Prevalence and prognostic influence of peripheral arterial disease in patients >or=40 years old admitted into hospital following an acute coronary event.

OBJECTIVE: A significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes. METHODS: The PAMISCA register is a prospective, multicenter study involving patients >or=40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event. RESULTS: 1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03-1.06; p<0.001), smoking (OR: 1.88; 95% CI: 1.41-2.49; p<0.0001), diabetes (OR: 1.30; 95% CI: 1.02-1.65; p<0.05), previous cardiac disease (OR: 1.54; 95% CI: 1.22-1.95; p<0.001) and previous cerebrovascular disease (OR: 1.90; 95% CI: 1.28-2.80; p<0.001). Following the ACS, an ABIor=40 years presenting with ACS is high and it is associated with increased cardiovascular risk.

Isosorbide dinitrate sublingual therapy for inferior myocardial infarction: randomized trial to assess infarct size limitation.

To assess the potential of isosorbide dinitrate sublingual therapy for limiting myocardial infarct size, 41 patients with inferior acute myocardial infarction (AMI) were studied. Twenty patients were randomly assigned to the control group and 21 to the treatment group. Patients in the treatment group received 10 mg of isosorbide dinitrate every 2 hours for 72 hours. To estimate infarct size, QRS scoring, peak creatine kinase (CK) serum levels and CK curves were used. There were no significant differences between the 2 groups in maximal or cumulative activity of CK or QRS score (percent of left ventricle infarcted: 16% in the control group, 17% in the treatment group). In both groups the QRS score increased significantly by 13 hours after AMI, and the increase was highly significant by 19 to 23 hours. Thus, sublingual isosorbide dinitrate at the dosage given did not reduce infarct size in patients with inferior AMI.

[Perforating epicardial lead: atypical evolution]. / Perforación de un electrodo epicárdico: una evolución atípica.

Endocarditis related to pacemaker lead is a rare complication of permanent transvenous pacing, of which the diagnosis is carried out with the presence of verrucae in echocardiography and positive blood cultures, its treatment being mixed -medical and surgical- because the isolated medical treatment is rarely successful and the lead should be extracted. We present the case of recurrent endocarditis of several years of evolution, in the which it was not possible to extract of the electrode due to the special characteristics of the patiente (epicardial lead perforating into right atrial).

[Ventricular tachycardia and cardiac hemochromatosis]. / Taquicardia ventricular y hemocromatosis cardíaca.

Hemochromatosis is characterized by an excessive iron deposit in different tissues. Cardiac involvement may be observed in one third of the patients due to hemochromatosis and occurs as a consequence of ferritin accumulation in the heart which on one hand induces alterations in systolic and diastolic ventricular function and on the other hand, an arrythmogenic substrate. The clinical manifestations can be indistinctly related to atrial tachyarrhythmia, ventricular tachyarrhythmia, atrio-ventricular blockade and congestive heart failure, with the first being the most frequent. We present the case of one patient with secondary hemochromatosis to repeated transfusions due to sideroblastic anemia with cardiac involvement, whose initial heart manifestations were recurrent atrial tachyarrhythmia and sustained ventricular tachycardia with syncope for which an automatic defibrillator was implanted.

[Atrial standstill and rheumatic mitral valvulopathy]. / Parálisis auricular y valvulopatía mitral reumática.

Atrial standstill is a very rare form of bradyarrhythmia and consists of a transitory or permanent loss of the electrical and mechanical activity of the atria. We report a series of 8 patients, all of them with rheumatic valve disease (5 of them with a prosthetic valve) with symptomatic bradyarrhythmia secondary to atrial standstill, requiring an implantable pacemaker.

[Cardiomyopathy (X). Clinical approach to the patient with hypertrophic cardiomyopathy]. / Miocardiopatías (X). Actitud clínica ante el paciente con miocardiopatía hipertrófica.

Hypertrophic cardiomyopathy is a clinical and anatomofunctional entity that determines a series of hemodynamic consequences closely related to sintomatology. Left ventricular hypertrophic, subaortic stenosis, diastolic dysfunction and myocardial ischemia are the different pathophysiology mechanisms that generate similar clinical manifestations. Sintomatology defines two groups of patients with different profiles and clinical management. Ventricular arrhythmias are not uncommon and the forms that imply a darkest prognosis are supported symptomatic ventricular tachycardia and the induced ventricular tachycardia in patients that have suffered a cardiac arrest or have had syncopes. Basic explorations in all patients, in addition to physical examination, chest radiography and rest electrocardiogram, are Doppler echocardiography and Holter. Other explorations, such as Tallium-201 stress test, tilt test, electrophysiological and hemodynamic studies, are rationalized according to risk profile, sintomatology and responses to indicated treatment. In general, prognosis in asymptomatic patients is good and complex explorations are not justified nor are preventive character treatments. Symptomatic patients who have a higher risk must be studied more closely, and frequently require complex and invasive explorations. They also need pharmacological treatment and often more invasive therapeutical options, DDD pacemakers or surgery, if those fail.

[The effect of the mean platelet volume on the short-term prognosis of acute myocardial infarct]. / Influencia del volumen plaquetario medio sobre el pronóstico a corto plazo del infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: The increase of mean platelet volume in the late phase of myocardial infarction is an independent predictor for recurrent myocardial infarction and death, but the association between this finding and the short-term prognosis after acute myocardial infarction is unknown. The goals of this study were to assess the influence of mean platelet volume on the risk of death, recurrent ischemic events or cardiac heart failure during the in-hospital phase of myocardial infarction and to analyse the relationship between mean platelet volume and several demographic and clinical variables registered on admission. MATERIAL AND METHODS: A population of 1,082 patients with acute myocardial infarction were distributed in two groups according to the platelet volume measured on admission: group 1, mean platelet volume > 9 fl (n = 443) and group 2, mean platelet volume < or = 9 fl (n = 639). The difference between both groups on the end-point of this study were assessed by univariate and multivariate statistical methods. An univariate analysis was also applied to assess the relationship between platelet volume and the baseline variables. RESULTS: A mean platelet volume > 9 fl was associated with a significant increase of risk for the combined end-point considered (OR = 1.37; p = 0.026). By univariate analysis, an increased platelet volume was related to a higher risk of cardiac failure (OR = 1.46; p = 0.01) and a non-significant increase in the incidence of recurrent ischemic events (OR = 1.35; p = 0.07). In addition, a large platelet volume was also associated with a higher prevalence of prior myocardial infarction, arterial hypertension and diabetes mellitus. CONCLUSIONS: The results of this study suggest that the increase of mean platelet volume on admission is an independent risk factor for cardiac heart failure and is associated with a non significant higher rates of ischemic events during the recovery phase of acute myocardial infarction.

[Drug treatment of angina pectoris. Study Group on Angina Pectoris of the Ischemic Cardiopathy and Coronary Units Section of the Spanish Society of Cardiology]. / Tratamiento médico de la angina de pecho. Grupo de Estudio de Angina de Pecho de la Sección de Cardiopatía Isquémica y Unidades Coronarias de la Sociedad Española de Cardiología.

Medical treatment in angina pectoris is supported by: 1) slowing in coronary artery disease progression; 2) control of the angina episodes and the enhanced of the functional status, and, 3) prognosis improvement. The authors describe in this review, inside the own experience and the large body of evidence, the general measures and pharmacological treatment of both stable and unstable angina. There are included some therapeutic options in associated clinical conditions.

[The "arrhythmic pattern": a new method with prognostic significance in myocardial infarct]. / "Patrón arrítmico": un nuevo método con significación pronóstica en el infarto de miocardio.

OBJECTIVES: To establish a score or arrhythmic pattern for the prediction of long-term cardiac deaths on patients who have survived to the first acute myocardial infarction. PATIENTS AND METHODS: We studied prospectively 200 patients that survived at a first myocardial infarction and in whom ambulatory ECG monitoring during 24 hours between days 7th and 18th (mean 12th) from the infarction was performed. The mean follow-up time was 51 +/- 18 months. The number and type of ventricular arrhythmias were analyzed and a score was measured, accordingly with Castellanos and Lown's classifications. An "arrhythmic pattern" or "total punctuation" was defined and compared among two groups: group 1 > 65 points and group 2 < 65 points. RESULTS: The differential characteristics of both groups were: age (60 +/- 9 versus 56 +/- 10 years old; p = 0.004); hypertension (63% versus 29%; p < 0.001); clinic stage II-III (23% versus 11%; p = 0.02); echocardiographic ejection fraction (45 +/- 11% versus 50 +/- 10%; p = 0.04); positive exercise testing (73% versus 56%; p = 0.01); arrhythmias on the exercise test (15% versus 25%; p = 0.006). The long-term cardiac mortality was 25% versus 6% (p = 0.01), with an incidence of sudden death of 11% versus 3% (p < 0.05). Specificity, sensibility, positive predictive value and negative predictive value (reference cut point of 100) were 94, 65, 71 and 91%, respectively. CONCLUSIONS: The use of a score of arrhythmic pattern may identify 2 groups of patients with different clinic profiles that probably justify a different long-term prognosis after a first acute myocardial infarction.

[Mitral prosthesis thrombosis treated by fibrinolysis with accelerated administration of r-TPA]. / Trombosis protésica mitral tratada mediante fibrinólisis con dosis acelerada de r-TPA.

We report the case of a 53-year-old patient with a mitral prosthesis hospitalized for heart failure. Diagnosis of mitral prosthetic thrombosis, led to a therapeutic disjunction between thrombolysis and surgery. Because of the high risk of surgical intervention, the patient was treated with r-TPA (accelerated infusion), showing immediate, successful response.

[Clinical characteristics and hospital mortality of acute myocardial infarction in elderly patients treated with thrombolytic agents]. / Características clínicas y mortalidad hospitalaria del infarto agudo de miocardio en ancianos tratados con fármacos trombolíticos.

OBJECTIVES: This study describes the clinical features of elderly patients with acute myocardial infarction treated with thrombolytics and the effect of such therapy on in-hospital mortality rates in these patients. METHODS AND RESULTS: A group of 463 consecutive patients older than 70 years with an acute myocardial infarction was studied. This population was divided into two groups: 157 patients who received thrombolytic therapy (group A) and 306 patients who did not (group B). Patients in group A were younger (77 vs 79 years; p = 0.01) and had a lower prevalence of females (32.5% vs 44.1%; p = 0.01), prior myocardial infarction (14% vs 28%; p = 0.0008), hypertension (38% vs 48%; p = 0.03), diabetes (17% vs 26%; p = 0.02), class Killip 3 at entry (3.5% vs 14%; p = 0.001), a higher frequency of Q wave MI (88% vs 50%; p = 0.0001), inferior location of MI (51% vs 32%; p = 0.00007) and Killip 1 (70% vs 57%; p = 0.01) compared to group B. No significant differences on the inhospital mortality between either group were observed (25.5% vs 24.8%; p = 0.88). However, the thrombolysis was associated with higher mortality in patients with left ventricular dysfunction at entry (41% vs 84%; p = 0.0008) and in those patients with a delay of more than four hours from the onset of symptoms to admission (19% versus 30%; p < 0.1). CONCLUSIONS: 1) In the elderly with acute myocardial infarction, thrombolytic therapy is administered to a lower risk population; 2) our findings do not confirm the benefits of chemical thrombolysis on cardiac mortality in the elderly, and 3) in selected subgroups (Killip > 2 at entry, symptoms delay > 4 hours) the risk/benefit ratio of thrombolytic therapy should be reevaluated. However, care needs to be taken in evaluating the data because this study was not blinded and the number of patients included was relatively small.

[Study of heart rate variability in acute myocardial infarction and its relationship with ventricular function and other clinical variables]. / Estudio de la variabilidad de la frecuencia cardíaca en el infarto agudo de miocardio y su relación con la función ventricular y otras variables clínicas.

BACKGROUND: The influence of ventricular function (VF) on prognosis in acute myocardial infarction (AMI) is well known. Heart rate variability (HRV), as a neurohumoral parameter could predict VF after discharge in AMI patients. Our goal is to investigate the possible relation among HRV, VF and another clinical variables in AMI. PATIENTS AND METHODS: We studied 37 patients with AMI after hospital discharge. Age, AMI type, location, enzymes, treatment (thrombolysis versus no thrombolysis) were evaluated. The left ventricular ejection fraction (LVEF) was assessed by radionuclide ventriculography in 27 subjects. Twenty nine subjects without cardiopathy were the control group. Twenty four hour electrocardiographic recordings were obtained and a proper software was used to measure HRV. This was evaluated with time domain measures: RR interval, standard deviation of the mean RR interval (SDNN), standard deviation of the average of the RR intervals measured every 5 minutes during 24 hours (SDANN) and number of two consecutive RR intervals with a variability > 50 ms (pNN50). We considered a decreased variability if SDANN was less than 100 ms. Two groups were established: 1) low heart rate variability (LHRV) if SDANN was less than 100 ms, and 2) normal heart rate variability (NHRV) if SDANN was larger than 100 ms. Continuous variables were examined by the t-test, chi square for discrete ones and linear regression analysis was used to assess the relation among variables. A p < 0.05 was considered significant. RESULTS: The percentage of infarcted patients in the group of LHRV is 75%, whereas it is 14% in the control group (p < 0.05). SDANN, SDNN and pNN50 values are significantly lower (p < 0.05) in the AMI than in the control group. LHRV was more frequent in patients with complicated AMI with congestive heart failure. LVEF was significantly lower (35% vs 56%) in the LHRV than in the NHRV group. No significant differences were found among: site, type infarct, treatment or ventricular ectopy in the Holter before discharge. There is good correlation (r = 0.635; p < 0.05) between LVEF and HRV measures. No correlation was found between HRV and age, or the enzymatic size of infarction. CONCLUSIONS: 1) LHRV is frequent in the late phase of AMI, and 2) LHRV can be an indirect index of left ventricular failure.

[Appraisal of the state of the autonomic nervous system in hypertrophic cardiomyopathy by the analysis of heart rate variability]. / Aproximación al conocimiento del estado del sistema nervioso autónomo en la miocardiopatía hipertrófica mediante el análisis de la variabilidad de la frecuencia cardíaca.

INTRODUCTION: The analysis of heart rate variability has been accepted as a non-invasive method to evaluate the influence of the autonomic nervous system over the heart. Although heart rate variability has been used during the last decade in several illnesses the studies in hypertrophic cardiomyopathy are scarce. OBJECTIVES: We report the activity of the autonomic nervous system in patients with hypertrophic cardiomyopathy using the analysis of heart rate variability. PATIENTS AND METHODS: Heart rate variability was evaluate by the analyzing 24-h ambulatory electrocardiograms (Holter) in 20 patients with hypertrophic cardiomyopathy and in 15 controls. This method has been used to measure heart rate variability. Spectral analysis of the frequencies were calculated using fast Fourier transformation. Spectral heart rate variability was computed as high (0.15 to 0.40 Hz) low (0.04 to 0.15 Hz) and total (0.01 to 1.0 Hz). We compared the relation between low/high frequency as an index of the sympathetic/parasympathetic balance. All data are expressed as mean value +/- SD. The unpaired Student t-test was used. A two tailed p valued < 0.05 was considered statistically significant. RESULTS: There were no differences in the mean heart rates among the patients with hypertrophic cardiomyopathy and normal subjects (mean +/- SD: 71 +/- 9 versus 74 +/- 11 beats/minute; p = NS) while there was a significant decline in total spectral (mean +/- SD: 7.14 +/- 1.1 versus 7.57 +/- 0.6 ln [ms2]; p = 0.02) and high (mean +/- SD: 5.22 +/- 0.8 versus 5.63 +/- 1.3 ln [ms2]; p = 0.04) as well as in low spectral frequency of heart rate variability (mean +/- SD: 22 +/- 0.8 versus 5.63 +/- 1.3 ln [ms2]; p = 0.04) in patients with hypertrophic cardiomyopathy. There were no differences in the low/high frequency component ratio in these patients (mean +/- SD: 1.1 +/- 0.1 versus 1.2 +/- 0.1 ln [ms2]; p = NS). CONCLUSIONS: These facts suggest that the patients with hypertrophic cardiomyopathy have an alteration in the autonomic nervous system: sympathetic (low spectral frequencies) and parasympathetic activity (high spectral frequencies), although this does not reflect an imbalance between sympathetic and parasympathetic activities (relation of low to high spectral frequencies).

[Permanent endocardial pacemaker. Review of 116 implantations (author's transl)]. / Marcapaso endocavitario permanente. A propósito de 116 implantaciones.

A retrospective study on the results of 116 permanent ventricular pacemaker implantations performed in the Service of Cardiology of the Hospital Clinico Universitario in Salamanca is reported. In the majority of cases the indication for a pacemaker was a complete atrioventricular block (53 cases). Sixteen cases had a "sick-sinus syndrome". An apparent cardiopathy was not found in 84 percent of the cases. In the group of patients with cardiopathy that of ischemic type was the most common. The technique of endocardiac catheter pacing was employed in all cases. An 18 percent of global complications occurred, but in no case an early electrode displacement was registered. Complications appeared at a later time included erosion of the pacemaker in ten cases, and displacement and/or deinsertion in seven. The mean life for 18 displaced generators was 41.3 months. A sudden equipment malfunction occurred in two cases, and an inhibition by potentials of the pectoralis major muscle in another. Morbidity rate was lower to that of other published series, may be due to the use of modern generators with a progressive reduction of its diameter and weight and more flexible electrodes which allow a better implantation. The mortality rate was zero.

[Changes in exercise capacity and in induced ischemia with an oral dose of 5 isosorbide mononitrate in patients with stable angina pectoris]. / Modificaciones en la capacidad de ejercicio y en la isquemia inducida con una dosis oral de 5-mononitrato de isosorbide en pacientes con angina de pecho estable.

In order to establish the effects of 5-isosorbide mononitrate on: the exercise capacity, the onset period of angina and ischemia along with the degree and on whether the duration time was prolonged up to 5 hours after the oral administration of 20 mg of this drug, we compare this drug against a placebo in a group of 15 patients with stable angina pectoris developed by effort who performed an exercise test using a bicycle ergometer. After the administration of 20 mg of 5-isosorbide mononitrate it was observed that onset time of angina (p less than 0.001), the onset time of ST decrease (p less than 0.002) and total time of exercise attained were significantly superior to those found in patients with placebo administration. Moreover, for the same degree of EKG ischemia (ST decrease) showed a superior exercise time was registered (p less than 0.002) after the administration of 5-isosorbide mononitrate (5-IM). Our results show that an oral dosage of 20 mg of 5-IM given to patients with stable angina pectoris increased the capacity and exercise tolerance delaying significantly the onset time of angina, the onset time of EKG ischemia and its decree induced by the effort up to 5 hours after its administration.

[Incidence and prognostic value of ischemic heart disease in high risk cardiovascular asymptomatic diabetic patients detected by gated myocardial perfusion SPECT study]. / Incidencia y valor pronóstico de la existencia de cardiopatía isquémica en pacientes diabéticos asintomáticos de alto riesgo cardiovascular sometidos a un estudio gated-SPECT de perfusión miocárdica.

AIM: To determine the clinical utility of the gated myocardial perfusion SPECT to detect silent ischemia in asymptomatic diabetic patients without previous coronary events and to evaluate the prognosis of this population. MATERIAL AND METHODS: A retrospective study of 56 asymptomatic diabetics referred for a gated myocardial perfusion SPECT for diagnosis of ischemic disease was performed. The criteria for ischemia were: mild SDS<4, moderate SDS 4-8, severe SDS>8. A multivariable statistical analysis was carried out to identify possible predictive variables of an abnormal SPECT. The cardiovascular events were recorded up to December-2010. RESULTS: A high proportion of the 56 patients had an abnormal perfusion study (46.4%), there being moderate-severe ischemia in 10.7%, necrosis with ischemia in 5.4% and necrosis in 7.1%. We found no statistical differences in the type of stress used (treadmill or dipyridamole). The patients had a high combination of cardiovascular risk factors. In the multivariate analysis, diabetic nephropathy was the only factor related to an abnormal SPECT (p=0.043). The events recorded in the follow-up were: 2 early revascularizations, 5 cardiology admissions, 10 non-cardiac related deaths. The existence of ischemia in the SPECT was significantly related to the appearance of cardiovascular events (p<0.05). CONCLUSION: A gated myocardial perfusion SPECT in asymptomatic diabetics with high combination of cardiovascular risk factors detects silent ischemia in a significant proportion and this seems to be related to future coronary events. Diabetic nephropathy implies a greater likelihood of abnormal studies. However, the screening criteria in this population still need to be established for better performance and lower cost.