Showing papers by "José Luis Zamorano published in 2010"

Guidelines for the management of atrial fibrillation

Abstract: Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A large number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The experts of the writing panels have provided disclosure statements of all relationships they may have that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report received its entire financial support from …

Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009)

Abstract: Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009).

Recommendations for the practice of echocardiography in infective endocarditis

Abstract: Echocardiography plays a key role in the assessment of infective endocarditis (IE). It is useful for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short- and long-term prognosis, the prediction of embolic events, and the follow-up of patients under specific antibiotic therapy. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical therapy is considered. Finally, intraoperative echocardiography must be performed in IE to help the surgeon in the assessment and management of patients with IE during surgery. The current ‘recommendations for the practice of echocardiography in infective endocarditis’ aims to provide both an updated summary concerning the value and limitations of echocardiography in

Echocardiography in aortic diseases: EAE recommendations for clinical practice

Abstract: Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Evaluation of the aorta is a routine part of the standard echocardiographic examination. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly the aortic root and proximal ascending aorta. Transoesophageal echocardiography (TOE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TOE should be used in a complementary manner. Echocardiography is useful for assessing aortic size, biophysical properties, and atherosclerotic involvement of the thoracic aorta. Although TOE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade, and left ventricular function can be easily visualized by TTE. However, a negative TTE does not rule out aortic dissection and other imaging techniques must be considered. TOE should define entry tear location, mechanisms and severity of aortic regurgitation, and true lumen compression. In addition, echocardiography is essential in selecting and monitoring surgical and endovascular treatment and in detecting possible complications. Although other imaging techniques such as computed tomography and magnetic resonance have a greater field of view and may yield complementary information, echocardiography is portable, rapid, accurate, and cost-effective in the diagnosis and follow-up of most aortic diseases.

Assessment of gastrointestinal and cardiovascular risk in patients with osteoarthritis who require NSAIDs: the LOGICA study

Abstract: Background Medical management of adults with osteoarthritis (OA) who require non-steroidal anti-inflammatory drugs (NSAIDs) must be decided after assessing prevalent gastrointestinal (GI) and cardiovascular (CV) risks in the individual patient. Objective To evaluate the GI and CV risk profile of patients with OA who require NSAIDs. Methods A transversal, multicentre and observational study was conducted in consecutive patients with OA who were considered candidates for NSAID treatment and were visited by 374 unselected rheumatologists throughout the National Health System. Patients were classified into three risk groups (low, moderate and high) for their GI and CV characteristics. These were defined by considering the presence of a number of well-established GI risk factors or by application of the Systematic Coronary Risk Evaluation model for assessing the overall risk for CV disease, respectively. Results Of 3293 consecutive patients, most (86.6%) were at increased GI risk and a considerable number, 22.3%, were at high GI risk. The CV risk was high in 44.2% of patients, moderate in 28.5% and low in 27.3%. Overall, 15.5% of patients presented a very high-risk profile, having high GI and CV risks. The type of NSAID prescription was similar regardless of the associated GI and CV risk profile. Conclusion Most patients with OA requiring NSAIDs for pain control showed a high prevalence of GI and CV risk factors. Over half of the patients were at either high GI or CV risk, or both, such that the prescription of OA treatments should be very carefully considered.

Unicuspid aortic valve in adults: a systematic review.

Abstract: BACKGROUND AND AIM OF THE STUDY: The natural history of the unicuspid aortic valve (UAV) is poorly described in the literature. In order to study the association between UAV with any other cardiac or extra cardiac abnormalities, an evidence-based systematic review was carried out. METHODS: A computerized search was carried out of the medical literature published between 1st January 1966 and 1st September 2008 of the following databases: MEDLINE; EMBASE; Web of Science; and the Cochrane Database. RESULTS: A total of 231 cases of adult UAV was identified in 38 articles. The mean patient age was 42 years, and the most common presenting symptoms reported (in 52 cases) included dyspnea (44%; n=23), angina (21%; n=11), and dizziness or syncope (8%; n=4). The most common lesion in UAV was isolated aortic stenosis (AS) (41%; n=95) and AS with or without aortic regurgitation (28%; n=64). The preoperative diagnosis of UAV is rare, and 139 cases (60%) of UAV were reported at autopsy or by examination of surgically excised valves. Aortic valve replacement was performed in 166 cases (82%). Concomitant aortic surgery was performed in 47 of the UAV cases (23%), either for a dilated or aneurysmal aorta. CONCLUSION: UAV shares many of the features of bicuspid aortic valve, including valvular dysfunction, aortic dilatation, aortic dissection, and dystrophic calcification, although these conditions develop at an earlier age and progress at a faster pace in UAV. Further investigations are warranted regarding the possibility of a familial incidence, associated histopathological changes in the aorta, preoperative diagnostic tools, ideal follow up and surgical intervention.

Adverse drug reactions in internal medicine units and associated risk factors

Abstract: This study was designed to assess the prevalence of adverse drug reactions (ADRs) in the internal medicine wards of two teaching Hospitals, identify the most common ADRs, the principal medications involved, and determine the risk factors implicated in the occurrence of such ADRs. All admissions over 10 weeks were followed prospectively using an intensive drug surveillance method to identify ADRs. Clinical laboratory data, the drug prescribed, and ADRs were taken into consideration. Status of nutrition, liver and kidney function at admission, and ADR time were determined. In order to assess drug interactions a software package was used. A total of 405 patients were evaluated, 126 patients (31%) had 128 ADRs, 122 ADRs occurred during hospitalization. Two ADR-related deaths were observed during the study. Reactions affecting the gastrointestinal tract, skin, and hematological system were among the most frequent ADRs. For ADRs observed during admission predictors of its occurrence in a multivariate regression model were: OR (95% CI); more than 12 days’ hospitalization: 2.11(1.27–3.47), any drug interaction: 9.33 (5.12–17) and acute change in estimated glomerular filtration rate over admission >20%: 2.46 (1.45–4.2). Worsening of renal function or drug interaction was observed in nine of the ten ADRs. Age, sex, nutrition, and number of drugs used were not related to ADRs. A significant prevalence of ADRs was found among hospitalized patients. Duration of hospital admission, changes in renal status during hospitalization and drug interactions seem to be important risk factors for ADRs.

The Freedom SOLO valve for aortic valve replacement: clinical and hemodynamic results from a prospective multicenter trial.

Abstract: BACKGROUND AND AIM OF THE STUDY The study aim was to investigate the early results, hemodynamics and left ventricular remodeling after aortic valve replacement (AVR) with the Freedom SOLO valve, a bovine pericardial valve bioprosthesis, using a single running suture line in a supra-annular position. METHODS Between July 2004 and September 2006, a total of 256 patients (116 males; 140 females; mean age 74.5 +/- 6.4 years; range: 41-89 years) who underwent AVR with the Freedom SOLO valve in nine European institutions were enrolled in the study. The indications for AVR were stenosis in 182 patients, regurgitation in 15, and combined in 57. Preoperatively, 37%, 59% and 4% of the patients were in NYHA classes I-II, III, and IV, respectively. Concomitant procedures were performed in 91 patients (36%). A patient subgroup underwent echocardiography preoperatively (n=192), and at one (n=194) and 12 (n=165) months postoperatively. RESULTS The early mortality was 2.3% (n=6). There were 18 late deaths (6.2%/pt-yr). After 12 months, 82% of the patients were in NYHA class I-II. Linearized rates were 0.69%/pt-yr for bleeding, 0.34%/pt-yr for thromboembolism, 0.0%/pt-yr for structural degeneration and thrombosis, 1.37%/pt-yr for paravalvular leak, and 2.06%/pt-yr for endocarditis. Five patients required reoperation. Twelve-month transprosthetic regurgitation was graded as absent in 92% of cases. The mean gradient was 42.3 +/- 20.2 mmHg preoperatively, 6.5 +/- 3.8 mmHg at one month, and 6.7 +/- 4.1 mmHg at 12 months. The effective orifice area was improved from 0.78 +/- 0.35 cm2 preoperatively to 1.90 +/- 0.56 cm2 at one month and 1.89 +/- 0.56 cm2 at 12 months. The left ventricular mass was decreased by 23%, from 217.8 +/- 77.2 g/m2 preoperatively to 167.4 +/- 68.2 g/m2 at one year. The mean left ventricular ejection fraction was 65.5 +/- 14.2% preoperatively, and 64.5 +/- 12.5% and 66.0 +/- 10.6% at one month and at 12 months, respectively. CONCLUSION The data obtained suggest that the Freedom SOLO stentless bioprosthesis shows excellent early clinical and hemodynamic results, resulting in a significant regression of left ventricular hypertrophy and improvement in left ventricular systolic function.

Recommendations for reporting perioperative transoesophageal echo studies

Abstract: Every perioperative transoesophageal echo (TEE) study should generate a written report. A verbal report may be given at the time of the study. Important findings must be included in the written report. Where the perioperative TEE findings are new, or have led to a change in operative surgery, postoperative care or in prognosis, it is essential that this information should be reported in writing and available as soon as possible after surgery. The ultrasound technology and methodology used to assess valve pathology, ventricular performance and any other derived information should be included to support any conclusions. This is particularly important in the case of new or unexpected findings. Particular attention should be attached to the echo findings following the completion of surgery. Every written report should include a written conclusion, which should be comprehensible to physicians who are not experts in echocardiography.

Real-Time Three-Dimensional Transesophageal Echocardiography

Abstract: In the 1970s, pioneers explored the esophagus with ultrasound in patients with chronic lung disease They obtained M-Mode recordings of the left ventricle, the aortic root, the mitral valve, and the left atrium In 18 of 38 patients examined, recordings were of sufficient quality to allow precise measurements of linear dimensions1 Thirty years later, transesophageal echocardiography has become an essential diagnostic tool and has contributed to the understanding of the pathology, clinical diagnosis, management, and prognosis of many cardiovascular conditions such as aortic dissection, mitral valve disease, and ischemic stroke2, 3 Transesophageal echocardiography provides, along with excellent spatial resolution, the possibility of obtaining views of anatomical structures of the heart that are not accessible by a transthoracic approach For example, in the horizontal long axis view of the right cardiac chambers, we can visualize the opening of the caval veins in the right atrium It was in the operating room and in the interventional lab where the development of three-dimensional capabilities for transesophageal imaging was carried out The consolidation and expansion of reparative mitral valve surgery in patients with prolapse led to the involvement of top surgical and imaging groups to detail the anatomy of mitral prolapse using cardiac ultrasound4 Three-dimensional transesophageal echocardiography allows the operator to move from the practice of imagining the stereoscopic appearance of the mitral valve (largely based on his/her experience and skill) to visualizing the valve in its correct anatomical orientation (the so-called surgeon’s view), providing newer, realistic views As our approach with mitral valve prolapse and cardiac surgery, one can do the same with interventional cardiology and percutaneous procedures: ostium secundum atrial septal defect closure, partial or total periprosthetic leak closure, transcatheter aortic prosthesis implant, mitral clips, and left atrial appendage closure

Echocardiography: guidance during valve implantation.

Abstract: Transcatheter aortic valve implantation (TAVI) by percutaneous or transapical aproach has emerged as an effective and less-invasive treatment for patients with severe symptomatic aortic valve stenosis and high surgical risk. Echocardiography is a fundamental tool in patients’ selection for TAVI, for guiding the intervention as well as evaluating the position, deployment and function of the prosthesis. This review describes the role of echocardiography during the intervention, in procedure guidance and in the assessment of complications.

Effect of the long-term administration of nebivolol on clinical symptoms, exercise capacity and left ventricular function in patients with heart failure and preserved left ventricular ejection fraction: background, aims and design of the ELANDD study

Abstract: The SENIORS trial demonstrated that nebivolol has beneficial effects in patients with heart failure. However, the role of beta-blocker therapy in patients with heart failure and preserved left ventricular ejection fraction (HFPEF) is still unsettled. To assess the long-term effects of administration of nebivolol, compared to placebo, on the clinical symptoms, exercise capacity and parameters of left ventricular (LV) function in patients with HFPEF. The Effect of Long-term Administration of Nebivolol on clinical symptoms, exercise capacity and left ventricular function in patients with Diastolic Dysfunction (ELANDD) study is a prospective multicenter European trial in 120 patients with HFPEF randomised to nebivolol or placebo. HFPEF is defined as symptoms or signs of heart failure, a LV ejection fraction >45% and evidence of diastolic LV dysfunction by Doppler echocardiography. Procedures include a baseline clinical examination, 6-min walk test (6MWT), electrocardiography, Doppler echocardiography and Minnesota QoL questionnaire. Nebivolol or placebo is started at 2.5 mg/day and gradually uptitrated to 10 mg/day. After initiation of the study, patients are assessed at 1, 2, 5 and 6 weeks (titration phase) and at weeks 12 and 26. The primary endpoint is the change from baseline in the 6MWT distance with nebivolol versus placebo. Sample size calculations are based on an anticipated 15% difference (70 m) in the 6MWT distance between nebivolol and placebo-treated patients. This study will allow the collection of data regarding the possible clinical benefits and the effects on LV function of nebivolol administration in patients with HFPEF.

Collateral Circulation From the Conus Coronary Artery to the Anterior Descending Coronary Artery: Assessment Using Multislice Coronary Computed Tomography

Abstract: The prognosis of patients with coronary artery disease largely depends on the presence of a collateral circulation. The location and extent of the collateral circulation is highly variable and these parameters determine whether or not ischemic symptoms occur and whether left ventricular contractility is abnormal. The collateral circulation is generally established through small-caliber distal vessels, although many different forms have been described. We report on three patients with severe left coronary artery disease and collateral circulation through a large conus coronary artery that joined a proximal or medial segment of the left anterior descending coronary artery. In all three cases, left ventricular function was preserved.

Supervisión con ecocardiografía 3D en tiempo real intraoperatoria de la implantación de prótesis valvular aórtica por vía transapical

Abstract: La estenosis aortica degenerativa es la valvulopatia mas frecuente en Europa. En pacientes sintomaticos, la sustitucion valvular aortica por una protesis mejora su pronostico. Un elevado porcentaje de candidatos a cirugia de reemplazo valvular son desestimados por elevado riesgo de complicaciones graves. En los ultimos anos, se han desarrollado tecnicas percutaneas o quirurgicas minimamente invasivas de implantacion de protesis valvular aortica transcateter (PATC), que persiguen elevar la tasa de intervencion en pacientes de alto riesgo manteniendo los beneficios en el pronostico y disminuyendo las complicaciones. Describimos el protocolo de supervision intraoperatoria con ecocardiografia transesofagica (ETE), hallazgos morfologicos, resultados hemodinamicos y complicaciones detectadas en 21 pacientes sometidos a la implantacion de PATC por abordaje transapical. Proponemos una estandarizacion de la exploracion, en la que la ETE tridimensional en tiempo real aportaria informacion adicional en la supervision intraoperatoria de implantacion por via transapical de la PATC.

Intraoperative monitoring with transesophageal real-time three-dimensional echocardiography during transapical prosthetic aortic valve implantation.

Abstract: Degenerative aortic stenosis is the most common valvulopathy in Europe. In symptomatic patients, aortic valve replacement with a prosthesis substantially improves prognosis. However, a high percentage of candidates for valve replacement surgery are rejected because of the high risk of serious complications. In recent years, percutaneous and minimally invasive surgical techniques have been developed for the transcatheter implantation of prosthetic aortic valves. These developments could lead to an increase in the number of interventions carried out in high-risk patients as the positive effect of treatment on prognosis would be retained while the complication rate would be reduced. We describe the use of transesophageal echocardiography (TEE) for intraoperative monitoring in 21 patients who underwent transcatheter aortic valve replacement using a transapical approach, and report morphologic findings, hemodynamic results, and complications observed. We propose a standard approach to imaging, in which real-time three-dimensional TEE is used to provide additional information during intraoperative monitoring of transapical transcatheter aortic valve replacement.

Assessment of Myocardial Deformation: Predicting Medium-term left Ventricular Dysfunction after Surgery in Patients With chronic Mitral regurgitation

Abstract: Introduction and objectives The development of left ventricular dysfunction after mitral valve replacement is a common problem in patients with chronic severe mitral regurgitation. Assessment of myocardial deformation enables myocardial contractility to be accurately estimated. Our aim was to compare the value of the preoperative strain and strain rate derived by either speckle-tracking echocardiography or tissue Doppler imaging (TDI) for predicting the medium-term decrease in left ventricular ejection fraction (LVEF) following surgery. Methods This prospective study involved 38 consecutive patients with chronic severe mitral regurgitation who were scheduled for mitral valve replacement. The longitudinal strain and strain rate in the interventricular septum were measured preoperatively using speckle-tracking echocardiography and TDI. The LVEF was determined preoperatively and postoperatively using 3-dimensional echocardiography. Echocardiographic assessments were performed in the 48 hours prior to surgery and 6 months postoperatively. Results The patients’ mean age was 59.9±11.3 years and 10 (29.4%) were male. Both speckle-tracking echocardiography and TDI were found to be predictors of a >10% decrease in LVEF at 6 months. However, the predictive value of speckle-tracking echocardiography was greater than that of TDI. The longitudinal strain at baseline in the interventricular septum as measured by speckle-tracking echocardiography was the most powerful predictor; the area under the curve was 0.85 and the optimal cut-off value was –0.11. Conclusions Speckle-tracking echocardiography can be used to predict a decrease in LVEF over the medium term after mitral valve replacement. Moreover, the predictive accuracy of speckle-tracking echocardiography was greater than that of TDI.

Design and Rationale of a Real-Life Study to Compare Treatment Strategies for Cardiovascular Risk Factors: The CRUCIAL Study

Abstract: The CRUCIAL trial was designed to compare the relative reduction in calculated Framingham coronary heart disease risk when a multiple risk factor intervention strategy, based on single-pill amlodipine besylate/atorvastatin calcium, was compared with a usual-care strategy. Eligible patients had treated or untreated hypertension, ≥ 3 additional cardiovascular risk factors, and baseline total cholesterol ≤ 6.5 mmol/L, but no coronary heart disease. The CRUCIAL trial was a 12-month, international, multicenter, prospective, stratified, cluster-randomized, parallel-design, open-label trial conducted in 20 countries in Asia, the Middle East, Europe, and Latin America. We anticipate the results of this study will be available in mid to late 2010. In this article we report the rationale for and design of the CRUCIAL trial and discuss how the challenges in the design and conduct of this cluster-randomized trial were addressed. The cluster-randomized trial design, with the investigator as the unit of randomi...

Role of Echocardiography

Abstract: Aortic aneurysms and aortic dissection are relatively frequent entities and their prognosis is sometimes fatal Transthoracic and trans-oesophageal echocardiography (TOE) are two of the main diagnostic tools for diagnosis, prognostic evaluation, and surgical assessment In this section, the potential use of echocardiography for patients with suspected or demonstrated aortic aneurysm dissection will be discussed

Estudio de la deformación miocárdica: predictor de disfunción ventricular a medio plazo tras cirugía en pacientes con insuficiencia mitral crónica

Abstract: Introduccion y objetivos. El desarrollo de disfuncion ventricular izquierda tras la sustitucion valvular mitral es un problema frecuente en pacientes con insuficiencia mitral grave cronica. El analisis de la deformacion miocardica permite estimar con precision la contractilidad miocardica. Nuestro objetivo fue comparar el valor predictivo de strain (S) y strain rate (SR) preoperatorios obtenidos por speckle-tracking y Doppler tisular (DTI) para predecir la disminucion de la fraccion de eyeccion del ventriculo izquierdo (FEVI) a medio plazo tras la cirugia. Metodos. Treinta y ocho pacientes consecutivos con insuficiencia mitral grave cronica programados para sustitucion valvular mitral fueron incluidos prospectivamente. Se analizo el S y el SR longitudinal del septo interventricular en el periodo preoperatorio mediante speckle-tracking y DTI. La FEVI preoperatoria y postoperatoria se obtuvo por ecocardiografia tridimensional. Los estudios ecocardiograficos se realizaron dentro de las 48 h previas a la cirugia y 6 meses despues de la cirugia. Resultados. La media de edad de los pacientes era 59,9 ± 11,3 anos; 10 pacientes (29,4%) eran varones. Tanto el speckle-tracking como el DTI resultaron predictores de disminucion de la FEVI > 10% a 6 meses. Sin embargo, el valor predictivo del speckle-tracking fue superior al del DTI. El S longitudinal del septo interventricular basal mediante speckle-tracking fue el parametro con mayor poder predictivo, con un area bajo la curva de 0,85 y un punto de corte optimo de -0,11. Conclusiones. El speckle-tracking permite predecir la disminucion de la FEVI a medio plazo tras la sustitucion valvular mitral. Ademas, el speckle-tracking es mas preciso que el DTI para este fin.

Exercise echocardiography in aortic stenosis: one more piece in the puzzle

Abstract: This editorial refers to ‘Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis’, by S. Marechaux et al. doi:10.1093/eurheartj/ehq076 Aortic valve replacement (AVR) is the current standard treatment for severe aortic stenosis (AS) with symptoms or left ventricle (LV) systolic dysfunction.1,2 However, controversy remains regarding the best treatment for asymptomatic patients with severe AS and preserved LV systolic function and also for those with moderate AS. Improved life expectancy has led to an increasing number of elderly patients with these conditions,3 in whom the symptoms are harder to evaluate. Many patients may reduce their level of physical activity to avoid or minimize symptoms and be unaware of subtle changes in effort tolerance. The accurate determination of symptoms is crucial, considering the risk of sudden death and the dismal prognosis once symptoms begin.4 Thus, the exercise test in ‘asymptomatic’ patients with severe AS has already established its role.5 The ESC guidelines recommend AVR whenever patients present symptoms (class I) or develop asymptomatic hypotension (class IIa) or asymptomatic ventricular arrhythmias (class IIb) during the exercise test.1 In contrast, the ACC/AHA guidelines recommend AVR if symptoms or hypotension appear during the exercise test (class IIb).2 The divergent strengths of these recommendations can be explained by the lack of definitive evidence from prospective clinical trials and subsequent different interpretation by the two groups. Conversely, exercise test echocardiography is not even recommended in the guidelines and remains an issue of debate. Lancellotti et al. 6 presented the first study to demonstrate that quantitative Doppler echocardiography has prognostic importance and provides additional information in patients with asymptomatic severe AS. Their results showed that 69 patients with an increase in mean pressure gradient ≥18 mmHg, during … *Corresponding author. Tel: +34 91 3303290, Fax: +34 91 3303292, Email: jlzamorano{at}vodafone.es

Ergonovine stress echocardiography: Recent experience and safety in our centre

Abstract: AIM: To study recent experience and safety of ergonovine stress echocardiography in our centre. METHODS: In this study we collected the clinical variables of patients referred since 2002 for ergonovine stress echocardiography, in addition to indications, the results of this test, complications, blood pressure and heart rate values during the test and the number and results of tests requested before this technique. RESULTS: We performed 40 tests in 38 patients, 2 tests were carried out to verify therapy efficacy. The prevalence of classic cardiovascular risk factors was low and the most frequent indication was chest pain (57.5%). Coronary angiography was performed in 32 patients, and showed normal coronary arteries in 27 patients and non-significant stenosis in 5 cases. In 16 patients, coronary angiography was carried out after a positive or inconclusive ischemia test. Another 6 patients had a normal stress test (5 exercise electrocardiography tests and 1 nuclear imaging test). Of the 40 ergonovine stress echocardiography tests, 6 were positive (4 in the right coronary artery territory and 2 in the circumflex coronary artery territory), all of them by echocardiographic criteria, and by electrocardiographic criteria in only 3 (50%). The presence of non-significant coronary artery stenosis was more frequent in patients with positive ergonovine stress echocardiography (50% vs 6%, P = 0.038), and were related to ischemic territory. During the maximum stress stage, there was a higher systolic (130.26 ± 19.17 mmHg vs 136.58 ± 27.27 mmHg, 95% CI: -12.77 to 0.14 mmHg, P = 0.055) and diastolic blood pressure (77.89 ± 13.49 mmHg vs 83.95 ± 15.73 mmHg, 95% CI: -10.41 to -1.69 mmHg, P = 0.008) than at the baseline stage, and the same was registered with heart rate (73 ± 10.96 beats/min vs 79.79 ± 11.72 beats/min, 95% CI: -9.46 to -4.11 beats/min, P < 0.01). Nevertheless, there were only 2 hypertensive reactions during the last stage, which did not force a premature end to the test, without sustained tachy or bradyarrhythmias, and the technique was well tolerated in 58% of cases. A unique complication (2.5%) of this test was a prolonged vasospasm with a slight increase in necrosis biomarkers, however, this was without repercussion. CONCLUSION: Ergonovine stress echocardiography can be performed with safety, is well tolerated in the majority of cases, and is useful for determining the ischemia mechanism in selected cases.

3D-wall motion tracking: a new tool for myocardial contractility analysis.

Abstract: BACKGROUND: Left-ventricular ejection fraction (LVEF), the most frequently used parameter to evaluate left ventricular (LV) systolic function, depends not only on LV contractility, but also on different variables such as pre-load and after-load. Three-dimensional wall motion tracking echocardiography (3D-WMT) is a new technique that provides information regarding different new parameters of LV systolic function. Our aim was to evaluate whether the new 3D-WMT-derived LV systolic function parameters are less dependent on load conditions than LVEF. METHODS: In order to modify the load conditions to study the dependence of the different LV systolic function parameters on them, a group of renal failure patients under chronic hemodialysis treatment was selected. The echocardiographic studies, including the 3D-WMT analysis, were performed immediately before and immediately after the hemodialysis session. RESULTS: Thirty-one consecutive patients were enrolled (mean age 65.5 ± 17.0 years; 74.2% men). There was a statistically significant change in predialysis and postdialysis, pre-load and after-load conditions (E/E ratio and systolic blood pressure) and in the LV end-diastolic volume and LVEF. Nevertheless, the findings did not show any significant change before and after dialysis in the 3D-WMT-derived parameters. CONCLUSIONS: LV 3D-wall motion tracking-derived systolic function parameters are less dependent on load conditions than LVEF. They might measure myocardial contractility in a more direct way than LVEF. Thus, hypothetically, they might be useful to detect early and subtle contractility impairments in a wide number of cardiac patients and they could help to optimize the clinical management of such patients.

Circulación colateral de arteria conal a descendente anterior: valoración con tomografía coronaria multidetector

Abstract: El pronostico de los pacientes con enfermedad coronaria depende en gran medida de la presencia de circulacion colateral. Existe gran variabilidad en cuanto a localizacion y extension, y de ello depende la aparicion de sintomas de isquemia o alteraciones de la contractilidad ventricular. Generalmente esta se establece a traves de vasos distales de pequeno calibre, si bien se han descrito formas muy diversas de circulacion colateral. Presentamos una serie de 3 pacientes con enfermedad severa de la coronaria izquierda y circulacion colateral a traves de una gran arteria conal que se une a la descendente anterior en segmento proximal o medio. En los 3 casos la funcion ventricular permanecia conservada.

Percutaneous Intervention in a single coronary artery: evaluation of multislice tomography and its feasibility.

Abstract: The presence of only a single coronary artery is a rare congenital coronary artery anomaly. In most cases, it is an incidental finding on coronary angiography and has no clinical significance. However, it can cause angina, myocardial infarction or even sudden death, particularly in young patients in whom the course of the artery runs between the aorta and pulmonary artery. In such cases, angiographic assessment may be difficult. Multislice coronary computed tomography might be better for visualizing the anatomy of the coronary artery tree in these patients. This article describes the cases of three patients with a single coronary artery and associated atherosclerotic coronary artery disease in whom a diagnosis was made using coronary angiography and multislice computed tomography.

Treatment strategies for cardiovascular risk factor management in patients with hypertension and additional risk factors - experiences from the usual care arm of the crucial trial: pp.16.90

Abstract: Objective: The CRUCIAL study cluster randomization scheme aimed to recruit and maintain a true “real-life” Usual Care control arm, where treatment was entirely based on the investigators' best clinical judgment. We report the proportion of patients treated with cardiovascular prophylactic medications in the Usual Care control arm at baseline, Months 4, and 12. Design and Method: Eligible patients were aged between 35 and 79 years with treated or untreated hypertension and 3+ additional risk factors, but no history of coronary disease and baseline total cholesterol 6.5 mmol/L or less and not receiving a statin. Patients received 12 months' treatment with single-pill amlodipine/atorvastatin-based treatment or continued usual care. Results: In the Usual Care control arm patients' mean age at baseline was 59.6 years, 50.5% were male, and mean duration of hypertension was 8.7 years. At baseline 94.9% received antihypertensive treatment and mean baseline blood pressure was 144.3/86.5 mm Hg; 5.3% received lipid-lowering treatment and mean LDL-C was 118.0 mg/dL. Mean BMI was 28.9 kg/m2, 36.2% were smokers, and 42.0% had diabetes. The proportion of patients taking 3+ antihypertensive medications increased from 29.5% at baseline to 40.8% at Month 12 (Table). The most frequently prescribed antihypertensives at baseline were ACE-inhibitors/ARBs (69.4%), CCBs (42.3%), beta-blockers (38.1%), diuretics (30.1%), and alpha-blockers (3.5%). This order remained consistent throughout the trial. The proportion of patients taking lipid-lowering medications increased from 5.3% to 31.5%, and the proportion taking aspirin increased from 26.2% to 35.0%. There was a small reduction in calculated 10-year Framingham coronary risk from 18.1% at baseline to 16.3% at Month 12. Figure 1. No caption available. Conclusions: Patients in the CRUCIAL study Usual Care control arm generally received good cardiovascular risk factor management at baseline. During the 12-month study there was a tendency towards increasing use of antihypertensive and lipid-lowering therapies, resulting in a reduction in calculated Framingham risk, and increasing use of aspirin. The increased use of these medications may, in part, be explained by study participation per se.

Aortic Root Pseudoaneurysm 1 Year After Transapical Aortic Valve Implantation

Abstract: An 84-year-old woman was admitted to our institution for transapical aortic valve implantation (TAVI) because of severe aortic stenosis coexisting with high-risk clinical conditions. She had a past history of type 2 diabetes mellitus, hypertension, intrinsic asthma, moderate to severe chronic renal insufficiency (Modification of Diet in Renal Disease glomerular filtration rate, 36 mL/min per 1.73 m2), and peripheral atherosclerotic vascular disease involving both iliofemoral arteries. Eighteen months before, she had suffered a non–ST-segment elevation myocardial infarction and was treated with 2 bare metal stents on the middle segment of the left anterior descending coronary artery and the very proximal or ostial segment of the right coronary artery. Aortic stenosis was evaluated as moderate. After 5 months, she developed advanced Mobitz II–type atrioventricular block, and a permanent sequential atrial synchronous ventricular inhibited pacemarker was indicated. Progression of the aortic valve disease was not noted. More recently, she was admitted to another hospital with severe dyspnea, showing signs of acute heart failure on physical examination. Urgent transthoracic echocardiogram disclosed a normal left ventricle with preserved ejection fraction and progression of the severity of the aortic valve stenosis. Because of the very high operative risk, conventional on-pump aortic valve replacement was dismissed. …

Cardiovascular risk factor management: single-pill amlodipine/atorvastatin versus usual care in patients with hypertension and additional risk factors - the crucial trial: pp.16.96

Abstract: Objective: To investigate whether a multi-factorial risk factor management strategy based on single-pill amlodipine/atorvastatin (5/10 mg to 10/10 mg) resulted in greater reduction in calculated Framingham 10-year coronary heart disease (CHD) risk compared with usual care after 12 months' treatment. Design and Method: Prospective, multinational, open-label, cluster-randomized trial. Eligible patients aged between 35 and 79 years with hypertension and 3 or more additional cardiovascular risk factors, but no history of CHD and baseline total cholesterol 6.5 mmol/L or less and not receiving a statin, were selected before site randomization. Results: A total of 136 sites contributing 1461 subjects were randomized. Mean baseline age was 59 years, 52% were male, 47% were White, and 36% Asian. Mean baseline age and low-density lipoprotein cholesterol (LDL-C) were comparable in the two treatment arms. Mean baseline blood pressure (150.3/89.7 mm Hg vs. 144.3/86.5 mm Hg) and CHD risk (20.0% vs. 18.1%) were higher in the single-pill amlodipine/atorvastatin arm versus the usual care arm (P < 0.002 for both). At Month 12, mean CHD risk was 12.5% in the single-pill amlodipine/atorvastatin arm and 16.3% in the usual care arm (P < 0.001). The difference was observed at Month 4 and maintained to Month 12 and was driven by significant differences in LDL-C between the two arms (Table). Overall, adverse events were reported in 48.8% of patients in the single-pill amlodipine/atorvastatin arm and 44.0% of patients in the usual care arm. The adverse event profile in the single-pill amlodipine/atorvastatin arm was consistent with previous safety experience for this medication. Peripheral oedema was reported in 6.8% and 1.6% of patients in the single-pill amlodipine/atorvastatin and usual care arms, respectively. Figure 1. No caption available. Conclusions: A global risk treatment approach, simultaneously targeting both blood pressure and lipids, regardless of individual risk factors per se, is more effective in reducing calculated Framingham 10-year CHD risk than usual care in patients with hypertension and additional risk factors.