Factores pronósticos de mortalidad de la insuficiencia cardíaca en una cohorte del noroeste de España. Estudio EPICOUR / Mortality prognosis factors in heart failure in a cohort of North-West Spain. EPICOUR study

Objetivos. La insuficiencia cardíaca (IC) supone un importante problema de salud pública, tanto por su elevada morbimortalidad como por el alto coste sanitario que provoca. Se realiza este estudio para estudiar la supervivencia de pacientes con IC en relación con la función ventricular y otros posibles factores de riesgo (FR) asociados con el pronóstico de la IC. Material y métodos. Estudio de cohortes, prospectivo, considerando como potenciales participantes a cualquier paciente hospitalizado por IC entre el 1 de enero de 1999 y el 31 de diciembre de 2002 (5.318 pacientes), a quien se le hubiese realizado ecocardiografía que mostrase disfunción sistólica ó diastólica (2.387 pacientes). Se eligió por muestreo aleatorio simple una muestra de 384 pacientes, transcurridos al menos 24 meses tras el episodio índice de hospitalización. La medición principal residió en la supervivencia y en las diferencias observadas en función de la fracción de eyección del ventrículo izquierdo, de la clase funcional (CF) de IC y de otras características clínicas y epidemiológicas. Se utilizaron las pruebas de Kaplan-Meier, del log-rank y de Cox. Resultados. La edad media fue de 74,84 años (rango: 36–95). 53,4% varones y 56,5% primer ingreso. El antecedente personal más frecuente fue hipertensión arterial (HTA) (59,9%), seguido de valvulopatía (41,9%) y enfermedad coronaria (EC) (26,8%). El 44,3% presentaban fibrilación-flutter auricular (FA). La supervivencia global observada a los 5 años fue de 47,9% y la específica por IC de 74,8%. No hubo diferencias significativas en supervivencia entre pacientes con insuficiencia cardíaca y función sistólica preservada (IC-FSP) y aquellos con disfunción sistólica (p=0,248). Son factores pronósticos de mortalidad por IC la CF basal previa al ingreso avanzada (Hazard ratio (HR) 5,37), el deterioro de filtrado glomerular (FG) (HR 0,98), la hipoalbuminemia (HR 0,59), la hiponatremia (HR 0,93), y la hiperpotasemia (HR 1,79). El índice de Castelli superior a 4,5 se halla en el límite de la significación estadística. Conclusiones. La supervivencia global observada a los 5 años es similar a la de otras series publicadas, siendo la específica por IC algo inferior, no habiendo diferencias en la supervivencia respecto a la fracción de eyección del ventrículo izquierdo (FEVI). Destacan como factores pronósticos de mortalidad por IC la hipoalbuminemia, la hiperpotasemia y el índice de Castelli elevado(AU)

Aims. Heart failure (HF) is a serious health problem in Spain because it has a high mortality rate and causes considerable costs to the health-care system. This paper presents a study made in the Spanish province of Ourense to study the survival of patients with HF related to the ventricular function or other possible risk factors (RF) associated with the HF prognosis. Material and methods. A prospective cohort study was performed, considering any patient hospitalized due to HF from 1 January 1999 to 31 December 2002 (5318 patients) who had undergone an echocardiography that showed systolic or diastolic dysfunction as potential participants (2387 patients). After at least 24 months of the index episode of hospitalization, a sample of 2384 patients was chosen by random sampling. The principal measurement was based on survival and the differences observed in the performance of the left ventricular ejection fraction, of functional class (FC) of HF and of other clinical and epidemiological characteristics. The Kaplan-Meier, log-rank and Cox tests were used. Results. Mean age of the patients 74.84 (range 36–95); 53.4% males and 56.5% first admission. The most common antecedent was arterial hypertension (HTA) (59.9%), followed by valvulopathy (41.9%) and heart disease (HD) (26.8%). A total of 44.3% of the patients had atrial fibrillation-flutter (AF). Global survival at 5 years was 47.9% and specific survival rate for HF was 74.8%. There were no significant differences in survival between patients with heart failure and preserved systolic function (HF-PSF) and those who suffered systolic dysfunction (p=0.248). Prognostic factors of mortality in patients with HF are: advanced functional class (class III–IV) prior to admission (Hazard ratio [HR] 5.37), deterioration of the glomerular filtration rate (GFR) (HR 0.98), hypoalbuminemia (HR 0.59), hyponatremia (HR 0.93) and hyperkalemia (HR 1.79). The Castelli index higher than 4.5 is in the limit of statistical significance. Conclusions. Global survival rate observed at 5 years of research is similar to the results found in already-published papers. Specific survival rate for HF is lower and there are no differences in the survival rate with regard to the left ventricle ejection fraction (Ef). However, we show that hypoalbuminemia, hyperkalemia and high Castelli index are important prognostic factors of mortality in patients with HF(AU)

[Mortality prognosis factors in heart failure in a cohort of North-West Spain. EPICOUR study]. / Factores pronósticos de mortalidad de la insuficiencia cardíaca en una cohorte del noroeste de España. Estudio EPICOUR.

AIMS: Heart failure (HF) is a serious health problem in Spain because it has a high mortality rate and causes considerable costs to the health-care system. This paper presents a study made in the Spanish province of Ourense to study the survival of patients with HF related to the ventricular function or other possible risk factors (RF) associated with the HF prognosis. MATERIAL AND METHODS: A prospective cohort study was performed, considering any patient hospitalized due to HF from 1 January 1999 to 31 December 2002 (5318 patients) who had undergone an echocardiography that showed systolic or diastolic dysfunction as potential participants (2387 patients). After at least 24 months of the index episode of hospitalization, a sample of 2384 patients was chosen by random sampling. The principal measurement was based on survival and the differences observed in the performance of the left ventricular ejection fraction, of functional class (FC) of HF and of other clinical and epidemiological characteristics. The Kaplan-Meier, log-rank and Cox tests were used. RESULTS: Mean age of the patients 74.84 (range 36-95); 53.4% males and 56.5% first admission. The most common antecedent was arterial hypertension (HTA) (59.9%), followed by valvulopathy (41.9%) and heart disease (HD) (26.8%). A total of 44.3% of the patients had atrial fibrillation-flutter (AF). Global survival at 5 years was 47.9% and specific survival rate for HF was 74.8%. There were no significant differences in survival between patients with heart failure and preserved systolic function (HF-PSF) and those who suffered systolic dysfunction (p=0.248). Prognostic factors of mortality in patients with HF are: advanced functional class (class III-IV) prior to admission (Hazard ratio [HR] 5.37), deterioration of the glomerular filtration rate (GFR) (HR 0.98), hypoalbuminemia (HR 0.59), hyponatremia (HR 0.93) and hyperkalemia (HR 1.79). The Castelli index higher than 4.5 is in the limit of statistical significance. CONCLUSIONS: Global survival rate observed at 5 years of research is similar to the results found in already-published papers. Specific survival rate for HF is lower and there are no differences in the survival rate with regard to the left ventricle ejection fraction (E(f)). However, we show that hypoalbuminemia, hyperkalemia and high Castelli index are important prognostic factors of mortality in patients with HF.

[Apical hypertrophic myocardiopathy: presentation of 3 cases and review of the literature]. / Miocardiopatía hipertrófica apical: presentación de tres casos y revisión de la literatura.

Apical hypertrophic myocardiopathy (AHM) is an entity less frequently reported in our country than in Japan. We studied only three patients between 1980 and 1987. Their age varied from 26 to 40 years. Other studies included vectorcardiograms, Holter monitoring, exercise stress testing, phonocardiograms and cardiac catheterization; only one case had a genetic study, program atrial stimulation and technetium-99m pyrophosphate scintigraphy. All patients underwent echocardiographic study. The clinical features had great variations, from asymptomatic cases to the presence of important left ventricular failure and brain embolism. Electrocardiogram was characteristic in two patients; in one, cardiac catheterization showed an intraventricular pressure gradient of 19 mmHg explained by trapping of the catheter and in the other one, the end-diastole pressure of left ventricle was 22 mmHg; in both, the left ventriculogram showed the characteristic spade image. In all of them the echocardiogram showed segmentary left apical ventricular hypertrophy similar to the angiographic image; one patients had mitral regurgitation. This study demonstrates the usefulness of echocardiogram in this pathology.

[Immediate and long-term results of aortic valvulotomy in aortic valve stenosis]. / Resultados inmediatos y a largo plazo de la valvulotomía aórtica en la estenosis aórtica valvular.

Between April 1962 and December 1982 we performed valvulotomies on 68 patients to correct valvular aortic stenosis (VAoS). Forty-one were men and 27 women whose ages ranged from 20 months to 47 years (mean = 11.9 +/- 6.4 years). In 95% of cases VAoS was congenital. All patients underwent clinical preoperative evaluation with chest roentgenogram and electrocardiogram (ECG). Catheterization was done on 89.7%. Symptoms varied from none to syncope and stress angina. Symptoms bore no relation to the systolic aortic gradient, which oscillated between 31 and 200 mm Hg. There was a significant postoperative improvement in symptoms and less notable improvement in chest X-rays and ECG. Follow-up was from 1 to 22 years (mean = 7.12 +/- 4.43 years). Thirty-nine patients were followed for 5 or more years with serial clinical, radiological and electrocardiographic control. Fifty percent underwent postoperative catheterization. Seventeen patients continued with residual aortic regurgitation (AoR). Fourteen patients were again operated. A new valvulotomy was performed on 2 and valve replacement was done on the rest. Perioperative mortality was 2.9% and long-term survival 88% with 84.6% of the patients asymptomatic or in functional class I of the NYHA. Survival curves were plotted and the literature reviewed. The conclusion was that although this surgery constitutes a low risk, it should be considered palliative in the majority of the cases.

[Aneurysm of the membranous interventricular septum. Study by Doppler echocardiography (color mapping in one of the cases)]. / Aneurisma del septum interventricular membranoso. Estudo por ecocardiografía Doppler (mapeo de color en uno de los casos).

Eight patients with aneurysm of the membranous interventricular septum (AMIS) were studied, in all of them the diagnosis was done by Doppler echocardiography (D-E). In all cases, the AMIS was visualized in left parasternal long and short axis views. In six of them by means of apical and subcostal four chamber views. The AMIS was identified as a bag-shaped echo at the level of the interventricular septum; it bulged into right ventricle during systole. Left-to-right shunt was demonstrated by pulsed wave Doppler in 5 patients and in another case with color flow mapping. AMIS has a mild hemodynamic repercussion as is the case with small ventricular septal defects. D-E offers diagnostic advantages, with high specificity if the AMIS is demonstrated in several views and the left-to-right shunt is recognized and quantified by Doppler technique.

[Hypertensive retinopathy in patients with aortic coarctation]. / Retinopatía hipertensiva en pacientes con coartación aórtica.

In order to assess the incidence and the determinants of hypertensive vascular changes in the retina of patients with coarctation of the aorta, fifty (37 male and 13 female) were analyzed. The mean age of the group was 18.7 +/- 10.3 years. No one had evidence of nephropathy. Different degrees of hypertensive retinopathy (Puig-Solanes classification) were observed in 54%. Of the patients, no one had papilledema. Retinal vascular damage was not related to either age or sex. The group of patients with retinal vascular lesions had a mean level of systolic arterial pressure higher than the group with normal retinas. Multivariant statistical analysis of the results permitted the identification of systolic arterial pressure higher than 150 mm Hg, age greater than 15 years and cardiomegaly as the three variables more frequently associated with retinal vascular lesions. Surgical correction of the aortic malformation resulted in normalization of both systolic and diastolic arterial pressures in 98% of the total number of patients as determined one year postoperatively. It is concluded that, in coarctation of the aorta, vascular damage of the retina appears to have an incidence that is similar to that observed in patients with other forms of systemic arterial hypertension. The development of these retinal lesions in patients with coarctation of the aorta would seem to be determined by the severity and duration of the hypertensive process.

[Echocardiographic diagnosis of pulmonary valve calcification]. / Diagnóstico ecocardiográfico de la calcificación valvular pulmonar.

Calcification of the pulmonary valve is a uncommon condition. Non invasive diagnostic methods such as M-mode and two dimensional echocardiography have facilitated the identification of vegetations and calcifications on the pulmonary valve. Very few cases of isolated calcification on the pulmonary valve have been reported; a previous lesion of the valve almost always exists. The purpose of this communication is to report two cases with calcification of pulmonary valves without underlying pathology and to highlight the great utility of echocardiography in diagnosis and follow-up of such cases.

[Coronary revascularization in the geriatric patient]. / Revascularización coronaria en el paciente geriátrico.

In order to determine the current status of coronary revascularization in the elderly, we studied 102 patients aged 65 to 77 years (mean 68 years) who had surgery at the Instituto Nacional de Cardiología "Ignacio Chávez". Seventy eight (76.4%) were male and 24 (23.5%) female. The coronary risk factors were cigarette smoking, systemic arterial hypertension and familiar history of coronary heart disease. Fifty five patients (54%) had myocardial infarction prior to surgery and in 29 (28.4%) the time between the ischemic event and surgery was less than one year. Ninety Patients (88.2%) presented with unstable and 12 (11.7%) with stable angina. Ejection fraction was less than 40% en 32 patients (31%). Coronary angiograms showed one vessel disease in 5 cases (4.9%), two vessel involvement in 29 (28.4%), three vessel lesions in 56 (55.8%) and left main coronary artery in 12 (11.7%). The patients underwent a mean of 2.1 bypasses (range 1 to 4). Perioperative mortality was 10.7%. Actuarial survival and angina pectoris relapse were 80 and 24% respectively at 6 years follow-up. We conclude that old age does not rule-out surgery for coronary heart disease.

[Myocardial infarction related to the association of physical exertion and the ingestion of cold drinks]. / Infarto del miocardio relacionado a la asociación de esfuerzo y la ingesta de bebida fría.

We describe 3 young individuals with acute myocardial infarction that developed after extenous stress followed by the intake of cold fluids. The patients had retrosternal chest pain and EKG changes suggestive of posterior-inferior myocardial infarction. Coronartiography demonstrated 40% and 50% narrowing of the right coronary artery. The remaining case had normal coronary arteries.

[Myocardial infarct secondary to a non-penetrating chest injury. Presentation of a case and review of the literature]. / Infarto miocárdico secundario a traumatismo no penetrante del tórax. Presentación de un caso y revisión de la literatura.

We describe a 21 year old male who had a myocardial infarction as a result of a horse kick in the chest. EKG Showed changes compatible with anterolateral infarction. Thallium scan demonstrated diffuse decreased uptake. Angiographic studied showed normal coronary arteries and abnormal movements of the posterior wall.