[Utility of perindopril in mild-moderate heart failure in daily clinical practice. METRICA trial]. / Utilidad del perindopril en insuficiencia cardíaca leve-moderada en la práctica clínica diaria. Estudio METRICA.

INTRODUCTION AND OBJECTIVES: Angiotensin II converting enzyme inhibitors have an unquestionable utility in heart failure, although these drugs are underused and rarely used at the recommended doses in the clinical practice. The objective of this investigation was to study the simplicity of perindopril use in the treatment of heart failure and to confirm its clinical and radiological efficacy. MATERIAL AND METHODS: Perindopril was orally administered at 2-4 mg/day doses to 180 patients with heart failure and functional class I-III who were not being treated with angiotensin II converting enzyme inhibitors. The percentage of patients who reached the target dose (4 mg/day) was studied as well as clinical (functional class of the NYHA) and radiological efficacy of this treatment in these patients. RESULTS: The target dose (4 mg/day) in heart failure was reached in 87.5% patients, with a rate of adverse effects of 18.9%. Eighty-nine percent of patients in the functional class III and 38.3% of patients in class II had clinical improvement. The cardio-thoracic index decreased from 0.57 to 0.54 (p < 0.05). A minimal irrelevant change was observed in the analytical levels of creatinine and potassium. Only three patients (1.7%) abandoned the trial early in its course. CONCLUSIONS: An efficient dose for heart failure is simply and safely obtained with perindopril, with a significant improvement in the NYHA functional class and in the radiological cardio-thoracic index.

Utilidad del perindopril en insuficiencia cardíaca leve-moderada en la práctica clínica diaria. EstudioMÉTRICA / Utility of perindopril in mild-moderate heart failure in the daily clinical practice. METRICA trial

Introducción y objetivos. Los inhibidores de la enzima conversora de la angiotensina II presentan en la insuficiencia cardíaca una utilidad incuestionable, si bien en la práctica clínica éstos se encuentran infrautilizados y raramente se usan las dosis recomendadas. El objetivo del estudio ha sido estudiar la facilidad de manejo de perindopril en la insuficiencia cardíaca y confirmar su eficacia clínica y radiológica. Material y métodos. Se administró perindopril a dosis de 2-4 mg/día por vía oral en 180 pacientes con insuficiencia cardíaca con clase funcional I-III que no estaban siendo tratados con inhibidores de la enzima conversora de la angiotensina II. Se estudió el porcentaje de pacientes que a los tres meses de tratamiento habían alcanzado la dosis eficaz (4 mg/día), así como la eficacia clínica (clase funcional de la NYHA) y radiológica del tratamiento en estos pacientes. Resultados. Se logró alcanzar la dosis eficaz (4 mg/día) en insuficiencia cardíaca en el 87,5 por ciento de los pacientes con una tasa de efectos adversos del 18,9 por ciento. Presentaron mejoría clínica el 89,1 por ciento de los pacientes en clase funcional III y el 38,3 por ciento de los de clase II. El índice cardiotorácico se redujo de 0,57 a 0,54 (p < 0,05). Se observó una alteración mínima de los niveles analíticos de creatinina y potasio, clínicamente no relevante. Sólo 3 pacientes (1,7 por ciento) abandonaron precozmente el estudio. Conclusiones. El perindopril permite alcanzar la dosis eficaz para insuficiencia cardíaca de forma sencilla y segura, obteniendo una mejoría significativa en la clase funcional de la NYHA y en el índice cardiotorácico radiológico (AU)

[Diastolic dysfunction in human immunodeficiency virus infection]. / Disfunción diastólica en la infección por el virus de la inmunodeficiencia humana.

AIMS: We sought to determine the prevalence and characteristics of echocardiographic abnormalities (systolic and/or diastolic dysfunction, pericardial effusion) in patients with human immunodeficiency virus infection (HIV) with no symptoms or previous history of cardiac disease, and compare them with a healthy control group. PATIENTS AND METHOD: Transthoracic echocardiography was performed in 125 patients (73% male, mean age 33.2 +/- 6.6 years) with HIV infection without cardiac involvement and 47 age and sex-matched healthy volunteers (78% male, 31.6 +/- 7.3 years). The immunologic situation was determined by CD4 lymphocyte counts. RESULTS: Abnormal left ventricular relaxation and filling patterns (E/A relation 1.31 +/- 0.35 in HIV group, 1.66 +/- 0.38 in control group, p < 0.001; pressure half-time 57.5 +/- 13 in HIV group, 50.6 +/- 6.6 in control group, p < 0.001), segmental wall-motion abnormalities (15%) and pericardial effusion (7.2%) were found in patients with HIV infection. Systolic function (EF 64.8 +/- 8.3) and left ventricular dimension (diastolic diameter 4.94 +/- 0.55, systolic diameter 3.17 +/- 0.51) showed normal patterns and did not significantly differ from those of the control group. CONCLUSIONS: Silent echocardiographic abnormalities in patients with HIV infection are frequent suggesting a direct myocardial effect of the virus. The development of diastolic dysfunction is directly related to a worse immunologic situation. Prospective studies are needed to clarify the clinical prognosis of these asymptomatic abnormalities.

[Incidence and dynamic behavior of spontaneous echocardiographic contrast and atrial thrombi in the transplanted heart]. / Incidencia y comportamiento dinámico del contraste ecocardiográfico espontáneo y del trombo auricular en el corazón trasplantado.

BACKGROUND: Standard orthotopic heart transplantation produces important anatomic and functional atrial alterations with subsequent thrombotic risk. Therefore the aim of this study was to analyze the prevalence and evolution of spontaneous echocardiography, atrial thrombi and embolic events. PATIENTS AND METHOD: 52 consecutive transplanted patients were analyzed with transesophageal echocardiography and hemodynamic studies performed at 15 days and one year after transplantation. RESULTS: Spontaneous echocardiography contrast was present in 27 patients (52%). Ten atrial thrombi were observed (19.2%), 9 with spontaneous echocardiography contrast. Six atrial thrombi appeared on day 15 and 4 after one year (with spontaneous echocardiography contrast on the previous study). Using multiple logistic regression analysis left atrial size was the only independent predictor factor for spontaneous echocardiography contrast (OR = 1.27; 95% CI, 1.09-1.54) and was an important predictor factor of atrial thrombi formation (OR = 1.19; 95% CI, 1.04-1.42). Likewise, the main predictor of atrial thrombi was the presence of spontaneous echocardiography contrast (OR = 116; 95% CI, 8.4-999). The hemodynamic pattern did not predict either the presence of spontaneous echocardiography contrast or atrial thrombi. The global incidence of embolic events was 4% less than previously described. CONCLUSIONS: The incidence of atrial thrombi and spontaneous echocardiographic contrast after standard orthotopic heart transplantation was 19.2% and 52%, respectively. An enlarged atrium and/or spontaneous echocardiography contrast was found to increase the risk of atrial thrombi. Considering the dynamic nature of atrial thrombi formation, periodical transesophageal echocardiography studies are recommended after heart transplantation.

Isquemia miocárdica en el paciente hipertenso: efecto del verapamilo / Myocardial ischemia in hypertensive patients: verapamilo effect

Introducción y objetivos. La hipertensión arterial es uno de los principales factores de riesgo para el desarrollo de aterosclerosis y es frecuente entre los pacientes que padecen cardiopatía isquémica. Para valorar el efecto del tratamiento farmacológico en sujetos hipertensos con isquemia miocárdica, hemos llevado a cabo un estudio en pacientes que recibieron 360 mg de verapamilo diariamente (180 mg/dos veces al día) y mononitrato de isosorbida cuando fue necesario para controlar la angina. Métodos: Estudio prospectivo, multicéntrico, de observación, abierto. 746 pacientes fueron evaluados mediante pruebas de esfuerzo y control de la presión arterial, durante los seis meses de duración del ensayo. Resultados: La presión arterial y la frecuencia cardiaca disminuyeron significativamente desde el primer mes de tratamiento. La clase funcional de angina mejoró al cabo de tres meses (p<0.001). El 84 por ciento de los pacientes pasaron a clase I, el 15,2 por ciento a clase II y el 1,2 por ciento permaneció en clase III. En las pruebas de esfuerzo, realizadas al inicio y al cabo de seis meses de tratamiento, se observaron mejorías relevantes en la isquemia miocárdica y en los parámetros de angina: la duración del ejercicio y el tiempo hasta la aparición de angina y/o isquemia se prolongaron significativamente. Al cabo de 30 días fue necesario añadir mononitrato de isosorbida en 141 pacientes. Conclusiones: En pacientes con hipertensión e isquemia miocárdica, el tratamiento con verapamilo, sólo o asociado a nitratos, controla la presión arterial y mejora las manifestaciones clínicas de cardiopatía isquémica, espontáneas o inducidas por el ejercicio (AU)

[Treatment of chronic stable angina: follow-up study with nifedipine gastrointestinal therapeutic system. SENIOR Study Group]. / Tratamiento de la angina de pecho crónica estable: estudio de seguimiento con nifedipino OROS (estudio SENIOR). Grupo de Trabajo del estudio SENIOR.

OBJECTIVE: To gather information about efficacy and tolerability of nifedipine GITS in patients with stable angina, and its impact on the patient quality of life. PATIENTS AND METHODS: 1076 patients of both sexes (63.5 +/- 12.8 year old) with stable angina (classes I to III of the CCVS) and evidence of coronary disease (43.3% previous myocardial infarction) were included. The treatment with nifedipine GITS 30-60 mg/day (monotherapy or combination) lasted for 6 months. The study variables were: weekly rate of anginal attacks, short-acting nitrate consumption, changes in the antianginal drug treatment, tolerability, and changes in the questionnaire score concerning the quality of life. RESULTS: A decrease in the number of the anginal attacks and in the short-acting nitrates consumption by 80.7% and 83.3%, respectively (both, p = 0.001), was found. Furthermore, the proportion of patients experiencing anginal attacks the week before the assessment visit fell from 71.7% to 10.9% (p < 0.001). At the end of the study, a remarkable decrease in the use of other antianginal medications was seen. Side effects were reported by 10.9% of the patients, 2.7% of which were withdrawn from the study for this reason. A favourable change in the patient quality of life was also noted. CONCLUSION: In patients with stable angina, nifedipine GITS is an effective, safe and well tolerated drug that remarkably enhances the patient quality of life.

[Spanish Society of Cardiology practice guidelines on arterial hypertension]. / Guías de práctica clínica de la Sociedad Española de Cardiología en hipertensión arterial.

High blood pressure is a well-known cardiovascular risk factor that is responsible for an elevated morbidity and mortality. However, although efficacious drugs for treatment and numerous and updated scientific training programs are available, the reality is that only a low percentage of patients are followed up in accordance with the rates which are presently considered normal. The purpose of these guidelines is to provide medical guidance for the prevention, detection and evaluation of hypertension, and to provide the best diagnosis and treatment. The factors involved in cardiovascular complications in the hypertensive patient are multiple. That is why this report places more emphasis in the individual cardiovascular risk stratification as part of the treatment strategy. The information obtained in the most recent studies published confirms the interest in achieving the greatest decrease in rates of blood pressure. This treatment to lower levels is especially useful in the high-risk subgroup. It maintains the necessity of nonpharmacological measures or lifestyle modifications in all patients with high blood pressure who either need or do not need drug therapy. All pharmacological groups may be used, but it is appropriate to choose the specific antihypertensive agent adapted to the clinical and individual situation with the use of low doses of drugs to initiate therapy and the use of appropriate drug combinations.

[Hypertension and dyslipidemia]. / Hipertensión y dislipemia.

Hypertension is a very important cardiovascular risk factor and directly leads to major atherosclerotic cardiovascular diseases, including coronary artery disease, stroke cardiac failure and peripheral artery disease. Hypertension tends to cluster with other atherogenic risk factors like dyslipidemia, insulin resistance, obesity and others. The association between hypertension and dyslipidemia is very frequent and the risk is more than additive and its possible pathogenesis may be of a common mechanism. Insulin resistance is the main cause of both risk factors. Endothelium dysfunction is present in arterial hypertension and dyslipidemia and the pathogenesis of atherosclerosis. The treatment of hypertensive patients must be individualized to accommodate both the concomitant dyslipidemia and other atherogenic factors.

[Current status of arterial hypertension as a cardiology topic: point of view of the cardiologist. Task force on Arterial Hypertension of the Spanish Cardiology Society]. / Estado actual de la hipertensión arterial como materia de la cardiología: punto de vista del cardiólogo. Grupo de Trabajo de HTA de la SEC.

Even if arterial hypertension (HT) is a process of multiorganic involvement, it is nevertheless in practice, one of the most powerful factors for the development of cardiovascular complications that increases very seriously, both cardiovascular morbidity and mortality. Paradoxically, in Spain, a significant proportion of cardiologists have neglected for many years this disease, at least, at its initial phase, acting mainly, only when the usual and severe cardiovascular complications of HT were clinically well established. Currently, this attitude is changing in such a way, that in the near future, the cardiologist's commitment to HT, will be definitely engaged in both; basic research and clinical aspects. The Spanish Hypertension Working Group, has worked out in an inquiry sent to all Spanish cardiologists, in order to know their point of view in relation to the main aspects involving HT and cardiological practice. This paper collects the results of the answers given anonymously by the doctors.

[Immediate hemodynamic response to atrioventricular+ stimulation in severe hypertrophic obstructive myocardiopathy]. / Respuesta hemodinámica inmediata a la estimulación bicameral en la miocardiopatía hipertrófica obstructiva severa.

INTRODUCTION AND OBJECTIVES: Atrial synchronized ventricular pacing has shown to be an alternative to surgery in the therapeutic management of obstructive hypertrophic cardiomyopathy. Our purpose is the analysis of the hemodynamic mechanisms associated with the reduction of left ventricular outflow tract gradient and the changes in left ventricular diastolic function induced by dual-chamber pacing. PATIENTS AND METHODS: We studied twenty patients (age range 40-78 years; mean 63 +/- 10), who were evaluated while receiving their current medication with cardiac catheterization and angiography, at baseline and under dual-chamber pacing. RESULTS: The atrioventricular delay was 127 +/- 26 ms. The subaortic gradient was reduced from 96 +/- 38 to 36 +/- 28 mmHg (p < 0.001), the ejection period index was shortened from 523 +/- 26 to 491 +/- 30 ms (p < 0.001) and the left ventricular end-diastolic pressure fell from 22 +/- 6 to 13 +/- 5 mmHg (p < 0.001). There was no remarkable change in cardiac output. The median wedge pressure decreased from 17 +/- 5 to 12 +/- 2.5 mmHg (p < 0.01), the pulmonary systolic pressure from 39 +/- 15 to 30 +/- 10 mmHg (p < 0.01), the pulmonary diastolic pressure from 19 +/- 5 to 13 +/- 4 mmHg (p < 0.01) and the right ventricular end-diastolic pressure from 7 +/- 3 to 5 +/- 3 mmHg (p < 0.05). The left ventricular ejection fraction was reduced from 79 +/- 6 to 72 +/- 6 per cent (p < 0.001). The initial ejection fraction diminished from 49 +/- 13 to 34 +/- 13 per cent (p < 0.01), the early diastolic filling increased from 39 +/- 11 to 52 +/- 10 per cent (p < 0.001) and the atrial contribution was reduced from 36 +/- 10 to 24 +/- 10 per cent (p < 0,001). The degree of mitral regurgitation changed from 1.4 +/- 1.2 to 0.7 +/- 0.9 (p < 0.01). CONCLUSIONS: There is an obstruction in the left ventricular outflow tract in patients with obstructive hypertrophic cardiomyopathy that is relieved with dual-chamber pacing. The reduction in the intraventricular pressure seems to improve the ventricular relaxation and the diastolic function. The decrease in the degree of mitral regurgitation and the improvement in diastolic function diminish pulmonary capillary and right circuit pressures.

[Effect of 3 hypertensive++ agents on ventricular geometry and function]. / Efecto de tres antihipertensivos sobre la geometría y función ventriculares.

BACKGROUND: To assess the prevalence of left ventricular hypertrophy in hypertensive patients referred to an outpatient cardiology unit, and to assess its evolution under antihypertensive treatment. METHODS: One hundred and seven mild to moderate hypertensive patients were randomized to receive either xipamide, verapamil or atenolol. Cross-sectional echocardiography was performed in order to assess left ventricular mass and function. RESULTS: Mean age was 56 years, with a 4:1 female/male ratio. Mean follow-up was 120 days. Left ventricular hypertrophy was very common (65%) and decreased to 54% under antihypertensive treatment. Left ventricular mass decreased from 134.3 g/m2 to 118.1 g/m2 (p < 0.001). Concentric hypertrophy was the most common geometric pattern (42%), decreasing to 30% with treatment. Xipamide decreased ventricular mass by decreasing left ventricular diameters, while verapamil and atenolol decreased left ventricular thickness, mainly in septal wall. Systolic function was not modified during the treatment period. Diastolic function was not modified by xipamide and verapamil, and improved with atenolol. CONCLUSIONS: Left ventricular hypertrophy is very frequent when determined by echocardiography and all three drugs produced regression of left ventricular hypertrophy in a different way with respect to left ventricle geometry, an effect which could have potential therapeutic implications.

[Cerebral embolism as the first manifestation of Staphylococcus aureus endocarditis: the role of transesophageal echocardiography in the therapeutic decision]. / Embolia cerebral como primera manifestación de endocarditis por Staphylococcus aureus: papel de la ecocardiografía transesofágica en la decisión terapéutica.

In patients with endocarditis due to Staphylococcus aureus, the issue of medical or surgical treatment still remains controversial. Likewise, there is no agreement in the management of those patients who have suffered cerebral embolism and show large vegetations in echocardiography. Moreover, transthoracic echocardiography not always disclose endocarditis vegetations as accurately as transesophageal echocardiography. We describe a patient with cerebral embolism due to Staphylococcus aureus endocarditis in which adequate medical diagnosis and management was achieved by means of transesophageal echocardiography.

Severe pulmonary arterial hypertension due to toxic oil syndrome: a new cause of plexogenic arteriopathy.

Ten patients with severe pulmonary hypertension due to Toxic Oil Syndrome (TOS) (3 men, 7 women; mean age 27.9 +/- 11.23 yrs.) are presented. The pulmonary vessels were examined with a micromorphometric technique. All patients had intimal fibrosis of the arteries and veins. Seven also had a thrombus in different stages. All arteries were shown to have medial hypertrophy. Plexiform lexions were found in eight cases. It is concluded that TOS can produce severe pulmonary hypertension histologically undistinguishable from the primary form. TOS can be added to the list of diseases causing plexogenic arteriopathy.

Acute effect of intrapulmonary enalaprilat in ten patients with severe pulmonary hypertension due to toxic oil syndrome.

Ten patients with severe pulmonary hypertension due to Toxic Oil Syndrome underwent cardiac catheterization to analyse the acute effect of intrapulmonary injection of 1.25 mg of enalaprilat. Haemodynamic parameters were obtained at basal state, 15, 30, 45 and 60 minutes after administration of the drug. Enalaprillat did not produce any statistically significant changes in pulmonary pressures and resistances or cardiac output. This lack of response is unknown but may be related to the presence of endothelial damage and fixed pulmonary vascular lesions observed at autopsy in three patients.