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MicroRNAs (miRNAs) are noncoding RNAs involved in post-transcriptional genetic regulation with a proposed role in intercellular communication. miRNAs are considered promising biomarkers in ischemic heart disease. Invasive physiological evaluation allows a precise assessment of each affected coronary compartment. Although some studies have associated the expression of circulating miRNAs with invasive physiological indexes, their global relationship with coronary compartments has not been assessed. Here, we will evaluate circulating miRNAs profiles according to the coronary pattern of the vascular compartment affectation. This is an investigator-initiated, multicentre, descriptive study to be conducted at three centres in Spain (NCT05374694). The study will include one hundred consecutive patients older than 18 years with chest pain of presumed coronary cause undergoing invasive physiological evaluation, including fractional flow reserve (FFR) and index of microvascular resistance (IMR). Patients will be initially classified into four groups, according to FFR and IMR: macrovascular and microvascular affectation (FFR≤0.80 / IMR≥25), isolated macrovascular affectation (FFR≤0.80 / IMR<25), isolated microvascular affectation (FFR>0.80 / IMR ≥25) and normal coronary indexes (FFR>0.80 / IMR<25). Patients with isolated microvascular affectation or normal indexes will also undergo the acetylcholine test and may be reclassified as a fifth group in the presence of spasm. A panel of miRNAs previously associated with molecular mechanisms linked to chronic coronary syndrome will be analysed using RT-qPCR. The results of this study will identify miRNA profiles associated with patterns of coronary affectation and will contribute to a better understanding of the mechanistic pathways of coronary pathology.

Background Despite its proven prognostic value in different contexts, the precise implications of left atrial strain (LAS) assessment throughout different phases of the atrial cycle remain uncertain. A direct correlation between left atrial reservoir strain (LARS) and left ventricular global longitudinal strain (GLS) has been consistently demonstrated in several studies involving patients with various heart diseases. The objective of our study is to identify factors directly associated with LARS, left atrial conduction strain (LACS) and left atrial booster strain (LABS) in patients without cardiovascular (CV) disease. Methods Transthoracic echocardiographic examinations in patients without CV disease were prospectively selected in two tertiary hospitals echocardiography labs for clinical purposes. LAS, maximal and minimal left atrial (LA) volumes and left atrial ejection fraction (LAEF) were measured using the two-dimensional strain analysis package provided by the EchoPAC Plugging workstation (AFI LA). Results A total of 196 cases were included, median age of 54 (45–62) with 85 (43%) being men. The mean left ventricular ejection fraction (LVEF) was 61% ± 5, and the median GLS was − 18% (-17 to -20). Median indexed maximum volume of left atrium (LAVI) was 27 ml/m 2 (22–31), and LAEF was 64% (58–70). The mean LARS biplane was 35,1% ± 8. Notably, LARS was greater in the 2-chamber view (36,1% ± 10) compared to the 4-chamber view (34,1% ± 8 p  < 0,05). The multivariate analysis of LARS revealed that sex, GLS, LAEF and e’ mean are independently correlated with LARS. Multivariate analysis of LACS showed independent correlations between LACS and age, GLS, LAEF, E/A ratio and e’ mean . Conversely, the multivariate analysis of LABS demonstrated significant correlations among A wave, e’ mean , and left atrial stiffness index (LASI). Conclusions In patients without CV disease, GLS emerges as a crucial determinant of LARS and LACS. LAEF and e’ mean are directly and independently related to both LARS and LACS. LARS (univariate) and LACS (multivariate) exhibited a decline with older age in individuals without CV disease.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of heart-failure admission among high-risk patients. However, most patients with valvular heart disease, including those undergoing transcatheter aortic-valve implantation (TAVI), have been excluded from randomized trials. We conducted this randomized, controlled trial in Spain to evaluate the efficacy of dapagliflozin (at a dose of 10 mg once daily) as compared with standard care alone in patients with aortic stenosis who were undergoing TAVI. All the patients had a history of heart failure plus at least one of the following: renal insufficiency, diabetes, or left ventricular systolic dysfunction. The primary outcome was a composite of death from any cause or worsening of heart failure, defined as hospitalization or an urgent visit, at 1 year of follow-up. A total of 620 patients were randomly assigned to receive dapagliflozin and 637 to receive standard care alone after TAVI; after exclusions, a total of 1222 patients were included in the primary analysis. A primary-outcome event occurred in 91 patients (15.0%) in the dapagliflozin group and in 124 patients (20.1%) in the standard-care group (hazard ratio, 0.72; 95% confidence interval [CI], 0.55 to 0.95; P = 0.02). Death from any cause occurred in 47 patients (7.8%) in the dapagliflozin group and in 55 (8.9%) in the standard-care group (hazard ratio, 0.87; 95% CI, 0.59 to 1.28). Worsening of heart failure occurred in 9.4% and 14.4% of the patients, respectively (subhazard ratio, 0.63; 95% CI, 0.45 to 0.88). Genital infection and hypotension were significantly more common in the dapagliflozin group. Among older adults with aortic stenosis undergoing TAVI who were at high risk for heart-failure events, dapagliflozin resulted in a significantly lower incidence of death from any cause or worsening of heart failure than standard care alone. (Funded by Instituto de Salud Carlos III and others; ClinicalTrials.gov number, NCT04696185.).

Background Prosthetic valve dysfunction due to entrapment of the subvalvular apparatus is a rare condition, particularly when occurring as a delayed postoperative complication. Spontaneous papillary muscle rupture in the absence of an ischemic event is also uncommon. The simultaneous presence of both conditions renders this case of intermittent symptomatic mitral regurgitation exceptional. Case presentation We present the case of a 72-year-old woman with a history of rheumatic heart disease and a mechanical mitral valve prosthesis. Although the initial postoperative course was uneventful, she developed rapidly progressive heart failure symptoms two years after surgery, secondary to newly onset severe mitral regurgitation. Transesophageal echocardiography was crucial in elucidating the underlying mechanism, revealing a ventricular mass intermittently interfering with the proper closure of the mechanical prosthesis. The main differential diagnoses regarding the origin of the mass included: remnants of the subvalvular apparatus, vegetation, thrombotic material and pannus formation. Given the clinical deterioration, surgical intervention was considered necessary despite the lack of precise knowledge regarding the nature of mass. Surgical exploration confirmed the rupture of the subvalvular apparatus involving the anterolateral papillary muscle as the underlying cause of the prosthetic dysfunction. Excision of the ruptured chordae tendineae and residual papillary muscle was performed with a favorable outcome and no complications. Conclusions This case illustrates a rare cause of late prosthetic mitral valve dysfunction: the entrapment of the subvalvular apparatus due to spontaneous rupture of the papillary muscle. Transesophageal echocardiography proved highly valuable in understanding the mechanism of dysfunction; however, surgical exploration ultimately established the definitive diagnosis and facilitated the correction of the issue.

Objectives. The aim of this study is to assess the utility of optical coherence tomography (OCT) in patients with exercise-related acute coronary syndrome (ACS) presenting with inconclusive angiographic findings. Background. Regular physical activity reduces the incidence of cardiovascular events. Nevertheless, the risk of ACS or sudden cardiac death (SCD) increases during sport. In adults older than 35 years, exercise-related ACS or SCD is associated with plaque rupture, but not infrequently patients present ambiguous angiographic findings. Methods. Between September 2015 and January 2020, patients admitted for ACS or SCD triggered by physical exertion and with coronary stenosis ≤50% were included in this prospective observational study. OCT was performed on the artery deemed to be responsible of the event. Results. Ten patients were enrolled, predominantly men (80%) of middle age (51 years old, IQR 41–63) with low cardiovascular risk burden. Cycling was the most frequent (50%) exercise-related trigger, 8 patients were regular sport practitioners, and 7 had the clinical event during strenuous exertion. Five patients presented with non-ST-elevation ACS, two with ST-elevation ACS, and three with SCD. Angiographic analysis showed nonsignificant stenosis in all patients (42% stenosis, IQR 36–46). OCT identified the etiology of the event in 9 patients (4 plaque erosion, 3 plaque rupture, 1 eruptive calcific nodule, and 1 coronary dissection). Treatment was adjusted according to OCT findings. Conclusions. OCT is a valuable technique to identify the etiology of exercise-related ACS or SCD in patients with nonobstructive coronary arteries and, as a result, may lead to a more specific treatment.

Patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) without myocardial infarction (MI) or stroke are at high risk for major cardiovascular events (MACEs). We aimed to provide real-world data on age-related clinical characteristics, treatment management, and incidence of major cardiovascular outcomes in T2DM-CAD patients in Spain from 2014 to 2018. We used EHRead® technology, which is based on natural language processing and machine learning, to extract unstructured clinical information from electronic health records (EHRs) from 12 hospitals. Of the 4072 included patients, 30.9% were younger than 65 years (66.3% male), 34.2% were aged 65–75 years (66.4% male), and 34.8% were older than 75 years (54.3% male). These older patients were more likely to have hypertension (OR 2.85), angina (OR 1.64), heart valve disease (OR 2.13), or peripheral vascular disease (OR 2.38) than those aged <65 years (p < 0.001 for all comparisons). In general, they were also more likely to receive pharmacological and interventional treatments. Moreover, these patients had a significantly higher risk of MACEs (HR 1.29; p = 0.003) and ischemic stroke (HR 2.39; p < 0.001). In summary, patients with T2DM-CAD in routine clinical practice tend to be older, have more comorbidities, are more heavily treated, and have a higher risk of developing MACE than is commonly assumed from clinical trial data.

Introduction Sacubitril/valsartan (S–V) has been shown to reduce clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This benefit has been mostly attributed to an improvement in systolic function. Aim This study aimed to evaluate longitudinal changes in several echocardiographic parameters of diastolic function in a cohort of patients with HFrEF receiving S–V. Methods Echocardiographic parameters of consecutive patients receiving S–V, such as diastolic dysfunction (DD) grade and other individual diastolic and systolic function parameters, were prospectively collected at baseline and at 6-month follow-up. New York Heart Association (NYHA) functional class was also recorded. Results 65 patients (73.9% males; 61.5 ± 13 years) with HFrEF in NYHA class II–IV were evaluated. There was a significant reduction in DD grade after treatment with maximal tolerated doses ( p  < 0.001). Patients with advanced DD showed the most significant improvements: 75% and 60% of patients with initial grade 3 and 2, respectively, had better grade after 6 months of S–V. Moreover, there was a reduction in E/e′ ratio ( p  = 0.004), left atrial longitudinal strain ( p  = 0.002), and an improvement of left ventricle ejection fraction ( p  < 0.001) and NYHA functional class ( p  = 0.001). Among those subjects who improved their functional class, a higher percentage improved their DD grade (39.3%, p  = 0.025) in comparison with those not improving their NYHA class (25%, p  = 0.434). Conclusions In addition to an improvement in systolic function parameters, patients with HFrEF receiving S–V improved their diastolic function. This echocardiographic improvement is particularly relevant in those patients with better NYHA class at 6-month follow-up.

Patients with Type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) are at high risk of developing major adverse cardiovascular events (MACE). This is a multicenter, retrospective, and observational study performed in Spain aimed to characterize these patients in a real-world setting. Unstructured data from the Electronic Health Records were extracted by EHRead®, a technology based on Natural Language Processing and machine learning. The association between new MACE and the variables of interest were investigated by univariable and multivariable analyses. From a source population of 2,184,662 patients, we identified 4072 adults diagnosed with T2DM and CAD (62.2% male, mean age 70 ± 11). The main comorbidities observed included arterial hypertension, hyperlipidemia, and obesity, with metformin and statins being the treatments most frequently prescribed. MACE development was associated with multivessel (Hazard Ratio (HR) = 2.49) and single coronary vessel disease (HR = 1.71), transient ischemic attack (HR = 2.01), heart failure (HR = 1.32), insulin treatment (HR = 1.40), and percutaneous coronary intervention (PCI) (HR = 2.27), whilst statins (HR = 0.73) were associated with a lower risk of MACE occurrence. In conclusion, we found six risk factors associated with the development of MACE which were related with cardiovascular diseases and T2DM severity, and treatment with statins was identified as a protective factor for new MACE in this study.