Predictors of mortality in patients undergoing surgery for ruptured aortic aneurysm.

BACKGROUND: A study was designed to determine significant variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm. PATIENTS AND METHODS: Data of 106 unselected consecutive patients with ruptured abdominal aortic aneurysm undergoing operation between 1989 and 1998 were identified from a prospective hospital-based registry. A total of 32 variables were analyzed including demographic characteristics, vascular risk factors, coexisting conditions, preoperative findings, intraoperative variables, and postoperative complications. Preoperative and intraoperative variables related to vital status (alive, death) in the univariate analysis were subjected to stepwise linear regression analysis to determine whether a combination of variables would predict death. Of 99 evaluable patients, 48 died (mortality rate 48.5%). RESULTS: At univariate analysis, age, serum creatinine, hemoglobin, electrocardiographic ischemia, loss of consciousness on admission, preoperative shock, supra-renal rupture, and transfusion requirements were significantly associated with 30-day operative mortality. Postoperative complications except sepsis, mesenteric ischemia, and neurologic events were significantly associated with mortality. Electrocardiographic ischemia, shock, and supra-renal rupture appeared to be independent predictors of mortality in the multivariate analysis. The cumulative effect of 0, 1, and > or = 2 risk factors on mortality was 29%, 39%, and 90%, respectively. CONCLUSIONS: Electrocardiographic ischemia, preoperative shock, and supra-renal rupture were predictors of death in patients with ruptured abdominal aortic aneurysm.

Intrastriatal administration of methylmercury increases in vivo dopamine release.

Mercury is a neurotoxin that exists in a number of physical and chemical forms, producing different effects in the brain. In the present work, we have studied the effects of intrastriatal administration of different doses (40 microM, 400 microM, and 4 mM) of organic mercury (methyl-mercury, MeHg) on the dopaminergic system of rat striatum, in conscious and freely-moving animals, using microdialysis coupled to Liquid Chromatography. In previous works, we have discussed the effects of chronic and acute administration of MeHg on striatal dopaminergic system assessing changes in both release and metabolism of striatal dopamine (DA). In the present study we report that the intrastriatal administration of different doses of MeHg (40 microM, 400 microM, and 4 mM) produced significant increases (907 +/- 31%, 2324 +/- 156%, and 9032 +/- 70% of basal levels, respectively for the different doses) in DA release from rat striatal tissue associated with significant decreases in extracellular levels of its main metabolites dihydroxyphenylacetic acid (DOPAC) and homovallinic acid (HVA) using the dose of 4 mM MeHg (35 +/- 3% and 48 +/- 1%, respectively), whereas non-significant changes in metabolite levels were observed with the doses of 40 microM and 400 microM MeHg. We explain these effects as a result of stimulated DA release and/or decreased DA intraneuronal degradation.

[The clinical management guidelines of the Sociedad Española de Cardiología in acute myocardial infarct]. / Guías de actuación clínica de la Sociedad Española de Cardiología en el infarto agudo de miocardio.

In the recent years, new possibilities have emerged in the diagnosis and management of acute myocardial infarction with ST segment elevation and its complications. Moreover, a deep transformation has taken place in the health care system organization, particularly in aspects related to care of patients presenting non-traumatic chest pain, both in pre-hospital and hospital areas. All these issues warrant a consensus document in Spain dealing with the role that these important changes should play in the whole management of myocardial infarction patients. This document revises and updates all the main clinical issues of acute myocardial infarction patients from the moment they contact with the health care system outside the hospital until they return home, after staying at the coronary care unit and the general hospitalization ward. All those aspects are considered not only in the uncomplicated myocardial infarction but also in the complicated one. This review also includes a set of recommendations on structural and organisational aspects, mainly referred to the prehospital and emergency levels.

A new electrocardiographic approach to identify the coronary artery responsible for acute inferior myocardial infarction: a study in 100 patients.

OBJECTIVE: The objective of this study is to analyze the value of the electrocardiogram in the identification of the coronary artery responsible for acute inferior myocardial infarction. MATERIAL AND METHODS: One hundred consecutive patients with acute inferior myocardial infarction were studied, 67 with a lesion in the right coronary artery and 33 in the circumflex artery. The ST segment changes in the inferior, lateral, precordial and right-chest leads were analyzed, as well as the arithmetic sum of the ST segment in the inferior and V2 leads (II + V2, III + V-2 and aVF + V2). We also developed a diagnostic process based on a stepwise approach of three electrocardiographic criteria: a) elevation of the ST segment in DI; b) arithmetic sum of the ST magnitude in DIII + V2 < 0; c) depression of the ST segment in V4R. RESULTS: This study shows that the most useful parameters to predict (with a specificity of 100%) the lesioned coronary artery in acute inferior myocardial infarction are: a) the arithmetic sum of the ST segment: aVF + V2 > 0, for the right coronary artery; b) the arithmetic sum of the ST segment: III + V2 < 0, for the circumflex artery; c) the arithmetic sum of the ST segment: aVF + V2 > 1 mm, for the proximal right coronary artery. CONCLUSIONS: The incorporation of these three criteria in an algorithm diagnostic system allows us to locate the coronary artery responsible for acute myocardial infarction with 100% sensitivity and specificity.

Electrocardiographic diagnosis of the responsible coronary artery in acute inferior myocardial infarction through right chest leads V3R-V8R. A prospective study.

In order to identify the electrocardiographic changes that occur in right-chest leads V3R-V8R for the most significant diagnosis of the responsible coronary artery of acute myocardial infarction, the authors performed a prospective study on 66 patients in whom coronary arteriography was done between the first and twelfth weeks after suffering the infarction. Electrocardiograms were done within the first six hours after the onset of symptoms. Lesions of the right coronary artery were found in 46 patients--27 at a proximal level and 19 at a distal one--and in 20 patients the circumflex coronary artery was injured. The electrocardiographic findings were studied in 2 groups of leads: V3R-V4R and V5R-V8R. An ST elevation equal to or higher than 0.5 mm and the presence of Q waves in V3R-V4R are specific markers of lesions of the right coronary artery (P < 0.001). Lowering of the ST segment in V3R-V4R is a specific marker of a circumflex artery lesion (P < 0.001). An ST elevation equal to or higher than 1 mm in V3R-V4R is specific for a proximal lesion of the right coronary artery (P < 0.001). No specific marker for a lesion of the distal right coronary artery was identified, its more significant characteristic being an "isoelectrical" ST segment (between 0 and 0.4 mm), an rS morphology and positive T waves in V3R-V4R.

[The acute and chronic effects of 10-mg nitroglycerin patches in stable angina of effort]. / Estudio del efecto agudo y crónico de los parches de 10 mg de nitroglicerina en la angina de esfuerzo estable.

INTRODUCTION AND OBJECTIVES: To assess the anti-ischemic efficacy of nitroglycerin patches (10 mg/day), we studied, by means of serial exercise testing (Bruce protocol), 10 patients with stable effort angina in a randomized, placebo-controlled, cross-over, double-blind essay. METHODS: Patients were exercised 1, 4, 12 and 24 hours after a single patch, and 4 and 12 hours after a 48 hours therapy course. Chronic therapy was assessed after both continuous and intermittent (intermission of 12 hours) patch application. RESULTS: After single patch, time to angina and time to 1 mm ST depression were significantly increased with respect to placebo at 1-hour test (83 +/- 27 s and 119 +/- 39 s, respectively), 4-hour test (100 +/- 34 s and 87 +/- 29 s, respectively) and 12-hour test (46 +/- 15 s and 64 +/- 20 s, respectively). No effect was demonstrated at 24-hour test. After continuous treatment no differences with respect to placebo were found at any test. After intermittent treatment time to angina was prolonged (75 +/- 23 s) only at 4-hour test, and time to 1 mm ST depression at 4-hour test (61 +/- 19 s) and 12-hour test (41 +/- 14 s). CONCLUSIONS: Nitroglycerin patches improve parameters of exercise ischemia for a 12 hours period. Tolerance is developed very early and provokes absolute lack of efficacy. Tolerance can be avoided with intermittent patch application. No treatment schedule shows 24 hours efficacy.

Comparison of acute and steady-state conditions of gallopamil therapy in stable angina pectoris.

We studied 12 patients with stable effort angina in a randomized, double-blind, cross-over and placebo-controlled trial to compare the different antianginal efficacy of "acute" and "chronic" (after reaching a steady-state level) gallopamil therapy. Efficacy was assessed using treadmill exercise testing (Bruce protocol) after a 50 mg single-dose and at the end of a nine-dose course of 50 mg of gallopamil (given three times a day). Three daily exercise tests were performed the first, second, fifth and eighth day of the study protocol at 8, 12 and 16 h. Four hours after a single-dose of gallopamil 50 mg both angina-free exercise time and time to 1 mm ST segment depression increased by a mean value of 78 s (p < 0.003) and 53 s (p < 0.03), respectively, with respect to placebo values. Under steady-state conditions exercise time and time to 1 mm ST segment depression increased by a mean value of 59 s (p < 0.009) and 46 s (p < 0.015), respectively, 4 h after the last dose. The duration of the anti-ischemic effects was no longer present after 8 h for both treatment schedules. Furthermore no significant differences were observed on parameters of ischemia after a single dose as compared to "chronic" therapy. The results of this study reveal that, in accordance with the pharmacodynamic properties of the drug, the anti-ischemic efficacy of 50 mg of gallopamil remains for approximately 4 h. Reaching a steady-state condition does not imply a prolongation of the anti-ischemic effect.

Amiodarone, phaeochromocytoma and cardiomyopathy.

The anaesthetic management of a patient with a phaeochromocytoma and cardiomyopathy is described. The control of dysrhythmias was the major problem. Ventricular dysrhythmias were treated with lignocaine, and intravenous amiodarone was used to control the supraventricular rhythm disturbances.