Aneurisma idiopático de la arteria pulmonar principal en paciente joven / Idiopathic pulmonary artery aneurysm in a young woman

Los aneurismas arteriales pulmonares son entidades muy poco frecuentes. Diversas causas como las anomalías cardiacas congénitas, las infecciones, las vasculitis, las neoplasias, las alteraciones del tejido conectivo, la hipertensión arterial pulmonar, los traumatismos y las complicaciones iatrogénicas contribuyen a su aparición. La mayoría de los pacientes con aneurismas arteriales pulmonares están asintomáticos o presentan sintomatología inespecífica. La etiología y el tamaño del aneurisma, la presencia de hipertensión arterial pulmonar y la clínica del paciente definen la actitud a seguir. Presentamos el caso de una paciente joven con dilatación idiopática de la arteria pulmonar principal (AU)

Pulmonary artery aneurysms are rare. Diverse causes, including congenital heart defects, infections, vasculitides, neoplasms, alterations in connective tissue, pulmonary artery hypertension, trauma, and iatrogenic complications, contribute to their development. Most patients with pulmonary artery aneurysms are asymptomatic or have nonspecific symptoms. The etiology and size of the aneurysm, the presence of pulmonary artery hypertension, and the patient's symptoms will define the management approach. We present the case of a young woman with idiopathic dilation of the main pulmonary artery (AU)

[Idiopathic pulmonary artery aneurysm in a young woman]. / Aneurisma idiopático de la arteria pulmonar principal en paciente joven.

Pulmonary artery aneurysms are rare. Diverse causes, including congenital heart defects, infections, vasculitides, neoplasms, alterations in connective tissue, pulmonary artery hypertension, trauma, and iatrogenic complications, contribute to their development. Most patients with pulmonary artery aneurysms are asymptomatic or have nonspecific symptoms. The etiology and size of the aneurysm, the presence of pulmonary artery hypertension, and the patient's symptoms will define the management approach. We present the case of a young woman with idiopathic dilation of the main pulmonary artery.

[Streptokinase-induced jaundice]. / Ictericia inducida por estreptocinasa.

Streptokinase is a thrombolytic agent used very frequently for the early treatment of acute myocardial infarction. A 35-year-old male with inferior acute myocardial infarction was admitted to the Coronary Care Unit and treated with systemic streptokinase. At the time of admission, he was a healthy male and he was not receiving any hepatotoxic agent. Six hours after thrombolysis, he developed high fever, painful hepatomegaly, jaundice and coluric urine. Leucocytosis with left deviation was observed in the hemogram and the liver function tests showed slight enzymatic elevation and hyperbilirubinemia. This condition was progressively improving and the patient was free of symptoms on the eighth day of evolution. Jaundice as secondary effect of streptokinase has been previously communicated in very few medical reports.

[Fixed-dose combination therapy: reduction of side effects with enhanced tolerance and antihypertensive efficacy]. / Terapia combinada a dosis fija: reducción de los efectos colaterales con aumento de la tolerancia y la eficacia antihipertensiva.

Despite the availability of many newer antihypertensive agents, hypertensive patients remain at a higher risk of premature death than the general population. This persistence of elevated morbidity and mortality may be accounted for by the frequent failure to achieve adequate blood pressure reduction despite an extensive range of available antihypertensive agents. Such considerations have led to the reassessment of the potential role of fixed-dose combination agents. The antihypertensive efficacy may be enhanced when two classes of agents are combined. In addition, combination therapy enhances tolerability because one drug of fixed combination can antagonize some of the adverse effects of the second drug. Fixed-dose combination therapy simplifies the treatment regimen, preventing treatment failures that might result from missed doses.

[Practice guidelines of the Spanish Society of Cardiology. Recommendations for the use of antithrombotic treatment in cardiology]. / Guías de actuación clínica de la Sociedad Española de Cardiología. Recomendaciones para el uso del tratamiento antitrombótico en cardiología.

The indications for the use of antithrombotic therapy are evolving as new drugs become available or new indications or dosages are recommended for drugs already in use. This document reviews and updates the former one published in 1994. To that end, an exhaustive revision of the literature published in the last 15 years has been undertaken. Following the evidence based medicine dictates, and aiming to select all the relevant publications for each pathology, all studies were selected through MEDLINE, using the specified key words for each subject, and were filtered using the following steps: a) only randomized, controlled studies, meta-analysis, guidelines and review articles were chosen; b) then, the Best-Evidence and Cochrane Collaboration databases were consulted; c) finally, the evidence based medicine validation, relevance and applicability criteria were assessed for each publication. The use of antiaggregants and anticoagulants are given for the following conditions: a) prevention of deep vein thrombosis and pulmonary embolism; b) prevention of systemic emboli in patients with lone atrial fibrillation, atrial fibrillation associated or not with rheumatic heart disease, in patients with biological or mechanical cardiac valvular prostheses and in dilated cardiomyopathy; c) antithrombotic therapy in coronary heart disease and in coronary intervention; d) the interactions with oral anticoagulants and how to control these therapies are also discussed.

[Focal auricular fibrillation: catheter ablation with radiofrequency]. / Fibrilación auricular focal: ablación con catéter mediante radiofrecuencia.

Although atrial fibrillation is usually caused by multiple circulating reentrant wavelets, a focal origin has recently been reported. This focal source could be successfully treated by discrete radiofrequency catheter ablation. We report a patient without structural heart disease, but with multiple episodes of palpitations related to atrial premature beats, irregular atrial tachycardia and atrial fibrillation. The electrophysiological study demonstrated that all the atrial arrhythmias were due to the same focus firing irregularly and exhibiting a unique and centrifugal pattern of activation. Successful radiofrequency catheter ablation of the focus was performed, without complications. After three months follow-up the patient is asymptomatic and she has not presented arrhythmia recurrences.

[Acute myocardial infarction secondary to Wegener's granulomatosis]. / Infarto agudo de miocardio secundario a granulomatosis de Wegener.

Wegener's granulomatosis (WG) is a necrotizing and granulomatous vasculitis that usually affects the upper and lower respiratory tract and the kidneys. Cardiac involvement is rare although pericarditis, coronary arteritis, myocarditis, valvulitis and arrhythmias have been described. Acute myocardial infarction with clinical expression is an exceptional complication of Wegener's granulomatosis. We report a case of a 30-year-old man with Wegener's granulomatosis who suffered an acute myocardial infarction during the initial phase of the disease, following seven days of treatment with glucocorticoids and cyclophosphamide. Transthoracic echocardiography showed abnormal regional wall motion with septal hypokinesia and apical akinesia. Cardiac catheterization revealed an ectasic segment in the proximal left anterior descending coronary artery and total occlusion in the mid-segment. Medical therapy with prednisone and cyclophosphamide was continued. No complications and initial remission were achieved.

[Uncommon atrial flutter related to cicatrix from atriotomy surgery: radiofrequency catheter ablation]. / Aleteo auricular no común relacionado con cicatriz de atriotomía quirúrgica: ablación con catéter mediante radiofrecuencia.

A patient with a complex congenital abnormality required the implantation of an interatrial septum patch through a right lateral atriotomy. Nine years later he developed two different morphologies of an incessant uncommon atrial flutter refractory to antiarrhythmic drug treatment. The electrophysiological study localized a site on the right atrium lateral wall where local activation time was 75 ms earlier than the onset of the P wave, transient entrainment with concealed fusion was obtained, the first postpacing interval after transient entrainment was 5 ms longer than tachycardia cycle length and the stimulus to P wave interval was 50 ms. At this site, radiofrequency delivery terminated the atrial flutter in less than 1 second. No further induction or recurrences of any morphology of the atrial flutter were observed after a four month follow up. These findings suggest the existence of a narrow conduction isthmus amenable to interruption by focal delivery of radiofrequency. The isthmus was most probably located between the atriotomy and the crista terminalis, posterior to the former and anterior to the latter.

[Attitude change of Spanish cardiologist with respect to hypolipidemic treatment in secondary prevention. The role of outside hospital care]. / Cambio de actitud de los cardiólogos españoles con respecto al tratamiento hipolipemiante en prevención secundaria. Papel de la asistencia extrahospitalaria.

INTRODUCTION AND OBJECTIVES: Hypolipemic treatment is a matter of controversy. The objective of this paper is to analyze how Spanish cardiologist knows the lipid role in ischemic heart disease and their intention of treatment hypercholesterolemia in ischemic cardiomiopathy patients. We also evaluate the grade of control and treatment of hypercholesterolemia in patients with ischemic heart disease who belong to a primary care center. MATERIAL AND METHODS: Two inquests were done to 1,850 Spanish cardiologist using a question paper in 1993 and 1996. At the Primary Care Center of Fuencarral (Madrid) we made a transversal study from February till March 1996. RESULTS: In 1993, 11% answered the questionnaire and 25% in 1996. Cardiologists who considered the ideal level of cholesterol lower than 200 mg/dl raised from 62% in 1993 to 86% in 1996 (p < 0.001). Cardiologists who considered that cholesterol linked to low density lipoproteins should be lower than 100 mg/dl raised from 0% in 1993 to 28% in 1996 (p < 0.001). Drug treatment was prescribed by 68% when total cholesterol levels were higher than 300 mg/dl in 1993 and 14% of cardiologists never prescribed drugs. In 1996, 71% prescribed drug treatment when total cholesterol was between 200 and 250 mg/dl (p < 0.001). Cardiologists who worked at hospitals began with drugs with a lower cholesterol levels than out-hospital cardiologists. Hypercholesterolemia was considered as the most important risk factor in secondary prevention. We review 94 patients with ischemic heart disease; 37 did not receive hypolipemic treatment, though they had more than 200 mg/dl of cholesterol. Just 12 of the 45 treated reached figures below 200 mg/dl. 32% of the patients where controlled by family doctor's. CONCLUSIONS: Results of the two surveys in 1993 and 1996 have produced a change in Spanish cardiologist attitude about indication of hypolipemic treatment for patients suffering from ischemic cardiomiopathy. Family doctor's and cardiologists must assume secondary prevention. Indeed, it is necessary to make them both become aware of the importance of a correct treatment of those patients.