Additive value of diabetes and peripheral arterial disease in the risk stratification of patients admitted after an acute coronary syndrome: a subanalysis of the PAMISCA Study.

BACKGROUND: There is an increasing interest in the use of non-invasive methods for the detection of subclinical atherosclerosis to better identify patients with high risk of cardiovascular events The presence of diabetes mellitus (DM) and peripheral arterial disease (PAD) is associated with increased risk of events but their value in the acute coronary syndrome (ACS) patient has not been ascertained. METHODS: We performed a subanalysis of the PAMISCA study, designed to investigate the prevalence of PAD in patients admitted to Spanish hospitals with a diagnosis of an ACS. RESULTS: A total of 1410 patients were analysed (71.4% men, age 66 +/- 11.9 years, 35% DM). The prevalence of PAD was higher in DM vs. no-DM (41.5% vs. 30.6% respectively, p < 0.001). Patients with PAD and DM had more in-hospital cardiac complications such as atrial fibrillation/flutter, recurrent myocardial ischaemia and heart failure and a trend towards higher in-hospital mortality (p = 0.08). Non-DM patients with PAD and DM without PAD shared similar cardiac complications and the group without neither PAD nor DM had the best prognosis. In patients without PAD, DM was an independent predictor of three-vessel coronary disease (OR 1.6; 95% CI: 1.1-2.5, p < 0.05) after adjustment by age, sex, low density lipoproteins (LDL), smoking and the previous myocardial infarction. However, in PAD patients, DM failed to be an independent risk factor in the multivariate analysis (OR 1.0; 95% CI 0.6-1.6, p < 0.05). CONCLUSIONS: The concurrence of DM and PAD helps identify patients with an adverse risk profile.

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.

Most advisable strategy in search of asymptomatic target organ damage in hypertensive patients.

OBJECTIVE: To evaluate the diagnostic potential of seven examinations in order to define the most suitable strategy for target organ damage (TOD) search in hypertensive patients. METHODS: This is a descriptive, cross-sectional study. 153 consecutive treated and essential hypertensive patients were enrolled. Patients with established cardiovascular or chronic renal disease (stage ≥4) were excluded. TOD search was assessed by: glomerular filtration rate (GFR), albumin/creatinine ratio (ACR), electrocardiogram (ECG), echocardiogram (ECO), ankle-brachial index (ABI), pulse wave velocity (PWV), and carotid ultrasound (intima media thickness and presence of plaques). The rationale of our strategy ought to determine the performance of applying a set of the most widely available tests (GFR, ACR, ABI, ECG) and advise about the optimal sequence of the remaining tests. RESULTS: The sample was 64.4±7.9 years old, 45.8% males. 82.6% of the sample had any TOD at all. The resulting algorithm found a 37% TOD in relation to GFR, ACR, ABI and ECG values. Adding carotid ultrasound added up to 70% of the studied population and properly classified (TOD+/TOD-) 89% of the cohort. When performing PWV, 78% of the patients had been identified as TOD+ and 96% of the population was correctly identified. Contribution of ECO was minor. CONCLUSION: After running the more widely available explorations (GFR, ACR, ABI, ECG), a step-by-step strategy that included carotid ultrasound, PWV and ECO could be the best sequence for TOD search in asymptomatic hypertensive patients.

[Hormone replacement therapy in hypertension in the postmenopausal woman]. / Terapia hormonal sustitutiva en la hipertensión de la mujer posmenopáusica.

Naturally occurring or surgically related hormonal deprivation at menopause is associated with cardiovascular and non-cardiovascular complications. Hormonal replacement therapy helps to prevent and treat these complications, not only symptoms associated with menopause (which continue to be their major indication) but also bone and cardiovascular related problems. It is well known that oral contraceptive use is one of the most common reversible causes of secondary hypertension. This is, in part, why the use of hormonal replacement therapy has provoked such suspicion among clinicians who have mainly believed that a similar effect on blood pressure would probably occur with the use of hormonal replacement therapy. However, the results of a variety of clinical studies and surveys do not confirm these suspicions. These beneficial effects have to be weighed against the risk of endometrial hyperplasia, endometrial cancer and breast cancer (among other unwanted effects) that could occur when long-term therapy is implemented. If one considers that the overall risk associated with cardiovascular mortality is more than four times higher than the risk associated with gynecological malignancies, even a modest decrease in the cardiovascular risk could easily outweigh other risks and result in an overall improved risk profile in postmenopausal women.

[Impact of diabetes mellitus on the late clinical outcome of coronary revascularization with stents]. / Influencia de la diabetes mellitus en los resultados clínicos tardíos de la revascularización coronaria con stents.

INTRODUCTION: The Influence of diabetes mellitus in the late outcome of coronary stenting remains controversial. AIM: The aim of this study was to determine the late clinical outcome of diabetics in comparison with non diabetics and to establish whether there are subgroups of diabetic patients with a greater need for target lesion revascularization. METHODS: Two hundred sixteen consecutive patients (74 diabetics; 95 stents in 90 lesions and 142 non diabetics) who had successfully undergone coronary stenting were included in the study and followed over 17.6 +/- 10 months. The clinical events evaluated were target lesion revascularization, death and acute myocardial infarction. Independent predictive variables of target lesion revascularization were studied in both groups of patients. RESULTS: The diabetic patients presented greater cardiovascular mortality (6.7% vs 1.4%; p=0.02) but the incidence of infarction was similar in the two groups (2.7% vs. 3.5%; p=0.6). The accumulated rate of target lesion revascularization at two years was 18.2% in diabetics vs 13.3% in non diabetics (p=0.09), respectively. The presence of three vessel disease (p=0.014), history of arterial hypertension ([=0.011) and residual stenosis > 0% (p=0.005) were specific predictive factors of target lesion revascularization for diabetic patients and together with vessel diameter < 3mm (p<0.001) subgroups of diabetics were independently selected with a significantly greater incidence of target lesion revascularization than the non diabetic patients. CONCLUSIONS: Following coronary stenting, diabetic patients show a greater cardiovascular mortality than non diabetics, but only some subgroups of diabetics (small vessels extensive coronary disease, associated arterial hypertension, residual stenosis) show a significantly greater risk of target lesion revascularization.

[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.

[Effect of obesity on the morphology of the left ventricle]. / Influencia de la obesidad sobre la morfología del ventrículo izquierdo.

BACKGROUND: To analyze the relationship between obesity in its different degrees and the left ventricle morphology. PATIENTS AND METHODS: M-mode echocardiography was used to estimate the mass, wall thickness and internal dimension of left ventricle in 48 obese women with different degrees of obesity, defined according to the body mass index. 25 women with normal weight were used as controls. RESULTS: The body mass index was correlated with left ventricular mass, as well as with both the wall thickness of the left ventricle and its diastolic internal dimension. The abnormalities in the heart morphology increased according to the obesity degree, ranging from a 59% in the lesser obesity group up to a 100% in the more obese women. The incidence of the left ventricular hypertrophy determined by echocardiography also increased along with the body mass index, ranging from a 29% in the lesser degree of obesity women up to an 82% in the patients with a body mass index > 35 kg/m2. CONCLUSIONS: Obesity, even in its lowest degrees, shows frequent alterations in the heart morphology. This is related with a left ventricular mass increase and a higher incidence of the left ventricular hypertrophy. The left ventricular mass increase is due to an increase in the left ventricular walls thickness and also to a dilatation of its cavity.

[Efficacy evaluation of cloxacillin and cloxacillin-gentamicin in an experimental model of methicillin-sensitive Staphylococcus aureus]. / Valoración de la eficacia de la cloxacilina y cloxacilina-gentamicina en un modelo experimental de Staphylococcus aureus meticilín-sensible.

23 rabbits with Staphylococcus aureus methicillin-sensitive, SAMS, experimentally induced endocarditis (EIE) were studied to compare the efficacy of cloxacillin vs the association cloxacillin-gentamicin. Twelve animals made the control group and 11 the treated ones, 5 with cloxacillin-gentamicin and 6 with cloxacillin. The animals were treated 3 days, then, mortality, blood cultures at 48 and 72 hours and the title of the unit-forming colonies per gram of vegetation (UFC/g) were evaluated. The control group had a mortality of 100% in the first 72 hours, its blood cultures were positive at 48 and 72 hours and the UFC/g was 10,48 o 0.20. There was statistical significance between the control group and both treatment, in mortality, blood culture's positivity and the UFC/g of vegetation. This results confirm the similar efficacy of cloxacillin either alone or in combination in the treatment of SAMSIE and the effectiveness of the experimental model to evaluate antimicrobial treatments.

Recovery of global systolic function after primary angioplasty. Influence of coronary flow velocity reserve measured by transthoracic echocardiography.

BACKGROUND: Our objective were to know whether coronary flow velocity reserve measured by transthoracic Doppler echocardiography, as marker of microvascular integrity, affects the recovery of global systolic function. Secondly, we intended to define the best cut-off point of coronary flow velocity reserve to predict recovery of global systolic function. METHODS: We studied 57 patients with coronary flow recorded by transthoracic Doppler echocardiography, after suffering a first anterior acute myocardial infarction and undergoing a successful primary percutaneous coronary intervention (TIMI 3 flow). We measured, at discharge and at 1 month: ejection fraction, volume indexes and anterior wall motion score index. Coronary flow in left anterior descending artery was detected by transthoracic Doppler echocardiography and coronary flow velocity reserve was calculated. RESULTS: After applying ROC curves, 1.54 was the best cut-off value of coronary flow velocity reserve for detection of recovery of global systolic function. Ejection fraction only increased significantly in patients with normal coronary flow velocity reserve. Only end-systolic volume index increased significantly at 1 month in patients with impaired coronary flow velocity reserve. CONCLUSION: We showed that coronary flow velocity reserve, measured by transthoracic Doppler echocardiography, influence the recovery of global systolic function, mainly by ventricular dilation. Furthermore, a quite lower value of coronary flow velocity reserve than that used for diagnostic purpose should be used to predict improvement of systolic function.

[Mitral valve insufficiency in acute myocardial infarction. Assessment with pulsed and coded Doppler color]. / Insuficiencia mitral en el infarto agudo del miocardio. Valoración con Doppler pulsado y codificado en color.

We studied 108 patients who sustained an acute myocardial infarction (AMI) by means of echocardiography, pulsed doppler (PD) and Doppler color flow imaging (CD). We evaluate the presence of mitral regurgitation (MR) and it relationship to the site of the AMI and also to the ventricular function. The incidence of MR was 50.92%, (55/108), it was detected in higher percentage when the AMI was inferior (61.8%) than when anterior (39.6%). The correlation with the ejection fraction (EF) was only significative when the AMI was anterior. The incidence of MR was 57.1% when the EF was below 25%. CD had better diagnostic capabilities independently of the site of the AMI, (48% vs 32.1% when the AMI was anterior and 76.1% vs 52.6% when it was inferior).

[Study of the influence of arterial pressure response to exertion on cardiac hypertrophy in patients with mild or moderate hypertension]. / Estudio de la influencia de la respuesta de la presión arterial al esfuerzo sobre la hipertrofia cardíaca en hipertensos ligeros y moderados.

In order to study the relationship between tensional response of an hypertensive patient to exercise and its cardiac repercussions, we have studied 42 essential hypertensive patients using echocardiography type M and 2D and exercise test. Patients were divided into two groups according to whether they had (GI) or not (GII) left ventricular hypertrophy. LVH was defined calculating left ventricular mass (LVM) or mean wall thickness (MWT). We have found significant correlations between tensional response and LVH, using only MWT as the index of LVH. This correlation was significant not only with maximum systolic arterial pressure but also with systolic arterial pressure in all intermediate charge stages. Evolution time of arterial hypertension significantly correlated with the degree of LVH according to MWT and less significantly with LVM. We conclude that the correlation between tensional response to exercise and cardiac hypertrophy is always higher when considering MWT as the index of LVH since the calculating the mass some other parameters are also present which hinder its significance and that correlation is established not only in the maximum exercise level.

[Study of blood pressure response to exertion in essential hypertension. Its modification with anti-hypertensive treatment]. / Estudio de la respuesta tensional al esfuerzo en hipertensos esenciales. Su modificación con el tratamiento antihipertensivo.

We have studied the effect of atenolol, xipamide, and verapamil in the control of effort tensional response in 54 patients suffering essential hypertension. A first effort test without treatment and a second after a one month treatment randomly assigned were performed in all patients, evaluating the tensional response at 30, 60 and 80 Watts of charge, maximum peak, and after five minutes in recovery. Atenolol significantly reduced (p less than 0.05) systolic arterial pressure and diastolic arterial pressure in every intermediate effort stage, maximum peak and post effort recovery, xipamide, also significantly reduced (p less than 0.05) the systolic hypertensive response at all different levels, however, the diastolic one did not reach any statistic significance. Verapamil at used doses did not modify neither systolic nor diastolic hypertensive response. The beneficial effect of beta-blockers is confirmed although we could not confirm the effect pointed out by other authors regarding calcium antagonists. Tensional control using xipamide was striking although there is some evidence to think that it can have a more important effect in the control than thiazide diuretics or amiloride.

Congenital diverticulum of the right ventricle associated with coarctation of aorta, atrial and ventricular septal defect and ductus.

Congenital right ventricular muscular diverticula are extremely rare and are usually associated with other congenital cardiac anomalies, (in half of the cases tetralogy of Fallot). They functionally behave like an accessory ventricular chamber which contracts synchronously with the normal ventricles. Less than 30 patients with a right ventricular diverticulum have been reported in literature. An apical right ventricular diverticulum occurs in patients with thoraco-abdominal midline defects or abnormalities of the cardiac position([1]). However, an antero-superior diverticulum is usually associated with other congenital cardiac defects, such as a ventricular septal defect, tetralogy of Fallot, double outlet right ventricle and pulmonary stenosis([2--9]). We report an 11-year-old boy with an antero-superior diverticulum of the right ventricle associated with a coarctation of aorta, ductus arteriosus, and atrial and ventricular septum defects. To the best of our knowledge, such an association has not been reported before.

[Importance of color-coded Doppler in a case of interventricular communication associated with fixed subaortic stenosis]. / Valor del Doppler codificado en color en un caso de comunicación interventricular asociado a estenosis subaórtica fija.

We describe a 10 year old girl with ventricular septal defect in whom bidimensional echocardiogram disclosed a membrane in the outflow tract of the left ventricle. Color Doppler found the presence of fixed subaortic stenosis.