High- versus low-gradient aortic stenosis: Is our evaluation limited by aorto-mitral angle on cardiovascular CT?

BACKGROUND: Accurate assessment of aortic valve (AV) stenosis (AS) on transthoracic echocardiogram is crucial for appropriate clinical management. However, discordance between aortic valve area (AVA) and Doppler can complicate the diagnosis of severe AS in low-gradient (LG) AS phenotypes. METHODS: We reviewed 220 consecutive patients with suspected severe AS and AVA ≤1.0 cm2 on transthoracic echocardiogram who were evaluated for transcatheter AV replacement (TAVR) within a large health system from 2015 to 2019. We compared AV calcium score and aorto-mitral angle (AMA) on 3-chamber views from ECG-gated cardiovascular CT among patients with high-gradient (HG) AS (N = 19), paradoxical low-flow low-gradient (PLFLG) AS (N = 24) and normal-flow low-gradient (NFLG) AS (N = 14). RESULTS: All groups had comparable age, comorbidities, and AV calcium scores. Compared to patients with HG AS (mean AMA 120 ± 10°), those with PLFLG AS (104 ± 12°; p < 0.001) and NFLG AS (106 ± 13°; p = 0.008) had narrower mean AMA values on cardiovascular CT. CONCLUSION: LG AS patients have significantly narrower AMA than HG AS patients on cardiovascular CT. Due to difficulty obtaining parallel Doppler alignment, narrower AMA may contribute to AVA-Doppler discordance on echocardiogram. These findings emphasize the need for additional information in the setting of LG AS.

Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real-world practice.

BACKGROUND: Guidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real-world practice. METHODS: We evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF. RESULTS: Among 35 641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18 391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n = 5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n = 15 933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n = 3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%-68.1%) among sonographers and 51.6% (46.5%-59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55-7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35-.40). CONCLUSIONS: Use of 3DE LVEF in real-world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.

Patient Awareness and Clinical Inertia: Obstacles to Hypertension Control in Rural Communities in the Dominican Republic.

BACKGROUND: Many obstacles exist for adequate hypertension control, including low individual awareness and clinical inertia (CI). In this study, we aimed to determine hypertension prevalence, awareness, treatment, and control among community residents of rural areas of Peravia in Dominican Republic (DR), followed by an assessment of CI in their primary care clinics (PCCs). METHODS: We interviewed 827 adults from 8 rural communities of Peravia. Demographics, medical history, health care information, and blood pressure (BP) were obtained. We reviewed the community PCC visits of patients with known hypertension or a BP ≥140/90, abstracting medical history and the physician's action toward uncontrolled BP. RESULTS: Of those interviewed, 57% (95% CI: 53%-60%) had hypertension, with 63% (95% CI: 59%-68%) of those aware of their diagnosis. Among individuals with hypertension, 60% (95% CI: 56%-65%) were receiving pharmacological treatment, and only 35% (95% CI: 31%-40%) were controlled. Characteristics associated with awareness were female sex, age >55 years, diabetes, private insurance, and having at least 1 health care visit within the past year. Of the 507 PCC patients reviewed, 340 (67%) had uncontrolled BP. Of these, 220 had no clinical action to address the uncontrolled BP, corresponding to a CI rate of 65%. CONCLUSIONS: Among rural communities in the DR, undiagnosed hypertension remains common, especially in individuals who are younger, uninsured, or with limited access to health care. For those seen in PCCs, therapeutic intensification to achieve controlled BP is infrequently done. Strategies to address population awareness and CI are needed to improve hypertension control.

Understanding Non-P2 Mitral Regurgitation Using Real-Time Three-Dimensional Transesophageal Echocardiography: Characterization and Factors Leading to Underestimation.

BACKGROUND: P2 prolapse is a common cause of degenerative mitral regurgitation (MR); echocardiographic characteristics of non-P2 prolapse are less known. Because of the eccentric nature of degenerative MR jets, the evaluation of MR severity is challenging. The aim of this study was to test the hypotheses that (1) the percentage of severe MR determined by transthoracic echocardiography (TTE) would be lower compared with that determined by transesophageal echocardiography (TEE) in patients with non-P2 prolapse and also in a subgroup with "horizontal MR" (a horizontal jet seen on TTE that hugs the leaflets without reaching the atrial wall, particularly found in non-P2 prolapse) and (2) the directions of MR jets between TTE and real-time (RT) three-dimensional (3D) TEE would be discordant. METHODS: One hundred eighteen patients with moderate to severe and severe degenerative MR defined by TEE were studied. The percentage of severe MR between TTE and TEE was compared in P2 and non-P2 prolapse groups and in horizontal and nonhorizontal MR groups. Additionally, differences in the directions of the MR jets between TTE and RT 3D TEE were assessed. RESULTS: Eighty-six percent of patients had severe MR according to TEE. TTE underestimated severe MR in the non-P2 group (severe MR on TTE, 57%; severe MR on TEE, 85%; P < .001) but not in the P2 group (severe MR on TTE, 79%; severe MR on TEE, 91%; P = .157). Most "horizontal" MR jets were found in the non-P2 group (85%), and this subgroup showed even more underestimation of severe MR on TTE (TTE, 22%; TEE, 89%; P < .001). There was discordance in MR jet direction between two-dimensional TTE and RT 3D TEE in 41% of patients. CONCLUSIONS: Non-P2 and "horizontal" MR are significantly underestimated on TTE compared with TEE. There is substantial discordance in the direction of the MR jet between RT 3D TEE and TTE. Therefore, TEE should be considered when these subgroups of MR are observed on TTE.

Differentiating spontaneous echo contrast, sludge, and thrombus in the left atrial appendage: Can ultrasound enhancing agents help?

The accurate identification of thrombus in the left atrial appendage with transesophageal echocardiogram (TEE) in patients with atrial fibrillation (AF) before cardioversion is essential. Most of these patients have some grade of spontaneous echo contrast (SEC). Severe SEC is often called "sludge," and its prognosis and treatment are still controversial. Current guidelines suggest the use of ultrasound enhancing agents (UEAs) when significant SEC is present. However, little is known about the utility of the UEAs in the differentiation between sludge and less severe SEC.

Hyperuricemia and Cardiovascular Disease in Patients with Hypertension.

BACKGROUND: Little is known about the role of serum uric acid in cardiovascular events. We studied the prevalence of hyperuricemia and the association between uric acid level and various cardiovascular risk factors. METHODS: This cross-sectional study was based on a population of patients with hypertension who attended a hypertension clinic in a university hospital in Bogotá, Colombia. Bivariate analysis and multivariate logistic regression models were utilized to investigate the relationship between hyperuricemia and cardiovascular risk factors. RESULTS: The study population included 444 patients. The overall prevalence of hyperuricemia was 28.8%. Male gender (OR 2.3), age (OR 1.03), BMI (OR 1.09), triglyceride level (OR 1.005) and low HDL (OR 0.96) were significantly associated with hyperuricemia. CONCLUSIONS: Prevalence of hyperuricemia is high in patients with hypertension. Serum uric acid is significantly associated with parameters of the metabolic syndrome. Hyperuricemia should be acknowledged and monitored as a risk factor for cardiovascular disease.

Prevalence of Metabolic Syndrome in Patients with HIV in the Era of Highly Active Antiretroviral Therapy.

OBJECTIVES: Since the introduction of combination antiretroviral therapy (cART) as the standard of care for HIV disease, there has been a precipitous decline in the death rate due to HIV/ AIDS. The purpose of this study was to report the prevalence of metabolic syndrome in HIV infected patients. METHODS: Retrospective, cross-sectional, observational study of 259 patients with HIV infection treated with cART from an urban community hospital. Metabolic syndrome prevalence was defined using the International Diabetes Federation (IDF) and the U.S. National Cholesterol Education Program Adult Treatment Panel III (ATP III) criteria. Study patients were included regardless of the duration of cART. RESULTS: The prevalence of metabolic syndrome was 27% using IDF criteria and 26% using ATP III criteria. Logistic regression analysis found an association between treatment with the protease inhibitor darunavir and metabolic syndrome. (OR 3.32 with 95% confidence interval between 1.54 and 7.15). CONCLUSION: There is a high prevalence of metabolic syndrome and obesity in HIV patients treated with cART, especially those taking the protease inhibitor darunavir.

Aneurisma coronario en un paciente con síndrome coronario agudo secundario a cocaína / Coronary aneurysm in a patient with acute coronary syndrome secondary to cocaine

La prevalencia actual del consumo de cocaína hace necesario conocer las complicaciones cardiovasculares derivadas de su uso, como lo es el síndrome coronario agudo, condición que se presenta en personas jóvenes que consultan a los servicios de Urgencias con dolor torácico y alteraciones electrocardiográficas. El consumo de esta sustancia se asocia con aterosclerosis acelerada, vasoconstricción de arterias coronarias, vasoespasmo, arritmias, miocardiopatía, endocarditis, disección y ruptura aórtica, y muerte cardiaca súbita. Aunque la incidencia de aneurismas de arterias coronarias es extremadamente baja en la población general, existe una asociación con el consumo de cocaína que debe ser considerada en estos pacientes.

The current prevalence of cocaine use makes necessary to know the cardiovascular complications derived from its use such as acute coronary syndrome, a condition that occurs in young people who consult the emergency departments with chest pain and electrocardiographic alterations. The consumption of this substance is associated with accelerated atherosclerosis, coronary artery vasoconstriction, vasospasm, arrhythmias, cardiomyopathy, endocarditis, aortic dissection and rupture, and sudden cardiac death. Although the incidence of coronary artery aneurysms is extremely low in the general population, there is an association with cocaine consumption that must be considered in these patients.

Ticagrelor: the evidence for its clinical potential as an oral antiplatelet treatment for the reduction of major adverse cardiac events in patients with acute coronary syndromes.

INTRODUCTION: Ticagrelor, the first direct-acting, reversibly binding oral P2Y12 receptor antagonist, appears to have a favorable efficacy and safety profile. AIMS: To update the evidence and provide an overview of the available data on ticagrelor. EVIDENCE REVIEW: Peer reviewed articles published and listed under Medline Search, and published updated guidelines for pharmacotherapies in acute coronary syndromes were reviewed. PLACE IN THERAPY: Clinical evidence is increasing to support the use of new thienopyridines and the direct-acting P2Y12 receptor in the setting of acute coronary syndromes. CONCLUSION: The options for drugs to inhibit the platelet P2Y12 receptor for adenosine diphosphate are rapidly expanding. Ticagrelor has shown benefits in clinical trials. Its rapid onset of platelet inhibition and short half-life make it an attractive alternative to thienopyridines, especially when rapid inhibition of platelet aggregation or its quick reversal are required.

Cardiomiopatía restrictiva como presentación de amiloidosis / Restrictive cardiomyopathy as a presentation of amyloidosis

La cardiopatía amiloidea es una rara entidad que se puede presentar dentro del contexto de la amiloidosis sistémica. Su presentación clínica tiende a ser tardía, cuando la función cardiaca se encuentra altamente comprometida. Actualmente han surgido herramientas no invasivas que facilitan su diagnóstico. El tratamiento depende del subtipo y en su mayoría comprende medidas de soporte a la falla cardiaca para proteger otros órganos, junto con quimioterapia oral y trasplante autólogo de medula ósea. Adicionalmente, nuevos factores pronósticos se han postulado para su manejo. Se presenta un paciente que ingresó por disnea de rápida progresión, y cuyo cuadro clínico es consistente con falla cardiaca congestiva. Los estudios paraclínicos reportaron hipertrofia concéntrica del ventrículo izquierdo y un patrón de infiltrados ecogénicos en el miocardio con extensa fibrosis. Se diagnóstica cardiomiopatía restrictiva secundaria a amiloidosis AL. A partir del caso, se describen las características de la enfermedad y los nuevos adelantos en su manejo (Acta Med Colomb 2010; 35: 126-131).

Cardiac amyloidosis is a rare disease that may occur as a component of systemic amyloidosis. Its symptomatic phase usually presents when cardiac function is highly compromised. Recently, some non-invasive diagnostic tools have emerged improving diagnosis. Treatment for this disease depends on its subtype. In most cases, it consists on supportive measures to improve heart failure and organ function, in addition with oral chemotherapy and autologous stem-cell transplantation. Alongside, new prognostic factors have been introduced. As an example, a clinical case about a patient who develops rapid-progression dyspnea and congestive heart failure is described. The ecocardiographic report stated a left ventricular concentric hypertrophy and ecogenic infiltrate patterns associated with extensive fibrosis. This leaded to the diagnosis of cardiac amyloidosis secondary to systemic amyloidosis. Based on this case, characteristics and new advances in its management are presented (Acta Med Colomb 2010; 35: 126-131).

Incidencia de trombosis de stents coronarios en el ®mundo real¼ / Incidence of coronary stent thrombosis in the ®real world¼

ANTECEDENTES: la evidencia disponible de stents liberadores de medicamento proviene de estudios controlados con estrictos criterios de inclusión, limitando sus conclusiones y haciendo difícil la aplicación de sus resultados en el mundo real. OBJETIVO: determinar la incidencia de trombosis de stents liberadores y no liberadores de medicamento en pacientes del ®mundo real¼. METODOLOGÍA: estudio de incidencia para determinar el número de casos de trombosis de stents implantados, mediante información obtenida a partir de historias clínicas, bases de datos y seguimiento clínico, y con base en características demográficas, factores de riesgo, consumo de clopidogrel y casos de trombosis del stent con un seguimiento de cero días a un año. RESULTADOS: 640 stents implantados (69,2% no medicados, 30,8% medicados de los cuales 18,9% eran medicados con placlitaxel y 11,9% medicados con sirolimus). Se identificaron doce eventos de trombosis (siete stents medicados y cinco no medicados). La incidencia de trombosis con cualquier tipo de stent fue de 1,88% (IC 95% 0,97-3,28). La incidencia de trombosis con stent medicado fue 3,55% (IC 95% 1,43-7,32), y con stent no medicado 1,13% (IC 95% 0,37-2,64) p=0,000. El riesgo relativo de trombosis con stent medicado es de 3,14 (IC 95% 1,01-9,78) p=0,037. El riesgo relativo de presentar trombosis con stent medicado en infarto agudo del miocardio es 8,11 (IC 95% 2,32-28,31) p=0,001. CONCLUSIONES: la incidencia de trombosis del stent aumenta en el mundo real, y existe mayor riesgo de trombosis de stents medicados especialmente cuando son implantados en el contexto de un infarto agudo del miocardio. Es necesario realizar estudios futuros que involucren una población de pacientes más amplia y con seguimiento a largo plazo.

BACKGROUND: The existing evidence of drug-eluting stents comes from controlled studies done with strict inclusion criteria, limiting their conclusions and making difficult to apply their findings in the real world.Objectives: determine the incidence of thrombosis between bare metal stents versus drug-eluting stents in patients in the ®real world¼. METHODS: incidence study to determine the number of cases of thrombosis in implanted stents through information gathered from clinical records, data bases and clinical follow-up, based on demographic characteristics, risk factors, clopidogrel treatment and events of stent thrombosis with a 0 days to 1 year follow-up. RESULTS: 640 stents were implanted. 69.2% were bare metal stents and 30.8% drug-eluting stents, from which 18.9% were with placlitaxel and 11.9% with sirolimus. 12 thrombosis events were identified (7 with drug-eluting stents and 5 with bare metal stents). The incidence of thrombosis with any kind of stent was 1.88 %( CI 95% 0.97-3.28). The incidence of thrombosis with drug-eluting stents was 3.55% (CI 95%1.43-7.32), and with bare metal stents 1.13% (CI 95% 0.37-2.64) p=0.000. The relative risk of thrombosis with drug eluting stents is 3.14 (CI 95%1.01-9.78) p=0.037. The relative risk of thrombosis with drug eluting stents and acute myocardial infarction is 8.11 (CI 95%2.32-28.31) p=0,001. CONCLUSIONS: there is an increased incidence of thrombosis of coronary stents in the real world and a greater risk of thrombosis with drug eluting stents, especially when implanted in the context of an acute myocardial infarction. It is necessary to conduct further studies that may involve a higher sample of patients population and long-term follow-up.

Prevalencia de síndrome metabólico en pacientes infectados con VIH: Utilizando los criterios del ATP III y de la IDF / Using ATP III and IDF criteria / Prevalence of metabolic syndrome in patients infected with HIV

Marco de referencia: el síndrome metabólico es un conjunto de anormalidades relacionadas entre sí, que se asocian con el desarrollo de enfermedades como diabetes, hipertensión y dislipidemia. En Colombia no existen estudios publicados con respecto a la prevalencia de síndrome metabólico en personas con infección por VIH (virus de inmunodeficiencia humana). Metodología: se llevó a cabo un estudio observacional de corte transversal. La muestra estuvo conformada por pacientes atendidos en la consulta de VIH-SIDA en un hospital de tercer nivel, durante el periodo comprendido entre marzo y abril de 2008; se tuvieron en cuenta pacientes mayores de 18 años, que no habían estado hospitalizados en el último mes. Resultados: la muestra final estuvo conformada por 137 pacientes, de los cuales 82,5% fueron hombres y 17,5% mujeres, con edades entre 19 y 65 años (edad promedio 39,7± 9,64 años), el índice de masa corporal fue en promedio 23,8 ± 3,13 kg/m2 y 78.4% recibían terapia antirretroviral. La prevalencia de síndrome metabólico de acuerdo con los criterios del ATPIII fue de 15,4% (IC95% 9.8%; 22.6%). Según los criterios de la IDF ésta fue de 21,3% (IC95% 14,43%-28,20%). No se encontró correlación entre el uso de terapia antirretroviral y la presencia de síndrome metabólico, se encontró una alta prevalencia de trastornos lipídicos en los pacientes con síndrome metabólico. Conclusiones: se necesitan más estudios para definir el papel que pueden tener las complicaciones metabólicas en la evolución de la enfermedad y en el pronóstico de los pacientes, haciendo énfasis en su papel como factor de riesgo cardiovascular.

Background: metabolic syndrome is a set of abnormalities related to one another that are associated with the development of diseases like diabetes, hypertension and dyslipidemia. In Colombia there are no published studies regarding the prevalence of metabolic syndrome in people with HIV infection. Methods: we carried out a cross-sectional observational study, the sample was composed by patients in consultation with HIV-AIDS in a hospital in third level, during the period March-April 2008; took into account patients over 18, who were not hospitalized during the past month. Results: the final sample was comprised of 137 patients, of whom 82.5% were men and 17.5% women, aged between 19 and 65 years (average age 39.7 ± 9.64 years), body mass index averaged 23.8 Kg/mt2 ± 3.13 and 78.4% were receiving antiretroviral therapy. The prevalence of metabolic syndrome according to the criteria of ATPIII was 15.4% (95% 9.8% 22.6%). According to the criteria of the IDF prevalence of metabolic syndrome was 21.3% (95% 14.43% - 28.20%); There was no correlation between the use of antiretroviral therapy and the presence of metabolic syndrome, was found a high prevalence of lipid disorders in patients with metabolic syndrome. Conclusions: further studies are needed in order to define the role of metabolic complications in the progression of the disease and the prognosis of patients, laying emphasis on its role as a cardiovascular risk factor.

Tomografía computarizada con multidetectores en el diagnóstico de la estenosis coronaria: [revisión] / Computed tomography with multidetectors in the diagnosis of coronary stenosis: [review]

La angiografía coronaria que emplea tomografía multidetector, es una técnica no invasiva para la detección de estenosis coronaria, que ha tenido avances tecnológicos significativos en los últimos años. La introducción de tomógrafos de 16 y 64 detectores, la posibilidad de poder sincronizar la toma de imágenes con el electrocardiograma y las técnicas de reconstrucción permiten una mejor resolución temporal y espacial que logra la identificación de placas ateromatosas y lesiones obstructivas significativas a nivel de las arterias coronarias. En los próximos años continuará su maduración y se convertirá en una herramienta útil como técnica no invasiva para el diagnóstico de la enfermedad coronaria y se integrará de forma definitiva a los protocolos de manejo. La siguiente revisión se enfocará en los aspectos básicos de la tomografía, su técnica, su desempeño diagnóstico y sus aplicaciones clínicas.

Coronary angiography that uses multislice spiral computed tomography is a noninvasive technique for the detection of coronary stenosis that has had significant improvements in recent years. The introduction of 16 and 64 row scanners, the development of synchronized scanning electrocardiogram and better reconstruction techniques permit higher spatial and temporal resolution that allows better identification of coronary plaques and significant obstructive coronary lesions. In the next years Multislice spiral computed tomography will continue maturing and it will become a useful non invasive diagnostic imaging tool for the diagnosis of coronary disease and will be integrated to the cardiologic management protocols. Our next review will be focused on the basic and technical aspects of the scanner, diagnostic performance and clinical applications of this new technology.

Prevalencia del síndrome metabólico en pacientes diabéticos / Prevalence of the metabolic syndrome in diabetic patients

Antecedentes: las diferentes definiciones que han surgido para síndrome metabólico (SM) en los últimos 10 años han llevado a confusiones. En octubre de 2005, la American Heart Association (AHA) realizó algunas modificaciones para optimizar el uso de los criterios del National Cholesterol Education Program’s Adult Treatment Panel III Report (ATPIII) en la práctica clínica diaria.Objetivo: determinar la prevalencia del síndrome metabólico como se define por el ATPIII comparado con la definición de la AHA 2005 en los pacientes de la clínica de diabetes de una institución de tercer nivel.Material y métodos: estudio de corte transversal. Se revisaron 249 historias clínicas entre enero de 2004 y septiembre de 2005. Se describió la población a estudio y se estimó la prevalencia del síndrome metabólico según los criterios del ATPIII y de la AHA...