Spanish Society Of Cardiology Research Articles

Outcomes of patients with heart failure followed in units accredited by the SEC-Excelente-IC quality program according to the type of unit

Introduction and objectivesThe development of specific heart failure (HF) units has improved the management of patients with this disease due to improved organization and resource management. The Spanish Society of Cardiology (SEC) has defined 3 types of HF units (community, specialized, and advanced) based on their complexity and service portfolio. Our aim was to compare the characteristics, treatment, and outcomes of patients with HF according to the type of unit. MethodsWe analyzed data from the SEC-Excelente-IC quality accreditation program registry, with 1716 patients consecutively included in two 1-month cutoffs (March and October) from 2019 to 2021 by 45 SEC-accredited HF units. We compared the characteristics, treatment and 1-year outcomes between the 3 types of units. ResultsOf the 1716 patients, 13.2% were treated in community units, 65.9% in specialized units, and 20.9% in advanced units. The rates of mortality (27.5 vs 15.5/100 patients-year; P<.001), admissions for HF (39.7 vs 29.2/100 patients-year; P=.019), total decompensations (56.1 vs 40.5/100 patients-year; P=.003), and combined death/admission for HF (45.2 vs 31.4/100 patients-year; P=.005) were higher in community units than in specialized/advanced units. Follow-up in a community unit was an independent predictor of higher mortality and admissions at 1 year. ConclusionsCompared with follow-up by more specialized units, follow-up in a community unit was associated with a higher decompensation rate and increased 1-year mortality.

Pronóstico de los pacientes con insuficiencia cardiaca seguidos en unidades acreditadas en el programa SEC-Excelente-IC con relación al tipo de unidad

Introduction and objectivesThe development of specific heart failure (HF) units has improved the management of patients with this disease due to improved organization and resource management. The Spanish Society of Cardiology (SEC) has defined 3 types of HF units (community, specialized, and advanced) based on their complexity and service portfolio. Our aim was to compare the characteristics, treatment, and outcomes of patients with HF according to the type of unit. MethodsWe analyzed data from the SEC-Excelente-IC quality accreditation program registry, with 1716 patients consecutively included in two 1-month cutoffs (March and October) from 2019 to 2021 by 45 SEC-accredited HF units. We compared the characteristics, treatment and 1-year outcomes between the 3 types of units. ResultsOf the 1716 patients, 13.2% were treated in community units, 65.9% in specialized units, and 20.9% in advanced units. The rates of mortality (27.5 vs 15.5/100 patients-year; P<.001), admissions for HF (39.7 vs 29.2/100 patients-year; P=.019), total decompensations (56.1 vs 40.5/100 patients-year; P=.003), and combined death/admission for HF (45.2 vs 31.4/100 patients-year; P=.005) were higher in community units than in specialized/advanced units. Follow-up in a community unit was an independent predictor of higher mortality and admissions at 1 year. ConclusionsCompared with follow-up by more specialized units, follow-up in a community unit was associated with a higher decompensation rate and increased 1-year mortality.Full English text available from:www.revespcardiol.org/en

Cardiovascular surgery and cardiology, current status of two sister specialties in Spain: the CARDIOXCARDIO study

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals’ opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

Cardiovascular considerations on recreational scuba diving. SEC-Clinical Cardiology Association/SEC-Working Group on Sports Cardiology consensus document

The practice of recreational scuba diving has increased worldwide, with millions of people taking part each year. The aquatic environment is a hostile setting that requires human physiology to adapt by undergoing a series of changes that stress the body. Therefore, physical fitness and control of cardiovascular risk factors are essential for practicing this sport. Medical assessment is not mandatory before participating in this sport and is only required when recommended by a health questionnaire designed for this purpose. However, due to the significance of cardiovascular disease, cardiology consultations are becoming more frequent. The aim of the present consensus document is to describe the cardiovascular physiological changes that occur during diving, focusing on related cardiovascular diseases, their management, and follow-up recommendations. The assessment and follow-up of individuals who practice diving with previous cardiovascular disease are also discussed. This document, endorsed by the Clinical Cardiology Association of the Spanish Society of Cardiology (SEC) and the SEC Working Group on Sports Cardiology of the Association of Preventive Cardiology, aims to assist both cardiologists in evaluating patients, as well as other specialists responsible for assessing individuals’ fitness for diving practice.

Cirugía cardiovascular y cardiología, situación actual en España de las dos especialidades hermanas: el estudio CARDIOXCARDIO

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals’ opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

Practical consensus for the treatment and follow-up of primary aldosteronism: a multidisciplinary consensus document.

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension and is associated with a higher cardiometabolic risk than essential hypertension. The aim of this consensus is to provide practical clinical recommendations for its surgical and medical treatment, pathology study and biochemical and clinical follow-up, as well as for the approach in special situations like advanced age, pregnancy and chronic kidney disease, from a multidisciplinary perspective, in a nominal group consensus approach of experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology and Spanish Association of Surgeons (AEC).

Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism.

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC).

Consensus on the approach to hydrosaline overload in acute heart failure. SEMI/SEC/S.E.N. recommendations

Most of the signs and symptoms of heart failure can be explained by fluid overload, which is also related to disease progression. Fluid overload is a complex phenomenon that extends beyond increased intravascular pressures and poses challenges for accurate diagnosis and effective treatment. Current recommendations advise a multiparametric approach, including clinical data (symptoms/signs), imaging tests, and biomarkers. This article proposes a practical therapeutic approach to managing hydrosaline overload in heart failure in both inpatient and outpatient settings. This document is an initiative of the Spanish Society of Internal Medicine (SEMI) in collaboration with the Spanish Society of Cardiology (SEC) and the Spanish Society of Nephrology (S.E.N.).

Consenso sobre el abordaje de la sobrecarga hidrosalina en insuficiencia cardiaca aguda. Recomendaciones SEMI/SEC/S.E.N.

Most of the signs and symptoms of heart failure can be explained by fluid overload, which is also related to disease progression. Fluid overload is a complex phenomenon that extends beyond increased intravascular pressures and poses challenges for accurate diagnosis and effective treatment. Current recommendations advise a multiparametric approach, including clinical data (symptoms/signs), imaging tests, and biomarkers. This article proposes a practical therapeutic approach to managing hydrosaline overload in heart failure in both inpatient and outpatient settings. This document is an initiative of the Spanish Society of Internal Medicine (SEMI) in collaboration with the Spanish Society of Cardiology (SEC) and the Spanish Society of Nephrology (S.E.N.).

Consideraciones cardiovasculares para la práctica de buceo recreativo con escafandra autónoma. Documento de consenso de SEC-Asociación de Cardiología Clínica/SEC-GT Cardiología del Deporte

The practice of recreational scuba diving has increased worldwide, with millions of people taking part each year. The aquatic environment is a hostile setting that requires human physiology to adapt by undergoing a series of changes that stress the body. Therefore, physical fitness and control of cardiovascular risk factors are essential for practicing this sport. Medical assessment is not mandatory before participating in this sport and is only required when recommended by a health questionnaire designed for this purpose. However, due to the significance of cardiovascular disease, cardiology consultations are becoming more frequent. The aim of the present consensus document is to describe the cardiovascular physiological changes that occur during diving, focusing on related cardiovascular diseases, their management, and follow-up recommendations. The assessment and follow-up of individuals who practice diving with previous cardiovascular disease are also discussed. This document, endorsed by the Clinical Cardiology Association of the Spanish Society of Cardiology (SEC) and the SEC Working Group on Sports Cardiology of the Association of Preventive Cardiology, aims to assist both cardiologists in evaluating patients, as well as other specialists responsible for assessing individuals’ fitness for diving practice.

Consensus document on the management of hyperkalemia

Hyperkalaemia is a common electrolyte imbalance with potentially serious short-, medium- and long-term consequences on morbidity and mortality rates and the use of national health service resources. The fact that different medical specialities can manage hyperkalaemia makes it important to have a unified approach, and the recent availability of new specific drug treatments means that the approach needs to be updated. This consensus document from the scientific societies most directly involved in the management of hyperkalaemia (Sociedad Española de Cardiología [Spanish Society of Cardiology], Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition], Sociedad Española de Medicina Interna [Spanish Society of Internal Medicine], Sociedad Española de Medicina de Urgencias y Emergencias [Spanish Society of Accident and Emergency Medicine] and Sociedad Española de Nefrología [Spanish Society of Nephrology]) first of all reviews basic aspects of potassium balance and blood potassium. Then it goes on to focus on the concept, epidemiology, pathophysiology and diagnostic and therapeutic approaches to hyperkalaemia. The available evidence and the main published studies have been reviewed with the aim of providing a useful tool in the multidisciplinary approach to patients with hyperkalaemia.

IV CardioMIR: el Congreso de los Jóvenes Cardiólogos

The IV edition of the Congress of Young Cardiologists, CardioMIR, was held in the city of Madrid on September 22 and 23, 2023, bringing together around 550 young cardiologists to learn about the latest developments in the diagnostic approach and therapeutics of cardiovascular disease. The congress also aims to be a meeting point for young cardiologists from the Spanish Society of Cardiology, especially residents, where they can share experiences and concerns. The aim of this article is to summarize of the main topics addressed in the IV edition of CardioMIR.

Insomnia in patients with myocardial infarction with and without obstructive coronary arteries: prevalence and prognosis

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Society of Cardiology. Introduction Although some studies suggest a relationship between insomnia and cardiovascular disease, the initial approach of patients with myocardial infarction does not usually include the evaluation of sleep disorders as a contributing factor to cardiovascular disease. This study aims to compare the prevalence of insomnia between patients with obstructive coronary artery disease (MICAD) and those without significant coronary obstruction (MINOCA) and its impact on prognosis. Methods During a five-year period (July 2017-July 2022), all consecutive patients with myocardial infarction and coronarography were included. This study was conducted in a university hospital which covers a population of 220,000 people. Insomnia severity index (ISI) questionnaire was completed by each patient during admission. Follow-up analysis included major adverse cardiovascular events (MACE: cardiovascular readmission, myocardial reinfarction, stroke, and death from any cause). Results Among 533 patients, 56 had MINOCA, and 477 had MICAD. There were no significant differences in the prevalence of insomnia between both groups: insomnia median value (M) in MINOCA: M=7 (3-11) vs MICAD M=7 (3-12), p=0.95. Analysing it by sex, the score remained similar: MINOCA women M=9 (3.5-11.5) vs MICAD M=8.5 (3.2-15), p=0.6. MINOCA men M=5.5 (3-9.7) vs MICAD M=7 (3-11), p=0.77. (Figure 1)- At the three-year follow-up, there was a relationship between the insomnia levels and survival (IC [1.1-6.6], p=0.03). When ISI score was over 7 points (subclinical insomnia, moderate insomnia, or severe insomnia) there was a relationship with more mortality: number of events under the median value =7; number of events over the median value =16; (IC [1.1-6.6], p=0.03); whereas MACE remained similar (IC [0.6-1.5], p=0.89). Conclusions In this study, the prevalence of insomnia was similar between MINOCA and MICAD patients. A higher score in the ISI questionnaire was related to a worse prognosis at the three-year follow-up.

Anxiety in patients with acute myocardial infarction: prevalence and prognosis

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): SPANISH SOCIETY OF CARDIOLOGY. Introduction Although some studies suggest a relationship between mental health and cardiovascular disease, the initial approach of patients with myocardial infarction does not usually include the evaluation of psychological stress as a contributing factor to cardiovascular disease. This study aims to compare the prevalence of anxiety between patients with obstructive coronary artery disease (MICAD) and those without significant coronary obstruction (MINOCA) and its impact on prognosis. Methods During a five-year period (July 2017-July 2022), all consecutive patients with myocardial infarction and coronarography were included. The state-trait anxiety inventory (STAI) was completed by each patient during admission. STAI is a self-report assessment device that includes separate measures of state of anxiety (STAI-S) and trait anxiety (STAI-T). Follow-up analysis included major adverse cardiovascular events (MACE: cardiovascular readmission, myocardial reinfarction, stroke, and death from any cause). Results Among 533 patients, 56 had MINOCA, and 477 had MICAD. There were no significant differences in the prevalence of anxiety between both groups: trait anxiety median value (M) MINOCA=18 (11-34) vs MICAD M=19 (12-27), p=0.8; state anxiety MINOCA M=19 (11-29) vs MICAD M=19 (12.2-26), p=0.6. Because of the fact that women had higher punctuation levels than men, data were analyzed separately without finding statistical differences between sex: STAI-T in MINOCA women M=22 (13–27) vs MICAD M=25 (13–32.5), p=0.9. STAI-S in MINOCA women M=23 (16.2–37) vs MICAD M=21 (13.5-28.5), p = 0.2. In a similar way, there were no differences between men: STAI-T in MINOCA men M=14 (10-21) vs MICAD M=18 (12-25), p=0.48. STAI-S in MINOCA men M=15 (9-25) vs MICAD M=18 (12-26), p=0.35. (Figure 1). In the total group of patients at the three-year follow-up, the median score value for women in STAI-T was 24 points (13-34) and in men 17.5 points (11-25), where a higher score was related to more MACE. Both women and men who scored over the median value presented more MACE: number of MACE under the median value =32, MACE over the median value =49, (IC [1.05-2.56], p=0.03). There were no differences in survival (IC [0.6-3,8], p=0.3). Median values for STAI-S were different: women M=22 (14-29.5), men M= 18 (12-26) and a higher score did not correlate with more MACE: (IC [0.55-1.33], p=0.5), nor with mortality: (IC [0.5-2.8], p=0.6). Conclusion In this study, the prevalence of anxiety was similar between MINOCA and MICAD patients. A higher score in the anxiety-trait questionnaire was related to a worse prognosis at the three-year follow-up. The anxiety trait component gives information about the patient´s baseline anxiety and it is important in the development of MACE.

Correction of dyssynchrony by conduction system pacing: results of LEVEL-AT trial

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Catalan Society of Cardiology; Asociación del Ritmo Cardiaco (Spanish Society of Cardiology). Background Correction of dyssynchrony measured with echo strain, in conduction system pacing (CSP) vs biventricular pacing (BIVP) has not been reported. Objectives Our purpose was to compare echocardiographic dyssynchrony correction and strain improvement during follow-up between CSP and BIVP. Methods A treatment received analysis was performed in patients (n=29 CSP; BIVP 40). Patients were evaluated at baseline (ON and OFF programming) and at 6 and 12 months. All echocardiograms were completed by operators blinded to the type of device implanted. Intraventricular (septal flash), interventricular (difference between left and right ventricular outflow times), and auriculoventricular (diastolic filling time) dyssynchrony, as well as strain parameters (septal rebound, global longitudinal strain (GLS), and Risum pattern (typical left bundle branch block contraction pattern)) were analyzed. Results 32% (22/69) were women; baseline LVEF was 27.5% (7% SD) and left ventricular end-systolic volume (LVESV) 138ml (77ml SD) without differences between groups. At the 12-month follow-up, there were no differences in CSP vs. BIVP in LVEF (45.8% (10% SD) vs. 42.7% (12% SD), p=0.25) and LVESV (81.5 ml (41 ml SD) vs. 101.7 ml (56 ml SD), p=0.08). Longitudinal analyses showed that the improvement of all echocardiographic dyssynchrony parameters over time was similar between groups (p&amp;lt;0.001) (Table 1 and Fig 1A). GLS acute correction significantly correlated with LVEF and LVESV at the 12-month follow-up (Fig 1B). Conclusions CSP and BIVP provided a similar dyssynchrony and strain correction over time. Acute strain correction predicted ventricular remodeling at 12 months follow-up.

Documento de consenso sobre el abordaje de la hiperpotasemia

Hyperkalaemia is a common electrolyte imbalance with potentially serious short-, medium- and long-term consequences on morbidity and mortality rates and the use of national health service resources. The fact that different medical specialities can manage hyperkalaemia makes it important to have a unified approach, and the recent availability of new specific drug treatments means that the approach needs to be updated. This consensus document from the scientific societies most directly involved in the management of hyperkalaemia (Sociedad Española de Cardiología [Spanish Society of Cardiology], Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition], Sociedad Española de Medicina Interna [Spanish Society of Internal Medicine], Sociedad Española de Medicina de Urgencias y Emergencias [Spanish Society of Emergency Medicine and Emergencies] and Sociedad Española de Nefrología [Spanish Society of Nephrology]) first of all reviews basic aspects of potassium balance and blood potassium. Then it goes on to focus on the concept, epidemiology, pathophysiology and diagnostic and therapeutic approaches to hyperkalaemia. The available evidence and the main published studies have been reviewed with the aim of providing a useful tool in the multidisciplinary approach to patients with hyperkalaemia.

Is it possible to start quadruple therapy in patients with a new diagnosis of HF and reduced ejection fraction? Real-life data from the TIDY-HF registry

Abstract Background The 2021 European heart failure (HF) guidelines recommended treatment with an inhibitor of the renin-angiotensin-aldosterone axis (RAAS), a beta-blocker (BB), a mineralocorticoid receptor antagonist (MRA), and a cotransporter sodium-glucose type 2 inhibitor (SGLT2) in patients with HF and left ventricular ejection fraction (LVEF) ≤40%. However, there is little evidence on implementing quadruple therapy in clinical practice. Purpose Study the implementation of quadruple therapy in patients with a new diagnosis of HF and reduced ejection fraction in clinical practice. Methods A prospective multicenter registry (38 centers in Spain) was carried out, including all patients newly diagnosed with HF with LVEF ≤40% in clinical practice. Their baseline and laboratory characteristics were recorded and their pharmacological treatment: at baseline (discharged from hospitalization or first outpatient visit within a maximum period of 1 month after the echocardiographic diagnosis), one month, and 3 months later. Results On 1th of March 2022, 349 patients were included, with baseline treatment data in 289. The mean age was 65.0±14.2 years, and 72.1% were men. The mean LVEF was 28.5±7.3%, with 57.6% in NYHA II and 29.1% in NYHA III–IV. The most frequent causes of cardiomyopathy were: ischemic (25.1%), tachycardiomyopathy (16.6%), and idiopathic (15.7%). 46.4% were dyslipidemic, 57.5% hypertensive and 33.3% diabetic. 65.1% of the patients were in sinus rhythm. Before HF diagnosis, 44.6% had been treated with RAASi, 22.8% with BB, 7.8% with MRA, 8.1% with iSGLT2, and 24.5% with diuretics. The drugs used at baseline and the changes during follow-up are shown in Table 1. Conclusions According to our cohort, almost 60% of newly diagnosed patients with HF and reduced LVEF start quadruple therapy during the first month after diagnosis, with sacubitril/valsartan being the preferred RAASi in most cases. The implementation of drugs with prognostic benefit is above 70% at baseline and exceeds 80% at one month of follow-up, with a progressive reduction in loop diuretics during follow-up. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Spanish Society of Cardiology

Advanced echocardiography with left atrial strain and indexed left atrial 3D volume for predicting underlying atrial fibrillation after cryptogenic stroke

Abstract Introduction Cryptogenic stroke (CS) represents one-third of ischemic strokes. Atrial fibrillation (AF) can be detected in up to 30% of CS. Therefore, there is a clinical need for predicting AF to guide the optimal secondary prevention strategy. The evidence about the role of advanced echocardiography, including left atrial 3D index volume and left atrial strain (LAS) techniques, to predict underlying AF in this setting is lacking. Methods From April 2019 to November 2021 seventy-eight consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography was performed during admission. All patients underwent 15 days wearable Holter monitoring. The primary outcome measure was AF detection during follow-up. Results Twenty -two patients (28%) developed AF. Patients in the AF group were older (81±6.3 vs 76.5±7.8 years; p=0.012). Left atrial (LA) diastolic indexed volume was higher in AF group (37.2±12.8 vs 29.7±11 ml/m2 p=0.01). 3D LA indexed volume were also higher in patients with AF (41.4±14 vs 32.2±10 ml/m2 p=0.009). LAS reservoir, LAS conduct and LAS contraction (LASct) were significantly lower in patients with AF (19±5.6 vs 32±10.3%; 9±4.5 vs 15±7.6; 10±5.3 vs 17±6.4, respectively, all p&amp;lt;0.001). On multivariate analysis LASct &amp;lt;13.5% and LA 3D indexed volume &amp;gt;44.5 ml/m2 were independent predictors of AF (OR 10.9 [95% CI 1.09–108.2], p=0.042) (Table 1, Figure 1) Conclusion LASct &amp;lt;13.5% and LA 3D indexed volume &amp;gt;44.5 ml/m2 are independent predictors of underlying AF in patients with CS. Our results demonstrate the usefulness of advanced echocardiography in this challenging clinical setting. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Spanish Society of Cardiology

Aortic flow patterns by 4D flow CMR in Marfan and Loeys-Dietz patients before and after valve sparing aortic root replacement: a comparison with healthy volunteers

Abstract Introduction Abnormal aortic flow patterns in patients with a connective tissue disorder (CTD), such as Marfan or Loeys-Dietz syndrome, may contribute to aortic root dilation [1,2]. Valve sparing aortic root replacement, which is effective in reducing the risk of aortic dissection in case of severe dilation, may also normalize flow patterns beyond the replaced aorta and potentially slow its progressive aortic dilation. Purpose To assess aortic flow dynamics in patients with a CTD by 4D flow cardiovascular magnetic resonance (CMR) before and after valve sparing aortic root replacement, and to compare the results with those of healthy volunteers (HV). Methods Patients with Marfan or Loeys-Dietz syndrome underwent two non-contrast enhanced 4D flow CMR, one before and another after undergoing valve sparing aortic root replacement. Healthy volunteers matched for age, sex and BSA were also included for comparison. Maximum velocity, in-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and wall shear stress (WSS) magnitude and its axial and circumferential components were obtained at 24 planes covering the thoracic aorta from the sinotubular junction to the descending aorta at the diaphragmatic level [3–5]. Results Sixteen patients and 21 healthy volunteers were included. Demographic and clinical data is presented in Table. The mean time between the CMR prior and posterior to surgery was 15 months. Compared to HV, patients with CTD before intervention presented lower maximum velocity at the proximal ascending aorta (Fig. 1A), lower IRF and circumferential WSS at the arch and the proximal descending aorta (Fig. 1B and F), lower magnitude and axial WSS at the proximal ascending and descending aorta (Fig. 1E and D), and increased SFRR at the proximal descending aorta (Fig. 1C). The intervention completely restored maximum velocity and partially-restored physiological helical flow and circumferential WSS, but barely improved axial WSS and SFRR. Conclusion Valve sparing aortic root replacement in patients with Marfan or Loeys-Dietz syndrome partially restore to physiological level both in-plane rotational flow and circumferential wall shear stress in the descending aorta. This flow normalization may contribute to prevent progressive dilation after the surgery. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III (Spain) (PI17/00381)Spanish Society of Cardiology (SEC/FEC-INV-CLI 20/015)

Cardioprotective effect of empagliflozin in acute myocardial infarction: the role of ketone bodies availability

Abstract Background The cardio-renal benefits of SGLT2i have been clearly established by clinical trials. Of interest, despite not having any effect on the incidence of classic atherothrombotic events (MI and strokes), patients receiving SGLT2i treatment had a higher chance of surviving myocardial infarction (MI). Purpose We aim to evaluate the cardioprotective potential of empagliflozin on acute myocardial infarction. We postulate that the benefits of SGLT2-I are mediated via an increase in circulating ketone bodies (KBs) induced by SGLT2i, and its preferential myocardial utilization energetically benefits the heart to better withstand an ischemic event. Methods The study was undertaken in our non-diabetic porcine model of ischemia/reperfusion. Animals were allocated to either one-week pre-treatment with empagliflozin or placebo before MI-induction. A third group received IV infusion of KBs at the time of the MI- induction to serve as positive-control. The acute effects of the treatments were studied 24 hours after MI-induction by Cardiac Magnetic Resonance (CMR). Immediately post-CMR, animals were sacrificed and heart samples collected for molecular analysis. Results (see Table and Figure): Despite similar initial ischemic injury (area at risk) in all groups, empagliflozin was associated with a significantly higher myocardial salvage (MSI 23.7±9.7 vs 4.5±3.6%, p&amp;lt;0.001) and better preserved cardiac function (LVEF 41.3±3.1 vs 33±5.5%, p&amp;lt;0.009) compared with placebo. The infusion of KBs replicated in part the beneficial profile of the empagliflozin group (MSI 16.7±8.8 and LVEF 39.1±3.6%). Histological analysis showed less cardiomyocyte apoptosis and less oxidative stress Conclusions To the best of our knowledge, this is the first study evaluating in vivo the cardioprotective potential of a SGLT2 inhibitor in a well-stablished porcine translational model. Furthermore, effects are evaluated using the gold standard for visualization and quantification of MI, Cardiac Magnetic Resonance (CMR). Three are the main conclusions: 1. One-week treatment with empagliflozin raises circulating KBs levels and confers significant cardio-protection during a myocardial infarction. Acute post-MI benefits (greater myocardial salvage and better preserved cardiac function) are already seen within 24 hours as compared with placebo. 2. Periprocedural IV infusion of KBs induces similar benefits than the SGLT2-I group. 3. These observations strongly support our hypothesis that SGLT2 inhibition is associated with increased circulating KBs and its selective use as preferential myocardial source of energy as a potential mechanism of action involved in the cardio-renal benefits observed with SGLT2i. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Spanish Society of Cardiology. Research Fellowship Grant.