Percutaneous Closure of a Poorly Tolerated Ventricular Septal Defect After Triple Valvular Prosthesis Surgery.

We describe the case of an 81-year-old woman with three biological prostheses at the aortic valve, mitral valve, and tricuspid valve with recurrent hospitalizations due to heart failure. To the best of our knowledge, this is the first percutaneous closure of ventricular septal defect in the presence of three valvular prostheses.

Factores asociados al error en la estimación visual de la importancia funcional de lesiones coronarias / Factors associated with errors in visual estimation of the functional significance of coronary lesions

Introducción y objetivos: La valoración angiográfica visual sigue utilizándose para decidir la revascularización de lesiones coronarias dudosas. Múltiples factores, distintos del grado de estenosis, se han asociado con la repercusión funcional de una lesión coronaria. El objetivo de este estudio es analizar la capacidad de predecir visualmente la repercusión funcional de una lesión coronaria y los condicionantes clínicos y angiográficos asociados con el error en la predicción. Métodos: Estudio de concordancia entre la predicción de repercusión funcional realizada por intervencionistas expertos y el valor de reserva fraccional de flujo obtenido mediante guía intracoronaria de presión en 665 lesiones intermedias (estenosis del 40-70% del diámetro) en 587 pacientes. Se determinaron los factores independientemente asociados a un error en la predicción. Resultados: Se observó una discordancia del 30,1% (sobrestimación, 11,3%; subestimación, 18,8%) entre el valor de reserva fraccional de flujo predicho menor o igual que 0,80 y el observado. La localización en elstent, en una arteria distinta de la descendente anterior y en una bifurcación se asoció a sobrestimación. El sexo masculino, la calcificación grave y el mayor territorio miocárdico distal a la lesión se asociaron significativamente con importancia funcional de la lesión subestimada. Conclusiones: Incluso integrando características angiográficas y clínicas, la estimación visual de la importancia funcional de estenosis coronarias intermedias se asocia a una alta tasa de discrepancias respecto a su determinación real. Determinadas características angiográficas y clínicas se asocian específicamente con mayor tendencia a sobrestimar o subestimar la importancia de la lesión (AU)

Introduction and objectives: Visual angiographic assessment continues to be used when decisions are made on whether to revascularize ambiguous coronary lesions. Multiple factors, other than the degree of stenosis, have been associated with the functional significance of a coronary lesion. The aim of this study was to investigate the ability of interventionists to visually predict the functional significance of a coronary lesion and the clinical and angiographic characteristics associated with errors in prediction. Methods: We conducted a concordance study of the functional significance of coronary lesions predicted by experienced interventionists and fractional flow reserve values measured by intracoronary pressure wire in 665 intermediate lesions (40%-70% diameter stenosis) in 587 patients. We determined which factors were independently associated with errors in prediction. Results: There was disagreement between the predicted fractional flow reserve value of less than or equal to 0.80 and the observed value in 30.1% of the lesions (overestimation: 11.3%; underestimation, 18.8%). Stent location in an artery other than the anterior descending artery or in a bifurcation was associated with overestimation. Male sex, severe calcification, and a greater myocardial territory distal to the lesion were significantly associated with the functional significance of the underestimated lesion. Conclusions: Even when taking into account angiographic and clinical characteristics, there is a high rate of disagreement between visual estimation and direct measurement of intermediate coronary stenosis in relation to its functional significance. Specific angiographic and clinical characteristics are associated with an increased tendency to overestimate or underestimate the significance of lesions (AU)

Factors Associated With Errors in Visual Estimation of the Functional Significance of Coronary Lesions.

UNLABELLED: INTRODUCTION AND  OBJECTIVES: Visual angiographic assessment continues to be used when decisions are made on whether to revascularize ambiguous coronary lesions. Multiple factors, other than the degree of stenosis, have been associated with the functional significance of a coronary lesion. The aim of this study was to investigate the ability of interventionists to visually predict the functional significance of a coronary lesion and the clinical and angiographic characteristics associated with errors in prediction. METHODS: We conducted a concordance study of the functional significance of coronary lesions predicted by experienced interventionists and fractional flow reserve values measured by intracoronary pressure wire in 665 intermediate lesions (40%-70% diameter stenosis) in 587 patients. We determined which factors were independently associated with errors in prediction. RESULTS: There was disagreement between the predicted fractional flow reserve value of ≤ 0.80 and the observed value in 30.1% of the lesions (overestimation: 11.3%; underestimation, 18.8%). Stent location in an artery other than the anterior descending artery or in a bifurcation was associated with overestimation. Male sex, severe calcification, and a greater myocardial territory distal to the lesion were significantly associated with the functional significance of the underestimated lesion. CONCLUSIONS: Even when taking into account angiographic and clinical characteristics, there is a high rate of disagreement between visual estimation and direct measurement of intermediate coronary stenosis in relation to its functional significance. Specific angiographic and clinical characteristics are associated with an increased tendency to overestimate or underestimate the significance of lesions.

The role for adjunctive image in pre-procedural assessment and peri-procedural management in chronic total occlusion recanalisation.

Non invasive coronary angiography with multislice computed tomography has exquisite sensitivity to detect calcium and even the faintest late contrast filling of the distal vessel. Calcium burden and occlusion length are still valuable markers of duration, complexity and success of the recanalisation procedure. The ability to visualise the vessel also in the occluded segment, especially if calcified, can also help the operator to understand where to pierce the proximal cap in stumpless occlusions and to predict unusual courses, especially in very tortuous arteries. Imaging side by side CT images and angiography during the recanalisation procedure is an established practice in many active CTO laboratories and algorithms for co-registration are designed to overcome the challenges of systo-diastolic and respiratory motion. Intravascular ultrasound is used in almost all cases by the experienced Japanese CTO operators but most of the times its main use is a better identification of the diseased segment after predilatation to ensure complete stent cover and appropriate stent expansion, an application similar to other complex non occlusive lesions. The specificity of IVUS during CTO recanalisation is the identification of the vessel path in stumpless occlusions and the guidance of wire reentry especially during reverse Controlled Retrograde Anterograde Tracking. Optical coherence tomography has limitations in the setting of CTO recanalisation because of the need of forceful contrast flushing to clear blood, contraindicated in the presence of anterograde dissections, and the limited penetration. The variability in the use of both non-invasive and invasive imaging during CTO recanalisation is immense, going from more than 90% in Japan to less than 20% in Europe and intermediate penetration in the USA. Probably the explanation is almost only in availability and cost because all countries see a progressive increase of use suggesting that these methods are becoming an established tool for guidance of CTO recanalisation.

Correlación entre ecografía intracoronaria y reserva fraccional de flujo en lesiones coronarias largas. Un estudio de ecografía intracoronaria tridimensional / Correlation between intracoronary ultrasound and fractional flow reserve in long coronary lesions. A three-dimensional intracoronary ultrasound study

Introducción y objetivos. La estimación mediante ecografía intracoronaria de la repercusión funcional de lesiones angiográficas intermedias se ha basado principalmente en la medición del área luminal mínima. Estas estimaciones no han tenido en cuenta la longitud de la lesión y no han sido estudiadas suficientemente en lesiones coronarias largas. Métodos. Se incluyen 61 lesiones con un 40-70% de estenosis angiográfica visual y necesidad de stent ≥ 20 mm para su tratamiento, que se estudiaron con ecografía y reserva fraccional de flujo. Se realizó un análisis tridimensional offline del estudio de ecografía, ciego al valor de reserva fraccional. Se correlacionaron los parámetros angiográficos y ecográficos con la reserva fraccional obtenida. Resultados. Se obtuvieron por angiografía valores medios de diámetro de referencia (2,87 ± 0,57 mm; longitud, 29,8 ± 10,01 mm) y grado de estenosis (50,3 ± 8,7%). El valor medio de reserva fraccional de flujo fue 0,78 ± 0,09. Se obtuvo una pobre correlación lineal (R) entre la reserva fraccional y los parámetros de ecografía que no incluían la longitud de la lesión: reserva fraccional-área luminal mínima (R = 0,4; p = 0,003); y mejor cuando se la tenía en cuenta: reserva fraccional − volumen de la placa (R = –0,65; p < 0,0005); reserva fraccional − longitud/área luminal media (R = 0,73; p < 0,0005). La mejor correlación se obtuvo con el producto estenosis media por área × longitud de la lesión (R = −0,78; p < 0,0005). Conclusiones. En las lesiones coronarias largas, el área luminal mínima medida por ecografía no tiene buena correlación con su repercusión funcional. En estos casos, la estimación de la repercusión funcional debe tener en cuenta la longitud de la lesión o realizarse por medición directa de la reserva fraccional de flujo(AU)

Introduction and objectives. Intracoronary ultrasound estimation of the functional significance of intermediate angiographic lesions has mainly been based on measuring the minimal lumen area. These estimates take no account of lesion length and pay insufficient attention to long coronary lesions. Methods We included 61 lesions with visual angiographic stenosis of 40% to 70% that required treatment with a ≥20 mm stent, studied with ultrasound and fractional flow reserve. Three-dimensional analysis of the ultrasound study was conducted offline and blinded to fractional reserve values. Angiographic and ultrasound parameters were correlated with fractional reserve. Results. From the angiography we obtained data on mean reference diameter (2.87 [0.57] mm), length (29.8 [10.01] mm), and severity of stenosis (50.3% [8.7]%). Mean fractional flow reserve was 0.78 (0.09). We found a weak linear correlation (R) between fractional reserve and the ultrasound parameters that did not include lesion length: fractional reserve-minimal luminal area (R=0.4; P=.003). The correlation was stronger when lesion length was included: fractional reserve–volume of plaque (R=–0.65; P<.0005); fractional reserve–length/mean luminal area (R=0.73; P<.0005). The strongest correlation came from the product of mean stenosis by area multiplied by lesion length (R=−0.78; P<.0005). Conclusions. In long coronary lesions, the correlation between ultrasound-measured minimal lumen area and functional significance is weak. In these cases, estimates of functional significance should incorporate lesion length or be derived from direct fractional flow reserve measurement(AU)

Comparison of effectiveness of high-dose intracoronary adenosine versus intravenous administration on the assessment of fractional flow reserve in patients with coronary heart disease.

Intravenous adenosine is considered the drug of choice to obtain maximum hyperemia in the measurement of the fractional flow reserve (FFR). However, comparative studies performed between intravenous and intracoronary administration have not used high doses of intracoronary adenosine. The present study compared the efficacy and safety of high doses of intracoronary adenosine to intravenous administration when calculating the FFR. Intracoronary bolus doses of 60, 180, 300, and 600 µg adenosine were compared to an intravenous administration of 140 µg/kg/min, 200 µg/kg/min, and 140 µg/kg/min plus an intracoronary bolus of 120 µg. All the cases were performed using the radial approach. FFR was assessed in 102 patients with 108 intermediate lesions by an intracoronary pressure wire. The intracoronary dose of 60 µg was associated with a significantly greater FFR compared to the intravenous infusion (0.02 ± 0.03, p = 0.001). The intracoronary doses of 300 (-0.01 ± 0.00; p = 0.006) and 600 µg (-0.02 ± 0.00; p <0.0005) were significantly associated with a smaller FFR compared to the intravenous infusion. An intracoronary dose of 600 µg revealed a significantly greater percentage of lesions with an FFR <0.80 compared to intravenous infusion at 140 µg/kg/min (37.6 vs 31.5%; p <0.05) and 200 µg/kg/min (37.6 vs 32.4%; p <0.05) and compared to intracoronary doses of 60 (26.9%) and 180 µg (31.5%). In conclusion, an intracoronary bolus dose >300 µg can be equal to or more effective than an intravenous infusion of adenosine in achieving maximum hyperemia when calculating the FFR. Its use could simplify these procedures without having an effect on safety.

Correlation between intracoronary ultrasound and fractional flow reserve in long coronary lesions. A three-dimensional intracoronary ultrasound study.

INTRODUCTION AND OBJECTIVES: Intracoronary ultrasound estimation of the functional significance of intermediate angiographic lesions has mainly been based on measuring the minimal lumen area. These estimates take no account of lesion length and pay insufficient attention to long coronary lesions. METHODS: We included 61 lesions with visual angiographic stenosis of 40% to 70% that required treatment with a ≥20mm stent, studied with ultrasound and fractional flow reserve. Three-dimensional analysis of the ultrasound study was conducted offline and blinded to fractional reserve values. Angiographic and ultrasound parameters were correlated with fractional reserve. RESULTS: From the angiography we obtained data on mean reference diameter (2.87 [0.57] mm), length (29.8 [10.01] mm), and severity of stenosis (50.3% [8.7]%). Mean fractional flow reserve was 0.78 (0.09). We found a weak linear correlation (R) between fractional reserve and the ultrasound parameters that did not include lesion length: fractional reserve-minimal luminal area (R=0.4; P=.003). The correlation was stronger when lesion length was included: fractional reserve-volume of plaque (R=-0.65; P<.0005); fractional reserve-length/mean luminal area (R=0.73; P<.0005). The strongest correlation came from the product of mean stenosis by area multiplied by lesion length (R=-0.78; P<.0005). CONCLUSIONS: In long coronary lesions, the correlation between ultrasound-measured minimal lumen area and functional significance is weak. In these cases, estimates of functional significance should incorporate lesion length or be derived from direct fractional flow reserve measurement.

Las concentraciones bajas de colesterol unido a las lipoproteínas de alta densidad se asocian de manera independiente a enfermedad coronaria aguda en pacientes que ingresan por dolor torácico / Low levels of high-density lipoproteins cholesterol are independently associated with acute coronary heart disease in patients hospitalized for chest pain

Introducción y objetivos. El papel las lipoproteínas de alta densidad en la estratificación de riesgo en pacientes con dolor torácico no está bien definido. El objetivo de este estudio es conocer la contribución relativa del perfil lipídico al riesgo de padecer síndrome coronario agudo de los pacientes ingresados por dolor torácico en una planta de cardiología. Métodos. Incluimos todos los ingresos consecutivos no programados en planta de cardiología durante 15 meses y realizamos seguimiento al año. Resultados. Se incluyó a 959 pacientes, 457 (47,7%) diagnosticados de dolor torácico no isquémico, 355 (37%) de síndrome coronario agudo sin elevación del ST y 147 (15,3%) de síndrome coronario agudo con elevación del ST. El 54,6% de los pacientes presentaron cifras de lipoproteínas de alta densidad < 40mg/dl y la prevalencia fue más elevada entre los pacientes con síndrome coronario agudo (el 69,4 frente al 30,6%; p<0,01). Se observó mayor presencia de síndrome coronario agudo a menores cifras medias de lipoproteínas de alta densidad. Edad, tabaquismo activo, diabetes mellitus, glucemia basal > 100mg/dl y concentraciones de lipoproteínas de alta densidad < 40mg/dl se asociaron independientemente a la presencia de síndrome coronario agudo, el factor con mayor asociación (odds ratio=4,11; intervalo de confianza del 95%, 2,87-5,96). El análisis de supervivencia determinó que los pacientes con síndrome coronario agudo, frente a dolor torácico no isquémico, asociaron un riesgo significativamente superior de mortalidad por cualquier causa, así como por causa cardiovascular. Conclusiones. Las concentraciones bajas de colesterol unido a las lipoproteínas de alta densidad (≤ 40mg/dl) se asociaron de manera independiente a diagnóstico de síndrome coronario agudo en pacientes ingresados por dolor torácico, con una relación inversa significativa entre los valores más bajos de lipoproteínas de alta densidad y el diagnóstico de síndrome coronario agudo (AU)

Introduction and objectives. The role of high-density lipoproteins in the context of acute chest pain has not been well characterized. The objective of this study was to determine the relative contribution of lipid profile to the risk of acute coronary syndrome in patients admitted to a cardiology ward for chest pain. Methods. We included all consecutive admissions in a single cardiology department over a period of 10 months and 1-year follow-up was performed. Results. In total, 959 patients were included: 457 (47.7%) were diagnosed with non-ischemic chest pain, 355 (37%) with non-ST-elevation acute coronary syndrome, and 147 (15.3%) with ST-elevation acute coronary syndrome. Prevalence of high-density lipoproteins <40mg/dL was 54.6%, and was higher in patients with acute coronary syndrome (69.4% vs 30.6%; P<.01). The prevalence of acute coronary syndrome increased with reductions in mean high-density lipoproteins. Age, active smoking, diabetes, fasting glucose >100mg/dL, and high-density lipoproteins <40mg/dL were independently associated with acute coronary syndrome, and low high-density lipoproteins was the main associated factor (odds ratio, 4.11; 95% confidence interval, 2.87-5.96). Survival analysis determined that, compared with non-ischemic chest pain, the presence of acute coronary syndrome was associated with significantly greater risk of all-cause and cardiovascular mortality. Conclusions. Low levels of high-density lipoproteins cholesterol (≤40mg/dL) were independently associated with a diagnosis of acute coronary syndrome in patients hospitalized for chest pain, with an inverse relationship between lower levels of high-density lipoproteins and prevalence of acute coronary syndrome (AU)

Low levels of high-density lipoproteins cholesterol are independently associated with acute coronary heart disease in patients hospitalized for chest pain.

INTRODUCTION AND OBJECTIVES: The role of high-density lipoproteins in the context of acute chest pain has not been well characterized. The objective of this study was to determine the relative contribution of lipid profile to the risk of acute coronary syndrome in patients admitted to a cardiology ward for chest pain. METHODS: We included all consecutive admissions in a single cardiology department over a period of 10 months and 1-year follow-up was performed. RESULTS: In total, 959 patients were included: 457 (47.7%) were diagnosed with non-ischemic chest pain, 355 (37%) with non-ST-elevation acute coronary syndrome, and 147 (15.3%) with ST-elevation acute coronary syndrome. Prevalence of high-density lipoproteins <40 mg/dL was 54.6%, and was higher in patients with acute coronary syndrome (69.4% vs 30.6%; P<.01). The prevalence of acute coronary syndrome increased with reductions in mean high-density lipoproteins. Age, active smoking, diabetes, fasting glucose >100 mg/dL, and high-density lipoproteins <40 mg/dL were independently associated with acute coronary syndrome, and low high-density lipoproteins was the main associated factor (odds ratio, 4.11; 95% confidence interval, 2.87-5.96). Survival analysis determined that, compared with non-ischemic chest pain, the presence of acute coronary syndrome was associated with significantly greater risk of all-cause and cardiovascular mortality. CONCLUSIONS: Low levels of high-density lipoproteins cholesterol (≤40 mg/dL) were independently associated with a diagnosis of acute coronary syndrome in patients hospitalized for chest pain, with an inverse relationship between lower levels of high-density lipoproteins and prevalence of acute coronary syndrome.

Validez diagnóstica del NT-proBNP frente al electrocardiograma en la detección de hipertrofia ventricular izquierda de origen hipertensivo / Diagnostic accuracy of NT-proBNP compared with electrocardiography in detecting left ventricular hypertrophy of hypertensive origin

El electrocardiograma (ECG) es el método más utilizado para el diagnóstico de hipertrofia ventricular izquierda (HVI) en pacientes hipertensos. Analizamos la utilidad del propéptido natriurético cerebral N-terminal (NT-proBNP) en la identificación de HVI comparado con el ECG en 336 pacientes hipertensos consecutivos con función sistólica conservada. Se encontró una correlación significativa entre concentración de NT-proBNP y masa ventricular izquierda ajustada por superficie corporal (r=0,41; p<0,001). El área bajo la curva receiver operating characteristic fue de 0,75 (intervalo de confianza del 95%, 0,7-0,8). Un punto de corte de 74,2 pg/ml presentaba una sensibilidad superior que el ECG (el 76,6 frente al 25,5%; p<0,001) y un mayor valor predictivo negativo (el 87,8 frente al 76,6%; p<0,001) en la identificación de HVI. El NT-proBNP puede ser una buena herramienta en el cribado de HVI en pacientes hipertensos (AU)

Electrocardiography (ECG) is the most widely used method for diagnosing left ventricular hypertrophy (LVH) in hypertensive patients. We assessed the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) determination compared with ECG for detecting LVH in 336 consecutive hypertensive patients with preserved systolic function. We found a significant correlation between NT-proBNP levels and left ventricular mass adjusted for body surface area (r=.41; P<.001). The area under the receiver operating characteristic curve was 0.75 (95% CI, 0.7-0.8). A cut-off of 74.2 pg/mL had a greater sensitivity than ECG (76.6% vs 25.5%; P<.001) and a higher negative predictive value (87.8% vs 76.6%; P<.001) in the identification of LVH. NT-proBNP determination may be a useful tool for LVH screening in hypertensive patients (AU)

Burden of systemic hypertension in patients admitted to cardiology hospitalization units.

Hypertension is 1 of the most prevalent cardiovascular risk factors; nevertheless, some studies have reported that the antecedent of hypertension does not impair prognosis in patients with established cardiovascular disease. The objective of this study was to describe the impact of hypertension on readmission and 1-year mortality in patients admitted to a single cardiology hospitalization unit. All consecutive hospitalizations in a single cardiology department through 10 months were included, and 1-year follow-up was performed. Clinical antecedents, risk factors, and main discharge diagnoses were collected. A total of 1,007 patients were included (mean age 71.1 ± 13.5 years). The antecedent of hypertension was present in 69.0%, and these patients had older mean age and higher prevalence of risk factors and previous cardiovascular disease. No differences in hospital discharge main diagnoses were observed according to the antecedent of hypertension. During a mean follow-up period of 404.82 ± 122.2 days, patients with hypertension had higher rates of rehospitalization for cardiac causes (31.1% vs 17.9%, p = 0.01) and of total (17.4% vs 9.3%, p <0.01) and cardiovascular (13.9% vs 5.9%, p <0.01) mortality. Multivariate analysis identified the antecedent of hypertension as an independent risk factor for cardiovascular readmission (hazard ratio 1.46, 95% confidence interval 1.10 to 1.98) and the combined end point of readmission or mortality (hazard ratio 1.45, 95% confidence interval 1.12 to 1.88); no independent association was observed for total mortality. In conclusion, hypertension was present in most patients admitted to a cardiology unit, and they had higher rates of rehospitalization and mortality at 1-year follow-up.

[Diagnostic accuracy of NT-proBNP compared with electrocardiography in detecting left ventricular hypertrophy of hypertensive origin]. / Validez diagnóstica del NT-proBNP frente al electrocardiograma en la detección de hipertrofia ventricular izquierda de origen hipertensivo.

Electrocardiography (ECG) is the most widely used method for diagnosing left ventricular hypertrophy (LVH) in hypertensive patients. We assessed the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) determination compared with ECG for detecting LVH in 336 consecutive hypertensive patients with preserved systolic function. We found a significant correlation between NT-proBNP levels and left ventricular mass adjusted for body surface area (r=.41; P<.001). The area under the receiver operating characteristic curve was 0.75 (95% CI, 0.7-0.8). A cut-off of 74.2 pg/mL had a greater sensitivity than ECG (76.6% vs 25.5%; P<.001) and a higher negative predictive value (87.8% vs 76.6%; P<.001) in the identification of LVH. NT-proBNP determination may be a useful tool for LVH screening in hypertensive patients.

¿Qué medida del grosor íntima-media carotídeo caracteriza mejor la carga aterosclerótica del paciente hipertenso: valor máximo o medio? / What Measure of Carotid Wall Thickening Is the Best Atherosclerotic Loading Score in the Hypertensive Patient: Maximum or Mean Value?

El aumento del grosor íntima-media carotídeo (GIMc) es un marcador de lesión de órgano diana establecido en las guías de hipertensión arterial, si bien no especifica si debemos utilizar el GIMc máximo o medio. Nuestro objetivo es comparar ambas medidas y su relación con la carga aterosclerótica. Hemos analizado consecutivamente a 215 pacientes hipertensos que han sido clasificados en tres grupos: GIMc máximo > 0,9 mm (GIMc medio<0,9 mm), GIMc medio>0,9 mm (GIMc medio y máximo>0,9 mm) y grupo GIMc normal. Los pacientes con GIMc patológico (máximo o medio) presentaban mayor prevalencia de dislipemia, mayor edad, mayor tiempo de evolución de la hipertensión y peor filtrado glomerular e índice tobillo-brazo. Además, los pacientes con GIMc medio>0,9 mm tenían mayor prevalencia de placas y estenosis carotÍdeas y peor índice tobillo-brazo que los pacientes con GIMc máximo>0,9 mm. El GIMc medio supone una mejor aproximación de la carga aterosclerótica del paciente hipertenso (AU)

Recent guidelines on arterial hypertension regard increased carotid intima–media thickness (IMT) as a marker of end-organ damage. However, these guidelines do not specify whether the maximum or mean IMT should be used as an indicator. The aim of this study was to compare these two measures and their relationship to atherosclerotic burden. The study involved 215 consecutive hypertensive patients who were divided into three groups according to their IMT: maximum IMT >0.9mm (with mean IMT<0.9mm); mean IMT >0.9mm (i.e. mean and maximum IMT >0.9mm); and normal IMT. Patients with a pathologically raised IMT (whether maximum or mean value) were more likely to be dyslipidemic, were older, had a longer history of hypertension, and had a poorer glomerular filtration rate and ankle–brachial index. Patients with a mean IMT >0.9mm were more likely to have carotid plaque, carotid stenosis and a low ankle–brachial index than those with a maximum IMT >0.9mm. The mean IMT provided a better indication of atherosclerotic burden in patients with hypertension (AU)

[What measure of carotid wall thickening is the best atherosclerotic loading score in the hypertensive patient: maximum or mean value?]. / ¿Qué medida del grosor íntima-media carotídeo caracteriza mejor la carga aterosclerótica del paciente hipertenso: valor máximo o medio?

Recent guidelines on arterial hypertension regard increased carotid intima-media thickness (IMT) as a marker of end-organ damage. However, these guidelines do not specify whether the maximum or mean IMT should be used as an indicator. The aim of this study was to compare these two measures and their relationship to atherosclerotic burden. The study involved 215 consecutive hypertensive patients who were divided into three groups according to their IMT: maximum IMT>0.9mm (with mean IMT<0.9mm); mean IMT>0.9mm (i.e. mean and maximum IMT>0.9mm); and normal IMT. Patients with a pathologically raised IMT (whether maximum or mean value) were more likely to be dyslipidemic, were older, had a longer history of hypertension, and had a poorer glomerular filtration rate and ankle-brachial index. Patients with a mean IMT>0.9mm were more likely to have carotid plaque, carotid stenosis and a low ankle-brachial index than those with a maximum IMT>0.9mm. The mean IMT provided a better indication of atherosclerotic burden in patients with hypertension.

Utilidades terapéuticas de la ranolazina en la cardiopatía isquémica / Therapeutic value of ranolazine in ischemic heart disease

La angina crónica estable afecta en torno al 6,7% de las mujeres y el 5,7% de los varones; además, la angina estable supone cerca de un tercio de las formas de cardiopatía isquémica y es uno de los síntomas que más limita la calidad de vida. La ranolazina proporciona una nueva estrategia antianginosa que ejerce su principales acciones previniendo la sobrecarga patológica de sodio y calcio intracelulares desencadenadas por la isquemia miocárdica; como consecuencia, no afecta a la frecuencia cardiaca y la presión arterial ni facilita la aparición de arritmias. La ranolazina aumenta el tiempo de ejercicio hasta la aparición de angina y disminuye el número de crisis de angina y la necesidad de tratamiento con nitratos. El único ensayo clínico realizado en el síndrome coronario agudo sin elevación del ST mostró una reducción significativa en la isquemia recurrente y tendencia a disminuir la mortalidad. Por último, la ranolazina es bien tolerada y no produce efectos secundarios graves ni taquicardias ventriculares (AU)

Chronic stable angina affects 6.7% of women and 5.7% of men. In addition, the condition predominates in one-third of all forms of ischemic heart disease and is one of the symptoms that can have the greatest impact on quality of life. Ranolazine provides a new form of antianginal therapy whose principle effect is to prevent the pathological intracellular sodium and calcium overload that results from myocardial ischemia. Consequently, the drug does not affect the heart rate or blood pressure, or induce arrhythmias. Ranolazine increases the duration of physical activity achievable before the onset of angina and decreases both the number of angina attacks and the need for nitrates. The only clinical trial of ranolazine performed in patients with non-ST elevation acute coronary syndrome demonstrated a significant reduction in recurrent ischemia and a trend towards lower mortality. Lastly, ranolazine is well tolerated, has no serious side effects, and does not induce ventricular tachycardia (AU)