Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention.

OBJECTIVE: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN: Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING: Transnational registry in Spain. SUBJECTS: We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS: Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES: All-cause death. RESULTS: Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION: Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

[Spanish Society of Cardiology practice guidelines on ambulatory monitoring of electrocardiogram and blood pressure]. / Guías de práctica clínica de la Sociedad Española de Cardiología en la monitorización ambulatoria del electrocardiograma y presión arterial.

In the present paper, a historical review and a clinical up-date are done on two procedures of great medical interest: Holter electrocardiography and ambulatory blood pressure monitoring. Technical and methodological characteristics of each procedure are carefully exposed, emphasizing each the lack of an international agreement in order to establish regulations that make all the equipment homogeneous and reliable in order to increase both accuracy and reliability in diagnosis. Based on published international scientific documents and the personal experience of the authors, guidelines for clinical applications, indications and limitations of each technique are analyzed in relation to capacities of the Spanish political and social public health system profile. New concepts and dynamics of developments such as; dynamic QT, RR variability or pulse wave velocity are exposed, in the frame of the present time and future for improving efficiency and clinical application.

[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.

[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).

[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.

[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.

[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.

[Focal infections caused by non-typhi Salmonella: a review of our case series and comparison with other series]. / Infecciones focales por Salmonella no typhi: revisión de nuestra casuística y comparación con otras series.

Nine cases of local infection due to non typhi Salmonella enterica, some of them of unusual localization, in 8 patients (mean age 64.9 +/- 12.4 years) attended in Zamora's Virgen de la Concha Hospital over a period of five years, are described. Focal salmonellosis represented 1.5% of non-typhi salmonellosis cases in that period (9 out of 606 detected cases). 6 of the 8 patients (75%) showed a predisposing disease. In two patients the previous existence of gastroenteritis due to Salmonella was assessed and only in one of them concomitant bacteremia was detected. Soft-tissue infections were the more frequent clinical feature: plantar abscess, two abdominal wall abscesses--one of them after cholecystectomy--post-pericardiotomy thoracic wall abscess and perianal abscess. Three soft-tissue infections were due to group B serotypes. 4 out of five soft-tissue infections evolved favorably with surgical treatment. The rest of the series is formed by two cases with acute cholecystitis in patients with previous cholelithiasis (one of whom relapsed originating an abdominal wall abscess), a recurrent pleural empyema and a purulent pericarditis. The pericarditis was produced by S. enteritidis. Patient showed signs of cardiac tamponade, his condition improving after pericardial drainage and parenteral and intrapericardial administration of ciprofloxacin. Epidemiologic and clinic characteristic of our series are compared with other series of focal salmonellosis.

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.

Cardiac tamponade in rheumatoid arthritis.

A 56-year-old woman with definite rheumatoid arthritis developed cardiac tamponade while her disease was both clinically and serologically inactive. To our knowledge such a complication has been reported only once previously.