Papel del aumento de la rigidez arterial central en el daño macro y microvascular en pacientes con enfermedad coronaria / Role of increased central arterial stiffness in macro and microvascular damage in patients with coronary artery disease

Antecedentes: Con frecuencia, los pacientes con cardiopatía tienen disfunción renal manifestada por el descenso del filtrado glomerular (FG) y/o aumento de la albuminuria. Objetivos: El objetivo fue estudiar el papel del aumento de la rigidez aórtica en la presencia y extensión de la enfermedad coronaria (EC) y en la disfunción renal en sujetos con EC. Pacientes y métodos: Estudio observacional transversal de 48 pacientes con sospecha de EC sometidos a coronariografía. Mediante tonometría de aplanamiento sobre la arterial radial y aplicando una función de transferencia, se calcularon los valores de presión arterial central. El estudio de la rigidez aórtica se hizo mediante la determinación de la velocidad de pulso carótida-femoral (Vpc-f). Resultados: De los 48 pacientes, 11 no tenían lesiones coronarias significativas, 24 evidenciaron lesiones significativas en una o dos arterias coronarias y 13 en ≥ tres arterias. El grupo con mayor grado de EC tenía valores de presión de pulso central (PPc) más altos que el grupo sin EC. La Vpc-f aumentaba de forma progresiva y significativa con el grado de EC. La regresión logística mostraba que la VPc-f predecía de forma independiente la presencia de EC. El FG se correlacionaba de forma negativa y significativa con la edad. La Vpc-f se asociaba a la albuminuria. Conclusiones: En pacientes con EC estable, la Vpc-f se relaciona de forma independiente con la existencia y extensión de la EC, así como con la disminución del FG y el aumento de la albuminuria.(AU)

Background: Patients with heart disease frequently have renal dysfunction manifested by a decrease in glomerular filtration rate (GFR) and / or increase of albuminuria. Objectives: The objective was to study the possible role of increased aortic stiffness in the presence and extent of coronary artery disease (CAD) and kidney dysfunction in a group of patients with suspected CAD. Patients and methods: We studied forty-eight patients undergoing coronariography for suspected coronary disease (CAD). Using applanation tonometry on the radial artery and applying a transfer function, central blood pressure values were calculated. The study of aortic stiffness was done by determining the carotid-femoral pulse velocity (Pvc-f). Results: Of the 48 patients, 11 had no significant coronary lesions, 24 showed significant lesions in 1 or 2 coronary arteries and 13 in ≥ 3 arteries. The group with a higher degree of CD had significantly higher cPP values than the group without CD. The Pvc-f increased progressively and significantly with the degree of CD. The logistic regression showed that Pvc-f independently predicted the presence of CD. The relative risk of CD increased 2.5 times for each meter of increase in Pvc-f. The GFR was negatively and significantly correlated with age and Pvc-f was associated with albuminuria. Conclusions: In patients with stable CD, Pvc-f, expression of aortic stiffness, is independently associated with the existence of CD and its degree of extension. The increase in arterial stiffness also participates in the decrease in GFR and in the increase in albuminuria.(AU)

Role of increased central arterial stiffness in macro and microvascular damage in patients with coronary artery disease. / Papel del aumento de la rigidez arterial central en el daño macro y microvascular en pacientes con enfermedad coronaria.

BACKGROUND: Patients with heart disease frequently have renal dysfunction manifested by a decrease in glomerular filtration rate (GFR) and / or increase of albuminuria. OBJECTIVES: The objective was to study the possible role of increased aortic stiffness in the presence and extent of coronary artery disease (CAD) and kidney dysfunction in a group of patients with suspected CAD. PATIENTS AND METHODS: We studied forty-eight patients undergoing coronariography for suspected coronary disease (CAD). Using applanation tonometry on the radial artery and applying a transfer function, central blood pressure values were calculated. The study of aortic stiffness was done by determining the carotid-femoral pulse velocity (Pvc-f). RESULTS: Of the 48 patients, 11 had no significant coronary lesions, 24 showed significant lesions in 1 or 2 coronary arteries and 13 in ≥ 3 arteries. The group with a higher degree of CD had significantly higher cPP values than the group without CD. The Pvc-f increased progressively and significantly with the degree of CD. The logistic regression showed that Pvc-f independently predicted the presence of CD. The relative risk of CD increased 2.5 times for each meter of increase in Pvc-f. The GFR was negatively and significantly correlated with age and Pvc-f was associated with albuminuria. CONCLUSIONS: In patients with stable CD, Pvc-f, expression of aortic stiffness, is independently associated with the existence of CD and its degree of extension. The increase in arterial stiffness also participates in the decrease in GFR and in the increase in albuminuria.

Prognostic value of aortic valve area normalized to body size in native aortic stenosis.

INTRODUCTION AND OBJECTIVES: Although guidelines recommend the use of a cutoff value of 0.60 cm2/m2 for aortic valve area (AVA) normalized to body surface area (BSA) for severe aortic stenosis, there is little evidence of its prognostic value. Our aim was to test the value of AVA normalized to body size for outcome prediction in aortic stenosis. METHODS: One-hundred and ninety patients with at least moderate aortic stenosis (AVA <1.50 cm2) were prospectively enrolled. AVA was normalized to BSA and height. The primary endpoint was cardiovascular death under medical management. A receiver operating characteristic curve was plotted to determine the best cutoff value for predicting cardiovascular death. RESULTS: An AVA/BSA cutoff value of 0.50 had a sensitivity of 96% and specificity of 51%. An AVA/height cutoff value of 0.49 showed a sensitivity of 96% and a specificity of 52%. During a mean follow-up of 247±190 days, there were 24 cardiovascular deaths, with higher cardiovascular mortality in patients with AVA/BSA <0.50 cm2/m2 (21% vs 2.5%, P <.001) and AVA/height <0.49 cm2/m (25% vs 12%, P <.001). Two-year survival was 95±5% in patients with AVA/BSA> 0.50 cm2/m2 and was 37±5% in patients with AVA/BSA <0.50 cm2/m2 (P <.001). Cardiovascular death risk was higher in patients with AVA/BSA <0.50 cm2/m2 (adjusted 10.9 [1.2-103.7], P=.037), but cardiovascular mortality was not significantly higher in multivariate analysis for patients with AVA/height <0.49 cm2/m (2.0 [0.6-6.0], P=.22). CONCLUSIONS: We could identify a subgroup of patients at high risk of cardiovascular death when they were medically treated. Consequently we recommend using an AVA/BSA cutoff value of 0.50 cm2/m2 to identify a subgroup of patients with higher cardiovascular risk.

Early recruitment of coronary collateral circulation: impact in late presentation nonreperfused acute coronary occlusion.

BACKGROUND: Debate still remains on whether the presence of early recruited collateral circulation (ERCC) in the setting of an acute coronary occlusion (ACO) has a prognosis benefit. Some previous reports have shown lower mortality and morbidity rates in well-collateralized patients compared with those with poorly recruited collateral circulation (PCC), but others have not. In the primary angioplasty era, the role of collateral circulation in these studies may have been influenced by the effect of early reperfusion. The actual impact of ERCC in ACO can be clarified by studying its effect on nonreperfused patients. OBJECTIVE: This study aimed to compare the 1-year clinical outcome in nonreperfused late presentation ACO in a major coronary artery with ERCC versus PCC. PATIENTS AND METHODS: Between 2008 and 2015, we included 164 patients with a nonreperfused late presentation ACO. The patients were divided according to the presence of angiographic ERCC (Rentrop 2-3) or PCC (Rentrop 0-1). ERCC was present in 54% of patients. Patients with ERCC less often presented with cardiogenic shock (P=0.02) and the right coronary artery was the most frequent culprit vessel (P=0.02). The presence of PCC was associated independently with higher 1-year cardiovascular mortality [hazard ratio (HR): 6.92; 95% confidence interval (95%CI): 1.37-34.7; P=0.019], 1-year total mortality (HR: 5.79; 95%CI: 1.95-17.1; P=0.001), and 1-year major adverse cardiac event (HR: 8.05; 95%CI: 1.73-37.4; P<0.01). CONCLUSION: The presence of angiographically PCC in the setting of late presentation nonreperfused ACO is relatively infrequent (46%) and is associated with worse 1-year major clinical outcomes.

Percutaneous coronary intervention for treating de-novo lesions in small coronary vessels: initial experience with the Essential paclitaxel-coated balloon.

BACKGROUND: Paclitaxel-coated balloon (PCB) coronary angioplasty is an alternative treatment for de-novo coronary lesions in small vessels. This study with the new Essential PCB aimed to evaluate early and mid-term clinical outcomes following angioplasty with the Essential PCB in the treatment of de-novo lesions in small vessels. PATIENTS AND METHODS: We included all patients who underwent PCB angioplasty for treating de-novo coronary lesions in small vessels (reference diameter <2.5 mm) between October 2015 and June 2016 in 2 centres. The primary endpoint was the 12-month target lesion failure (TLF) rate: a composite of cardiac death, target vessel-related myocardial infarction, and target lesion revascularization. The secondary endpoints were rates of target vessel failure and global major adverse cardiac events (MACE). RESULTS: A total of 71 patients (comprising 71 lesions) were included, with a mean age of 66±11 years. A 56% were diabetic and 70% had an acute coronary syndrome as an indication for coronary revascularization. The mean vessel diameter and lesion length were 2.21±0.41 and 20.7±9.2 mm, respectively. Predilatation was performed in 85.9% of patients. The median diameter, length, and inflation pressure of the Essential balloon were 2.0 [interquartile range (IQR): 2.0-2.5] mm, 20 (IQR: 15-30) mm, and 12±2 atmospheres, respectively. Angiographic success was achieved in 97.2% of cases, and bail-out stenting was required in nine (12.7%) cases. The incidence of TLF at the 12-month follow-up was 4.2%, with a target lesion revascularization rate of 4.2%. Target vessel failure and global MACE rates were 4.2 and 9.9%, respectively. CONCLUSION: Use of the Essential PCB for treating de-novo coronary lesions in small vessels was safe, with low TLF and MACE rates at the 12-month follow-up.

Acceleration Time and Ratio of Acceleration Time to Ejection Time in Aortic Stenosis: New Echocardiographic Diagnostic Parameters.

BACKGROUND: Inconsistencies between gradients and aortic valve area are frequent in the echocardiographic evaluation of aortic stenosis (AS). Assessing AS severity is essential for the correct management of the disease. The aim of this study was to evaluate whether ejection dynamics, particularly acceleration time (AT) and the ratio of AT to ejection time (ET), could be diagnostic parameters in patients with AS. METHODS: Patients with AS (aortic peak velocity > 2 m/sec) were prospectively enrolled. Quantitative echocardiographic Doppler parameters including ejection dynamics (AT, ET, and AT/ET ratio) as well as conventional and clinical parameters were analyzed. AT, ET, and AT/ET ratio were calculated in different stages of AS. A receiver operating characteristic curve was plotted to determine the best cutoff value to identify severe AS. RESULTS: Two hundred sixty-two patients were included (mean age, 75 ± 8 years; 54% women), of whom 109 (42%) had severe AS, 99 (38%) had moderate AS, 22 (8%) had mild AS, 24 (9%) had classical low-flow, low-gradient severe AS, and eight (3%) had paradoxical low-flow, low-gradient severe AS. AT was higher in patients with higher levels of severity of AS (65 ± 16 vs 82 ± 19 vs 109 ± 23 msec, P < .001) as well as AT/ET ratios (0.22 ± 0.05 vs 0.29 ± 0.07 vs 0.37 ± 0.06, P < .001). Using a cutoff of 94 msec, AT had sensitivity of 71% and specificity of 81% for severe AS; using a cutoff of 0.35, the AT/ET ratio had sensitivity of 59% and specificity of 86%. On multivariate analysis, AT was associated with effective orifice area (B = -0.64, P < .001) and ET with heart rate (B = -0.62, P < .001) and age (B = 0.30, P = .04). CONCLUSIONS: Ejection dynamics parameters, such as AT and AT/ET, can help evaluate AS severity.

Invasive assessment of coronary flow reserve impairment in severe aortic stenosis and ecochadiographic correlations.

OBJECTIVES AND BACKGROUND: Patients with aortic stenosis (AS) may have impaired coronary flow reserve (CFR) despite angiographically normal coronary arteries. This is the first report of invasive thermodilution-derived CFR and IMR in patients with AS and their associations with echocardiographic parameters for AS assessment. METHODS: Thirty-six consecutive severe AS patients and ten patients without AS underwent prospectively cardiac catheterization and coronary physiological parameters were determined in the left anterior descending (LAD). Mean transit time (Tmn), a surrogate of absolute coronary flow, was obtained from the coronary thermodilution curve. RESULTS: In AS patients we found a high LAD flow at rest (Tmn rest 0.55±0.3 vs 0.99±0.4, p=0.01) and a low flow at hyperemia (Tmnhyp 0.44±0.2 vs 27.7±0.1, p=0.02) and consequently a severe CFR impairment (1.4±0.4 vs 3.8±1.4, p<0.001) compared with controls. An elevated index of microvascular resistance (IMR) (32.7±16 vs 17.8±6.5, p=0.01) and a low baseline microvascular coronary resistance (48.1±29 vs 84±34, p=0.02) were also found. In AS patients there were significant correlations between CFR and left ventricular mass index (r=-0.32; p=0.02), and the ratio of acceleration time to ejection time (AT/ET) (r=-0.4; p=0.01) a non-flow dependent echocardiographic parameter for AS assessment. Multiple linear stepwise regression analysis showed that AT/ET (ß=-0.441, p=0.019) was the only independently variable associated with CFR CONCLUSIONS: In severe AS, invasive CFR shows a progressive decrease with AS severity and a good correlation with echocardiographic parameters of AS, especially with flow-independent ones.

Invasive assessment of coronary microvascular dysfunction in hypertrophic cardiomyopathy: the index of microvascular resistance.

We present a review of microvascular dysfunction in hypertrophic cardiomyopathy (HCM) and an interesting case of a symptomatic familial HCM patient with inducible ischemia by single photon emission computed tomography. Coronary angiography revealed normal epicardial arteries. Pressure wire measurements of fractional flow reserve (FFR), coronary flow reserve (CFR) and index of microvascular resistance (IMR) demonstrated a significant microcirculatory dysfunction. This is the first such case that documents this abnormality invasively using the IMR. The measurement of IMR, a novel marker of microcirculatory dysfunction, provides novel insights into the pathophysiology of this condition.

La ergometría en la vigilancia de la saluden una población laboral de extinción de incendios / The ergometry in the vigilance of the health in firemen

La indicación de la ergometría en determinados colectivos de personas trabajadoras está recogida con la categoría IIa (opinión a favor de su utilidad) de la American Hearth Association. Los protocolos de vigilancia en salud laboral (Ministerio de Sanidad y Consumo) no recogen la realización de ergometrías. Objetivo: analizar los datos de ergometrías realizadas a 31 bomberos mayores de 44 años. Método: Se aplicó protocolo BRUCE sobre tapiz rodante. Se analizaron los siguientes datos: edad, consumo de tabaco, frecuencia cardiaca basal, PR, eje QRS, frecuencia cardiaca submáxima, TAS/TAD basal, TAS/TAD máxima, capacidad funcional, tiempo de duración de la prueba, colesterol total, HDL, LDL y glucemia. Se analizó el riesgo cardiovascular. Resultados: La media de edad fue de 48,82 años. El 29,03% eran fumadores. Los datos analítico fueron: glucemia 85,37 mg/100 cc, colesterol total 205 mg/100 cc, HDL 53,03 mg/100 cc, LDL 151,07 mg/100 cc. Buena respuesta al ejercicio físico. La capacidad funcional fue de 12,87 Mets, y la duración de 11,46 minutos. Conclusión: Incluir la ergometría en los protocolos de vigilancia de la salud para determinados colectivos de trabajadores (AU)

The indication of the ergometry in certain groups of hard–working persons is gathered by the categoryIIa (opinion in favour of its utility) of the American Hearth Association. The protocols of alertness in labourhealth (Ministry of Health and Consumption) do not gather the accomplishment of ergometry.Objective: to analyze the information of ergometry realized to 31 44–year–old major firemen.Method: Applied protocol BRUCE on rolling tapestry. The following information was analyzed: age,consumption of tobacco, cardiac frequency basal, PR, axis(axle) QRS, cardiac submaximum frequency, TAS/TAD basal, maximum TAS/TAD, functional capacity, time of duration of the test(proof), total cholesterol,HDL, LDL and glucose. The cardiovascular risk was analyzedResults: The average of age was 48,82 years. 29,03 % was smoking. The information analytical was:glycemia 85,37 mg/100 cc, total cholesterol 205 mg/100 cc, HDL 53,03 mg/100 cc, LDL 151,07 mg/100 cc.Good response to the physical exercise(fiscal year). The functional capacity was 12,87 Mets, and the durationof 11,46 minutes.Conclusion: To include the ergometry in the protocols of alertness of the health for certain groupsof workers (AU)