IVUS-guided treatment strategies for definite late and very late stent thrombosis.

AIMS: Our aim was to describe the intravascular ultrasound (IVUS) findings of patients with late stent thrombosis (ST) undergoing percutaneous intervention, and to compare the pre- and post-intervention IVUS findings of patients treated with balloon angioplasty (BA) vs. additional stent implantation (ASI). METHODS AND RESULTS: A total of 117 patients with late ST imaged with IVUS were included (51.2% had drug-eluting stent ST). Treatment was left to the operator's discretion: BA was performed in 53.8% and ASI in 46.2%. Pre-intervention, incomplete stent apposition (ISA) was observed in 69.8% vs. 63.0% (p=0.43), underexpansion in 33.3% vs. 18.5% (p=0.07) and restenosis in 15.9% vs. 27.8% (p=0.12), respectively. Post-intervention, persistent ISA was observed in 37.2% vs. 60.9% (p=0.03) and malapposition volume decreased by 43.6% vs. 2.6% (p=0.03). Persistent underexpansion was observed in 9.3% vs. 17.4% (p=0.26); however, the stent expansion index was largely increased with BA (from 0.75 to 0.88) compared to ASI (from 0.80 to 0.82); p=0.046. At two years, recurrent ST was observed in one (1.7%) vs. four (7.7%) patients, respectively; p=0.09. CONCLUSIONS: Non-optimal IVUS criteria of stent implantation are often observed in patients with late ST. Treatment of late ST with BA leads to a larger reduction of malapposition and underexpansion with respect to ASI and is associated with favourable outcomes.

Treatment of Small Vessel Disease With the Paclitaxel Drug-Eluting Balloon: 6-Month Angiographic and 1-Year Clinical Outcomes of the Spanish Multicenter Registry.

BACKGROUND: Small vessel disease (SMD) remains a major challenge because of the increased risk of restenosis. We sought to assess the efficacy and safety of a paclitaxel-eluting balloon (PEB) in patients with SMD. METHODS AND RESULTS: One-hundred and four patients with native coronary lesions in small vessels treated by using a PEB were included in this prospective multicenter registry. In each case, after regular balloon dilatation, a larger PEB was inflated for a minimum of 45-60 seconds. Patients were 65 ± 10 years old, 43% diabetic, and 58% presented acutely. Angiographic success was 93% (7% bailout BMS implantation due to coronary dissection). The rate of major adverse cardiac events (MACE) at 12 months was 4.8% (1.9% cardiac death, 1.0% MI, and 2.9% TLR). One definite stent thrombosis was reported at 6 months in a patient with bailout BMS implantation. At 7 months, late loss was 0.31 ± 0.2 mm. Bail-out BMS after DEB use, was an independent predictor of MACE, HR 18.74, 95%CI (2.58-135.84) and TLR, HR 30.99, 95%CI (2.79-344.07). CONCLUSION: The use of this PEB for the treatment of SMD provides excellent 1-year outcomes with only 4.8% MACE. The need for a bailout BMS was a strong predictor of MACE and TLR.

Control glucémico de los pacientes con diabetes tipo 1 y 2 tratados mediante procedimientos de cardiología intervencionista / Glycaemic management in type 1 and 2 diabetes patients undergoing interventional cardiology procedures

A pesar del creciente número tanto de alternativas terapéuticas disponibles para el tratamiento de la diabetes como de revisiones y guías de práctica clínica generales, en el caso de contextos específicos como la cardiología intervencionista se encuentra una ausencia de pautas terapéuticas claras e inequívocas. En esta guía de actuación clínica se propone un algoritmo consensuado, basado tanto en la revisión crítica de la evidencia de ensayos clínicos recientes como en criterios subjetivos derivados de la experiencia clínica y conocimiento colectivos, para orientar en la elección de las alternativas más adecuadas en esta situación clínica del manejo del control glucémico de pacientes con diabetes tipo 1 y 2 que van a ser sometidos a procedimientos de cardiología intervencionista en el laboratorio de hemodinámica (AU)

Despite the growing number of therapeutic alternatives available as well as general reviews and treatment guidelines for the treatment of diabetes, physicians are often left without a clear pathway of therapy to follow in specific clinical contexts such as interventional cardiology. The present document proposes a consensus treatment algorithm, based both on a critical appraisal of evidence from recent clinical trials and on value judgements supported by the authors’ collective clinical knowledge and experience, in an attempt to guide practitioners when choosing the most appropriate alternatives in the context of glycemic management in type 1 and 2 diabetic patients scheduled to undergo interventional cardiology procedures in a haemodynamic laboratory (AU)

Bench top evaluation and clinical experience with the Szabo technique: new questions for a complex lesion.

BACKGROUND: The Szabo technique has been described as a method to ensure accurate ostial stent placement. We sought to investigate this novel technique in detail both in vitro and in vivo. METHODS AND RESULTS: The technique was subjected to bench testing and also undertaken in 26 patients. Each step was recorded with cine angiography and the stents imaged by microcomputed tomography. The ostial LAD was treated in 81% and a DES was implanted in 92%. Angiographic success was 88.5% (one case of stent dislodgement). Repeat angiography was performed in 78% and restenosis observed in two patients. MACE rate at 15.5 ± 5.1 months was 13% (1 TLR, 1 MI, 1 cardiac death). Despite a seemingly excellent immediate angiographic result, we report one case of restenosis at follow up and one case of IVUS examination (performed in four patients) in which significant stent protrusion, into the proximal main vessel, was observed. In vitro bench testing confirmed a significant and asymmetric (carina side) stent protrusion into the main branch, with the last cell of the stent undergoing significant deformation. CONCLUSIONS: The Szabo technique is not a precise technique to implant a stent at the level of the ostium. The proximal end of the stent undergoes significant and asymmetric deformation, protruding into main branch. Additional concerns with this complex technique include the potential for stent damage or contamination before implantation and the risk of stent dislodgement. We conclude that there are more disadvantages than benefits to this technique which only partially addresses the difficulties encountered in the treating ostial lesions.

[Glycaemic management in type 1 and 2 diabetes patients undergoing interventional cardiology procedures. Heart and Diabetes Working Group. Sociedad Espan˜ola de Cardiologi´a. Sociedad Espan˜ola de Diabetes]. / Control glucémico de los pacientes con diabetes tipo 1 y 2 tratados mediante procedimientos de cardiología intervencionista.

Despite the growing number of therapeutic alternatives available as well as general reviews and treatment guidelines for the treatment of diabetes, physicians are often left without a clear pathway of therapy to follow in specific clinical contexts such as interventional cardiology. The present document proposes a consensus treatment algorithm, based both on a critical appraisal of evidence from recent clinical trials and on value judgements supported by the authors' collective clinical knowledge and experience, in an attempt to guide practitioners when choosing the most appropriate alternatives in the context of glycemic management in type 1 and 2 diabetic patients scheduled to undergo interventional cardiology procedures in a haemodynamic laboratory.

One-year outcomes with angiographic follow-up of paclitaxel-eluting balloon for the treatment of in-stent restenosis: insights from Spanish multicenter registry.

INTRODUCTION: Even in the drug-eluting stent (DES) era treatment of in-stent restenosis (ISR) is still a relatively common problem for which a satisfactory solution is yet to be found. We wished to assess the efficacy of a new paclitaxel-coated drug-eluting balloon (DEB) in the treatment of these lesions. METHODS: In this prospective multicenter registry 126 patients with ISR, treated with a new paclitaxel-eluting balloon (3.0 µg/m(2) balloon surface area), were included. All lesions were predilated using conventional balloon angioplasty. The DEB was inflated for a minimum of 60 seconds. Dual antiplatelet therapy was recommended for at least 1 month. The only exclusion criteria were acute STEMI and cardiogenic shock. RESULTS: Thirty-three percent of patients were diabetic and 51% presented acutely. Interestingly, 48% had ISR of DES, 54% had ISR in a small vessel, and 29% involved bifurcation lesions. The pattern of ISR was focal in 59% and the most treated artery was the left anterior descending artery (LAD). Angiographic success was 96%. In 2 centers, repeat angiography was performed in 79% and restenosis observed in 6 patients (17.6%). MACE rate at a median of 12 (6-13) months was 16.7% (4.0% cardiac death, 4.0% MI, and 12.0% TLR). There was only 1 probable thombotic event (ARC). As compared with BMS-ISR, patients with DES-ISR were more often diabetic (40 vs. 28%) and had more re-restenosis (TLR 14.8 vs. 9.2%). CONCLUSION: In a real-world population, treatment of ISR (including 48% DES-ISR) with this DEB provides good mid-term results with 12% TLR at 1 year, especially in ISR pattern IC (9% MACE).

Novedades en stents farmacoactivos. Actualización y futuros desarrollos / News in drug-eluting stents. update and future developments

Con el objetivo de mejorar las limitaciones de la primera generación de stents farmacoactivos, las nuevas generaciones se han desarrollado para mejorar su seguridad y su biocompatibilidad optimizando sus tres principales componentes: la plataforma, el polímero y el fármaco. Además de estas, otras líneas de investigación se centran en desarrollar nuevos dispositivos con polímeros biodegradables, sin polímero, entre los que se incluyen los llamados stents bioactivos, que introducen mejoras en la superficie del stent para optimizar la reendotelización arterial, y finalmente prototipos completamente biodegradables. Es impresionante el esfuerzo en investigación básica, estudios de anatomía patológica e ingeniería de diseño que se ha realizado en los últimos años en este campo. Por lo tanto, la información que ha surgido en poco tiempo también es increíble. En esta revisión se hace un análisis de las novedades y los estudios aparecidos en los últimos 3 años en relación con los stents farmacoactivos. Se analizan las mejoras en la segunda generación y se describe la llamada tercera o siguiente generación de stents farmacoactivos (AU)

With the aim of overcoming the limitations of firstgeneration drug-eluting stents, a new generation of stents has been developed to improve safety and biocompatibility by optimizing their three main components: the stent platform, coating and drug. In addition, other lines of research have focused on developing new devices either with biodegradable polymers or without polymers, including so-called bio-active stents, in which the stent surface is modified to optimize arterial endothelialization. Finally, prototypes of fully biodegradable stents are also being developed. The effort put into basic research, studies of anatomy and pathology, and engineering design in recent years in this field has been impressive. As a result, the amount of data that has been produced in a short time has also been remarkable. This review provides an analysis of developments in and studies on drugeluting stents that have taken place in the last 3 years. Improvements in second-generation stents are discussed and the nature of the so-called third or next generation of drug-eluting stents is described (AU)

Angiographic quantification of thrombus in ST-elevation acute myocardial infarction presenting with an occluded infarct-related artery and its relationship with results of percutaneous intervention.

INTRODUCTION: Routine thrombectomy has been advocated for ST-segment-elevation myocardial infarction (STEMI), but it is unknown how many patients present with a large thrombus. We aimed to quantify the intracoronary thrombus in STEMI and to correlate it with procedure results. METHODS: In 98 patients with STEMI and TIMI flow grades 0-2 in the infarct-related artery, thrombus was qualified as small (ST) when its maximal dimension was <2 vessel diameters and large (LT) when >or=2. Main outcome measures were TIMI flow, myocardial blush grade (MBG), corrected TIMI frame count (cTFC), and ST-segment elevation resolution (STSER). RESULTS: Only a third of the patients presented with an LT. Thrombus grade was independent of the initial vessel patency. Diabetes (OR 3.1, 95% CI 1.20-8.02, P = 0.027) and pretreatment with clopidogrel (OR 0.27, 95% CI 0.08-0.86, P = 0.034) were independent predictors of LT. LT was an independent predictor of unfavorable results: <3 TIMI flow (OR 2.87, 95% CI 1.04-8.00, P = 0.043), MBG 0-1 (OR 3.36, 95% CI 1.10-10.26, P = 0.033), cTFC > 21 (OR 2.86, 95% CI 1.09-7.49, P = 0.033) and <50% STSER (OR 3.19, 95% CI 1.06-9.63, P = 0.039). CONCLUSION: Only a third of STEMI patients present with an LT, being diabetes and lack of clopidogrel pretreatment independent predictors. An LT is strongly associated with worse PCI results.

Causes of ineligibility in randomized controlled trials and long-term mortality in patients with non-ST-segment elevation acute coronary syndromes.

PURPOSE: To determine the long-term mortality of patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) that are eligible versus those not eligible in randomized controlled trials (RCT), and how each exclusion criteria is associated with outcome. METHODS: Common causes of exclusion in six published RCT on intravenous antithrombotic therapy were prospectively assessed in a cohort of 452 consecutive patients with NSTEACS that were followed for up to 3 years. RESULTS: Forty-one percent of patients had one or more exclusion criteria establishing the ineligible group. These patients were older, more likely to have coronary risk factors, ischemic ECG changes, heart failure at admission, higher creatinine levels and a lower ejection fraction than eligible patients. There were no differences between both groups in the antithrombotic treatment received or in the performance of revascularization procedures during hospitalization or in the prescription of antiplatelet treatment and beta-blockers at discharge. Cumulative 3-year mortality rate was 25% in ineligible patients compared to 9% in eligible patients (p<0.001). The hazard ratio (HR) of mortality was of 9.1 (95% CI: 4.5-18.7) for severe renal dysfunction; 6.0 (3.3-11.4) for concomitant non-vascular diseases; 3.0 (1.6-5.5) for contraindications to anticoagulation; 2.5 (1.1-5.7) for heart failure; and 2.3 (1.1-4.6) for prior cerebrovascular disease. After adjusting for baseline differences, ineligible patients had a HR of total mortality of 1.88 (1.04-3.38), and of cardiac mortality of 2 (1.01-3.98). CONCLUSION: Patients with NSTEACS who are ineligible in RCT have a higher risk profile and a two-fold adjusted long-term mortality than eligible patients, especially those with comorbid conditions and those with contraindications to anticoagulation.

Análisis y características de los stents farmacoactivos disponibles en la actualidad. Futuros desarrollos / Characteristics of currently available drug-eluting stents. Future developments

Los stents metálicos se desarrollaron para combatir el retroceso elástico, las complicaciones agudas y la reestenosis de la angioplastia con balón, pero crearon una nueva entidad, la restenosis intra-stent, ligada a múltiples factores. Entre ellos, las características clínicas del paciente y el tipo de lesión son inmodificables. Sin embargo, la técnica de implante y, muy particularmente, el diseño del stent han experimentado una gran transformación que ha desembocado en la nueva era de los stents recubiertos, stents liberadores de fármacos o el término que mejor los define, stents farmacoactivos. Estos nuevos stents son dispositivos muy complejos que involucran tecnología y diseño de la plataforma o stent, investigación y desarrollo en el terreno de los polímeros que actuan como transportadores y liberadores de los fármacos, y el propio fármaco que debe inhibir la proliferación neointimal. Si bien los primeros diseños, con 5 años de seguimiento clínico a sus espaldas, han mostrado una reducción significativa y sostenida de la reestenosis y las nuevas revascularizaciones frente a los stents metálicos convencionales, también han mostrado debilidades y sombras, que deben irse corrrigiendo en las próximas generaciones de stents farmacoactivos. En esta revisión se lleva a cabo un análisis detallado de la importancia del diseño del stent, se hace una incursión breve en el mundo de los polímeros, sus tipos y su funcionamiento, y se describen los fármacos empleados en los stents farmacoactivos. Se analizan las características y los resultados clínicos y angiográficos de los stents actualmente disponibles o en fase de estudio, y se abre una ventana hacia los futuros desarrollos (AU)

Metallic stents were developed to minimize the elastic recoil, acute complications, and restenosis that occur with balloon angioplasty. However, they also led to the new problem of in-stent restenosis, which is associated with a number of factors, including some that can not be modified, such as the patient’s clinical characteristics and the type of lesion. Nevertheless, stent implantation techniques and, most importantly, stent design have undergone an enormous transformation, which has led to the new era of coated stents and drug-eluting stents, or, in the terminology that best defines them, active stents. These new stents are very sophisticated devices, which involve innovative stent technology and design, and research and development into polymer coatings for drug storage and release and into the drugs for inhibiting intimal thickening themselves. Although first-generation drug-eluting stents, which have already been followed up clinically for 5 years, have resulted in significant and sustained improvements in the rates of restenosis and revascularization compared with bare metal stents, they have also been found to have weaknesses and disadvantages that will have to be corrected in future generations of drug-eluting stents. This review contains a detailed description of the importance of stent design, involves a brief exploration of the world of polymers and how they function, and surveys the different drugs used in drugeluting stents. It also summarizes the characteristics of and clinical and angiographic data on the drug-eluting stents that are either currently available or being investigated in clinical trails, and provides a glimpse of future developments (AU)

[Differences in the management and prognosis of patients with non-ST segment elevation acute coronary syndrome according to the department of initial admission]. / Diferencias en el tratamiento y la evolución clínica de los pacientes con síndrome coronario agudo sin elevación del segmento ST en función del servico clínico de ingreso.

OBJECTIVES: To assess the influence of the department of initial admission on the hospital management and 3-month prognosis of patients with non-ST elevation acute coronary syndromes. PATIENTS AND METHOD: The data for the 4115 patients admitted to 18 hospitals in the PEPA study were compared according to the department of initial admission. RESULTS: Twenty-six percent of the patients were admitted to the coronary care unit, 53% to the cardiology department, 9% to the internal medicine department, and 12% were discharged from the emergency ward. The baseline risk profile was high in patients admitted to the coronary care unit and decreased progressively in patients admitted to the cardiology, internal medicine and emergency departments (P<.00001). The intensity of medical management was progressively lower in these departments, but not in parallel to their different baseline lower risk profile. Beta blockers were administered to 50%, 45%, 27% and 21% of the patients, respectively; an exercise test was performed in 34%, 44%, 35% and 12%; coronary angiography in 46%, 34%, 19% and 0%; and coronary revascularization in 22%, 12%, 9% and 0% (P<.00001). The 3-month incidence of mortality or myocardial infarction was 12.2%, 6.4%, 8.7% and 3.8%, respectively (P<.00001), differences that became nonsignificant after adjustment for risk profile on admission. CONCLUSIONS: Patients with non-ST elevation acute coronary syndrome admitted to the coronary care unit or cardiology department have a profile of higher risk on admission than patients admitted to the internal medicine department. Also, these patients more frequently receive pharmacological treatments and diagnostic and therapeutic procedures of proven efficacy but not in a manner that parallels their different risk profile on admission. However, these differences in the intensity of in-hospital management do not seem to lead to differences in the 3-month prognosis.

[Left ventricular remodeling in patients with hypertrophic obstructive cardiomyopathy treated with percutaneous alcohol septal ablation: an echocardiographic study]. / Remodelado ventricular izquierdo tras ablación septal percutánea con alcohol en pacientes con micardiopatía hipertrófica obstructiva: estudio ecocardiográfico.

INTRODUCTION: In patients with hypertrophic obstructive cardiomyopathy, obstruction in the left ventricular outflow tract may generate more hypertrophy. Our aim was to evaluate the impact of reducing ventricular outflow tract obstruction on left ventricular hypertrophy and remodeling after alcohol septal ablation. PATIENTS AND METHOD: 20 patients with hypertrophic obstructive cardiomyopathy who underwent alcohol septal ablation were included. Doppler echocardiography was performed in all patients at baseline, immediately after alcohol septal ablation, and at 3 and 12 months' follow-up. Left ventricular diameters and wall thickness and pressure gradients in the ventricular outflow tract were determined. RESULTS: Immediately after alcohol septal ablation, ventricular outflow tract pressure gradient decreased from 63.0 27.7 to 28.2 24.7 mmHg (p < 0.001), without significant changes in left ventricular dimensions. However, after 12 months we observed an increase in left ventricular end-diastolic (from 47.1 4.9 to 50.8 4.5 mm) and end-systolic diameter (from 27.1 3.0 to 33.7 4.6 mm), as well as a reduction in septal (from 19.5 4.0 to 15.5 2.7 mm) and posterior wall thickness (from 14.0 2.2 to 12.9 1.3 mm) (p < 0.01 in all cases). Left ventricular end-diastolic and end-systolic volumes increased (from 106.4 26.9 to 123.1 28.7 ml and from 50.2 17.3 to 56.7 18.3 ml, respectively, p < 0.01 in both cases), without changes in left ventricular ejection fraction. The reduction in ventricular outflow tract pressure gradient at 12 months' follow-up correlated significantly with the increase in left ventricular end-systolic diameter (r = 0.63; p < 0.01). CONCLUSIONS: In patients with hypertrophic obstructive cardiomyopathy who underwent alcohol septal ablation, relief of ventricular outflow tract obstruction is associated with an increase in left ventricular chamber diameters and volume. These findings suggest that middle- and long-term ventricular remodeling and regression of hypertrophy occur in these patients, which may contribute to their clinical improvement.

Remodelado ventricular izquierdo tras ablación septal percutánea con alcohol en pacientes con miocardiopatía hipertrófica obstructiva: estudio ecocardiográfico / Left ventricular remodeling in patients with hypertrophic obstructive cardiomyopathy treated with percutaneous alcohol septal ablation: an echocardiographic study

Introducción. Evaluamos el impacto de la reducción de la obstrucción en el tracto de salida del ventrículo izquierdo tras la ablación septal percutánea con alcohol sobre la hipertrofia y el remodelado del ventrículo izquierdo (VI). Pacientes y método. Se incluyó a 20 pacientes con miocardiopatía hipertrófica tratados con ablación septal percutánea. Se realizó ecocardiograma Doppler en situación basal, inmediatamente después de la ablación septal percutánea y a los 3 y 12 meses de seguimiento, en el que se midieron los diámetros y grosores del VI y del gradiente de presión en el tracto de salida del ventrículo izquierdo. Resultados. Inmediatamente después de la ablación septal percutánea, el gradiente de presión en el tracto de salida del VI disminuyó de 63,0 ñ 27,7 a 28,2 ñ 24,7 mmHg (p < 0,001), sin que se apreciaran cambios significativos en las dimensiones del VI. Doce meses después se observó un incremento en los diámetros telediastólico (de 47,1 ñ 4,9 a 50,8 ñ 4,5 mm; p < 0,01) y telesistólico del VI (de 27,1 ñ 3,0 a 33,7 ñ 4,6 mm; p < 0,01) y una reducción en los grosores del septo (de 19,5 ñ 4,0 a 15,5 ñ 2,7 mm; p < 0,01) y de la pared posterior del VI (de 14,0 ñ 2,2 a 12,9 ñ 1,3 mm; p < 0,01). Los volúmenes telediastólico y telesistólico del VI aumentaron (de 106,4 ñ 26,9 a 123,1 ñ 28,7 ml; p < 0,01, y de 50,2 ñ 17,3 a 56,7 ñ 18,3 ml; p < 0,01, respectivamente), sin que se observaran cambios en la fracción de eyección del VI. La reducción del gradiente de presión en el tracto de salida del ventrículo izquierdo observada a los 12 meses de la ablación septal percutánea se correlacionó de manera significati a con el incremento del diámetro telesistólico del VI (r = 0,63; p < 0,01).Conclusiones. La reducción de la obstrucción en el tracto de salida del ventrículo izquierdo en pacientes con miocardiopatía hipertrófica tratados con ablación septal percutánea se acompaña de un incremento de los diáme tros y volúmenes del VI en el seguimiento. Esto indica el desarrollo de un remodelado cardíaco y de una regresión en la hipertrofia del VI de estos pacientes que podría contribuir a su mejoría sintomática (AU)

[Clinical characteristics, prognosis, and variability in the management of non-ST-segment elevation acute coronary syndromes. Data from the PEPA registry]. / Perfil clínico, pronóstico y variabilidad en el tratamiento del síndrome coronario agudo sin elevación del segmento ST. Datos del registro PEPA.

OBJECTIVES: To assess the clinical characteristics and inter-hospital variability in the treatment and prognosis of patients with non-ST-segment elevation acute coronary syndromes. PATIENTS AND METHOD: Data from the PEPA study, a prospective registry that enrolled 4,115 patients in 18 Spanish hospitals, were analyzed. RESULTS: The mean age of the patients enrolled was 65 years, 33% were women, and 26% had diabetes. Large differences were observed in the clinical profile of patients admitted to different centers, especially relative the history of previous disease, prior coronary revascularization, and co-morbidity. Antiplatelet treatment was used in 93% of patients, heparin in 45%, beta-blockers in 42%, nitrates in 67%, and calcium antagonists in 46%. During hospitalization, exercise stress testing was performed in 37% of patients, coronary angiography in 32%, coronary angioplasty in 9%, and coronary surgery in 4%. Inter-hospital variability was minimal for the use of antiplatelet agents, wide for the use of heparin and beta-blockers, and huge for the use of revascularization procedures. Mortality and the incidence of death or myocardial infarction were 2.6% and 4.4% during hospitalization, and 4.6% and 8% at 3 months, with wide inter-hospital variability. These differences were not significant once adjusted for clinical characteristics and the treatment received at admission. CONCLUSIONS: Patients with non-ST-segment elevation acute coronary syndromes represent an heterogeneous group with a high incidence of complications. Pharmacologic and, especially, invasive treatment varies widely in different hospitals. These results underline the importance of correct initial risk stratification and uniform treatment following the recommendations of clinical guidelines.

Perfil clínico, pronóstico y variabilidad en el tratamiento del síndrome coronario agudo sin elevación del segmento ST. Datos del registro PEPA / Clinical characteristics, prognosis, and variability in the management of Non-ST-Segment elevation acute coronary syndromes. Data from the PEPA registry

Objetivos. Conocer el perfil clínico y la variabilidad interhospitalaria en el tratamiento y pronóstico de los pacientes con síndrome coronario agudo sin elevación del segmento ST. Pacientes y método. Se analizaron los datos del estudio PEPA, registro prospectivo que incluyó a 4.115 pacientes ingresados en 18 hospitales españoles. Resultados. La edad media fue de 65 años, un 33 por ciento eran mujeres y un 26 por ciento, diabéticos. Se observaron grandes diferencias en el tipo de pacientes ingresados en cada centro, especialmente en los antecedentes patológicos, revascularización coronaria previa y comorbilidad. El 93 por ciento de los pacientes recibieron tratamiento antiagregante, el 45 por ciento, heparina, el 42 por ciento, bloqueadores beta, el 67 por ciento, nitratos y el 46 por ciento, antagonistas del calcio. Durante el ingreso se realizó una ergometría al 37 por ciento de los pacientes, coronariografía al 32 por ciento, angioplastia coronaria al 9 por ciento y cirugía de revascularización al 4 por ciento. La variabilidad fue mínima en la administración de antiagregantes plaquetarios, importante en la de heparina y bloqueadores beta, y muy marcada en el uso de procedimientos de revascularización. La mortalidad y la incidencia de muerte o infarto fue del 2,6 y 4,4 por ciento durante la hospitalización, y del 4,6 y 8 por ciento a los 3 meses, con una amplia variabilidad interhospitalaria. Estas diferencias dejaron de ser significativas tras ajustar por las características clínicas y el tratamiento recibido en el momento del ingreso. Conclusiones. Los pacientes con síndrome coronario agudo sin elevación del segmento ST forman un grupo heterogéneo con una elevada incidencia de complicaciones y con una gran variabilidad interhospitalaria en su manejo terapéutico, tanto farmacológico como, sobre todo, invasivo. Estos resultados resaltan la importancia de la correcta estratificación inicial del riesgo y la homogeneización de su tratamiento, siguiendo las recomendaciones de las guías de práctica clínica (AU)

[Long-term prognosis of women with non-ST-segment elevation acute coronary syndromes. a case-control study]. / Prónostico a largo plazo de las mujeres con síndrome coronario agudo sin elevación del segmento STN un esutudio de casos y controles.

BACKGROUND AND OBJECTIVES: Women with ST-segment-elevation myocardial infarction have a worse prognosis than men. However, information about the prognosis of women with non-ST-segment-elevation acute coronary syndromes (NSTEACS) is scarce. The aim of this study was to determine if the long-term prognosis of men and women with NSTEACS differs. PATIENTS AND METHOD: Case-control study. In a consecutive series of 300 patients admitted for a NSTEACS and ischemic ECG changes, we compared the clinical characteristics, in-hospital and long-term follow-up of 95 women and 95 men matched for age, presence of diabetes, and past history of hypertension. RESULTS: The median age of patients was 69 years, 36% had diabetes, and 65% had a history of hypertension. There were no gender differences in the history of angina or hypercholesterolemia, clinical presentation, number of patients with ST-segment depression, and CK-MB elevation. However, smoking, coronary artery disease, and peripheral vascular disease were less frequent in women. Treatment at admission and at discharge was similar in men and women, as was the use of in-hospital diagnostic and therapeutic procedures (echocardiography: 80 vs 88%; coronary angiography: 57 vs 59%; percutaneous coronary intervention: 17 vs 14%; coronary surgery 13 vs. 11%). Women had a better mean ejection fraction (55 13 vs 49 14%; p < 0.01) and fewer stenosed coronary vessels (1.4 1.1 vs 2.2 0.9; p < 0.01). There were no differences in the frequency of recurrent angina (28 vs 25%), death, or infarction (both 3.2%) during hospitalization. However, during a 30-month follow-up the incidence of death, myocardial infarction, or a new episode of NSTEACS was significantly lower in women with a relative risk (RR) of 0.53 (95% CI: 0.33-0.86; p < 0.01). This apparently better prognosis persisted after adjusting for clinical data and ejection fraction (RR: 0.57 (0.33-0.98); p < 0.05), but disappeared after adjusting for the number of diseased coronary vessels (RR: 0.71 (0.35-1.47); p = 0.36). CONCLUSIONS: Women with NSTEACS had a better long-term prognosis than men. This better prognosis was independent of the patients' clinical characteristics and treatment, and could be explained by a less severe and less extensive coronary artery disease.

Pronóstico a largo plazo de las mujeres con síndrome coronario agudo sin elevación del segmento ST: un estudio de casos y controles / Long-term prognosis of women with non-STsegment elevation acute coronary syndromes. A case-control study

Antecedentes y objetivos. Las mujeres con infarto y elevación del segmento ST tienen un peor pronóstico que los varones. Sin embargo, existe poca información sobre el pronóstico de las mujeres con síndrome coronario agudo sin elevación del segmento ST (SCASEST). El objetivo del estudio fue conocer si el pronóstico a largo plazo de las mujeres con SCASEST es diferente al de los varones.Pacientes y método. De un total de 300 pacientes consecutivos ingresados por SCASEST con cambios isquémicos en el ECG, se compararon las características clínicas y la evolución de las 95 mujeres con las de 95 varones seleccionados por tener la misma edad, prevalencia de diabetes mellitus e hipertensión arterial, siguiendo un diseño de casos y controles.Resultados. La edad media de los pacientes fue de 69 años, el 36 por ciento eran diabéticos y el 65 por ciento tenía antecedentes de hipertensión arterial. No existieron diferencias entre géneros en los antecedentes de angina o hipercolesterolemia, forma de presentación clínica, frecuencia de descenso del segmento ST en el ingreso o elevación de la CK-MB. Sin embargo, las mujeres presentaron menos antecedentes de tabaquismo, enfermedad coronaria y vasculopatía periférica. El tratamiento al ingreso y al alta fue similar en ambos grupos, así como la frecuencia de procedimientos realizados (ecocardiografía: 80 frente a 88 por ciento; coronariografía: 57 frente a 59 por ciento; angioplastia: 17 frente a 14 por ciento, y cirugía: 13 frente a 11 por ciento). Las mujeres tuvieron mejor fracción de eyección (55 ñ 13 frente a 49 ñ 14 por ciento; p < 0,01) y un menor número de vasos estenosados (1,4 ñ 1,1 frente a 2,2 ñ 0,9; p < 0,01).Durante la hospitalización no se observaron diferencias en la incidencia de angina recurrente (28 frente a 25 por ciento) ni en la de mortalidad o infarto (3,2 por ciento en ambos casos).Sin embargo, en el seguimiento a 30 meses la incidencia acumulada de mortalidad, infarto o nuevo episodio de SCASEST fue significativamente menor en las mujeres con un RR (IC del 95 por ciento) de 0,53 (0,33-0,86; p < 0,01).Este mejor pronóstico se mantuvo al corregir los resulta dos por los demás datos clínicos y la fracción de eyección (RR = 0,57; IC del 95 por ciento, 0,33-0,98; p < 0,05), pero desapareció al corregir por el número de vasos estenosados (RR = 0,71; IC del 95 por ciento, 0,35-1,47; p = 0,36).Conclusiones. Las mujeres con SCASEST y cambios electrocardiográficos en el ingreso presentan una evolución mejor que los varones a largo plazo. Este mejor pronóstico es independiente de las características clínicas y del tratamiento realizado y parece explicarse por una menor extensión y gravedad de la enfermedad coronaria. (AU)

Elevation of serum levels of the anti-inflammatory cytokine interleukin-10 and decreased risk of coronary events in patients with unstable angina.

BACKGROUND: Inflammation is an important phenomenon in atherosclerotic plaque growth and in plaque instability. Cytokines are nuclear mediators in the inflammatory response; some have proinflammatory and others anti-inflammatory roles. Proinflammatory cytokines have been associated with worse outcomes in unstable angina. The aims of this study were to determine the role of the anti-inflammatory cytokine interleukin (IL)-10 and the proinflammatory to anti-inflammatory ratios in the short-term prognosis of patients with unstable angina. METHODS: Serum levels of proinflammatory cytokines IL-1beta, IL-6, and IL-8, and of the anti-inflammatory cytokine IL-10 were determined on admission in 127 consecutive patients with severe unstable angina, and comparisons were made between patients who had cardiovascular events (death, nonfatal myocardial infarction, readmission for refractory angina) (n = 20) and patients without coronary events (n = 107) during a follow-up period of 3 months. RESULTS: IL-10 levels were lower (0.67 +/- 1.13 vs 1.33 +/- 1.67 pg/mL, P =.04) and IL-8 levels were higher (3.6 +/- 2.41 vs 2.23 +/- 2.47 pg/mL, P =.029) in patients in whom cardiovascular events subsequently developed compared with those without events, with resulting higher proinflammatory to anti-inflammatory cytokine ratios in the former group, whereas no significant differences were seen in IL-1beta or IL-6 levels between the groups, except for the subgroup of patients with prolonged rest angina and persistent electrocardiographic changes. A greater ratio of IL-8 to IL-10 serum levels was observed in patients who had coronary events (28 +/- 25 vs 12 +/- 21, P =.007). The risk of subsequent coronary events increased in patients in the highest quartile of proinflammatory to anti-inflammatory cytokine ratio (IL-8/IL-10). Patients in the highest quartile had a relative risk 3.8 times higher than those in the lowest quartile (P =.01). CONCLUSIONS: Lower levels of IL-10, with higher proinflammatory to anti-inflammatory cytokine ratios, were observed on admission in patients with unstable angina who subsequently had cardiovascular events. Higher levels of the anti-inflammatory cytokine IL-10 may be needed to provide protection in unstable angina.

Evolución hospitalaria y pronóstico actual de la angina inestable / In-Hospital evolution and current prognosis of unstable angina

Introducción y objetivos. El pronóstico de los pacientes con angina inestable ha mejorado en los últimos años, lo que ha conducido a una progresiva reducción de la estancia y el tratamiento hospitalarios. El objetivo de este estudio fue conocer el pronóstico actual de la angina inestable en una población no seleccionada seguida durante un período de 3 meses. Pacientes y métodos. Se estudiaron 478 pacientes consecutivos con angina inestable, que fueron tratados siguiendo una pauta de tratamiento guiada por los síntomas y los resultados de una prueba de esfuerzo o de estrés farmacológico realizada antes del alta. Resultados. La edad media fue de 66 ñ 11 años, un 30 por ciento eran mujeres, un 35 por ciento tenían antecedentes de infarto, un 61 por ciento presentaban cambios isquémicos en el ECG de ingreso y un 16 por ciento tuvieron elevación de las CK-MB. Se practicó un ecocardiograma al 80 por ciento de los pacientes, prueba de esfuerzo al 62 por ciento y coronariografía al 51 por ciento, siendo revascularizados el 27 por ciento. Durante la hospitalización, la incidencia de mortalidad o infarto, angina refractaria o complicaciones isquémicas fue del 3,6 por ciento, 11 por ciento y 13 por ciento, respectivamente. Después del alta, la incidencia de estas complicaciones fue del 3,3 por ciento, 9 por ciento y 10 por ciento (NS respecto a la fase hospitalaria). Globalmente, desde el ingreso hasta los 3 meses de seguimiento un 4,2 por ciento de los pacientes fallecieron, un 7 por ciento fallecieron o tuvieron un infarto, un 20 por ciento presentó angina refractaria y un 26 por ciento tuvo alguna complicación isquémica. Conclusiones. El pronóstico actual de la angina inestable durante la fase hospitalaria es relativamente bueno. Sin embargo, los pacientes dados de alta una vez estabilizados presentan una elevada incidencia de complicaciones isquémicas durante los primeros 3 meses de seguimiento, similar a la presentada durante la fase aguda por todos los pacientes (AU)

A Case of Uterine Leiomyomatosis Extending into the Right Heart with an Unusual Echocardiographic Appearance.

Intravenous extension of uterine leiomyomatosis is a rare condition characterized by tumor invasion of the venous system and propagation toward the large abdominal veins. A few cases with extension to the right atrium have been reported, and the echocardiographic appearance of this entity is well described. The case we herein report is of interest because of its unusual echocardiographic findings.