Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia.

BACKGROUND: The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). METHODS: Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. RESULTS: Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. CONCLUSION: Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.

Clinical and Echocardiographic Factors Associated with Right Ventricular Systolic Dysfunction in Hemodialysis Patients.

BACKGROUND: Chronic kidney disease is a disorder of epidemic proportions that impairs cardiac function. Cardiovascular diseases are the leading cause of death in hemodialysis patients, and the understanding of new nontraditional predictors of mortality could improve their outcomes. Right ventricular systolic dysfunction (RVSD) has recently been recognized as a predictor of cardiovascular death in heart failure and hemodialysis patients. However, the factors contributing to RVSD in hemodialysis patients remain unknown. The aim of this study was to evaluate the clinical and echocardiographic factors associated with RVSD in hemodialysis patients. METHODS: A cross-sectional study was conducted in which 100 outpatients with end-stage renal disease on chronic hemodialysis were evaluated. A transthoracic echocardiographic examination was performed at optimal dry weight. Right ventricular systolic function was evaluated using tricuspid annular plane systolic excursion (TAPSE). Clinical and echocardiographic data were recorded for each patient. A multivariate linear logistic regression was created using RVSD (TAPSE <14 mm) as the dependent variable. RESULTS: Fifteen patients with RVSD and 85 patients without RVSD were analyzed. TAPSE had a positive correlation with left ventricular ejection fraction (LVEF) and myocardial relaxation velocity. Independent contributors to RVSD were LVEF (OR 1.14, 95% CI 1.05-1.26), left ventricular mass index (OR 1.02, 95% CI 1.00-1.04), and myocardial relaxation velocity (OR 1.81, 95% CI 1.18-3.19). CONCLUSIONS: Echocardiographic factors were significant contributors to RVSD. These measurements could be included as part of the routine workup in all end-stage renal disease patients on hemodialysis.

[Cell therapy for ischemic heart disease]. / La terapia celular en la cardiopatía isquémica.

Ischemic heart disease is the leading cause of death and heart failure worldwide. That is why it is important to develop new therapeutic modalities to decrease mortality and long-term complications in these patients. One of the main lines of research worldwide is myocardial regeneration, using progenitor cells in order to improve systolic and diastolic function in patients with ischemic heart disease, as well as to increase their survival. There have been carried out, with great enthusiasm worldwide, human and animal studies to define the usefulness of stem cells in the management of patients with ischemic heart disease. Today, regenerative therapy in ischemic heart disease is considered a novel therapeutic tool, with substantial theoretical benefits and few side effects. Here we present the scientific principles that support the use of this therapy, discuss the current clinical evidence available; and point out the controversial issues still not clarified on its use and usefulness in the short and long term.

La terapia celular en la cardiopatía isquémica / Cell therapy for ischemic heart disease

La cardiopatía isquémica es la principal causa de muerte e insuficiencia cardiaca a nivel mundial. Esto hace de vital importancia el desarrollo de nuevas modalidades terapéuticas, que disminuyan la mortalidad y complicaciones a largo plazo en estos pacientes. Una de las principales líneas de investigación a nivel mundial es la regeneración miocárdica a partir de células progenitoras, con el fin de mejorar la función sistólica y diastólica de los pacientes con cardiopatía isquémica, además de incrementar su sobrevida. Con bases teóricas y fisiológicas sobre la función de estas células, se han llevado a cabo con gran entusiasmo a nivel mundial, estudios en animales y humanos para tratar de definir la utilidad del empleo de las células madre, en el manejo de los pacientes con cardiopatía isquémica. En la actualidad, la terapia regenerativa en la cardiopatía isquémica es considerada una herramienta terapéutica novedosa, de beneficios teóricos considerables y pocos efectos adversos. En esta revisión presentamos los fundamentos científicos básicos que apoyan el empleo de esta terapia, la evidencia clínica actual sobre su beneficio. Señalamos los puntos controversiales y las perspectivas sobre su empleo y utilidad a corto y largo plazo.

Ischemic heart disease is the leading cause of death and heart failure worldwide. That is why it is important to develop new therapeutic modalities to decrease mortality and long-term complications in these patients. One of the main lines of research worldwide is myocardial regeneration, using progenitor cells in order to improve systolic and diastolic function in patients with ischemic heart disease, as well as to increase their survival. There have been carried out, with great enthusiasm worldwide, human and animal studies to define the usefulness of stem cells in the management of patients with ischemic heart disease. Today, regenerative therapy in ischemic heart disease is considered a novel therapeutic tool, with substantial theoretical benefits and few side effects. Here we present the scientific principles that support the use of this therapy, discuss the current clinical evidence available; and point out the controversial issues still not clarified on its use and usefulness in the short and long term.

[Ventricular pseudoaneurysm. Clinical and echocardiographic evolution]. / Pseudoaneurisma ventricular. Evolución clínica y ecocardiogiráfica.

The case of a patient with cardiac rupture following a myocardial infarction is presented. The rupture led to the formation of a ventricular pseudoaneurysm that was occupied by a thrombus that sealed the breakthrough point. The patient has survived without surgical treatment during the last 5 years.

Pseudoaneurisma ventricular. Evolución clínica y ecocardiográfica / Ventricular pseudoaneurysm. Clinical and echocardiographic evolution

Presentamos el caso de un paciente con una ruptura cardíaca secundaria a un infarto miocárdico al nivel del ápex del ventrículo izquierdo. La complicación mecánica condicionó la formación de un pseudoaneurisma que fue ocupado por un trombo que selló el punto de ruptura. El paciente sobrevive sin tratamiento quirúrgico tras 5 años de seguimiento.

The case of a patient with cardiac rupture following a myocardial infarction is presented. The rupture led to the formation of a ventricular pseudoaneurysm that was occupied by a thrombus that sealed the breakthrough point. The patient has survived without surgical treatment during the last 5 years. (Arch Cardiol Mex 2005; 75: 182-183).

Anticuerpos antineutrófilo: inmunopatogenia, enfermedades asociadas y esquemas de tratamiento / Antineutrophil antibodies: associated with diseases and therapeutic

La determinación de anticuerpos contra neutrófilos (ANCA) ha sido de gran utilidad en la comprensión de diversas vasculitis sistémicas principalmente granulomatosis de Wegener (GW), poliangeítis microscópica (PM), síndrome de Churg-Strauss, glomerulonefritis idiopática necrotizante progresiva (GNN) y otras. Su determinación se realiza por inmunofluorescencia o ELISA. Hay dos patrones de tinción inmunofluorescencia: citoplásmico (c-ANCA) y perinuclear (p-ANCA); el primero se asocia a GW y el segundo a PM y GNN. Estos anticuerpos pueden tener un papel importante en la patogenia de esta enfermedades, asociados a la acción de citocina e interacción con los polimorfonucleares que resulta en daño al endotelio vascular. Se han asociado a recaídas o exacerbaciones del padecimiento, lo que les confiere importancia como marcadores de actividad de la enfermedad y pueden ser útiles para modificar el tratamiento. Se reconoce su importancia en el diagnóstico diferencial de la hemorragia pulmonar masiva y de la glomerulonefritis rápidamente progresiva. Otras enfermedades en las que se pueden encontrar ANCA positivos son: síndrome de Goodpasture, nefropatía lúpica, enfermedad inflamatoria intestinal y hepatopatías autoinmunes. Aunque el tratamiento es variable, éste depende de la gravedad de la enfermedad y la afección renal; los inmunosupresores (esteroides y citotóxicos) son los más frecuentemente empleados. Se ha informado la potencial eficacia de la globulina antitimocito y de los anticuerpos monoclonales, pero no existe actualmente un consenso para hablar de la terapia idónea