Effect of an intensive lifestyle intervention on the structural and functional substrate for atrial fibrillation in people with metabolic syndrome.

AIMS: To evaluate the effect of an intensive lifestyle intervention (ILI) on the structural and functional cardiac substrate of atrial fibrillation (AF) in overweight or obese people with metabolic syndrome (Mets). METHODS AND RESULTS: Participants of the PREvención con DIeta MEDiterranea-Plus trial (n = 6874) were randomized 1:1 to an ILI programme based on an energy-reduced Mediterranean diet, increased physical activity, and cognitive-behavioural weight management or to a control intervention of low-intensity dietary advice. A core echocardiography lab evaluated left atrial (LA) strain, function, and volumes in 534 participants at baseline, 3-year, and 5-year follow-ups. Mixed models were used to evaluate the effect of the ILI on LA structure and function. In the subsample, the baseline mean age was 65 years [standard deviation (SD) 5 years], and 40% of the participants were women. The mean weight change after 5 years was -3.9 kg (SD 5.3 kg) in the ILI group and -0.3 kg (SD 5.1 kg) in the control group. Over the 5-year period, both groups experienced a worsening of LA structure and function, with increases in LA volumes and stiffness index and decreases in LA longitudinal strain, LA function index, and LA emptying fraction over time. Changes in the ILI and control groups were not significantly different for any of the primary outcomes {LA emptying fraction: -0.95% [95% confidence interval (CI) -0.93, -0.98] in the control group, -0.97% [95% CI -0.94, -1.00] in the ILI group, Pbetween groups = 0.80; LA longitudinal strain: 0.82% [95% CI 0.79, 0.85] in the control group, 0.85% [95% CI 0.82, 0.89] in the ILI group, Pbetween groups = 0.24} or any of the secondary outcomes. CONCLUSION: In overweight or obese people with Mets, an ILI had no impact on the underlying structural and functional LA substrate measurements associated with AF risk.

This study evaluated whether an intervention-modifying lifestyle had an effect on the parts of the heart involved in the development of atrial fibrillation (AF), a common problem of the heart rhythm. This intervention was implemented in people who had excessive body weight and the metabolic syndrome (Mets), which is a combination of several cardiovascular risk factors. The lifestyle intervention included promoting a Mediterranean diet low in calories and increasing exercise to facilitate weight loss, and this intervention was compared with a control intervention to follow a healthy diet. We performed repeated studies of the heart structure and function with imaging over a period of 5 years. During the 5 years of the study, both study groups (intervention and control) showed changes in their heart consistent with ageing. However, these changes were not different in those who were receiving the lifestyle intervention. Also, participants who lost more weight, adhered better to the study diet, or did more physical activity, overall did not show any differences in their heart compared with those who did not achieve their lifestyle goals.In conclusion, a lifestyle intervention focusing on weight loss, better diet, and more exercise was not effective in improving parts of the heart potentially involved with the risk of AF.In people with metabolic syndrome, a weight control lifestyle intervention, based on an energy-reduced Mediterranean diet and physical activity, had no effect on the structural and functional cardiac substrate of atrial fibrillation.

Effect of an intensive lifestyle intervention on the structural and functional substrate for atrial fibrillation in people with metabolic syndrome.

Aims: To evaluate the effect of an intensive lifestyle intervention (ILI) on the structural and functional cardiac substrate of atrial fibrillation (AF) in overweight or obese people with metabolic syndrome (MetS). Methods: Participants of the PREDIMED-PLUS trial (n=6874) were randomised 1:1 to an ILI program based on an energy-reduced Mediterranean diet, increased physical activity, and cognitive-behavioural weight management, or to a control intervention of low-intensity dietary advice. Left atrial (LA) strain, function, and volumes were evaluated by a core echocardiography lab in 534 participants at baseline, 3-year and 5-year follow-up. Mixed models were used to evaluate the effect of the ILI on LA structure and function. Results: In the subsample, baseline mean age was 65 years (SD 5 years), and 40% of the participants were women. Over the 5-year period, both groups experienced worsening of LA structure and function, with increases in LA volumes and stiffness index and decreases in LA longitudinal strain, LA function index and LA emptying fraction over time. Changes in the ILI and control group were not significantly different for any of the primary outcomes (LA emptying fraction: -0.95% (95%CI -0.93, -0.98) in control group, -0.97% (95%CI -0.94, -1.00) in ILI group, p between groups =0.80; LA longitudinal strain: 0.82% (95%CI 0.79, 0.85) in control group, 0.85% (95%CI 0.82, 0.89) in ILI group, p between groups =0.24) or any of the secondary outcomes. Conclusions: In overweight or obese people with MetS, an ILI had no impact on the underlying structural and functional left atrial substrate measurements associated with AF risk.

The Palma Echo Platform: Rationale and Design of an Echocardiography Core Lab.

Background: The metabolic syndrome (MetS) is associated with increased cardiovascular morbidity and mortality. Characterization of cardiac structural and functional abnormalities due to the MetS can help recognize individuals who would benefit the most from preventive interventions. Transthoracic echocardiography (TTE) provides an opportunity to identify those abnormalities in a reproducible and cost-efficient manner. In research settings, implementation of protocols for the acquisition and analysis of TTE images are key to ensure validity and reproducibility, thus facilitating answering relevant questions about the association of the MetS with cardiac alterations. Methods and Results: The Palma Echo Platform (PEP) is a coordinated network that is built up to evaluate the underlying structural and functional cardiac substrate of participants with MetS. Repeated TTE will be used to evaluate 5-year changes in the cardiac structure and function in a group of 565 individuals participating in a randomized trial of a lifestyle intervention for the primary prevention of cardiovascular disease. The echocardiographic studies will be performed at three study sites, and will be centrally evaluated at the PEP core laboratory. Planned analyses will involve evaluating the effect of the lifestyle intervention on cardiac structure and function, and the association of the MetS and its components with changes in cardiac structure and function. Particular emphasis will be placed on evaluating parameters of left atrial structure and function, which have received more limited attention in past investigations. This PEP will be available for future studies addressing comparable questions. Conclusion: In this article we describe the protocol of a central echocardiography laboratory for the study of functional and structural alterations of the MetS.

Aortic coarctation endarteritis: The importance of a systematic echocardiographic study.

Aortic coarctation determines a favorable anatomical condition for the development of endocarditis-endarteritis due to the presence of an alteration in blood flow dynamics that favors the appearance of endothelial damage and the adhesion of microorganisms. At present, endarteritis of aortic coarctation is a rare entity due to early detection and surgical treatment of patient carriers of aortic coarctation. We present a case of a patient affected with a previously unknown aortic coarctation, who developed infective endarteritis with secondary formation of mycotic aneurysm. The echocardiography techniques proved determinant in establishing the diagnosis of aortic coarctation, as well as the associated infectious complications. .

Relationship between Urinary Level of Phytate and Valvular Calcification in an Elderly Population: A Cross-Sectional Study.

Pathological calcification generally consists of the formation of solid deposits of hydroxyapatite (calcium phosphate) in soft tissues. Supersaturation is the thermodynamic driving force for crystallization, so it is believed that higher blood levels of calcium and phosphate increase the risk of cardiovascular calcification. However several factors can promote or inhibit the natural process of pathological calcification. This cross-sectional study evaluated the relationship between physiological levels of urinary phytate and heart valve calcification in a population of elderly out subjects. A population of 188 elderly subjects (mean age: 68 years) was studied. Valve calcification was measured by echocardiography. Phytate determination was performed from a urine sample and data on blood chemistry, end-systolic volume, concomitant diseases, cardiovascular risk factors, medication usage and food were obtained. The study population was classified in three tertiles according to level of urinary phytate: low (<0.610 µM), intermediate (0.61-1.21 µM), and high (>1.21 µM). Subjects with higher levels of urinary phytate had less mitral annulus calcification and were less likely to have diabetes and hypercholesterolemia. In the multivariate analysis, age, serum phosphorous, leukocytes total count and urinary phytate excretion appeared as independent factors predictive of presence of mitral annulus calcification. There was an inverse correlation between urinary phytate content and mitral annulus calcification in our population of elderly out subjects. These results suggest that consumption of phytate-rich foods may help to prevent cardiovascular calcification evolution.

Right atrial thrombosis associated with hemodialysis catheter: first description of recurrence in a poorly understood problem.

Catheter-related right atrial thrombosis (CRAT) is an underreported and potentially life-threatening complication of central venous catheter in hemodialysis patients. The accurate incidence is unknown, with reported rates ranging from 2 to 12.8% [1] in series, up to 29% [2] in a postmortem prospective study, and high mortality rates (18%) [1]. The optimal treatment for CRAT is controversial and nonsystematized, including anticoagulation, thrombolysis, and surgical thrombectomy. We report two cases of CRAT in dialysis patients, who underwent surgical thrombectomy. One case required reintervention because of recurrence, a first reported case in hemodialysis population.

El análisis del flujo aórtico por ecocardiografía Doppler es útil en la estratificación pronóstica de los pacientes con estenosis aórtica grave con fracción de eyección normal / Systolic volume index by doppler echocardiography is an useful marker for stratification and prognostic evaluation in patients with severe aortic stenosis and preserved ejection fraction

Introducción y objetivos. El pronóstico de los pacientes con estenosis aórtica grave con bajo gradiente aórtico y fracción de eyección normal es controvertido. Nuestro estudio analiza el pronóstico de estos pacientes y su relación con el gradiente de presión y el flujo valvular aórtico. Métodos. Cohorte retrospectiva de 363 pacientes consecutivos con estenosis aórtica grave y fracción de eyección normal, dividida en cuatro grupos según índice de volumen sistólico mayor o menor que 35 ml/m2 y gradiente aórtico medio mayor o menor que 40 mmHg. Grupo I, flujo normal y gradiente elevado (n = 169; 47%); grupo II, flujo normal y bajo gradiente (n = 98; 27%); grupo III, bajo flujo y gradiente elevado (n = 54; 15%), y grupo IV, bajo flujo y bajo gradiente (n = 42; 12%). El objetivo primario es la mortalidad total. Resultados. Los factores de riesgo independientes de mortalidad son la edad (hazard ratio = 1,04; intervalo de confianza del 95%, 1,01-1,08) y la fibrilación auricular (hazard ratio = 2,21; intervalo de confianza del 95%, 1,24-3,94). El tratamiento quirúrgico se asocia a mayor supervivencia en todos los grupos (hazard ratio = 0,25; intervalo de confianza del 95%, 0,13-0,49). Los pacientes con bajo flujo presentan mayor mortalidad que los pacientes con flujo normal (el 26,6 frente al 13,6%; p = 0,004). El grupo II muestra mejor pronóstico (hazard ratio = 0,4; intervalo de confianza del 95%, 0,2-0,9). Conclusiones. Los pacientes con estenosis aórtica grave, fracción de eyección normal y bajo flujo aórtico presentan peor pronóstico. El análisis del flujo aórtico mediante ecocardiografía Doppler es útil en la estratificación de riesgo y en la toma de decisiones terapéuticas en pacientes con estenosis aórtica (AU)

Introduction and objectives. The prognosis of patients with severe aortic stenosis, low aortic gradient and preserved ejection fraction is controversial. Our study analyzed the prognosis of these patients and its relation to pressure gradient and aortic valve flow. Methods. We performed a retrospective cohort study of 363 consecutive patients with severe aortic stenosis and preserved ejection fraction, divided into 4 groups, based on the presence of a systolic volume index greater or lower than 35mL/m2 and the presence of a mean aortic gradient greater or lower than 40mmHg. Group I: normal flow, high gradient (n=169, 47%); group II: normal flow, low gradient (n=98, 27%); group III: low flow, high gradient (n=54, 15%), and group IV: low flow, low gradient (n=42, 12%). The primary endpoint was overall mortality. Results. Independent risk factors for mortality were age (hazard ratio=1.04; 95% confidence interval, 1.01-1.08) and atrial fibrillation (hazard ratio=2.21; 95% confidence interval, 1.24-3.94). Surgical treatment was associated with longer survival in all groups (hazard ratio=0.25; 95% confidence interval: 0.13-0.49). Mortality was higher in patients with low flow than in those with with normal flow (26.6% vs 13.6%; P=.004). The most favorable mean prognosis was found in group II (hazard ratio=0.4; 95% confidence interval, 0.2-0.9). Conclusions. Patients with severe aortic stenosis, normal ejection fraction and low aortic flow have a worse prognosis. Analysis of aortic flow by Doppler echocardiography is useful in risk stratification and therapeutic decision-making in patients with aortic stenosis (AU)

Echocardiographic abnormalities in patients with COPD at their first hospital admission.

Cardiovascular disease accounts for significant morbidity and mortality in chronic obstructive pulmonary disease (COPD). Its prevalence and mechanisms of association have not been elucidated. The study aimed to assess the prevalence of echocardiographic abnormalities and potential risk factors in patients with COPD at their first exacerbation requiring hospital admission. Transthoracic echocardiography was prospectively performed in 342 patients (forced expiratory volume in 1 s 52 ± 16% predicted) 3 months after discharge. Significant cardiac alterations were present in 64% of patients; 27% left- and 48% right-heart disorders. The most common were right ventricle enlargement (30%) and pulmonary hypertension (19%). Left ventricle enlargement was present in 6%, left ventricle systolic dysfunction in 13%, left ventricle diastolic impairment in 12% and left atrial dilatation in 29%. Echocardiographic abnormalities were unrelated to COPD severity and were more frequent in patients with self-reported cardiac disease. They were also observed in 63% of patients with no known cardiac disease or cardiovascular risk factors other than smoking. We conclude that cardiac abnormalities are highly prevalent in COPD patients at the time of their first severe exacerbation, even in the absence of established cardiac disease or cardiovascular risk factors. Considering the prognostic and therapeutic implications of cardiac comorbidity, echocardiography should be considered in the assessment of patients with clinically significant COPD.

Systolic volume index by Doppler echocardiography is an useful marker for stratification and prognostic evaluation in patients with severe aortic stenosis and preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: The prognosis of patients with severe aortic stenosis, low aortic gradient and preserved ejection fraction is controversial. Our study analyzed the prognosis of these patients and its relation to pressure gradient and aortic valve flow. METHODS: We performed a retrospective cohort study of 363 consecutive patients with severe aortic stenosis and preserved ejection fraction, divided into 4 groups, based on the presence of a systolic volume index greater or lower than 35 mL/m(2) and the presence of a mean aortic gradient greater or lower than 40 mmHg. Group I: normal flow, high gradient (n=169, 47%); group II: normal flow, low gradient (n=98, 27%); group III: low flow, high gradient (n=54, 15%), and group IV: low flow, low gradient (n=42, 12%). The primary endpoint was overall mortality. RESULTS: Independent risk factors for mortality were age (hazard ratio=1.04; 95% confidence interval, 1.01-1.08) and atrial fibrillation (hazard ratio=2.21; 95% confidence interval, 1.24-3.94). Surgical treatment was associated with longer survival in all groups (hazard ratio=0.25; 95% confidence interval: 0.13-0.49). Mortality was higher in patients with low flow than in those with with normal flow (26.6% vs 13.6%; P=.004). The most favorable mean prognosis was found in group II (hazard ratio=0.4; 95% confidence interval, 0.2-0.9). CONCLUSIONS: Patients with severe aortic stenosis, normal ejection fraction and low aortic flow have a worse prognosis. Analysis of aortic flow by Doppler echocardiography is useful in risk stratification and therapeutic decision-making in patients with aortic stenosis.

Modelo de intervención coronaria percutánea primaria en las Islas Baleares / The primary percutaneous coronary intervention program in the Balearic Islands

Uno de los objetivos críticos de la estrategia de salud en la cardiopatía isquémica es la atención urgente del infarto agudo de miocardio con elevación del ST (IAMCEST) y más concretamente del síndrome coronario agudo con elevación del ST, en los que el tiempo asistencial es crítico. Esta inmediatez del tratamiento (ya sea mecánica o farmacológica) se debería reflejar en los resultados de morbimortalidad. En 2003, tras la evidencia científica de la necesidad de una revascularización mecánica (intervención coronaria percutánea primaria) en el infarto agudo de miocardio con elevación del segmento ST, se estableció esta opción terapéutica en el hospital de referencia de nuestra comunidad (programa de intervención coronaria percutánea primaria). En marzo de 2008, tras múltiples reuniones con diferentes estamentos y centros, se puso en marcha el Registro Comunitario de la Asistencia al Síndrome Coronario Agudo con Elevación del ST (Registro Código Infarto de las Illes Balears). Se realiza: a) detección y documentación de todos los casos diagnosticados de IAMCEST en la comunidad autónoma; b) evaluación sistemática de los resultados asistenciales del IAMCEST y su ajuste a los objetivos asistenciales (tiempos, morbimortalidad, complicaciones, tratamientos, etc.); c) identificación y abordaje de las desviaciones respecto a los objetivos; d) conocimiento exhaustivo e implicación en el proyecto de todos los dispositivos asistenciales, y e) seguimiento al mes, a los 6 meses y al año del alta hospitalaria tras el proceso agudo del IAMCEST (AU)

One of the main objectives of any health-care strategy for ischemic heart disease is to provide emergency treatment for acute myocardial infarction and especially for ST-elevation acute coronary syndrome (STEACS), where any delay in treatment is crucial. The speed with which treatment (whether mechanical or pharmacologic) can be implemented will be reflected in morbidity and mortality rates. In 2003, in response to scientific evidence that mechanical revascularization (i.e. primary percutaneous coronary intervention) is essential for ST-elevation acute myocardial infarction, this therapeutic technique was introduced at the referral hospital in our region (in a primary percutaneous coronary intervention program). In March 2008, after several meetings between various stakeholders and institutions, a regional trial of treatment for STEACS (i.e. the Balearic Islands myocardial infarction code trial) started. It involved: a) the identification and reporting of all patients diagnosed with STEACS in the region; b) a systematic analysis of the results of treatment for STEACS in comparison with treatment goals (e.g. treatment times, morbidity, mortality, complications and treatment provided); c) identifying and responding to any deviations from targets; d) thorough understanding of and involvement in the project by all parts of the health-care system, and e) follow-up 1 month, 6 months and 1 year after hospital discharge following the STEACS episode (AU)

Abnormal levels of circulating endothelial progenitor cells during exacerbations of COPD.

Cardiovascular morbidity and mortality is increased in patients with chronic obstructive pulmonary disease (COPD). Reduced levels of circulating endothelial progenitor cells (EPCs) are associated with increased risk of death in patients with stable coronary artery disease (CAD). Likewise, during acute events of CAD, the number of circulating EPCs increases under the influence of vascular endothelial growth factor (VEGF) and systemic inflammation. Abnormal levels of circulating EPCs have been reported in patients with COPD. However, the response of EPCs to episodes of exacerbation of the disease (ECOPD) has not been investigated yet. We hypothesized that similar to what occurs during acute events of CAD, levels of circulating EPCs would increase during ECOPD. We compared levels of circulating EPCs (assessed by the % of CD34(+)KDR(+) cells determined by flow cytometry) in patients hospitalized because of ECOPD (n = 35; 65 +/- 9 years [mean +/- SD]; FEV(1) = 46 +/- 15% predicted), patients with stable COPD (n = 44; 68 +/- 8 years; FEV(1) = 49 +/- 17% predicted), smokers with normal lung function (n = 10; 60 +/- 9 years), and healthy never smokers (n = 10; 62 +/- 4 years). To investigate potential mechanisms of EPC regulation, we assessed both VEGF and high-sensitivity C-reactive protein (hsC-RP) in plasma. Our results show that EPC levels were higher (p < 0.05) in patients with ECOPD (1.46 +/- 1.63%) than in those with stable disease (0.68 +/- 0.83%), healthy smokers (0.65 +/- 1.11%), and healthy never smokers (1.05 +/- 1.36%). The percentage of circulating EPCs was positively related to VEGF plasma levels during ECOPD (r = 0.51, p = 0.003). In a subset of 12 patients who could be studied during both ECOPD and clinical stability, the EPCs levels increased during ECOPD. We conclude that EPC levels are increased during ECOPD, likely in relation to VEGF upregulation.

Association of blood pressure and its evolving changes with the survival of patients with heart failure.

OBJECTIVE: The association between low blood pressure (BP) levels and increased mortality has been established in several studies of heart failure (HF). Although many drugs administered to these patients decrease BP, the relationship between changes in BP and survival has not been investigated. Nor have previous analyses distinguished among different forms of death. We investigated the influence of baseline BP and changes in BP during a 1-year period on the survival of patients with HF, distinguishing among sudden cardiac death, nonsudden cardiac death, and noncardiac death. We also identified the possible relationship with the baseline values of and changes in other clinical and treatment variables, including pharmacologic treatments. METHOD AND RESULTS: A total of 1062 patients with chronic HF included in the Spanish National Registry of Sudden Death (mean age of 64.5 +/- 11.8 years, 72% were men, and 21% were in New York Heart Association class III with a mean left ventricular ejection fraction of 36.7% +/- 14.2%) were prospectively investigated for a mean of 1.9 +/- 0.6 years. A multivariable Cox proportional hazards model adjusting for clinical and therapeutic variables showed an independent association between low baseline systolic blood pressure (SBP) and nonsudden cardiac death (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.93-0.98), but changes in SBP during the following year did not influence survival, regardless of the baseline SBP level (P = .55). Contrariwise, baseline diastolic BP was not associated with mortality, but an increase in diastolic BP during the following year showed a borderline independent significant association with lower nonsudden cardiac death (HR 0.90, 95% CI 0.82-1.00). Treatment with angiotensin-converting enzyme inhibitors or beta-blockers at baseline was also associated with lower nonsudden cardiac mortality, as was an increase in left ventricular ejection fraction during the following year (HR 0.69, 95% CI 0.51-0.93; P = .015). CONCLUSION: Among patients with stable HF, low SBP is associated with a greater risk of nonsudden cardiac death. The change in SBP during a 1-year period has no prognostic value. Because the beneficial effects of drugs associated with increased survival (in this study, angiotensin-converting enzyme inhibitors and beta-blockers) thus seem to be independent of their effects on BP, changes in BP should probably not influence the decision to use such drugs or continue their administration.

Phytate reduces age-related cardiovascular calcification.

The aim of this research was to evaluate the effect of dietary phytate on cardiovascular calcification in rats during aging. Male Wistar rats (10 weeks old) were randomly assigned to four diet groups. The control group was fed with a balanced diet (UAR-A04) containing phytate. The AIN group was fed a purified diet (AIN-76A) with an undetectable level of phytate. The PHY group was fed with a purified diet (AIN-76A) enriched with phytate (phytin, as the calcium magnesium salt). The MOD group was fed with the AIN-76A diet (phytate undetectable) enriched with MgO, inositol and CaHPO4. At 76 weeks of age all rats were sacrificed, and the aortas, hearts, kidneys, livers and femurs were removed for chemical analysis. The most significant differences were found in the aorta calcium content. Phytate-treated rats (the control and PHY groups) had significantly lower levels of calcium in the aorta compared to nonphytate-treated rats (AIN and MOD groups). The present study demonstrated that dietary phytate treatment significantly reduced age-related aorta calcification.

Effect of crystallization inhibitors on vascular calcifications induced by vitamin D: a pilot study in Sprague-Dawley rats.

BACKGROUND: Pathological calcification in soft tissues (ie, ectopic calcification) can have severe consequences. Hydroxyapatite is the common mineral phase present in all tissue calcifications. In general, the development of tissue calcifications requires a pre-existing injury as an inducer (heterogeneous nucleant), whereas further progression requires the presence of other promoter factors (such as hypercalcemia and/or hyperphosphatemia) and/or a deficiency in calcification repressor factors (crystallization inhibitors and cellular defense mechanisms). The present study investigated the capacity of etidronate (a bisphosphonate used in osteoporosis treatment) and phytate (a natural product) to inhibit vascular calcification in rats. METHODS AND RESULTS: Six male Sprague-Dawley rats in each of the 3 treatment groups were subcutaneously injected with either a placebo (physiological serum solution), etidronate (0.825 micromol x kg(-1) x day (-1)) or phytate (0.825 micromol x kg (-1) x day(-1)) for 8 days. Four days into this regimen, calcinosis was induced by subcutaneous injections of 500,000 IU/kg vitamin D at 0 h, 24 h and 48 h. Ninety-six hours after the final vitamin D injection, the rats were killed and aortas and their hearts were removed for histological and calcium analyses. The data showed that phytate-treated rats had lower levels of aortic calcium than placebo-treated rats. All groups had similar heart calcium levels. CONCLUSIONS: The present study found that phytate acted as a vascular calcification inhibitor. Thus, the action of polyphosphates could be important in protecting against vascular calcification.

Left atrial enlargement and NT-proBNP as predictors of sudden cardiac death in patients with heart failure.

AIMS: The identification of valuable markers of sudden cardiac death (SCD) in patients with established HF remains a challenge. We sought to assess the value of clinical, echocardiographic and biochemical variables to predict SCD in a consecutive cohort of patients with heart failure (HF) due to systolic dysfunction. METHODS: A cohort of 494 patients with established HF had baseline echocardiographic and NT-proBNP measurements and were followed for 942+/-323 days. RESULTS: Fifty patients suffered SCD. Independent predictors of SCD were indexed LA size>26 mm/m2 (HR 2.8; 95% CI 1.5-5.0; p=0.0007), NT-proBNP>908 ng/L (HR 3.1; 95% CI 1.5-6.7; p=0.003), history of myocardial infarction (HR 2.3; 95% CI 1.3-4.1; p=0.007), peripheral oedema (HR 2.1; 95% CI 1.1-3.9; p=0.02), and diabetes mellitus (HR 1.9; 95% CI 1.1-3.3; p=0.03). NYHA functional class, left ventricular ejection fraction and glomerular filtration rate were not independent predictors of SCD in this cohort. Notably, the combination of both LA size>26 mm/m2 and NT-proBNP>908 ng/L increased the risk of SCD (HR 4.3; 95% CI 2.5-7.6; p<0.0001). At 36 months, risk of SCD in patients with indexed LA size26 mm/m2 and NT-proBNP>908 ng/L reached 25% (p<0.0001). CONCLUSIONS: Among HF patients, indexed LA size and NT-proBNP levels are more useful to stratify risk of SCD than other clinical, echocardiographic or biochemical variables. The combination of these two parameters should be considered for predicting SCD in patients with HF.

Phytate (Myo-inositol hexakisphosphate) inhibits cardiovascular calcifications in rats.

Calcification is an undesirable disorder, which frequently occurs in the heart vessels. In general, the formation of calcific vascular lesions involves complex physicochemical and molecular events. Calcification (hydroxyapatite) is initiated by injury and is progressed by promoter factors and/or the deficit of inhibitory signals. Myo-inositol hexakisphosphate (phytate, InsP6) is found in organs, tissues and fluids of all mammals and exhibits an important capacity as a crystallization inhibitor of calcium salts in urine and soft tissues. The levels found clearly depend on the dietary intake but it can also be absorbed topically. In this paper, the capacity of InsP6 as a potential inhibitor of cardiovascular calcifications was assessed in Wistar rats. Three groups were included, a control group, an InsP6 treated group (subjected to calcinosis induction by Vitamin D and nicotine and treated with standard cream with a 2% of InsP6 as potassium salt) and an InsP6 non-treated group (only subjected to calcinosis induction). All rats were fed AIN 76-A diet (a purified diet in which InsP6 is undetectable). Animals were monitorized every 12 hours. After 60 hours of calcinosis treatment, all rats of the InsP6 non-treated group died and the rest were sacrificed. Aortas and hearts were removed. A highly significant increase in the calcium content of aorta and heart tissue was observed in the InsP6 non-treated rats (21 +/- 1 mg calcium/g dry aorta tissue, 10 +/- 1 mg calcium/g dry heart tissue) when compared with controls (1.3 +/- 0.1 mg calcium/g dry aorta tissue, 0.023 +/- 0.004 mg calcium/g heart dry tissue) and InsP6 treated (0.9 +/- 0.2 mg calcium/g dry aorta tissue, 0.30 +/- 0.03 mg calcium/g dry heart tissue) animals. Only InsP6 non-treated rats displayed important mineral deposits in aorta and heart. These findings are consistent with the action of InsP6, as an inhibitor of calcification of cardiovascular system.

[Survival after recurrent left ventricular free wall rupture, with an atypical occurrence after post-infarction exercise test]. / Supervivencia a rotura cardíaca recurrente de pared libre ventricular izquierda, con presentación atípica tras ergometría postinfarto.

Left ventricular free wall rupture is an unusual but highly lethal complication of acute myocardial infarction. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture within a seven-month period. The first event happened in the course of an exercise testing after a seemingly uncomplicated inferior acute myocardial infarction; the second, seven months after the first, as a pseudoaneurysm in the setting of a new inferior wall infarction. Surgical repair was successful in both instances, with patient remaining asymptomatic in follow-up.

Supervivencia a rotura cardíaca recurrente de pared libre ventricular izquierda, con presentación atípica tras ergometría postinfarto / Survival after Two Consecutive Left Ventricular Free Wall Ruptures, with an Atypical Occurrence after a Pre-Discharge Exercise Test

La rotura aguda de la pared libre ventricular izquierda es una complicación poco frecuente del infarto agudo de miocardio, pero que comporta una elevada mortalidad.Presentamos el caso infrecuente de un paciente que 'sobrevivió' a 2 roturas cardíacas, en ambas ocasiones con una presentación atípica: la primera durante la realización de una ergometría tras un infarto no complicado, y la segunda 7 meses después de la primera, en forma de seudoaneurisma, en el contexto de la fase hiperaguda de un nuevo infarto inferior. En ambos casos el paciente fue tratado quirúrgicamente con éxito, quedando asintomático en el seguimiento (AU)

Rotura espontánea de músculo papilar con coronarias angiográficamente normales / Spontaneous Papillary Muscle Rupture in the Absence of Coronary Artery Disease

La rotura de músculo papilar es una afección poco frecuente, normalmente secundaria a una complicación mecánica del infarto agudo de miocardio o a un traumatismo torácico. Presentamos el caso clínico de una paciente que presentó una rotura espontánea completa de músculo papilar posteromedial e insuficiencia mitral severa secundaria, por necrosis aislada del papilar, sin lesiones coronarias angiográficas, que evolucionó a shock cardiogénico, requiriendo cirugía emergente de sustitución valvular mitral, realizada con éxito. Se ha revisado la escasa bibliografía clínica e histopatológica al respecto y se comentan los posibles mecanismos de dicha rotura. (AU)