The use of the acute Pd/Pa drop after intracoronary nitroglycerin infusion to rule out significant FFR: CANICA (Can intracoronary nitroglycerin predict fractional flow reserve without adenosine?) multicenter study.

OBJECTIVE: Functional assessment of coronary artery stenosis is performed by measuring the fractional flow reserve (FFR) under hyperemic conditions (Adenosine). However, the use of adenosine portends limitations. OBJECTIVE: We sought to investigate the relationship and correlation between FFR and the Pd/Pa value obtained just after the intracoronary infusion (acute drop) of nitroglycerin (Pd/Pa-NTG) and if this parameter enhances diagnostic accuracy for FFR prediction compared to the resting baseline Pd/Pa. METHODS: We conducted a multicenter study including prospectively patients presenting intermediate coronary artery stenosis (30-70%) evaluated with pressure wire. Resting baseline Pd/Pa, Pd/Pa-NTG and FFR were measured. RESULTS: 283 patients (335 lesions) were included. Resting baseline Pd/Pa value was 0.72 to 1.0 (0.93 ± 0.04), Pd/Pa-NTG was 0.60 to 1.0 (0.87 ± 0.07) and FFR 0.55 to 1.0 (0.83 ± 0.08). The ROC curves for resting baseline Pd/Pa and for Pd/Pa-NTG, using a FFR ≤ 0.80 showed an AUC of 0.88 (95% CI: 0.84-0.92, P < 0.001) and 0.94 (95% CI: 0.92-0.96, P < 0.001) respectively. The optimal cutoff values of resting baseline Pd/Pa and Pd/Pa-NTG for an FFR > 0.80, were >0.96 and >0.88, respectively. These values were present in a 29.8% (n = 100) and a 47.1% (n = 158), of the total lesions. Scatter plots showed a better correlation and agreement points with Pd/Pa-NTG than resting baseline Pd/Pa. The cutoff value of Pd/Pa-NTG > 0.88 showed an excellent NPV (96.2% for FFR > 0.8 and 100% for FFR > 0.75) and sensitivity (95% for FFR > 0.8 and 100% for FFR > 0.75) which were consistently high across all the subgroups analysis. CONCLUSION: The cutoff value of acute Pd/Pa-NTG > 0.88 has a high NPV meaning adenosine-FFR can be avoided in almost half of lesions.

Anomalía coronaria congénita, un enemigo silencioso del ejercicio físico / Congenital coronary anomaly, a silent enemy of exercise

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La aplicación de hipotermia moderada tras la reanimación cardiaca iniciada en el medio extrahospitalario puede incrementar la supervivencia sin deterioro neurológico. Estudio de casos y controles / Prehospital induction of moderate hypothermia after cardiac resuscitation can increase survival without increasing neurologic impairment: a case-control study

Objetivos: Evaluar el efecto que tiene la aplicación por un servicio de emergencias de una hipotermia moderada precoz en el medio extrahospitalario sobre la evolución neurológica de los pacientes recuperados de una parada cardiaca. Método: Estudio comparativo caso-control. Se incluyeron como casos los 40 primeros pacientes en parada cardiorrespiratoria (PCR) que fueron reanimados por el SAMUR Protección Civil y tratados con hipotermia en la propia ambulancia, continuada posteriormente en el medio hospitalario. En el grupo control, se incluyeron los últimos 40 pacientes que habiendo sufrido una PCR de origen médico, fueron reanimados por el SAMUR Protección Civil antes de la implantación del protocolo de hipotermia postresucitación, y fueron sometidos, también, al procedimiento de hipotermia tras el ingreso en el hospital. Se descartaron las PCR de origen neurológico, dado que se pretende conocer la influencia de la técnica en ese órgano diana. Para valorar el deterioro neurológico de de los pacientes, se utilizó la escala CPC (Cerebral Perfomance Category). Se consideró en el estudio los grados I y II como "buena evolución neurológica". Resultados: El 50% de los casos presentaron una buena recuperación neurológica frente al 27,5% de los controles (p = 0,039). Esas diferencias se mantuvieron tanto si el ritmo inicial era desfibrilable (58,3% frente a 37,5% de los controles) como no desfibrilable(42,8% frente a 14,2% respectivamente).Conclusiones: Los datos demuestran que existe una relación estadísticamente significativa entre la aplicación de hipotermia moderada prehospitalaria y una mayor probabilidad de recuperación neurológica (CPC I y II). Así, existe una probabilidad de 2,6 veces mayor de que el paciente que ha sufrido una parada cardiorrespiratoria tenga una buena recuperación neurológica si el inicio de la hipotermia moderada se realiza antes de llegar al hospital (AU)

Objectives: To assess the effect of early prehospital emergency responder implementation of moderate hypothermia on neurologic outcome in patients recovering from cardiac arrest. Methods: Case-control comparative study. The cases were the first 40 patients in cardiorespiratory arrest in who mhypothermia was induced in the ambulance after resuscitation by responders from the Citizen Protection Emergency Service of Madrid (SAMUR); hypothermia was also later used in the hospital. The controls were the last 40 patients in cardiorespiratory arrest who were resuscitated by the SAMUR responders before the prehospital hypothermia protocol had been established; hypothermia was later induced after the control patients’ arrival at the hospital. Patients whose cardiorespiratory arrest had neurologic causes were excluded given that the effect on neurologic outcome was underevaluation. The Cerebral Performance Category scale was used to assess impairment. A grade 1 or 2 assessment was considered to indicate a good neurologic outcome. Results: Neurologic outcome was good for 50% of the patients in whom hypothermia was induced early; outcome was good for 27.5% of the control patients (P=.039). The significant difference between cases and controls was maintained regardless of whether the initial heart rhythm was shockable (58.3% of such cases had good neurologic outcomes with early hypothermia vs 37.5% of the controls with shockable rhythm) or not (42.8% of such cases had good outcomes vs14.2% of the controls with non shockable rhythm).Conclusions: Our findings show a significant relationship between prehospital induction of moderate hypothermia and a higher probability of neurologic recovery (performance categories 1 and 2). If moderate hypothermia is initiated before arrival at the hospital, the likelihood of good neurologic recovery is 2.6-times greater (AU)

Episodios repetidos de disociación electromecánica en un paciente con angina de Prinzmetal / No disponible

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Pulmonary artery dissection and conservative medical management.

Pulmonary artery dissection is a rare clinical entity, which has been related to pulmonary arterial hypertension. It is frequently presented as cardiogenic shock or sudden death, so diagnosis is often made at autopsy. The management with best results is surgery. We report a case of pulmonary artery dissection associated with previous aortic valve replacement with a favourable outcome, using conservative medical therapy.

Tratamiento perioperatorio de una gestante con infarto cerebral reciente secundario a miocardiopatía no compactada / Perioperative treatment of a pregnant woman with recent cerebral infarction secondary to noncompaction cardiomyopathy

La miocardiopatía no compactada (MNC) es una entidadde reciente acuñamiento, de presentación infrecuentepero con manifestaciones clínicas importantes y pronósticosombrío. El infarto cerebral es una de sus formasde presentación; y el embarazo, estado de hipercoagulabilidad,lo favorece. Se presenta el caso de una mujerembarazada que fue llevada a urgencias con un infartocerebral isquémico, en cuyo estudio se demostró etiologíacardioembólica, con diagnóstico de MNC. Días después,tras su estabilización, fue sometida a cesárea electivabajo anestesia general. La intervención transcurriósin incidencias, al igual que el postoperatorio, tras elcual fue trasladada al Servicio de Rehabilitación. Esobligatorio en estos casos evitar el daño miocárdico y laprogresión del accidente cerebrovascular; para ello previoa la cirugía se debe estabilizar al paciente e iniciartratamiento antiagregante y/o anticoagulante. Es necesariomantener la estabilidad hemodinámica durante todoel perioperatorio, evitando en lo posible la depresión delneonato tras su extracción. Para ello existen diferentesestrategias, que deben adecuarse al estado y al momentoen el que se encuentre la paciente

Recent-onset noncompaction of the myocardium is arare but serious entity with uncertain prognosis. Cerebralinfarction is among the forms of presentation, andpregnancy and hypercoagulability increase risk. Wereport the case of a pregnant woman brought to theemergency department with ischemic cerebral infarction.Investigation demonstrated the cause to be cardiac embolism,and noncompaction of the myocardium was diagnosed.She was stabilized and a few days later underwentelective cesarean section under general anesthesia. Surgeryand postoperative recovery were uneventful, and shewas transferred for rehabilitation. Myocardial injury andprogression to cerebrovascular accident must beprevented in such cases; the patient must be stabilizedand antiplatelet and/or anticoagulant therapy initiatedbefore surgery. Hemodynamic stability must be maintainedthroughout the perioperative period and neonataldepression avoided after delivery. Various approaches areavailable to be adapted to the patient's situation

[Perioperative treatment of a pregnant woman with recent cerebral infarction secondary to noncompaction cardiomyopathy]. / Tratamiento perioperatorio de una gestante con infarto cerebral reciente secundario a miocardiopatía no compactada.

Recent-onset noncompaction of the myocardium is a rare but serious entity with uncertain prognosis. Cerebral infarction is among the forms of presentation, and pregnancy and hypercoagulability increase risk. We report the case of a pregnant woman brought to the emergency department with ischemic cerebral infarction. Investigation demonstrated the cause to be cardiac embolism, and noncompaction of the myocardium was diagnosed. She was stabilized and a few days later underwent elective cesarean section under general anesthesia. Surgery and postoperative recovery were uneventful, and she was transferred for rehabilitation. Myocardial injury and progression to cerebrovascular accident must be prevented in such cases; the patient must be stabilized and antiplatelet and/or anticoagulant therapy initiated before surgery. Hemodynamic stability must be maintained throughout the perioperative period and neonatal depression avoided after delivery. Various approaches are available to be adapted to the patient's situation.