[Subcutaneous implantable Holter. A new instrument for the diagnosis of syncope of undetermined origin]. / El Holter implantable subcutáneo. Un nuevo instrumento para el diagnóstico del síncope de origen no determinado.

We present a recurrent syncope case with no clear origin or not stabilized after complete diagnostic exploration including echocardiogram, Holter, carotid Doppler, electrophysiologic study, computerized tomography, etc. Due to its recurrence and sudden appearance which was presumed to be of cardiac origin we implanted a long recording subcutaneous Holter system, the first unit used in Spain. This device, which has several advantages compared to external recorders previous in use, facilitated the patient's diagnosis (arrhythmic syncope of cardiac origin due to a paroxysmal atrioventricular block) one month after implantation. We describe the system, which includes a recorder and an external activator, its handling and diagnostic capabilities as well as the implantation procedures.

[The therapeutic focus in severe hypertrophic obstructive cardiomyopathy with multivessel coronary disease]. / Enfoque terapéutico en la miocardiopatía hipertrófica obstructiva severa con enfermedad coronaria multivaso.

The association of severe hypertrophic obstructive cardiomyopathy and coronary artery disease increases surgical morbimortality, even more in patients over 65 years. We describe a combined therapeutic approach to these diseases. A 68-year-old woman with a diagnosis of hypertrophic obstructive cardiomyopathy was in functional class IV for angina and dyspnea despite 360 mg of propranolol a day. An echocardiogram and a complete cardiac catheterization were performed under betablocker therapy, confirming a severe hypertrophic obstructive cardiomyopathy and revealing severe stenosis in the proximal left circumflex and the proximal right coronary arteries, and a moderate lesion in the mid-left anterior descendent. They were both treated with balloon PTCA, and a 3 x 15 mm stent was placed in the circumflex and a 3.5 x 20 mm stent in the right coronary, with an excellent angiographic result. A basal hemodynamic study was then performed and A-V sequential pacing was attempted, achieving a significant decrease in the left ventricle outflow tract gradient. A DDD-R pacemaker was implanted. Echocardiographic study was performed post-implantation, and follow-up was made six months later with a new coronary angiography, hemodynamic study and a Doppler echocardiogram. At the present time A-V sequential pacing as a therapeutic option for hypertrophic obstructive cardiomyopathy and coronary angioplasty and stenting for the treatment of coronary artery disease are sufficiently established and supported to be offered as a combined therapy to patients suffering from both diseases, specially those with a higher surgical risk.

[Clinical practice guidelines of the Spanish Society of Cardiology for pulmonary thromboembolism and hypertension]. / Guías de práctica clínica de la Sociedad Española de Cardiología en tromboembolismo e hipertensión pulmonar.

Primary pulmonary hypertension is a progressive disease. Most affected patients are young and middle-aged women. Etiology is unknown, although a familial and genetic factor is present in up to 6% of cases. Endothelial dysfunction and abnormalities in calcium channels of smooth muscle fibers are the present pathogenetics theories. Diagnostic tests try to exclude secondary causes of pulmonary hypertension and to evaluate its severity. Acute vasodilatory test is vital in the selection of treatment. Oral anticoagulation is indicated in all patients. Lung transplant is performed when medical treatment is unsuccessful. Atrial septostomy is an alternative and palliative treatment for selected cases. Chronic thromboembolic pulmonary hypertension is a special form of secondary pulmonary hypertension, clinically undistinguishable from primary primary hypertension, is of mandatory diagnosis because it can be cured with thromboembolectomy. Pulmonary embolism is common in hospitalised patients. The mortality rate for pulmonary embolism continues to be high: up to 30% in untreated patients. The accurate detection of pulmonary embolism remains difficult, as pulmonary embolism can accompany as well as mimic other cardiopulmonary illnesses. Non-invasive diagnostic tests have poor specificity and sensitivity. The D-dimer level and the spiral CT angiography have also been employed as new alternatives and important tools for precise diagnosis of suspected pulmonary embolism. The standard therapy of pulmonary embolism is intravenous heparin for 5 to 10 days in conjunction with oral anticoagulants posteriorly for 3 to 6 months. The incidence of deep venous thrombosis, pulmonary embolism and death due to pulmonary embolism, can be reduced significantly and shown clear benefits only by adoption of a prophylactic strategy with low-molecular-weight-heparins or dextrans in patients at risk.

[Hypertension and dyslipidemia]. / Hipertensión y dislipemia.

Hypertension is a very important cardiovascular risk factor and directly leads to major atherosclerotic cardiovascular diseases, including coronary artery disease, stroke cardiac failure and peripheral artery disease. Hypertension tends to cluster with other atherogenic risk factors like dyslipidemia, insulin resistance, obesity and others. The association between hypertension and dyslipidemia is very frequent and the risk is more than additive and its possible pathogenesis may be of a common mechanism. Insulin resistance is the main cause of both risk factors. Endothelium dysfunction is present in arterial hypertension and dyslipidemia and the pathogenesis of atherosclerosis. The treatment of hypertensive patients must be individualized to accommodate both the concomitant dyslipidemia and other atherogenic factors.

Effect of different pharmacologic agents to reverse severe pulmonary hypertension among end-stage heart failure patients.

OBJECTIVE: The goal of this study was to analyze the hemodynamic responses during vasoreactivity tests among candidates for heart transplantation who displayed severe pulmonary hypertension seeking to identify risk markers of nonresponse to the test. MATERIALS AND METHODS: In this observational retrospective study we evaluated demographic, clinical, echocardiographic, and hemodynamic variables. The target hemodynamic goal in the vasoreactivity test was to achieve a transpulmonary gradient (TPG) <12 mm Hg and/or pulmonary vascular resistances (PVR) <2.5 Wood Units (WU). RESULTS: We analyzed medical records from 79 patients. Inotropes (dopamine or dobutamine) were used to treat 33 patients, nonselective vasodilators (nitroglycerin or sodium nitroprusside) were used in 22 patients, and prostacyclin (PC) was used in 24 patients. The study observed a significant decrease in pulmonary pressures, PVR, and TPG, with increased cardiac output (CO) compared with baseline hemodynamics in all groups. No significant differences were observed between agents except for an increase in CO, which was greater in the PC group. Also, 49.4% of patients were considered responders to the vasoreactivity test without significant differences between groups. Risk markers for absence of a response to the vasoreactivity test were a CO <2.5 L/min (odds ratio [OR] = 2.1; confidence interval [CI] 95%, 1.1-3.9; P = .035) and a PVR >6 WU (OR = 3.7; CI 95%, 1.8-7.6; P < .001) in the baseline hemodynamic study. CONCLUSIONS: Inotropes, nonselective vasodilators, and prostacyclin produced effective vasodilator responses in the pulmonary vascular bed during the vasoreactivity test. The presence of a baseline high PVR or a low CO were predictors of nonresponse to the test.