Interatrial blocks. A separate entity from left atrial enlargement: a consensus report.

Impaired interatrial conduction or interatrial block is well documented but is not described as an individual electrocardiographic (ECG) pattern in most of ECG books, although the term atrial abnormalities to encompass both concepts, left atrial enlargement (LAE) and interatrial block, has been coined. In fact, LAE and interatrial block are often associated, similarly to what happens with ventricular enlargement and ventricular block. The interatrial blocks, that is, the presence of delay of conduction between the right and left atria, are the most frequent atrial blocks. These may be of first degree (P-wave duration >120 milliseconds), third degree (longer P wave with biphasic [±] morphology in inferior leads), and second degree when these patterns appear transiently in the same ECG recording (atrial aberrancy). There are evidences that these electrocardiographic P-wave patterns are due to a block because they may (a) appear transiently, (b) be without associated atrial enlargement, and (c) may be reproduced experimentally. The presence of interatrial blocks may be seen in the absence of atrial enlargement but often are present in case of LAE. The most important clinical implications of interatrial block are the following: (a) the first degree interatrial blocks are very common, and their relation with atrial fibrillation and an increased risk for global and cardiovascular mortality has been demonstrated; (b) the third degree interatrial blocks are less frequent but are strong markers of LAE and paroxysmal supraventricular tachyarrhythmias. Their presence has been considered a true arrhythmological syndrome.

Pathological ankle-brachial index is equivalent of advanced age in acute coronary syndromes.

BACKGROUND: Age is one the factors associated with poor prognosis in acute coronary syndromes (ACS) and elderly patients are a high-risk collective with few parameters for mid-term cardiovascular stratification. We aimed to assess the predictive value of ankle-brachial index (ABI) in patients (> 75 years) for 1-year mortality after an ACS. MATERIALS AND METHODS: Prospective, observational and multicentre study of ACS patients in whom ABI was assessed during hospitalization. RESULTS: A total of 1·054 patients were included, mean age 66·6 (11·7) years from whom 26·6% were > 75 years. Elderly patients showed more history of cardiovascular disease and higher prevalence of all risk factors, except current smoking. Angiography and revascularization were performed less frequently in the elderly. Patients > 75 years showed higher presence of three vessel coronary disease and received fewer guideline-recommended treatments. Patients who died through the follow-up, mean time 387·9 ± 7·2 days, had lower ABI (0·73 ± 0·24 vs. 0·92 ± 0·22; P < 0·01), also in the elderly patients (0·73 ± 0·24 vs. 0·86 ± 0·23; P < 0·01). Cox regression analysis identified age > 75 years (HR: 2·30; IC 95% 1·26-4·18; P < 0·01) and ABI < 0·90 (HR: 3·58; IC 95% 1·80-7·15; P < 0·01) as risk factors for to 1-year mortality. Mortality was similar in elderly patients with ABI > 0·90 and young patients with ABI < 0·90; the worst prognosis was observed in elderly patients with ABI < 0·90 (HR: 10·01; 95% CI 3·74-27·15). CONCLUSIONS: Elderly patients represent a relevant collective of patients with ACS and are treated less optimally. ABI predicts 1-year mortality after an ACS in elderly patients.

Usefulness of an abnormal ankle-brachial index for detecting multivessel coronary disease in patients with acute coronary syndrome.

INTRODUCTION AND OBJECTIVES: The presence of peripheral arterial disease in patients with coronary artery disease is associated with a poor cardiovascular outcome. However, the majority of affected patients are asymptomatic and the condition is underdiagnosed. The ankle-brachial index (ABI) provides a simple method of diagnosis. The aim of this study was to assess the usefulness of an abnormal ABI for identifying multivessel coronary artery disease in patients with acute coronary syndrome (ACS). METHODS: We analyzed data on all ACS patients included in the PAMISCA multicenter study (with 94 participating hospitals) who underwent catheterization during admission. Patients were diagnosed with multivessel coronary disease if two or more major epicardial vessels or the left main coronary artery, or both, were affected. An ABI 1.4 was considered abnormal. RESULTS: The study included 1031 patients with a mean age of 67.7 years. Of these, 542 had multivessel disease (52.6%). Compare with those without multivessel disease, these patients were older (66.6 years vs. 62.6 years; P< .001), had higher prevalences of hypertension (65.9% vs. 56.2%; P< .005), diabetes mellitus (40.6% vs. 26.0%; P< .001) and hypercholesterolemia (89.1% vs. 80.4%; P< .001), and were more likely to have a history of cardiovascular disease (30.1% vs. 13.9%; P< .001) or an abnormal ABI (45.4% vs. 30.3%; P< .001). Multivariate analysis showed that the presence of an abnormal ABI was associated with an increased risk of multivessel disease (odds ratio=1.58; 95% confidence interval, 1.16-2.15; P< .05). CONCLUSIONS: In patients with ACS, an abnormal ABI was independently associated with the risk of multivessel coronary artery disease.

Utilidad de un índice tobillo-brazo patológico en la identificación de la enfermedad coronaria multivaso en pacientes con síndrome coronario agudo / Usefulness of an abnormal ankle-brachial index for detecting multivessel coronary disease in patients with acute coronary syndrome

Introducción y objetivos. La presencia de enfermedad arterial periférica se asocia con un peor pronóstico cardiovascular en el paciente coronario; sin embargo, la mayor parte de ellos están asintomáticos e infradiagnosticados. El índice tobillo-brazo (ITB) es un método sencillo para el diagnóstico de esta entidad. El objetivo del presente estudio es determinar el papel de un ITB patológico en la identificación de enfermedad coronaria multivaso en pacientes con síndrome coronario agudo (SCA). Métodos. Se analizaron todos los pacientes con SCA del registro multicéntrico PAMISCA (94 centros participantes) a los que se les había realizado un cateterismo durante su ingreso. Se consideró enfermedad coronaria multivaso la afectación de dos o más vasos mayores epicárdicos y/o enfermedad de tronco coronario izquierdo. Se consideró patológico un ITB > 1,4 o ≤ 0,9. Resultados. Se incluyeron 1.031 pacientes, con una edad media de 67,7 años. De ellos, 542 pacientes presentaron afectación multivaso (52,6%). Respecto a los pacientes sin afectación multivaso, este grupo presentaba una mayor edad (66,6 frente a 62,6; p < 0,001) y una mayor prevalencia de hipertensión arterial (el 65,9 frente al 56,2%; p < 0,005), diabetes mellitus (el 40,6 frente al 26%; p < 0,001), hipercolesterolemia (el 89,1 frente al 80,4%; p < 0,001), antecedentes de enfermedad cardiovascular (el 30,1 frente al 13,9%; p < 0,001) y un ITB patológico (el 45,4 frente al 30,3%; p < 0,001). En el análisis multivariante la presencia de un ITB patológico se asoció con un mayor riesgo de afectación multivaso (odds ratio = 1,58; intervalo de confianza del 95%, 1,16-2,15; p < 0,05). Conclusiones. En el paciente con SCA, un ITB patológico se asocia de manera independiente con la probabilidad de padecer enfermedad coronaria multivaso (AU)

Introduction and objectives. The presence of peripheral arterial disease in patients with coronary artery disease is associated with a poor cardiovascular outcome. However, the majority of affected patients are asymptomatic and the condition is underdiagnosed. The ankle-brachial index (ABI) provides a simple method of diagnosis. The aim of this study was to assess the usefulness of an abnormal ABI for identifying multivessel coronary artery disease in patients with acute coronary syndrome (ACS). Methods. We analyzed data on all ACS patients included in the PAMISCA multicenter study (with 94 participating hospitals) who underwent catheterization during admission. Patients were diagnosed with multivessel coronary disease if two or more major epicardial vessels or the left main coronary artery, or both, were affected. An ABI ≤0.9 or >1.4 was considered abnormal. Results. The study included 1031 patients with a mean age of 67.7 years. Of these, 542 had multivessel disease (52.6%). Compare with those without multivessel disease, these patients were older (66.6 years vs. 62.6 years; P < .001), had higher prevalences of hypertension (65.9% vs. 56.2%; P < .005), diabetes mellitus (40.6% vs. 26.0%; P < .001) and hypercholesterolemia (89.1% vs. 80.4%; P < .001), and were more likely to have a history of cardiovascular disease (30.1% vs. 13.9%; P < .001) or an abnormal ABI (45.4% vs. 30.3%; P < .001). Multivariate analysis showed that the presence of an abnormal ABI was associated with an increased risk of multivessel disease (odds ratio=1.58; 95% confidence interval, 1.16-2.15; P < .05). Conclusions. In patients with ACS, an abnormal ABI was independently associated with the risk of multivessel coronary artery disease (AU)

Impact of clinical and subclinical peripheral arterial disease in mid-term prognosis of patients with acute coronary syndrome.

Observational studies report poor prognosis of patients after acute coronary syndrome (ACS) in the presence of previous peripheral arterial disease (PAD), but data on subclinical PAD are scarce. This study was designed to assess the predictive value of clinical and subclinical PAD in the follow-up of patients after an ACS. We included 1,054 patients hospitalized for an ACS who survived the acute phase. Patients were divided into 3 groups: clinical PAD (previously diagnosed PAD or intermittent claudication), subclinical PAD (defined as ankle-brachial index 1.4), and no PAD. Clinical PAD was present in 150 patients (14.2%) and 298 cases of subclinical PAD were detected (28.3%). Patients with PAD (clinical and subclinical PAD) were significantly older and had a higher prevalence of hypertension and diabetes mellitus than those without PAD. During the 1-year follow-up, 59 patients died (5.6%). Previous PAD (hazard ratio 4.38, 95% confidence interval 1.96 to 9.82, p <0.001) and subclinical PAD (hazard ratio 2.35, 95% confidence interval 1.05 to 5.23, p <0.05) were associated with increased cardiovascular mortality. Moreover, patients with clinical PAD had higher rates of major cardiovascular events (myocardial infarction, angina, and heart failure) than patients with subclinical PAD or without PAD. In conclusion, beyond clinical PAD, measurement of ankle-brachial index after ACS provides substantial information on intermediate-term prognosis.

Prognostic value of low ankle-brachial index in patients with hypertension and acute coronary syndromes.

BACKGROUND: Peripheral arterial disease (PAD) is associated with an increased risk of cardiovascular morbidity and mortality. Nevertheless, many patients are asymptomatic, and this condition frequently remains underdiagnosed. An ankle-brachial index (ABI) of less than 0.9 is a noninvasive and simple marker in the diagnosis of PAD and is also predictive of target organ damage in hypertension. The prognostic value of such measurements in hypertensive patients with acute coronary syndrome (ACS) is unknown. METHODS: The Prevalence of Peripheral Arterial Disease in Patients with Acute Coronary Syndrome registry is a multicentre, observational and prospective study that aims to describe the prevalence of and prognosis for PAD, diagnosed by ABI in hypertensive patients with ACS. RESULTS: One thousand one hundred and one hypertensive patients with ACS and at least 40 years of age were prospectively studied. Mean age of the population was 67.4 (11.4) years, and 67.7% were men. The prevalence of ABI less than 0.9 was 42.6% (469 patients). This subgroup was significantly older, had a higher prevalence of diabetes, previous coronary heart disease or stroke, left ventricular hypertrophy and more severe coronary lesions. Hospital mortality was higher in hypertensive patients with ABI less than 0.9 (2.3 vs. 0.2%; P< 0.01). An ABI less than 0.9 was associated with an increased risk of heart failure after ACS (odds ratio, 1.4; P=0.04), higher hospital mortality (odds ratio, 13.0; P=0.03) and the composite endpoint of mortality, heart failure and angina (odds ratio, 1.4; P=0.03). CONCLUSION: Asymptomatic PAD is highly prevalent in hypertensive patients with ACS. An ABI less than 0.9 identifies a subset of patients with more extensive target organ damage and higher risk of hospital cardiovascular complications after an ACS.

Métodos diagnósticos de la enfermedad arterial periférica. Importancia del índice tobillo-brazo como técnica de criba / Diagnosis of peripheral vascular disease. Usefulness of the ankle-brachial index for screening

Debido a la elevada prevalencia de la enfermedad arterial periférica (EAP), que con frecuencia es asintomática, y sus graves repercusiones pronósticas, se recomienda la criba diagnóstica de los pacientes con alto riesgo de sufrirla: a) pacientes de edad > 70 años; b) pacientes de 50-69 años con historia de tabaquismo o diabetes mellitus; c) pacientes de 40-49 años con diabetes mellitus y al menos otro factor de riesgo de arteriosclerosis; d) síntomas compatibles con claudicación al esfuerzo o dolor isquémico en reposo; e) pulsos anormales en las extremidades inferiores; f) enfermedad arteriosclerosa en otros territorios, o g) pacientes con un score de Framingham entre el 10 y el 20%. Tanto la anamnesis como la exploración física tienen un valor para el diagnóstico de la enfermedad limitado porque, aunque son muy específicos, su sensibilidad es muy baja. Existen múltiples pruebas diagnósticas para valorar la presencia y la severidad de la enfermedad vascular periférica, entre las que cabe destacar el índice tobillo-brazo, las determinaciones de la presión segmentarias, los estudios de ecografía-Doppler y la angiografía mediante resonancia megnética, tomografía computarizada o de sustracción digital. En la actualidad se considera que el índice tobillo-brazo es el método no invasivo que presenta mejor rendimiento diagnóstico, ya que se trata de una prueba incruenta, fácil de realizar a la cabecera del paciente y con una elevada sensibilidad (superior al 90%) (AU)

Because peripheral arterial disease is highly prevalent, frequently silent, and has serious prognostic implications, it is recommended that diagnostic screening should be carried out in individuals at a high risk. This includes: a) those aged >70 years; b) those aged 50-69 years with a history of smoking or diabetes; c) those aged 40-49 years with diabetes mellitus and at least one other risk factor for atherosclerosis; d) those with symptoms indicating claudication on exercise or ischemic pain at rest; e) those with abnormal pulses in the lower extremities; f) those with atherosclerosis in other vascular territories; and g) those with a Framingham score of 10-20%. Neither anamnesis nor physical examination is of much value for disease diagnosis; although they are very specific, their sensitivity is very low. A large number of different diagnostic techniques are available for investigating the presence and severity of peripheral vascular disease, including ankle-brachial index measurement, segmental limb pressure measurement, Doppler ultrasonography, and various forms of angiography involving magnetic resonance imaging, computed tomography or digital subtraction imaging. At present, the ankle-brachial index is the non-invasive method that gives the best diagnostic performance. It is simple, inexpensive and has a high sensitivity (i.e. greater than 90%) (AU)

[Outcome of pericardiectomy for chronic constrictive pericarditis]. / Resultados de la pericardiectomía por pericarditis constrictiva crónica.

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1-9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover.

Resultados de la pericardiectomía por pericarditis constrictiva crónica / Outcome of pericardiectomy for chronic constrictive pericarditis

El objetivo del presente estudio fue analizar los resultados de la pericardiectomía para el tratamiento de la pericarditis constrictiva crónica. Se analizó retrospectivamente a 31 pacientes consecutivos intervenidos entre 1982 y 2005. El seguimiento medio fue de 6,7 años. La mortalidad hospitalaria fue del 16% (5/31 pacientes). La causa de la muerte fue bajo gasto en 3 pacientes, shock séptico en 1 y sangrado en otro. La clase funcional no mejoró de forma sustancial en 6 de 26 pacientes que sobrevivieron y empeoró en 1 paciente. La probabilidad acumulada de supervivencia actuarial fue del 82% a los 6 meses, el 82% a los 1-9 años y el 64% a los 10 años. En conclusión, la pericardiectomía mejoró de los síntomas a la mayoría de los pacientes en el seguimiento tardío. Un subgrupo de pacientes no experimentó alivio de los síntomas clínicos probablemente porque la función cardiaca no se restableció completamente (AU)

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1­9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover (AU)

[Intermediate coronary care units: rationale, infrastructure, equipment, and referral criteria]. / Unidades coronarias de cuidados intermedios: base racional, infraestructura, equipamiento e indicaciones de ingreso.

The Spanish Working Group on Coronary Artery Disease of Spanish Society of Cardiology has considered to be necessary the development of this document on the need, structure and organization of Intermediate Cardiac Care Units (ICCU). Acute coronary syndrome registries show that an important percentage of patients receive a suboptimal care, due to an inadequate management of health resources or absence of them. Intermediate cardiac care units arise to solve these challenges and to manage in an efficient way these expensive and limited resources. Their aims are: a) to provide each patient the level of care required; b) to optimize the structural, technical and human resources, and c) to make easier continuous care and care gradient. As a result, ICCU should be established as an essential part of the cardiology department aim to cardiac patients requiring monitoring and medical care superior to those available in a regular cardiac ward but whose risk does not justify the technical and human costs of a Coronary Unit. This document describes the structure (equipment, human resources, management) required to reach the goals previously reported and includes recommendations about indications of admission in a ICCU. These indications include: a) patients with NSTE-ACS with intermediate or high risk but hemodynamically stable, and b) low risk STEAMI or high risk STEAMI stabilized after an initial admission at the Coronary Unit. The admission of some patients undergoing invasive procedures or suffering non-coronary acute cardiac diseases, is also considered.

Unidades coronarias de cuidados intermedios: base racional, infraestructura, equipamiento e indicaciones de ingreso / Intermediate coronary care units: rationale, infrastructure, equipment, and referral criteria

La Sección de Cardiopatía Isquémica y Unidades de la Sociedad Española ha considerado necesario el desarrollo de este documento sobre la necesidad, la estructura y la organización de las unidades coronarias de cuidados intermedios (UCCI). Los registros de síndrome coronario agudo (SCA) realizados en España indican que una proporción importante de pacientes recibe una atención subóptima, en parte debido a una organización inadecuada de los recursos asistenciales o a la falta de éstos. Las UCCI surgen de la necesidad de corregir estos aspectos y gestionar con eficiencia unos recursos escasos y costosos. Sus objetivos son: a) proporcionar a cada paciente el grado de cuidados que requiere; b) optimizar los recursos estructurales, técnicos y humanos, y c) facilitar el continuo asistencial y el gradiente de cuidados. Las UCCI se deben constituir en una parte esencial del servicio de cardiología destinada a la atención de enfermos cardiológicos que requieren monitorización, cuidados y capacidad de respuesta médica superiores a los disponibles en una planta de hospitalización convencional de cardiología, pero cuyo riesgo no justifica la utilización de los recursos técnicos y humanos de una unidad coronaria. Este documento describe la infraestructura (equipamiento, dotación de personal y organización) que se precisa para cumplir los objetivos descritos anteriormente y contiene recomendaciones sobre las indicaciones de ingreso en estas unidades intermedias. Éstas incluyen a determinados pacientes con: a) SCA sin elevación del segmento ST de riesgo intermedio o alto pero estables hemodinámicamente, y b) infarto agudo de miocardio con elevación del segmento ST no de alto riesgo, o bien, de alto riesgo, pero estabilizado después de una fase inicial complicada en la unidad coronaria. También se contempla el ingreso de algunos pacientes después de determinados procedimientos invasivos y de algunas formas de cardiopatías agudas no coronarias (AU)

The Spanish Working Group on Coronary Artery Disease of Spanish Society of Cardiology has considered to be necessary the development of this document on the need, structure and organization of Intermediate Cardiac Care Units (ICCU). Acute coronary syndrome registries show that an important percentage of patients receive a suboptimal care, due to an inadequate management of health resources or absence of them. Intermediate cardiac care units arise to solve these challenges and to manage in an efficient way these expensive and limited resources. Their aims are: a) to provide each patient the level of care required; b) to optimize the structural, technical and human resources, and c) to make easier continuous care and care gradient. As a result, ICCU should be established as an essential part of the cardiology department aim to cardiac patients requiring monitoring and medical care superior to those available in a regular cardiac ward but whose risk does not justify the technical and human costs of a Coronary Unit. This document describes the structure (equipment, human resources, management) required to reach the goals previously reported and includes recommendations about indications of admission in a ICCU. These indications include: a) patients with NSTE-ACS with intermediate or high risk but hemodynamically stable, and b) low risk STEAMI or high risk STEAMI stabilized after an initial admission at the Coronary Unit. The admission of some patients undergoing invasive procedures or suffering non-coronary acute cardiac diseases, is also considered (AU)

Delayed-contrast enhancement cardioresonance in transient left ventricular apical ballooning.

Transient left ventricular apical ballooning (TAB) is a condition that mimics acute coronary syndrome typically without coronary angiographic stenosis. Patients present with typical chest pain, ECG changes suggesting ischemia, and a slight elevation of myocardial injury markers such as creatine kinase and troponines. Ballooning during ventricular systole of the cardiac apex is a characteristic feature of this entity. It is transient and it usually resolves after a few days together with normalization of ECG changes. Initially, apical dyskinesis can be diagnosed by any cardiac imaging technique that allows myocardial wall motion assessment. Recent advances in cardiovascular magnetic resonance imaging (CMR) have made this technique to become the gold-standard method to assess myocardial infarction. CMR provides an excellent and reproducible assessment of segmental wall motion abnormalities and, more importantly, it allows an accurate depiction of myocardial necrotic area by means of delayed contrast-enhancement method. Therefore, it may be particularly useful in the assessment of TAB by demonstrating segmental dysfunction in the absence of myocardial irreversible damage. We report three cases of TAB in which contrast- enhanced CMR emerged as an excellent diagnostic tool.

Revascularización coronaria en el paciente diabético / Coronary revascularization in diabetic patients

La enfermedad cardiovascular es la principal causa de morbilidad y mortalidad en los pacientes con diabetes mellitus. Se ha demostrado que los pacientes diabéticos presentan una mayor incidencia de enfermedad coronaria multivaso, con mayor frecuencia de lesiones complejas, pobres lechos distales y una progresión de la enfermedad más rápida que la población general no diabética. La revascularización coronaria percutánea (ICP) ha demostrado su utilidad en los pacientes diabéticos. Sin embargo, aunque los resultados angiográficos iniciales son buenos, hay una mayor incidencia de reestenosis, un riesgo más elevado de complicaciones y una menor supervivencia a largo plazo. Los stents farmacoactivos han reducido notablemente el riesgo de reestenosis y complicaciones tardías. En espera de los resultados de los estudios actualmente en marcha, en los pacientes diabéticos con enfermedad multivaso, la cirugía de derivación aortocoronaria sigue siendo el tratamiento de primera elección. Sin embargo, hay que destacar que, desde un punto de vista práctico, a la hora de indicar cirugía de derivación aortocoronaria o ICP deberemos basarnos en las características particulares del paciente (p. ej., comorbilidad asociada) y en la experiencia del propio centro, ya que hay notables diferencias en función de la experiencia del equipo quirúrgico y de cardiología intervencionista. Por último, es muy importante destacar que, en los pacientes diabéticos en los que se realiza revascularización coronaria, con independencia del método utilizado, es de trascendental importancia establecer un tratamiento médico enérgico que incluya modificaciones en el estilo de vida (tabaquismo, síndrome metabólico, etc.), antiagregación plaquetaria, tratamiento con estatinas en las dosis adecuadas (objetivo terapéutico con un valor de colesterol unido a lipoproteínas de baja densidad < 70 mg/dl), bloqueadores beta, inhibidores de la enzima de conversión de la angiotensina-inhibidores de los receptores de la angiotensina II, control glicérico-metabólico, etc., ya que en estos pacientes la progresión de la enfermedad es mucho más rápida que en la población no diabética y el riesgo de complicaciones, a pesar de la revascularización, sigue siendo elevado (AU)

Cardiovascular disease is the principle cause of morbidity and mortality in patients with diabetes mellitus. It has been observed that diabetic patients usually present with a higher incidence of coronary artery disease involving multiple vessels, complex lesions, poor distal vascular beds, and more rapid disease progression than does the general nondiabetic population. Percutaneous coronary revascularization has been shown to be useful in diabetic patients. However, although initial angiographic results are good, there is a high incidence of restenosis, a increased risk of complications, and a low long-term survival rate. Drugeluting stent have markedly reduced the risk of restenosis and late complications. While the results of ongoing studies are still awaited, bypass surgery remains the treatment of first choice in diabetic patients with multivessel disease. Nevertheless, it is important to remember that, from a practical point of view, the decision on when to carry out bypass surgery or percutaneous coronary intervention must be based on the individual patient’s characteristics (e.g., associated comorbid conditions) and on the experience of the center involved. The level of experience of surgical teams and interventional cardiologists varies widely. Finally, it should be emphasized that the administration of aggressive medical treatment is of paramount importance in diabetic patients who are undergoing coronary revascularization, irrespective of the technique used. Treatment should include lifestyle modification (e.g., for smoking and metabolic syndrome), and, for example, antiplatelet therapy, an adequate statin dose (with the aim of achieving a low-density lipoprotein cholesterol level < 70 mg/dL), beta-blockers, angiotensinconverting enzyme inhibitors, and angiotensin II receptor antagonists because disease progression is much more rapid in these patients than in the nondiabetic population and the risk of complications remains elevated, despite revascularization (AU)

Stent implantation in variant angina refractory to medical treatment.

BACKGROUND: Vasospastic angina usually responds well to medical treatment. HYPOTHESIS: The present study describes our experience in patients who received a coronary stent because of recurrent variant angina refractory to medical treatment and evaluates stent implantation as an alternative treatment. MATERIALS AND METHODS: Between March 1998 and February 2005, recurrent variant angina was diagnosed in 22 patients admitted to our coronary care unit. Of these, five patients (22.7%), were refractory to pharmacologic treatment. Coronary angiography and coronary stents were indicated. Clinical follow-up was 29 +/- 6 months. RESULTS: Stenting was performed during diagnostic coronary angiography in two patients. In the other three patients, the stent was implanted 24-48 h later. We observed coronary spasm recurrences proximal or distal to the stent in four patients-two during the stent implantation procedure and the other two in the coronary care unit within 48 h post angioplasty. Three patients where treated with additional stenting and the fourth patient improved with pharmacologic treatment. During follow-up three patients remained asymptomatic. The fourth patient had diffuse in-stent restenosis in the third month, and the fifth patient showed a de novo lesion in the treated segment 2 years later. CONCLUSIONS: Stent implantation in patients with recurrent variant angina refractory to medical treatment may be an alternative treatment in carefully selected, clinically unstable patients. Spasm recurrences may occur in other segments of the treated artery, probably due to the diffuse nature of the disease. Immediate and continued surveillance is recommended because of the risk of adverse clinical events.

[Prognosis of patients admitted in a coronary care unit after resucitating from out-of-hospital sudden cardiac death]. / Pronóstico de los pacientes ingresados en una unidad coronaria después de la recuperación de una muerte súbita de causa cardíaca fuera del hospital.

BACKGROUND AND OBJECTIVE: The aims of the present study were to analyze the prognosis after resuscitation from out-of-hospital sudden cardiac death in patients admitted to the coronary care unit, and to identify the predictor variables of morbi-mortality. PATIENTS AND METHOD: From November 1999 to January 2004 we analyzed 63 patients (47 males) aged 61 +/- 12 years who were admitted to the coronary care unit following successful resuscitation from sudden cardiac death. The clinical and electrocardiographic characteristics were correlated with the mortality and neurological impairment. RESULTS: Thirty-five patients (55.5%) were discharged, while twenty-eight patients (45.5%) died 28 +/- 4 days after admission, most of them during hospitalization. The main underlying disorder was coronary artery disease (80.9%). When survivors and non-survivors were compared, the variables associated with a worse prognosis were diabetes mellitus (68.4% vs 17.1%, P < .02), the presence of valvular heart disease (28.6% vs 0%, p < 0.003), chronic atrial fibrillation (42.9% vs 14.3%, P < .02) and asystole as the initial rhythm observed (42.9% vs 11.4%, P < .01). Multivariate analysis identified asystole as an independent factor of poor prognosis (P < .02). Death was due to severe postanoxic neurological damage in 23 of 28 deaths (82.1%). The remaining 5 patients died due to their underlying cardiac disease (P < .01). The variables associated with neurological damage were out-of hospital resuscitation, delay in beginning resuscitation maneuvers, arrival time > 5 minutes and unconsciousness on admission. CONCLUSIONS: Although many patients survive following resuscitation from out-of-hospital sudden cardiac death, mortality remains high. Neurological impairment is the main cause of mortality. Prognosis is determined by the variables related to the underlying disease, the delay in onset of resuscitation maneuvers and postanoxia cerebral damage.

Pronóstico de los pacientes ingresados en una unidad coronaria después de la recuperación de una muerte súbita de causa cardíaca fuera del hospital / Prognosis of patients admitted in a coronary care unit after resucitating from out-of-hospital sudden cardiac death

Fundamento y objetivo: Los objetivos del presente estudio han sido analizar el pronóstico en pacientes recuperados de una muerte súbita cardíaca extrahospitalaria que ingresaron en la unidad de cuidados intensivos coronarios, así como identificar los factores asociados a la morbimortalidad. Pacientes y método: Analizamos a 63 pacientes consecutivos (47 varones), con una edad media (desviación estándar) de 61 (12) años, que ingresaron entre noviembre de 1999 y enero de 2004 recuperados de una muerte súbita cardíaca y permanecieron en la unidad de cuidados intensivos coronarios. Se examinó la relación de las características clínicas y electrocardiográficas con la mortalidad y las secuelas neurólogicas. Resultados: Sobrevivieron 35 pacientes (55,5%), mientras que 28 (44,5%) fallecieron transcurridos una media de 28 (4) días desde el ingreso, la mayoría en el hospital. El sustrato anatómico principal fue la cardiopatía isquémica (80,9%). En los pacientes que fallecieron, comparados con los que sobrevivieron, las variables que se asociaron a un peor pronóstico fueron la diabetes mellitus (un 68,4 frente al 17,1%; p < 0,02), la presencia de cardiopatía valvular (el 28,6 frente al 0%; p < 0,003), la fibrilación auricular crónica (un 42,9 frente al 14,3%; p < 0,02) y la asistolia como primer ritmo observado (el 42,9 frente al 11,4%; p < 0,01). El análisis multivariable identificó la asistolia como factor independiente de mal pronóstico (p < 0,02). En 23 de los 28 pacientes que fallecieron la muerte fue secundaria a secuelas cerebrales postanóxicas graves (82,1%), mientras que los 5 pacientes restantes fallecieron a consecuencia de su cardiopatía subyacente (p < 0,01). Las variables que se asociaron a daño neurológico fueron la reanimación realizada extrahospitalariamente, el hecho de que el paciente ingresara inconsciente, el tiempo de llegada superior a 5 min y el tiempo de retraso en el inicio de la resucitación cardiopulmonar. Conclusiones: La supervivencia en pacientes recuperados de una muerte súbita cardíaca extrahospitalaria es alta, aunque la mortalidad todavía sigue siendo elevada. Las complicaciones neurológicas son la principal causa de mortalidad. El pronóstico viene determinado por la presencia de factores relacionados con la enfermedad subyacente, el tiempo en iniciar las maniobras de recuperación y la lesión cerebral postanóxica

Background and objective: The aims of the present study were to analyze the prognosis after resuscitation from out-of-hospital sudden cardiac death in patients admitted to the coronary care unit, and to identify the predictor variables of morbi-mortality. Patients and method: From November 1999 to January 2004 we analyzed 63 patients (47 males) aged 61±12 years who were admitted to the coronary care unit following successful resuscitation from sudden cardiac death. The clinical and electrocardiographic characteristics were correlated with the mortality and neurological impairment. Results: Thirty-five patients (55.5%) were discharged, while twenty-eight patients (45.5%) died 28±4 days after admission, most of them during hospitalization. The main underlying disorder was coronary artery disease (80.9%). When survivors and non-survivors were compared, the variables associated with a worse prognosis were diabetes mellitus (68.4% vs 17.1%, P5 minutes and unconsciousness on admission. Conclusions: Although many patients survive following resuscitation from out-of-hospital sudden cardiac death, mortality remains high. Neurological impairment is the main cause of mortality. Prognosis is determined by the variables related to the underlying disease, the delay in onset of resuscitation maneuvers and postanoxia cerebral damage

Angina variante asociada con latanoprost / Variant angina associated with latanoprost

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