Home Respiratory Polygraphy is Useful in the Diagnosis of Childhood Obstructive Sleep Apnea Syndrome.

The utility of home respiratory polygraphy (HRP) was assessed as an alternative to polysomnography (PSG) in the diagnosis of childhood obstructive sleep apnea syndrome (OSAS). PSG was indicated only in patients with concomitant disease or where HRP results were questionable. The follow-up period was 1 year. We recorded clinical and anthropometric data, physical examination findings, respiratory variables, severity level and choice of therapy. We assessed 121 children, 70 boys and 51 girls, with mean age 7 ± 4 years, mean body mass index (BMI) 19 ± 5 kg/m2, and mean BMI percentile 62 ± 38%. We included 104 HRP and 24 PSG recordings. Of the latter, 7 were preceded by HRP (false negatives) and 17 were indicated as the first-choice method owing to concomitant disease. Of the initial HRP recordings, 93% were technically valid. All technically valid HRPs and 96% of PSGs resulted in a diagnosis of OSAS (apnea-hypopnea index 9.5 ± 9.1/h). Thirty-three percent of cases were moderate and 22% severe. Apnea-hypopnea index showed no correlation with BMI or BMI percentile. Adenotonsillectomy was indicated in 93 patients (77%), conservative treatment in 17 (14%), and conservative treatment combined with CPAP/BiPAP in 11 (9%). There were no significant differences between children diagnosed by HRP and by PSG in terms of treatment choice. The prevalence of OSAS in our sample was 96.7%. In conclusion, when the probability of OSAS is high, HRP is usually sufficient for diagnosing the syndrome and establishing therapy in children. PSG is advisable in complex or questionable cases.

Estenosis aórtica grave con bajo gradiente y fracción de eyección normal: una cuestión de mala clasificación / Severe aortic valve stenosis with low-gradient and preserved ejection fraction: a misclassification issue

Introducción y objetivos. La estenosis aórtica grave con gradientes bajos y fracción de eyección normal es una entidad discutida. Las discrepancias sobre su pronóstico indican que podría tratarse de una incorrecta clasificación de su gravedad. La planimetría del área aórtica mediante ecografía transesofágica tridimensional podría esclarecer estas dudas. Los objetivos de este trabajo son valorar la concordancia de la medida del área valvular aórtica obtenida mediante ecuación de continuidad en ecocardiografía transtorácica y la obtenida por planimetría mediante ecocardiografía transesofágica tridimensional en pacientes con estenosis aórtica grave y bajo gradiente paradójico. Métodos. Estudio transversal descriptivo de pacientes consecutivos remitidos por estenosis aórtica grave, a los que se practicó ecocardiografía transtorácica y transesofágica tridimensional. Se consideró estenosis aórtica con bajo gradiente paradójico la presencia de un área efectiva < 1 cm2, gradiente ventricular medio < 40 mmHg y fracción de eyección >= 50%. Se estudió la concordancia entre las dos técnicas. Resultados. Estudiamos a 212 pacientes consecutivos con estenosis aórtica grave. De ellos, 63 casos (29,7%) satisfacían los criterios de bajo gradiente paradójico y en 61 se obtuvieron imágenes adecuadas para la comparación de los métodos. La planimetría tridimensional confirmó un área valvular < 1 cm2 en 52 pacientes (85,2%). El coeficiente de correlación intraclase entre las técnicas fue 0,505 (intervalo de confianza del 95%, 0,290-0,671; p < 0,001). Conclusiones. La estenosis aórtica grave con bajo gradiente paradójico es una entidad real que se confirma en el 85% de los pacientes evaluados mediante ecocardiografía transesofágica tridimensional (AU)

Introduction and objectives. Low-gradient severe aortic stenosis with preserved ejection fraction is a controversial entity. Misclassification of valvulopathy severity could explain the inconsistencies reported in the prognosis of these patients. Planimetry of the aortic area using three-dimensional transesophageal echocardiography could clear up these doubts. The objectives were to assess the agreement between measurements of the valvular aortic area by continuity equation in transthoracic echocardiography and that obtained through planimetry with three-dimensional transesophageal echocardiography in low-gradient severe aortic stenosis patients. Methods. Cross-sectional descriptive study of consecutive patients referred due to severe aortic stenosis. Patients underwent transthoracic echocardiography and three-dimensional transesophageal echocardiography. Paradoxical low-gradient severe aortic stenosis was defined by the presence in the transthoracic echocardiography of aortic valve area<1 cm2, mean ventricular gradient<40mmHg, and ejection fraction >=50%. Concordance between the two techniques was evaluated. Results. Of 212 consecutive severe aortic stenosis patients evaluated, 63 cases (29.7%) fulfilled the paradoxical low-gradient inclusion criteria. We obtained three-dimensional aortic valve planimetry in 61 (96.8%) of those patients. In 52 patients (85.2%), aortic valve area by transesophageal echocardiography was <1 cm2. The intraclass correlation coefficient between the two methods was 0.505 (95% confidence interval, 0.290-0.671; P<.001). Conclusions. Paradoxical low-gradient severe aortic stenosis is an actual entity, confirmed in 85% of cases evaluated by three-dimensional transesophageal echocardiography (AU)

Severe aortic valve stenosis with low-gradient and preserved ejection fraction: a misclassification issue?

INTRODUCTION AND OBJECTIVES: Low-gradient severe aortic stenosis with preserved ejection fraction is a controversial entity. Misclassification of valvulopathy severity could explain the inconsistencies reported in the prognosis of these patients. Planimetry of the aortic area using three-dimensional transesophageal echocardiography could clear up these doubts. The objectives were to assess the agreement between measurements of the valvular aortic area by continuity equation in transthoracic echocardiography and that obtained through planimetry with three-dimensional transesophageal echocardiography in low-gradient severe aortic stenosis patients. METHODS: Cross-sectional descriptive study of consecutive patients referred due to severe aortic stenosis. Patients underwent transthoracic echocardiography and three-dimensional transesophageal echocardiography. Paradoxical low-gradient severe aortic stenosis was defined by the presence in the transthoracic echocardiography of aortic valve area<1 cm(2), mean ventricular gradient<40 mmHg, and ejection fraction ≥ 50%. Concordance between the two techniques was evaluated. RESULTS: Of 212 consecutive severe aortic stenosis patients evaluated, 63 cases (29.7%) fulfilled the paradoxical low-gradient inclusion criteria. We obtained three-dimensional aortic valve planimetry in 61 (96.8%) of those patients. In 52 patients (85.2%), aortic valve area by transesophageal echocardiography was <1 cm(2). The intraclass correlation coefficient between the two methods was 0.505 (95% confidence interval, 0.290-0.671; P<.001). CONCLUSIONS: Paradoxical low-gradient severe aortic stenosis is an actual entity, confirmed in 85% of cases evaluated by three-dimensional transesophageal echocardiography.

El ancho de distribución eritrocitaria aporta valor pronóstico adicional en pacientes ambulatorios con insuficiencia cardiaca crónica / Red blood cell distribution width adds prognostic value for outpatients with chronic heart failure

Introducción y objetivos. El ancho de distribución eritrocitaria ha surgido como un marcador biológico con valor pronóstico en enfermedades cardiovasculares. Su valor adicional en la estratificación de riesgo de pacientes con insuficiencia cardiaca crónica no se encuentra establecido. Métodos. Se estudió consecutivamente a 698 pacientes ambulatorios con insuficiencia cardiaca crónica (edad, 71 años [intervalo intercuartílico, 62-77]; el 63% varones; fracción de eyección del ventrículo izquierdo, 40±14%). A su inclusión, se midió el ancho de distribución eritrocitaria y se registraron variables clínicas, bioquímicas y ecocardiográficas. La mediana de seguimiento fue 2,5 años [1,2-3,7]. Resultados. En total, fallecieron 211 pacientes y 206 precisaron hospitalización por insuficiencia cardiaca descompensada. El análisis de Kaplan-Meier mostró un incremento tanto de la probabilidad de muerte como de ingreso por insuficiencia cardiaca a través de cuartiles de ancho de distribución eritrocitaria (log rank, p<0,001). El análisis ROC identificó el valor de ancho de distribución eritrocitaria del 15,4% como mejor punto de corte, asociado a un incremento independiente del riesgo tanto de muerte (hazard ratio=2,63; intervalo de confianza del 95%, 2,01-3,45; p<0,001) como de ingreso por insuficiencia cardiaca (hazard ratio=2,37; intervalo de confianza del 95%, 1,80-3,13; p<0,001). Este valor predictivo se mantuvo con o sin anemia. Además, la adición del ancho de distribución eritrocitaria a la estratificación de riesgo de muerte o ingreso por insuficiencia cardiaca a 1 año se asoció con una mejora tanto del índice relativo de discriminación integrada (33%; p<0,001) como de la reclasificación neta de eventos (10,3%; p=0,001). Conclusiones. El ancho de distribución eritrocitaria es un marcador de riesgo independiente y añade información pronóstica sobre pacientes ambulatorios con insuficiencia cardiaca crónica. Los hallazgos indican su incorporación al manejo de estos pacientes (AU)

Introduction and objectives. Red blood cell distribution width has emerged as a new prognostic biomarker in cardiovascular diseases. Its additional value in risk stratification of patients with chronic heart failure has not yet been established. Methods. A total of 698 consecutive outpatients with chronic heart failure were studied (median age 71 years [interquartile range, 62-77], 63% male, left ventricular ejection fraction 40 [14]%). On inclusion, the red cell distribution width was measured and clinical, biochemical, and echocardiographic variables were recorded. The median follow-up period was 2.5 years [interquartile range, 1.2-3.7]. Results. A total of 211 patients died and 206 required hospitalization for decompensated heart failure. Kaplan-Meier analysis showed an increase in the probability of death and hospitalization for heart failure with red cell distribution width quartiles (log rank, P<.001). A ROC analysis identified a red cell distribution width of 15.4% as the optimal cut-off point for a significantly higher risk of death (P<.001; hazard ratio=2.63; 95% confidence interval, 2.01-3.45) and hospitalization for heart failure (P<.001; hazard ratio=2.37; 95% confidence interval, 1.80-3.13). This predictive value was independent of other covariates, and regardless of the presence or not of anaemia. Importantly, the addition of red cell distribution width to the clinical risk model for the prediction of death or hospitalization for heart failure at 1 year had a significant integrated discrimination improvement of 33% (P<.001) and a net reclassification improvement of 10.3% (P=.001). Conclusions. Red cell distribution width is an independent risk marker and adds prognostic information in outpatients with chronic heart failure. These findings suggest that this biological measurement should be included in the management of these patients (AU)

Red blood cell distribution width adds prognostic value for outpatients with chronic heart failure.

INTRODUCTION AND OBJECTIVES: Red blood cell distribution width has emerged as a new prognostic biomarker in cardiovascular diseases. Its additional value in risk stratification of patients with chronic heart failure has not yet been established. METHODS: A total of 698 consecutive outpatients with chronic heart failure were studied (median age 71 years [interquartile range, 62-77], 63% male, left ventricular ejection fraction 40 [14]%). On inclusion, the red cell distribution width was measured and clinical, biochemical, and echocardiographic variables were recorded. The median follow-up period was 2.5 years [interquartile range 1.2-3.7]. RESULTS: A total of 211 patients died and 206 required hospitalization for decompensated heart failure. Kaplan-Meier analysis showed an increase in the probability of death and hospitalization for heart failure with red cell distribution width quartiles (log rank, P<.001). A ROC analysis identified a red cell distribution width of 15.4% as the optimal cut-off point for a significantly higher risk of death (P<.001; hazard ratio=2.63; 95% confidence interval, 2.01-3.45) and hospitalization for heart failure (P<.001; hazard ratio=2.37; 95% confidence interval, 1.80-3.13). This predictive value was independent of other covariates, and regardless of the presence or not of anaemia. Importantly, the addition of red cell distribution width to the clinical risk model for the prediction of death or hospitalization for heart failure at 1 year had a significant integrated discrimination improvement of 33% (P<.001) and a net reclassification improvement of 10.3% (P=.001). CONCLUSIONS: Red cell distribution width is an independent risk marker and adds prognostic information in outpatients with chronic heart failure. These findings suggest that this biological measurement should be included in the management of these patients. Full English text available from:www.revespcardiol.org.

Utilidad de la prueba de troponina T de alta sensibilidad en la detección de rechazo agudo en trasplante cardiaco / Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation

Introducción y objetivos. La detección del rechazo agudo en pacientes trasplantados cardiacos mediante métodos no invasivos representa un reto. La disponibilidad de un nuevo método de alta sensibilidad para la determinación de troponina T podría ayudar a su detección. Métodos. Estudio case-crossover, en el que cada paciente sirvió como control de sí mismo, mediante la selección de muestras obtenidas en episodios de rechazo agudo tratados (29 casos) y muestras sin rechazo obtenidas inmediatamente antes y/o después (38 controles). La determinación de alta sensibilidad de troponina T se realizó mediante un nuevo test precomercial (Elecsys Troponina T HS). Resultados. La troponina T fue detectable en todas las muestras: mediana, 0,068 [intervalo intercuartílico, 0,030-0,300] ng/l. Sus concentraciones se correlacionaron con la presión auricular derecha (r=0,37; p=0,002), la fracción aminoterminal del propéptido natriurético cerebral (r=0,67; p<0,001) y el tiempo transcurrido desde el trasplante (r=–0,81; p<0,001). Las concentraciones de troponina T fueron mayores en presencia de rechazo (0,155 frente a 0,047 ng/l; p=0,006). En el análisis operador-receptor, el área bajo la curva fue 0,67 (intervalo de confianza del 95%, 0,53-0,77) y el mejor punto de corte, 0,035 ng/l, que se asoció con mayor riesgo de rechazo (odds ratio=3,7; intervalo de confianza del 95%, 1,2-11,9; p=0,02). Durante los primeros 2 meses, el área bajo la curva aumentó hasta 0,86 (intervalo de confianza del 95%, 0,66-0,97), con un punto de corte óptimo de 1,1 ng/l (sensibilidad, 58% [28-85%]; especificidad, 100% [74-100%]). Conclusiones. El análisis de alta sensibilidad detectó troponina T en todas las muestras tras el trasplante, en mayor concentración en caso de rechazo agudo, si bien su utilidad en la monitorización se limitaría a servir como apoyo ante la sospecha clínica o histológica, especialmente en los primeros meses (AU)

Introduction and objectives. Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. Methods. We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). Results. In all samples, highly sensitive troponin was detectable, with a median of 0.068 ng/mL (IQR, 0.030-0.300 ng/mL). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=–0.81; P<.001). The highly sensitive troponin concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). Conclusions. Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period (AU)

[Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation]. / Utilidad de la prueba de troponina T de alta sensibilidad en la detección de rechazo agudo en trasplante cardiaco.

INTRODUCTION AND OBJECTIVES: Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. METHODS: We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). RESULTS: In all samples, highly sensitive troponin T was detectable, with a median of 0.068 ng/L (IQR, 0.030-0.300 ng/L). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=-0.81; P<.001). The highly sensitive troponin T concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). CONCLUSIONS: Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period.