The EXTREME registry: titanium-nitride-oxide coated stents in small coronary arteries.

OBJECTIVES: We sought to explore the immediate results of Titan2 stent implantation in small coronary arteries, as well as the incidence of major adverse cardiac events (MACE) at six months follow-up. BACKGROUND: The safety of Titan2 stent has been confirmed in several studies in real-life unselected populations. METHODS: We enrolled 311 consecutive patients admitted for percutaneous intervention for at least one significant (50%) de novo lesion in a native small coronary artery (2.0-2.75 mm). All lesions were treated with Titan2 stent implantation. Patients were prospectively followed up for at least six months. The primary endpoint was MACE at six months follow-up [death, myocardial infarction (MI), or target vessel revascularization (TVR)]. Secondary endpoints included angiographic and clinical procedural success, in-hospital MACE, target lesion revascularization (TLR) during follow-up, and stent thrombosis. RESULTS: The mean age was 67.3 +/- 10.9 years (65.9% males). A total of 356 Titan2 stents were implanted in 353 lesions. Angiographic and clinical procedural success was achieved in 344 (97.5%) patients. No case of in-hospital MACE or acute stent thrombosis was reported. Clinical follow-up was completed for an average of 8 +/- 2 months. Two patients (0.7%) died, and 6 (2.1%) developed MI. TLR was performed in 12 (4.2%) and TVR in 16 (5.5%) patients, all were clinically driven. Cumulative MACE occurred in 20 (6.9%) patients. One patient suffered subacute stent thrombosis, but no late stent thrombosis. CONCLUSIONS: Titan2 stent implantation in small coronary arteries achieves excellent immediate outcome, with a low incidence of MACE at mid-term follow-up.

Intravenous N-acetylcysteine for preventing contrast-induced nephropathy: a randomised trial.

BACKGROUND: Studies evaluating the role of N-acetylcysteine in patients undergoing coronary angiography have yielded inconsistent data. Less is known about patients with normal renal function at baseline. METHODS: Prospective, double-blind, placebo-controlled trial to determine the benefits of intravenous N-acetylcysteine as an adjunct to hydration in this kind of population. Patients were randomly assigned to receive either N-acetylcysteine (600 mg twice daily) or placebo, in addition to 0.45% intravenous saline. The primary end point was development of contrast-induced nephropathy, defined as an acute increase in the serum creatinine concentration > or = 0.5 mg/dl and/or > 25% increase above baseline level at 48 h after contrast dosing. RESULTS: A total of 216 patients were studied: N-acetylcysteine = 107 and placebo = 109. Treatment groups were similar with respect to baseline clinical characteristics. Overall incidence of contrast-induced nephropathy was 10.2%, 10.3% in the N-acetylcysteine group and 10.1% in the placebo group. Furthermore, no significant differences were observed when considering the non-diabetic population, although there was a trend towards a protective effect of N-acetylcysteine in the subgroup of 47 patients with both hypertension and diabetes. There were no significant changes in serum urea nitrogen concentrations. The incidence of in-hospital adverse clinical events was low: no patient with contrast-induced nephropathy required dialysis, the median Coronary Unit stay was 4.5 vs. 4 days, and the mortality rate was 2.8% vs. 4.6% in the N-acetylcysteine and placebo groups, respectively (p=NS). CONCLUSIONS: The prophylactic administration of intravenous N-acetylcysteine provides no additional benefit to saline hydration in high-risk coronary patients with normal renal function.

Implications of the "watermelon seeding" phenomenon during coronary interventions for in-stent restenosis.

The occurrence of balloon slippage ("watermelon seeding"; WMS) during treatment of patients with in-stent restenosis (ISR) has been described, but predisposing factors and the potential implications of this phenomenon remain unknown. In the Restenosis Intrastent: Balloon Angioplasty vs. Elective Stenting (RIBS) randomized study, 450 patients with ISR were included. Of these, 42 patients (9%) presented WMS during the procedure. WMS was detected in 26 patients (12%) in the balloon arm and 16 (7%) in the stent arm (P=0.11). In the stent arm, WMS was only noticed during balloon predilation, never during stent implantation. As compared with 408 patients without WMS, patients with WMS had more severe (TIMI flow 1; 21% vs. 8%; P=0.01) and diffuse (length>15 mm: 45% vs. 28%; P=0.02) ISR lesions. Patients with WMS required more balloon inflations, longer total inflation time, had more frequent crossover to stenting or ended the procedure with residual dissections, and eventually obtained poorer acute results (minimal lumen diameter, 2.35+/-0.5 vs. 2.53+/-0.5 mm; P=0.03). In addition, at 6-month follow-up, patients with WMS had a smaller minimal lumen diameter (1.26+/-0.7 vs. 1.61+/-0.7 mm; P=0.007) and a higher restenosis rate (56% vs. 37%; P=0.017). On logistic regression analysis, the WMS phenomenon emerged as an independent predictor of recurrent restenosis (adjusted RR=2.1; 95% CI=1.1-4.1; P=0.04). The WMS phenomenon may complicate treatment of patients with ISR. Long and severe lesions appear to predispose to this technical problem that never occurs during stent deployment. In patients with ISR, WMS is associated with cumbersome procedures and poorer acute and long-term angiographic results.

Early results of direct coronary stenting in consecutive patients when multivessel, complex, long lesions, and small vessels are included.

BACKGROUND: Direct coronary stenting is the dominant technique for coronary stent implantation, but previous randomized studies have strongly selected lesions to treat. To evaluate whether the results can be generalized to routine clinical practice, all consecutive patients with direct stenting in 15 hospitals were entered into a prospective registry. Single vessels and simple lesions, but also multivessel, complex and long lesions, and small vessels size (< or =2.5 mm) were included. Immediately results as well as clinical events within 30 days after the procedure were evaluated. METHODS: Between April and November 2002, direct coronary stenting was performed in 452 consecutive patients (559 lesions) at 15 sites. Stents edge-protected by "sleeves" (SOX technology, NIR Stent, Boston Scientific) or with short transitional edge protection (STEP technology, Multilink Stents, Guidant) were selected to minimize vessel injury outside the stent edges during balloon inflation/deployment. RESULTS: Stents were successfully implanted in 96% of lesions. Lesions were multivessel in 27%, type B2-C in 40%, very angulated in 28%, calcified in 18%, and longer than 20 mm in 10% of patients. Vessels were smaller than < or =2.5 mm in 27% of patients. Direct coronary stenting was unsuccessful in 25 lesions (24 patients) characterized by more unstable angina (p=0.07), more treated lesions (p<0.01), and more distal locations (p=0.001). Dissection occurred in 6% of patients, and one stent embolised. The 30-day follow-up period included 1 death (due to subacute occlusion), 11 (2.4%) acute myocardial infarctions (8 non-Q wave), and one stroke (following carotid surgery). CONCLUSIONS: Direct coronary stenting yielded excellent results at 30 days although some expanded indications will be included.

[Relationship of C-reactive protein levels with angiographic findings and markers of necrosis in non-ST-segment elevation acute coronary syndrome]. / Relación de los valores de proteína C reactiva con los hallazgos angiográficos y los marcadores de necrosis en el síndrome coronario agudo sin elevación del segmento ST.

INTRODUCTION AND OBJECTIVES: The mechanism responsible for elevated C-reactive protein levels (inflammation of the ruptured atherosclerotic plaque or myocardial necrosis) in acute coronary syndromes is controversial. The aim of this study was to investigate the relationship between C-reactive protein levels and angiographic complexity of the culprit lesion and troponin elevation in patients with non-ST elevation acute coronary syndromes. PATIENTS AND METHOD: The study group consisted of 125 patients with single-vessel disease. Troponin-I and C-reactive protein were measured, and the complexity of the culprit lesion was analyzed (TIMI flow and thrombus). Information on age, sex, smoking habit, hypertension, hypercholesterolemia and diabetes was obtained from the medical record. RESULTS: The quartile distribution of C-reactive protein showed more patients with TIMI flow < 3 (31%, 28%, 18%, and 55%; P=.02), thrombus (3%, 6%, 7%, and 28%; P=.007) and troponin-I elevation (19%, 44%, 50%, and 66%; P=.003) in the fourth quartile. Multivariate analysis showed both thrombus (OR = 4.1; 95% CI, 1.2-14.3; P=.03) and troponin elevation (OR = 2.6; 95% CI, 1.1-6.3; P=.03) to be associated with C-reactive protein > 18 mg/L (fourth quartile cut-off). When treated as a continuous variable, higher levels of C-reactive protein were also associated with thrombus (P=.02) and troponin elevation (P=.003). No other clinical variables were related with C-reactive protein levels. CONCLUSIONS: Both angiographic complexity of the culprit lesion and elevated troponin level are related with increased C-reactive protein levels in non-ST elevation acute coronary syndromes.

[Myocardial echocardiography with intracoronary injection of contrast in post-infarction patients. Implications and comparison with angiography and magnetic resonance imaging]. / Myocardial echocardiography with intracoronary injection of contrast in post-infarction patients. Implications and comparison with angiography and magnetic resonance imaging.

OBJECTIVES: We analyzed the safety and feasibility of myocardial echocardiography with intracoronary injection of contrast, its effect on left ventricular remodeling and systolic function, and its relationship with angiography and magnetic resonance imaging (MRI) for the evaluation of post-infarction coronary microcirculation. PATIENTS AND METHOD: Thirty patients with a first ST-elevation myocardial infarction and a patent infarct-related artery were studied. Mean perfusion score of the infarcted area was analyzed with myocardial echocardiography. TIMI and Blush grades (angiography) were determined. Mean perfusion score (MRI-perfusion), end-diastolic volume index and ejection fraction were determined with MRI. At 6 months all studies were repeated in the first 17 patients. RESULTS: Forty-seven perfusion studies (30 in the first week and 17 after 6 months) were done without complications (6 [2] min per myocardial echocardiography study). Normal perfusion (myocardial echocardiography 0.75) was detected in 67% of the patients. Myocardial echocardiography was the best predictor of end-diastolic volume (r=-0.69; P =.002) and ejection fraction (r=0.72; P=.001) after 6 months. Normal perfusion was observed in 80% of the patients with TIMI grade 3, and in 14% of those with TIMI grade 2. Of the 40 studies in patients with TIMI grade 3, normal perfusion was seen in 85% of the patients with Blush grade 2-3 and in 50% of those with Blush 0-1. Perfusion was also normal in 90% of the patients with MRI-perfusion =1 and in 62% of those with MRI-perfusion < 1. CONCLUSIONS: Myocardial echocardiography is a feasible and relatively rapid technique with no side effects. This technique provided the most reliable perfusion index for predicting late left ventricular remodeling and systolic function. To achieve normal perfusion, TIMI grade 3 is necessary but does not guarantee success. In patients with TIMI grade 3, a normal Blush score or a normal MRI-perfusion study suggests good reperfusion.

Estudio de perfusión en pacientes postinfarto mediante ecografía miocárdica con inyección de contraste intracoronario. Implicaciones y relación con la angiografía y la resonancia magnética / Myocardial echocardiography with intracoronary injection of contrast in post-infarction patients. Implications and comparison with angiography and magnetic resonance imaging

Objetivos. Analizamos la aplicabilidad y seguridad de la ecografía miocárdica con inyección intracoronaria de contraste, su papel en la remodelación ventricular y en la función sistólica, así como su relación con la angiografía y la resonancia magnética para valorar la microcirculación coronaria postinfarto. Pacientes y método. Se estudió a 30 pacientes con un primer infarto de miocardio con elevación del segmento ST y arteria responsable abierta. Con inyección intracoronaria de contraste se determinó la puntuación media de perfusión en la zona infartada. Mediante angiografía se cuantificaron los grados TIMI y Blush. Se utilizó la resonancia magnética para determinar la puntuación media de perfusión (RM-perfusión), el índice de volumen telediastólico y la fracción de eyección. Al sexto mes se repitieron todas las exploraciones en los primeros 17 pacientes. Resultados. Se realizaron 47 estudios de perfusión (30 en la primera semana y 17 en el sexto mes) sin complicaciones (6 ñ 2 min por estudio de inyección intracoronaria de contraste). Se observó una perfusión normal (inyección intracoronaria de contraste > 0,75) en el 67 por ciento de los casos. La inyección intracoronaria de contraste fue el mejor predictor de volumen telediastólico (r = -0,69; p = 0,002) y de fracción de eyección (r = 0,72; p = 0,001) al sexto mes. Hubo perfusión normal en el 80 por ciento de los casos con TIMI 3 y en el 14 por ciento de los casos con TIMI 2.Entre los 40 estudios con TIMI 3 se observó una perfusión normal en el 85 por ciento de casos con un índice de Blush de 2-3 y en el 50 por ciento de aquellos con un índice de Blush de 0-1, así como en el 90 por ciento de casos con RM-perfusión = 1 y en el 62 por ciento con RM-perfusión < 1. Conclusiones. La inyección intracoronaria de contraste es factible con un escaso consumo de tiempo y sin efectos secundarios; asimismo, fue el índice de perfusión más fiable para predecir la remodelación y la función sistólica tardía. Para lograr una perfusión normal es indispensable TÉCNICAS DE IMAGEN (aunque no una garantía) que el paciente se encuentre con flujo TIMI 3. En los casos con TIMI 3, la normalidad en el índice Blush o en el estudio de perfusión con resonancia magnética sugiere una buena reperfusión (AU)

[Prognostic factors in unstable angina with dynamic electrocardiographic changes. Value of fibrinogen]. / Factores pronósticos en la angina inestable con cambios dinámicos del electrocardiograma. Valor del fibrinógeno.

INTRODUCTION AND OBJECTIVES: The prognosis of unstable angina varies between series depending on the inclusion criteria and management protocol used. The aim of this study was to analyze in-hospital events and their predictors in a homogeneous single-center series of patients with unstable angina. MATERIAL AND METHODS: A total of 246 patients with the following inclusion criteria were studied: 1) resting anginal pain, 2) transient electrocardiographic changes during anginal pain, 3) normal CK-MB levels and 4) exclusion of postinfarction angina. All patients were treated with aspirin and enoxaparin (1 mg/kg/12 h). Coronary angiography was performed in the case of recurrent angina or ischemia in Bruce I-II stage during the predischarge effort stress test. The variables recorded were risk factors, history of ischemic heart disease, history of coronary surgery, ECG upon admission, and fibrinogen. RESULTS: During the hospital stay the following events were recorded: 36% recurrent angina, 58% cardiac catheterization, and 5,7% major events (infarction or death). Multivariate analysis found recurrent angina to be more frequent in patients with a history of coronary bypass surgery (p = 0.004. OR = 22; CI 95%, 3-182), ST-segment changes (p = 0.01. OR = 4.7, CI 95%; 1.4-15.9) and higher fibrinogen (p = 0.002. OR = 1,4, CI 95%; 1.1-1.7). Fibrinogen was the only variable related to cardiac catheterization (p = 0,009. OR = 1.3. CI 95%, 1.1-1.6) and major events (p = 0.001. OR = 2.0. CI 95%, 1.4-3.1). CONCLUSIONS: 1) Unstable angina with electrocardiographic changes was associated to a high rate of in-hospital events. 2) Fibrinogen was related to any event, and previous by-pass surgery and ST changes were related to recurrent angina.

Factores pronósticos en la angina inestable con cambios dinámicos del electrocardiograma. Valor del fibrinógeno / Prognostic factors in unstable angina with dynamic electrocardiographic changes. Value of fibrinogen

Introducción y objetivos. El pronóstico de la angina inestable varía entre diferentes series según los criterios de inclusión. El objetivo ha sido evaluar los episodios hospitalarios y sus predictores en una serie homogénea de angina inestable. Material y métodos. Se incluyó a 246 pacientes consecutivos con los siguientes criterios: a) dolor anginoso en reposo; b) cambios electrocardiográficos dinámicos durante el dolor; c) CK-MB normal, y d) angina postinfarto excluida. Se trataron con aspirina y enoxaparina (1 mg/kg/12 h) y se efectuó coronariografía en caso de angina recurrente o isquemia en el estadio I-II de Bruce en el test de esfuerzo prealta. Se recogieron los factores de riesgo, historia previa de cardiopatía isquémica, historia de cirugía coronaria, electrocardiograma durante el dolor y fibrinógeno. Resultados. Durante el ingreso se presentaron los siguientes episodios: 36 por ciento, angina recurrente; 58 por ciento, cateterismo cardíaco y 5,7 por ciento, episodios mayores (infarto o muerte). Mediante análisis multivariado se observó que la angina recurrente fue más frecuente con antecedentes de cirugía coronaria (p = 0,004; OR = 22; IC del 95 por ciento, 3-182), desviación del segmento ST (p = 0,01; OR: 4,7; IC del 95 por ciento, 1,4-15,9) y mayor fibrinógeno (p = 0,002; OR = 1,4; IC del 95 por ciento, 1,1-1,7). El fibrinógeno fue la única variable relacionada con la necesidad de cateterismo (p = 0,009; OR = 1,3; IC del 95 por ciento, 1,1-1,6) y episodios mayores (p = 0,001; OR = 2,0; IC del 95 por ciento, 1,4-3,1).Conclusiones. a) La angina inestable con cambios electrocardiográficos se acompaña de una alta tasa de episodios hospitalarios, y b) los valores elevados de fibrinógeno se asocian con todos los episodios desfavorables, y los antecedentes de cirugía coronaria y la desviación del ST con angina recurrente (AU)

[Short-term prognosis of patients admitted for probable acute coronary syndrome without ST-segment elevation. Role of new myocardial damage markers and acute-phase reactants]. / Pronóstico a corto plazo de los pacientes ingresados por probable síndrome coronario agudo sin elevación del segmento ST. Papel de los nuevos marcadores de daño miocárdico y de los reactantes de fase aguda.

OBJECTIVES: The relative value of classic markers, myocardial damage variables, and levels of acute-phase reactants in establishing the pre-discharge prognosis of acute coronary syndrome without ST-segment elevation was analyzed. METHOD: We prospectively studied 385 consecutive patients admitted from our chest pain unit with a high-probability diagnosis of acute coronary syndrome without ST-segment elevation. The clinical and electrocardiographic data, myocardial damage markers (troponin I, CK-Mb mass, myoglobin), and acute-phase reactants (high-sensitivity C-reactive protein, fibrinogen) were recorded. RESULTS: During admission, 15 deaths (3.9%) and 16 complicative infarctions (4.2%) occurred, for a total of 31 major events (death and/or infarction: 8.1%). Age (p = 0.03), insulin-dependent diabetes (p = 0.009), and C-reactive protein (p = 0.05) were independently related to death. Fibrinogen was related to infarction (p = 0.01); by fibrinogen quartiles: 1.4%; 1.4%; 2.9%, and 11.7% (p = 0.02). Age (p = 0.01), insulin-dependent diabetes (p = 0.02), and C-reactive protein (p = 0.04) were independent predictors of major events; by C-reactive protein quartiles: 1.4%; 5.5%; 5.4%, and 16.7% (p = 0.004). Troponin I was related to major events (p = 0.03), but it was not an independent predictor. CONCLUSIONS: Acute-phase reactants add independent information to clinical variables in the short-term risk stratification of patients with an acute coronary syndrome. The predictive power of troponins is lower than that of other variables.

Pronóstico a corto plazo de los pacientes ingresados por probable síndrome coronario agudo sin elevación del segmento ST. Papel de los nuevos marcadores de daño miocárdico y de los reactantes de fase aguda / Short-term prognosis of patients admitted for probable acute coronary syndrome without ST-segment elevation. Role of new myocardial damage markers and acute-phase reactants

Objetivos. Se analiza el papel relativo de los marcadores clásicos, de las variables de daño miocárdico y reactantes de fase aguda en el pronóstico prealta del síndrome coronario agudo sin elevación del segmento ST.Método. Se estudió prospectivamente a 385 pacientes consecutivos ingresados desde nuestra unidad de dolor torácico con el diagnóstico de alta probabilidad de síndrome coronario agudo sin elevación del segmento ST. Se recogieron las variables clínicas, electrocardiográficas, indicadores de daño miocárdico (troponina I, Ck-Mb masa, mioglobina) y reactantes de fase aguda (proteína C reactiva de alta sensibilidad y fibrinógeno).Resultados. Durante el ingreso hospitalario se detectaron 15 fallecimientos (3,9 por ciento), 16 infartos complicativos (4,2 por ciento) y 31 episodios mayores (fallecimiento y/o infarto: 8,1 por ciento). Fueron predictores independientes de fallecimiento la edad (p = 0,03), la diabetes insulinodependiente (p = 0,009) y la proteína C reactiva (p = 0,05). El fibrinógeno (p = 0,01) predijo infarto; por cuartiles: 1,4; 1,4; 2,9, y 11,7 por ciento (p = 0,02). La edad (p = 0,01), la diabetes insulinodependiente (p = 0,02) y la proteína C reactiva (p = 0,04) fueron predictores independientes de episodio mayor; por cuartiles de proteína C reactiva: 1,4; 5,5; 5,4, y 16,7 por ciento (p = 0,004). La troponina I se relacionó con una mayor tasa de episodios mayores (p = 0,03), pero no fue un predictor independiente.Conclusiones. Los reactantes de fase aguda añaden información independiente a las variables clínicas en la estratificación de riesgo a corto plazo de los pacientes con síndrome coronario agudo. El poder predictor de la troponina disminuye al ser comparado con otras variables (AU)

[Is troponin I useful for predicting in-hospital risk for unstable angina patients in a community hospital? Results of a prospective study]. / Es la troponina I útil para predecir el riesgo hospitalario en pacientes con angina inestable ingresados en un hospital comarcal? Resultados de un estudio prospectivo.

INTRODUCTION AND OBJECTIVES: Before including troponin I detection in the daily practice of our hospital we performed a prospective study to determine its real usefulness and to establish the best cut-off point. METHODS: We studied 82 consecutive patients admitted with unstable angina to a community hospital. Troponin I was determined (> 10 h after chest pain). Patients were referred to a tertiary hospital for catheterization/revascularization if clinical events developed. RESULTS: Twenty-five patients (31%) suffered events during admission: recurrent angina in 23 cases (28%); heart failure in 5 (6%); exitus in 3 (4%); myocardial infarction in 1 (1%). The cut-off point for troponin I that best predicted events was 0.1 ng/ml. Patients with troponin I > 0.1 (34 patients, 42%) experienced more events [47 vs. 19%; OR = 3.8 (1.4-10.4); p = 0.01] and had higher rates of recurrent angina (42 vs. 19%), heart failure (12 vs. 2%) and exitus (9 vs 0%). Patients with ECG changes and troponin I > 0.1 showed a significantly higher percentage of events (63%) than those with ECG changes alone (23%) or troponin I > 0.1 alone (15%) or those without ECG changes and troponin I < 0.1 (17%) (p < 0.0001). CONCLUSIONS: Troponin I elevation is useful for predicting in-hospital risk for unstable angina patients admitted to a community hospital. A low cut-off value (0.1 ng/ml) predicts events. The association of ECG changes and high troponin I identifies a population at very high risk; however, the absence of both variables in patients with a diagnosis of unstable angina does not preclude the development of events.

¿Es la troponina i útil para predecir el riesgo hospitalario en pacientes con angina inestable ingresados en un hospital comarcal? Resultados de un estudio prospectivo / Is Troponin I Useful for Predicting In-Hospital Risk for Unstable Angina Patients in a Community Hospital? Results of a Prospective Study

Introducción y objetivos. Antes de incluir la troponina I en la práctica diaria de nuestro hospital, realizamos un estudio prospectivo para determinar su utilidad real y el mejor punto de corte. Métodos. Estudiamos a 82 pacientes consecutivos ingresados por angina inestable en un hospital comarcal. Se determinó la troponina I (> 10 h del episodio de dolor torácico). Los pacientes fueron remitidos a un hospital terciario para cateterismo/revascularización en caso de algún acontecimiento clínico. Resultados. Durante el ingreso se detectaron acontecimientos en 25 casos (31 por ciento): angina recurrente en 23 (28 por ciento), insuficiencia cardíaca en 5 (6 por ciento), infarto en 1 (1 por ciento) y muerte en 3 (4 por ciento). El mejor punto de corte de la troponina I para predecir acontecimientos fue 0,1 ng/ml. Los 34 pacientes (42 por ciento) con troponina I > 0,1 presentaron más acontecimientos (47 frente a 19 por ciento; OR = 3,8 [1,4-10,4]; p = 0,01), angina recurrente (42 frente a 19 por ciento), insuficiencia cardíaca (12 frente a 2 por ciento) y fallecimiento (9 frente a 0 por ciento). Los pacientes con cambios ECG y troponina I > 0,1 sufrieron más acontecimientos (63 por ciento; p 0,1 (15 por ciento), o aquellos sin cambios ECG y troponina I < 0,1 (17 por ciento).Conclusiones. La troponina I es de utilidad para predecir el riesgo hospitalario en pacientes con angina inestable en un hospital comarcal. Un punto de corte bajo (0,1 ng/ml) predice la aparición de acontecimientos. La asociación de cambios ECG y troponina I positiva identifica a un grupo de alto riesgo; sin embargo, la ausencia de ambas variables en pacientes con un diagnóstico de angina inestable no asegura una buena evolución (AU)

Persistent truncus arteriosus type 4 with survival to the age of 54 years.

We describe a case of persistent truncus arteriosus type 4 in an unrepaired 54-year-old woman with the peculiarities of long survival, absence of pulmonary arteries and good clinical status.

Determinantes de la reserva contráctil en la zona del infarto. Estudio cuantitativo mediante ventriculografía de contraste con dobutamina / Determinants of contractile reserve in the infarction area. A quantitative study using dobutamine contrast in left ventriculography

Objetivos. El objetivo del presente estudio ha sido relacionar la reserva contráctil en la zona del infarto con la disfunción basal y la estenosis coronaria residual. Métodos. Se han estudiado 95 pacientes con un primer infarto de miocardio. Se ha efectuado una ventriculografía de contraste basal y tras 7,5 µg/kg/min de dobutamina, y una coronariografía. Mediante el método de la línea central se ha calculado la extensión de la disfunción (porcentaje de cuerdas con disfunción en el territorio de la arteria del infarto) y su severidad máxima (máximo de unidades de desviación estándar [DE] por debajo de la referencia). Se ha cuantificado la reducción de la extensión tras dobutamina. Resultados. Al incrementarse la severidad de la disfunción, ha disminuido la magnitud de la respuesta a la dobutamina ( 2 DE [n = 12] = 33 ñ 19 por ciento, > 2 DE 3 DE [n = 20] = 20 ñ 16 por ciento, > 3 DE 4 DE [n = 35] = 16 ñ 19 por ciento, > 4 DE ñ 5 DE [n = 15] = 9 ñ 13 por ciento, > 5 DE [n = 13] = 3 ñ 4 por ciento, p = 0,0001) y el número de pacientes con respuesta significativa ( 15 por ciento) positiva ( 2 DE = 12 [100 por ciento], > 2 DE 3 DE = 11 [55 por ciento], > 3 DE 4 DE = 17 [49 por ciento], > 4 DE 5 DE = 3 [20 por ciento], > 5 DE = 0 por ciento, p 5 DE (alta prevalencia de respuestas negativas), el test de la dobutamina no parece indicado. La presencia de estenosis coronaria residual no limita la reserva contráctil ante bajas dosis de dobutamina (AU)