Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention.

OBJECTIVE: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN: Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING: Transnational registry in Spain. SUBJECTS: We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS: Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES: All-cause death. RESULTS: Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION: Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

[The value of cardiac troponin I as diagnostic test in the study of chest pain]. / Valor de la troponina I cardíaca como prueba diagnóstica en el estudio del dolor torácico.

BACKGROUND AND OBJECTIVES: Cardiac troponin I is a highly sensitive and specific myocardial injury marker. We have analyzed the use of cardiac troponin I values in the diagnosis of coronary artery disease, in previously healthy patients who developed chest pain with inconclusive analytical and ECG diagnostic findings. PATIENTS, MATERIAL AND METHODS: A one year cross-sectional consecutive study was conducted, in a total of 37 patients with no previously known heart disease who were admitted to the coronary unit for suspected anginal chest pain with normal cardiac enzymes and ECG. Abnormal cardiac troponin I levels at admission were defined as > or = 0.4 ng/ml, and were compared with coronary angiography or exercise test results and related to the duration of pain and the time from the appearance of symptoms to blood extraction. RESULTS: Thirty-three of the 37 initially included patients were studied. Coronary artery disease was diagnosed in 22, 15 of whom had increased troponin I values, yielding a sensitivity of 68% (48%-84%) and a specificity of 82% (53%-97%). In the subgroup of patients with pain lasting > 30 min, sensitivity reached 85% (59%-97%) and specificity 83% (42%-99%). There were no significant differences between subgroups with different time delays from appearance of symptoms to blood extraction. CONCLUSIONS: Cardiac troponin I is very useful for the studying ischemic chest pain without a definitive diagnostic ECG nor biochemical data, resulting in a high sensitivity and specificity for myocardial ischemic injury detection. Its diagnostic value increases in cases of prolonged pain episodes.

[Identification of the ischemic origin of dilated myocardiopathy using positron emission tomography]. / Identificación del origen isquémico de la miocardiopatía dilatada mediante tomografía por emisión de positrones.

INTRODUCTION AND OBJECTIVES: The aim of this study was to differentiate ischemic from nonischemic dilated cardiomyopathy with positron emission tomography. This differentiation is necessary to establish an adequate treatment, and it is often difficult with non-invasive diagnostic procedures. METHODS: Ten patients with an echocardiographic diagnosis of dilated cardiomyopathy who had undergone coronary angiography were selected. The presence or absence of angiographic coronary lesions was used to define the ischemic (n = 6) and the nonischemic group (n = 4). The ejection fraction was depressed in both groups, with no significant differences found. A perfusion study with 13N-ammonium and a metabolic imaging with 18F-florodeoxyglucose were performed on each patient. The images were quantitatively and qualitatively analysed, defining three criteria: accumulation defect (areas with activity under 50% of the maximal radioactivity), degree of heterogeneity, and match of images with both tracers. To determinate the degree of heterogeneity, nine segments on the three standard tomographic planes were studied. Based on the following heterogeneity features: irregular borders, coexisting different degrees of accumulation, and patched accumulation, a score ranging from 0 to 3 points was assigned to these segments. To analyse the radioactivity defects and the matching of studies with both tracers, the accumulation defects or the accumulating surface were outlined on a midventricular level coronal plane. RESULTS: The ischemic group has contrary to the nonischemic one, wider perfusion (0.26 +/- 0.21 vs 0.00) and metabolism defects (0.38 +/- 0.30 vs 0.06 +/- 0.09; p < 0.05). The degree of heterogeneity is significantly higher in the nonischemic group, either in perfusion (14.5 +/- 8.38 vs 2.5 +/- 1.04; p < 0.05) or in metabolism studies (15.5 +/- 3.31 vs 2.33 +/- 1.50; p < 0.005). Assigning wide defects and homogeneous accumulation to ischemic cardiomyopathy, and absence of defects and heterogeneous accumulation to nonischemic cardiomyopathy, the aetiology of the disease was identified in 9 of the 10 cases in the perfusion study and 100% of them with the metabolism imaging. CONCLUSIONS: Positron emission tomography allows to identify the aetiology of dilated cardiomyopathy, either with coronary perfusion or with myocardial glucose metabolism studies. Thus, only one of both PET studies could be used. Ischemic cardiomyopathy is characterised by wide defects and homogeneous radioactivity, and the nonischemic one by the absence of defects and heterogeneous accumulation of the tracer.

[Cardiac pathology of extracardiac origin (II). The cardiac repercussion of amyloidosis and hemochromatosis]. / Patología del corazón de origen extracardíaco (II). Repercusión cardíaca de la amiloidosis y de la hemocromatosis.

Although rare, amyloidosis and hemochromatosis are the infiltrative diseases in which the heart is more frequently involved. The most common clinical presentation is heart failure with hemodynamic features of restrictive heart disease in cardiac amyloidosis. The diagnosis is often made because of symptoms of other organ involvement, although sometimes cardiac symptoms may be the initial manifestation. The non-specific clinical presentation and the low prevalence of these cardiomyopathies make the diagnosis difficult if the clinician does not suspect it. Once symptoms develop, the evolution is fast. Usually, the unsatisfactory and ineffective treatment of amyloidosis and hemochromatosis contribute to the poor prognosis. The indication of cardiac transplantation in advanced cases is questionable because of the high recurrence of the illness.