A case report of a triad causing platypnoea-orthodeoxia syndrome.

BACKGROUND: Platypnoea-orthodeoxia syndrome (POS) is a rare condition characterized by hypoxaemia and dyspnoea when changing from a recumbent to an upright position. Diagnosis requires a high clinical suspicion and is often underdiagnosed. CASE SUMMARY: We report a case of POS in a 50-year-old woman with dyspnoea and new-onset atrial fibrillation. Oxygen saturation and dyspnoea worsened as she changed from a supine to a sitting position (96 vs. 86%, respectively). Transoesophageal echocardiography demonstrated enlargement of both atria and right ventricle with reduced systolic function and a large Chiari network (CN). Colour Doppler discovered severe tricuspid regurgitation with tenting and tethering of the valve leaflets. Finally, a bubble test revealed the cause of POS to be a patent foramen ovale along with the severe tricuspid regurgitant jet moving into the left atrium and favoured by the CN. Surgical closure of the foramen ovale resulted in the resolution of symptoms. DISCUSSION: Platypnoea-orthodeoxia syndrome is most commonly caused by a right-to-left shunt through an anatomical defect of the interatrial septum, typically a patent foramen ovale, combined with elevated right atrium pressure. This case illustrates an uncommon cause of POS in the absence of elevated atrium pressure due to the interplay of three key elements: a patent foramen ovale, tricuspid regurgitation, and the CN. Our aim is to alert physicians to the possibility of an intracardiac shunt as the cause of unexplained and/or refractory hypoxaemia related to position changes. Early recognition of this syndrome promotes timely treatment, greatly improving patient outcomes.

Hyperkalemia in heart failure patients in Spain and its impact on guidelines and recommendations: ESC-EORP-HFA Heart Failure Long-Term Registry.

INTRODUCTION AND OBJECTIVES: Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors. METHODS: This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment. RESULTS: Hyperkalemia (K+> 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia. CONCLUSIONS: This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment.

Hiperpotasemia en pacientes con insuficiencia cardiaca en España y su impacto en las recomendaciones. Registro ESC-EORP-HFA Heart Failure Long-Term / Hyperkalemia in heart failure patients in Spain and its impact on guidelines and recommendations: ESC-EORP-HFA Heart Failure Long-Term Registry

INTRODUCCIÓN Y OBJETIVOS: La hiperpotasemia es una preocupación creciente en el tratamiento de los pacientes con insuficiencia cardiaca y fracción de eyección reducida, pues limita el uso de fármacos eficaces. Este trabajo ofrece estimaciones de la magnitud de este problema en la práctica clínica habitual en España, los cambios en las concentraciones de potasio en el seguimiento y los factores asociados. MÉTODOS: Pacientes con insuficiencia cardiaca aguda (n=881) y crónica (n=3.587) seleccionados en 28 hospitales españoles del registro europeo de insuficiencia cardiaca de la European Society of Cardiology y seguidos 1 año para diferentes desenlaces, incluidos cambios en las cifras de potasio y su impacto en el tratamiento. RESULTADOS: La hiperpotasemia (K+> 5,4 mEq/l) está presente en el 4,3% (IC95%, 3,7-5,0%) y el 8,2% (6,5-10,2%) de los pacientes con insuficiencia cardiaca crónica y aguda; causa el 28,9% de todos los casos en que se contraindica el uso de antagonistas del receptor de mineralocorticoides y el 10,8% de los que no alcanzan la dosis objetivo. Del total de 2.693 pacientes ambulatorios con fracción de eyección reducida, 291 (10,8%) no tenían registrada medición de potasio. Durante el seguimiento, 179 de 1.431 (12,5%, IC95%, 10,8-14,3%) aumentaron su concentración de potasio, aumento relacionado directamente con la edad, la diabetes mellitus y los antecedentes de ictus e inversamente con los antecedentes de hiperpotasemia. CONCLUSIONES: Este trabajo destaca el problema de la hiperpotasemia en pacientes con insuficiencia cardiaca de la práctica clínica habitual y la necesidad de continuar y mejorar la vigilancia de este factor en estos pacientes por su interferencia en el tratamiento óptimo

INTRODUCTION AND OBJECTIVES: Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors. METHODS: This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment. RESULTS: Hyperkalemia (K+> 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia. CONCLUSIONS: This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment

[Advances in hypertension and diabetes]. / Temas de actualidad en hipertensión arterial y diabetes.

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year.

[Global treatment of cardiovascular risk in the hypertensive patient]. / Tratamiento global del riesgo cardiovascular en el paciente hipertenso.

During 2006, new evidence supporting the need to adopt a global approach to the treatment of cardiovascular risk in hypertensive patients has been reported. It is increasingly clear that it is not sufficient to aim for optimum blood pressure control, which in any case is not easy to achieve, and that it is essential to treat all cardiovascular risk factors by using drugs with proven benefits, even when those benefits are supplementary to the drug's principal effects. In addition, drugs that could have a detrimental effect or that are, merely, less beneficial should be avoided or kept as a last resort. This appears to have happened with atenolol, and with beta-blockers in general, which have been withdrawn as first-line treatment in the recommendations of some professional societies. To lower cardiovascular risk, it is essential to prevent the development of conditions like diabetes, which are known to have drastic effect on the patient's prognosis. Recently, the results of the DREAM study, which are discussed in detail in this article, have been reported. They could lead to a change in therapeutic strategy in patients who are expected to develop diabetes. In addition, this year has seen the publication of substantial data on a new antihypertensive agent, aliskiren, the first oral renin inhibitor. It is awaiting approval by the international medicine agencies (i.e., the FDA and the EMEA), but should provide a very promising tool in the difficult area of high blood pressure management. Despite numerous advances in the pharmacologic treatment of high blood pressure, control is very difficult to achieve, principally in the elderly, in whom the prevalence of hypertension is high. In these patients, social factors and difficulties with treatment compliance also have an influence and must be dealt with by public health measures aimed at improving blood pressure control.

Temas de actualidad en hipertensión arterial y diabetes / Advances in hypertension and diabetes

Durante 2008 se han publicado importantes ensayos clínicos en patología cardiovascular, principalmente sobre pacientes hipertensos y diabéticos. Sus resultados, algunos inesperados, en ocasiones nos han permitido confirmar lo que ya sabíamos respecto al control de estos factores de riesgo, pero también han creado bastante debate sobre cuestiones previamente establecidas, como hasta dónde bajar la presión arterial y la glucemia en pacientes con enfermedad cardiovascular. También disponemos de información reciente sobre estrategias terapéuticas antihipertensivas basadas en nuevos fármacos o en combinaciones de fármacos ya existentes. En este artículo se revisan estos aspectos y también algunos registros promovidos por nuestra sección, publicados el pasado año (AU)

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year (AU)

Temas de actualidad en hipertensión arterial y diabetes / Advances in Hypertension and Diabetes in 2007

En este artículo revisaremos algunas de las principales novedades en el campo de la hipertensión arterial y la diabetes del año 2007, en el que lo más relevante ha sido la publicación de las Guías de Práctica Clínica de la Sociedad Europea de Cardiología, asumidas por nuestra Sociedad, en ambas enfermedades. Por otro lado, estamos asistiendo a una reciente e importante polémica respecto al tratamiento de la diabetes con rosiglitazona y su efecto en las complicaciones cardiovasculares, que analizaremos a partir de las pruebas científicas disponibles hasta el momento. Finalmente, revisaremos los resultados del último gran ensayo clínico publicado sobre la prevención de complicaciones vasculares en diabéticos, precisamente mediante una estrategia antihipertensiva (AU)

This article contains a review of some of the main developments reported in 2007 on the topics of hypertension and diabetes. The most important was the publication of the European Society of Cardiology's clinical practice guidelines on the two conditions, both of which have been adopted by the Spanish Society of Cardiology. Elsewhere, we have recently been witnessing crucial debates on the use of rosiglitazone for the treatment of diabetes and on the drug's effect on cardiovascular outcomes. The evidence available up to the present time is assessed. Finally, we will review the results of the most recent large clinical trial on the prevention of vascular complications in diabetics, which employed an antihypertensive approach (AU)

Tratamiento global del riesgo cardiovascular en el paciente hipertenso / Global treatment of cardiovascular risk in the hypertensive patient

A lo largo del año 2006 han aparecido nuevas evidencias sobre la necesidad del tratamiento global del riesgo cardiovascular en el paciente hipertenso. Cada vez es mayor la certeza de que no basta con buscar un óptimo control de las cifras de presión arterial, lo que además no es fácil lograr, sino que es imprescindible tratar todos los factores de riesgo cardiovascular mediante la utilización de los fármacos de demostrado beneficio, incluso más allá de sus efectos principales, y evitando, o dejando para último recurso, los que puedan resultar perjudiciales o, simplemente, menos beneficiosos, como parece ser el caso de atenolol (extensivo a los bloqueadores beta en general), que ya ha sido retirado de la primera línea de tratamiento en las recomendaciones de algunas sociedades científicas. En la reducción del riesgo es fundamental la prevención de algunas enfermedades como la diabetes, que sabemos ensombrece de forma alarmante el pronóstico de nuestros pacientes. Recientemente hemos conocido los resultados del estudio DREAM, que se analizarán con detalle en este artículo y que pueden suponer un cambio en la estrategia terapéutica de los pacientes en los que es previsible la aparición de diabetes. También a lo largo del presente año hemos recibido amplia información sobre un nuevo fármaco antihipertensivo, aliskiren, primer inhibidor de la renina disponible por vía oral. Pendiente de aprobación por las agencias internacionales de medicamentos (Food and Drug Administration [FDA] y Agencia Europea de Evaluación de Medicamentos [EMEA]), es una herramienta muy prometedora en el difícil control de la hipertensión arterial. A pesar de todos los avances en el tratamiento farmacológico de la hipertensión arterial, persiste un escaso control de las cifras tensionales, sobre todo en los pacientes de mayor edad, en los que la prevalencia es más elevada. En estos pacientes influyen también factores sociales y la dificultad en el cumplimiento terapéutico, que precisan medidas sociosanitarias dirigidas a mejorar su control

During 2006, new evidence supporting the need to adopt a global approach to the treatment of cardiovascular risk in hypertensive patients has been reported. It is increasingly clear that it is not sufficient to aim for optimum blood pressure control, which in any case is not easy to achieve, and that it is essential to treat all cardiovascular risk factors by using drugs with proven benefits, even when those benefits are supplementary to the drug's principal effects. In addition, drugs that could have a detrimental effect or that are, merely, less beneficial should be avoided or kept as a last resort. This appears to have happened with atenolol, and with beta-blockers in general, which have been withdrawn as first-line treatment in the recommendations of some professional societies. To lower cardiovascular risk, it is essential to prevent the development of conditions like diabetes, which are known to have drastic effect on the patient's prognosis. Recently, the results of the DREAM study, which are discussed in detail in this article, have been reported. They could lead to a change in therapeutic strategy in patients who are expected to develop diabetes. In addition, this year has seen the publication of substantial data on a new antihypertensive agent, aliskiren, the first oral renin inhibitor. It is awaiting approval by the international medicine agencies (i.e., the FDA and the EMEA), but should provide a very promising tool in the difficult area of high blood pressure management. Despite numerous advances in the pharmacologic treatment of high blood pressure, control is very difficult to achieve, principally in the elderly, in whom the prevalence of hypertension is high. In these patients, social factors and difficulties with treatment compliance also have an influence and must be dealt with by public health measures aimed at improving blood pressure control