ISSN 1671-5411 CN 11-5329/R

2022 Vol. 19, No. 5

EDITORIAL
The coronavirus disease-19 pandemic and acute coronary syndrome: a specific impact in the elderly
Viktor Čulić, Ahmed AlTurki, Riccardo Proietti
2022, 19(5): 325-334. doi: 10.11909/j.issn.1671-5411.2022.05.001
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RESEARCH ARTICLE
Fifteen-year mortality and prognostic factors in patients with dilated cardiomyopathy: persistent standardized application of drug therapy and strengthened management may bring about encouraging change in an aging society
Xiao-Rong XU, Meng-Meng HAN, Yi-Zhen YANG, Xin WANG, Dong-Yan HOU, Xian-Chen MENG, Hua WANG, Wen-Shu ZHAO, Lin ZHANG, Lin XU
2022, 19(5): 335-342. doi: 10.11909/j.issn.1671-5411.2022.05.003
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 BACKGROUND  There is scarce data on the long-term mortality and associated prognostic factors in patients with dilated cardiomyopathy (DCM). The study aimed to investigate the all-cause mortality up to 15 years (mean 7.9 ± 5.7 years) in such patients, and the independent prognostic factors influencing their long-term mortality.  METHODS  One hundred and sixty-six consecutive patients with DCM were prospectively enrolled from 2002 to 2003. The mean age of patients was 59.5 ± 10.4 years, and approximately 57% were male. They were followed up by telephone or outpatient visit at least every three months until 2019 or all-cause death occurred. Predictors of mortality were identified using multivariate logistic regression analysis.  RESULTS During the 15 years of follow-up, five patients were lost to follow-up, and the complete data records of 161 patients were included in the analysis. Patients were treated with angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin-receptor blocker (ARB), β-blockers, mineralocorticoid receptor antagonist (MRA), diuretics and digitalis from 2002 to 2004, and maintained at the maximum tolerated doses between 2004 and 2019. Our safety targets to maintain heart rate and blood pressure at 60-80 beats/min and 90-120/60-80 mmHg, respectively. All-cause mortality in the first five years was 55.9%. The independent risk factors for the 5-year mortality were age ≥ 70 years old (OR = 5.45, P = 0.006), systolic blood pressure (SBP) > 120 mmHg (OR = 3.63, P = 0.004), 6-minute walk distance (6MWD) < 450 m (OR = 3.84, P = 0.001). 15-year all-cause mortality was 65.8%. The independent risk factors for 15-year mortality were age ≥ 70 years old (OR = 16.07, P = 0.009), LVEF ≤ 35% (OR = 5.69, P = 0.003), and SBP > 120 mmHg (OR = 9.56, P < 0.001).  CONCLUSIONS This study was the first to demonstrate the 15-year survival rate of 34% in DCM patients. The DCM patients’ first five-year all-cause mortality decreased significantly after continuous standardized treatment and intensive management. The mortality then plateaued in the following 10 years. Age ≥ 70 years, LVEF ≤ 35%, and SBP > 120 mmHg were independent predictors of 15-year all-cause mortality.
Comparison of the prognostic value of frailty assessment tools in patients aged ≥ 65 years hospitalized in a cardiac care unit with acute coronary syndrome
Wojciech Nowak, Ilona Kowalik, Małgorzata Kuzin, Agnieszka Krauze, Anna Mierzyńska, Ewa Sadowy, Kamil Marcinkiewicz, Janina Stępińska
2022, 19(5): 343-353. doi: 10.11909/j.issn.1671-5411.2022.05.010
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 BACKGROUND  Frailty is associated with adverse events in elderly patients with acute coronary syndrome (ACS). Our aim was to compare the prognostic value of four frailty scales in patients aged ≥ 65 years hospitalized with ACS in a cardiac care unit (CCU). METHODS  Patients aged ≥ 65 years with ACS were included. Frailty was assessed using the Fried frailty scale (reference standard), the Edmonton Frail Scale (EFS), the FRAIL scale, and the Clinical frailty scale (CFS). The primary end point was all-cause mortality and the secondary end point was unscheduled rehospitalization. RESULTS One hundred and seventy four patients aged ≥ 65 years with ACS were recruited. The median follow-up was 637.5 days. Frailty was identified in 41.4%, 40.2%, 39.1% and 36.3% patients by the Fried frailty scale, EFS, FRAIL scale and CFS, respectively. The agreement coefficients were 0.88, 0.86, and 0.79 for the FRAIL scale, EFS and CFS, respectively. In the Cox regression model, frailty was associated with all-cause mortality regardless of the scale used (univariate: hazard ratio [HR] 95% CI = 10.5, 2.4–46.8 Fried frailty scale; 12.0, 2.7–53.4 FRAIL scale; 7.1, 2.0–25.2 EFS; 8.3, 2.4–29.6 CFS. Multivariate: HR = 5.1, 1.1–23.8 Fried frailty scale; 5.7, 1.2–26.8 FRAIL scale; 3.7, 1.0–14.0 EFS; 4.2, 1.1–15.9 CFS). The FRAIL scale had the highest HR. In the univariate analysis, frailty was associated with unscheduled rehospitalization (HR = 3.2, 1.7–6.0 Fried frailty scale; 3.4, 1.8–6.3 FRAIL scale; 3.5, 1.8–6.6 EFS; 3.1, 1.7–5.8 CFS). In the multivariate analysis, only the EFS independently predicted unscheduled rehospitalization (HR = 2.2, 1.1–4.63). CONCLUSIONS  Frailty assessed by the Fried frailty scale, FRAIL scale, EFS and CFS is associated with all-cause mortality and unscheduled rehospitalization in elderly patients hospitalized in a CCU with ACS. The adjusted HR of the FRAIL scale for all-cause mortality was the highest among the scales compared, whereas the EFS was an independent predictor of unscheduled rehospitalization. These data should be taken into consideration when choosing a frailty assessment tool.
Prospective application of a bleeding and ischemic risks-adjusted antithrombotic protocol in elderly patients revascularized with everolimus-eluting stents: EPIC05-Sierra75 study
Jose M de la Torre Hernandez, Ramon Lopez Palop, Jesus M Jimenez Mazuecos, Pilar Carrillo Sáez, Alejandro Gutierez-Barrios, Eduardo Pinar, Belen Cid, Luis Fernandez, Tamara Garcia Camarero, Cristóbal Urbano-Carrillo, Juan F Oteo Dominguez, Victor A Jimenez Diaz, Antonio E. Gomez Menchero, Eladio Galindo Fernández, Juan G. Córdoba Soriano, Raymundo Ocaranza, Eduardo Arroyo Úcar, Koldobika Garcia San Roman, Silvio Leal, Ginés Martínez Cáceres, Jose A Linares Vicente, Georgina Fuertes Ferre, Xavier Carrillo, Juan C. Rama Merchán, Catia Costa, Juan Sanchis, Renato Fernandes, Alberto Rodrigues, Jose M Vegas Valle, Hélder Pereira, Armando Perez de Prado
2022, 19(5): 354-366. doi: 10.11909/j.issn.1671-5411.2022.05.009
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 OBJECTIVES  Elderly patients show a higher incidence of ischemic and bleeding events after percutaneous transluminal coronary intervention (PCI). We sought to investigate outcomes in elderly patients treated with antithrombotic strategy guided by bleeding and ischemic risks after revascularization with last generation everolimus-eluting stent (EES).  METHODS Prospective multicenter registry including patients over 75 years revascularized with EES and antithrombotic therapy guided by clinical presentation, PCI complexity and PRECISE DAPT score. Co-primary safety endpoints were: (1) composite of cardiac death, myocardial infarction and stent thrombosis and; (2) bleeding (BARC 2-5). Primary efficacy endpoint was target lesion revascularization. A matched group of patients revascularized with current drug-eluting stents and no such tailored antithrombotic therapy was used as control.  RESULTS Finally, 1064 patients were included in SIERRA-75 cohort, 80.8 ± 4.2 years, 36.6% women, 71% acute coronary syndromes (ACS) and 53.6% complex PCI. Co-primary safety endpoint of major adverse cardiovascular events was met in 6.2%, co-primary safety endpoint of bleeding in 7.8% and primary efficacy endpoint of TKLR in 1.5%. The multivariable adjusted model showed no significant association of the prescribed short/long dual antiplatelet therapy (DAPT) durations with any endpoint suggesting a well tailored therapy. No stent thrombosis reported in the subgroup with 1-3 months DAPT duration. As compared to control group, bleeding BARC 2-5 was significantly lower in SIERRA-75 group (7.4% vs. 10.2%, P = 0.04) as well as the net safety-efficacy endpoint (14.3% vs. 18.5%, P = 0.02).  CONCLUSIONS In elderly population, the application of this risks-adjusted antithrombotic protocol after revascularization with last generation EES seems to be associated with an improved prognosis in terms of ischemic and bleeding outcomes.
Using machine learning to aid treatment decision and risk assessment for severe three-vessel coronary artery disease
Jie LIU, Xin-Xing FENG, Yan-Feng DUAN, Jun-Hao LIU, Ce ZHANG, Lin JIANG, Lian-Jun XU, Jian TIAN, Xue-Yan ZHAO, Yin ZHANG, Kai SUN, Bo XU, Wei ZHAO, Ru-Tai HUI, Run-Lin GAO, Ji-Zheng WANG, Jin-Qing YUAN, Xin HUANG, Lei SONG
2022, 19(5): 367-376. doi: 10.11909/j.issn.1671-5411.2022.05.005
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 BACKGROUND Three-vessel disease (TVD) with a SYNergy between PCI with TAXus and cardiac surgery (SYNTAX) score of ≥ 23 is one of the most severe types of coronary artery disease. We aimed to take advantage of machine learning to help in decision-making and prognostic evaluation in such patients.  METHODS We analyzed 3786 patients who had TVD with a SYNTAX score of ≥ 23, had no history of previous revascularization, and underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) after enrollment. The patients were randomly assigned to a training group and testing group. The C4.5 decision tree algorithm was applied in the training group, and all-cause death after a median follow-up of 6.6 years was regarded as the class label.  RESULTS The decision tree algorithm selected age and left ventricular end-diastolic diameter (LVEDD) as splitting features and divided the patients into three subgroups: subgroup 1 (age of ≤ 67 years and LVEDD of ≤ 53 mm), subgroup 2 (age of ≤ 67 years and LVEDD of > 53 mm), and subgroup 3 (age of > 67 years). PCI conferred a patient survival benefit over CABG in subgroup 2. There was no significant difference in the risk of all-cause death between PCI and CABG in subgroup 1 and subgroup 3 in both the training data and testing data. Among the total study population, the multivariable analysis revealed significant differences in the risk of all-cause death among patients in three subgroups.  CONCLUSIONS The combination of age and LVEDD identified by machine learning can contribute to decision-making and risk assessment of death in patients with severe TVD. The present results suggest that PCI is a better choice for young patients with severe TVD characterized by left ventricular dilation.
REVIEW
Cardiovascular prevention in elderly patients
Clara Bonanad, Rosa Fernández-Olmo, Sergio García-Blas, Jose Antonio Alarcon, Pablo Díez-Villanueva, Carmen Rus Mansilla, Héctor García-Pardo, Pablo Toledo, Ana Ayesta, Eva Pereira, Antoni Carol, Almudena Castro-Conde, Carmen de Pablo-Zarzoso, Manuel Martínez-Sellés, Vicente Arrarte, Raquel Campuzano, Albert Ariza-Solé
2022, 19(5): 377-392. doi: 10.11909/j.issn.1671-5411.2022.05.004
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In recent decades, life expectancy has been increasing significantly. In this scenario, health interventions are necessary to improve prognosis and quality of life of elderly with cardiovascular risk factors and cardiovascular disease. However, the number of elderly patients included in clinical trials is low, thus current clinical practice guidelines do not include specific recommendations. This document aims to review prevention recommendations focused in patients ≥ 75 years with high or very high cardiovascular risk, regarding objectives, medical treatment options and also including physical exercise and their inclusion in cardiac rehabilitation programs. Also, we will show why geriatric syndromes such as frailty, dependence, cognitive impairment, and nutritional status, as well as comorbidities, ought to be considered in this population regarding their important prognostic impact.
LETTER TO THE EDITOR
Ventricular tachycardia induced by functional ventricular undersensing and AutoCapture®
Shing Ching, Chiu Sun Yue
2022, 19(5): 393-397. doi: 10.11909/j.issn.1671-5411.2022.05.002
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Multidisciplinary team management and long-term prognosis of an elderly patient with severe cardiac amyloidosis complicated with multiple myeloma
Zhi SHANG, Meng-Lin ZHAO, Xin-Yu WANG, Wei GAO
2022, 19(5): 398-402. doi: 10.11909/j.issn.1671-5411.2022.05.006
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Rapid progression of atherosclerosis in a patient with acute coronary syndrome and ANCA-associated vasculitis: split or confluence?
Ya-Chao LI, Meng-Jie LEI, Yan-Li YANG, Zeng-Ming XUE
2022, 19(5): 403-408. doi: 10.11909/j.issn.1671-5411.2022.05.008
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