The effect of post-discharge educational intervention on patients in achieving objectives in modifiable risk factors six months after discharge following an episode of acute coronary syndrome, (CAM-2 Project): a randomized controlled trial.

OBJECTIVES: We investigated whether an intervention mainly consisting of a signed agreement between patient and physician on the objectives to be reached, improves reaching these secondary prevention objectives in modifiable cardiovascular risk factors six-months after discharge following an acute coronary syndrome. BACKGROUND: There is room to improve mid-term adherence to clinical guidelines' recommendations in coronary heart disease secondary prevention, specially non-pharmacological ones, often neglected. METHODS: In CAM-2, patients discharged after an acute coronary syndrome were randomly assigned to the intervention or the usual care group. The primary outcome was reaching therapeutic objectives in various secondary prevention variables: smoking, obesity, blood lipids, blood pressure control, exercise and taking of medication. RESULTS: 1757 patients were recruited in 64 hospitals and 1510 (762 in the intervention and 748 in the control group) attended the six-months follow-up visit. After adjustment for potentially important variables, there were, between the intervention and control group, differences in the mean reduction of body mass index (0.5 vs. 0.2; p < 0.001) and waist circumference (1.6 cm vs. 0.6 cm; p = 0.05), proportion of patients who exercise regularly and those with total cholesterol below 175 mg/dl (64.7% vs. 56.5%; p = 0.001). The reported intake of medications was high in both groups for all the drugs considered with no differences except for statins (98.1% vs. 95.9%; p = 0.029). CONCLUSIONS: At least in the short term, lifestyle changes among coronary heart disease patients are achievable by intensifying the responsibility of the patient himself by means of a simple and feasible intervention.

Elevated serum neopterin levels and adverse cardiac events at 6 months follow-up in Mediterranean patients with non-ST-segment elevation acute coronary syndrome.

BACKGROUND: Little information exists regarding the prognostic role of biomarkers of inflammation in Mediterranean patients. High C-reactive protein and neopterin levels - a marker of macrophage activation - predict cardiovascular events in stable angina patients and patients with acute coronary syndromes (ACS). We sought to assess whether plasma neopterin levels predict adverse clinical outcomes in Mediterranean patients with non-ST elevation (NSTE) ACS, i.e. unstable angina (UA) and NSTE myocardial infarction (MI). METHODS: We prospectively assessed 397 patients (74% men) admitted with NSTEACS, 147 (37%) had unstable angina and 250 (63%) NSTEMI. Blood samples for neopterin and CRP assessment were obtained at admission. The study endpoint was the composite of cardiac death, acute myocardial infarction and unstable angina at 180 days. RESULTS: Baseline neopterin concentrations (nmol/L) were similar in unstable angina and NSTEMI patients (8.3 [6.6-10.7] vs. 7.9 [6.2-10.9]; p=0.4). Fifty-nine patients (14.9%) had events during follow-up. Twenty-nine (21.5%) patients with neopterin levels in the highest third experienced the combined endpoint, compared to 30 (11.5%) patients with neopterin levels in the second and the lowest thirds (log-rank 7.435, p=0.024). On multivariable hazard Cox regression, neopterin (highest vs. 1st and 2nd thirds, HR 1.762, 95% CI [1.023-3.036]) was independently associated with the combined endpoint. CONCLUSION: Increased neopterin levels are an independent predictor of 180-day adverse cardiac events in Mediterranean patients with NSTEACS.

[Valve repair for bicuspid aortic valve regurgitation: an option?]. / Reparación valvular en la insuficiencia aórtica por válvula bicúspide: una alternativa?

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre.

Reparación valvular en la insuficiencia aórtica por válvula bicúspide: ¿una alternativa? / Valve repair for bicuspid aortic valve regurgitation: an option?

La válvula aórtica bicúspide es la cardiopatía congénita más frecuente. Se asocia tanto a enfermedad valvular como a enfermedad aórtica. La insuficiencia aórtica por válvula aórtica bicúspide es susceptible de corregirse mediante técnicas de reparación quirúrgica, con buenos resultados a corto plazo. Sin embargo, la tasa de recurrencia de insuficiencia aórtica en el seguimiento continúa siendo un problema, en parte motivado por la dilatación aórtica progresiva propia de esta entidad. Presentamos 3 casos distintos de válvula aórtica bicúspide tratados mediante reparación en nuestro centro

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre

Abnormal transient Q waves: does electrocardiography continue to be a useful tool?

Continuous electrocardiograph monitoring in initial phases of Acute Coronary Syndrome (ACS) is well established. We present a patient case with ACS without ST elevation who developed transient pathological Q waves accompanying angina symptoms. The possible mechanisms and prognostic implications are discussed.

[Cardiac hamartoma. Case report and literature review]. / Hamartoma intracardíaco. Caso clínico y revisión de la bibliografía.

Primary cardiac tumors are infrequent and usually benign. They can manifest as dyspnea, chest pain, palpitations, sudden death, peripheral embolism, cyanosis, or general symptoms. They are sometimes an incidental finding in an asymptomatic patient. We describe a 33-year-old man who was seen because of dyspnea and palpitations. Transthoracic echocardiography revealed, on the lateral wall of the left ventricle, an intramyocardial mass that was successfully resected surgically. The pathologic diagnosis was hamartoma of mature cardiac myocytes. We discuss the usefulness of imaging techniques for identifying cardiac masses.

Hamartoma intracardíaco. Caso clínico y revisión de la bibliografía / Cardiac hamartoma. Case report and literature review

Los tumores cardíacos primarios son infrecuentes y habitualmente benignos. Pueden manifestarse con disnea, dolor torácico, palpitaciones, muerte súbita, embolia periférica, cianosis o síndrome constitucional. A veces es un hallazgo casual en un individuo asintomático. Presentamos el caso de 1 paciente de 33 años que consultó por disnea y palpitaciones. El ecocardiograma transtorácico reveló una masa intramiocárdica en la pared lateral del ventrículo izquierdo. Fue extirpada quirúrgicamente con éxito. El diagnóstico anatomo-patológico fue de hamartoma de células miocárdicas maduras. Se discute la utilidad de las pruebas de imagen en el estudio y la definición de las masas cardíacas

Primary cardiac tumors are infrequent and usually benign.They can manifest as dyspnea, chest pain, palpitations, sudden death, peripheral embolism, cyanosis, orgeneral symptoms. They are sometimes an incidental finding in an asymptomatic patient. We describe a 33-yearoldman who was seen because of dyspnea and palpitations. Transthoracic echocardiography revealed, on the lateral wall of the left ventricle, an intramyocardial mass that was successfully resected surgically. The pathologic diagnosis was hamartoma of mature cardiac myocytes. We discuss the usefulness of imaging techniques for identifying cardiac masses

[Effect of a simple educational program for physicians on adherence to secondary prevention measures after discharge following acute coronary syndrome. The CAM Project]. / Efecto de un programa sencillo de educación de los profesionales en el cumplimiento de medidas de prevención secundaria en el momento del alta hospitalaria tras un síndrome coronario agudo. Proyecto CAM.

INTRODUCTION AND OBJECTIVES: Adherence to established guidelines for patients discharged from the hospital after acute coronary syndrome is known to be suboptimal. The aim of this study was to assess the efficacy of a program for physicians centered on the treatment of acute coronary syndrome. PATIENTS AND METHOD: 39 hospitals participated. INTERVENTION: a set of measures was developed by consensus for the creation and distribution of educational materials. OUTCOMES OF INTEREST: Proportion of patients in whom ejection fraction and residual ischemia were evaluated, treatment at discharge, and health and dietary recommendations to patients (smoking, diet, exercise, etc.) referred to all patients in whom these measures or treatments should have been used ("ideal patients"). Changes were assessed with four cross-sectional surveys. RESULTS: A total of 1157, 1162, 1149 and 1158 patients were included. There were no relevant differences between these groups in baseline characteristics. In general, there was improvement in all variables between the first and the last survey. The proportion of patients who were weighed and measured increased (from 33.5% to 53.4%; P<.0001), as did the proportion of those in whom cholesterol was measured early (42.6 to 53.7%; P=.006). The proportion in whom residual ischemia was not measured despite indications for this test decreased (18.2% to 10.8%; P=.013), and the proportion increased for appropriate treatment with statins on discharge (68.6% to 81.4%; P<.0001), advice to quit smoking (60.1% to 72.2%; P<.0001) and advice to exercise (58.3% to 67.4%; P=.003). CONCLUSIONS: The educational intervention seems to have had a positive effect on improving the appropriateness of procedures and treatments for patients discharged after acute coronary syndrome.

Efecto de un programa sencillo de educación de los profesionales en el cumplimiento de medidas de prevención secundaria en el momento del alta hospitalaria tras un síndrome coronario agudo. Proyecto CAM* / Effect of a simple educational program for physicians on adherence to secondary prevention measures after discharge following acute coronary syndrome. The CAM project

Introducción y objetivos. El cumplimiento de las recomendaciones establecidas como eficaces en el momento del alta en los pacientes hospitalizados por un síndrome coronario agudo es subóptimo. El objetivo de este estudio es evaluar la eficacia de un programa de intervención centrado en el abordaje y tratamiento del síndrome coronario agudo. Pacientes y método. Participaron en el proyecto 39 hospitales. La intervención realizada consistió en el desarrollo consensuado de acuerdos de mínimos y la elaboración y difusión de materiales educativos. Entre las medidas de interés cabe destacar la proporción de pacientes en la que se evaluaron la fracción de eyección, la isquemia residual y los tratamientos y recomendaciones higiénico-dietéticas en el momento del alta (tabaco, dieta, ejercicio, etc.) del total de pacientes en los que se deben determinar según el acuerdo de mínimos ("pacientes ideales"). Asimismo, se valoraron los cambios en 4 cortes transversales. Resultados. Se incluyó a 1.157, 1.162, 1.149 y 1.158 pacientes, respectivamente. No había diferencias en las características basales de pacientes analizados en cada corte. En general, se aprecia una mejoría entre el primer y el último corte en todas las variables analizadas. Mejoró especialmente la proporción de pacientes en los que se determinaron el peso y la talla (del 33,5 al 53,4 por ciento; p < 0,0001). También se observó una mejoría en la medición precoz del colesterol (del 42,6 al 53,7 por ciento; p = 0,006) y una reducción del porcentaje de pacientes en los que no se realizó un test de isquemia pese a estar indicado (del 18,2 al 10,8 por ciento; p = 0,013); asimismo, aumentó la propoción de pacientes con un tratamiento adecuado con estatinas en el momento del alta (del 68,6 al 81,4 por ciento; p < 0,0001) y el número de recomendaciones sobre tabaquismo (del 60,1 al 72,2 por ciento; p < 0,0001) y ejercicio (del 58,3 al 67,4 por ciento; p = 0,003).Conclusiones. La intervención educativa parece que tiene un efecto positivo en la mejora de la adecuación de los procedimientos realizados y en los tratamientos prescritos en el momento del alta tras un síndrome coronario agudo (AU)

Expression of activation molecules in neutrophils, monocytes and lymphocytes from patients with unstable angina treated with stent implantation.

Coronary angioplasty is known to mediate an inflammatory response. Recently, we have characterized the transient systemic inflammatory response after coronary stent implantation in patients with unstable angina by measuring different soluble protein markers. In the present study we have characterized the expression of various cellular activation markers in neutrophils, monocytes and lymphocytes from the same group of patients. Peripheral blood samples were taken before and 24 h, 48 h and 7 days after successful coronary stenting in 58 patients. Cell surface markers (CD11b/CD18 and CD38) were analyzed by flow cytometry to determine the activation of neutrophils, monocytes and T lymphocytes. We found that coronary angioplasty with stent implantation produces an increase in the cell surface expression of CD11b/CD18 in neutrophils and CD38 in monocytes, following a similar time-course with a peak after 24 h, returning to basal levels after 48 h and a second peak after 7 days. However, T lymphocytes were not found to be activated. These results suggest that coronary stent implantation induces a different pattern inducing soluble and cellular inflammation markers, and therefore, they should be taken into account in patients undergoing stent implantation to study clinical correlations.

Inflammatory response to coronary stent implantation in patients with unstable angina.

Previous evidence has shown that coronary angioplasty leads to the release of inflammatory mediators. In this study, we sought to characterize the systemic inflammatory response after coronary stent implantation in patients with unstable angina by measuring different protein markers. Peripheral blood samples were taken before and 24 h, 48 h, and 7 days after successful coronary stenting in 58 patients. Several markers of acute-phase response were determined: C-reactive protein (CRP), alpha2-macroglobulin, haptoglobin, acid alpha1-glycoprotein, prealbumin and albumin. Besides, proinflammatory cytokines (tumor necrosis factor-alpha, IL-6, IL-8) and the anti-inflammatory cytokine IL-10 were also measured. We have found that coronary angioplasty with stent implantation produces a systemic inflammatory response with a rise in inflammation markers concentration. CRP plasma levels declined 1 week after the intervention, but the other marker levels were even higher after 7 days. IL-6 was the only cytokine whose plasma levels significantly increased in peripheral blood after stenting, with a rise after 24 h, maintained after 48 h, and decreased to near-basal levels after 1 week. There was a good correlation between CRP and IL-6 plasma levels (r=0.5, p<0.001). IL-10 levels were slightly decreased after 24 h. Although no significant differences in the means at different time points were found, there was a decrease in IL-10 in most patients 24 h after the intervention. These results indicate that coronary stent implantation induces a systemic inflammatory reaction, with a temporal increase in the concentration of the inflammation markers, especially CRP and IL-6. Since these markers had been previously used as prognostic markers, this needs to be taken into account in patients undergoing stent implantation.

[Role of coronary artery revascularization and aneurysmectomy in ventricular arrhythmias in the chronic phase of myocardial infarction]. / Papel de la revascularización coronaria y la aneurismectomía en las arritmias ventriculares asociadas a infarto de miocardio crónico.

INTRODUCTION AND OBJECTIVES: The influence of coronary artery revascularization on the control of ventricular arrhythmias in patients with chronic myocardial infarction is uncertain. However, ablation of the arrhythmogenic circuit in these patients by aneurysm resection is useful for controlling ventricular arrhythmias. We made a prospective analysis of our clinical strategy in patients who were candidates for coronary artery revascularization and/or aneurysmectomy to determine its influence on the recurrence of ventricular arrhythmias. PATIENTS AND METHOD: Prospective study of 17 consecutive patients with chronic myocardial infarction and ventricular arrhythmias unrelated with an acute ischemic event, who had coronary artery disease and/or ventricular aneurysm susceptible to aggressive treatment. We evaluated our clinical strategy and the recurrence of ventricular arrhythmias during a mean follow-up period of 33.64 months. RESULTS: Two groups of patients were studied: patients with ventricular aneurysm (group I: 12 patients) and patients without ventricular aneurysm (group II: 5 patients). Seven patients of group I underwent endoaneurysmorrhaphy and endocardial resection (4 of these patients had associated revascularization procedures). Three patients were not candidates for aneurysmectomy or revascularization procedures. Two patients underwent only revascularization procedures. All the patients in group II were revascularized. The patients who underwent aneurysmectomy did not have recurrence of arrhythmias. In 5 of the 6 patients who underwent programmed electrophysiological stimulation after aneurysmectomy, no sustained arrhythmia could be induced. Patients who were only revascularized had a high rate of recurrence of ventricular arrhythmias (57%), which were inducible after revascularization. CONCLUSION: Aneurysmectomy and endocardial resection constituted, in our experience, an effective tool for controlling ventricular arrhythmias associated with left ventricular aneurysm. Coronary artery revascularization in patients with ventricular arrhythmias and chronic myocardial infarction probably does not prevent the recurrence of ventricular arrhythmias.