Cardiac sympathetic innervation assessed with 123I-MIBG retains prognostic utility in diabetic patients with severe left ventricular dysfunction evaluated for primary prevention implantable cardioverter-defibrillator / La valoración de la inervación simpática cardiaca con 123I-MIBG mantiene su utilidad pronóstica en pacientes diabéticos con disfunción ventricular grave evaluados para implante de desfibrilador automático en prevención primaria

Background. Scintigraphy with iodine-123-metaiodobenzylguanidine (123I-MIBG) is a non-invasive tool for the assessment of cardiac sympathetic innervation (CSI) that has proven to be an independent predictor of survival. Recent studies have shown that diabetic patients with heart failure (HF) have a higher deterioration in CSI. It is unknown if 123I-MIBG has the same predictive value for diabetic and non-diabetic patients with advanced HF. An analysis is performed to determine whether CSI with 123I-MIBG retains prognostic utility in diabetic patients with HF, evaluated for a primary prevention implantable cardioverter-defibrillator (ICD). Material and methods. Seventy-eight consecutive HF patients (48 diabetic) evaluated for primary prevention ICD implantation were prospectively enrolled and underwent 123I-MIBG to assess CSI (heart-to-mediastinum ratio - HMR). A Cox proportional hazards multivariate analysis was used to determine the influence of 123I-MIBG images for prediction of cardiac events in both diabetic and non-diabetic patients. The primary end-point was a composite of arrhythmic event, cardiac death, or admission due to HF. Results. During a mean follow-up of 19.5 [9.3-29.3] months, the primary end-point occurred in 24 (31%) patients. Late HMR was significantly lower in diabetic patients (1.30 vs. 1.41, p = 0.014). Late HMR ≤ 1.30 was an independent predictor of cardiac events in diabetic (hazard ratio 4.53; p = 0.012) and non-diabetic patients (hazard ratio 12.31; p = 0.023). Conclusions. Diabetic patients with HF evaluated for primary prevention ICD show a higher deterioration in CSI than non-diabetics; nevertheless 123I-MIBG imaging retained prognostic utility for both diabetic and non-diabetic patients (AU)

Antecedentes. La gammagrafía con yodo-123-metayodobenzilguanidina (123I-MIBG) es una herramienta de la valoración de la actividad simpática cardiaca (ASC) que ha demostrado ser un predictor independiente de supervivencia. Estudios recientes han demostrado que los pacientes diabéticos con insuficiencia cardiaca (IC) presentan mayor deterioro de la ASC. Si 123I-MIBG tiene el mismo valor predictivo en diabéticos y no diabéticos es desconocido. Analizamos si la evaluación de la ASC con 123I-MIBG mantiene su utilidad pronóstica en pacientes diabéticos con IC evaluados para implante de DAI en prevención primaria. Material y métodos. Se incluyeron prospectivamente 78 pacientes (48 diabéticos) consecutivos evaluados para implante de DAI en prevención primaria a los que se les realizó una gammagrafía con 123I-MIBG para evaluar la ASC (índice corazón mediastino - ICM-). Se usó un modelo multivariado de riesgos proporcionales de Cox para analizar la influencia de 123I-MIBG en la predicción de eventos cardiacos tanto en pacientes diabéticos como no diabéticos. La variable principal de resultado es un compuesto de evento arrítmico, muerte cardiaca y hospitalización por IC. Resultados. Durante una media de seguimiento de 19.5 [9.3-29.3] meses, la variable principal de resultado ocurrío en 24 (31%) de los pacientes. El ICM tardío fue significativamente menor en el grupo de pacientes con diabetes mellitus (1.30 vs 1.41, p = 0.014). Un ICM tardío ≤1,30 fue predictor independiente de eventos cardiacos en pacientes diabéticos (HR 4,53; p = 0,012) y no diabéticos (HR 12,31; p = 0,023). Conclusión. Los pacientes diabéticos con IC grave evaluados para implante de DAI en prevención primaria presentan mayor deterioro de la ASC que los no diabéticos. 123I-MIBG mantiene utilidad pronóstica en pacientes diabéticos y no diabéticos con IC (AU)

Cardiac sympathetic innervation assessed with (123)I-MIBG retains prognostic utility in diabetic patients with severe left ventricular dysfunction evaluated for primary prevention implantable cardioverter-defibrillator.

BACKGROUND: Scintigraphy with iodine-123-metaiodobenzylguanidine ((123)I-MIBG) is a non-invasive tool for the assessment of cardiac sympathetic innervation (CSI) that has proven to be an independent predictor of survival. Recent studies have shown that diabetic patients with heart failure (HF) have a higher deterioration in CSI. It is unknown if (123)I-MIBG has the same predictive value for diabetic and non-diabetic patients with advanced HF. An analysis is performed to determine whether CSI with (123)I-MIBG retains prognostic utility in diabetic patients with HF, evaluated for a primary prevention implantable cardioverter-defibrillator (ICD). MATERIAL AND METHODS: Seventy-eight consecutive HF patients (48 diabetic) evaluated for primary prevention ICD implantation were prospectively enrolled and underwent (123)I-MIBG to assess CSI (heart-to-mediastinum ratio - HMR). A Cox proportional hazards multivariate analysis was used to determine the influence of (123)I-MIBG images for prediction of cardiac events in both diabetic and non-diabetic patients. The primary end-point was a composite of arrhythmic event, cardiac death, or admission due to HF. RESULTS: During a mean follow-up of 19.5 [9.3-29.3] months, the primary end-point occurred in 24 (31%) patients. Late HMR was significantly lower in diabetic patients (1.30 vs. 1.41, p=0.014). Late HMR≤1.30 was an independent predictor of cardiac events in diabetic (hazard ratio 4.53; p=0.012) and non-diabetic patients (hazard ratio 12.31; p=0.023). CONCLUSIONS: Diabetic patients with HF evaluated for primary prevention ICD show a higher deterioration in CSI than non-diabetics; nevertheless (123)I-MIBG imaging retained prognostic utility for both diabetic and non-diabetic patients.

[One-year clinical and angiographic follow-up after primary stenting]. / Evolución clínica y angiográfica al año de pacientes con infarto agudo de miocardio tratados con stent primario.

INTRODUCTION AND OBJECTIVES: The late reocclusion or restenosis rate of the infarct related artery is frequent after primary angioplasty. An implanted stent may be able to improve the coronary angioplasty results and long-term outcome of these patients. We present the clinical and angiographic outcome of a cohort of patients treated with primary stenting. PATIENTS AND METHODS: A group of 74 consecutive patients with acute myocardial infarction treated with primary angioplasty and stenting were followed for one year. An angiographic control was performed at the 6th month of follow-up in 91% of patients to assess the restenosis and reocclusion rates of the infarct-related artery. RESULTS: There were eight in-hospital deaths and three during follow-up (mortality rate 14.8%) and one non-fatal reinfarction (1.5%). The cumulative rate of recurrent ischemia was 6% at 3 months and 15% at 6 months, without any further increment at one-year follow-up. A new angioplasty was performed in 7 patients and three patients underwent surgical revascularization. Thus 80% of patients after discharge were free of events. The angiographic control showed only one reocclusion of the infarct related artery and a restenosis rate of 27%. CONCLUSIONS: These results show that primary stenting is an effective procedure in treating non-selected patients with acute myocardial infarction with a low long-term incidence of adverse events and a low restenosis rate.

[Syncope and a negative electrophysiological study. The usefulness of an implantable Holter monitor for the diagnosis of ventricular arrhythmias]. / Síncope y estudio electrofisiológico negativo. Utilidad del Holter implantable para el diagnóstico de arritmias ventriculares.

Currently the insertable loop recorder is usually indicated when the patient has recurrent syncopes and conventional Holter and electrophysiological testing have been negative. We report the case of a patient with dilated cardiomyopathy, admitted to our hospital due to a single episode of syncope. After performing conventional diagnostic procedures, including continuous electrocardiographic monitoring for 48 hours, 24-hour Holter and electrophysiological study, no abnormalities were detected. Therefore, a insertable loop recorder was implanted, which was activated by the patient one month later after a pre-syncopal situation. The Holter reading evidenced self-limited monomorphic ventricular tachycardia, confirming the arrhythmic origin of the syncope. In patients with severe structural heart disease, in whom syncope can be caused by a malignant ventricular arrhythmia, the insertable loop recorder can be indicated in a single episode of syncope when the electrophysiological study is negative.

[Transitory left deviation in the electrical axis of QRS during an exercise test as a manifestation of a severe proximal lesion of the descending anterior artery]. / Desviación izquierda transitoria del eje eléctrico del QRS durante la prueba de esfuerzo como manifestación de lesión severa proximal de la arteria descendente anterior.

The case of a patient in whom transient left axis deviation occurred during a treadmill exercise test is reported. Coronary angiography showed a 90% obstruction of the proximal left anterior descending artery. After a successful coronary angioplasty and stent implantation, a control exercise test was performed without a recurrence of angina or transient intraventricular conduction disturbance, reflecting the ischaemic nature of this abnormality.

[Intracoronary stent in primary angioplasty in acute myocardial infarction]. / Stent intracoronario en la angioplastia primaria en el infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: Stent implantation has been generally contraindicated during primary percutaneous transluminal balloon angioplasty in AMI, because of its possible trombogenicity. Report the early outcome of patients undergoing coronary stenting during primary PTCA. METHODS: From january 1995 to april 1996, 31 patients underwent stent implantation in primary. Mean age 62 +/- 11 years. Infarct location was anterior in 20 (65%), and inferior in 11 patients (35%). Four patients were in Killip class IV. Mean onset of chest pain was 129 +/- 29 minutes. Indications for stenting were suboptimal result (64%), dissection (29%) and elective (6%). All patients were treated with heparin during 72 hours and antiplatelet therapy with ticlopidine and aspirin. RESULTS: Coronary stenting restored vessel patency with TIMI 3 flow in 29 patients (94%) and TIMI 2 flow in 2 patients. Angiographic control was performed in 80% of the patients: no stent occlusion was observed and all patients showed a TIMI 3 flow. There were 3 deaths (9%): 2 patients died due to cardiogenic shock and 1 to severe right ventricular dysfunction. 2 patients (6%) had recurrent angina, due to other artery. One patient with left main coronary disease underwent elective coronary artery bypass graft surgery. CONCLUSIONS: Intracoronary stent can be used successfully during primary angioplasty with a low incidence of complications. The long term benefits remains to be established.