Bispectral index and suppression ratio after cardiac arrest: are they useful as bedside tools for rational treatment escalation plans?

INTRODUCTION AND OBJECTIVES: Myocardial dysfunction contributes to early mortality (24-72 hours) among survivors of a cardiac arrest (CA). The benefits of mechanical support in refractory shock should be balanced against the patient's potential for neurological recovery. To date, these early treatment decisions have been taken based on limited information leading mainly to undertreatment. Therefore, there is a need for early, reliable, accessible, and simple tools that offer information on the possibilities of neurological improvement. METHODS: We collected data from bispectral index (BIS) and suppression ratio (SR) monitoring of adult comatose survivors of CA managed with targeted temperature management (TTM). Neurological status was assessed according to the Cerebral Performance Category (CPC) scale. RESULTS: We included 340 patients. At the first full neurological evaluation, 211 patients (62.1%) achieved good outcome or CPC 1-2. Mean BIS values were significantly higher and median SR lower in patients with CPC 1-2. An average BIS> 26 during first 12 hours of TTM predicted good outcome with 89.5% sensitivity and 75.8% specificity (AUC of 0.869), while average SR values> 24 during the first 12 hours of TTM predicted poor outcome (CPC 3-5) with 91.5% sensitivity and 81.8% specificity (AUC, 0.906). Hourly BIS and SR values exhibited good predictive performance (AUC> 0.85), as soon as hour 2 for SR and hour 4 for BIS. CONCLUSIONS: BIS/SR are associated with patients' potential for neurological recovery after CA. This finding could help to create awareness of the possibility of a better outcome in patients who might otherwise be wrongly considered as nonviable and to establish personalized treatment escalation plans.

Obstructive sleep apnea and coronary artery disease: from pathophysiology to clinical implications.

Coronary artery disease (CAD) and obstructive sleep apnea (OSA) are both complex and significant clinical problems. The pathophysiological mechanisms that link OSA with CAD are complex and can influence the broad spectrum of conditions caused by CAD, from subclinical atherosclerosis to myocardial infarction. OSA remains a significant clinical problem among patients with CAD, and evidence suggesting its role as a risk factor for CAD is growing. Furthermore, increasing data support that CAD prognosis may be influenced by OSA and its treatment by continuous positive airway pressure (CPAP) therapy. However, stronger evidence is needed to definitely answer these questions. This paper focuses on the relationship between OSA and CAD from the pathophysiological effects of OSA in CAD, to the clinical implications of OSA and its treatment in CAD patients.

Do patients with ST segment elevation myocardial infarction in Killip class I need intensive cardiac care after a successful primary percutaneous intervention?

BACKGROUND AND OBJECTIVE: There are limited data regarding the need for intensive care or the appropriate length of hospital stay for patients with ST elevation acute myocardial infarction (STEMI). In order to optimize resources, we tried to determine the need of coronary care unit (CCU) admission for patients with STEMI who remained in Killip class I after a successful primary percutaneous coronary intervention (PPCI). METHODS: From August of 2006 till June of 2008, we analyzed data from all patients admitted in our CCU who met these criteria, a total of 278. We prospectively recorded all in-hospital adverse events and event-free survival at 30 and 90 days (all cause death, stroke, new acute coronary syndrome or re-hospitalization due to heart failure). Medical treatment was optimized according to the current guidelines. RESULTS: A coronary stent was implanted in 96% of the patients. None of the patients had any adverse event that could not be resolved in a step-down unit. Survival at 30 and at 90 days was 99.6% and 98.3% respectively. Event-free survival was 97.3% at 30 days and 94.3% at 90 days. The median length of stay was three days in the CCU and five days in the hospital. CONCLUSION: Patients with STEMI treated with PPCI who remained in Killip class I after the procedure and receive optimal pharmacological treatment have an excellent prognosis. All of them can probably be admitted safely to a step-down unit. Wide application of this management strategy may result in substantial cost savings.

[Predictive factors of abnormal dynamic intraventricular gradient after valve replacement in severe aortic stenosis]. / Aparición de gradiente dinámico intraventricular después de la sustitución valvular aórtica en pacientes con estenosis aórtica severa.

INTRODUCTION: Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood.Aim. To evaluate the incidence of DIG)and determine risk factors and associated morbimortality. PATIENTS AND METHOD: One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity >/= 2.5 m/s. RESULTS: Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, p < 0.001; left end-systolic ventricular diameter (LESVD) 21 vs. 29 mm, p < 0.001); left ventricular mass index (165 vs. 193 g/m(2), p < 0.05); mean aortic valve gradient (68 vs. 59 mmHg, p < 0.01),; ejection fraction (73 vs. 61%, p < 0.001). No significant differences were found with respect to ventricular wall thicknesses (septal 16.3 vs. 15.7; posterior 14.37 vs. 14.62), the presence of aortic insufficiency, or other postoperative factors (anemia, inotropic agents, etc.). CONCLUSIONS: DIG after aortic valve replacement to treat severe stenosis is not unusual (15%). DIG is usually found at a midventricular location, close to the septum. In patients with postoperative DIG the most common associated factors were small LEDVD, high ejection fractions and ratios of intraventricular septal to posterior wall ratios, high valve gradients and small left ventricular masses. Preoperative echocardiography can identify patients with a higher risk of developing DIG after aortic valve replacement.

Aparición de gradiente dinámico intraventricular después de la sustitución valvular aórtica en pacientes con estenosis aórtica severa / Predictive Factors of Abnormal Dynamic Intraventricular Gradient After Valve Replacement in Severe Aortic Stenosis

Introducción. Se conoce la existencia de un gradiente dinámico intraventricular (GDI) en el postoperatorio de recambio valvular aórtico, aunque se desconoce la incidencia del mismo, así como los factores determinantes de su presentación. Objetivos. Determinar la incidencia de aparición de GDI, así como los posibles factores predictivos y la existencia de morbimortalidad asociada a este proceso. Pacientes y método. Se ha realizado un estudio prospectivo mediante ecocardiografía-Doppler en 109 pacientes con estenosis aórtica valvular severa sometidos consecutivamente a recambio valvular y se ha valorado la aparición durante el período postoperatorio de GDI, definido por una velocidad máxima superior a 2,5 m/s.Resultados. Se observó la aparición de GDI durante el postoperatorio en 16 pacientes (14,9 por ciento del total). Se encontraron diferencias significativas entre los pacientes que desarrollaron o no GDI con respecto a los diámetros ventriculares: diámetro telediástolico del ventrículo izquierdo (DTDVI) de 43,2 frente a 47,7 mm, respectivamente; p < 0,001; diámetro telesistólico del ventrículo izquierdo (DTSVI) de 21 frente a 29 mm; p < 0,001, el índice de masa del VI de 165 frente a 193 g/m2; p < 0,05; el gradiente medio transvalvular de 68 frente a 59 mmHg; p < 0,01; y la fracción de eyección de 73 frente a 61 por ciento; p < 0,001. No se encontraron diferencias significativas en cuanto al grosor de las paredes ventriculares (TIV de 16,3 frente a 15,7; PP de 14,37 frente a 14,62), ni en la existencia de insuficiencia aórtica, ni en otros factores clínicos postoperatorios (anemización, fármacos inotrópicos, etc.).Conclusiones. Durante el postoperatorio del recambio valvular por estenosis aórtica severa aparece GDI en un número no despreciable de pacientes (15 por ciento). Habitualmente su localización es mesoventricuar. Los factores asociados a esta aparición de gradiente intraventricular fueron: DTDVI pequeños, fracciones de acortamiento altas, fracciones de eyección elevadas, relación tabique interventricular/pared posterior (TIV/PP) elevada, gradiente valvular elevado y masa del ventrículo izquierdo pequeña. El ecocardiograma preoperatorio permite identificar a los pacientes con riesgo de presentar GDI (AU)

Guías de práctica clínica de la Sociedad Española de Cardiología en la gestante con cardiopatía / Guidelines of the Spanish Society of Cardiology for the management of cardiovascular diseases during pregnancy

Durante la gestación normal se producen cambios hormonales, se establece la circulación uteroplacentaria, se incrementa el volumen plasmático, disminuyen las resistencias vasculares periféricas y se producen modificaciones que favorecen la hipercoagulabilidad. Todo ello favorece la aparición de semiología cardiovascular, haciendo que el diagnóstico diferencial con la existencia de cardiopatía subyacente sea a la vez fundamental y complejo. Además, estos cambios fisiológicos aumentan el riesgo de complicaciones maternofetales en las mujeres con cardiopatía. Se considera que la cardiopatía en el embarazo es la primera causa de morbimortalidad materna de causa no obstétrica. Las cardiopatías reumática y congénitas son, hoy día, las más frecuentes en la mujer embarazada, seguidas por la hipertensión arterial, la cardiopatía isquémica y las arritmias. En general, la enfermedad cardíaca tiende a empeorar con el tiempo, por lo que las mujeres con cualquier tipo de cardiopatía que deseen tener niños deberían hacerlo lo antes posible. La mayoría de las pacientes con cardiopatía no tienen problemas para llevar a término un embarazo. Las excepciones a esta regla son las pacientes en grado funcional III-IV con severo compromiso de la función cardíaca, la hipertensión pulmonar de cualquier origen, las cardiopatías congénitas con cianosis y grado funcional IIIIV, el síndrome de Marfan, las lesiones obstructivas izquierdas severas sintomáticas o asintomáticas con datos de disfunción sistólica, las portadoras de válvulas cardíacas artificiales y las mujeres con antecedentes de miocardiopatía asociada al embarazo, en las cuales debe desaconsejarse el embarazo o, en caso de producirse, puede recomendarse su interrupción, asumiendo los problemas éticos que se generan a la embarazada y al médico. Las cardiopatías más graves conllevan una elevada incidencia de aborto espontáneo, y en las cardiopatías congénitas debe valorarse el riesgo asociado de herencia. La intervención médica debe iniciarse precozmente, antes de la concepción, incluyendo la información respecto a las posibles repercusiones sobre la cardiopatía materna y el feto (AU)