Maria Melendo-Viu

BACKGROUND: Effective risk communication is essential in managing cardiovascular disease, the leading cause of global mortality. Clear communication between patients and physicians supports informed decision-making, yet comprehension gaps persist. We aimed to assess the quality of risk communication during hospital admissions for cardiovascular events, from patient and physician perspectives, and identify discrepancies in risk perception and associated factors. METHODS: The HARIPA study (Heart Risk Perception and Communication Inpatient) by the Spanish Society of Cardiology was a multicenter, cross-sectional analysis conducted in 28 hospitals across Spain from October 2022 to March 2023. It included consecutive cardiology inpatients (urgent or scheduled), aged ≥18 years, who could complete structured questionnaires. Participating physicians also completed parallel questionnaires. These assessed admission diagnosis, perceptions of future cardiovascular risk, and communication about potential procedural complications. Agreement between responses was evaluated using kappa indices (weighted for ordinal variables), and multivariable logistic regression was used to examine the impact of demographic and clinical factors (odds ratios with 95% CIs). RESULTS: We included 943 patients (mean age, 68.2 years; 29.4% women). The most frequent reason for admission was ischemic heart disease (41.3%). Responses resulted in a substantial agreement, with a kappa index of 0.72. Concordance between patients and physicians regarding future cardiovascular risk was low (weighted kappa: 0.29), with patients often underestimating their risk. And for assessment about procedural potential complications was moderate (kappa: 0.34). Although 76.9% of patients reported feeling adequately informed about procedural risks, 69.3% of those who experienced complications (n=208) stated they had not been warned about them. CONCLUSIONS: This study reveals significant gaps in risk communication in cardiovascular care, particularly regarding future risks and complications. As well-informed patients are more likely to adhere to preventive therapies, tailoring communication strategies to individual patient characteristics could improve understanding and align perceptions with clinical realities, enhancing health outcomes.

Background: Effective risk communication is crucial for managing cardiovascular disease, the leading cause of global mortality. Clear communication between patients and physicians is essential for informed decision-making, yet gaps in understanding often persist. Objective: This study examines the state of risk communication during hospital admissions for cardiovascular events, evaluating both patient and physician perspectives and identifying factors influencing risk perception. Methods: The SEC-HARIPA study is a multicenter, cross-sectional analysis conducted across 28 Spanish centers from October 2022 to March 2023. It included 943 patients admitted to cardiology departments, either urgently or for scheduled procedures. Patients and their physicians completed parallel questionnaires assessing perceptions of cardiovascular risk, procedural complications, and overall communication. Statistical analysis focused on agreement between patient and physician perceptions and the impact of demographic and clinical variables. Results: The mean age of participants was 68.2 years, with ischemic heart disease being the most common cause of admission (41.3%). While 76.9% of patients felt adequately informed about procedural risks, 69.3% of those experiencing adverse events reported a lack of information on potential complications. A significant discrepancy was found between patients’ and physicians’ perceptions of future cardiovascular risk, with patients often underestimating their risk (weighted kappa index of 0.29). Key factors influencing risk perception included prior cardiovascular history, age, gender, and diabetes mellitus. Conclusions: This study reveals significant gaps in risk communication in cardiovascular care, particularly regarding future risks and complications. Tailoring communication strategies to individual patient characteristics could improve understanding and align perceptions with clinical realities, enhancing health outcomes.

Background: Hypertrophic cardiomyopathy (HCM) is an inherited disorder whose causal variants involve sarcomeric protein genes. One of these is myosin-binding protein C (MYBPC3), being previously associated with a favourable prognosis. Our objective is to describe the clinical characteristics and events of a molecularly homogeneous HCM cohort associated with truncating MYBPC3 variants. Methods and results: A cohort of patients and relatives with HCM diagnosis and carrying a truncating MYBPC3 variant were retrospectively recruited. Subjects had an average follow-up of 7.77 years, with an incident HCM phenotype of 10%. They were middle-aged adult patients (47±16.8 years) without significant comorbidities or symptoms. Hypertrophy was discrete with a significative difference between probands and relatives (17.5±4 mm vs 14.6±5 mm; pMYBPC3 truncating variants. Patients showed a good prognosis with a low event rate. In our cohort, major arrhythmic events were not related to measured environmental or genetic factors.

Cirrhosis is a chronic disease with multiple etiologies, multiple manifestations, and multi-organ involvement. Affects about 200 million people worldwide. Its main complication is Portal hypertension (PHT). Cirrhotic cardiomyopathy is a consequence of PHT, with heart failure (HF) being the main manifestation. On the other hand, for people with cardiopathy due to other reasons beyond cirrhosis, the presence of the last could act as a trigger to acute HF. Finally, when HF and cirrhosis coexist, the renal system suffers the most, originating from type-5 cardio-renal syndrome, a complex entity with many challenges in diagnosis and treatment. This entity was recently defined and there is a lack of data on the epidemiology of this syndrome. A 77-year-old woman, with cardiovascular risk factors; heart failure with reduced ejection fraction (HFrEF), secondary ischemic and valvular cardiopathy, chronic Kidney disease (CKD), and stable decompensated cirrhosis, went to the emergency department after progressive abdominal perimeter augmentation, legs’ edema and hematochezia. It was assumed acute decompensated cirrhosis and acute decompensated chronic kidney disease, had triggered digestive bleeding and the patient stayed hospitalized. Intravenous diuretic therapy was started but, the ascites and kidney function got worse, the Nt pro-BNP grew until 1125000 pg/ml, and a transthoracic echocardiography showed important signs of congestion, isolated right ventricular dysfunction, with normal cardiac output. After teamwork’s discussion, a type-5 cardio-renal syndrome was assumed deciding not to act on tricuspid regurgitation due to the maladaptive RV remodeling. Hepatorenal syndrome treatment was begun (oral terlipressin and intravenous albumin), followed by decongestion therapy, resulting in a marked improvement in clinical presentation. The kidney, heart, and liver recovered to these basal states. With this clinical case, the authors want to show how multidisciplinary management is important to face tricuspid regurgitation and right ventricular dysfunction.

Advanced heart failure is a growing problem for which the best treatment is cardiac transplantation. However, the shortage of donors’ hearts made left ventricular assist devices as destination therapy (DT-LVAD) a highly recommended alternative: they improved mid-term prognosis as well as patients’ quality of life. Current intracorporeal pumps with a centrifugal continuous flow evolved in the last few years. Since 2003, when first LVAD was approved for long-term support, smaller device sizes with better survival and hemocompatibility profile were reached. The most important difficulty lies in the moment of the implant. Recent indications range from INTERMACS class 2 to 4, with close monitoring in intermediate cases. Moreover, a large multiparametric study is needed for considering the candidacy: basal situation, with a special interest in frailty, comorbidities, including renal and hepatic dysfunction, and medical background, considering every prior cardiac condition, must be evaluated. In addition, some clinical risk scores can be helpful to measure the possibility of right heart failure or morbi-mortality. With this review, we sought to summarize all the device improvements, with their updated clinical results, as well as to focus on all the patient selection criteria.

Aim: Patients with advanced heart failure (AHF) who are not candidates to advanced therapies have poor prognosis. Some trials have shown that intermittent levosimendan can reduce HF hospitalizations in AHF in the short term. In this real-life registry, we describe the patterns of use, safety and factors related to the response to intermittent levosimendan infusions in AHF patients not candidates to advanced therapies. Methods and results: Multicentre retrospective study of patients diagnosed with advanced heart failure, not HT or LVAD candidates. Patients needed to be on the optimal medical therapy according to their treating physician. Patients with de novo heart failure or who underwent any procedure that could improve prognosis were not included in the registry. Four hundred three patients were included; 77.9% needed at least one admission the year before levosimendan was first administered because of heart failure. Death rate at 1 year was 26.8% and median survival was 24.7 [95% CI: 20.4–26.9] months, and 43.7% of patients fulfilled the criteria for being considered a responder lo levosimendan (no death, heart failure admission or unplanned HF visit at 1 year after first levosimendan administration). Compared with the year before there was a significant reduction in HF admissions (38.7% vs. 77.9%; P < 0.0001), unplanned HF visits (22.7% vs. 43.7%; P < 0.0001) or the combined event including deaths (56.3% vs. 81.4%; P < 0.0001) during the year after. We created a score that helps predicting the responder status at 1 year after levosimendan, resulting in a score summatory of five variables: TEER (+2), treatment with beta-blockers (+1.5), Haemoglobin >12 g/dL (+1.5), amiodarone use (−1.5) HF visit 1 year before levosimendan (−1.5) and heart rate >70 b.p.m. (−2). Patients with a score less than −1 had a very low probability of response (21.5% free of death or HF event at 1 year) meanwhile those with a score over 1.5 had the better chance of response (68.4% free of death or HF event at 1 year). LEVO-D score performed well in the ROC analysis. Conclusion: In this large real-life series of AHF patients treated with levosimendan as destination therapy, we show a significant decrease of heart failure events during the year after the first administration. The simple LEVO-D Score could be of help when deciding about futile therapy in this population.

Background: Direct oral anticoagulants (DOACs) are presented as a good option for older patients owing to their safety profile. However, the dosing can become challenging especially in this population. Objective: Our aim is to evaluate the predictors of inappropriate dosing of DOACs. Methods: The authors analyzed the use of DOACs in 726 patients aged ≥90 years with a diagnosis of atrial fibrillation (AF) from a retrospective multicenter registry from 3 health areas in Spain. We studied the dosing, differentiating between appropriate dose, underdosing or overdosing. To evaluate the best predictive model, the Akaike information criterion (AIC) was used. Results: Follow-up was 27.7±18.3 months. Mean age was 93.0±5.2 years, and 60.1% of patients were female. 339 patients received rivaroxaban (47.3%), 237 apixaban (33.1%), 105 dabigatran (14.7%) and 35 edoxaban (4.9%). An important proportion of patients received a suboptimal dose (41.5%, n=297): 35.3% underdosed and 6.1% overdosed. The rate of suboptimal dosing was higher for apixaban and lower for dabigatran (Figure 1A). In our registry we found as a predictors of inappropriate dosing: kidney function (Chronic Kidney Disease Epidemiology Collaboration), odds Ratio (OR) 1.04; 95% CI: 1.03–1.05, P<0.001; weight measured in kilograms, OR 1.04; 95% CI: 1.01–1.07, P=0.012; and high blood pressure (HBP), OR 1.61; 95% CI: 1.02–2.53, P=0.041 (Figure 1B). Other variables such as HASBLED, CHADSVASc, anemia, prior bleeding, or concomitant use of antiplatelet therapy, were not significantly associated. Conclusions: We want to highlight that the use of an inappropriate dose of DOAC in older patients is common, about 40% in our study. Apixaban was the most frequently underdosed DOAC. HBP, weight, and kidney function were associated with an inappropriate dosing prescription. Therefore, it is important to carefully evaluate the characteristics of the patient to prescribe the appropriate dose that guarantees a correct action. Funding Acknowledgement: Type of funding sources: None. Dosing of DOACsPredictors of inappropriate dosing