Manejo clínico y pronóstico de pacientes mayores supervivientes al infarto de miocardio / Clinical management and prognosis in elderly survivors of myocardial infarction

Introducción: los pacientes de edad avanzada con infarto agudo de miocardio (IAM) presentan elevada morbimortalidad. Nuestro objetivo es conocer el abordaje clínico recibido por el paciente de edad avanzada que sobrevive al IAM en nuestro medio y su pronóstico a corto plazo. Material y métodos: se recogieron datos correspondientes a los pacientes dados de alta tras presentar un IAM. Se comparó el tratamiento clínico y el pronóstico de los pacientes mayores de 70 años con el resto. Se realizó un seguimiento medio de 11,7 meses. Resultados: doscientos nueve pacientes, que se dividieron en 2 grupos según su edad: grupo de jóvenes (111 pacientes = 70 años de edad). No hubo diferencias en el tipo de infarto presentado ni en el tratamiento de revascularización recibido. En los mayores hubo una menor realización de ergometría y de cateterismo. Entre los que se realizó cateterismo, los mayores presentaban un mayor número de arterias coronarias con lesiones graves (1,67 ± 0,9 frente a 1,32 ± 0,9; p = 0,03). El porcentaje de revascularización fue similar. Durante el seguimiento, no se observaron diferencias en la mortalidad (global, 5,7%), ni en la tasa de reingresos o revascularización. Conclusiones: los pacientes mayores que sobreviven a un IAM han sido tratados de forma similar al resto, aunque la realización de ergometría y cateterismo es más baja. Su enfermedad coronaria es más grave y el porcentaje de revascularización en los que se indicó cateterismo, similar al resto. Su pronóstico a corto plazo es bueno

ntroduction: patients of an advanced age who suffer an acute myocardial infarction (AMI) have an elevated risk of morbidity and mortality. Our objective was to identify the clinical management of elderly patients recovering from an AMI in our milieu and their short-term prognosis. Material and methods: data were collected on survivors of an AMI. The clinical management and outcome of patients aged over 70 years was compared with those of patients aged less than 70 years. The mean follow-up was 11.7 months. Results: two hundred and nine patients were divided into two groups according to age: a «younger» group (111 patients aged under 70 years) and an «older» group (98 patients aged 70 and over). There were no differences in the type of infarction or in the type of revascularisation. Fewer ergometries and catheterisations were performed in the older patients. Among those who underwent catheterisation, the older group presented a greater number of coronary arteries with severe lesions (1.67 ± 0.9 as opposed to 1.32 ± 0.9, p = 0.03) than the younger group. The percentage of revascularisation was similar in both groups. During the follow-up, no differences in mortality (overall mortality was 5.7%), the rate of re-admissions or revascularisation were observed. Conclusions: patients of an advanced age surviving an AMI were treated similarly to all other patients, although they underwent less ergometry and cardiac catheterisation. Their coronary disease is more severe and the percentage of revascularisation for which catheterisation was indicated was similar to that in younger patients. Their short-term prognosis was good

[Skin lesions and renal failure after myocardial infarction]. / Lesiones cutáneas e insuficiencia renal tras infarto agudo de miocardio.

We describe the clinical case of a patient with acute myocardial infarction treated with t-PA fibrinolysis, who developed renal failure and cutaneous lesions of the livedo reticularis type, probably caused by embolization of cholesterol crystals. The main characteristics of this rare clinical entity are reviewed.

[Anomalous origin of the left coronary artery from the right sinus of Valsalva with retro-aortic path]. / Origen anómalo de la arteria coronaria izquierda del seno de Valsalva derecho con trayecto retroaórtico.

We present the case of a patient with a dilated cardiomyopathy in which an anomaly in the origin of the left coronary artery, that arose from the right sinus of Valsalva through an own ostium and followed a retro aortic course, was recognized as an angiographic finding. The possible pathways the anomalous artery may follow, and their different clinical significances are reviewed. The angiographic sign of the aortic root, described for the identification of the anomalous origin of circumflex artery, is reviewed and its utility in the case of anomalous left coronary artery is demonstrated. In our case, Thallium-201 didn't show myocardial ischemia with the exercise and that justified, beside the doubtful efficacy of surgery as prophylaxis of sudden death when the anomalous course is retro-aortic, to maintain a conservative attitude.

[Heart effect of arterial hypertension. Heart hypertrophy as a risk factor. Study technics (electrocardiogram, echocardiography, exercise test and Holter]. / Repercusión cardíaca de la hipertensión arterial. Hipertrofia cardíaca como factor de riesgo. Técnicas de estudio (electrocardiograma, ecocardiografía, prueba de esfuerzo y Holter).

Left ventricular hypertrophy, a known consequence of hypertension, is associated with an excess mortality independent of other known cardiovascular risk factors. There are multiple mechanisms in which left ventricular hypertrophy may account for this excess mortality including increased incidence of arrhythmias, systolic an diastolic dysfunction, relative ischemia, and associated coronary artery disease. Diastolic dysfunction, manifested by reduced ventricular distensibility of the hypertrophic left ventricle, appears to be an early characteristic of the hypertensive heart since echocardiographic techniques have demonstrated diastolic filling abnormalities in untreated essential hypertensives even before significant left ventricular hypertrophy appears. The presence of left ventricular hypertrophy is difficult to detect by electrocardiography. Echocardiography seems to be the best non-invasive method for the detection of hypertensive heart disease: it shows early abnormalities of left ventricular compliance, frequently left ventricular hypertrophy and late abnormalities of myocardial contractility.

[Up-dated treatment of arterial hypertension: progressive and individualized. Reduction of the heart mass]. / Tratamiento actualizado de la hipertensión arterial: escalonado e individualizado. Reducción de la masa cardíaca.

The usefulness and limitations of the current medical treatment of high blood pressure are analysed. The latest strategies in the management of hypertension are presented, with emphasis on the treatment of all associated cardiovascular risk factors. This is and important therapeutic goal of Preventive Cardiology. The individualized treatment, that is to say, the selection of the antihypertensive therapy according to the characteristics of each patient, is discussed as an objective of the present therapy. Finally, the new drugs and the recent advances in the classic ones are examined with a special focus on their hemodynamic actions and on their role in left ventricular hypertrophy.