The tobacco paradox in acute coronary syndrome. The prior cessation of smoking as a marker of a better short-term prognosis. / La paradoja del tabaco en el síndrome coronario agudo. El abandono previo del hábito tabáquico como marcador de mejor pronóstico a corto plazo.

OBJECTIVE: The tobacco paradox is a phenomenon insufficiently explained by previous studies. This study analyses the prognostic role of prior or active smoking in patients with acute coronary syndrome. METHODS: We obtained data from the ARIAM registry, between 2001 and 2012. The study included 42,827 patients with acute coronary syndrome (mean age, 65±13 years; 26.4% women). The influence of smoking and that of being an ex-smoker on mortality was analysed using a multivariate analysis. RESULTS: The smokers were younger, were more often men, had less diabetes, hypertension and prior history of heart failure, stroke, arrhythmia and renal failure and more frequently had ST-elevation and a family history of smoking. The ex-smokers had more dyslipidaemia and history of angina, myocardial infarction, ischemic heart disease, peripheral vasculopathy and chronic bronchial disease. Smokers and ex-smokers less frequently developed cardiogenic shock (smokers 4.2%, ex-smokers 4.7% and nonsmokers 6.9%, P<.001). Hospital mortality was 7.8% for the nonsmokers, 4.9% for the ex-smokers and 3.1% for the smokers (P<.001). In the multivariate analysis, the smoker factor lost its influence in the prognosis (-0.26%, p=.52 using an inverse probability calculation; and+0.26%, P=.691 using a propensity analysis). However, the exsmoker factor showed a significant reduction in mortality in both tests (-2.4% in the inverse probability analysis, P<.001; and -1.5% in the propensity analysis, P=.005). CONCLUSIONS: The tobacco paradox is a finding that could be explained by other prognostic factors. Smoking cessation prior to hospitalization for acute coronary syndrome is associated with a better prognosis.

Anorexia nervosa and myocardial infarction.

A 39-year-old woman with long-standing anorexia nervosa was admitted to our hospital because of extreme weakness and cachexia. During a hyperalimentation therapy, she developed chest pain, revealing the electrocardiogram and cardiac enzymes a myocardial infarction of the inferior wall. We suggest that anorexia nervosa does not 'protect' against coronary atherosclerosis, and that some of the cases of sudden death could be related to myocardial ischemia.

Magnesium sulphate for torsade de pointes in a patient with congenital long QT syndrome.

A young woman with congenital long QT syndrome presented with repetitive torsade de pointes. A single bolus of magnesium sulphate abolished the arrhythmia.

Adverse effect of sodium nitroprusside 48 hours after myocardial infarction.

We present a patient with acute myocardial infarction in whom the use of nitroprusside 48 hours after the first symptom, was accompanied by a rise in the ST segment representative of the ischemic area. Our experience suggests that precaution is needed in the use of nitroprusside even several days after an acute myocardial infarction.

[Can we modify the pathogenesis of coronary disease? Introduction]. / Podemos modificar la patogénesis de la enfermedad coronaria? Introducción.

Recently the European Societies of Cardiology Atherosclerosis and Hypertension have published a document of Recommendations on the Prevention of Coronary Disease in Clinical Practice. The information given in the document has proven that a reduction in cholesterol reduces the risk of the onset of new coronary as well as cardiovascular mortality. It has been accepted that such reduction can induce the regression of the atheroma plaque, and the slowing of its progression. In Spain cardiovascular mortality has progressively decreased since 1975. This is true for the coronary caused mortality and the secondary to a cerebrovascular disease, the latter being that where the greatest change has been noticed, as well as in women. Probably, this trend may be explained by a better control on hypertension, as well as by a more adequate hospital net. Spain has one of the lowest rates of mortality due to coronary disease among the industrialized countries. Nevertheless, the cardiovascular mortality is still the first cause of death in Spain. Spanish cardiologist are convinced that the relationship between the levels of cholesterol and coronary risk happened in Spain, in quantitative terms, differently than in Central Europe and the USA. They consider that the "Mediterranean diet" is the protective factor.

[The prognosis for elderly patients admitted to a coronary unit for myocardial infarct: the changes over a decade]. / Pronóstico de los ancianos ingresados en la unidad coronaria por infarto de miocardio: cambios en una década.

INTRODUCTION AND AIM: New therapies have been added that improve prognosis of patients with myocardial infarction. Our purpose was to know if elderly patients reach benefit from these therapeutic changes. METHODS: We have analyzed the clinical data of 227 patients older than 70 who were admitted in our coronary care unit: 78 admitted in 1980-81 and 14 admitted in 1990-91. RESULTS: Although differences were not significant, in 1990-91 there were more women (36% versus 28%), less smoking (24% versus 33%), more patients with previous infarction (19% versus 12%), more hypertension (53% versus 43%), less anterior infarcts (38% versus 45%) more non Q infarcts (11% versus 1%), and less bundle branch block (21% versus 31%). In 1990-91, pacemakers were used less often (13% versus 27%, p = 0.03), thrombolytic therapy was given to 16 patients (10.7%), and the mortality rate was a little inferior (22% versus 30%, not significant). Female sex, not being a smoker, Killip class and bundle branch block were significantly related to mortality. After a multivariate analysis in which these factors we included, the date of admission resulted an independent predictor of mortality, with an odds ratio of 1990-91 to 1980-81 of 0.43 (p = 0.039). CONCLUSIONS: The management of patients older than 70 with myocardial infarction has improved, with a significantly lesser risk of dead after multivariate analysis, despite that thrombolysis has been scarcely applied.

[Intrapericardial cisplatin for malignant tamponade]. / Cisplatino intrapericárdico en el taponamiento neoplásico.

The choice therapy of malignant pericardial effusion is controversial. Pericardiocentesis is usually successful in alleviating tamponade, but unfortunately, that tamponade recurs frequently and patients are then again exposed to a critical situation and need hospitalization. Several different approaches have been advocated in order to prevent reaccumulation of the pericardial fluid, most of them quite cumbersome. We present our experience with intrapericardial administration of cisplatin. There were 6 patients, and the primary tumor was breast carcinoma in 2, lung in 1, ovary in 1, mediastinal fibrosarcoma in 1, and unknown in 1. Administration of cisplatin was virtually uneventful and painless, and there were no recurrences, with a survival of 2 to 18 months (mean 5.6).We conclude that intrapericardial cisplatin is safe and effective in treating malignant pericardial tamponade and preventing recurrence.

[Circulatory arrest after combined intravenous drugs for the treatment of orthodromic circular tachycardia of Wolff-Parkinson-White syndrome]. / Parada circulatoria tras uso combinado de fármacos intravenosos para tratar una taquicardia circular ortodrómica de un síndrome de Wolff-Parkinson-White.

Antiarrhythmic drugs administered intravenously run the risk of producing a hemodynamic collapse even when used by expert and well trained hands. The arrhythmias in the focal point of a preexcitation syndrome constitute a very special situation in which extreme caution must be used when using intravenous drugs, because the conduction through accessory channels can vary, depending on multiple factors. We describe a case of a patient with an accessory atrioventricular pathway and orthodromic tachycardia who developed cardiac arrest by wide QRS tachycardia after receiving intravenous amiodarone.

[Neurohormonal factors in heart failure (and III)]. / Factores neurohormonales en la insuficiencia cardíaca (y III).

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as "compensators", which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these system, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatments for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Neurohormonal factors in heart failure. II]. / Factores neurohormonales en la insuficiencia cardíaca (II).

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as "compensators", which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these systems, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at the cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatments for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Neurohormonal factors in heart failure. I]. / Factores neurohormonales en la insuficienica cardíaca (I).

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as 'compensators', which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these systems, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at the cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatment for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Clinical and electrocardiographic characteristics of masquerading bifascicular block]. / Características clínicas y electrocardiográficas del bloqueo bifascicular disfrazado.

INTRODUCTION: Masquerading bundle branch block is a right bundle branch block with a left anterior hemiblock which appears similar to a left bundle branch block in the frontal plane leads. MATERIAL AND METHODS: We have followed 22 patients with such a pattern in the electrocardiogram for 3 years. RESULTS: Thirteen patients (59%) developed high degree atrioventricular block. During this period, there were 4 deaths, 3 from heart failure and 1 due to sepsis. CONCLUSIONS: We conclude that progression to high degree atrioventricular block is quite common in the presence of this kind of branch block. It is frequently associated to advanced heart failure, so the prognosis is usually poor.

[Variant angina pectoris related to the treatment of migraine]. / Angina variante en relación con el tratamiento de la migranña.

A 54 years-old man with a history of migraine, suffered from chest pain together with ST-segment elevation related to the intake of drugs against migraine attacks. The coronary arteriography showed normal coronary arteries. We suggest coronary artery spasm as the most probable cause of ischemia. We conclude that vasoactive drugs against migraine must be utilized with caution, or even avoided in patients with chest pain suggestive of myocardial ischemia.

[Spanish Society of Cardiology practice guidelines on arterial hypertension]. / Guías de práctica clínica de la Sociedad Española de Cardiología en hipertensión arterial.

High blood pressure is a well-known cardiovascular risk factor that is responsible for an elevated morbidity and mortality. However, although efficacious drugs for treatment and numerous and updated scientific training programs are available, the reality is that only a low percentage of patients are followed up in accordance with the rates which are presently considered normal. The purpose of these guidelines is to provide medical guidance for the prevention, detection and evaluation of hypertension, and to provide the best diagnosis and treatment. The factors involved in cardiovascular complications in the hypertensive patient are multiple. That is why this report places more emphasis in the individual cardiovascular risk stratification as part of the treatment strategy. The information obtained in the most recent studies published confirms the interest in achieving the greatest decrease in rates of blood pressure. This treatment to lower levels is especially useful in the high-risk subgroup. It maintains the necessity of nonpharmacological measures or lifestyle modifications in all patients with high blood pressure who either need or do not need drug therapy. All pharmacological groups may be used, but it is appropriate to choose the specific antihypertensive agent adapted to the clinical and individual situation with the use of low doses of drugs to initiate therapy and the use of appropriate drug combinations.

[Influence of coronary risk factors in secondary prevention: tobacco]. / Influencia de los factores de riesgo coronario en prevención secundaria: tabaco.

Tobacco smoking is a strong independent factor for atherosclerotic disease, equivalent to hypertension or high cholesterol levels. Middle age people are especially involved, with a mortality rate of about 20% as a consequence of smoking, and a mean loss of life expectancy of 20 years. There is a positive correlation between smoking and severity of atherosclerotic disease in the coronary and cerebral arteries, and the aorta. It has been shown that smoking cessation clearly enhances the prognosis of patients with myocardial infarction. Twice a increase in mortality rate has been found among nonstopping smokers compared with those who stopped smoking eight years after myocardial infarction. In addition, progression of atherosclerosis as shown by angiography is slowed by stopping to smoke. As the coronary risk factors act in a synergistic way, a comprehensive approach to the patient is recommended, especially in smokers with myocardial infarction. It is justified an intensive intervention because of the advantages in this population. The physician should clearly communicate to the patient the need of stopping to smoke, which carries sometimes as beneficial effects as other interventions. A wise use of replacement therapy with transdermal nicotine, together with other useful measures, allows us to manage patients with a broad margin of safety, especially in coronary patients, who win most benefit from ceasing to smoke.

[A right atrial thrombus in transit: its echocardiographic diagnosis 72 hours before a pulmonary embolism]. / Trombo en tránsito en aurícula derecha: diagnóstico ecocardiográfico 72 horas antes de un embolismo pulmonar.

We report a case of a 72-year-old woman with coronary artery disease in whom a thrombus in transit in the right atrium was diagnosed accidentally. After 72 hours of treatment with intravenous anticoagulants she developed a pulmonary thromboembolism resolved with systemic fibrinolysis. This is a rare case in which such a diagnosis preceded an embolic event. This fact raises the controversy about the best therapeutic management of this unusual form of thromboembolic illness.

[Aortic coarctation: different anatomo-clinical forms depending on the age of presentation]. / Coartación de aorta: diferentes formas anatomoclínicas según la edad de presentación.

OBJECTIVE: To analyse the anatomo-clinical characteristics of the coarctation of the aorta at different ages of presentation as well as the findings and results of its surgical correction at different periods. PATIENTS AND METHODS: We retrospectively studied the clinical and angiographic data, as well as the intraoperative findings and surgical outcomes of 82 consecutive patients (54 M and 28 F) with coarctation of the aorta. Mean age was 16.2 +/- 13.7 years (1 month to 63 years). The patients were divided into three groups according to age: Group A (n = 10) under 1 year; Group B (n = 30) from 1 to 12 years and Group C (n = 42) over 12 years. RESULTS: A preductal form was found in 20.7% cases (50.0%, 30.0% and 7.1% of groups A, B, and C respectively; p = 0.003). An associated left-to-right shunt was present in 19.5% (40.0%, 16.7% and 16.7% of groups A, B and C respectively; p = NS). The first manifestation of the disease was different in groups A, B and C. Among group A patients, congestive heart failure was the most frequent presentation (70.0%). In group B, the most frequent presentation (30%) was as an incidental finding in an asymptomatic patient. Finally, systemic hypertension or its complications predominated among group C patients (38.0%). Left ventricular hypertrophy on ECG was present in 0.0%, 30.0% and 54.7% of patients in groups A, B and C (p = 0.003) respectively. Postoperative complications including death, hypertensive crisis and re-coarctation were observed in 90.0%, 33.3% and 21.4% in groups A, B and C (p = 0.01) respectively. CONCLUSIONS: Among patients with coarctation of the aorta, the age of clinical presentation allows us to define groups of patients with different anatomical characteristics, clinical course and postoperative outcome.

[Age is the independent prognostic factor in acute myocardial infarct. The clinical course of infarct in the elderly patient]. / La edad es factor pronóstico independiente en el infarto agudo de miocardio. Curso clínico del infarto en el anciano.

We analyze the influence of age in the evolution of patients with acute myocardial infarction admitted to our Coronary Care Unit throughout two years (1990 and 1991). All 542 patients admitted during this period were classified in three groups: 299 less than 65 year old (group A), 170 between 65 and 74 year old (group B), and 73 with 75 year old or more (group C). Aged patients had a worse clinical condition, with significantly more previous heart failure, diabetes or hypertension, and the Killip's class was worse in group C than in group B, and worse in this than in group A (p = 0.00000). The mortality rate was 6.7% in group A, 12.9% in group B, and 31.5% group C (p = 0.00000). After a multivariate analysis, only three factors were significantly associated to prognosis: previous stroke, Killip's class, and group of age. Fibrinolytic therapy and coronary arteriography were less frequent with old people (p = 0.00000 and p = 0.00000 respectively). We conclude that age is an independent factor of prognosis during myocardial infarction. Old people have a worse clinical condition and the treatment is less aggressive than in young people.

Clinical scores and patient risk stratification in non-ST elevation acute coronary syndrome.

BACKGROUND: Risk stratification of patients with unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI) is problematic given the heterogeneous presentation of the condition. This study was undertaken to compare, in UA/NSTEMI patients, the prognostic value of two clinical risk scores (RS) (i.e. Thrombolysis in Myocardial Infarction (TIMI) and physician's risk assessment (PRA)) and to assess whether serum biomarkers can increase the prognostic accuracy of these RS. METHODS: We prospectively assessed 610 consecutive UA/NSTEMI patients, 217 (36%) UA and 393 (64%) NSTEMI. In all patients RS, high sensitivity C-reactive protein, CD40 ligand, IL6, IL10, IL18, E-selectin, P-selectin, white blood cell count, neopterin, myeloperoxidase, fibrinogen and NT proBNP were assessed at study entry. The primary study endpoint was death and non-fatal MI at 30 and 360 days of follow-up. RESULTS: At 1 year, 54 patients (8.9%) had reached the primary study endpoint (26 suffered a cardiac death (4.3%) and 34 (5.6%) a non-fatal MI). For both RS, the study endpoint occurred more commonly in patients at a "higher risk" compared to those classified as being at a "lower risk". Moreover, TIMI and PRA RS had similar discriminatory accuracy. TIMI RS, however, was a better predictor of events than PRA at both 30- and 360-day follow-up. The inflammatory biomarkers assessed in the study did not improve significantly the predictive value of RS. CONCLUSIONS: Our study suggests both that TIMI RS is a better marker of risk than PRA RS and inflammatory biomarkers do not increase the predictive value of these clinical risk scores.