Parathyroid hormone, calcidiol, calcitriol and adverse events in the acute coronary syndrome. / Hormona paratiroidea, calcidiol, calcitriol y riesgo de eventos adversos en pacientes con síndrome coronario agudo.

OBJECTIVE: To know the clinical profile as well as the prognostic significance of elevated levels of parathyroid hormone (PTH) in patients admitted for acute coronary syndrome (ACS). DESIGN AND SETTING: Observational and prospective study of patients admitted for ACS in a single Spanish center during a period of six months. INTERVENTION AND VARIABLES OF INTEREST: The circulating concentrations of PTH, calcidiol, calcitriol, NT-proBNP, C-reactive protein, cystatinC and fibrinogen were determined within the first 48h at admission. We performed adjusted models to predict death or re-entry for ACS after hospital discharge. RESULTS: A total of 161 patients were recruited (age 67±14 years, 75.2% were men). Forty-one (25.5%) patients had elevated PTH values. During follow-up for a period of 275 person-years, 50 adverse events were recorded. Patients with elevated PTH levels were proportionally more women (21.2 vs. 39.0%) and older (63.3 vs. 77.8 years, both P<.05). Likewise, they presented significantly more cardiovascular risk and a worse prognosis during follow-up (incidence rate ratio 2.64 CI 95%: 1.5-4.6). However, in an adjusted model by the GRACE score, PTH levels were not shown to be an independent risk factor (hazard ratio=1.1; 95% CI: 0.6-2.2), neither other components of the panel. CONCLUSIONS: The proportion of patients with elevated levels of PTH admitted for ACS was high. The presence of high PTH levels was associated with an unfavorable clinical profile and a worse outcome during the follow-up, although it was not an independent predictor of poor prognosis.

The exercise test that indicates a low risk of events. Differences in prognostic significance between patients with chronic stable angina and patients with unstable angina.

OBJECTIVES: The objective of this prospective study was to determine the differences in the prognostic significance of an exercise test (ET) that indicates a low risk of events (low-risk exercise test [LRET]) between patients with unstable angina (UA) and those with chronic stable angina (CSA). BACKGROUND: It is not known whether the prognostic significance of an LRET is influenced by the disease; that is the reason for performing exercise testing. METHODS: All patients not presenting with high-risk criteria were submitted to a prognostic ET. The ET was performed by patients with CSA and patients with primary UA stabilized with medical therapy. Medical therapy was planned for all patients. A combined end point was defined as cardiac death, nonfatal acute myocardial infarction or hospital admission for UA. Multivariate analysis was performed to determine the independent predictors of events. RESULTS: Low-risk criteria were fulfilled by 105 patients with UA and 86 patients with CSA. The mean follow-up time was 347 +/- 229 days. The event rate was higher in the UA group than in the CSA group (28% vs. 9%, p = 0.001). The CSA group showed worse ET results. Performance of ET by patients with UA was the principal predictor of events (odds ratio 4.2, p = 0.0005). CONCLUSIONS: Among patients who underwent an LRET, those with UA had a rate of events significantly higher than that of patients with CSA, despite the worse results of ET in patients with CSA.

[Percutaneous mitral valvotomy. The experience of the Hospital Universitario San Carlos of Madrid]. / Valvotomía mitral percutánea. Experiencia del Hospital Universitario San Carlos de Madrid.

Percutaneous mitral valvotomy is an alternative to surgery for the treatment of selected patients with mitral stenosis. With the purpose of reviewing our own experience and to determine the relationship of several variables with procedural success or complications rate, we have analyzed the immediate results of 335 consecutive procedures (90% with the Inoue balloon). Mean age was 51 +/- 12 years, 79% were female, 59% were in atrial fibrillation, 49% in NYHA class > or = III and 34% had mild mitral regurgitation. Mean echocardiographic score was 7.6 +/- 1.9 and up to 25% of patients had a total score > or = 8. Mean mitral valve area (Gorlin) increased from 0.94 +/- 0.2 to 1.87 +/- 0.5 cm2, with increments > or = 50% in mitral area in 88% and a final area > or = 1.5 cm2 in 85% of patients. Patients with an score > 8 obtained smaller mitral areas (1.64 +/- 0.4 vs 1.95 +/- 0.5 cm2. p < 0.01), and a higher percent of suboptimal (< 1.5 cm2) mitral area (22 vs 2%, p < 0.001) than patients with a lower score. Echocardiographic score (p = 0.009), balloon size (p = 0.01) and left atrial diameter (p = 0.04) were identified as independent predictors of a post-procedural mitral area > or = 1.5 cm2. Complications including cardiac tamponade (3 cases), cerebral ischemic events (1 case) and death (1 case) were rare. Mitral regurgitation increased by 2 or more grades in 14%, but regurgitation was severe in only 6% and early mitral surgery was required in 6 (2%) patients. No clinical, anatomical or procedural variables were found to be predictors of a significant increase in mitral regurgitation, a complication which occurred even in valves with a low echocardiographic score. In conclusion, percutaneous mitral valvotomy is a safe and effective procedure for the treatment of selected patients with mitral stenosis. Since complications, even if rare might be serious, the procedure should be performed only in symptomatic patients.