Papers by Cristina Enjuanes
Pulmonary Valve Infective Endocarditis in an Adult Patient with Severe Congenital Pulmonary Stenosis
Copyright © 2010 Juan Lacalzada et al. This is an open access article distributed under the Creat... more Copyright © 2010 Juan Lacalzada et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A hypertensive 76-year-old man with severe pulmonary valve stenosis (PVS) and recent initiation of haemodialysis was referred with fever, chills, and asthenia. One month prior, he had been admitted with similar symptoms. Transthoracic echocardiography (TTE) had shown a PVS and no valve vegetations were observed. Following discharge, he was readmitted with fever and blood cultures positive for Staphylococcus haemolyticus. A new TTE revealed two pulmonary valve vegetations and a previously undetected ostium secundum-type atrial septal defect (ASD), confirmed by transesophageal echocardiography. The clinical course was uneventful with intravenous antibiotic treatment and the patient was safely discharged. This is a case of pulmonary val...
Journal of Clinical Medicine
Acute hyperglycemia has been associated with worse prognosis in patients hospitalized for heart f... more Acute hyperglycemia has been associated with worse prognosis in patients hospitalized for heart failure (HF). Nevertheless, studies evaluating the impact of glycemic control on long-term prognosis have shown conflicting results. Our aim was to assess the relationship between acute-to-chronic (A/C) glycemic ratio and 4-year mortality in a cohort of subjects hospitalized for acute HF. A total of 1062 subjects were consecutively included. We measured glycaemia at admission and estimated average chronic glucose levels and the A/C glycemic ratio were calculated. Subjects were stratified into groups according to the A/C glycemic ratio tertiles. The primary endpoint was 4-year mortality. Subjects with diabetes had higher risk for mortality compared to those without (HR 1.35 [95% CI: 1.10–1.65]; p = 0.004). A U-shape curve association was found between glucose at admission and mortality, with a HR of 1.60 [95% CI: 1.22–2.11]; p = 0.001, and a HR of 1.29 [95% CI: 0.97–1.70]; p = 0.078 for th...
European Heart Journal - Case Reports
Background Chronic heart failure (CHF) is a growing epidemic. The cornerstone of pharmacological ... more Background Chronic heart failure (CHF) is a growing epidemic. The cornerstone of pharmacological therapy in CHF patients with reduced ejection fraction (HFrEF) is the inhibition of the renin–angiotensin–aldosterone system (RAAS). One of the adverse effects of RAAS blockade is the development of hyperkalaemia, which often limits the optimization of recommended, Class I treatments. In this context, potassium binders patiromer or sodium zirconium cyclosilicate (ZS-9) provide an opportunity to optimize the pharmacological management of these patients. Case summary We present a case report illustrating our real-life experience using the potassium-binder patiromer in a patient with HFrEF, in whom recurrent hyperkalaemia (up to 6.3 mmol/L with low doses of enalapril) was preventing titration of RAAS inhibition therapies. Use of patiromer allowed re-introducing ramipril (subsequently switched to sacubitril/valsartan) and eplerenone. Serum potassium levels remained normal with patiromer 16.8...
Iron deficiency contributes to resistance to endogenous erythropoietin in anaemic heart failure patients
European Journal of Heart Failure
AIMS Abnormal endogenous erythropoietin (EPO) constitutes an important cause of anaemia in chroni... more AIMS Abnormal endogenous erythropoietin (EPO) constitutes an important cause of anaemia in chronic diseases. We analyzed the relationships between iron deficiency (ID) and the adequacy of endogenous EPO in anaemic heart failure (HF) patients, and the impact of abnormal EPO on a 12-month mortality. METHODS AND RESULTS We investigated 435 anaemic HF patients (age: 74±10 years; males: 60%; New York Heart Association class I or II: 39%; left ventricular ejection fraction [LVEF]: 43±17%). Patients with EPO higher than expected for a given haemoglobin were considered EPO-resistant whereas those with EPO lower than expected - EPO-deficient. ID was defined as serum ferritin <100 μg/L or 100-299 μg/L with transferrin saturation <20%. EPO-resistant patients (21%) had more advanced HF whereas those with EPO deficiency (57%) were more frequently females and had worse renal function. Lower serum ferritin (indicating depleted body iron stores) was related to higher EPO observed/predicted ratio when adjusted for significant clinical confounders, including C-reactive protein. One year all-cause mortality was 28% in patients with EPO resistance, compared to 17% in patients with EPO deficiency and 10% in patients with adequate EPO (log-rank test for the comparison EPO resistance vs. adequate EPO: p=0.02). When adjusted for other prognosticators, there was still a trend towards increased 12-month mortality in patients with higher EPO level. CONCLUSION Anaemic HF patients with endogenous EPO deficiency versus resistance have different clinical and laboratory characteristics. In such patients ID contributes to EPO resistance independently of inflammation.
Sympathetic activation and outcomes in chronic heart failure: Does the neurohormonal hypothesis apply to mid-range and preserved ejection fraction patients?
European Journal of Internal Medicine
Journal of the American Heart Association
Background-Mechanisms underlying iron homeostasis dysregulation in patients with chronic heart fa... more Background-Mechanisms underlying iron homeostasis dysregulation in patients with chronic heart failure remain unsettled. In cardiomyocyte models, norepinephrine may lead to intracellular iron depletion, but the potential association between catecholamines (sympathetic activation markers) and iron metabolism biomarkers in chronic heart failure is unknown. Methods and Results-In this cross-sectional analysis, we studied the association between plasma norepinephrine levels and serum iron status biomarkers indicating iron storage (ferritin), iron transport (transferrin saturation), and iron demand (soluble transferrin receptor) in a prospective cohort of 742 chronic heart failure patients (mean age, 72AE11 years; 56% male). Impaired iron status was defined as ferritin <100 lg/L or transferrin saturation <20%. Impaired iron status was observed in 69% of patients. In multivariate models, greater norepinephrine levels were associated with impaired iron transport (transferrin saturation <20%, odds ratio=2.28; 95% CI [1.19-4.35]; P=0.013), but not with impaired iron storage (ferritin <100 lg/L, odds ratio=1.25; 95% CI [0.73-2.16]; P=0.415). Norepinephrine was a significant predictor of increased iron demand (soluble transferrin receptor, standardized b-coefficient=0.12; P=0.006) and low transferrin saturation (standardized b-coefficient=À0.12; P=0.003). However, norepinephrine levels were not associated with iron or ferritin levels (P>0.05). Adjusted norepinephrine marginal means were significantly higher in patients with impaired iron status compared with those with normal iron status (528 pg/mL [505-551] versus 482 pg/mL [448-518], respectively; P=0.038). Conclusions-In chronic heart failure patients, increased sympathetic activation estimated with norepinephrine levels is associated with impaired iron status and, particularly, dysregulation of biomarkers suggesting impaired iron transport and increased iron demand. Whether the relationship between norepinephrine and iron metabolism is bidirectional and entails causality need to be elucidated in future research.
European Heart Journal, Aug 1, 2017
admission was 5.9%, the mean length of stay was 14.9 days, 60.6% of patients had a central line a... more admission was 5.9%, the mean length of stay was 14.9 days, 60.6% of patients had a central line access, 11.6% required hemodialysis, and 22.5% underwent valve repair or replacement. The top 3 causes for readmission were endocarditis (22.1%), sepsis with or without septic shock (8.7%), and acute congestive heart failure (8.1%). Almost 60% of patients were discharged to a nursing home or facility after the first hospital admission. Conclusion: Two weeks of hospitalization was the average length of stay for patients with infective endocarditis. A significant percentage of patients (17.7%) were readmitted within 30-days and a relapse or an unsuccessfully treated endocarditis was the most common cause for readmission. The elevated number of patient that were discharged to nursing home or a facility could be explained by the need of intravenous antibiotics. About 1 in every 5 patients required valve intervention.
The relationship between self-care, long-term mortality, and heart failure hospitalization: insights from a real-world cohort study
European Journal of Cardiovascular Nursing
Aims The assumption that improved self-care in the setting of heart failure (HF) care necessarily... more Aims The assumption that improved self-care in the setting of heart failure (HF) care necessarily translates into improvements in long-term mortality and/or hospitalization is not well established. We aimed to study the association between self-care and long-term mortality and other major adverse HF events (MAHFE). Methods and results We conducted an observational, prospective, cohort study of 1123 consecutive patients with chronic HF. The primary endpoint was all-cause mortality. We used the European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure global self-care (overall score) and three specific dimensions of self-care including autonomy-based adherence, consulting behaviour and provider-based adherence. After a mean follow-up of 3.3 years, all-cause death occurred in 487 patients (43%). In adjusted analysis, higher EHFScBS-9 scores (better self-care) at baseline were associated with lower risk of all-cause death [hazard ratio (HR) 0.993, 95% confid...
Effectiveness of telemedicine in patients with heart failure according to frailty phenotypes: Insights from the iCOR randomised controlled trial
European Journal of Internal Medicine
International Journal of Molecular Sciences
MicroRNAs (miRNAs) participate in atrial remodeling and atrial fibrillation (AF) promotion. We de... more MicroRNAs (miRNAs) participate in atrial remodeling and atrial fibrillation (AF) promotion. We determined the circulating miRNA profile in patients with AF and heart failure with reduced ejection fraction (HFrEF), and its potential role in promoting the arrhythmia. In plasma of 98 patients with HFrEF (49 with AF and 49 in sinus rhythm, SR), differential miRNA expression was determined by high-throughput microarray analysis followed by replication of selected candidates. Validated miRNAs were determined in human atrial samples, and potential arrhythmogenic mechanisms studied in HL-1 cells. Circulating miR-199a-5p and miR-22-5p were significantly increased in HFrEF patients with AF versus those with HFrEF in SR. Both miRNAs, but particularly miR-199a-5p, were increased in atrial samples of patients with AF. Overexpression of both miRNAs in HL-1 cells resulted in decreased protein levels of L-type Ca2+ channel, NCX and connexin-40, leading to lower basal intracellular Ca2+ levels, fewe...
Clinical Epidemiology
Background: The aims of the present analysis are to estimate the prevalence of five key chronic c... more Background: The aims of the present analysis are to estimate the prevalence of five key chronic cardiovascular, metabolic and renal conditions at the population level, the prevalence of renin-angiotensin-aldosterone system inhibitor (RAASI) medication use and the magnitude of potassium (K +) derangements among RAASI users. Methods and Results: We used data from more than 375,000 individuals, 55 years of age or older, included in the population-based healthcare database of the Catalan Institute of Health between 2015 and 2017. The conditions of interest were chronic heart failure (CHF), chronic kidney disease (CKD), diabetes mellitus, ischemic heart disease and hypertension. RAASI medications included angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs) and renin inhibitors. Hyperkalemia was defined as K + levels >5.0 mEq/L and hypokalemia as K + <3.5 mEq/L. The prevalence of chronic cardiovascular, metabolic and renal conditions was high, and particularly that of hypertension (prevalence ranging from 48.2% to 48.9%). The use of at least one RAASI medication was almost ubiquitous in these patients (75.2-77.3%). Among RAASI users, the frequency of K + derangements, mainly of hyperkalemia, was very noticeable (12% overall), particularly in patients with CKD or CHF, elderly individuals and users of MRAs. Hypokalemia was less frequent (1%). Conclusion: The high prevalence of K + derangements, and particularly hyperkalemia, among RAASI users highlights the real-world relevance of K + derangements, and the importance of close monitoring and management of K + levels in routine clinical practice. This is likely to benefit a large number of patients, particularly those at higher risk.
Journal of Clinical Medicine
Previous studies have shown that heart failure is associated with worse health-related quality of... more Previous studies have shown that heart failure is associated with worse health-related quality of life (HRQoL). The existence of differences according to gender remains controversial. We studied 1028 consecutive outpatients with heart failure and reduced ejection fraction (HFrEF) from a multicentre cross-sectional descriptive study across Spain that assessed HRQoL using two questionnaires (KCCQ, Kansas City Cardiomyopathy Questionnaire; and EQ-5D, EuroQoL 5 dimensions). The primary objective of the study was to describe differences in HRQoL between men and women in global scores and domains of health status of patients and explore gender differences and its interactions with heart failure related factors. In adjusted analysis women had lower scores in KCCQ overall summary scores when compared to men denoting worse HRQoL (54.7 ± 1.3 vs. 62.7 ± 0.8, p < 0.0001), and specifically got lower score in domains of symptom frequency, symptoms burden, physical limitation, quality of life a...
Impacto clínico y en costes sanitarios de alteraciones de potasio en pacientes con enfermedades cardiovasculares, metabólicas y renales crónicas
Revista Española de Cardiología
Study design of Heart failure Events reduction with Remote Monitoring and eHealth Support (HERMeS)
ESC Heart Failure
Journal of Clinical Medicine
The effects of iron deficiency (ID) have been widely studied in heart failure (HF) with reduced e... more The effects of iron deficiency (ID) have been widely studied in heart failure (HF) with reduced ejection fraction. On the other hand, studies in HF with preserved ejection fraction (HFpEF) are few and have included small numbers of participants. The aim of this study was to assess the role that ID plays in functional capacity and quality of life (QoL) in HFpEF while comparing several iron-related biomarkers to be used as potential predictors. ID was defined as ferritin <100 ng/mL or transferrin saturation <20%. Submaximal exercise capacity, measured by the 6-min walking test (6MWT), and QoL, assessed by the Minnesotta Living with Heart Failure Questionnaire (MLHFQ), were compared between iron deficient patients and patients with normal iron status. A total of 447 HFpEF patients were included in the present cross-sectional study, and ID prevalence was 73%. Patients with ID performed worse in the 6MWT compared to patients with normal iron status (ID 271 ± 94 m vs. non-ID 310 ± 1...
Journal of Telemedicine and Telecare
Background The efficacy of telemedicine in the management of patients with chronic heart failure ... more Background The efficacy of telemedicine in the management of patients with chronic heart failure and left ventricular ejection fraction ≥40% is poorly understood. The aim of our analysis was to evaluate the efficacy of a telemedicine-based intervention specifically in these patients, as compared to standard of care alone. Methods The Insuficiència Cardiaca Optimització Remota (iCOR) study was a single centre, randomised, controlled trial, designed to evaluate a telemedicine intervention added to an existing hospital/primary care multidisciplinary, integrated programme for chronic heart failure patients. 178 participants were randomised to telemedicine or usual care, and were followed for six months. For the present sub-analysis, only iCOR participants (n = 116) with left ventricular ejection fraction ≥40% were included. The primary study endpoint was the incidence of an acute non-fatal heart failure event, defined as a new episode of worsening of symptoms and signs consistent with a...
Nursing knowledge of the principles of self‐care of heart failure in primary care: a multicentre study
Scandinavian Journal of Caring Sciences
European Journal of Cardiovascular Nursing
Background Lack of achievement of secondary prevention objectives in patients with ischemic heart... more Background Lack of achievement of secondary prevention objectives in patients with ischemic heart disease (IHD) remains an unmet need in this patient population. Aims We aimed at evaluating the 6-month efficacy of an intensive lipid-lowering intervention, coordinated by nurses and implemented after hospital discharge, in patients hospitalized for an IHD event. Methods Pilot randomized controlled trial enrolling 78 patients (39 in each arm). A nurse-led intervention including follow-up, serial lipid level controls, and subsequent optimization of lipid-lowering therapy, was compared to standard of care in terms of serum lipid-level control at 6 months after discharge. Results The nurse-led intervention was associated with an improved management of LDL cholesterol levels compared to standard of care alone: LDL cholesterol levels ≤100 mg/dL were achieved in 97% participants in the intervention arm as compared to 67% in the standard care arm (p value <0.001), the LDL cholesterol ≤70 mg/dL target recommended by the 2016 European Society of Cardiology guidelines was achieved in 62% vs 37% participants (p value 0.047), and the LDL cholesterol reduction ≥50% recommended by the American College of Cardiology/American Heart Association in 2013 was achieved in 25.6% participants in the intervention arm as compared to 2.6% in the standard care arm (p value 0.007). The intervention was also associated with improved blood pressure control among individuals with hypertension. Conclusions Our findings highlight the opportunity that nurse-led, intensive, post-discharge follow-up plans may represent for achieving LDL cholesterol guideline-recommended objectives in patients with IHD. These findings should be replicated in larger cohorts.
Cardiovascular risk factors and disease among non-European immigrants living in Catalonia
Heart
ObjectiveTo describe the prevalence and incidence of cardiovascular risk factors, established car... more ObjectiveTo describe the prevalence and incidence of cardiovascular risk factors, established cardiovascular disease (CVD) and cardiovascular medication use, among immigrant individuals of diverse national origins living in Catalonia (Spain), a region receiving large groups of immigrants from all around the world, and with universal access to healthcare.MethodsWe conducted a population-based analysis including >6 million adult individuals living in Catalonia, using the local administrative healthcare databases. Immigrants were classified in 6 World Bank geographic areas: Latin America/Caribbean, North Africa/Middle East, sub-Saharan Africa, East Asia and South Asia. Prevalence calculations were set as of 31 December 2017.ResultsImmigrant groups were younger than the local population; despite this, the prevalence of CVD risk factors and of established CVD was very high in some immigrant subgroups compared with local individuals. South Asians had the highest prevalence of diabetes,...
The prognostic value of interleukin 6 in multiple chronic diseases and all-cause death: The Multi-Ethnic Study of Atherosclerosis (MESA)
Atherosclerosis
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Papers by Cristina Enjuanes