Showing papers by "José Luis Zamorano published in 2012"

Guidelines on the management of valvular heart disease (version 2012)

Abstract: ACE : angiotensin-converting enzyme AF : atrial fibrillation aPTT : activated partial thromboplastin time AR : aortic regurgitation ARB : angiotensin receptor blockers AS : aortic stenosis AVR : aortic valve replacement BNP : B-type natriuretic peptide BSA : body surface area CABG : coronary artery bypass grafting CAD : coronary artery disease CMR : cardiac magnetic resonance CPG : Committee for Practice Guidelines CRT : cardiac resynchronization therapy CT : computed tomography EACTS : European Association for Cardio-Thoracic Surgery ECG : electrocardiogram EF : ejection fraction EROA : effective regurgitant orifice area ESC : European Society of Cardiology EVEREST : (Endovascular Valve Edge-to-Edge REpair STudy) HF : heart failure INR : international normalized ratio LA : left atrial LMWH : low molecular weight heparin LV : left ventricular LVEF : left ventricular ejection fraction LVEDD : left ventricular end-diastolic diameter LVESD : left ventricular end-systolic diameter MR : mitral regurgitation MS : mitral stenosis MSCT : multi-slice computed tomography NYHA : New York Heart Association PISA : proximal isovelocity surface area PMC : percutaneous mitral commissurotomy PVL : paravalvular leak RV : right ventricular rtPA : recombinant tissue plasminogen activator SVD : structural valve deterioration STS : Society of Thoracic Surgeons TAPSE : tricuspid annular plane systolic excursion TAVI : transcatheter aortic valve implantation TOE : transoesophageal echocardiography TR : tricuspid regurgitation TS : tricuspid stenosis TTE : transthoracic echocardiography UFH : unfractionated heparin VHD : valvular heart disease 3DE : three-dimensional echocardiography Guidelines summarize and evaluate all evidence available, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well …

EAE/ASE Recommendations for Image Acquisition and Display Using Three-Dimensional Echocardiography

Abstract: CRT : Cardiac resynchronization therapy ECG : Electrocardiographic LV : Left ventricular RV : Right ventricular SDI : Systolic dyssynchrony index TEE : Transesophageal echocardiographic 3D : Three-dimensional 3DE : Three-dimensional echocardiographic TTE : Transthoracic echocardiographic TV : Tricuspid valve 2D : Two-dimensional Three-dimensional (3D) echocardiographic (3DE) imaging represents a major innovation in cardiovascular ultrasound. Advancements in computer and transducer technologies permit real-time 3DE acquisition and presentation of cardiac structures from any spatial point of view. The usefulness of 3D echocardiography has been demonstrated in (1) the evaluation of cardiac chamber volumes and mass, which avoids geometric assumptions; (2) the assessment of regional left ventricular (LV) wall motion and quantification of systolic dyssynchrony; (3) presentation of realistic views of heart valves; (4) volumetric evaluation of regurgitant lesions and shunts with 3DE color Doppler imaging; and (5) 3DE stress imaging. However, for 3D echocardiography to be implemented in routine clinical practice, a full understanding of its technical principles and a systematic approach to image acquisition and analysis are required. The main goal of this document is to provide a practical guide on how to acquire, analyze, and display the various cardiac structures using 3D echocardiography, as well as limitations of the technique. In addition, this document describes the current and potential clinical applications of 3D echocardiography along with their strengths and weaknesses. ### a. Fully Sampled Matrix-Array Transducers An important milestone in the history of real-time 3D echocardiography was reached shortly after the year 2000, with the development of fully sampled matrix-array transducers. These transducers provided excellent real-time imaging of the beating heart in three dimensions and required significant technological developments in both hardware and software, including transducer design, microelectronic techniques, and computing. Currently, 3DE matrix-array transducers are composed of nearly 3,000 piezoelectric elements with operating frequencies ranging from 2 to 4 MHz and from 5 to 7 MHz for transthoracic echocardiographic (TTE) and transesophageal echocardiographic (TEE) imaging, respectively. These piezoelectric elements are arranged in a matrix configuration within the transducer and require a large number of digital channels for these fully sampled elements to be connected. To reduce both …

European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).

Abstract: European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) : the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts)

European guidelines on cardiovascular disease prevention in clinical practice (Version 2012)

Abstract: Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)y Authors/Task Force Members: Joep Perk (Chairperson) (Sweden)*, Guy De Backer (Belgium), Helmut Gohlke (Germany), Ian Graham (Ireland), Željko Reiner (Croatia), WM Monique Verschuren (The Netherlands), Christian Albus (Germany), Pascale Benlian (France), Gudrun Boysen (Denmark), Renata Cifkova (Czech Republic), Christi Deaton (UK), Shah Ebrahim (UK), Miles Fisher (UK), Giuseppe Germano (Italy), Richard Hobbs (UK), Arno Hoes (The Netherlands), Sehnaz Karadeniz (Turkey), Alessandro Mezzani (Italy), Eva Prescott (Denmark), Lars Ryden (Sweden), Martin Scherer (Germany), Mikko Syvänne (Finland), Wilma JM Scholte Op Reimer (The Netherlands), Christiaan Vrints (Belgium), David Wood (UK), Jose Luis Zamorano (Spain), Faiez Zannad (France).

Effects of the long-term administration of nebivolol on the clinical symptoms, exercise capacity, and left ventricular function of patients with diastolic dysfunction: results of the ELANDD study.

Abstract: Aims We hypothesized that nebivolol, a beta-blocker with nitric oxide-releasing properties, could favourably affect exercise capacity in patients with heart failure and preserved left ventricular ejection fraction (HFPEF). Methods and results A total of 116 subjects with HFPEF, in New York Heart Association (NYHA) functional class II–III, with left ventricular ejection fraction (LVEF) >45%, and with echo-Doppler signs of LV diastolic dysfunction, were randomized to 6 months treatment with nebivolol or placebo, following a double-blind, parallel group design. The primary endpoint of the study was the change in 6 min walk test distance (6MWTD) after 6 months. Nebivolol did not improve 6MWTD (from 420 ±143 to 428 ±141 m with nebivolol vs. from 412 ±123 to 446 ±119 m with placebo, P = 0.004 for interaction) compared with placebo, and the peak oxygen uptake also remained unchanged (peakVO2; from 17.02 ±4.79 to 16.32 ±3.76 mL/kg/min with nebivolol vs. from 17.79 ±5.96 to 18.59 ±5.64 mL/kg/min with placebo, P = 0.63 for interaction). Resting and peak blood pressure and heart rate decreased with nebivolol. A significant correlation was found between the change in peak exercise heart rate and that in peakVO2 (r = 0.391; P = 0.003) for the nebivolol group. Quality of life, assessed using the Minnesota Living with Heart Failure™ Questionnaire, and NYHA classification improved to a similar extent in both groups, whereas N-terminal pro brain natriuretic peptide (NT-pro BNP) plasma levels remained unchanged. Conclusions Compared with placebo, 6 months treatment with nebivolol did not improve exercise capacity in patients with HFPEF. Its negative chronotropic effect may have contributed to this result.

Quantitation of Mitral Regurgitation

Abstract: Significant mitral regurgitation (MR) is estimated to afflict >2 million Americans and is anticipated to increase in prevalence as the baby boomer population ages.1 Approximately 10% of people ≥75 years of age have significant MR,1 and these patients have decreased survival regardless of whether MR is caused by a primary leaflet abnormality2 or is secondary to left ventricular (LV) dysfunction.3–7 The primary clinical tool for evaluation of the mechanism and severity of MR is echocardiography; however, many patients referred to surgical centers for severe MR by echocardiography have only mild or moderate MR on quantitative evaluation.8 Because surgery is only indicated in patients with severe MR,9,10 it is imperative to quantify MR severity accurately. In 2003, the American Society of Echocardiography (ASE) and the European Association of Echocardiography (EAE) jointly published recommendations for quantification of valvular regurgitation.11 In 2010, the EAE published an updated guideline document.12 The present review aims to summarize those recommendations and to incorporate new data regarding the use of 3-dimensional (3D) echocardiographic parameters to determine MR severity. First, a theoretical framework for understanding the quantitative determinants of MR severity will be presented. Then, the practical application of various techniques for assessment of MR severity will be discussed, including their strengths and weaknesses. New evidence regarding the use of 3D echocardiography to quantify MR severity will be presented. As with the ASE and EAE guidelines, we will emphasize the importance of an integrative approach. Integration of multiple quantitative parameters, including newly available 3D parameters, is needed for the final determination of MR severity. Finally, the role of cine magnetic resonance imaging (CMR) and cardiac catheterization in quantitation of MR will be discussed. As described by Levine and Gaasch,13 the Gorlin hydraulic orifice equation can …

Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the

Abstract: Authors/Task Force Members: Alec Vahanian (Chairperson) (France)*, Ottavio Alfieri (Chairperson)* (Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal), Gonzalo Barón-Esquivias (Spain), Helmut Baumgartner (Germany), Michael Andrew Borger (Germany), Thierry P. Carrel (Switzerland), Michele De Bonis (Italy), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Bernard Iung (France), Patrizio Lancellotti (Belgium), Luc Pierard (Belgium), Susanna Price (UK), Hans-Joachim Schäfers (Germany), Gerhard Schuler (Germany), Janina Stepinska (Poland), Karl Swedberg (Sweden), Johanna Takkenberg (The Netherlands), Ulrich Otto Von Oppell (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain), Marian Zembala (Poland)

Three-dimensional echocardiography in paravalvular aortic regurgitation assessment after transcatheter aortic valve implantation.

Abstract: Background Paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is common, but the evaluation of its severity by two-dimensional (2D) transthoracic echocardiography (TTE) presents several constrains. The aim of this study was to assess the usefulness of a new methodology, using three-dimensional (3D) TTE, for better assessment of paravalvular AR after TAVI. Methods Two-dimensional and 3D TTE was performed in 72 patients, 5 months after TAVI, using the X5-1 PureWave microbeamforming xMATRIX probe. The position and severity of the paravalvular AR jets were described using 2D and 3D TTE, and a model was designed for paravalvular AR systematic location description. Vena contracta width was measured using 2D transthoracic echocardiographic views, and the planimetry of the vena contracta was assessed after the perfect alignment plane was obtained using the multiplanar 3D transthoracic echocardiographic reconstruction tool. AR volume was calculated as the difference between 3D TTE–derived total left ventricular stroke volume and right ventricular stroke volume estimated using 2D TTE. Diagnostic efficiency for moderate AR was assessed using receiver operating characteristic curve analysis. Results Forty-three patients (57.4%) presented with AR; 10 (13.3%) had central AR, and 33 (44.0%) had paravalvular AR jets. Vena contracta widths were similar between patients with moderate and mild AR (2.1 ± 0.53 vs 1.9 ± 0.16 mm, P = .16), but vena contracta planimetry was larger in patients with moderate AR than in those with mild AR (0.30 ± 0.12 vs 0.09 ± 0.07 cm 2 , P = .001). Vena contracta planimetry on 3D TTE was better correlated with AR volume than vena contracta width on 2D TTE (Kendall's τ = 0.82 [ P P Conclusions This study proposes an alternative methodology for paravalvular AR assessment after TAVI. Using vena contracta planimetry on 3D TTE, an accurate methodology for paravalvular AR jet evaluation and moderate AR classification is described.

Direct measurement of proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography in mitral regurgitation: a validation study.

Abstract: Background The two-dimensional (2D) proximal isovelocity surface area (PISA) method has some technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat, real-time three-dimensional (3D) color Doppler imaging allows direct measurement of PISA without geometric assumptions. The aim of this study was to validate this novel method in patients with chronic mitral regurgitation (MR). Methods Thirty-three patients were included, 25 (75.7%) with degenerative MR and eight (24.2%) with functional MR. EROA and regurgitant volume were assessed using transthoracic 2D and 3D PISA methods. The quantitative Doppler method and 3D transesophageal echocardiographic planimetry of EROA were used as reference methods. Results Both EROA and regurgitant volume assessed using the 3D PISA method had better correlations with the reference methods than conventional 2D PISA. A consistent significant underestimation of EROA and regurgitant volume using 2D PISA was observed, particularly in the assessment of eccentric jets. On the basis of 3D transesophageal echocardiographic planimetry of EROA, 14 patients had severe MR (EROA ≥ 0.4 cm 2 ). Of these 14 patients, 42.8% (6 of 14) were underestimated as having nonsevere MR (EROA ≤ 0.4 cm 2 ) by the 2D PISA method. In contrast, the 3D PISA method had 92.9% (13 of 14) agreement with 3D transesophageal planimetry in classifying severe MR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.96 and 0.92, respectively. Conclusions Direct measurement of PISA without geometric assumptions using single-beat, real-time 3D color Doppler echocardiography is feasible in the clinical setting. MR quantification using this methodology is more accurate than the conventional 2D PISA method.

Prevalence and risk factors associated with pulmonary hypertension in HIV-infected patients on regular follow-up.

Abstract: Background Pulmonary arterial hypertension (PAH) is uncommon among HIV-positive patients. However, it is a potentially life-threatening condition. Transthoracic echocardiography (TTE) is a noninvasive tool validated for PAH screening. The aim of our study was to establish the prevalence and factors associated with PAH in HIV-infected patients. Methods Consecutive HIV-infected individuals attended at one HIV reference clinic in Madrid, Spain, during year 2011 were examined. Demographics and clinical data were recorded and a Doppler echocardiography was performed in all individuals. PAH was considered when right ventricular pressure was more than 35 mmHg (mild if 65 mmHg). Results Three hundred and ninety-two individuals were examined (83.4% men, median age 47 years, 53% were men who have sex with men and 53% former intravenous drug addicts). Overall, 84% were on HAART, 76% had undetectable HIV viral load and median CD4 cell counts were 577 cells/μl. Cardiovascular risk factors were smoking 50%, arterial hypertension 16% and diabetes mellitus 9%. A total of 28.5 and 4.8% had chronic hepatitis C (CHC) and 4.8% chronic hepatitis B, respectively. PAH was diagnosed in 9.9% of patients (6.4% mild, 2.8% moderate and 0.8% severe). Multivariate logistic regression analysis [odds ratio (OR), 95% confidence interval (CI)] showed that detectable plasma HIV-RNA [OR, 3.3; 95% CI, 1.04-10], CHC [OR, 3.1; 95% CI 1.2-8.2] and female sex [OR, 2.9; 95% CI, 1.04-8.3] were independently associated with PAH. Conclusion The prevalence of PAH HIV-infected patients on regular follow-up approaches 10%, being moderate-severe in nearly 4% of cases. Patients with CHC and/or uncontrolled HIV replication exhibit a higher risk of PAH.

Prosthesis/annulus discongruence assessed by three-dimensional transoesophageal echocardiography: A predictor of significant paravalvular aortic regurgitation after transcatheter aortic valve implantation

Abstract: Aims Paravalvular aortic regurgitation (AR) is common after transcatheter aortic valve implantation (TAVI) This study aimed to assess the prosthesis/aortic annulus discongruence by three-dimensional (3D) transoesophageal (TOE) planimetry of aortic annulus and its impact on the occurrence of significant AR after TAVI Methods and results We included 33 patients who underwent TAVI with a balloon expandable device for severe aortic stenosis To appraise the prosthesis/annulus discongruence, we defined a ‘mismatch index’ expressed as: annulus area − prosthesis area The aortic annulus area was planimetered with 3D TOE, and approximated by circular area formula ( π r 2) using annulus diameter obtained by two-dimensional (2D) TOE After TAVI, 13 patients (393%) developed significant AR (≥2/4) The occurrence of significant AR was associated to the 3D planimetered annulus area ( P = 004), and the ‘mismatch index’ obtained through 3D planimetered annulus area ( P = 003), but not to ‘mismatch index’ derived of 2D annulus diameter In multivariate analysis, ‘mismatch index’ for 3D planimetered annulus area was the only independent predictor of significant AR (odds ratio: 10614; 95% CI: 1044–1721; P = 004) The area under the receiver operating characteristic curve for the ‘mismatch index’ by the 3D planimetered annulus area was 076 (95% CI: 054–092), whereas for ‘mismatch index’ obtained by the 2D circular area was 036 (95% CI: 017–055) Using the 3D planimetered annulus area as the reference parameter to decide the prosthetic size, the choice would have been different in 21 patients (63%) Conclusion Three-dimensional TOE planimetry of aortic annulus improves the assessment of prosthesis/annulus discongruence and predicts the appearance of significant AR after TAVI

Síndrome de tako-tsubo e insuficiencia cardiaca: seguimiento a largo plazo

Abstract: Resumen Introduccion y objetivos El sindrome de tako-tsubo induce un grado variable de disfuncion ventricular izquierda transitoria. Nuestro objetivo es determinar su pronostico a corto y largo plazo y valorar la incidencia de insuficiencia cardiaca en este ambito, los factores de riesgo relacionados con su desarrollo y su influencia en la evolucion posterior en nuestro medio. Metodos Se recogieron prospectivamente las caracteristicas clinicas y los eventos durante el ingreso hospitalario y durante el seguimiento de 100 pacientes con sindrome de tako-tsubo. Se llevo a cabo un analisis estratificado en relacion con el desarrollo de insuficiencia cardiaca (Killip ≥ II) durante el ingreso indice. Resultados El 89% eran mujeres (media de edad, 68 anos); 70 pacientes cursaban sin insuficiencia cardiaca; 15 estaban en Killip II; 5; en Killip III, y 10, en Killip IV. Los factores de riesgo cardiovascular —diabetes incluida— eran frecuentes, pero mas en el grupo con insuficiencia cardiaca. La fraccion de eyeccion del ventriculo izquierdo era inferior en aquellos con insuficiencia cardiaca al ingreso (el 51 frente al 42%; p Conclusiones En el sindrome de tako-tsubo, la insuficiencia cardiaca es frecuente; se observa sobre todo en pacientes con mas comorbilidades y peores clases funcionales previas y se asocia a mas eventos adversos, tanto durante el ingreso como en el seguimiento a largo plazo. El pronostico a largo plazo es generalmente bueno.

Tako-tsubo Syndrome and Heart Failure: Long-term Follow-up

Abstract: A B S T R A C T Introduction and objectives: Tako-tsubo syndrome produces a variable degree of transient left ventricular dysfunction. Our objective was to determine the short- and long-term prognosis of this syndrome, the incidence of and risk factors for the development of heart failure, and the influence on heart failure on the long-term outcome in our patient population. Methods: We prospectively recorded the clinical features and events during the hospital stay and follow- up of 100 patients with tako-tsubo syndrome. The risk factors for heart failure during hospital stay, considered as Killip classII, were assessed. Results: Most of the patients were women (89%), with a mean age of 68 years. The distribution according to Killip class was: Killip I, 70 patients; Killip II, 15; Killip III, 5; and Killip IV, 10. Cardiovascular risk factors, including diabetes, were common in the overall group, but were more so in the heart failure cohort. The left ventricular ejection fraction was lower in the heart failure group (51% vs 42%; P<.01). There were no differences in preadmission medications or biomarkers of necrosis. Over a median follow- up of 1380 days, the incidence of events reported during the hospital stay and long-term follow-up, both for death and the combined endpoints, was higher in the heart failure cohort. Conclusions: Although the prognosis in tako-tsubo syndrome is usually good, heart failure occurs quite frequently, mainly in patients with a greater number of comorbidities and poorer previous functional class. Moreover, heart failure is associated with a higher number of early and late adverse events. The overall long-term prognosis is good.

Puente miocárdico evaluado mediante tomografía computarizada multidetectores: posible causa del dolor torácico en pacientes más jóvenes con baja prevalencia de dislipemia

Abstract: Introduccion y objetivos La relacion entre los puentes miocardicos y el dolor toracico todavia no esta bien definida. El objetivo de nuestro estudio es evaluar la relacion entre los puentes miocardicos detectados mediante tomografia computarizada multidetectores y los sintomas de una poblacion de pacientes evaluados por dolor toracico. Metodos Se incluyo a 393 pacientes consecutivos sin enfermedad coronaria previa, estudiados por dolor toracico y remitidos para tomografia computarizada multidetectores entre enero de 2007 y diciembre de 2010. Se les realizo una coronariografia no invasiva mediante tomografia computarizada multidetectores. Se definio puente miocardico como una parte de una arteria coronaria completamente rodeada por el miocardio en las imagenes axiales y las reconstrucciones multiplanares. Resultados La media de edad fue 64,6±12,4 anos; el 44,8% de los pacientes eran varones. La tomografia computarizada multidetectores mostro 86 puentes miocardicos en 82 de los 393 pacientes (20,9%). La descendente anterior izquierda fue la arteria coronaria afectada con mayor frecuencia (87,2%). La prevalencia de puente miocardico fue significativamente superior entre los pacientes sin estenosis coronaria aterosclerotica significativa segun la tomografia computarizada multidetectores (el 24,9 frente al 15,0%; p=0,02). Los pacientes con puente miocardico eran mas jovenes (60,3±13,8 frente a 65,8±11,9 anos; p < 0,001), tenian menor prevalencia de hiperlipemia (el 29,3 frente al 41,8%; p=0,03) y mayor prevalencia de miocardiopatia (el 6,1 frente al 1,6%; p=0,02) que los pacientes sin puente miocardico observado en la tomografia computarizada multidetectores. Conclusiones La tomografia computarizada multidetectores es una herramienta facil y fiable para diagnosticar los puentes miocardicos in vivo. Los resultados del presente estudio indican que los puentes miocardicos son la causa del dolor toracico en un subgrupo de pacientes mas jovenes, con menor prevalencia de hiperlipemia y mayor prevalencia de miocardiopatia que los pacientes en que se observa ateroesclerosis coronaria significativa en la tomografia computarizada multidetectores

Distinguishing eosinophilic esophagitis from gastroesophageal reflux disease upon PPI refractoriness: what about PPI-responsive esophageal eosinophilia?

Abstract: on PPI therapy [3–7] , leading to the description of a new potential disease phenotype in the 2011 updated guidelines, i.e. PPI-responsive esophageal eosinophilia (PPIRee) [8] . Whether these patients represent a sub-phenotype of GERD, EoE or a combined mechanism of both disorders remains unknown. In the aforementioned reports neither histological specific features [6] , pH esophageal monitoring [4, 6] nor quantitative immunohistochemistry for mast cells [7] were capable to discern between PPIRee and EoE. In addition, a recent investigation has demonstrated that the secretion of eotaxin-3 could be blocked by PPI therapy in esophageal squamous epithelial cell lines from patients with EoE stimulated with either IL-13 or IL-4 [9] . These findings suggest that PPI therapy can have anti-inflammaDear Sir, We read with great interest the article by von Arnim et al. [1] recently published in your journal. The authors show that eosinophilic esophagitis (EoE) can be easily suspected before upper endoscopy on the basis of some laboratory and clinical markers. The authors conclude that their set of markers ‘allow physicians to distinguish EoE from gastroesophageal reflux disease (GERD) even before upper gastrointestinal endoscopy’, but things may not be as simple as they seem. According to the 2007 first consensus EoE guidelines [2] , it was established that GERD and EoE could be easily distinguished upon responsiveness to PPI therapy. However, recent reports since 2006 have shown that up to 40–50% of pediatric and adult patients with dense esophageal eosinophilia achieve complete remission Published online: February 17, 2012

Influence of lipoprotein (a) on inflammatory biomarkers in metabolic syndrome.

Abstract: OBJECTIVE To examine the relation between plasma lipoprotein (a) (Lp[a]) levels and oxidative stress biomarkers, serum cytokines, and atherosclerotic burden among individuals recently diagnosed as having metabolic syndrome (MS). METHODS Eighty-four white patients with MS were classified according to two Lp(a) levels (normal Lp[a]: 30 mg/dL) and were compared with 42 healthy controls. Oxidative stress biomarkers (oxidized low-density lipoprotein, antibodies to oxidized low-density lipoprotein, and nitric oxide metabolites) and proinflammatory cytokines (interleukin [IL]-2, IL-4, IL-5, IL-6, IL-10, IL-12P70, IL-13, and interferon-γ) were measured in plasma. Atherosclerotic significance was determined using carotid ultrasound and endothelial function by standardized protocols. RESULTS Patients with MS had higher levels of serum cytokines, oxidative stress markers, and C-reactive protein, and greater atherosclerosis burden as compared with controls. Among the group members, 58 patients had normal Lp(a) levels and 26 had high Lp(a) levels. Cytokines and C-reactive protein levels were significantly higher in patients with high Lp(a) compared with those with normal Lp(a) (P < 0.01 for IL-2 and P < 0.001 for the others). Nitric oxide metabolites were significantly lower in patients with high Lp(a) as compared with those with normal Lp(a) (P < 0.05). No differences were found in oxidized low-density lipoprotein and atherosclerotic burden between the two groups of patients with MS with respect to Lp(a) levels. CONCLUSIONS Elevated Lp(a) plasma levels are associated with higher proinflammatory markers in patients newly diagnosed as having MS.

Myocardial Bridging Assessed by Multidetector Computed Tomography: Likely Cause of Chest Pain in Younger Patients With Low Prevalence of Dyslipidemia

Abstract: A B S T R A C T Introduction and objectives: The relationship between myocardial bridging and symptoms is still unclear. The purpose of our study was to assess the relationship between myocardial bridging detected by multidetector computed tomography and symptoms in a patient population with chest pain syndrome. Methods: The study enrolled 393 consecutive patients without previous coronary artery disease studied for chest pain and referred to multidetector computed tomography between January 2007 and December 2010. Noninvasive coronary angiography was performed using multidetector computed tomography. Myocardial bridging was defined as part of a coronary artery completely surrounded by myocardium on axial and multiplanar reformatted images. Results: Mean age was 64.6 (12.4) years and 44.8% were male. Multidetector computed tomography detected 86 myocardial bridging images in 82 of the 393 patients (20.9%). Left anterior descending was the most frequent coronary artery involved (87.2%). The prevalence of myocardial bridging was significantly higher in patients without significant atherosclerotic coronary stenosis on multidetector computed tomography (24.9% vs 15.0%; P=.02). Patients with myocardial bridging were younger (60.3 (13.8) vs 65.8 (11.9); P<.001), had less prevalence of hyperlipidemia (29.3% vs 41.8%; P=.03), and more prevalence of cardiomyopathy (6.1% vs 1.6%; P=.02) compared with patients without myocardial bridging on multidetector computed tomography. Conclusions: Multidetector computed tomography is an easy and reliable tool for comprehensive in vivo diagnosis of myocardial bridging. The results of the present study suggest myocardial bridging is the cause of chest pain in a subgroup of younger aged patients with less prevalence of hyperlipidemia and more prevalence of cardiomyopathy than patients with significant atherosclerotic coronary artery disease on multidetector computed tomography.

Análisis transversal de la resincronización cardiaca en España. Indicaciones. técnicas de implante. optimización y seguimiento

Abstract: Resumen Introduccion y objetivos Realizar un estudio transversal de la terapia de resincronizacion cardiaca en Espana, analizando los problemas en las indicaciones, el implante y el seguimiento del paciente. Metodos Identificar los centros espanoles que realizan implantes de resincronizacion solicitando un cuestionario (septiembre de 2010 a septiembre de 2011) a cada equipo. Resultados Se identifico un total de 88 centros, de los que 85 (96,6%) cumplimentaron la hoja de recogida de datos. El numero de implantes de resincronizador (marcapasos o desfibriladores) fue de 2.147 (el 85,6% del total estimado de 2.518 por la European Confederation of Medical Suppliers Associations en ese periodo). El numero de implantes/millon de habitantes comunicados fue 46 y el estimado, 54 (media en Europa, 131). Los implantes/recambios de resincronizador suponen el 84% y las mejoras del modo de estimulacion upgrade de dispositivos previos, un 16%. La mayor parte de los resincronizadores se implantaron en varones (70,7%), con medias de edad de 68 ± 12 anos y de fraccion de eyeccion ventricular izquierda del 26,4 ± 5%. La mayoria de los pacientes (67%) estaban en clase funcional III de la New York Heart Association. El grupo de pacientes con nueva indicacion segun la ultima actualizacion de guias es ya significativo, con el 17,3% entre los pacientes en clase II y el 21,6% de los pacientes con fibrilacion auricular. El 73,8% de los implantadores son electrofisiologos, seguidos por los cirujanos (21,4%). Conclusiones Las nuevas indicaciones recomendadas se estan implantando progresivamente segun los datos obtenidos en pacientes en clase II o fibrilacion auricular. Sin embargo, el numero de implantes de resincronizador en Espana aun esta lejos de la media europea.

Changes in calculated coronary heart disease risk using proactive multifactorial intervention versus continued usual care in Latin-American and non-Latin-American patients enrolled in the CRUCIAL trial

Abstract: Objective:To compare the change in calculated coronary heart disease (CHD) risk using a proactive multifactorial intervention (PMI) versus usual care (UC), among Latin-American (LA) and non-LA patients enrolled in the CRUCIAL trial.Research design and methods:This is a sub-analysis of the Cluster Randomized Usual Care versus Caduet Investigation Assessing Long-term-risk (CRUCIAL) trial. CRUCIAL was a prospective, multinational, open-label, cluster-randomized trial. Eligible patients had hypertension and ≥3 additional cardiovascular risk factors, but no history of CHD and baseline total cholesterol ≤6.5 mmol/l (250 mg/dl). The PMI strategy was implemented by the inclusion of single-pill amlodipine/atorvastatin (SPAA) in the patients’ treatment regimen. Overall, 20% of patients resided in the LA region.Main outcome measure:Treatment-related change in calculated Framingham 10-year CHD risk between baseline and Week 52 in the LA and non-LA regions.Results:A greater relative reduction in calculated CHD...

Inverted McConnell sign.

Abstract: A 85-year-old man presented to the emergency room with nonradiating, midsternal chest pressure with associated dyspnea. He was found to be hypotensive, in sinus tachycardia, and with a new right bundle-branch block on the ECG. A chest computed tomography angiogram (Brilliance 64, Philips Medical Systems, Best, The Netherlands) was performed which revealed massive bilateral pulmonary embolism (Fig. 1A). An immediate transthoracic echocardiogram (ACUSON SC2000, Siemens Medical Solutions, Mountain View, CA, USA) was performed which showed that the right ventricle (RV) was dilated with an unusual pattern of right ventricular wall motion consisting of vigorous contraction of the basal segment of the RV free wall and akinesia of the mid-RV free wall and RV apex (Fig. 1B–D; movie clip 1). Moderate tricuspid regurgitation was noted with an estimated pulmonary artery pressure of 100 mmHg. Left ventricular cavity size appeared reduced with preserved systolic function. Septal flattening throughout the cardiac cycle was seen consistent with significant RV pressure overload. Considering such large bilateral pulmonary embolism and severe right ventricular dysfunction, fibrinolytic therapy with alteplase was administered. In the next few hours, both dyspnea and resting hypoxia improved. A repeated echocardiogram 2 days later showed a decrease in right ventricular size with complete resolution of McConnell sign and right ventricle dysfunction (movie clip 2) and a pulmonary artery pressure of 28 mmHg. The patient had an uneventful hospital course.