The tobacco paradox in acute coronary syndrome. The prior cessation of smoking as a marker of a better short-term prognosis. / La paradoja del tabaco en el síndrome coronario agudo. El abandono previo del hábito tabáquico como marcador de mejor pronóstico a corto plazo.

OBJECTIVE: The tobacco paradox is a phenomenon insufficiently explained by previous studies. This study analyses the prognostic role of prior or active smoking in patients with acute coronary syndrome. METHODS: We obtained data from the ARIAM registry, between 2001 and 2012. The study included 42,827 patients with acute coronary syndrome (mean age, 65±13 years; 26.4% women). The influence of smoking and that of being an ex-smoker on mortality was analysed using a multivariate analysis. RESULTS: The smokers were younger, were more often men, had less diabetes, hypertension and prior history of heart failure, stroke, arrhythmia and renal failure and more frequently had ST-elevation and a family history of smoking. The ex-smokers had more dyslipidaemia and history of angina, myocardial infarction, ischemic heart disease, peripheral vasculopathy and chronic bronchial disease. Smokers and ex-smokers less frequently developed cardiogenic shock (smokers 4.2%, ex-smokers 4.7% and nonsmokers 6.9%, P<.001). Hospital mortality was 7.8% for the nonsmokers, 4.9% for the ex-smokers and 3.1% for the smokers (P<.001). In the multivariate analysis, the smoker factor lost its influence in the prognosis (-0.26%, p=.52 using an inverse probability calculation; and+0.26%, P=.691 using a propensity analysis). However, the exsmoker factor showed a significant reduction in mortality in both tests (-2.4% in the inverse probability analysis, P<.001; and -1.5% in the propensity analysis, P=.005). CONCLUSIONS: The tobacco paradox is a finding that could be explained by other prognostic factors. Smoking cessation prior to hospitalization for acute coronary syndrome is associated with a better prognosis.

Clinical scores and patient risk stratification in non-ST elevation acute coronary syndrome.

BACKGROUND: Risk stratification of patients with unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI) is problematic given the heterogeneous presentation of the condition. This study was undertaken to compare, in UA/NSTEMI patients, the prognostic value of two clinical risk scores (RS) (i.e. Thrombolysis in Myocardial Infarction (TIMI) and physician's risk assessment (PRA)) and to assess whether serum biomarkers can increase the prognostic accuracy of these RS. METHODS: We prospectively assessed 610 consecutive UA/NSTEMI patients, 217 (36%) UA and 393 (64%) NSTEMI. In all patients RS, high sensitivity C-reactive protein, CD40 ligand, IL6, IL10, IL18, E-selectin, P-selectin, white blood cell count, neopterin, myeloperoxidase, fibrinogen and NT proBNP were assessed at study entry. The primary study endpoint was death and non-fatal MI at 30 and 360 days of follow-up. RESULTS: At 1 year, 54 patients (8.9%) had reached the primary study endpoint (26 suffered a cardiac death (4.3%) and 34 (5.6%) a non-fatal MI). For both RS, the study endpoint occurred more commonly in patients at a "higher risk" compared to those classified as being at a "lower risk". Moreover, TIMI and PRA RS had similar discriminatory accuracy. TIMI RS, however, was a better predictor of events than PRA at both 30- and 360-day follow-up. The inflammatory biomarkers assessed in the study did not improve significantly the predictive value of RS. CONCLUSIONS: Our study suggests both that TIMI RS is a better marker of risk than PRA RS and inflammatory biomarkers do not increase the predictive value of these clinical risk scores.

Prediction of infarction-related artery occlusion and multivessel disease in postinfarction angina.

CONDENSED ABSTRACT: To investigate the predictive value of clinical data for infarction-related artery (IRA) occlusion and multivessel coronary disease in postinfarction angina (PIA), we studied 181 consecutive patients presenting PIA following a first uncomplicated ST elevation AMI. Multivariate analysis showed ECG changes during PIA and the absence of thrombolytic therapy as independent predictors of IRA occlusion. Independent clinical predictors of multivessel coronary disease were age, previous history of angina and the number of cardiovascular risk factors. We conclude that reversible ECG changes during PIA correlated to IRA occlusion but failed to predict a multivessel coronary disease. AIM: To identify clinical variables predictive of infarction-related artery (IRA) occlusion and multivessel coronary disease in patients with postinfarction angina pectoris (PIA) after a first uncomplicated acute myocardial infarction (AMI). METHODS: We studied 181 consecutive patients with PIA following a first uncomplicated AMI. Clinical variables included cardiovascular risk factors, clinical history of angina before the event of inclusion, use of thrombolytic therapy in the previous AMI, ST-T changes during PIA, time to onset, number of episodes and delay to angiography after PIA. Angiographic variables were IRA TIMI flow, number of diseased vessels and ventricular function. RESULTS: The IRA was occluded in 67 patients with PIA (37.0%). Reversible ECG changes during PIA were detected in 121 patients (67.0%): 79 cases (43.6%) with ST/T elevation and 42 cases (23.2%) with ST/T depression. Multivariate logistic regression analysis showed ECG changes during PIA (OR 3.12 CI 95% 1.48-6.54, p<0.01) and the absence of thrombolytic therapy (OR 2.21 95% CI 1.11-4.43, p<0.05) as independent predictors of IRA occlusion. We found multivessel coronary disease in 89 patients (49.2%) without any correlation to ECG changes during PIA. Independent clinical predictors of multivessel coronary disease were age (OR 1.03 95% CI 1.01-1.06, p<0.05), previous history of angina (OR 2.37 95% CI 1.06-5.28, p<0.05) and the number of cardiovascular risk factors (OR 1.37 95% CI 0.97-1.92, p=0.07). CONCLUSIONS: ECG changes during PIA was correlated to IRA occlusion in spite of previous thrombolytic therapy but failed to predict a multivessel coronary disease in our patients.

Efficacy and safety of ezetimibe co-administered with ongoing atorvastatin therapy in achieving low-density lipoprotein goal in patients with hypercholesterolemia and coronary heart disease.

This randomised, double-blind, placebo (PBO)-controlled study evaluated the efficacy and safety of ezetimibe (EZE) co-administered with ongoing atorvastatin (ATV) therapy in 450 hypercholesterolemic patients with coronary heart disease (CHD) who had not achieved their low-density lipoprotein cholesterol (LDL-C) goal < or =2.60 mmol/l while on a stable dose of ATV 10 or 20 mg/day for > or =6 weeks. After a 4-week diet/baseline active run-in period, patients with LDL-C >2.60 mmol/l and < or =4.20 mmol/l were stratified by ATV dose and randomised (1 : 1) to EZE 10 mg or PBO for 6 weeks while continuing open-label ATV. Significantly more patients achieved an LDL-C goal < or =2.6 mmol/l with EZE than PBO (81.3 vs. 21.8%; p < or = 0.001). Compared to PBO, co-administration of EZE with ongoing ATV led to significantly (p < or = 0.001) greater reductions in LDL-C, total cholesterol, triglycerides, non-high-density lipoprotein cholesterol (non-HDL-C), and apolipoprotein B; HDL-C was significantly (p < or = 0.05) increased. Co-administration of EZE and ATV was well tolerated, with an overall safety profile similar to ATV alone.

[Thromboembolism prevention in acute myocardial infarction]. / Profilaxis tromboembólica en infarto agudo de miocardio.

The objectives were to identify risk factors for vein thromboembolic disease (VTD) among patients with acute myocardial infarction (AMI) and to analyse both quantitatively and qualitatively the performed thromboembolic prophylaxis. A cross-sectional study was carried out with all inpatients at the Coronary Unit at our hospital during 1998. The risk factors for thromboembolism included: inmobilization (79.2%), heart failure (33.2%) and age over 70 years (31%). VTD prophylaxis was performed in 86.9% of the time. Non-fractioned heparin (NFH) and low molecular weight heparins (LMWH), mostly nadroparine, were the most commonly used drugs at admission and at discharge, respectively. Overdosage and underdosage for NFH and LMWH, respectively, were observed. That patients received or not VTD prophylaxis was not influenced by thromboembolic risk factors.

Profilaxis tromboembólica en infarto agudo de miocardio / Thromboembolic prophylaxis in acute myocardial infarction

Los objetivos eran identificar los factores de riesgo de enfermedad tromboembólica venosa (ETV) en los pacientes con infarto agudo de miocardio (IAM) y analizar cuantitativa y cualitativamente la profilaxis tromboembólica realizada. Se ha hecho un estudio transversal de todos los pacientes ingresados en la Unidad Coronaria de nuestro hospital durante 1998. Los factores de riesgo tromboembólico han sido: inmovilización (79,2 por ciento), insuficiencia cardíaca (33,2 por ciento) y edad superior a 70 años (31 por ciento). Se hizo profilaxis de ETV en el 86,9 por ciento. La heparina no fraccionada (HNF) fue el fármaco más utilizado durante el ingreso y las heparinas de bajo peso molecular (HBPM) al alta, mayoritariamente nadroparina. Existía sobredosificación para las HNF e infradosificación para las HBPM. Los factores de riesgo tromboembólico no influyeron en que los pacientes recibieran o no profilaxis de ETV (AU)

[Intrapericardial cisplatin for malignant tamponade]. / Cisplatino intrapericárdico en el taponamiento neoplásico.

The choice therapy of malignant pericardial effusion is controversial. Pericardiocentesis is usually successful in alleviating tamponade, but unfortunately, that tamponade recurs frequently and patients are then again exposed to a critical situation and need hospitalization. Several different approaches have been advocated in order to prevent reaccumulation of the pericardial fluid, most of them quite cumbersome. We present our experience with intrapericardial administration of cisplatin. There were 6 patients, and the primary tumor was breast carcinoma in 2, lung in 1, ovary in 1, mediastinal fibrosarcoma in 1, and unknown in 1. Administration of cisplatin was virtually uneventful and painless, and there were no recurrences, with a survival of 2 to 18 months (mean 5.6).We conclude that intrapericardial cisplatin is safe and effective in treating malignant pericardial tamponade and preventing recurrence.

[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.

Randomized comparative trial of triflusal and aspirin following acute myocardial infarction.

AIMS: To compare the efficacy and tolerability of the antiplatelet agent triflusal with aspirin in the prevention of cardiovascular events following acute myocardial infarction. METHODS AND RESULTS: In this double-blind, multicentre, sequential design study, patients were randomized within 24 h of acute myocardial infarction symptom onset to receive triflusal 600 mg or aspirin 300 mg once daily for 35 days. The primary end-point was death, non-fatal myocardial reinfarction or a non-fatal cerebrovascular event. The incidences of these individual outcomes and urgent revascularization were secondary end-points. The null hypothesis of no difference between treatments in the primary combined end-point was accepted with 80% power after recruiting 2124 validated patients (odds ratio (OR) for failure [95% confidence interval (CI)]: 0.882 [0.634-1.227]). Non-fatal cerebrovascular events were significantly less frequent with triflusal (OR [95% CI]: 0.364 [0.146-0.908]; P = 0.030). There was no significant difference between treatments for death (OR [95% CI]: 0.816 [0.564-1.179]; P = 0.278), non-fatal reinfarction (OR [95% CI]: 1.577 [0.873-2.848]; P = 0.131) or revascularization (OR [95% CI]: 0.864 [0.644-1.161]; P = 0.334). Overall, both drugs were well tolerated, although there was a trend towards fewer bleeding episodes with triflusal; significantly fewer central nervous system bleeding episodes were observed in triflusal-treated patients (0.27% vs. 0.97%; P = 0.033). CONCLUSION: Triflusal and aspirin have similar efficacy in preventing further cardiovascular events after acute myocardial infarction, but triflusal showed a more favourable safety profile. Triflusal significantly reduced the incidence of non-fatal cerebrovascular events compared with aspirin.

[A right atrial thrombus in transit: its echocardiographic diagnosis 72 hours before a pulmonary embolism]. / Trombo en tránsito en aurícula derecha: diagnóstico ecocardiográfico 72 horas antes de un embolismo pulmonar.

We report a case of a 72-year-old woman with coronary artery disease in whom a thrombus in transit in the right atrium was diagnosed accidentally. After 72 hours of treatment with intravenous anticoagulants she developed a pulmonary thromboembolism resolved with systemic fibrinolysis. This is a rare case in which such a diagnosis preceded an embolic event. This fact raises the controversy about the best therapeutic management of this unusual form of thromboembolic illness.

[Aortic coarctation: different anatomo-clinical forms depending on the age of presentation]. / Coartación de aorta: diferentes formas anatomoclínicas según la edad de presentación.

OBJECTIVE: To analyse the anatomo-clinical characteristics of the coarctation of the aorta at different ages of presentation as well as the findings and results of its surgical correction at different periods. PATIENTS AND METHODS: We retrospectively studied the clinical and angiographic data, as well as the intraoperative findings and surgical outcomes of 82 consecutive patients (54 M and 28 F) with coarctation of the aorta. Mean age was 16.2 +/- 13.7 years (1 month to 63 years). The patients were divided into three groups according to age: Group A (n = 10) under 1 year; Group B (n = 30) from 1 to 12 years and Group C (n = 42) over 12 years. RESULTS: A preductal form was found in 20.7% cases (50.0%, 30.0% and 7.1% of groups A, B, and C respectively; p = 0.003). An associated left-to-right shunt was present in 19.5% (40.0%, 16.7% and 16.7% of groups A, B and C respectively; p = NS). The first manifestation of the disease was different in groups A, B and C. Among group A patients, congestive heart failure was the most frequent presentation (70.0%). In group B, the most frequent presentation (30%) was as an incidental finding in an asymptomatic patient. Finally, systemic hypertension or its complications predominated among group C patients (38.0%). Left ventricular hypertrophy on ECG was present in 0.0%, 30.0% and 54.7% of patients in groups A, B and C (p = 0.003) respectively. Postoperative complications including death, hypertensive crisis and re-coarctation were observed in 90.0%, 33.3% and 21.4% in groups A, B and C (p = 0.01) respectively. CONCLUSIONS: Among patients with coarctation of the aorta, the age of clinical presentation allows us to define groups of patients with different anatomical characteristics, clinical course and postoperative outcome.

[Influence of coronary risk factors in secondary prevention: tobacco]. / Influencia de los factores de riesgo coronario en prevención secundaria: tabaco.

Tobacco smoking is a strong independent factor for atherosclerotic disease, equivalent to hypertension or high cholesterol levels. Middle age people are especially involved, with a mortality rate of about 20% as a consequence of smoking, and a mean loss of life expectancy of 20 years. There is a positive correlation between smoking and severity of atherosclerotic disease in the coronary and cerebral arteries, and the aorta. It has been shown that smoking cessation clearly enhances the prognosis of patients with myocardial infarction. Twice a increase in mortality rate has been found among nonstopping smokers compared with those who stopped smoking eight years after myocardial infarction. In addition, progression of atherosclerosis as shown by angiography is slowed by stopping to smoke. As the coronary risk factors act in a synergistic way, a comprehensive approach to the patient is recommended, especially in smokers with myocardial infarction. It is justified an intensive intervention because of the advantages in this population. The physician should clearly communicate to the patient the need of stopping to smoke, which carries sometimes as beneficial effects as other interventions. A wise use of replacement therapy with transdermal nicotine, together with other useful measures, allows us to manage patients with a broad margin of safety, especially in coronary patients, who win most benefit from ceasing to smoke.

[Clinical and electrocardiographic characteristics of masquerading bifascicular block]. / Características clínicas y electrocardiográficas del bloqueo bifascicular disfrazado.

INTRODUCTION: Masquerading bundle branch block is a right bundle branch block with a left anterior hemiblock which appears similar to a left bundle branch block in the frontal plane leads. MATERIAL AND METHODS: We have followed 22 patients with such a pattern in the electrocardiogram for 3 years. RESULTS: Thirteen patients (59%) developed high degree atrioventricular block. During this period, there were 4 deaths, 3 from heart failure and 1 due to sepsis. CONCLUSIONS: We conclude that progression to high degree atrioventricular block is quite common in the presence of this kind of branch block. It is frequently associated to advanced heart failure, so the prognosis is usually poor.

[Circulatory arrest after combined intravenous drugs for the treatment of orthodromic circular tachycardia of Wolff-Parkinson-White syndrome]. / Parada circulatoria tras uso combinado de fármacos intravenosos para tratar una taquicardia circular ortodrómica de un síndrome de Wolff-Parkinson-White.

Antiarrhythmic drugs administered intravenously run the risk of producing a hemodynamic collapse even when used by expert and well trained hands. The arrhythmias in the focal point of a preexcitation syndrome constitute a very special situation in which extreme caution must be used when using intravenous drugs, because the conduction through accessory channels can vary, depending on multiple factors. We describe a case of a patient with an accessory atrioventricular pathway and orthodromic tachycardia who developed cardiac arrest by wide QRS tachycardia after receiving intravenous amiodarone.

[Neurohormonal factors in heart failure (and III)]. / Factores neurohormonales en la insuficiencia cardíaca (y III).

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as "compensators", which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these system, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatments for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Neurohormonal factors in heart failure. II]. / Factores neurohormonales en la insuficiencia cardíaca (II).

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as "compensators", which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these systems, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at the cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatments for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Neurohormonal factors in heart failure. I]. / Factores neurohormonales en la insuficienica cardíaca (I).

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as 'compensators', which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these systems, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at the cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatment for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Variant angina pectoris related to the treatment of migraine]. / Angina variante en relación con el tratamiento de la migranña.

A 54 years-old man with a history of migraine, suffered from chest pain together with ST-segment elevation related to the intake of drugs against migraine attacks. The coronary arteriography showed normal coronary arteries. We suggest coronary artery spasm as the most probable cause of ischemia. We conclude that vasoactive drugs against migraine must be utilized with caution, or even avoided in patients with chest pain suggestive of myocardial ischemia.