Introduction and objectives: The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24 hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. Methods: This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. Results: Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67 +/- 12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score > 140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). Conclusions: In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

Objetivo. Evaluar las diferencias en el manejo clínico y eventos intrahospitalarios en una cohorte de pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en función del sexo. Métodos. Estudio observacional, prospectivo y multicéntrico que incluyó pacientes consecutivos con diagnóstico de SCASEST sometidos a coronariografía con enfermedad ateroesclerótica responsable. Resultados. Entre abril y mayo de 2022 se incluyeron 1.020 pacientes; de ellos, 240 eran mujeres (23,5%). En comparación con los hombres, las mujeres fueron mayores (72,6 años vs 66,5 años; p < 0,001) y más frágiles (17,1% vs 5,6%; p < 0,001). No hubo diferencias en el pretratamiento con un inhibidor del receptor P2Y12 (68,8% vs 70,2%, p = 0,67), aunque las mujeres recibieron más pretratamiento con clopidogrel (56% vs 44%, p = 0,009), principalmente aquellas de edad < 75 años y sin fragilidad. En las mujeres se realizaron menos coronariografías precoces (# 24 h) (29,8% vs 36,9%; p = 0,03) a pesar de presentar la misma indicación (criterios de alto riesgo). En el análisis ajustado, la fragilidad, pero no el sexo, se asoció de forma independiente con la realización de una coronariografía diferida. La tasa y el tipo de revascularización fue igual en ambos sexos, y no hubo diferencias en los eventos cardiovasculares intrahospitalarios. Conclusiones. Las mujeres recibieron con mayor frecuencia un tratamiento antitrombótico menos potente. La fragilidad y no el sexo se asoció con la realización de coronariografía diferida. Sin embargo, no hubo diferencias en la tasa de revascularización coronaria ni en los eventos intrahospitalarios en función del sexo.

IntroducciónLa cardiopatía isquémica es la primera causa de insuficiencia cardíaca (IC), y se necesitan herramientas para identificar a los pacientes con mayor probabilidad de desarrollar IC tras un síndrome coronario agudo (SCA). La inteligencia artificial (IA) ha demostrado ser útil para identificar variables relacionadas con el desarrollo de complicaciones cardiovasculares.MétodosIncluimos todos los pacientes consecutivos dados de alta tras SCA en dos centros españoles entre 2006 y 2017. Se recopilaron datos clínicos y se realizó un seguimiento de los pacientes durante una mediana de 53meses. Los modelos de árboles de decisión fueron creados por el algoritmo de partición recursivo basado en modelos.ResultadosLa cohorte fue de 7.097 pacientes, con una mediana de seguimiento de 53meses (rango intercuartílico: 18-77). La tasa de reingreso por IC fue del 13,6% (964 pacientes). Se identificaron ocho variables relevantes para predecir el tiempo de hospitalización por IC: IC en la hospitalización índice, diabetes, fibrilación auricular, tasa de filtración glomerular, edad, índice de Charlson, hemoglobina y fracción de eyección del ventrículo izquierdo. El modelo de árbol de decisiones proporcionó 15 patrones de riesgo clínico con tasas de reingreso por IC estadísticamente diferentes.ConclusionesEl modelo de árbol de decisión, obtenido por IA, identificó ocho variables principales capaces de predecir IC y generó 15 patrones clínicos diferenciados con respecto a la probabilidad de ser hospitalizado por IC. Se creó una aplicación electrónica gratuita.

Background: Coronary heart disease is the leading cause of heart failure (HF), and tools are needed to identify patients with a higher probability of developing HF after an acute coronary syndrome (ACS). Artificial intelligence (AI) has proven to be useful in identifying variables related to the development of cardiovascular complications. Methods: We included all consecutive patients discharged after ACS in two Spanish centers between 2006 and 2017. Clinical data were collected and patients were followed up for a median of 53 months. Decision tree models were created by the model-based recursive partitioning algorithm. Results: The cohort consisted of 7,097 patients with a median follow-up of 53 months (interquartile range: 18-77). The readmission rate for HF was 13.6% (964 patients). Eight relevant variables were identified to predict HF hospitalization time: HF at index hospitalization, diabetes, atrial fibrillation, glomerular filtration rate, age, Charlson index, hemoglobin, and left ventricular ejection fraction. The decision tree model provided 15 clinical risk patterns with significantly different HF readmission rates. Conclusions: The decision tree model, obtained by AI, identified 8 leading variables capable of predicting HF and generated 15 differentiated clinical patterns with respect to the probability of being hospitalized for HF. An electronic application was created and made available for free. (c) 2024 Elsevier Espana, S.L.U. All rights reserved.

RESUMEN Introducción y objetivos: El momento óptimo para la realización de un cateterismo diagnóstico en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) y la necesidad de pretratamiento con doble antiagregación son motivo de controversia. Este estudio pretende conocer el abordaje diagnóstico y terapéutico actual, así como la evolución clínica de los pacientes con SCASEST en España. Métodos: El estudio IMPACT of Time of Intervention in patients with Myocardial Infarction with Non-ST seGment elevation. ManaGement and Outcomes (IMPACT-TIMING-GO) es un registro nacional observacional, prospectivo y multicéntrico, que incluirá pacientes consecutivos con diagnóstico de SCASEST tratados con coronariografía diagnóstica y que presenten enfermedad coronaria aterosclerótica inestable o causal en 24 centros españoles. El objetivo primario del estudio es conocer el grado de cumplimiento de las recomendaciones de las guías de práctica clínica en pacientes que ingresan por SCASEST tratados con coronariografía en España, describir el uso del tratamiento antitrombótico antes del cateterismo y determinar el tiempo hasta este en la práctica clínica real. Se describirán también los eventos adversos cardiovasculares mayores: mortalidad por cualquier causa, infarto no fatal e ictus no fatal, y también la incidencia de hemorragia mayor según la escala BARC (Bleeding Academic Research Consortium) durante el seguimiento a 1 y 3 años. Resultados: Este registro permitirá mejorar el conocimiento en relación con el abordaje terapéutico inicial en pacientes que ingresan por SCASEST en España. Contribuirá a conocer sus características basales y su evolución clínica, así como el grado de adherencia y cumplimiento de las recomendaciones de las que se dispone actualmente. Conclusiones: Se trata del primer estudio prospectivo realizado en España que permitirá conocer las estrategias terapéuticas iniciales, tanto farmacológicas como intervencionistas, que se realizan en nuestro país en pacientes con SCASEST tras la publicación de las guías europeas de 2020, y la evolución clínica de estos pacientes a corto y largo plazo.

Background: Statins are the cornerstone of lipid-lowering therapy (LLT) for reduction of low-density lipoprotein cholesterol (LDLc) levels and high percentage of patients require LLT combinations or alternative treatments for adequate LDLc control.Methods: We performed an intention-to-treat meta-analysis of published data of phase III trials evaluating LLT efficacy on major adverse cardiovascular events (MACE). The primary endpoint was MACE incidence, as reported in each trial, and secondary analyses included myocardial infarction, stroke and mortality.Results: Eleven clinical trials and 135,688 patients were included; seven trials tested high intensity LLT and 4 LLT combinations. Intensive LLT reduced MACE risk by 15% (12.03% vs. 13.79%, HR: 0.85 95% CI 0.80-0.90; p < 0.001). The number needed to treat was 56 patients. Meta-regression analyses showed a linear correlation between absolute LDLc reductions and the risk of MACE. Significant reductions in myocardial infarction (HR: 0.83, 95% CI 0.80-0.86) and stroke (HR: 0.81, 95% CI 0.75-0.87) were observed. Cardiovascular death rate was 3.32% in LLT treatment arm vs. 3.56% in controls, resulting in a HR: 0.94 (95% CI 0.88-0.99; p = 0.03); no effect on all-cause mortality was observed (HR: 0.97 95% CI 0.93-1.01; p = 0.09). The sensitivity analyses verified the lack of heterogeneity, except for MACE that was mainly driven by the divergent results of the 2 trials. Small study effect was detected for the assessment of mortality. Conclusions: Current evidence consistently supports the efficacy of available intensity LLT for LDLc decrease on MACE and cardiovascular mortality reduction.(c) 2023 National Lipid Association. Published by Elsevier Inc. All rights reserved.

El momento óptimo para un cateterismo en el síndrome coronario agudo sin elevación del segmento ST (SCASEST) y la necesidad de pretratamiento son motivo de controversia. El objetivo principal del registro IMPACT-TIMING-GO es conocer el porcentaje de pacientes examinados con una coronariografía precoz (0-24 h) y que no recibieron doble antiagregación plaquetaria antes del cateterismo (estrategia sin pretratamiento) en España. Estudio observacional, prospectivo y multicéntrico, que incluyó a pacientes consecutivos con diagnóstico de SCASEST sometidos a cateterismo en los que se evidenció enfermedad coronaria ateroesclerótica causal. Entre abril y mayo de 2022 se incluyó a 1.021 pacientes (media de edad, 67 ± 12 años; el 23,6% mujeres). El 86,8% de los pacientes cumplían criterios de alto riesgo (elevación de troponina, cambios electrocardiográficos o puntuación GRACE > 140); sin embargo, únicamente el 37,8% se sometió a una estrategia invasiva precoz, y el 30,3% no recibió pretratamiento. Globalmente, solo el 13,6% de los pacientes se sometieron a una estrategia invasiva precoz sin un segundo antiagregante plaquetario, y la estrategia diferida con pretratamiento fue la más utilizada (46%). Durante el ingreso, 9 pacientes (0,9%) fallecieron y 34 (3,3%) presentaron una hemorragia grave. En España, solo el 13,6% de los pacientes con SCASEST sometidos a cateterismo reciben una estrategia invasiva precoz sin pretratamiento. La incidencia de eventos cardiovasculares y hemorragias graves en el ingreso es baja. The optimal timing of coronary angiography in patients admitted with non–ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24 hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67 ± 12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score > 140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

Los valores de colesterol unido de lipoproteínas de baja densidad (cLDL) se asocian linealmente con la incidencia de cardiopatía isquémica, aunque muchas personas desconocen si tienen o no dislipemia. Estudio retrospectivo de todos los pacientes ingresados por un primer síndrome coronario agudo (SCA). Consideramos desconocimiento del perfil lipídico cuando no constaba el diagnóstico previo de dislipidemia, no seguían tratamiento hipolipemiante ni existía determinación de laboratorio de cLDL en los últimos cinco años. Se incluyeron 3.122 pacientes con edad de 67,1 (13,2) años, 73,4% varones y 54% ingresados por SCA con elevación del segmento ST (SCACEST); 1.325 (42,44%) desconocían sus niveles de colesterol y las variables asociadas fueron no tener hipertensión arterial ni diabetes, edad < 55, sexo masculino, baja carga de comorbilidad y presentación como SCACEST. Se detectó una interacción significativa entre la edad y el conocimiento de la dislipemia (p = 0,02). La mortalidad hospitalaria fue 6,5% (201 pacientes) y fue igual en los que conocían o no sus niveles de colesterol; sin embargo, fue mayor en los que desconocían su cLDL y tenían < 65 años (3,8 frente a 1,5%; p < 0,01). El análisis multivariante identificó una asociación independiente entre el desconocimiento del colesterol y la mortalidad hospitalaria, pero solo en pacientes con < 65 años (OR = 2,39; IC 95%, 1,12-5,27; p = 0,031). El no conocer los valores de colesterol es muy prevalente entre los pacientes que ingresan por un primer SCA y se asocia a mayor mortalidad en los < 65 años. Low-density lipoprotein cholesterol (LDL-C) values are linearly associated with the incidence of ischemic heart disease, although many people are unaware of whether or not they have dyslipidemia. Retrospective study of all patients admitted for a first acute coronary syndrome (ACS). We considered ignorance of the lipid profile when there was no previous diagnosis of dyslipidemia, no lipid-lowering treatment was followed, nor was there laboratory determination of LDL-C in the last 5 years. A total of 3122 patients were included, aged 67.1 (13.2) years, 73.4% men and 54% admitted for ST-segment elevation acute coronary syndrome (STEACS); 1325 (42.44%) did not know their cholesterol levels and the associated variables were not having high blood pressure or diabetes, age < 55 years, male sex, low burden of comorbidity and presentation as STEACS. A significant interaction was detected between age and knowledge of dyslipidemia (P = .02). Hospital mortality was 6.5% (201 patients) and was the same in patients who knew or did not know their cholesterol levels; However, it was higher in those who did not know their LDL-C and were < 65 years of age (3.8% vs 1.5%; P < .01). The multivariate analysis identified an independent association between ignorance of cholesterol and in-hospital mortality, but only in patients aged < 65 years (OR, 2.39; 95%CI, 1.12-5.27; P = .031). Cholesterol unawareness is very prevalent in patients admitted for a first acute coronary syndrome and it is associated to higher in-hospital mortality rates for patients < 65 years old.

La mayoría de los pacientes con síndrome coronario crónico tienen alteraciones en el electrocardiograma y se desconoce el valor pronóstico de la hipertrofia ventricular izquierda (HVI) valorada por criterios de electrocardiograma. Registro retrospectivo de todos los pacientes con síndrome coronario crónico atendidos en una consulta monográfica. Se calculó el índice de Cornell y Sokolov-Lyon, considerándose HVI por voltaje valores > 28 (varones) o > 20 (mujeres) en el primero, y > 35 para el segundo. Durante el seguimiento se evaluó la mortalidad por causa cardiovascular, cualquier causa o eventos adversos cardiovasculares mayores (MACE) considerando reinfarto, insuficiencia cardiaca, accidente cerebrovascular o hemorragia mayor. Se incluyó a 774 pacientes y 60 (8,31%) cumplían criterios de HVI por cualquiera de los criterios. La mediana de seguimiento fue de 960 días [rango intercuartílico 538-1.586] y durante este periodo fallecieron 33 (4,6%) pacientes, 22 (3,1%) atribuibles a causa cardiovascular, y 110 (15,2%) presentaron MACE. En el análisis multivariante, ajustado por edad, sexo, diabetes, tratamiento médico y frecuencia cardiaca, los índices de HVI se asociaron linealmente con mayor riesgo de muerte por cualquier causa (HR = 1,11; IC95%, 1,07-1,16; p > 0,001), por causa cardiovascular (HR = 1,11; IC 95%, 1,06-1,17; p > 0,001) y MACE (HR = 1,04; IC 95%, 1,01-1,06; p = 0,015). También se encontró un riesgo independiente para HVI. La HVI, valorada por criterios de voltaje en el electrocardiograma, tiene un elevado valor predictivo de mortalidad y complicaciones cardiovasculares mayores en pacientes con síndrome coronario crónico. Most patients with chronic coronary syndrome altered electrocardiogram hypertension, but the prognostic value of left ventricular hypertrophy (LVH) assessed by electrocardiogram criteria is unknown. Retrosprospective registry of all patients with chronic coronary syndrome attended in a monographic clinic. We calculated the Cornell index and Sokolov-Lyon index and values > 28 (men) or > 20 (women) were considered for LVH for the first and > 35 mm in the second. During follow-up, all-cause or cardiovascular mortality or major cardiovascular events (MACE), considering reinfarction, heart failure, cerebrovascular accident, or major hemorrhage, were evaluated. A total of 774 patients were included and 60 (8.31%) fulfilled the LVH criteria by the electrocardiogram. The median follow-up was 960 days [interquartile range 538-1586] and during this period 33 (4.6%) patients died, 22 (3.1%) of the deaths were attributable to cardiovascular causes, and 110 (15,2%) patients presented a MACE. In the multivariate analysis, adjusted for age, sex, diabetes, medical treatment and heart rate, both Cornell and Sokolow-Lyon index were linearly associated with a higher risk of death from any cause (HR, 1.11; 95% CI, 1.07-1.16; P > .001), due to cardiovascular causes (HR, 1.11; 95% CI, 1.06-1.17; P > .001) and MACE (HR, 1.04; 95%CI, 1.01-1.06; P = .015). An independent risk was also observed for LVH. LVH, obtained by electrocardiogram criteria, has a high predictive value for mortality and major cardiovascular complications in patients with chronic coronary syndrome.

Patients admitted for acute coronary syndrome (ACS) usually have high cardiovascular risk scores with low levels of high-density lipoprotein cholesterol (HDL-C) and high low-density lipoprotein cholesterol (LDL-C) levels. Here, we investigated the role of lipoprotein functionality as well as particle number and size in patients with a first-onset ACS with on-target LDL-C levels. Ninety-seven patients with chest pain and first-onset ACS with LDL-C levels of 100 ± 4 mg/dL and non-HDL-C levels of 128 ± 4.0 mg/dL were included in the study. Patients were categorized as ACS and non-ACS after all diagnostic tests were performed (electrocardiogram, echocardiogram, troponin levels and angiography) on admission. HDL-C and LDL-C functionality and particle number/size by nuclear magnetic resonance (NMR) were blindly investigated. A group of matched healthy volunteers (n = 31) was included as a reference for these novel laboratory variables. LDL susceptibility to oxidation was higher and HDL-antioxidant capacity lower in the ACS patients than in the non-ACS individuals. ACS patients had lower HDL-C and Apolipoprotein A-I levels than non-ACS patients despite the same prevalence of classical cardiovascular risk factors. Cholesterol efflux potential was impaired only in the ACS patients. ACS-STEMI (Acute Coronary Syndrome-ST-segment-elevation myocardial infarction) patients, had a larger HDL particle diameter than non-ACS individuals (8.4 ± 0.02 vs. 8.3 ± 0.02 and, ANOVA test, p = 0.004). In conclusion, patients admitted for chest pain with a first-onset ACS and on-target lipid levels had impaired lipoprotein functionality and NMR measured larger HDL particles. This study shows the relevance of HDL functionality rather than HDL-C concentration in ACS patients.

Background: Current evidence supports the efficacy of prolonged dual antiplatelet treatment (DAPT) for patients at high-ischemic risk and low bleeding risk as well as the efficacy and safety of short DAPT in high-bleeding risk (HBR) patients. Methods: We evaluated patterns of DAPT candidates in all patients discharged in 2 hospitals after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. Major bleeding (MB) was registered according to 3 or 5 of the BARC consortium definitions. Results: We included 8252 patients and 3215 (39 %) were candidates for abbreviated DAPT, 3119 (37.8 %) for prolonged DAPT, and 1918 (23.2 %) for 12 m DAPT. Relevant differences were observed between the 3 cate-gories beyond the bleeding risk. Median follow-up was 57 months. Multivariate analysis identified higher risk of all-cause mortality (HR: 1.96 95 % CI 1.45-2.67; p < 0.001), cardiovascular mortality (HR: 2.10 95 % CI 1.39-3.19; p < 0.011), MACE (HR: 1.69 95 % 1.50-2.02; p < 0.001) and MB (sHR: 3.41 95 % CI 1.45-8.02; p = 0.005) in candidates to short DAPT. Candidates to prolonged DAPT had higher risk of MACE (HR: 1.17 95 % CI 1.02-1.35; p = 0.027). Conclusions: Almost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality.

Introduction and objectives: Liver fibrosis is present in nonalcoholic liver disease (NAFLD) and both precede liver failure. Subclinical forms of liver fibrosis might increase the risk of cardiovascular events. The objective of this study was to describe the prognostic value of the FIB-4 index on in-hospital mortality and postdischarge outcomes in patients with acute coronary syndrome (ACS).Methods: Retrospective study including all consecutive patients admitted for ACS between 2009 and 2019. According to the FIB-4 index, patients were categorized as <1.30, 1.30-2.67 or> 2.67. Heart failure (HF) and major bleeding (MB) were assessed taking all-cause mortality as a competing event and subhazard ratios (sHR) are presented. Recurrent events were evaluated by the incidence rate ratio (IRR).Results: We included 3106 patients and 6.66% had a FIB-4 index >= 1.3. A multivariate analysis verified a higher risk of in-hospital mortality associated with the FIB-4 index (OR, 1.24; P=.016). Patients with a FIB-4 index> 2.67 had a 2-fold higher in-hospital mortality risk (OR, 2.35; P=.038). After discharge (median follow-up 1112 days), the FIB-4 index had no prognostic value for mortality. In contrast, patients with FIB-4 index >= 1.3 had a higher risk of first (sHR, 1.61; P=.04) or recurrent (IRR, 1.70; P=.001) HF readmission. Similarly, FIB-4 index >= 1.30 was associated with a higher MB risk (sHR, 1.62; P=.030).Conclusions: The assessment of liver fibrosis by the FIB-4 index identifies ACS patients not only at higher risk of in-hospital mortality but also at higher risk of HF and MB after discharge.

Introduction and objectives: The optimal time to perform a diagnostic coronary angiography in patients admitted due to non- ST-segment elevation acute coronary syndrome (NSTEACS) and start pretreatment with dual antiplatelet therapy is controversial. Our study aims to identify the current diagnostic and therapeutic approach, and clinical progression of patients with NSTEACS in our country. Methods: The IMPACT-TIMING-GO trial (Impact of time of intervention in patients with myocardial infarction with non-ST segment elevation. Management and outcomes) is a national, observational, prospective, and multicenter registry that will include consecutive patients from 24 Spanish centers with a clinical diagnosis of NSTEACS treated with diagnostic coronary angiography and with present unstable or causal atherosclerotic coronary artery disease. The study primary endpoint is to assess the level of compliance to clinical practice guidelines in patients admitted due to NSTEACS undergoing coronary angiography in Spain, describe the use of antithrombotic treatment prior to cardiac catheterization, and register the time elapsed until it is performed. Major adverse cardiovascular events will also be described like all-cause mortality, non-fatal myocardial infarction and non-fatal stroke, and the rate of major bleeding according to the BARC (Bleeding Academic Research Consortium) scale at 1- and 3-year follow-up. Results: This study will provide more information on the impact of different early management strategies in patients admitted with NSTEACS in Spain, and the degree of implementation of current recommendations into the routine clinical practice. It will also provide information on these patients' baseline and clinical characteristics. Conclusions: This is the first prospective study conducted in Spain that will be reporting on the early therapeutic strategies-both pharmacological and interventional-implemented in our country in patients with NSTEACS after the publication of the 2020 European guidelines, and on the clinical short- and long-term outcomes of these patients.

The Zwolle risk score was designed to stratify in-hospital mortality risk of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (pPCI) and for decision-making in the unit where patients are admitted. We assessed the accuracy of Zwolle risk score for in-hospital mortality estimation compared with the GRACE score in all patients (n = 4446) admitted for STEMI in 3 university hospitals. Only one fourth of the patients were classified as high-risk by the Zwolle risk score vs 60% by the GRACE score. In-hospital mortality was 10.6%. A statistically significant increase in in-hospital mortality, adjusted by age, gender, and revascularization, was observed with both scores. The assessment of the optimal cut-off points verified the accuracy of Zwolle score ≥4 as optimal threshold for high-risk categorization. In contrast, GRACE score ≥140 had very low specificity as well as percentage of patients correctly classified; GRACE score ≥175 was fairly better. The reclassification index of the Zwolle score after applying the GRACE score was 35.5%. Selection of high-risk STEMI patients treated with pPCI based on the Zwolle risk score has higher specificity than the GRACE score and might be useful in clinical practice.

Background: The angiotensin receptor neprilysin inhibitor sacubitril-valsartan is included in the first-line treatment for patients with heart failure (HF) and left ventricle ejection fraction (LVEF). Three clinical trials have evaluated the effect of sacubitril-valsartan in 3 different clinical settings, although all included patients at high-risk of mortality or HF hospitalization. Nonetheless, only the PARADIGM-HF trial demonstrated a significant benefit with sacubitril-valsartan.Methods: We performed a metanalysis with the 3 currently available trials to assess the effect of sacubitril-valsartan on mortality and HF hospitalizations.Results: A total of 18,856 were analyzed: 9,424 treated with sacubitril-valsartan and 9,432 in the conventional treatment arm (7,043 with valsartan and 2,389 with ramipril). Sacubitril-valsartan treatment reduced all-cause mortality in 11% (HR: 0.89 95% CI 0.83-0.95; p=0.001), cardiovascular in 15% (HR: 0.85 95% CI 0.78-0.92; p=0.001) and HF hospitalizations by 16% (HR: 0.84 95% CI 0.79-0.90; p<0.001). No heterogeneity or small-study effect were observed in any of the endpoints. We also assessed the effect of sacubitril-valsartan according to the subgroups of LVEF reported in each trial (5,767 patients (30.6%) had LVEF >40%) and no correlation (p=0.937) was observed between baseline LVEF and treatment effect on the primary end-point.Conclusions: Despite the wide range of clinical scenarios where treatment with sacubitril-valsartan has been tested, it efficiently reduces mortality and HF hospitalizations.Funding Statement: Investigators received the support of the Centro de Investigación Biomédica enRed de Enfermedades Cardiovasculares (CIBERCV) Spain, the National Network for Biomedical Research in Cardiovascular Disease.Declaration of Interests: - Alberto Cordero reports a) honoraria for lectures from AstraZeneca, Bristol- Myers Squibb, Ferrer, Boehringer Ingelheim, MSD, and Bristol-Myers Squibb and AMGEN; b) consulting fees from AstraZeneca, Ferrer and AMGEN. - Julio Nuñez reports a) honoraria for lectures from AstraZeneca, Boehringer Ingelheim, Eli Lilly Co, Novartis, and Rovi; b) consulting fees from AstraZeneca, Boehringer Ingelheim, Bayer, and Novartis - Lorenzo Fácila reports a) honoraria for lectures from Eli Lilly Co, Daiichi Sankyo, Inc., Bayer, Pfizer, Novartis Boehringer Ingelheim b) consulting fees from AstraZeneca, Boehringer, Bayer - María Amparo Quintanilla reports a) honoraria for lectures from Astra Zeneca, Boehringer Ingelheim, Eli Lilly, and Rovi; b) consulting fees from Boehringer Ingelheim, Eli Lilly and AstraZeneca - Vicente Bertomeu-González reports a) honoraria for lectures from Daiichi Sankyo, Boehringer Ingelheim, Bayer, Pfizer-BMS, LivaNova, Ferrer, Cardiome, MSD; b) consulting fees none; c) research grants from Medtronic Iberica. - Moisés Rodríguez-Mañero report research grants from Fundación Mutua Madrileña, Biosense Webseter, Medtronic and from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain). - Javier Torres Llergo reports a) lecture honoraria from AstraZeneca, Bayer, Boehringer-Ingelheim, Pfizer-BMS, Rovi, Eli Lilly, Novartis and Vifor ; b) consulting fees from AstraZeneca, Boehringer, Novartis. - Antoni Bayes-Genís reports lecture honoraria from Abbott, AstraZeneca, Boehringer-Ingelheim, Novartis, Vifor, Roche Diagnostics, and Critical Diagnostics. - José Ramón González-Juanatey reports a) honoraria for lectures from Eli Lilly Co, Daiichi Sankyo, Inc., Bayer, Pfizer, Abbott, Boehringer Ingelheim, MSD, Ferrer, and Bristol-Myers Squibb; b) consulting fees from AstraZeneca, Ferrer, Bayer, Boehringer-Ingelheim; c) research grants from AstraZeneca, Boehringer- Ingelheim and Daichii-Saunkyo.

Background: In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. Methods: This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography <= 24 h vs. coronarography >24 h) after the diagnosis of NSTEACS. Results: Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. Concusions: In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. Brief summary: In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

Background: The incidence of myocarditis after RNA-based vaccines for coronavirus has gained social and medical interest. Methods: We performed an intention-to-treat meta-analysis, following the PRISMA statement. After a systematic search, without language restriction, 9 publications were selected. Two were excluded (one was only in subjects with age 12-17 and other might had included subjects from a larger publication). We followed the PRISMA guidelines for abstracting data and assessing data quality and validity. Data was verified by 2 investigators. Results: We analyzed 17,704,413 subjects, from 7 studies, that included 627 cases of confirmed myocarditis). The incidence of myocarditis was 0.0035% (95% CI 0.0034-0.0035). Mean incidence rate was 10.69 per 100.000 persons-year. Cases reported from Israel represented 45.14% from total (283 out of the 627). Only 1 case of fatal myocarditis or death was reported. There was significant heterogeneity between results. The meta-regression analysis excluded mean age, region, number of cases or number of people included as sources of heterogeneity. No small-study effect was observed (p = 0.19). Conclusions and relevance: Myocarditis incidence after RNA vaccines is very rare (0.0035%) and has a very favorable clinical course.

Cardiovascular disease (CVD) has been outlined as a possible risk factor for poorer outcomes in patients with COVID-19. A meta-analysis was performed with currently available studies that report the prevalence of CVD in survivors vs non-survivors in patients with COVID-19 using reports available at 16 July 2020. Analyses were performed by a random effects model and sensitivity analyses were performed for the identification of potential sources of heterogeneity or to assess the small-study effects. A total of 307 596 patients from 16 reports were included and 46 321 (15.1%) had CVD. Globally, mortality rate was 8.2% (20 534 patients) and mortality rates were higher in hospital registries (48.7%) compared to national reports (23.1%). A total of 11 213 (24.2%) patients with CVD died and mortality rates were also higher in hospital registries (48.7%) compared to national reports (23.1%). CVD was associated to a 4-fold higher risk of mortality (OR, 4.33; 95%CI, 3.16–5.94). Data from 28 048 patients with diabetes was available. Diabetes was associated to higher mortality risk (OR, 2.41; 95%CI, 1.79–3.26; P < .001). From 40 173 subjects with hypertension it was concluded that hypertension was also a risk factor for higher mortality (OR, 2.60; 95%CI, 2.10–3.21; P < .001). Patients with CVD and COVID-19 have a 4-fold higher risk of death. Diabetes and hypertension are also associated with higher mortality risk. Las enfermedades cardiovasculares (ECV) se han identificado como un factor de riesgo de mal pronóstico en los pacientes con COVID-19. Se realizó un metanálisis de estudios actualmente disponibles con la prevalencia de ECV en supervivientes frente a no supervivientes en pacientes con COVID-19 hasta el 16 de julio de 2020. Los análisis se realizaron mediante un modelo de efectos aleatorios y sensibilidad. Se realizaron análisis para identificar posibles fuentes de heterogeneidad o evaluar los efectos de los estudios pequeños. Se incluyó a 307.596 pacientes de 16 estudios, de los que 46.321 (15,1%) tenían ECV. La tasa de mortalidad fue del 8,2% (20.534 pacientes) y fue superior en los registros hospitalarios (48,7%) en comparación con los informes nacionales (23,1%). Un total de 11.213 (24,2%) pacientes con ECV fallecieron y las tasas de mortalidad también fueron más altas en los registros hospitalarios (48,7%) en comparación con los informes nacionales (23,1%). La ECV se asoció con un riesgo de mortalidad 4 veces mayor (OR; 4,33; IC 95%: 3,16-5,94). Se disponía de datos de 28.048 pacientes con diabetes que también se asoció a un mayor riesgo de mortalidad (OR: 2,41; IC 95%: 1,79-3,26; p < 0,001). De 40.173 pacientes con hipertensión, también se concluyó que era un factor de riesgo de mayor mortalidad (OR: 2,60; IC 95%: 2,10-3,21; p < 0,001). Los pacientes con ECV y COVID-19 tienen un riesgo 4 veces mayor de muerte. La diabetes y la hipertensión arterial también son factores de mayor riesgo en los pacientes con COVID-19.

BACKGROUND:Clinical trials have assessed the effect of direct oral antagonists (DOACs) in patients with atrial fibrillation (AF) after percutaneous coronary interventions (PCI). Studies were designed to test the effect on bleeding incidence, but concerns related to safety on ischemic events remain.METHODS:We performed a meta-analysis with currently available studies involving DOACs versus Vitamin-K antagonist (VKA) in patients with AF after PCI. The primary endpoint was the incidence of cardiac ischemic events, including myocardial infarction and stent thrombosis. Secondary endpoints were the incidence of stroke, all-cause mortality, and major bleeding.RESULTS:Eleven thousand twenty-three patients were included in the analysis: 5510 receiving DOACs and 5513 VKA. A total of 190 cases of myocardial infarction were registered in patients treated with DOACs and 177 in patients on VKA, and no statistical difference was noted [relative risk (RR): 1.07 95% confidence interval (CI) 0.88-1.31]. The incidence of stent thrombosis was very low with no differences between both treatment strategies (RR: 1.14 95% CI 0.76-1.71). The incidence of cardiac ischemic events was the same in patients receiving DOACs or VKA (HR 1.09 95% CI 0.91-1.30). No differences were observed in the incidence of stroke (RR: 0.86 95% CI 0.61-1.23) or mortality (RR: 1.09, 95% CI 0.90-1.31). Treatment with DOACs was associated with 34% reduction in major bleeding (RR: 0.66, 95% CI 0.54-0.81).CONCLUSIONS:Treatment with DOACs in patients with AF after a PCI do not increase the risk of cardiac ischemic events, stroke, or death and reduce the incidence of major bleeding by 34% as compared with VKA.