardiology (ESC) set (in 2017) 20 QIs to evaluate several dimensions of care. These 20 QIs are organized in 3 areas and 7 domains defined in structural, performance measures including patient's feedback and outcomes. Several registries have reported their performance using real-world data, and some of them have reported that higher compliance is associated with lower mortality. There is a need to compile and summarize QI availability, feasibility and global compliance in real-world registries.
Methods
A systematic review of PubMed and Web of Science was conducted including all original articles reporting the use of the ESC QIs in AMI patients. Methods and reporting follow the guidelines of the PRISMA Statement and the protocol was registered in PROSPERO (CRD42020190541). Inclusion criteria were studies providing original data, and studies evaluating the 2017 ESC ACVC set of QIs in patients with AMI (STEMI or NSTEMI). The main exclusion criterion was for non-original articles and studies evaluating a different set of QIs.
Results
Among de 220 screened citations, 9 studies met the inclusion criteria after full-text review. Among these 9 studies, there were 11 different cohorts. Patients were recruited from 3 different continents (31 countries) between 2003 and 2018. The number of QIs assessed ranged from 6 to 20, with 5 studies (56%) reporting data for at least 75% of the 20 QIs. There was variability in the percentage of data availability with 4 QIs from 3 different cohort with limited data (2.4, 3.1, 3.2 and 6.1) and 13 QIs reported in 64% of the cohorts. We found that some publications were unable to provide the exact definition determined by the ESC ACVC working group, with 6 QIs with suboptimal definition (QIs 2.2, 5.1, 6.1, and the 3 QIs from domain 7). The rate of attainment had a great variation. In performance measures we found a higher level of compliance in the QIs 2.1, 4.3 and 5.2, and lower in 2.2 and 4.2.
Conclusions
Our systematic review has shown that it is possible to measure most QIs in existing registries, and that there is room for improvement in terms of data availability, feasibility and levels of attainment to QIs. Our findings may influence the design of future registries to capture this information and help in QIs definition updates. In light of the experience accumulated from existing registries, there is a need to design registries and surveys specifically assessing QIs to have a more accurate picture.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
| | - A Perello Bordoy
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
| | - C Mas Llado
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
| | - M Ramis Barcelo
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
| | - M Vives Borras
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
| | - J Pons
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
| | - V Peral
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
| | - X Rossello
- Hospital Universitari Son Espases, Cardiology, Palma de Mallorca, Spain
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14
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Perello-Bordoy A, Masso-Van Roessel A, Mas-Llado C, Ramis-Barcelo MF, Vives-Borras M, Pons J, Peral V, Rossello X. The prognostic value of the ESC quality indicators in patients with acute myocardial infarction: a systematic review. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Quality indicators (QIs) provide a mechanism for measuring opportunities to improve cardiovascular care and outcomes. To help improving quality of care in patients with acute myocardial infarction (AMI), the European Society of Cardiology (ESC) set 20 QIs to evaluate several dimensions of care. These 20 QIs are organized in 3 areas and 7 domain defined in structural, performance measures including patient's feedback and outcomes. Several registries have reported their performance using real-world data, and some of them reported their prognostic value. For this purpose, we systematically reviewed the literature evaluating the 2017 ESC ACVC set of QIs in previous observational studies, with the aim to summarise their prognostic value.
Methods
A systematic review of PubMed and Web of Science was conducted including all original articles reporting the use of the ESC QIs in AMI patients. Inclusion criteria were studies providing original data, and studies evaluating the 2017 ESC ACVC set of QIs in patients with AMI (STEMI or NSTEMI). The main exclusion criterion was for non-original articles and studies evaluating a different set of QIs. Adjusted estimates (odds or hazard ratio) for the association between QIs and mortality were used to report the prognostic value of QIs.
Results
Among de 220 screened citations, 9 studies met the inclusion criteria after full-text review. Among these 9 studies, there were 11 different cohorts. Patients were recruited from 3 different continents (31 countries) between 2003 and 2018. The association between QIs and mortality have been reported in three cohorts: EPICOR, FAST-MI and MINAP. EPICOR evaluated this association for 15 QIs and 2-year mortality, whereas FAST-MI evaluated the relationship for 11 QIs and 30-day mortality, and MINAP for 9 QIs and 3-year mortality. In general, higher compliance was associated with better prognosis in most QIs (Figure 1). The association between mortality and some QIs (1.3, 3.1, 3.2, and QI 6) was not reported in any study, and their prognostic value is therefore unknown to date. Composite QIs, which combine individual indicators from domains 1–6 to summarise the multiple dimensions of quality of care, were associated with mortality in all comparisons (7.1 was tested in the 3 studies, whereas 7.2 was only tested in EPICOR).
Conclusions
Our review has shown a consistent association between higher attainment of QIs and decreased mortality in the three cohorts that evaluated this association. These data support the use of QIs as a useful tool for assessing quality of care across centres and countries. There is a need to design registries and surveys specifically assessing QIs to have a more accurate picture about the implementation of ESC QIs.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
| | | | - C Mas-Llado
- Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - M Vives-Borras
- Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - J Pons
- Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - V Peral
- Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - X Rossello
- Hospital Universitari Son Espases, Palma de Mallorca, Spain
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15
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Macaya F, Camacho-Freire SJ, García-Guimaraes M, Peral V, Alfonso y F, Escaned J. Percepci�n y experiencia sobre la disecci�n coronaria espont�nea en Espa�a: resultados de una encuesta nacional. RECIC 2021. [DOI: 10.24875/recic.m19000052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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16
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Mesnier J, Cruz-González I, Peral V, Nombela-Franco L, Freixa X, Laffond AE, Mas-Lladó C, McInerney A, Regueiro A, O'Hara G, Rodés-Cabau J. Ten-Year Outcomes Following Percutaneous Left Atrial Appendage Closure in Patients With Atrial Fibrillation and Absolute or Relative Contraindications to Chronic Anticoagulation. Circ Cardiovasc Interv 2021; 14:e010821. [PMID: 34266312 DOI: 10.1161/circinterventions.121.010821] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., G.O., J.R.-C.)
| | | | - Vicente Peral
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain (V.P., C.M.-L.)
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain (L.N.-F., A.M.)
| | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., A.R., J.R.-C.)
| | - Ana E Laffond
- University Hospital Salamanca, IBSAL, CIBER-CV, Spain (I.C.-G., A.A.E.L.)
| | - Caterina Mas-Lladó
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain (V.P., C.M.-L.)
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain (L.N.-F., A.M.)
| | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., A.R., J.R.-C.)
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., G.O., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., G.O., J.R.-C.).,Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., A.R., J.R.-C.)
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17
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Faroux L, Cruz-González I, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Regueiro A, McInerney A, Morcuende Gonzalez A, Estevez-Loureiro R, Laricchia A, O'Hara G, Rodés-Cabau J. Incidence, predictors, and clinical impact of bleeding recurrence in patients with prior gastrointestinal bleeding undergoing LAAC. Pacing Clin Electrophysiol 2021; 44:1216-1223. [PMID: 34110038 DOI: 10.1111/pace.14293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/20/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is associated with a high recurrence rate and a prior GIB episode is common in real-world left atrial appendage closure (LAAC) recipients. The present study sought to evaluate the clinical characteristics and outcomes of patients with prior GIB undergoing LAAC, and to determine the factors associated with and clinical impact of GIB recurrence. METHODS Multicenter study including 277 consecutive patients who underwent percutaneous LAAC and had prior GIB. All-cause death, all bleeding, GIB recurrence, and clinical ischemic stroke were recorded. RESULTS After a median follow-up of 17 (interquartile range: 6-37) months post-LAAC, the rates of death, bleeding, GIB recurrence, and ischemic stroke were 14.0 per 100 person-year (PY), 29.3 per 100 PY, 17.7 per 100 PY, and 1.1 per 100 PY, respectively. GIB recurrence occurred within 3 months post-LAAC in 55.8% of patients. A previous lower GIB (vs. upper or unclassified) (HR: 1.76; 95% CI: 1.09-2.82; p = .020) and eGFR < 45 mL/min (HR: 1.70; 95% CI:1.04-2.67; p = .033) determined an increased risk of GIB recurrence. By multivariable analysis, eGFR < 45 mL/min (HR: 2.72; 95% CI: 1.70-4.34; p < .001), GIB recurrence following LAAC (HR: 2.15; 95% CI: 1.33-3.46; p = .002), diabetes mellitus (HR: 1.77; 95% CI: 1.10-2.84; p = .018), and age (HR: 1.06; 95% CI: 1.03-1.10; p < .001) were associated with an increased mortality. CONCLUSIONS Patients with prior GIB undergoing LAAC exhibited a relatively low rate of GIB recurrence, and prior lower GIB and moderate-to-severe chronic kidney disease determined an increased risk. GIB recurrence was associated with an increased mortality.
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Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Vicente Peral
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | | | | | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Antonio Morcuende Gonzalez
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
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Rossello X, Massó-van Roessel A, Perelló-Bordoy A, Mas-Lladó C, Ramis-Barceló MF, Vives-Borrás M, Pons J, Peral V. Assessment of the ESC quality indicators in patients with acute myocardial infarction: a systematic review. Eur Heart J Acute Cardiovasc Care 2021; 10:878-889. [PMID: 34151368 DOI: 10.1093/ehjacc/zuab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 11/14/2022]
Abstract
AIMS To help improving quality of care in patients with acute myocardial infarction (AMI), the European Society of Cardiology (ESC) set 20 quality indicators (QIs). There is a need to compile and summarize QI availability, feasibility, and global compliance in real-world registries. METHODS AND RESULTS A systematic review of PubMed and Web of Science was conducted including all original articles reporting the use of the ESC QIs in AMI patients. Methods and reporting follow the guidelines of the PRISMA Statement and the protocol was registered in PROSPERO (CRD42020190541). Among the 220 screened citations, 9 studies met the inclusion criteria after full-text review. Among these 9 studies, there were 11 different cohorts. Patients were recruited from three different continents (31 countries). The number of QIs assessed ranged from 6 to 20, with 5 studies (56%) reporting data for at least 75% of the 20 QIs. There were room for improvement in terms of data availability (i.e. domain 6 measuring patient's satisfaction), feasibility (i.e. difficulties to find all data for composite QIs in domain 7), and attainment (i.e. high levels of compliance with the percentage of reperfused ST-segment elevation myocardial infarction patients, but low levels for a timely reperfusion). CONCLUSIONS Our systematic review has shown that it is possible to measure most QIs in existing registries, and that there is room for improvement in terms of data availability, feasibility, and levels of attainment to QIs. Our findings may influence the design of future registries to capture this information and help in QIs definition updates.
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Affiliation(s)
- Xavier Rossello
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Facultat de Medicina, Universitat de les Illes Balears (UIB), Palma, Illes Balears, Spain
| | - Albert Massó-van Roessel
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | - Antoni Perelló-Bordoy
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | - Caterina Mas-Lladó
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | - Maria F Ramis-Barceló
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | - Miquel Vives-Borrás
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | - Jaume Pons
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | - Vicente Peral
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
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Faroux L, Cruz-González I, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Regueiro A, McInerney A, Mas-Lladó C, Estevez-Loureiro R, Laricchia A, O'Hara G, Rodés-Cabau J. Short-term direct oral anticoagulation or dual antiplatelet therapy following left atrial appendage closure in patients with relative contraindications to chronic anticoagulation therapy. Int J Cardiol 2021; 333:77-82. [PMID: 33647365 DOI: 10.1016/j.ijcard.2021.02.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/04/2021] [Accepted: 02/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Biological data suggest that short-term anticoagulation would be more effective than dual antiplatelet therapy (DAPT) to reduce the thrombotic risk following left atrial appendage closure (LAAC). This study sought to assess the safety and efficacy of direct oral anticoagulation (DOAC) versus DAPT immediately post-LAAC. METHODS Multicenter study including 592 consecutive patients with relative contraindication to chronic anticoagulation who underwent LAAC and received either DAPT or DOAC for 1-3 months. Each patient receiving DOAC was matched with 2 patients on DAPT based on propensity-score (propensity-matched population of 285 patients). Outcomes recorded were death, stroke, non-procedural related severe bleeding, serious adverse event (SAE: composite of death, stroke, bleeding) and early (within 3 months post-LAAC) device-related thrombosis (DRT). RESULTS Early outcomes (within 3-month post-LAAC) did not significantly differ between groups, but a numerically higher rate of early death (3.7% vs. 1.1%), non-procedural related severe bleeding (7.4% vs. 3.2%), and SAE (11.1% vs. 5.3%) were observed in patients receiving DAPT. After a median follow-up of 22 (8-38) months, similar outcomes were observed in DAPT and DOAC groups regarding death (HR: 1.18; 95% CI: 0.58-2.37; p = 0.652), stroke (HR: 1.01; 95% CI: 0.22-5.45; p = 0.908), non-procedural related severe bleeding (HR: 1.68; 95% CI: 0.69-4.12; p = 0.257), and SAE (HR: 1.28; 95% CI: 0.73-2.24; p = 0.383). DRT was identified in 4 patients (2.6%) receiving DAPT versus 0 patient receiving DOAC (p = 0.162). CONCLUSIONS Short-term DOAC following LAAC in patients with contraindications to chronic anticoagulation was safe and tended to associate with a lower rate of SAE and DRT compared to DAPT.
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Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Vicente Peral
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | | | | | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Caterina Mas-Lladó
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Rodríguez-Leor O, Cid-Álvarez B, Pérez de Prado A, Rossello X, Ojeda S, Serrador A, López-Palop R, Martín-Moreiras J, Rumoroso JR, Cequier Á, Ibáñez B, Cruz-González I, Romaguera R, Moreno R, Villa M, Ruíz-Salmerón R, Molano F, Sánchez C, Muñoz-García E, Íñigo L, Herrador J, Gómez-Menchero A, Gómez-Menchero A, Caballero J, Ojeda S, Cárdenas M, Gheorghe L, Oneto J, Morales F, Valencia F, Ruíz JR, Diarte JA, Avanzas P, Rondán J, Peral V, Pernasetti LV, Hernández J, Bosa F, Lorenzo PLM, Jiménez F, Hernández JMDLT, Jiménez-Mazuecos J, Lozano F, Moreu J, Novo E, Robles J, Moreiras JM, Fernández-Vázquez F, Amat-Santos IJ, Gómez-Hospital JA, García-Picart J, Blanco BGD, Regueiro A, Carrillo-Suárez X, Tizón H, Mohandes M, Casanova J, Agudelo-Montañez V, Muñoz JF, Franco J, Del Castillo R, Salinas P, Elizaga J, Sarnago F, Jiménez-Valero S, Rivero F, Oteo JF, Alegría-Barrero E, Sánchez-Recalde Á, Ruíz V, Pinar E, Pinar E, Planas A, Ledesma BL, Berenguer A, Fernández-Cisnal A, Aguar P, Pomar F, Jerez M, Torres F, García R, Frutos A, Nodar JMR, García K, Sáez R, Torres A, Tellería M, Sadaba M, Mínguez JRL, Merchán JCR, Portales J, Trillo R, Aldama G, Fernández S, Santás M, Pérez MPP. Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience. ACTA ACUST UNITED AC 2020; 73:994-1002. [PMID: 32917566 PMCID: PMC7834732 DOI: 10.1016/j.rec.2020.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/28/2020] [Indexed: 12/29/2022]
Abstract
Introduction and objectives The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. Methods Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. Results Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P < .001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P < .001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P = .017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization. Conclusions The number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.
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Affiliation(s)
- Oriol Rodríguez-Leor
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Belén Cid-Álvarez
- Servicio de Cardiología, Hospital Clínico de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | | | - Xavier Rossello
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Servicio de Cardiología, Institut d'Investigació Sanitària de les Illes Balears (IdISBa), Hospital Universitari Son Espases, Palma de Mallorca, Islas Baleares, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Soledad Ojeda
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Ana Serrador
- Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Ramón López-Palop
- Servicio de Cardiología, Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Javier Martín-Moreiras
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - José Ramón Rumoroso
- Servicio de Cardiología, Hospital de Galdakao-Usansolo, Galdakao, Vizcaya, Spain
| | - Ángel Cequier
- Servicio de Cardiología, Hospital de Bellvitge-Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Borja Ibáñez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Ignacio Cruz-González
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Romaguera
- Servicio de Cardiología, Hospital de Bellvitge-Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Raúl Moreno
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jesús Oneto
- Hospital Universitario de Jerez de la Frontera
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Juan Franco
- Hospital Universitario Fundación Jiménez Díaz
| | | | - Pablo Salinas
- Hospital Clínico San Carlos y Hospital Príncipe de Asturias
| | | | | | | | | | | | | | | | | | | | - Eduardo Pinar
- Luciano Consuegra-Sánchez, Hospital Universitario Santa Lucía de Cartagena
| | - Ana Planas
- Hospital General Universitario de Castellón
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ramiro Trillo
- Hospital Clínico Universitario Santiago de Compostela
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Olmos C, Vilacosta I, López J, Sáez C, Anguita M, García-Granja PE, Sarriá C, Silva J, Álvarez-Álvarez B, Martínez-Monzonis MA, Castillo JC, Seijas J, López-Picado A, Peral V, Maroto L, San Román JA. Short-course antibiotic regimen compared to conventional antibiotic treatment for gram-positive cocci infective endocarditis: randomized clinical trial (SATIE). BMC Infect Dis 2020; 20:417. [PMID: 32546269 PMCID: PMC7298739 DOI: 10.1186/s12879-020-05132-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023] Open
Abstract
Background Most serious complications of infective endocarditis (IE) appear in the so-called “critical phase” of the disease, which represents the first days after diagnosis. The majority of patients overcoming the acute phase has a favorable outcome, yet they remain hospitalized for a long period of time mainly to complete antibiotic therapy. The major hypothesis of this trial is that in patients with clinically stable IE and adequate response to antibiotic treatment, without signs of persistent infection, periannular complications or metastatic foci, a shorter antibiotic time period would be as efficient and safe as the classic 4 to 6 weeks antibiotic regimen. Methods Multicenter, prospective, randomized, controlled open-label, phase IV clinical trial with a non-inferiority design to evaluate the efficacy of a short course (2 weeks) of parenteral antibiotic therapy compared with conventional antibiotic therapy (4–6 weeks). Sample: patients with IE caused by gram-positive cocci, having received at least 10 days of conventional antibiotic treatment, and at least 7 days after surgery when indicated, without clinical, analytical, microbiological or echocardiographic signs of persistent infection. Estimated sample size: 298 patients. Intervention: Control group: standard duration antibiotic therapy, (4 to 6 weeks) according to ESC guidelines recommendations. Experimental group: short-course antibiotic therapy for 2 weeks. The incidence of the primary composite endpoint of all-cause mortality, unplanned cardiac surgery, symptomatic embolisms and relapses within 6 months after the inclusion in the study will be prospectively registered and compared. Conclusions SATIE will investigate whether a two weeks short-course of intravenous antibiotics in patients with IE caused by gram-positive cocci, without signs of persistent infection, is not inferior in safety and efficacy to conventional antibiotic treatment (4–6 weeks). Trial registration ClinicalTrials.gov Identifier: NCT04222257 (January 7, 2020). EudraCT 2019–003358-10.
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Affiliation(s)
- Carmen Olmos
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Prof. Martín Lagos s/n, 28040, Madrid, Spain.
| | - Isidre Vilacosta
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - Javier López
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), CIBERCV, Valladolid, Spain
| | - Carmen Sáez
- Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | | | - Cristina Sarriá
- Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain
| | - Jacobo Silva
- Servicio de Cirugía Cardiaca, Hospital Universitario Central de Oviedo, Oviedo, Spain
| | - Belén Álvarez-Álvarez
- Servicio de Cardiología y Unidad Coronaria, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - María Amparo Martínez-Monzonis
- Servicio de Cardiología y Unidad Coronaria, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Juan Carlos Castillo
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | - José Seijas
- Servicio de Cardiología y Unidad Coronaria, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Amanda López-Picado
- Unidad de Investigación y Ensayos Clinicos. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
| | - Vicente Peral
- Servicio de Cardiología, Hospital Universitario de Son Espases, Palma de Mallorca, Spain
| | - Luis Maroto
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Prof. Martín Lagos s/n, 28040, Madrid, Spain
| | - J Alberto San Román
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), CIBERCV, Valladolid, Spain
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Ramis Barcelo MF, Mas Llado C, Rodriguez A, Valadron I, Noris M, Forteza JF, Pericas P, Pasamar L, Gonzalez R, Peral V. P772 Percutaneous transcatheter patent foramen ovale closure: does size really matter? Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Patent foramen ovale (PFO) has been associated with cryptogenic stroke. Percutaneous transcatheter PFO closure has been in development for the last years. In recent studies, it has shown a reduction of recurrent ischemic stroke events. Several manufactures of PFO device closure have developed guidelines for selection of device size based on anatomic measurements obtained through echocardiography. A study showed that according to the guidelines few patients had adequate tissue rim to allow device implantation, and yet almost all the patients had an effective closure.
Purpose and methods
The aim of this study was to evaluate the characteristics of PFO with transesophageal echocardiogram (TEE) (size, distance between foramen ovale-superior vena cava (FO-SVC) and distance between FO-aortic annulus (FO-AoAn)) and to determinate the correlation between the size of PFO device implanted and the theoretical device size according to the guidelines.
We performed a retrospective study among patients who underwent a PFO closure procedure between 2006 and 2018.
Results
42 patients were included, 55% male, mean age 56 years and mean BSA 1,83 m². The PFO mean diameter and length were 3 and 13 mm respectively. The majority of PFO were complex: 91% of patients had defects larger than 8mm and 36% had atrial septum aneurism. Characteristic of PFO were measured (Table). In older patients the distance between PFO-SVC and PFO-AoAn was larger and the septum secundum was thicker (p 0.02). The right-to-left shunt was moderated or severe in most cases (75%). The PFO closure device was successfully implanted in all patients. The majority of them received an Amplatzer PFO device (45%) followed by an Hyperion PFO device. The size of the device was 25mm in half of the patients followed by 30mm device. According to the guidelines, in 67% of the cases the wrong size was chosen and the mean size of the device should had been 30mm (SD ±5,2). TEE examination during follow up showed no residual or mild residual shunt in 80% of the patients. Residual shunt was more prevalent with larger devices (p 0.008)
Conclusions
These results showed that the size of PFO closure device implanted in our population differed from the size recommended by guidelines. Smaller devices have been used. According to our results, larger devices are associated with more residual shunt, which suggests that a different approach may be necessary to establish new protocols for PFO device closure
Table Minimal Maximal Mean SD SVC (mm) 10 30 17.55 ±3,7 AoAn (mm) 9 23 14.1 ±3,5 Minimal and maximal distance between PFO-SVC and AoAn
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Affiliation(s)
| | - C Mas Llado
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - A Rodriguez
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - I Valadron
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - M Noris
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - J F Forteza
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - P Pericas
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - L Pasamar
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - R Gonzalez
- University Hospital Son Espases, Palma de Mallorca, Spain
| | - V Peral
- University Hospital Son Espases, Palma de Mallorca, Spain
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Asmarats L, Cruz-González I, Nombela-Franco L, Arzamendi D, Peral V, Nietlispach F, Latib A, Maffeo D, González-Ferreiro R, Rodríguez-Gabella T, Agudelo V, Alamar M, Ghenzi RA, Mangieri A, Bernier M, Rodés-Cabau J. Recurrence of Device-Related Thrombus After Percutaneous Left Atrial Appendage Closure. Circulation 2019; 140:1441-1443. [PMID: 31634013 DOI: 10.1161/circulationaha.119.040860] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lluis Asmarats
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (L.A., M.B., J.R-C.)
| | | | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (L.N-F., T.R-G.)
| | - Dabit Arzamendi
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A.)
| | - Vicente Peral
- Hospital Universitario Son Espases, Palma, Spain (V.P., M.A.)
| | - Fabian Nietlispach
- University Heart Center Zürich, University Hospital of Zurich, Switzerland (F.N., R.G.)
| | - Azeem Latib
- San Raffaele Hospital, Milan, Italy (A.L., A.M.).,Montefiore Medical Center, New York (A.L.)
| | | | | | | | - Victor Agudelo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A.)
| | - Marta Alamar
- Hospital Universitario Son Espases, Palma, Spain (V.P., M.A.)
| | - Raffael A Ghenzi
- University Heart Center Zürich, University Hospital of Zurich, Switzerland (F.N., R.G.)
| | | | - Mathieu Bernier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (L.A., M.B., J.R-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (L.A., M.B., J.R-C.)
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Ventosa-Fernandez G, Vidal L, Tarrio R, Gomez A, Peral V, Saez de Ibarra JI. Simultaneous Transcatheter Mitral and Tricuspid Valve-in-Valve Replacement. Ann Thorac Surg 2019; 108:e241-e243. [PMID: 30905586 DOI: 10.1016/j.athoracsur.2019.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 11/20/2022]
Abstract
After the popularization of transcatheter aortic valve-in-valve replacement, mitral valve-in-valve is being increasingly performed for failing bioprostheses or annuloplasty rings. In the tricuspid position, despite smaller experience, valve-in-valve is also becoming an alternative to high-risk redo tricuspid surgery. We report the case of a patient with 2 failing mitral and tricuspid bioprostheses who was successfully treated with simultaneous transapical mitral and percutaneous transjugular tricuspid transcatheter valve-in-valve replacements.
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Affiliation(s)
| | - Laura Vidal
- Department of Cardiac Surgery, Hospital Son Espases, Mallorca, Spain
| | - Ruben Tarrio
- Department of Cardiac Surgery, Hospital Son Espases, Mallorca, Spain
| | - Alfredo Gomez
- Department of Cardiology, Hospital Son Espases, Mallorca, Spain
| | - Vicente Peral
- Department of Cardiology, Hospital Son Espases, Mallorca, Spain
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25
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Socias L, Frontera G, Rubert C, Carrillo A, Peral V, Rodriguez A, Royo C, Ferreruela M, Torres J, Elosua R, Bethencourt A, Fiol M. Análisis comparativo de 2 registros de infarto agudo de miocardio tras una década de cambios. Estudio IBERICA (1996-1998) y Código Infarto-Illes Balears (2008-2010). Med Intensiva 2016; 40:541-549. [DOI: 10.1016/j.medin.2016.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/11/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
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26
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Macaya F, Peral V, Alameda M, Pascual M, Gomez-Jaume A, Asmarats L, Maristany J, Ojeda M, Bethencourt A. Bioresorbable Scaffolds to Treat Spontaneous Coronary Artery Dissection. Circ Cardiovasc Interv 2016; 9:e003133. [DOI: 10.1161/circinterventions.115.003133] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fernando Macaya
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Vicente Peral
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Mar Alameda
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Marcos Pascual
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Alfredo Gomez-Jaume
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Luis Asmarats
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Jaume Maristany
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Manuel Ojeda
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
| | - Armando Bethencourt
- From the Hospital Universitario Son Espases, Carretera Valldemossa 79, 07120 Palma de Mallorca, Spain
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27
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Fiol M, Carrillo A, Cygankiewicz I, Velasco J, Riera M, Bayés-Genis A, Gómez A, Peral V, Bethencourt A, Goldwasser D, Molina F, Bayés de Luna A. A new electrocardiographic algorithm to locate the occlusion in left anterior descending coronary artery. Clin Cardiol 2010; 32:E1-6. [PMID: 19816974 DOI: 10.1002/clc.20347] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Early prediction of proximal left anterior descending coronary artery (LAD) occlusion is essential from a clinical point of view HYPOTHESIS To develop an electrocardiogram (ECG) algorithm based on ST-segment deviations to predict the location of occlusion of LAD as a culprit artery. METHODS ECG and angiographic findings were correlated in 100 patients with an ST-segment elevation myocardial infarction (MI) in precordial leads V(1), V(2), and V(4) through V(6). RESULTS ST-depression > or = 2.5 mm in leads III + ventricular fibrillation (VF) presents sensitivity (SE) of 77% and specificity (SP) of 84% for LAD occlusion proximal to the first diagonal artery (D1). ST-segment in III + VF isoelectric or elevated, presents SE of 44% and SP of 100% for LAD occlusion distal to D1. Subsequent analysis of the equation summation operator of ST-deviation in VR + V(1) - V(6) < 0, allows us to predict occlusion distal to first septal artery (S1) with 100% SP. On the other hand, any ST-depression in III + VF > 0.5 mm + summation operator of ST-deviation in VR + V(1) - V(6) > or = 0 identifies a high-risk group (lower ejection fraction, worse Killip findings, higher peak of CPK and CK-MB, and major adverse cardiac events [MACE]: death, reinfarction, recurrent angina, persistent left ventricular failure, or sustained ventricular arrhythmia during hospitalization). CONCLUSIONS This sequential ECG algorithm based on ST-segment deviations in different leads allowed us to predict the location of occlusion in LAD with good accuracy. Cases with proximal LAD occlusion present the most markers of poor prognosis. We recommend the use of the algorithm in everyday clinical practice.
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Affiliation(s)
- Miguel Fiol
- Son Dureta University Hospital and University Institute for Investigation on Health Sciences, Coronary and Critical Care Unit, Barcelona.
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28
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Vilacosta I, San Román JA, Castillo JA, Arganda L, Rollán MJ, Peral V, Sánchez-Harguindey L, Zarco P. Retrograde atrial kick in acute aortic regurgitation. Study of mitral and pulmonary venous flow velocities by transthoracic and transesophageal echocardiography. Clin Cardiol 2009; 20:35-40. [PMID: 8994736 PMCID: PMC6655506 DOI: 10.1002/clc.4960200109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND HYPOTHESIS The purpose of this study was the comprehensive evaluation of the changes in pulmonary venous and mitral flow velocities of patients with acute and chronic severe aortic regurgitation. Transmitral flow velocities obtained with pulsed-wave Doppler echocardiography have been used to provide information on left ventricular (LV) filling and diastolic function. Pulmonary venous flow tracings are an important adjunct to LV inflow pattern in assessing LV diastolic function. METHODS Fourteen patients with severe aortic regurgitation (8 chronic and 6 acute) and in sinus rhythm were examined by transthoracic and transesophageal pulsed Doppler echocardiography. Mitral and pulmonary flow velocities were recorded and compared. All patients had ejection fractions > 40%. RESULTS Early mitral flow peak velocity was higher in patients with acute regurgitation (p < 0.001). The mitral A wave was absent in five patients with acute regurgitation. In contrast, a prominent reverse atrial pulmonary systolic wave AR was demonstrated in these patients. Peak diastolic velocity of the pulmonary venous flow was greater in patients with acute aortic regurgitation (0.76 +/- 0.13) than in patients with chronic aortic regurgitation (0.40 +/- 0.09) (p < 0.001). Peak systolic velocity did not differ significantly between the two groups. The systolic fraction of pulmonary venous flow in patients with acute aortic regurgitation was lower (0.43 +/- 0.05) than that of patients with chronic regurgitation (0.63 +/- 0.1) (p < 0.01). All patients with acute aortic regurgitation had an S/D ratio < 1, while those with chronic regurgitation had an S/D > 1 (p < 0.001) and an E/A < 1. CONCLUSION Patients with severe acute aortic regurgitation showed a retrograde atrial kick (absence of transmitral A wave with prominent pulmonary AR wave). These patients had an S/D ratio < 1 (restrictive Doppler pattern). Patients with chronic aortic regurgitation exhibited a Doppler pattern of abnormal LV relaxation (E/A < 1, S/D > 1).
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Affiliation(s)
- I Vilacosta
- Hospital Universitario de San Carlos, Madrid, Spain
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29
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Gómez-Jaume A, Peral V, Alameda M, Bethencourt A. [Coronary aneurysms of the left anterior descending coronary artery and the right coronary artery after drug-eluting stent implantation]. Rev Esp Cardiol 2007; 60:995-7. [PMID: 17915161 DOI: 10.1157/13109658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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30
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Fiol M, Carrillo A, Cygankiewicz I, Ayestarán J, Caldés O, Peral V, Bethencourt A, Zareba W, de Luna AB. New criteria based on ST changes in 12-lead surface ECG to detect proximal versus distal right coronary artery occlusion in a case of acute inferoposterior myocardial infarction. Ann Noninvasive Electrocardiol 2005; 9:383-8. [PMID: 15485518 PMCID: PMC6932715 DOI: 10.1111/j.1542-474x.2004.94585.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The outcome of patients with inferoposterior myocardial infarction (MI) due to occlusion of right coronary artery (RCA) depends mainly on the location of occlusion (distal vs. proximal). The aim of this study was to evaluate the value of new ECG criteria: the sum of ST depression in I and VL leads and ST changes in V1 lead to predict the location of RCA occlusion in the case of an inferoposterior MI. METHODS The ECG and angiographical findings of 50 patients with acute inferoposterior MI due to RCA occlusion were analyzed. The value of new criteria was studied alone and in combination to predict proximal versus distal RCA occlusion and compared with previously described criterion based only on ST changes in VL. RESULTS Isoelectric or elevated ST in V1 allowed predicting proximal RCA occlusion with 70% sensitivity and 87% specificity with high positive and negative predictive value (87% and 71%, respectively). The new criterion of the sum of ST depression in I and VL >or= 5.5 mm compared to the criterion based only on ST depression in VL was also more specific (91% vs. 72%) for proximal RCA occlusion with better positive and negative predictive values. CONCLUSIONS The new criterion based on the ST changes in V1 lead is highly accurate in detecting the location of occlusion in the RCA compared to the criteria based only on ST changes in lateral leads. The use of this criterion might increase the accuracy of ECG-based identification of myocardial involvement in acute inferoposterior MI.
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Affiliation(s)
- Miquel Fiol
- Hospital Son Dureta, Palma de Mallorca, Spain.
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31
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Hernandez-Pampaloni M, Peral V, Carreras JL, Sanchez-Harguindey L, Vilacosta I. Biphasic response to dobutamine predicts improvement of left ventricular dysfunction after revascularization: correlation with positron emission and rest-redistribution 201Tl tomographies. Int J Cardiovasc Imaging 2003; 19:519-28. [PMID: 14690191 DOI: 10.1023/b:caim.0000004302.68305.80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Dobutamine echocardiography (DSE), positron emission tomography (PET) and 201Tl-single photon emission computed tomography (SPECT) have been used to identify myocardial viability. There are few reports, however, that compare high doses DSE with myocardial metabolic and perfusion imaging techniques in the same patient population. The aim of this study was to determine the correlation between high doses DSE, metabolic PET and 201Tl-SPECT imaging to predict the recovery of function after revascularization in patients with severe left ventricular (LV) dysfunction. METHODS Twenty-five patients underwent DSE (up to 40 microg/kg/min), rest and 4-hour redistribution 201Tl SPECT, rest 13N-ammonia and 18fluoro-deoxy-glucose PET imaging and coronary angiography 7-10 days before surgical revascularization. A follow-up 2D-echocardiography was performed 6 weeks after surgery. RESULTS Of the 109 successfully revascularized segments with severe dysfunction, 62 (57%) improved. LV ejection fraction increased from 30 +/- 10% to 42 +/- 13 at follow-up (p < 0.05). 201Tl SPECT, PET and the presence of contractile reserve determined by DSE had a similar sensitivity (77-87%) to predict recovery of function, but specificity was higher for the PET mismatch pattern and biphasic DSE (85-89%) than for any of the 201Tl viability patterns (19-64%). The highest positive predictive values were obtained by biphasic DSE and PET mismatch pattern (78-79%) compared to all other criteria (54-67%). In a multivariate model, which included evidence of viability by all imaging modalities, biphasic response was the best predictor of regional recovery of function (Odds ratio, OR: 9.9, 95% confidence intervals, 95% CI: 3.5-27.8). CONCLUSIONS Although DSE and PET had overall comparable results, the presence of contractile reserve by the biphasic response to dobutamine was a best predictor for the improvement of LV contractile function in this group of patients.
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Peral V, Vilacosta I, Fernández C, Hernández M, San Román JA, Batlle E, Meroño E, Carreras JL, Bethencourt A. [Comparison of dobutamine echocardiography and rest-redistribution 201-thallium SPECT in the assessment of myocardial viability taking PET as gold standard]. Rev Esp Cardiol 2001; 54:1394-405. [PMID: 11754785 DOI: 10.1016/s0300-8932(01)76522-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM To compare Tl-201 SPECT and dobutamine stress echocardiography for the detection of myocardial viability in patients with severe left ventricular dysfunction using metabolic imaging by positron emission tomography as the standard reference. MATERIAL AND METHODS We studied 25 consecutive patients with severe coronary artery disease and left ventricular dysfunction that underwent two different diagnostic modalities for evaluating myocardial viability: stress echocardiography with incremental doses of dobutamine from 5 up to 40 g/kg/min in 3 min stages, and 201 Tl SPECT using a rest-redistribution protocol with delayed images obtained at 4 hours. Fluorodeoxyglucose uptake by PET was used as the gold standard. Viability criteria were as follows, for 201Tl SPECT imaging: normal uptake at rest and presence of redistribution in the delayed images, for dobutamine stress echocardiography: sustained improvement and biphasic response. RESULTS Sensitivity of thallium redistribution was 46%, for normal uptake, plus redistribution 82%, 34% for dobutamine biphasic response and 58% for sustained improvement plus biphasic response. Specificity of biphasic response was 82% and that of redistribution 67%. Stepwise logistic regression indicated that biphasic wall motion response during dobutamine stress echocardiography (2.01 CI 95%; 1.10 to 3.99) and the presence of redistribution plus normal uptake at rest with thallium imaging (2.68 CI 95%; 1.42 to 5.13) were the best predictors of viability. These results were the same when both techniques were analyzed together. CONCLUSIONS Biphasic wall motion response during dobutamine stress echocardiography and the normal uptake plus presence of redistribution with thallium imaging were the best pre
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Affiliation(s)
- V Peral
- Hospital Universitario Son Dureta.Palma de Mallorca, Spain
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33
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Peral V, Vilacosta I, de la Peña A, San Román JA, Fernández C, Hernández M, Batlle E, Carreras JL, Bethencourt A. [Thallium-201 scintigraphy and dobutamine echocardiography in the assessment of myocardial viability]. Rev Clin Esp 2001; 201:5-15. [PMID: 11293986 DOI: 10.1016/s0014-2565(01)70732-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The possibility of differentiating viable from non-viable tissue among patients with severe coronary artery disease and severe left ventricular impairment entails relevant clinical and therapeutic implications since it may influence the indication of patient revascularization. To evaluate the presence of myocardial viability two techniques are available in the clinical setting: echocardiography with intravenous infusion of dobutamine and scintigraphy with myocardial perfusion with thalliem-201 by means of single-photon emission tomography. OBJECTIVE To compare prospectively the value of these techniques for detecting viable myocardium. MATERIAL AND METHODS Thirty-five patients with severe coronary disease and severe left ventricular dysfunction were included in the study. All patients underwent an echocardiogram using incremental doses of dobutamine, from 5 up to 40 micrograms/kg/min in three-minute periods. For thallium-201 scintigraphy the rest redistribution protocol with delayed images at 4 hours was used. The criteria for detecting viability were: a) for thallium-201, the presence of redistribution in delayed images and normal uptake at rest, and b) for dobutamine echocardiography, a sustained improvement in regional motion, biphasic response, and worsening. RESULTS By considering the segmental improvement post-revascularization as "gold standard" of viability, the statistically significant variables in a logistic regression model and, therefore, predictors of segmental functional recovery were the biphasic response and the sustained response for dobutamine echocardiography and normal uptake at rest and redistribution in the delayed images for thallium-201. Taken together, the result was significant for the biphasic response of dobutamine echocardiography. CONCLUSIONS The biphasic response with dobutamine echocardiography is the echocardiographic pattern that best predicts the functional recovery of the ischemic myocardium. A normal uptake and redistribution at four hours is the only scintigraphic pattern that can predict functional improvement. Of both patterns, the biphasic response is the best predictor of the functional recovery of the dysfunctional myocardium.
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Affiliation(s)
- V Peral
- Servicio de Cardiología, Hospital Universitario Son Dureta, C./Andrea Doria, 55, 07014 Palma de Mallorca
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Vilacosta I, San Román JA, Sarriá C, Iturralde E, Graupner C, Batlle E, Peral V, Aragoncillo P, Stoermann W. Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve. Am J Cardiol 1999; 84:110-3, A9. [PMID: 10404866 DOI: 10.1016/s0002-9149(99)00206-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study describes the clinical, anatomic, echocardiographic, and Doppler features of 13 patients with mitral valve aneurysms. Eleven patients had definitive criteria for infective endocarditis. Transesophageal echocardiography was superior to conventional echocardiography in detecting and assessing aneurysms. Patients with heart failure required surgery. Echocardiographic detection of this lesion should not be, by itself, an immediate surgical indication.
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Affiliation(s)
- I Vilacosta
- Department of Cardiology, Hospital Clínico San Carlos, Spain
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35
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Bethencourt A, Fernández-Palomeque C, Gómez-Jaume A, Peral V. [Early percutaneous revascularization in patients with unstable angina. Current results and comparison with conservative medical treatment]. Rev Esp Cardiol 1999; 52 Suppl 1:117-30. [PMID: 10364821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
In patients with ongoing angina, despite optimal medical therapy, the best therapeutic alternative is coronary angiography followed by emergency coronary revascularization with surgery or angioplasty. However, whether or not all patients should have early angiography and revascularization is a matter of debate. This paper reviews the advantages of modern medical therapy in this setting and the problems associated with early coronary revascularization. In particular, it analyses the data from the main clinical trials that have specifically compared an early invasive procedure with a conservative strategy in unstable coronary syndromes. Finally, it assesses the impact of the new antithrombotic agents, such as glycoprotein IIb/IIIa receptor blockers, particularly during coronary percutaneous interventions. The data reviewed suggest that early invasive intervention should be reconsidered, and that patients should be controlled (if possible) under medical treatment until non invasive stratification tests allow the identification of those patients who would benefit most from revascularization.
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Affiliation(s)
- A Bethencourt
- Servicio de Cardiología, Hospital Universitario Son Dureta, Palma de Mallorca.
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36
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San Román JA, Vilacosta I, Castillo JA, Rollán MJ, Hernández M, Peral V, Garcimartín I, de la Torre MM, Fernández-Avilés F. Selection of the optimal stress test for the diagnosis of coronary artery disease. Heart 1998; 80:370-6. [PMID: 9875115 PMCID: PMC1728805 DOI: 10.1136/hrt.80.4.370] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare the value and limitations of exercise testing, dipyridamole echocardiography, dobutamine-atropine echocardiography, and MIBI-SPECT (technetium-99m methoxyisobutyl nitrile single photon emission computed tomography) during dobutamine infusion in the diagnosis of coronary artery disease. DESIGN The performance of these four tests was assessed in random order on a consecutive cohort of patients. The presence or absence of coronary artery disease was confirmed by coronary angiography. SETTING Two tertiary care and university centres. PATIENTS 102 consecutive patients with chest pain and no previous history of coronary artery disease. Ten patients with left bundle branch block were excluded for further analysis of exercise testing and scintigraphy results. RESULTS MIBI-SPECT was the most sensitive (87%) but the least specific test (70%). Exercise stress testing had a sensitivity of 66%, which increased to 80% when patients with inconclusive results were excluded. Dipyridamole and dobutamine echocardiography had similar sensitivity (81%, 78%) and specificity (94%, 88%). All four tests had similar accuracy and positive and negative predictive values. Agreement between the echocardiographic techniques was excellent (detection of coronary artery disease 87%, kappa = 0.72; regional analysis 93%, kappa = 0.72; diagnosis of the "culprit" vessel 95%, kappa = 0.92), and it was good between echocardiographic techniques and MIBI-SPECT (diagnosis of the culprit vessel 90%, kappa = 0.84 with dobutamine and 92%, kappa = 0.85 with dipyridamole). CONCLUSIONS Exercise stress testing has a sensitivity comparable to other tests in patients capable of exercising and with no basal electrical abnormalities. The greatest sensitivity is offered by MIBI-SPECT and the greatest specificity is obtained with stress echocardiography. Redundant information is obtained with dipyridamole echocardiography, dobutamine echocardiography, and MIBI-SPECT.
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Affiliation(s)
- J A San Román
- Department of Cardiology, Hospital Universitario, Valladolid, Spain
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37
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Santos E, Peral V, Aroca M, Hernández Lezana A, Serrano FJ, Vilacosta I, Gallego J. Arteriovenous fistula as a complication of lumbar disc surgery: case report. Neuroradiology 1998; 40:459-61. [PMID: 9730348 DOI: 10.1007/s002340050624] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Arteriovenous fistula (AVF) is a rare, late complication of lumbar disc surgery. It is often not suspected and the symptoms are diagnosed as heart failure or deep venous thrombosis. We report a case in which the patient developed leg swelling and high-output congestive heart failure due to a left ilioiliac AVF after lumbar laminectomy.
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Affiliation(s)
- E Santos
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
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38
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Vilacosta I, San Román JA, Rollán MJ, Castillo JA, Peral V, Batlle E, Sánchez-Harguindey L. Prevalence and relevance of a septal diastolic notch during dobutamine stress echocardiography. Eur Heart J 1998; 19:669-73. [PMID: 9597418 DOI: 10.1053/euhj.1997.0826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Dobutamine stress echocardiography has become an accepted simple and inexpensive method of detecting coronary artery disease. In this pharmacological stress test, particular attention has been paid to transient systolic wall motion abnormalities. Our group has noted an abnormal diastolic ventricular septal motion, a 'diastolic notch', during dobutamine stress echocardiography that has not been previously described. METHODS AND RESULTS To find out whether this anomalous septal motion is related to coronary artery disease we have analysed the stress studies of 125 patients (69 men, age 61 +/- 9 years) with chest pain, no previous myocardial infarction and no left bundle branch block, who underwent a dobutamine stress test. Dobutamine was infused up to 40 mu.kg.l-1 min-1 in 3 min stages. A positive stress test was defined as the appearance of transient asynergy. Dobutamine time was the time from the infusion of dobutamine to the appearance of transient asynergy. The diastolic notch time was the time at which diastolic notch was first detected. Diastolic notch was detected in 21 patients with single coronary artery disease, 19 of whom had a severe left anterior descending artery stenosis. Diastolic notch was present in 19 out of 27 patients (70%) with single left anterior descending stenosis. Twenty-six out of 44 patients with multivessel coronary artery disease had evidence of a diastolic notch and 20 of these 26 had severe stenosis of the left anterior descending artery. Finally, all three patients with left main coronary artery disease had a diastolic notch while no patient with angiographically normal coronary arteries had this sign. In patients with a diastolic notch and a positive dobutamine stress test, diastolic notch time was shorter than dobutamine time (9 +/- 4 min vs 11 +/- 3 min, P < 0.05). CONCLUSIONS In patients without previous myocardial infarction and without left bundle branch block (1) the appearance of a septal diastolic notch during dobutamine stress echocardiography is very specific for the presence of coronary artery disease; (2) the detection of diastolic notch is mostly related to the existence of severe left anterior descending artery stenosis; (3) diastolic notch precedes the development of ventricular asynergy.
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Affiliation(s)
- I Vilacosta
- Department of Cardiology, Hospital Universitario de San Carlos, Madrid, Spain
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de la Torre MM, San Román JA, Vilacosta I, Peral V, Hernández M, Garcimartín I, Castillo JA, Rollán MJ, de la Fuente L, Gervacio-Domingo G, Fernández-Avilés F. [MIBI-echocardiography with dobutamine: Significance of changes of contractility in patients with changes in perfusion]. Rev Esp Cardiol 1998; 51:204-10. [PMID: 9577165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES In the presence of coronary artery disease and with an appropriate stressor, perfusion defects precede contractility abnormalities. Perfusion defects without contractility abnormalities may be due to the absence of ischemia or mild ischemia. Our purpose has been to compare the clinical characteristics, hemodynamic response and severity of perfusion defects in patients with coronary artery disease and perfusion defects with and without wall motion abnormalities during dobutamine infusion. PATIENTS AND METHODS Eighty two patients with significant coronary artery disease demonstrated by angiography without previous myocardial infarction underwent dobutamine infusion (up to 40 mg/kg/min). Atropine was given when necessary. Stress scientigraphic MIBI-SPECT images were acquired 1 hour after peak stress and rest studies were obtained 24 hours after stress testing. The perfusion score was calculated by dividing the total uptake score between the number of segments affected. RESULTS Among the 73 patients with perfusion defects, stress echocardiography was positive in 59 (Group A) and was negative in the remaining 14 (Group B). There were more hypertensive patients in Group A (33 vs 4; p = 0.04). There was no significant difference between the two groups with respect to other clinical characteristics. The peak rate-pressure product was similar in both groups (18.520 +/- 5.691 vs 18.680 +/- 5.329; p = NS). The development of electric abnormalities and angina was more common in Group A (42 vs 3, p < 0.001 and 33 vs 1; p < 0.001). Perfusion defects were not more extensive in Group A (abnormal segments 2.15 vs 2.21; p = NS) but they were more severe (segments with severe uptake reduction or no uptake 1.10 vs 0.28; p < 0.05; perfusion score 2.62 vs 2.21; p < 0.05). CONCLUSION In patients with severe coronary artery disease and perfusion defects during dobutamine-MIBI-SPECT, the presence of wall motion abnormalities defines patients with more severe perfusion defects.
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Batlle E, Vilacosta I, San Román JA, Peral V, Hernández M, Castillo JA, Graupner C, Meroño E, Stoermann W, Herrera D, Sánchez-Harguindey L. [Elective noninvasive test in the diagnosis of coronary disease in the aged]. Rev Esp Cardiol 1998; 51:35-42. [PMID: 9580166 DOI: 10.1016/s0300-8932(98)74708-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to determine the best noninvasive test to diagnose coronary artery disease in the elderly. PATTERNS AND METHODS: We conducted a study on 56 elderly patients (> 65 years) with chest pain and no previous history of coronary artery disease. They underwent exercise stress test, dipyridamole echocardiography (0.84 mg/kg), dobutamine echocardiography (up to a total dose of 40 microgram/kg/min and atropine when it was necessary), dobutamine MIBI-SPECT and coronary angiography. RESULTS Angiography detected significant coronary artery disease in 41 patients. All tests used in this study had a similar sensitivity (conclusive exercise stress test 87%, dipyridamole echocardiography 83%, dobutamine echocardiography 80% and MIBI-SPECT 87%; p = NS). Coronary angiography did not identify significant lesions in 15 patients. Specificity of conclusive exercise stress test, dipyridamole and dobutamine echocardiography was similar (75%, 100% and 93% respectively; p = NS). However, the specificity of stress echocardiography was higher than that of scintigraphy (100% vs 66%; p = 0.02 for dipyridamole echocardiography and 93% vs 66%; p = 0.07 for dobutamine echocardiography). Diagnostic accuracy of each test was similar. CONCLUSIONS Exercise stress test remains the non invasive diagnostic test of choice to detect coronary disease in the elderly. If this test is inconclusive, both stress echocardiography and isotopic studies are useful, although the specificity of stress echocardiography is higher than that of scintigraphy.
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Affiliation(s)
- E Batlle
- Servicio de Cardiología, Hospital Universitario San Carlos, Madrid
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Mar de la Torre MD, San Román JA, Peral V, Garcimartín I, de la Fuente L, Gervacio-Domingo G, Fernández-Avilés F, Vilacosta I, Hernández M, Antonio Castillo J, Jesús Rollán M. Ecocardiografía-MIBI con dobutamina: significado de las alteraciones de la contractilidad en pacientes con alteraciones de la perfusión. Rev Esp Cardiol (Engl Ed) 1998. [DOI: 10.1016/s0300-8932(98)74734-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Vilacosta I, San Román JA, Ferreirós J, Aragoncillo P, Méndez R, Castillo JA, Rollán MJ, Batlle E, Peral V, Sánchez-Harguindey L. Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection. Am Heart J 1997; 134:495-507. [PMID: 9327708 DOI: 10.1016/s0002-8703(97)70087-5] [Citation(s) in RCA: 149] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute aortic dissection is a cardiovascular emergency that requires prompt diagnosis and treatment. Transesophageal echocardiography is the current standard diagnostic imaging modality in many medical centers. Aortic intramural hematoma is a variant of aortic dissection whose natural history and prognosis have not been well studied. We performed transesophageal echocardiography in patients with aortic intramural hematoma to determine the echocardiographic characteristics and echocardiographic evolution of this lesion, impact on patient management, and patient outcome. METHODS AND RESULTS Twenty-one consecutive patients with aortic intramural hematoma confirmed anatomically (four patients) or with an additional diagnostic imaging technique (17 patients) underwent a transesophageal echocardiographic examination. Fifteen patients with longstanding hypertension had chest or back pain, and the intramural hematoma was visualized in the ascending aorta (n = 4), along the whole aorta (n = 4), in the descending aorta (n = 6), or in the aortic arch (n = 1). The thickening of the aortic wall was crescentic. Patients with ascending aortic intramural hematoma had the following results: two patients died suddenly, three patients underwent surgery because of increased aortic wall thickening (one patient) or secondary intimal tear (two patients), and the remaining three patients had regression of the hematoma. Patients with hematoma confined to the descending aorta and the patient with aortic arch involvement (n = 7) had a different result: one patient died from aortic rupture and the remaining six patients did well. Six patients had a traumatic aortic injury, and the intramural hematoma was located along the descending thoracic aorta. The thickening of the aortic wall was circular in five patients and crescentic in one. Three of these patients had normalized thickness of the aortic wall on follow-up transesophageal echocardiographic studies. The other three patients died from multiorgan system failure. Aortography showed a reduction of the diameter of the aortic lumen in four patients; diameter in the remaining 17 patients was normal. CONCLUSIONS Aortic intramural hematoma can be detected and monitored by transesophageal echocardiography but not by aortography. Two types of aortic intramural hematoma can be distinguished: (1) traumatic of good prognosis and (2) nontraumatic, which can be an early stage of the classic aortic dissection, with bad prognosis in cases involving the ascending aorta.
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Affiliation(s)
- I Vilacosta
- Department of Cardiology, Hospital Universitario de San Carlos, Madrid, Spain
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Affiliation(s)
- I Vilacosta
- Department of Cardiology, Hospital Universitario San Carlos, Madrid, Spain
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San Román JA, Vilacosta I, Castillo JA, Rollán MJ, Peral V, Sánchez-Harguindey L, Fernández-Avilés F. Dipyridamole and dobutamine-atropine stress echocardiography in the diagnosis of coronary artery disease. Comparison with exercise stress test, analysis of agreement, and impact of antianginal treatment. Chest 1996; 110:1248-54. [PMID: 8915229 DOI: 10.1378/chest.110.5.1248] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
STUDY OBJECTIVES To compare the usefulness of dipyridamole echocardiography, dobutamine-atropine echocardiography, and exercise stress testing in the diagnosis of coronary artery disease and to analyze the agreement among the tests. DESIGN Performance of these three tests in random order on a consecutive cohort of patients. SETTING A tertiary care and university center. PATIENTS One hundred two consecutive patients with chest pain and no history of coronary artery disease. INTERVENTIONS Dipyridamole echocardiography, dobutamine-atropine echocardiography, exercise stress testing, and coronary angiography. MEASUREMENTS AND RESULTS Dobutamine-atropine test was positive in 49 (77%) of 63 patients with coronary artery disease, dipyridamole test in 49 (77%), and exercise stress test in 44 (68%; p = NS). Both echocardiographic tests showed an overall specificity (dipyridamole, 97%; dobutamine, 95%) higher than exercise stress test (79%; p < 0.05). Sensitivity of dipyridamole testing decreased from 93 to 61% (p = 0.002) if patients were receiving antianginal treatment but sensitivity of dobutamine-atropine testing was not affected (77% in patients receiving and not receiving treatment). When results were considered as positive-negative, agreement between dipyridamole and dobutamine-atropine echocardiography was 85% (kappa = 0.70). With regards to regional analysis, concordance was good (93% for segments, kappa = 0.76; and 95% for coronary arteries, kappa = 0.92). Major complications were more frequent during dobutamine-atropine (n = 7) than during dipyridamole infusion (n = 2) (p = 0.06). CONCLUSIONS Dobutamine-atropine and dipyridamole echocardiography have a similar sensitivity and a higher specificity than that obtained by exercise ECG for the diagnosis of coronary artery disease. Similar information is obtained with dipyridamole and dobutamine-atropine echocardiography. It is our thought that pharmacologic stress echocardiography should be used as a first-step test to rule out coronary artery disease in patients not capable of exercising.
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Affiliation(s)
- J A San Román
- Division of Cardiology, Hospital Universitario, Valladolid, Spain
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Castillo JA, Vilacosta I, San Román JA, Rollán MJ, Peral V, de la Torre MM, Sánchez-Harguindey L. [Echocardiography with dobutamine in hypertensive patients with chest pain]. Rev Esp Cardiol 1996; 49:747-52. [PMID: 9036477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease. PURPOSE Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients. MATERIAL AND METHODS Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease. RESULTS Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005). CONCLUSIONS Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.
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Affiliation(s)
- J A Castillo
- Servicio de Cardiología, Hospital Santa María del Rosell, Cartagena, Murcia
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Vilacosta I, San Román JA, Antonio J, Jesús M, Peral V. Myocardial Stunning and Unique ECG Changes Associated with Dobutamine Stress Echocardiography. Echocardiography 1996; 13:407-410. [PMID: 11442948 DOI: 10.1111/j.1540-8175.1996.tb00913.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The clinical, electrocardiographic, and echocardiographic changes associated with myocardial stunning during dobutamine stress echocardiography in a patient with severe left main coronary artery disease are presented. (ECHOCARDIOGRAPHY, Volume 13, July 1996)
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Vilacosta I, Antonio Castillo J, Alberto San Román J, Gómez J, Jesús Rollán M, Arganda L, Peral V, Batlle E, Ferreirós J, Aragoncillo P, Sánchez-Harguindey L. [Identification of intramural aortic hematoma by transesophageal echocardiography]. Rev Esp Cardiol 1996; 49:196-203. [PMID: 8685523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIM The usefulness of transesophageal echocardiography in the diagnosis and assessment of patients with aortic dissection has been widely demonstrated. The aim of this study was to evaluate the role of this technique in the detection of intramural aortic hematoma and in the follow-up of these patients. METHODS The records of 51 patients with aortic dissection by transesophageal echocardiography diagnosed between May 1990 and May 1994 were reviewed. RESULTS The diagnosis of intramural aortic hematoma was established in 6 patients by transesophageal echocardiography (11%). This diagnosis was confirmed either anatomically (3 patients) or with an additional diagnostic technique (computed tomography or magnetic resonance imaging) and on the basis of echocardiographic follow-up changes (3 patients). CONCLUSIONS Intramural aortic hematoma represents an infrequent variant of aortic dissection that can be detected by transesophageal echocardiography and is usually unrecognized by aortography.
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Affiliation(s)
- I Vilacosta
- Servicio de Cardiología, Hospital Universitario de San Carlos, Madrid
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Domínguez Arganda L, Goicolea J, Alfonso F, Peral V, Jesús Rollán M, Alonso L, Hernández R, Zarco P, Macaya C. [Morphological and quantitative analysis of the mechanism of balloon angioplasty. An intravascular ultrasonic study]. Rev Esp Cardiol 1996; 49:13-21. [PMID: 8685507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Intracoronary ultrasound allows to study in vivo the morphology of the arterial wall, the presence and composition of atheroma and the associated lumen encroachment. The objective of our study was to assess the value of intravascular ultrasound to determine the dilatation mechanism after a conventional balloon angioplasty. PATIENTS AND METHODS Sixteen patients were examined with intravascular ultrasound before and after they had undergone percutaneous transluminal coronary angioplasty. A mechanical intravascular ultrasound system was used. Two different types of imaging catheters were used in this study: a 20 MHz, 4.8 F catheter in 5 patients and a 30 MHz, 3.5 F in 11 patients. RESULTS Quantitative and qualitative assessments were made from the angiograms and the ultrasound images. Seven out of 16 patients had a calcified plaque, in 8 patients the plaque was fibrotic and in 1 patient soft. Rupture of the plaque was the most common dilatation pattern. Post-PTCA the cross-sectional arterial area was increased from 15.3 +/- 5.2 mm2 to 17.3 +/- 6.2 mm2, the intraluminal area was increased from 2.7 +/- 2.5 mm2 to 7.3 +/- 3.4 mm2, and the plaque area was reduced from 12.3 +/- 4.8 mm2 to 9.7 +/- 3.4 mm2. The quantitative analysis showed that the "most frequent dilatation mechanism" found was the reduction of size plaque, an increase in cross-sectional arterial area was present in only 4 patients (25%). The incidence of depth rupture of the plaque was greater in patients with a calcified plaque than in those without (NS). CONCLUSIONS 1). Intracoronary ultrasound provides a complete description of plaque composition and geometry before and after coronary balloon angioplasty; 2) several morphologic dilatation patterns were found, and plaque tearing was the most common, and 3) increase in luminal area was most frequently due to a reduction in plaque area. Nevertheless an increase in the cross-sectional arterial area was also common, but less important.
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Affiliation(s)
- L Domínguez Arganda
- Departamento de Exploración Cardiopulmonar, Hospital Universitario de San Carlos, Madrid
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Vilacosta I, Castillo JA, Peral V, Batlle E, Rollán MJ, Sánchez-Harguindey L. Intramural aortic haematoma following intra-aortic balloon counterpulsation. Documentation by transoesophageal echocardiography. Eur Heart J 1995; 16:2015-6. [PMID: 8682052 DOI: 10.1093/oxfordjournals.eurheartj.a060873] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Zamorano J, Vilacosta I, Almería C, Alonso L, Batlle E, Conde A, Castillo JA, Peral V, Sánchez-Harguindey L. [Cardiac tamponade with the absence of a paradoxical pulse. The practical utility of echocardiography]. Rev Esp Cardiol 1995; 48:443-5. [PMID: 9324696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A patient with cardiac tamponade but without hypotension and pulsus paradoxus is reported. In this patient, echocardiography confirmed the diagnosis of cardiac tamponade, showing diastolic collapse of the right ventricle and also the presence of an atrial septal defect (ostium secundum) that explains the absence of pulsus paradoxus. The role of echocardiography in those rare clinical situations that in the presence of cardiac tamponade showed no pulsus paradoxus are discussed.
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Affiliation(s)
- J Zamorano
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid
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