Therapeutic choices in patients with Ph-positive CML living in Mexico in the tyrosine kinase inhibitor era: SCT or TKIs?

A total of 72 patients with Ph-positive CML in first chronic phase were followed during a 6-year period in two different institutions in México. Among them, 22 were given a reduced-intensity allogeneic SCT, whereas 50 were given a tyrosine kinase inhibitor (TKI), mainly imatinib mesylate. The 6-year overall survival (OS) after the therapeutic intervention for patients allografted or given a TKI was 77 and 84%, respectively (P, NS); the median OS for both groups has not been reached, being above 90 and 71 months, respectively (P, NS). The freedom from progression to blast or accelerated phases was also similar for both groups, as well as the overall OS after diagnosis. Most patients allografted (91%) chose this treatment because they were unable to afford continuing treatment with the TKI, whereas most treated with the TKI (84%) were given the treatment without charge, through institutions able to pay for their treatment. The median cost of each nonmyeloablative allograft was US$18,000, an amount that is enough to cover 180 days of treatment with imatinib (400 mg per day) in México. Cost considerations favor allogeneic SCT as a 'once only' procedure whereas lifelong treatment with an expensive drug represents an excessive burden on resources.

[Predictive value of the increase in diastolic arterial pressure during the exercise test in ischemic cardiopathy]. / Valor predictivo del incremento de la presión arterial diastólica durante la prueba de esfuerzo en la cardiopatía isquémica.

There are few studies on the behavior of the diastolic blood pressure during the stress test. The purpose of this report is to present a simple, noninvasive technique of measuring the mean diastolic arterial blood pressure at rest, during maximal exercise testing and in the first minute of recovery (X delta DAP). We studied 132 patients with exercise testing (E/T) and coronariography (C). Of these, 116 had coronary artery disease and 16 did not. The following data were analyzed: Age (A) X delta DAP, X2, p value, sensitivity, specificity, positive predictive value (PV+), and negative predictive value (PV-). As we analyzed our patients with coronary arterial disease, we found that in 75% of the cases, the X delta DAP increased more than 15 mmHg, immediately after maximal effort, and 86% of these cases had poor myocardial contratility by angiocardiogram. We conclude that the increase of X delta DAP has a significant value in a ischemic heart disease.

[Aortic prosthesis, long-term results and evolution]. / Prótesis aórtica, Resultado y evolución a largo plazo

The results and evolution of 126 aortic prosthesis implanted from 1964 to 1971 were reported. The results are appraised according to the criteria of the NYHA. The hospital mortality in the first five years was 40%; in those operated on in the following 3 it fell to 21% and finally those treated in the last 2 years had 16%. The delayed mortality was 19%. Depending on the type of valvular lesion, the stenosis have the highest mortality (50%). The group II and II of the NYHA had less mortality. In the evolution of the survivors at ten years, the incidence of actual survivors shows that after the first two years of prosthetic change, the survival rate tends to stabilize staying at 77% at the end of 10 years; of which 75% evolve well and 17% badly. A separate analysis was made of the factors which modify the results and evolution such as calcifications, associated mitraltricuspid lesions, and myocardial damage. The most frequent complications were embolisms 14%, prosthetic dysfunction 12.8%, endocarditis 3.8%, and hemolysis 2.5%.

[Antiarrhythmic effects of verapamil]. / Effectos antiarrítmicos del verapamil.

The effect of verapamil were studied on 50 episodes of supraventricular and ventricular tachycardia in 44 patients. An i.v. dose of 0.10 to 0.15 mg/kg. was used. In 5 cases His bundle electrograms were obtained while maximal dp/dt was determined in 7 others. Sinus rhythm was obtained in 21 (81%) of 26 cases of PSVT. In all cases of rapid atrial fibrillation (n-11), an important decrease in the ventricular response was elicited. Of 7 cases of atrial flutter, verapamil induced sinus rhythm in 3 and a significant decrease in the ventricular rate in 3 others. In 2 out of 6 cases ventricular tachycardia reverted to sinus rhythm. The latency time between the injection and the manifestation of the effect ranged from 2 to 4 minutes. A slight and short-lasting depression of dp/dt was observed in all cases studied. Verapamil produced an increase in the A-H interval in 4 of the 5 cases studied with His bundle recordings. Verapamil was found to be a useful drug to suppress PSVT, to decrease the ventricular response in flutter or atrial fibrillation and to convert some ventricular tachycardias to sinus rhythm. Verapamil should be used with caution in previously digitalized patients and is contraindicated when there is S-A node dysfunction as in the tachycardia-bradycardia syndrome.

[Trans and postoperative myocardial infarct in heart surgery]. / El infarto del miocardio trans y postoperatorio en la cirugía cardíaca

1. A study was made of 34 cases (33%) of myocardial infarction trans and immediately postoperative which occurred in 11,210 surgical interventions with and without extracorporeal circulation. 2. This presents a statistical relation of the frequency of myocardial infarction in realtion to the heart disease acquired with or without extracorporeal circulation with the mitral, aortic, and double prosthesis of the mitral and aortic valves. A correlation was also made with the ischemic heart disease subjected to revascularization. The same analysis was carried out in the congenital heart disease with or without extracorporeal circulation. 3. In all cases the antecedents, precipitating factors, and the clinical picture were studied and in 12 cases the necropsy was analized. The principal finding was transmural myocardial infarction with electrocardiographic proof and serial enzymes. 4. The group was divided into two sub-groups; Group "A" with acute myocardial infarction transoperative, and Group "B" with acute myocardial infarction in the first eight postoperative days. The electrical and mechanical complications were analized. 5. A correlation was made of the causes of mortality related to the type of congenital or acquired heart disease with or without extracorporeal circulation. 6. The frequency of this entity was studied with the total time of aortic clamping, and the complications such as the low cardiac output syndrome, rupture of the wall, aneurysms, acute pulmonary edema, and with the disturbances of rhythm and conduction. 7. The presence of 33.3% of normal coronaries in these of necropsy was emphasized. 8. The importance of the coronary profile of this group in relation to the consequences of a stress from anesthesia, surgery, extracorporeal circulation, and aortic clamping is mentioned. 9. The diagnostic parameters such as arterial hypotension with or without the low cardiac output syndrome, enzyme levels, and the action of the potassium ion are mentioned. 10. An analysis is made of the possible etiological factors of the precipitation of the myocardial necrosis in the cases with normal coronaries and those in which there was no important obstruction of the coronary macrocirculation. 11. In the subgroup "A" it was found that the frequency of myocardial infarction was less than in the subgroup "B", but there was greater mortality in group "A". The possible causal factors are analized.