Showing papers in "Revista Espanola De Cardiologia in 2003"

Estimación del riesgo coronario en España mediante la ecuación de Framingham calibrada

Abstract: Introduction and objectives. The Framingham coronary heart disease (CHD) functions overestimate the risk of CHD in countries with a low incidence. Consequently, these functions should be calibrated for the purpose of primary prevention. Calibrated Framingham function charts of overall CHD risk for the Spanish population are presented. Patients and methods. The Framingham functions were calibrated by substituting the prevalence of CHD risk factors and incidence found in Framingham with the same values for Spain. The Framingham function that included high-density lipoprotein (HDL) cholesterol was used. The 10-year probability of developing a CHD event was estimated for several combinations of risk factors and HDL levels ranging from 35 to 59 mg/dl. Color-coded charts were prepared that show the exact probability of CHD corresponding to each combination of risk factors, shown in separate cells on the chart. Results. The event rate and prevalence of CHD risk factors differed considerably between Girona and Framingham. HDL 60 mg/dL reduced it by 50%. The proportion of cells in which the 10-year probability of developing a CHD event was > 9% was 2.3 times higher and that of cells with a probability > 19% was 13 times lower in the chart calibrated for Spain than in the original Framingham charts. Conclusions. The calibrated Framingham function may help to more accurately estimate the overall risk of CHD in the Spanish population for primary prevention purposes. The calibrated function should be validated, and the development of functions for the Spanish population should be promoted.

Tratamiento del infarto agudo de miocardio en España en el año 2000. El estudio PRIAMHO II

Abstract: Introduccion y objetivos Los registros hospitalarios son utiles para conocer el grado de aplicacion de las nuevas evidencias y recomendaciones de las guias de practica clinica. Pacientes y metodo El registro PRIAMHO II es un estudio prospectivo con una seleccion aleatoria de los hospitales espanoles con unidad coronaria y control de calidad externo. Se incluyo a los pacientes con infarto agudo de miocardio ingresados en la unidad coronaria. Se recogieron las caracteristicas clinicas, el tratamiento y la evolucion hospitalaria, asi como la supervivencia a los 28 dias y al ano. Resultados Del 15 de mayo al 15 de diciembre de 2000, 6.221 pacientes fueron registrados en los 58 hospitales que cumplieron los controles de calidad (el 71,6% de los seleccionados). La mortalidad en la unidad coronaria fue del 9,6%, del 11,4% a los 28 dias y del 16,5% al ano. Recibio tratamiento de reperfusion el 71,6% de los pacientes con elevacion del segmento ST y menos de 12 h de evolucion, el 89% con fibrinolisis con un tiempo puerta-aguja de 48 min. La fraccion de eyeccion se midio en el 81% de los pacientes y en el 43% se realizo una prueba de isquemia. Al alta, el 91% recibio al menos un antiagregante; el 56%, bloqueadores beta; el 45%, inhibidores de la enzima de conversion de la angiotensina y el 45%, hipolipemiantes, con un coeficiente de variabilidad superior al 25%, excepto en la aspirina. Conclusiones El porcentaje de pacientes con elevacion del segmento ST que recibio reperfusion puede aumentar, sobre todo a expensas de la angioplastia primaria. Los retrasos son superiores a los recomendados. La estratificacion pronostica subaguda no es sistematica en la funcion ventricular y resulta suboptima en el estudio de isquemia residual. Al alta, la prescripcion de bloqueadores beta, inhibidores de la enzima de conversion de la angiotensina e hipolipemiantes puede aumentar y muestra una importante variabilidad entre los hospitales.

Malformaciones cardíacas en los niños con síndrome de Down

Abstract: Introduction and objectives. A longitudinal, retrospective, observational descriptive study was done at the National Institute of Pediatrics in Mexico City to determine the incidence, type of heart disease and clinical course in patients with Down syndrome (DS), and to compare the findings with data from other countries. Down syndrome is a disease caused by trisomy of chromosome 21. The frequency of presentation in one in 650 live births. Frequency in the general population is about 1%. Cardiac malformation is the main cause of mortality in the first 2 years of life. Patients and method. In a 5-year period 275 patients (aged neonate to 13 years) were diagnosed with DS. Diagnosis was based on echocardiogram, catheterization, genetics, surgical exploration or necropsy. Age, sex, clinical manifestations, mother’s age, type of heart defect were recorded. Results. Of the 275 children with DS, 160 had congenital heart disease. The most frequent cardiopathies were interauricular septal defect (IASD), interventricular septal defect (IVSD) and patent ductus arteriousus (PDA) (90%). In contrast to the data from other countries, only 14 patients (8%) had atrioventricular septal defect (AVSD). Twenty-five patients died (15%) from sepsis and cardiogenic shock. Conclusions. At our institute 58% of the children with DS had congenital heart malformation. The most frequent cardiopathies were different from those reported in other countries.

Ectasia coronaria: prevalencia, características clínicas y angiográficas

Abstract: Introduction and objectives. Coronary ectasia is characterized by the presence of diffuse dilation of the coronary vessels and is detected in 0.3-5.3% of angiographic studies. Our objective was to evaluate the prevalence of this condition, to analyze its clinical and angiographic characteristics, and to compare patients with ectasia and patients without it. Patients and method. Coronary angiography was performed in 4.332 patients from October 1998 to June 2001. This population was divided in two groups, patients with and patients without ectasia and patients without ectasia. Angiographic and clinical variables were compared in these groups. Results. The prevalence of ectasia was 3.39%. Most patients with ectasia (77.6%) had coronary stenosis. Ectasia affected a single vessel in 49.7%, most frequently the right coronary artery (132 patients), which also showed the greatest dilation. Most patients with ectasia were men (91.2%), smokers (56.5%), and younger than patients without ectasia (60.8 ± 11.7 vs. 63.3 ± 10.7 years; P = 0.01). They also had a lower prevalence of diabetes (22.4%) and previous revascularization procedures (8.2% angioplasty and 1.4% surgical revascularization). Logistical regression analysis showed that only male sex was associated to the presence of ectasia (OR = 3.33; 95% CI, 1.81-6.13) and that only diabetes was independently associated with absence of ectasia (OR = 0.65; 95% CI, 0.43-0.98). Conclusions. The prevalence of coronary ectasia in patients who underwent angiography was 3.4%. Coronary ectasia was prevalent in males and associated to the classic cardiovascular risk factors, except diabetes, a pathology that was less frequent than usual.

Actualización (2003) de las Guías de Práctica Clínica de la Sociedad Española de Cardiología en hipertensión arterial

Abstract: Desde la elaboracion de las guias de practica clinica en hipertension arterial en enero del ano 2000 se han producido nuevas evidencias cientificas que hay que tener en cuenta en el ambito de la practica clinica. Es necesario realizar la evaluacion clinica del hipertenso mediante la estratificacion de su riesgo cardiovascular global, en la que los datos aportados por el electrocardiograma (ECG) y el analisis de orina (deteccion de excrecion urinaria de albumina) son de especial relevancia. Hasta la actualidad, los resultados de multiples estudios disponibles indican que en la hipertension arterial lo mas importante es normalizar los valores de la presion arterial, con un control mas estricto en los hipertensos de mayor riesgo (diabeticos, lesion de organo diana y enfermedad cardiovascular asociada). La individualizacion del tratamiento constituye la base de la eleccion de farmacos antihipertensivos. Sin embargo, debe tenerse en cuenta que los hipertensos con ciertas enfermedades asociadas obtienen un mayor beneficio de determinados grupos farmacologicos. Los hipertensos diabeticos o con hipertrofia ventricular izquierda parecen beneficiarse del bloqueo farmacologico del sistema renina-angiotensina y los pacientes con insuficiencia cardiaca deben recibir tratamiento combinado con inhibidores de la enzima de conversion de la angiotensina (IECA) y bloqueadores beta.

Anatomía de los nodos cardíacos y del sistema de conducción específico auriculoventricular

Abstract: Concomitant with the development of catheter ablation techniques for the treatment of atrial arrhythmias, there has been renewed interest in the morphologic arrangement of the cardiac conduction system. The first descriptions of the anatomy of the nodes and atrioventricular conduction system appeared nearly 100 years ago. Since then the subject has been controversial, possibly because of the early researchers' imprecise knowledge of histology. The components and structure of the specific conduction system in humans are similar to those found in commonly used laboratory animals. The conduction system is composed of specialized myocytes. Its atrial components, the sinus node and the atrioventricular node, are in contact with atrial myocardium. The His bundle penetrates the right fibrous trigone, then divides into two specialized ventricular bundle branches (right and left), which also are surrounded by a fibrous sheath that separates the specialized myocytes from the ordinary myocardium. Only at the distal ramifications of the bundle branches do the fibrous sheaths disappear, allowing continuity with the ventricular myocardium. Knowledge of the specialized myocardium can help in the development of potentially useful therapies for some forms of cardiac arrhythmia.

Utilización de recursos diagnósticos y terapéuticos en pacientes ingresados por insuficiencia cardíaca: influencia del servicio de ingreso (estudio INCARGAL)

Abstract: Background. Heart failure (HF) is the most rapidly growing cardiac pathology in industrialized countries, and already the primary cause of hospital admissions of elderly people. Outside the field of clinical trials, there have not been many studies in Spain of the influence of the admission department on diagnostic and therapeutic management, whether this affects short-term and long-term prognosis, and the factors that determine the department the patient is admitted to. Objectives. To analyze whether management and prognosis of patients admitted with heart failure differ depending on the admission ward (cardiology versus internal medicine-geriatrics). Patients and method. Cross-sectional study of 951 patients (505 men and 446 women) consecutively hospitalized for HF in the cardiology (n = 363) and internal medicine-geriatrics (n = 588) wards of 12 hospitals of Galicia and recruited over a maximum period of 6 months. The main epidemiological and clinical variables were recorded at admission, and the complications, treatments, and clinical status were recorded at release. Results. HF patients had a mean age of 75.5 ± 12 years (women 78.5 years and men 72.6 years). The average hospitalization time was 11 ± 8 days and 50.8% were first admissions. Total hospital mortality was 6.8%. Fifty-nine percent (58.9%) of patients had arterial hypertension, 31.9% ischemic heart disease, 27.6% cardiac valve disease, 28.5% diabetes mellitus, and 32.5% chronic obstructive pulmonary disease (COPD). The patients admitted to cardiology ward were younger (72.5 ± 13 vs 77.4 ± 11 years; p < 0.005), more frequently men (51.9 vs 43.7%; p < 0.005), more often first hospitalizations (54.8 vs 48.4%; p < 0.005), and acute pulmonary edema was more H EART F AILURE

Registro Español de Trasplante Cardiaco. XIX Informe Oficial de la Sección de Insuficiencia Cardiaca, Trasplante Cardiaco y Otras Alternativas Terapéuticas de la Sociedad Española de Cardiología (1984-2007)

Abstract: Introduccion y metodos En este articulo se describen las caracteristicas generales y los resultados obtenidos con el trasplante cardiaco en Espana tras incluir los datos del ultimo ano. Resultados En 2005 se realizaron 287 trasplantes que, junto con los realizados desde 1984, hacen un total de 4.967. El perfil clinico medio del paciente que recibe un trasplante en Espana corresponde a un varon de aproximadamente 50 anos, de grupo sanguineo A o 0, con enfermedad coronaria no revascularizable o miocardiopatia dilatada idiopatica y situacion funcional IV/IV de la New York Heart Association. El porcentaje de trasplantes cardiacos urgentes fue del 22%; esta cifra fue muy inferior a la del ano previo (35%) y ligeramente menor que la media de los ultimos 5 anos (23%). La mortalidad precoz fue del 10%, cifra similar a la del ano previo e inferior a la media de los ultimos 5 anos (12%). Tras incorporar los resultados del pasado ano a los previos se obtuvo una probabilidad de supervivencia al primero, quinto y decimo ano del 75, el 65 y el 50%, respectivamente. Al separar las curvas de supervivencia por periodos se objetivo la importante mejoria en los ultimos 5 anos, con valores al primero y quinto anos del 80 y el 70%. La causa mas frecuente de fallecimiento en el primer mes fue el fallo agudo del injerto, en el primer ano la infeccion y el rechazo, y a largo plazo los tumores y el combinado de enfermedad vascular del injerto con muerte subita. Conclusiones El analisis comparativo de la supervivencia muestra que los resultados a corto, medio y largo plazo son superponibles a los publicados en la literature cientifica mundial, con una progresiva tendencia hacia una mejora de la supervivencia con los anos.

Registro Español de Ablación con Catéter. II Informe Oficial de la Sección de Electrofisiología y Arritmias de la Sociedad Española de Cardiología (2002)

Abstract: Introduccion y objetivos Se detallan los resultados (exito y complicaciones) del Registro Nacional de Ablacion del ano 2002, elaborado por la Seccion de Electrofisiologia y Arritmias, por segundo ano consecutivo. Material y metodo La recogida de datos se realizo, como en el registro anterior del ano 2001, de forma retrospectiva cumplimentando un cuestionario que fue enviado, desde la Seccion de Electrofisiologia y Arritmias, a los laboratorios de electrofisiologia. Se recogian los procedimientos de ablacion realizados durante el ano 2002, detallando los resultados y las complicaciones en funcion del sustrato o mecanismo arritmico tratado. Resultados Un total de 43 centros contestaron el cuestionario. El numero de procedimientos de ablacion analizados fue de 4.970 (42 centros), con una media de 118 ± 78 procedimientos por centro. Los 3 sustratos mas frecuentemente abordados fueron la taquicardia intranodal (29%), las vias accesorias (28%) y la ablacion del istmo cavotricuspideo (24%), y el porcentaje de exito fue del 99, 93 y 94%, respectivamente. El porcentaje global de exito, analizado por paciente, fue del 93%, el de complicaciones mayores del 1,2% y el de mortalidad del 0,04%. Conclusiones El Registro Nacional de Ablacion con Cateter del ano 2002 se consolida como una de las mayores series publicadas hasta el momento de procedimientos de ablacion, y recoge la actividad de la mayoria de los laboratorios de electrofisiologia de nuestro pais (90%). La eficacia de este procedimiento en nuestro medio sigue siendo elevada, con un escaso porcentaje de complicaciones mayores y de mortalidad.

Registro Español de Hemodinámica y Cardiología Intervencionista. xiI Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2002)

Abstract: Se presentan los resultados del Registro de actividad de la Seccion de Hemodinamica y Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia del ano 2002. Se han recogido datos de 101 centros, la practica totalidad de los laboratorios del pais, de los que 95 realizaron su actividad sobre todo en pacientes adultos y 6 exclusivamente en pacientes pediatricos. Se realizaron 97.609 estudios diagnosticos, con una cifra de 83.667 coronariografias, con un incremento de estas del 5,1% respecto al ano 2001 y una tasa de 2.053 coronariografias por millon de habitantes. Se efectuaron 34.723 procedimientos de intervencionismo coronario, con un incremento del 11% respecto al ano anterior y una tasa de 850 intervenciones por millon de habitantes. El stent intracoronario fue el dispositivo mas empleado, en el 91,7% de los procedimientos, con 47.249 unidades utilizadas (incremento del 20%). El stent con caracter directo, sin predilatacion, fue utilizado en 13.768 procedimientos, el 43,2% de los casos. Los inhibidores de la glucoproteina IIb/IIIa fueron utilizados en 9.966 procedimientos (28,7%). En 9.830 casos (28%) se efectuo un procedimiento en multivaso, y en 26.341 casos (76%) la intervencion coronaria percutanea se realizo en la misma sesion que la coronariografia diagnostica. Se llevaron a cabo 4.766 procedimientos de intervencionismo en el infarto agudo de miocardio, lo que supone un 23,9% mas respecto al ano 2001 y el 13,7% del total de las intervenciones coronarias percutaneas. En el intervencionismo no coronario destaca el descenso del numero de valvuloplastias mitrales (21,2%), un descenso en los cierres percutaneos de comunicacion interauricular en pacientes adultos (11,1%), y un ligero incremento de los procedimientos intervencionistas en pacientes en edad pediatrica (3,7%). Finalmente, destacamos el alto grado de participacion de centros en el registro, lo que hace que los datos aqui presentados sean representativos de la actividad hemodinamica en nuestro pais.

Factores de riesgo coronario en la adolescencia. Estudio FRICELA

Abstract: Objetivos Conocer la prevalencia de conductas y factores de riesgo para la enfermedad arterial coronaria en la adolescencia, asi como algunas de las asociaciones de dichos factores. Pacientes y metodo Se estudio a una poblacion de 2.599 adolescentes de ambos sexos, de 12 a 19 anos, procedentes de 30 centros sanitarios, publicos o privados, de la Capital Federal y de 12 provincias de la Republica Argentina. Resultados Los pacientes que presentaron hipercolesterolemia resultaron tener un mayor indice de masa corporal, hipertension arterial y sedentarismo. Se observo una correlacion positiva de la hipertension arterial con el indice de masa corporal y con la historia familiar de hipertension arterial, y negativa con el ejercicio fisico regular. La obesidad de los jovenes se vinculo con la de sus progenitores. A los 19 anos, el consumo regular de alcohol y de tabaco ascendia al 42 y 28%, respectivamente. La asociacion del consumo de tabaco y alcohol resulto ser alta (p Conclusiones Los estilos de vida saludables incorporados de manera temprana, como el ejercicio fisico regular, los habitos alimentarios adecuados y la abstencion de tabaco, podrian contribuir a intervenir sobre las mas importantes conductas y factores de riesgo para la enfermedad vascular aterosclerotica, con el objeto de disminuir la incidencia de la misma en la edad adulta.

Implantación y características de los programas de rehabilitación cardíaca en el Sistema Nacional de Salud español

Abstract: Objetivos Estimar el grado de implantacion de la rehabilitacion cardiaca en el Sistema Nacional de Salud, describir las caracteristicas de los programas y las opiniones de sus responsables sobre su desarrollo. Pacientes y metodo Se identificaron las unidades de rehabilitacion cardiaca a partir de diversas fuentes. Se envio un cuestionario postal a sus responsables, con preguntas sobre cobertura, recursos, actividades y servicios, seleccion de pacientes, y opiniones. Resultados Se localizaron 12 hospitales publicos que llevaban a cabo rehabilitacion cardiaca. Como media, esta se oferta al 53% de los pacientes elegibles. Todas las unidades incluyen a pacientes con infarto de miocardio, un 64% con insuficiencia cardiaca y un 60% pacientes de alto riesgo. Un 10-19% de los pacientes son mujeres. Los medicos mas implicados son los cardiologos; los profesionales no medicos que mas participan son los fisioterapeutas, y un 64% de las unidades cuenta con psicologo. La realizacion de la fase II es generalizada, y la fase III se realiza mas en unidades coordinadas con centros extrahospitalarios (45%). Ademas del ejercicio fisico, todas las unidades ofrecen consejo sobre la enfermedad y los factores de riesgo, y el 73%, apoyo psicologico. Las principales motivaciones mencionadas para hacer rehabilitacion son su caracter preventivo y la eficacia, y las principales barreras, la falta de medios y apoyo. Se cree que la atencion primaria puede desempenar un papel importante. Conclusiones La rehabilitacion cardiaca esta escasamente implantada en el sistema sanitario publico. Las mayores diferencias entre programas son la inclusion de pacientes de alto riesgo y con diagnosticos distintos del infarto, la coordinacion con centros extrahospitalarios y realizacion de fase III.

Tendencias en la mortalidad por cardiopatía isquémica en 50 provincias españolas

Abstract: Introduction and objectives. Ischemic heart disease is the leading cause of cardiovascular mortality and the second most frequent cause in women in Spain. It is responsible for 12% and 10%, respectively, of all-cause mortality. Our aim was to identify those provinces where recent trends differ significantly from the overall national pattern of decreasing rates in recent years, and where intervention is probably needed. Patients and method. We report mortality trends due to ischemic heart disease for the periods 1988-1991 and 1994-1997 for each province in persons aged 35 to 64 years, and mortality trends in Spain in the last 19 years for all age groups. Data for ischemic heart disease mortality were obtained from files supplied by the Spanish National Institute for Statistics. Mortality rates in the two 4-year periods were compared with log-linear Poisson regression models to estimate trends. Age-adjusted and mortality hazard-rates are presented with 95% CI, and time trends and geographical variations are also reported. Results. The highest rates were seen at Andalucia (south), Levante (east) and the oversea provinces (Balearic [Mediterranean] and Canary Islands [Atlantic]). There were considerable geographical differences in mortality rates. Time trends showed a decrease in men in 27 provinces and a decrease in women in 12 provinces. Overall mortality trends decreased in the last 19 years in Spain. Conclusions. Although the general trend is toward a decrease, there are differences between provinces in Spain. The previously reported North-South gradient and regional discrepancies were confirmed.

Séptimo informe del Joint National Committee para la Prevención, Detección, Evaluación y Tratamiento de la Hipertensión Arterial: el armamento está a punto

Abstract: The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) has recently came to light in a short version. A complete version will soon be available. JNC 7 is the last attempt to bridge the big gap between the current availability of potent and well tolerated antihypertensive strategies and their poor implementation in the clinical practice. Some new and important features characterize the JNC 7 document. The aim of the new and challenging definition of pre-hypertension (BP 120-139/80-89 mmHg) is to sensitize the general population and health professionals to implement effective strategies for a healthier life in order to prevent hypertension and related cardiovascular disease as early as possible. Stage 3 hypertension has been deleted and merged with stage 2 (systolic > or = 160 or diastolic > or = 100 mmHg). BP levels to achieve with treatment (goals) are < 140/90 mmHg (< 130/80 mmHg in diabetics). To reach the goal, diuretics are recommended for initial treatment in most subjects with stage I hypertension. However, combination of at least 2 drugs is recommended if initial BP is 20/10 mmHg higher than goal BP. Apart from the definition of pre-hypertension and the advice to begin therapy with diuretics in most patients with stage 1 hypertension, JNC 7 shares several positions with the hypertension guidelines recently released by the European Society of Cardiology and European Society of Hypertension. JNC 7 seems to dedicate limited space to stratify the level of cardiovascular risk in the individual subjects on the basis of the different combinations between BP levels and concomitant risk factors. In summary, JNC 7 is an updated and well equipped arsenal of formidable weapons against hypertension and its complications. The stage is now set for an hard task: their effective implementation in the clinical practice with the aim to decrease cardiovascular morbidity and mortality.

Cardiopatías congénitas del adulto: residuos, secuelas y complicaciones de las cardiopatías congénitas operadas en la infancia

Abstract: Hoy dia se estima que el 85% de los ninos nacidos con cardiopatias congenitas (CC) sobrevivira hasta la vida adulta, la mayoria gracias a procedimientos terapeuticos realizados en la infancia. El espectro de CC del adulto se esta modificando, y enfermedades como la tetralogia de Fallot, la transposicion de grandes vasos o el corazon univentricular estan emergiendo como enfermedades practicamente nuevas, transformadas por los procedimientos terapeuticos. Casi todos los pacientes que sobreviven presentan lesiones residuales, secuelas o complicaciones que pueden tener un caracter evolutivo durante la vida adulta. Estas lesiones se pueden manifestar como alteraciones electrofisiologicas, enfermedad valvular, cortocircuitos persistentes, disfuncion miocardica, lesiones vasculares, problemas derivados de materiales protesicos, complicaciones infecciosas, fenomenos tromboembolicos o alteraciones totalmente extravasculares que afectan a multiples organos o sistemas. En la tetralogia de Fallot operada, los problemas de mayor impacto sobre la longevidad se relacionan con insuficiencia de la valvula pulmonar, disfuncion del ventriculo derecho y arritmias auriculares o ventriculares. En la transposicion de grandes vasos con correccion fisiologica auricular, los problemas mas graves se relacionan con la funcion del ventriculo derecho, que no esta estructuralmente preparado para soportar la circulacion sistemica, y las arritmias auriculares. La cirugia de Fontan, para la correccion del corazon univentricular, debe considerarse como una tecnica paliativa que no modifica la alteracion estructural basica y expone al paciente postoperatorio a graves complicaciones y problemas. El incremento del numero de CC que llegaran a la edad adulta durante las proximas decadas demanda una cuidadosa consideracion sobre que nuevas necesidades asistenciales se estan generando, quien debe responsabilizarse de ellas y como y donde se pueden encontrar soluciones.

Función cardiopulmonar y capacidad de ejercicio en pacientes con obesidad mórbida

Abstract: Introduction and objectives. The effect of obesity on cardiac function is still under discussion. The objective of this study was to assess cardiopulmonary capacity in morbidly obese patients. Patients and method. A symptom-limited cardiopulmonary exercise stress test was carried out in 31 morbidly obese patients (BMI 50 ± 9 kg/m 2 ) and 30 normal controls (BMI 24 ± 2 kg/m 2 ). Cardiovascular function was evaluated using the oxygen pulse (oxygen uptake/heart rate). Results. There were no differences in age, sex and height between both groups. During the effort the obese subjects presented greater oxygen uptake, heart rate, systolic arterial pressure and minute ventilation and shorter test duration than control group (14 ± 3 vs 27 ± 4 min; p < 0.001). Oxygen pulse values were higher in obese patients. However, after oxygen uptake indexation by fat free mass, these differences disappeared, suggesting a similar cardiovascular function. At the end of the exercise, the control group reached 96% of their age-predicted maximal heart rate and their respiratory exchange ratio was 1 ± 0.2. Obese patients only reached 86% and 0.87 ± 0.2, respectively. Conclusions. Due to their need of more energy output to move total body mass morbidly obese patients have a reduced exercise capacity. They finish the test having done a submaximal exercise. However, during this effort they show a normal cardiopulmonar capacity.

Tratamiento de la hipertensión pulmonar asociada a la infección por VIH con treprostinil

Abstract: Background and objective. The treatment of pulmonary hypertension associated with infection by human immunodeficiency virus has not been well defined. Treprostinil is a prostacyclin analogue that has recently been shown to be useful for the treatment of pulmonary hypertension, whether primary, secondary to congenital heart disease, or associated with collagen disease, in a 12-week, double-blind study. We report the results of a one-year follow-up of three patients with pulmonary hypertension associated with human immunodeficiency virus infection who are being treated with treprostinil at our center.

Coronariografía y angioplastia coronaria por vía radial: experiencia inicial y curva de aprendizaje

Abstract: Introduction. The transradial approach has emerged as an attractive alternative to the femoral approach for coronary angiography and interventions. We describe our experience with the transradial approach and analyze the influence of the learning curve. Patients and methods. The transradial approach was attempted in patients with a good radial pulse and normal Allen test. When feasible and clinically indicated, we attempted ad hoc intervention. We divided the study population into two groups: Group A (the first 200 cases) and B (all other patients). We compared the radial group with a matched femoral control group. Results. We attempted the transradial approach in 526 patients (77.6% male; age 63.5 ± 11.51), and obtained a success rate of 93.7%. We found differences between group A and B in the success rate (91.0 vs 95.4%, p = 0,04), duration of procedure [23 (16-29) vs. 19 (15-24) minutes; p < 0.001], and fluoroscopy time [6.4 (4.2-10) vs. 5.0 (3.0-7.7) minutes; p < 0,001]. At 24 h of follow-up, we found small hematomas in 9.4%, bleeding in 4.9%, and radial artery obstruction in 2.8%, with no cases of arteriovenous fistula, pseudoaneurysm, or need for vascular surgery. We attempted intervention in 169 patients with 258 lesions, achieving angiographic success in 96.1%. We found no differences in the characteristics of the lesions and patients, or in the angiographic success rate of the radial and femoral PTCA groups. Conclusions. The transradial approach is a safe and effective alternative to femoral catherization. There is a significant learning curve associated with the successful performance of transradial procedures.

Alteraciones cardiológicas en mujeres adolescentes con anorexia nerviosa

Abstract: Results. QT and corrected QT intervals were significantly greater in patients with anorexia nervosa than in the control group. QT dispersion and corrected QT dispersion were significantly greater in anorexia nervosa than in the control group (QTd, 59.3 ± 23.0 vs 38.4 ± 8.0 ms; p = 0.000; QTcd, 56.5 ± 24.2 vs. 40.3 ± 21.8 ms; p = 0.011). Left ventricular mass was significantly lower in young women with anorexia nervosa. We found a significant relationship between body mass index and left ventricular mass index, and between the former and corrected QT dispersion. Conclusions. Adolescents with anorexia nervosa show significant cardiac disorders in comparison to healthy women of the same age. This finding may be a useful indicator of the risk of arrhythmia and sudden death in patients with anorexia nervosa.

Abandono del tabaco y riesgo de nuevo infarto en pacientes coronarios: estudio de casos y controles anidado

Abstract: Introduction and objectives. Smoking cessation reduces mortality in coronary patients. The aim of this study was to estimate association measures between the risk of occurrence of fatal or non-fatal reinfarction in patients who either continue to smoke or stop after a first infarction and are treated with secondary prevention measures. Patients and method. The study was a case-control (1:1) design nested in a cohort of 985 coronary patients under the age of 76 years who were not treated with invasive procedures and survived more than 6 months after the first acute myocardial infarction. Cases were all patients who suffered reinfarction (n = 137) between 1997 and 2000. A control patient was matched with each case by gender, age, hospital, interviewer, and the secondary prevention timeframe. Results. Patiehts who smoke after the first acute myocardial infarction had an odds ratio (OR) of 2.83 (95% CI, 1.47-5.47) for a new acute myocardial infarction. Adjustment for lifestyle, drug treatment, and risk factors (family history of coronary disease, high blood pressure, hypercholesterolemia, and diabetes mellitus) did not change the OR (2.80 [95% CI, 1.35-5.80]). Patients who quit smoking had an adjusted OR of 0.90 (95% CI, 0.471.71) compared with non-smokers before the first acute myocardial infarction. Continued smoking had an adjusted OR of 2.90 (95% CI, 1.35-6.20) compared to quitting after the first acute myocardial infarction. Conclusion. The risk of acute myocardial infarctions is three times higher in patients who continue to smoke after an acute coronary event compared with patients who quit. The risk of reinfarction in patients who stop smoking is similar to the risk of non-smokers before the first infarction.

Predictores de mortalidad hospitalaria en 186 episodios de endocarditis infecciosa activa en un centro de tercer nivel (1992-2001)

Abstract: Introduction and objectives. The aim of this study was to describe the predictors of hospital mortality found in patients admitted for infective endocarditis (IE) to a cardiovascular surgery ward. Patients and method. Prospective study of 186 patients with IE treated in our hospital between 1992 and 2001. Results. One hundred fourteen patients (61.3%) had native valve endocarditis and 72 (38.7%) had prosthetic valve endocarditis (early in 28 patients [up to 12 months after surgery] and late in 44 [later than 12 months]). Blood cultures were positive in 82%. The predominant organism was Streptococcus viridans (36%) in native valve endocarditis and Staphylococcus aureus (33%) in prosthetic valve endocarditis. The hospital mortality was 22.6%. Severe sepsis (4.8%) produced a high mortality rate (88%) and was caused by Staphylococcus aureus in 60%. One hundred nineteen patients (64%) required surgery, 79 (66.4%) of them urgently. Negative blood cultures predicted need for surgery in native valve endocarditis (p < 0.05). The surgical mortality was 21.8% and was related to NYHA III-IV class (p = 0.014) and emergency surgery (p = 0.009) in patients with native valve endocarditis. This last factor also predicted higher surgical mortality in patients with early prosthetic valve endocarditis (p < 0.001). Conclusions. The hospital mortality of this group of patients with infective endocarditis treated in a tertiary medical center was high. The presence of severe sepsis, although infrequent, had a somber prognosis. Severe heart failure in native valve endocarditis and urgent surgery in native and prosthetic valve endocarditis increased surgical mortality.

Prevalencia de foramen oval permeable en pacientes jóvenes con accidente isquémico cerebral de causa desconocida

Abstract: Introduction and objective. Patent foramen ovale has been associated with stroke in young patients with «cryptogenic» stroke. The purpose of this study is to examine the prevalence of patent foramen ovale in this group of patients, as well as their anatomical and functional characteristics by contrast echocardiography, trying to determine ictus risk markers in young patients with acute ischemic stroke. Patients and method. Prospective study of 90 patients under the age of 50 who were hospitalised consecutively due to a clinical presentation suggestive of stroke. No cause was found in 55 out of 90 (group I) and the rest, in which an stroke was finally disregarded, were used as the control group (group II). A transthoracic and transesophageal echocardiography examination with 2 types of contrast agents was performed in all patients to determine the presence of a patent foramen ovale and its anatomical and functional characteristics. Results. Patent foramen ovale was observed more frequently in group I than in group II (43 versus 21%; p < 0.05). Among patients with a patent foramen ovale those with an ischemic stroke showed greater mobility of the oval membrane, more frequent «large» shunts of contrast in a single frame in the left heart, and more frequent shunts at rest. Transesophageal echocardiography without contrast showed a high sensitivity (90%) and specificity (93%) for detecting «anatomically permeable foramen ovale» whereas contrast transthoracic echocardiography showed a low sensitivity (13%). There were no differences between the two contrasts used. Conclusions. Near half of young patients with ischemic stroke of an unknown origin have a patent foramen ovale. A bigger mobility of the membrane of the oval cavity and a «large» degree of shunt contrast as well as shunt at rest detected by contrast transesophageal echocardiography, seem to identify patent foramen ovale patients with ischemic stroke. In these patients, transthoracic echocardiography has low sensibility for detecting permeability of the foramen ovale. I MAGING T ECHNIQUES

Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias

Abstract: Objectives. To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. Patients and method. 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (< 24 h) exercise testing was done for the low-risk subgroup of patients (n = 203). All patients were followed during 3 months for major events (acute myocardial infarction or death). Results. Major events occurred in 71 patients (9.6%). Multivariate analysis (C stadistic = 0.79; 95% CI 0.730.84; p = 0.0001) identified the following predictors: age ≥ 72 years (OR = 1.7; 95% CI, 1.0-2.9; p = 0.05), insulindependent diabetes mellitus (OR = 2.9; 95% CI, 1.5-5.4; p = 0.001), previous ischemic heart disease (OR = 1.9; 95% CI, 1.1-3.2; p = 0.02), ST depression (OR = 2.1; 95% CI, 1.2-3.8; p = 0.01) and troponin I elevation (OR = 2.9; 95% CI, 1.5-5.3; p = 0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and ≥ 8 points (26.2% events); p = 0.0001. No patient with negative findings in the early exercise testing had major events. Conclusions. In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.

Ritmo luz/oscuridad de las citocinas proinflamatorias en el infarto agudo de miocardio

Abstract: Introduction and objectives. The concentration of certain proinflammatory cytokines has been found to be elevated in patients with acute coronary syndrome. Many studies have shown that coronary ischemic accidents do not show a uniform distribution throughout the day, but instead exhibit rhythmic variations. The objective of this study is to determine whether there is a circadian pattern of variation in the concentrations of proinflammatory cytokines in patients with acute myocardial infarction. Patients and method. The sample included 40 patients with acute myocardial infarction and 40 controls. Levels of interleukin 6 and 1β were determined in the first 24 hours after the acute coronary ischemic episode. Blood samples were extracted at 3:00 a.m. (period of darkness) and at 10:00 a.m. (period of daylight). Results. Both groups were similar in age, sex distribution, and coronary risk factors. Interleukin 6 levels showed a significant variation between daylight and nighttime concentrations in patients with acute myocardial infarction and controls (41.93 ± 5.90/100.39 ± 13.60 vs 25.76 ± 4.45/52.67 ± 7.73 pg/ml). However, interleukin 6 concentrations were higher in the acute myocardial infarction group than in the control group. Interleukin 1β concentrations did not vary between daylight and darkness. Conclusions. In both the control group and acute myocardial infarction group, interleukin 6 concentrations varied between daylight and darkness. Patients with acute myocardial infarction shown a higher concentration of interleukin 6 secondary to the physiological response to tissue damage. Circadian variations can affect the measurements obtained for different physiological and biochemical parameters.

Papel de los factores de riesgo en la trombogenicidad sanguínea y los síndromes coronarios agudos

Abstract: Recent advances in basic science have linked some systemic risk factors to endothelial dysfunction which gives rise to atherosclerotic disease and triggers the progression of thrombotic complications. Superficial erosion of the stenotic plaque can be observed in onethird of acute coronary syndromes (ACS). In these cases the presence of classic risk factors such as diabetes mellitus, hypercholesterolemia and smoking favor a state of «vulnerable blood» or high risk. Increased thrombogenicity can exacerbate thrombus formation and is able to trigger an ACS. The vessel endothelium regulates contractile, mitogenic and thrombotic activities of the vessel wall. Risk factors impair both homeostasis and hemostasis of the vessel wall and promote inflammatory signals. Platelet and monocyte activation favors the expression of tissue factor (TF), thus triggering the coagulation cascade with thrombin generation and clot formation. Increased blood thrombogenicity linked to classic risk factors may be associated with circulating TF levels which are much higher than those observed in healthy subjects without risk factors. These observations not only emphasize the usefulness of aggressive management of risk factors but open a new avenue for future studies to devise therapeutic strategies to treat ACS by inhibiting TF expression.

Características clínicas y pronóstico a medio plazo de la insuficiencia cardíaca con función sistólica conservada. ¿Es diferente de la insuficiencia cardíaca sistólica?

Abstract: Objetivos Analizar la prevalencia, las caracteristicas clinicas y el pronostico a medio plazo de los pacientes con insuficiencia cardiaca y funcion sistolica conservada, y compararlos con los que presentan disfuncion ventricular. Pacientes y metodo Se incluyo a un total de 153 pacientes, 62 con funcion sistolica conservada (fraccion de eyeccion ventricular izquierda ≥ 45%) y 91 con disfuncion ventricular (fraccion de eyeccion Resultados Las edades medias fueron similares (66 ± 10 frente a 65 ± 10 anos; p = 0,54). La proporcion de mujeres fue mayor entre los pacientes con funcion sistolica conservada (53 frente a 28%; p Conclusiones Una importante proporcion de pacientes con insuficiencia cardiaca presentan una funcion ventricular sistolica conservada. Aunque las caracteristicas clinicas de estos pacientes son distintas de las de aquellos con disfuncion ventricular sistolica, el pronostico a medio plazo fue similar.

Diagnóstico y guía terapéutica del paciente con taponamiento cardíaco o constricción pericárdica

Abstract: Echocardiography, thoracic computed tomography, and magnetic resonance imaging are three valuable imaging techniques for the management and pathophysiological understanding of cardiac tamponade and constrictive pericarditis. However, these techniques should not be used independently from clinical findings. In this article we describe the findings that can be obtained with these imaging techniques, emphasizing how they should be integrated in the clinical context of the patient. Only the proper use of these imaging techniques can optimize the management of patients with pericardial disease.

Valor pronóstico tardío de la troponina I en los pacientes ingresados en una unidad coronaria por angina inestable

Abstract: Introduccion y objetivos La troponina I (TnI) es un marcador de dano miocardico utilizado en la estratificacion pronostica del sindrome coronario agudo. El objetivo del estudio fue analizar el valor pronostico tardio del nivel maximo de TnI obtenido en las 48 h tras el ingreso en una unidad coronaria por angina inestable. Metodos Se incluyo a 149 pacientes consecutivos. Se realizaron determinaciones seriadas de la fraccion MB de la creatincinasa (CK-MB) y TnI. Los pacientes sin elevacion de la CK-MB fueron clasificados en dos grupos, en funcion de la presencia de TnI elevada (n = 58) o normal (n = 91). Se analizaron prospectivamente los factores clinicos y evolutivos relacionados con la probabilidad de muerte, nuevo episodio agudo coronario o revascularizacion coronaria tras un ano de seguimiento. Resultados No se observaron diferencias entre los dos grupos en relacion con las caracteristicas clinicas, salvo la edad, que fue mayor en el grupo con TnI elevada (69 frente a 64 anos; p = 0,01). Tras un ano de seguimiento no se apreciaron diferencias en la incidencia de nuevos acontecimientos coronarios agudos ni en la revascularizacion; sin embargo, la mortalidad fue mayor en el grupo con TnI elevada (el 13 frente al 4%; p = 0,01). Los predictores independientes de mortalidad fueron el infarto previo (riesgo relativo [RR] = 3), TnI elevada (RR = 3,2), fraccion de eyeccion 70 anos (RR = 15). Conclusiones En la angina inestable, un valor elevado de TnI dentro de las primeras 48 h del ingreso se asocia con un aumento de la mortalidad al ano de seguimiento.

Moléculas de adhesión endoteliales ICAM-1, VCAM-1 y E-selectina en pacientes con síndrome coronario agudo

Abstract: Introduccion y objetivos La respuesta inflamatoria aguda es un importante fenomeno en la patogenia del dano miocardico durante el sindrome coronario agudo, y se ha demostrado la existencia de disfuncion endotelial con resultados controvertidos. El proposito de este estudio fue determinar los valores de las moleculas de adhesion endoteliales solubles ICAM-1, VCAM-1 y E-selectina en pacientes con angina inestable e infarto, comparar los resultados en ambos grupos y analizar su relacion con el grado de dano miocardico. Metodo Las concentraciones sericas de estas moleculas se estudiaron en 37 controles sanos y 43 pacientes, 32 con infarto de miocardio y 11 con angina inestable, en el momento del diagnostico y 10 dias mas tarde, utilizando enzimoinmunoanalisis (ELISA) mediante estuches comerciales (R&D Systems, Reino Unido). Resultados Se observo un incremento significativo de la E-selectina (p Conclusion Este estudio indica que los valores sericos de la E-selectina, medidos en el momento de la admision y 10 dias mas tarde, podrian ser un marcador para la angina inestable y en el diagnostico diferencial con el infarto agudo de miocardio.

Complicaciones del acceso femoral en el cateterismo cardíaco: impacto de la angiografía femoral sistemática previa y la hemostasia con tapón de colágeno VasoSeal-ES

Abstract: Introduccion y objetivos.Dado el uso generalizado del acceso femoral y del material hemostatico, se plantea realizar la angiografia femoral sistematica y la hemostasia con VasoSeal-ES