Publications by authors named "Manuel Martínez-Sellés"

286 Publications

Ischemic Etiology and Prognosis in Men and Women with Acute Heart Failure.

J Clin Med 2021 Apr 15;10(8). Epub 2021 Apr 15.

CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.

Coronary heart disease is common in heart failure (HF). Our aim was to determine the impact of ischemic etiology on prognosis among men and women with HF. This study is a prospective national multicenter registry. The primary endpoint was 12-month mortality. Patients with HF and ischemic heart disease were stratified according to sex. A total of 1830 patients were enrolled of which 756 (41.3%) were women. Ischemic etiology was more common in men (446 (41.6%)) than in women (167 (22.2%)). Among patients with ischemic HF, diabetes was more frequent in women than in men. Ischemic etiology was not associated with higher mortality risk, and this was true for women (Hazard Ratio [HR] 1.51, 95% Confidence Interval [CI] 0.98-2.32; = 0.61) and men (HR 1.14, 95% CI 0.81-1.61; = 0.46), -value for interaction: 0.067. Mortality/readmission risk in ischemic HF increased in men with previous readmissions (HR 1.15, 95% CI 1.02-1.29; = 0.022), chronic obstructive pulmonary disease (HR1.20, 95% CI 1.02-1.41; = 0.026) and in women with diabetes (HR 2.23, 95% CI 1.05-4.47; = 0.035). Ischemic etiology was not associated with mortality in HF patients. In ischemic HF, the variables associated with a poor prognosis were diabetes in women and previous readmissions and chronic obstructive pulmonary disease in men.
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http://dx.doi.org/10.3390/jcm10081713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071524PMC
April 2021

ECG patterns of typical and atypical advanced interatrial block: prevalence and clinical relevance.

Rev Esp Cardiol (Engl Ed) 2021 Apr 12. Epub 2021 Apr 12.

Fundación Investigación Cardiovascular, Programa Cardiovascular-ICCC, Institut de Recerca del Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.

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http://dx.doi.org/10.1016/j.rec.2021.02.008DOI Listing
April 2021

Impact of intrapatient blood level variability of calcineurin inhibitors on heart transplant outcomes.

Rev Esp Cardiol (Engl Ed) 2021 Mar 17. Epub 2021 Mar 17.

Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain.

Introduction And Objectives: Intrapatient blood level variability (IPV) of calcineurin inhibitors has been associated with poor outcomes in solid-organ transplant, but data for heart transplant are scarce. Our purpose was to ascertain the clinical impact of IPV in a multi-institutional cohort of heart transplant recipients.

Methods: We retrospectively studied patients aged ≥18 years, with a first heart transplant performed between 2000 and 2014 and surviving≥ 1 year. IPV was assessed by the coefficient of variation of trough levels from posttransplant months 4 to 12. A composite of rejection or mortality/graft loss or rejection and all-cause mortality/graft loss between years 1 to 5 posttransplant were analyzed by Cox regression analysis.

Results: The study group consisted of 1581 recipients (median age, 56 years; women, 21%). Cyclosporine immediate-release tacrolimus and prolonged-release tacrolimus were used in 790, 527 and 264 patients, respectively. On multivariable analysis, coefficient of variation> 27.8% showed a nonsignificant trend to association with 5-year rejection-free survival (HR, 1.298; 95%CI, 0.993-1.695; P=.056) and with 5-year mortality (HR, 1.387; 95%CI, 0.979-1.963; P=.065). Association with rejection became significant on analysis of only those patients without rejection episodes during the first year posttransplant (HR, 1.609; 95%CI, 1.129-2.295; P=.011). The tacrolimus-based formulation had less IPV than cyclosporine and better results with less influence of IPV.

Conclusions: IPV of calcineurin inhibitors is only marginally associated with mid-term outcomes after heart transplant, particularly with the tacrolimus-based immunosuppression, although it could play a role in the most stable recipients.
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http://dx.doi.org/10.1016/j.rec.2021.02.001DOI Listing
March 2021

Tuberculosis and the Heart.

J Am Heart Assoc 2021 Apr 18;10(7):e019435. Epub 2021 Mar 18.

Division of Cardiology Kingston Health Science CenterQueen's University Kingston Canada.

Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.
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http://dx.doi.org/10.1161/JAHA.120.019435DOI Listing
April 2021

Influence of Gender in Advanced Heart Failure Therapies and Outcome Following Transplantation.

Front Cardiovasc Med 2021 25;8:630113. Epub 2021 Feb 25.

Servicio de Cardiología, Hospital 12 de Octubre Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.

Biological differences between males and females change the course of different diseases and affect therapeutic measures' responses. Heart failure is not an exception to these differences. Women account for a minority of patients on the waiting list for heart transplantation or other advanced heart failure therapies. The reason for this under-representation is unknown. Men have a worse cardiovascular risk profile and suffer more often from ischemic heart disease. Conversely, transplanted women are younger and more frequently have non-ischemic cardiac disorders. Women's poorer survival on the waiting list for heart transplantation has been previously described, but this trend has been corrected in recent years. The use of ventricular assist devices in women is progressively increasing, with comparable results than in men. The indication rate for a heart transplant in women (number of women on the waiting list for millions of habitants) has remained unchanged over the past 25 years. Long-term results of heart transplants are equal for both men and women. We have analyzed the data of a national registry of heart transplant patients to look for possible future directions for a more in-depth study of sex differences in this area. We have analyzed 1-year outcomes of heart transplant recipients. We found similar results in men and women and no sex-related interactions with any of the factors related to survival or differences in death causes between men and women. We should keep trying to approach sex differences in prospective studies to confirm if they deserve a different approach, which is not supported by current evidence.
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http://dx.doi.org/10.3389/fcvm.2021.630113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946818PMC
February 2021

Infective endocarditis in patients with solid organ transplantation. A nationwide descriptive study.

Eur J Intern Med 2021 May 6;87:59-65. Epub 2021 Mar 6.

Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid. Instituto de Investigación Sanitaria Gregorio Marañón. CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058). Facultad de Medicina, Universidad Complutense de Madrid.

Background: Solid organ transplantation (SOT) implies immunosuppression and frequent health care contact. Our aim was to compare the characteristics of patients with infective endocarditis (IE) and SOT against those without SOT.

Methods: We used data from the Spanish Collaboration on Endocarditis during the period 2008-2018.

Results: We identified 4794 cases of IE, 85 (1.8%) in SOT (56 kidney, 18 liver, 8 heart, 3 lung). Thirteen patients with other transplantation types (bone marrow, hematopoietic precursors, and cornea) were excluded from the analysis. Compared with patients without SOT, patients with SOT had lower median age (61 vs. 69 years, p<0.001), more comorbidities (mean age-adjusted Charlson index 5.7±2.9 vs. 4.9±2.9, p=0.004), a lower prevalence of native valvular heart disease (29.4 vs. 45.4%, p=0.003), more in-hospital and healthcare-related IE (70.5% vs. 36.3%, p<0.001) and staphylococcal etiology (57.7% vs. 39.7%, p=0.001). Patients with SOT had more frequent kidney function worsening (47.1% vs. 34.6%, p=0.02), septic shock (25.9% vs. 12.1 %, p<0.001), sepsis (27.1% vs. 17.2%, p=0.02), and less surgery indication (54.1% vs 66.3%, p=0.02) and surgery (32.9% vs. 46.3%, p=0.01) than patients without SOT. There were no significant differences in mortality: inhospital (30.6% SOT vs. 25.6% without SOT, p=0.31), 1-year (38.8% SOT vs. 31.9% without SOT, p=0.18).

Conclusions: Most IE in SOT recipients are nosocomial and over 70% are health care-related. Half have previously normal heart valves and almost 60% are due to Staphylococcus spp. infections. Mortality seems to be similar to non-SOT counterparts.
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http://dx.doi.org/10.1016/j.ejim.2021.02.017DOI Listing
May 2021

Atypical advanced interatrial block due to giant atrial lipoma.

Pacing Clin Electrophysiol 2021 Apr 17;44(4):737-739. Epub 2021 Mar 17.

Cardiovascular Research Foundation. Cardiovascular ICCC- Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.

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http://dx.doi.org/10.1111/pace.14210DOI Listing
April 2021

Cardiac troponin and infective endocarditis prognosis: a systematic review and meta-analysis.

Eur Heart J Acute Cardiovasc Care 2021 Feb 28. Epub 2021 Feb 28.

Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.

Aims: Infective endocarditis (IE) is associated with high mortality and morbidity. Cardiac troponin (Tn) elevation seems to be common in patients with IE and could be associated with a poor prognosis. The aim of this study was to synthesize the prognostic value of Tn in patients with IE.

Methods And Results: We searched in MEDLINE, EMBASE, and the Cochrane library, including the Cochrane Central Register of Controlled Trials (CENTRAL) until February 2020. Observational studies reporting on the association between Tn and in-hospital and 1-year mortality, and IE complications were considered eligible. As each centre uses different conventional or ultra-sensitive Tn, with different normality threshold, we considered them as normal or elevated according to the criteria specified in each article. Articles were systematically selected, assessed for bias, and, when possible, meta-analysed using a random effect model. After retrieving 542 articles, 18 were included for qualitative synthesis and 9 for quantitative meta-analysis. Compared with patients with normal Tn levels, patients with Tn elevation presented higher in-hospital mortality [odds ratio (OR) 5.96, 95% confidence interval (CI) 3.46-10.26; P < 0.0001], 1-year mortality (OR 2.67, 95% CI 1.42-5.02; P = 0.002), and surgery rates (OR 2.34, 95% CI 1.42-3.85; P = 0.0008). They also suffered more frequent complications: central nervous system events (OR 8.85, 95% CI 3.23-24.26; P < 0.0001) and cardiac abscesses (OR 4.96, 95% CI 1.94-12.70; P = 0.0008).

Conclusion: Tn elevation is associated with a poor prognosis in patients with IE. Troponin determination seems to provide additional help in the prognostic assessment of these patients.
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http://dx.doi.org/10.1093/ehjacc/zuab008DOI Listing
February 2021

Infectious complications associated with short-term mechanical circulatory support in urgent heart transplant candidates.

Rev Esp Cardiol (Engl Ed) 2021 Feb 26. Epub 2021 Feb 26.

Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain. Electronic address:

Introduction And Objectives: Short-term mechanical circulatory support is frequently used as a bridge to heart transplant in Spain. The epidemiology and prognostic impact of infectious complications in these patients are unknown.

Methods: Systematic description of the epidemiology of infectious complications and analysis of their prognostic impact in a multicenter, retrospective registry of patients treated with short-term mechanical devices as a bridge to urgent heart transplant from 2010 to 2015 in 16 Spanish hospitals.

Results: We studied 249 patients, of which 87 (34.9%) had a total of 102 infections. The most frequent site was the respiratory tract (n=47; 46.1%). Microbiological confirmation was obtained in 78 (76.5%) episodes, with a total of 100 causative agents, showing a predominance of gram-negative bacteria (n=58, 58%). Compared with patients without infection, those with infectious complications showed higher mortality during the support period (25.3% vs 12.3%, P=.009) and a lower probability of receiving a transplant (73.6% vs 85.2%, P=.025). In-hospital posttransplant mortality was similar in the 2 groups (with infection: 28.3%; without infection: 23.4%; P=.471).

Conclusions: Patients supported with temporary devices as a bridge to heart transplant are exposed to a high risk of infectious complications, which are associated with higher mortality during the organ waiting period.
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http://dx.doi.org/10.1016/j.rec.2020.11.019DOI Listing
February 2021

Influence of left ventricular systolic function on the long-term benefit of beta-blockers after ST-segment elevation myocardial infarction.

Rev Port Cardiol 2021 Apr 26;40(4):285-290. Epub 2021 Feb 26.

Department of Cardiology. Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain; Universidad Complutense, Madrid, Spain; Universidad Europea, Madrid, Spain. Electronic address:

Introduction: Beta-blockers are recommended after ST-elevation myocardial infarction (STEMI), but their benefit in patients with preserved left ventricular ejection fraction (LVEF) is unclear.

Methods: Consecutive patients discharged in sinus rhythm after STEMI between January 2010 and April 2015 were followed until December 2017. Percutaneous coronary intervention (PCI) was performed in 969 (99.7%, including 112 with rescue PCI) and three (0.3%) received only thrombolytic therapy without rescue PCI.

Results: Of these 972 patients, mean age 62.6±13.5 years, 212 (21.8%) were women and 835 (85.9%) were prescribed beta-blockers at discharge. Patients who did not receive beta-blockers had more comorbidities than those who did, including chronic obstructive pulmonary disease (14.6% vs. 4.2%), anemia (8.0% vs. 3.7%), and cancer (7.3% vs. 2.8%), and more frequently had inferior STEMI (75.9% vs. 56.0%) and high-grade atrioventricular block (13.1% vs. 5.3%) (all p<0.01). After a mean follow-up of 49.6±24.9 months, beta-blocker treatment at discharge was independently associated with lower mortality (HR 0.61, 95% confidence interval [CI] 0.38-0.96, p=0.03). This effect was present in 192 patients with LVEF ≤40% (HR 0.57, 95% 95% CI 0.34-0.97, p=0.04) but was not clear in 643 patients with LVEF >40% (HR 0.67, 95% 95% CI 0.25-1.76, p=0.42).

Conclusion: In the LVEF >40% group, the results raise reasonable doubts about the real benefit of systematic use of beta-blockers as treatment for these patients. These findings reinforce the need for large randomized clinical trials within this group of patients.
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http://dx.doi.org/10.1016/j.repc.2020.07.017DOI Listing
April 2021

Malaria and the Heart: JACC State-of-the-Art Review.

J Am Coll Cardiol 2021 Mar;77(8):1110-1121

Department of Medicine, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada. Electronic address:

As one of the tropical diseases, malaria is endemic in developing countries. Severe malaria, mainly caused by the Plasmodium falciparum parasite, can result in life-threatening complications. Traditionally, cardiac involvement has not been included as a frequent cause of morbidity and mortality. This could be due to under-reporting or underdiagnosing. Specific cardiovascular (CV) complications include electrocardiogram abnormalities, myocarditis, pericarditis, pericardial effusion, ischemic disease, and heart failure. According to the data analyzed, CV manifestations can lead to severe consequences. Possible theories related to the pathophysiological mechanisms related to CV compromise include an imbalanced pro-inflammatory cytokine response and/or erythrocyte sequestration by increased cytoadherence to endothelium. Although there is a paucity of data regarding cardiac manifestations of malaria, an algorithm for appropriate use of diagnostic tools to assess cardiac involvement has been developed in this paper. Furthermore, it is important to note that typical antimalarial treatment regimens can have fatal cardiac side-effects.
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http://dx.doi.org/10.1016/j.jacc.2020.12.042DOI Listing
March 2021

Sinus bradycardia in paediatric athletes.

Eur J Prev Cardiol 2020 Jun 10. Epub 2020 Jun 10.

Cardiology Department, University General Hospital Gregorio Marañon, Spain.

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http://dx.doi.org/10.1177/2047487320932254DOI Listing
June 2020

Baseline CHA DS -VASc score and prognosis in octogenarians with non-ST segment elevation acute coronary syndrome.

Int J Clin Pract 2021 Feb 10:e14082. Epub 2021 Feb 10.

Cardiology Department, Hospital Universitario La Princesa, Madrid, Spain.

Background: CHA DS -VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We sought to study if this score predicts outcomes in elderly patients with Non-ST segment Elevation Acute Coronary Syndromes (NSTEACS).

Methods: The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEACS aged ≥80 years. Data to calculate CHA DS -VASc Score were available in 523 patients (98.3%). They were classified according to CHA DS -VASc Score: group 1 (score ≤ 4), and 2 (5-9). We studied outcomes in terms of mortality or readmission at 6 months follow-up.

Results: A total of 266 patients (51%) had a high CHA DS -VASc Score (group 2). They were more often women, with more cardiovascular risk factors, such as hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, P = .001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment, and frailty) and Charlson Index were worse in this group (all, P = .001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, P = .001), and developed new-onset AF more often during admission (12.4% vs. 6.6%, P = .024). At six months follow-up, patients in group 2 had higher reinfarction, all-cause mortality, and mortality or readmission rates. A CHA DS -VASc Score > 4 was associated with mortality or readmission at 6 months (HR 2.07, P < .001). However, after adjusting for potential confounders, this last association was not significant (P = .175).

Conclusions: A CHA DS -VASc Score > 4 is present in half of octogenarians with NSTEACS and is associated with poorer outcomes. However, it is not an independent predictor of events and should not replace recommended tools for risk prediction in this setting.
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http://dx.doi.org/10.1111/ijcp.14082DOI Listing
February 2021

Characteristics and outcome of acute heart failure in infective endocarditis: focus on cardiogenic shock.

Clin Infect Dis 2021 Feb 9. Epub 2021 Feb 9.

Infectious Diseases Service. Hospital Clinic-IDIBAPS. University of Barcelona, Barcelona, Spain.

Background: Studies investigating the impact of cardiogenic shock (CS) on endocarditis are lacking. We aimed to investigate the characteristics and outcomes of endocarditis patients presenting with acute heart failure (AHF), particularly of those developing CS.

Methods: Prospectively collected cohort from 35 Spanish centers (2008-2018). Logistic regression analyses were performed to identify risk factors for developing CS and predictors of mortality.

Results: Amongst 4,856 endocarditis patients, 1,652 (34%) had AHF and 244 (5%) CS. Compared to patients without AHF and AHF but no CS, patients with CS presented higher rates of surgery (40.5%, 52.5% and 68%,p<.001) and in-hospital mortality (16.3%,39.1%, and 52.5%). Compared to patients with septic shock, CS patients presented higher rates of surgery (42.5% vs. 68%, p<.001), and lower rates of in-hospital and 1-year mortality (62.3% vs. 52.5%,p.008;and 65.3% vs. 57.4%,p.030). Severe aortic and mitral regurgitation (OR 2.47, 95%CI 1.82-3.35 and OR 3.03, 95%CI 2.26-4.07, both p<.001), left-ventricle ejection fraction<60% (OR 1.72, 95%CI 1.22-2.40, p.002), heart block (OR 2.22, 95%CI 1.41-3.47, p.001), tachyarrhythmias (OR 5.07,95%CI 3.13-8.19, p<.001) and acute kidney failure (OR 2.29, 95%CI 1.73-3.03,p<.001) were associated to a higher likelihood of developing CS. Prosthetic endocarditis (OR 2.03, 95%CI 1.06-3.88, p.032), S. aureus (OR 3.10, 95%CI 1.16-8.30, p.024), tachyarrhythmias (OR 3.09,95%CI 1.50-10.13, p.005), and not performing cardiac surgery (OR 11.40, 95%CI 4.83-26.90, p<.001) were associated to a higher risk of mortality.

Conclusions: Acute heart failure is common among patients with endocarditis. Cardiogenic shock is associated to very high mortality and should be promptly identified and assessed for cardiac surgery.
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http://dx.doi.org/10.1093/cid/ciab098DOI Listing
February 2021

Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial.

JAMA 2021 02;325(6):552-560

Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.

Importance: The optimal transfusion strategy in patients with acute myocardial infarction and anemia is unclear.

Objective: To determine whether a restrictive transfusion strategy would be clinically noninferior to a liberal strategy.

Design, Setting, And Participants: Open-label, noninferiority, randomized trial conducted in 35 hospitals in France and Spain including 668 patients with myocardial infarction and hemoglobin level between 7 and 10 g/dL. Enrollment could be considered at any time during the index admission for myocardial infarction. The first participant was enrolled in March 2016 and the last was enrolled in September 2019. The final 30-day follow-up was accrued in November 2019.

Interventions: Patients were randomly assigned to undergo a restrictive (transfusion triggered by hemoglobin ≤8; n = 342) or a liberal (transfusion triggered by hemoglobin ≤10 g/dL; n = 324) transfusion strategy.

Main Outcomes And Measures: The primary clinical outcome was major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days. Noninferiority required that the upper bound of the 1-sided 97.5% CI for the relative risk of the primary outcome be less than 1.25. The secondary outcomes included the individual components of the primary outcome.

Results: Among 668 patients who were randomized, 666 patients (median [interquartile range] age, 77 [69-84] years; 281 [42.2%] women) completed the 30-day follow-up, including 342 in the restrictive transfusion group (122 [35.7%] received transfusion; 342 total units of packed red blood cells transfused) and 324 in the liberal transfusion group (323 [99.7%] received transfusion; 758 total units transfused). At 30 days, MACE occurred in 36 patients (11.0% [95% CI, 7.5%-14.6%]) in the restrictive group and in 45 patients (14.0% [95% CI, 10.0%-17.9%]) in the liberal group (difference, -3.0% [95% CI, -8.4% to 2.4%]). The relative risk of the primary outcome was 0.79 (1-sided 97.5% CI, 0.00-1.19), meeting the prespecified noninferiority criterion. In the restrictive vs liberal group, all-cause death occurred in 5.6% vs 7.7% of patients, recurrent myocardial infarction occurred in 2.1% vs 3.1%, emergency revascularization prompted by ischemia occurred in 1.5% vs 1.9%, and nonfatal ischemic stroke occurred in 0.6% of patients in both groups.

Conclusions And Relevance: Among patients with acute myocardial infarction and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of MACE after 30 days. However, the CI included what may be a clinically important harm.

Trial Registration: ClinicalTrials.gov Identifier: NCT02648113.
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http://dx.doi.org/10.1001/jama.2021.0135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873781PMC
February 2021

Impact of frailty and atrial fibrillation in elderly patients with acute coronary syndromes.

Eur J Clin Invest 2021 May 12;51(5):e13505. Epub 2021 Feb 12.

Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain.

Background: There is scarce information on the prognostic role of frailty and atrial fibrillation (AF) in elderly patients with acute coronary syndrome (ACS).

Methods: The aim was to analyse the management of elderly patients with frailty and AF who suffered an ACS using data of the prospective multicentre LONGEVO-SCA registry. We evaluated the predictive performance of FRAIL, Charlson scores and AF status for adverse events at 6-month follow-up.

Results: A total of 531 unselected patients with ACS and above 80 years old [mean age 84.4 (SD = 3.6) years; 322 (60.6%) male] were enrolled, of whom 128 (24.1%) with AF and 145 (27.3%) with frailty. Mutually exclusive number of patients were as follows: non-frail and sinus rhythm (SR) 304 (57.2%); frail and SR 99 (18.6%); non-frail and AF 82 (15.4%); and frail and AF 46 (8.7%). Frail and AF patients compared with non-frail and SR patients had higher risk of all-cause mortality [HR 2.61, (95% CI 1.28-5.31; P = .008)], readmissions [HR 2.28, (95%CI 1.37-3.80); P = .002)] and its composite [HR 2.28, (95% CI 1.44-3.60); P < .001)]. After multivariate adjustment, FRAIL score [HR 1.41, (95% CI 1.02-1.97); P = .040] and Charlson index [HR 1.32, (95% CI 1.09-1.59); P = .003] were significantly associated with mortality. AF status was not independently related with adverse events.

Conclusions: Frailty but not AF status was independently associated with follow-up adverse events. Frailty status and high Charlson index were independent conditions associated with adverse events during the follow-up. The impact of functional status has a bigger prognostic role over AF status in elderly patients with ACS.
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http://dx.doi.org/10.1111/eci.13505DOI Listing
May 2021

The "V1 continuum" in the athletes' ECG.

Scand J Med Sci Sports 2020 11;30(11):2277-2278

Department of Cardiology, Sports Medicine Center, Spanish Agency for Health Protection in Sports, Madrid, Spain.

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http://dx.doi.org/10.1111/sms.13806DOI Listing
November 2020

Atrial Conduction Disorders.

Curr Cardiol Rev 2021 ;17(1):68-73

Division of Cardiology, Queen's University, Kingston, Ontario, ON K7L 3N6, Canada.

Atrial conduction disorders result from impaired propagation of cardiac impulses from the sinoatrial node through the atrial conduction pathways. Disorders affecting interatrial conduction alter P-wave characteristics on the surface electrocardiogram. A variety of P-wave indices reflecting derangements in atrial conduction have been described and have been associated with an increased risk of atrial fibrillation (AF) and stroke. Interatrial block (IAB) is the most well-known of the different P-wave indices and is important clinically due to its ability to predict patients who are at risk of the development of AF and other supraventricular tachycardias. P-Wave Axis is a measure of the net direction of atrial depolarization and is determined by calculating the net vector of the P-wave electrical activation in the six limb-leads using the hexaxial reference system. It has been associated with stroke and it has been proposed that this variable be added to the existing CHA2DS2-VASc score to create a P2-CHA2DS2-VASc score to improve stroke prediction. P-Terminal Force in V1 is thought to be an epiphenomenon of advanced atrial fibrotic disease and has been shown to be associated with a higher risk of death, cardiac death, and congestive heart failure as well as an increased risk of AF. P-wave Dispersion is defined as the difference between the shortest and longest P-wave duration recorded on multiple concurrent surface ECG leads on a standard 12-lead ECG and has also been associated with the development of AF and AF recurrence. Pwave voltage in lead I (PVL1) is thought to be an electrocardiographic representation of cardiac conductive properties and, therefore, the extent of atrial fibrosis relative to myocardial mass. Reduced PVL1 has been demonstrated to be associated with new-onset AF in patients with coronary artery disease and may be useful for predicting AF. Recently a risk score (the MVP risk score) has been developed using IAB and PVL1 to predict atrial fibrillation and has shown a good predictive ability to determine patients at high risk of developing atrial fibrillation. The MVP risk score is currently undergoing validation in other populations. This section reviews the different P-wave indices in-depth, reflecting atrial conduction abnormalities.
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http://dx.doi.org/10.2174/1573403X17666210112161524DOI Listing
April 2021

Sex Influence on Heart Failure Prognosis.

Front Cardiovasc Med 2020 21;7:616273. Epub 2020 Dec 21.

Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.

Heart failure (HF) affects 1-2% of the population in developed countries and ~50% of patients living with it are women. Compared to men, women are more likely to be older and suffer hypertension, valvular heart disease, and non-ischemic cardiomyopathy. Since the number of women included in prospective HF studies has been low, much information regarding HF in women has been inferred from clinical trials observations in men and data obtained from registries. Several relevant sex-related differences in HF patients have been described, including biological mechanisms, age, etiology, precipitating factors, comorbidities, left ventricular ejection fraction, treatment effects, and prognosis. Women have greater clinical severity of HF, with more symptoms and worse functional class. However, females with HF have better prognosis compared to males. This survival advantage is particularly impressive given that women are less likely to receive guideline-proven therapies for HF than men. The reasons for this better prognosis are unknown but prior pregnancies may play a role. In this review article we aim to describe sex-related differences in HF and how these differences might explain why women with HF can expect to survive longer than men.
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http://dx.doi.org/10.3389/fcvm.2020.616273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779486PMC
December 2020

Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial.

Clin Cardiol 2021 Feb 6;44(2):143-150. Epub 2021 Jan 6.

Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.

Background: Anemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear.

Hypothesis: We hypothesized that a "restrictive" transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a "liberal" transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly.

Methods: REALITY is an international, randomized, multicenter, open-label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost-effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all-cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year.

Results: The trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost-effectiveness of the restrictive strategy at a threshold of €50 000 per quality-adjusted life year.

Conclusions: REALITY will provide important guidance on the management of patients with AMI and anemia.
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http://dx.doi.org/10.1002/clc.23453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7852166PMC
February 2021

Telematic cardiology consultation in the elderly. The 5M framework can help.

Rev Esp Cardiol (Engl Ed) 2021 01 21;74(1):116-117. Epub 2020 Oct 21.

Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain. Electronic address:

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http://dx.doi.org/10.1016/j.rec.2020.08.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577676PMC
January 2021

Infective endocarditis in patients with heart transplantation.

Int J Cardiol 2021 Apr 10;328:158-162. Epub 2020 Dec 10.

Facultad de Medicina, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.

Background: The incidence of nosocomial and health care-related infective endocarditis (IE) is increasing. Heart transplantation (HT) implies immunosuppression and frequent health care contact. Our aim was to describe the current profile and prognosis of IE in HT recipients.

Methods: Multicenter retrospective registry-based study in Spain and France that included cases between 2008 and 2019.

Results: During the study period, 8305 HT were performed in Spain and France. We identified 18 IE cases (rate 0.2%). Median age was 57 years; 12 were men (67%). Valve involvement did not have a predominant location and three patients (16.7%) had atrial or ventricular vegetations without valve involvement. The median age-adjusted Charlson index was 4 (interquartile range 3-5). Eleven IE cases (61%) were nosocomial/health care-related. Median time (range) between HT and development of IE was 43 months (interquartile range 6-104). The major pathogens were Staphylococcus sp. (n = 8, 44%), Enterococcus sp. (n = 4, 22%), and Aspergillus sp. (n = 3, 17%). Although eight patients (44%) had a surgical indication, it was only performed in three cases (17%). Three patients (17%) died during the first IE hospital admission.

Conclusions: IE in HT recipients has specific characteristics. Valve involvement does not have a predominant location and non-valvular involvement is common. Three fifths have a nosocomial/health care-related origin. The major pathogens were staphylococci (44%), enterococci (22%), and Aspergillus (17%). In-hospital mortality was 17%.
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http://dx.doi.org/10.1016/j.ijcard.2020.12.018DOI Listing
April 2021

Cardiovascular events after Zika virus infection.

Trends Cardiovasc Med 2020 Dec 3. Epub 2020 Dec 3.

Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV. Universidad Europea. Universidad Complutense. Madrid, Spain. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2020.11.008DOI Listing
December 2020

Baseline ECG and Prognosis After Transcatheter Aortic Valve Implantation: The Role of Interatrial Block.

J Am Heart Assoc 2020 11 3;9(22):e017624. Epub 2020 Nov 3.

Department of Cardiology Hospital General Universitario Gregorio Marañón CIBERCV Madrid Spain.

Background The clinical significance of conduction disturbances after transcatheter aortic valve implantation has been described; however, little is known about the influence of baseline ECGs in the prognosis of these patients. Our aim was to study the influence of baseline ECG parameters, including interatrial block (IAB), in the prognosis of patients treated with transcatheter aortic valve implantation. Methods and Results The BIT (Baseline Interatrial Block and Transcatheter Aortic Valve Implantation) registry included 2527 patients with aortic stenosis treated with transcatheter aortic valve implantation. A centralized analysis of baseline ECGs was performed. Patients were divided into 4 groups: normal P wave duration (<120 ms); partial IAB (P wave duration ≥120 ms, positive in the inferior leads); advanced IAB (P wave duration ≥120 ms, biphasic [+/-] morphology in the inferior leads); and nonsinus rhythm (atrial fibrillation/flutter and paced rhythm). The mean age of patients was 82.6±9.8 years and 1397 (55.3%) were women. A total of 960 patients (38.0%) had a normal P wave, 582 (23.0%) had partial IAB, 300 (11.9%) had advanced IAB, and 685 (27.1%) presented with nonsinus rhythm. Mean follow-up duration was 465±171 days. Advanced IAB was the only independent predictor of all-cause mortality (hazard ratio [HR], 1.48; 95% CI, 1.10-1.98 [=0.010]) and of the composite end point (death/stroke/new atrial fibrillation) (HR, 1.51; 95% CI, 1.17-1.94 [=0.001]). Conclusions Baseline ECG characteristics influence the prognosis of patients with aortic stenosis treated with transcatheter aortic valve implantation. Advanced IAB is present in about an eighth of patients and is associated with all-cause death and the composite end point of death, stroke, and new atrial fibrillation during follow-up.
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http://dx.doi.org/10.1161/JAHA.120.017624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763710PMC
November 2020

Serum potassium dynamics during acute heart failure hospitalization.

Clin Res Cardiol 2020 Oct 17. Epub 2020 Oct 17.

CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.

Background: Available information about prognostic implications of potassium levels alteration in the setting of acute heart failure (AHF) is scarce.

Objectives: We aim to describe the prevalence of dyskalemia (hypo or hyperkalemia), its dynamic changes during AHF-hospitalization, and its long-term clinical impact after hospitalization.

Methods: We analyzed 1779 patients hospitalized with AHF who were included in the REDINSCOR II registry. Patients were classified in three groups, according to potassium levels both on admission and discharge: hypokalemia (potassium < 3.5 mEq/L), normokalemia (potassium = 3.5-5.0 mEq/L and, hyperkalemia (potassium > 5 mEq/L).

Results: The prevalence of hypokalemia and hyperkalemia on admission was 8.2 and 4.6%, respectively, and 6.4 and 2.7% at discharge. Hyperkalemia on admission was associated with higher in-hospital mortality (OR = 2.32 [95% CI: 1.04-5.21] p = 0.045). Among patients with hypokalemia on admission, 79% had normalized potassium levels at discharge. In the case of patients with hyperkalemia on admission, 89% normalized kalemia before discharge. In multivariate Cox regression, dyskalemia was associated with higher 12-month mortality, (HR = 1.48 [95% CI, 1.12-1.96], p = 0.005). Among all patterns of dyskalemia persistent hypokalemia (HR = 3.17 [95% CI: 1.71-5.88]; p < 0.001), and transient hyperkalemia (HR = 1.75 [95% CI: 1.07-2.86]; p = 0.023) were related to reduced 12-month survival.

Conclusions: Potassium levels alterations are frequent and show a dynamic behavior during AHF admission. Hyperkalemia on admission is an independent predictor of higher in-hospital mortality. Furthermore, persistent hypokalemia and transient hyperkalemia on admission are independent predictors of 12-month mortality.
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http://dx.doi.org/10.1007/s00392-020-01753-3DOI Listing
October 2020

Main challenges of electrolyte imbalance in older patients with COVID-19 and risk of QT prolongation. Response.

Rev Esp Cardiol (Engl Ed) 2021 02 1;74(2):199-200. Epub 2020 Oct 1.

Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.

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http://dx.doi.org/10.1016/j.rec.2020.08.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528876PMC
February 2021

Spanish Heart Transplant Registry. 31th Official Report of the Heart Failure Association of the Spanish Society of Cardiology.

Rev Esp Cardiol (Engl Ed) 2020 Oct 8. Epub 2020 Oct 8.

Hospital Universitario Marqués de Valdecilla, Santander, Cantabria.

Introduction And Objectives: The present report describes the clinical characteristics and outcomes of heart transplants in Spain and updates the data to 2019.

Methods: We describe the clinical characteristics and outcomes of heart transplants performed in Spain in 2019, as well as trends in this procedure from 2010 to 2018.

Results: In 2019, 300 transplants were performed (8794 since 1984; 2745 between 2010 and 2019). Compared with previous years, the most notable findings were the decreasing rate of urgent transplants (38%), and the consolidation of the type of circulatory support prior to transplant, with an almost complete disappearance of counterpulsation balloon (0.7%), stabilization in the use of extracorporeal membrane oxygenation (9.6%), and an increase in the use of ventricular assist devices (29.0%). Survival from 2016 to 2018 was similar to that from 2013 to 2015 (P=.34). Survival in both these periods was better than that from 2010 to 2012 (P=.002 and P=.01, respectively).

Conclusions: Heart transplant activity has remained stable during the last few years, as have outcomes (in terms of survival). There has been a trend to a lower rate of urgent transplants and to a higher use of ventricular assist devices prior to transplant.
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http://dx.doi.org/10.1016/j.rec.2020.06.035DOI Listing
October 2020

[Telematic cardiology consultation in the elderly. The 5 M framework can help].

Rev Esp Cardiol 2021 Jan 24;74(1):116-117. Epub 2020 Sep 24.

Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, España.

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http://dx.doi.org/10.1016/j.recesp.2020.08.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7513820PMC
January 2021

[Main challenges of electrolyte imbalance in older patients with COVID-19 and risk of QT prolongation. Response].

Rev Esp Cardiol 2021 Feb 18;74(2):199-200. Epub 2020 Sep 18.

Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, España.

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http://dx.doi.org/10.1016/j.recesp.2020.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500888PMC
February 2021