Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE) Follow-up.

PURPOSE: Short-term outcomes have been well characterized in acute coronary syndromes; however, longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore, we describe the longer-term outcomes, procedures, and medication use in Global Registry of Acute Coronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performance of the discharge GRACE risk score in predicting 2-year mortality. METHODS: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome were enrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronary syndrome diagnosis in 57 sites. RESULTS: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge, 14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery, and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), beta-blocker (80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heart failure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE risk score was highly predictive of all-cause mortality at 2 years (c-statistic 0.80). CONCLUSION: In this large multinational cohort of acute coronary syndrome patients, there were important later adverse consequences, including frequent morbidity and mortality. These findings were seen in the context of additional coronary procedures and despite continued use of evidence-based therapies in a high proportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors for predicting longer-term mortality was maintained.

Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE)Follow-up

PURPOSE: Short-term outcomes have been well characterized in acute coronary syndromes; however,longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardialinfarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore,we describe the longer-term outcomes, procedures, and medication use in Global Registry of AcuteCoronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performanceof the discharge GRACE risk score in predicting 2-year mortality.METHODS: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome wereenrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronarysyndrome diagnosis in 57 sites.RESULTS: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge,14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery,and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), betablocker(80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heartfailure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE riskscore was highly predictive of all-cause mortality at 2 years (c-statistic 0.80).CONCLUSION: In this large multinational cohort of acute coronary syndrome patients, there were importantlater adverse consequences, including frequent morbidity and mortality. These findings were seen in thecontext of additional coronary procedures and despite continued use of evidence-based therapies in a highproportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors forpredicting longer-term mortality was maintained.

Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE)Follow-up

PURPOSE: Short-term outcomes have been well characterized in acute coronary syndromes; however,longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardialinfarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore,we describe the longer-term outcomes, procedures, and medication use in Global Registry of AcuteCoronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performanceof the discharge GRACE risk score in predicting 2-year mortality.METHODS: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome wereenrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronarysyndrome diagnosis in 57 sites.RESULTS: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge,14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery,and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), betablocker(80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heartfailure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE riskscore was highly predictive of all-cause mortality at 2 years (c-statistic 0.80).CONCLUSION: In this large multinational cohort of acute coronary syndrome patients, there were importantlater adverse consequences, including frequent morbidity and mortality. These findings were seen in thecontext of additional coronary procedures and despite continued use of evidence-based therapies in a highproportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors forpredicting longer-term mortality was maintained.

Evaluación del haz espinotalámico mediante tractografía por resonancia magnética: nuevos aportes en la fisiopatología del dolor en pacientes con síndrome X / Spinothalamic Assessment by Magnetic Resonance Tractography: new Contributions in the Pathophysiology of Pain in Patients with Syndrome X

Introducción El síndrome X se asocia con signos y síntomas de isquemia, sin obstrucción significativa de las arterias coronarias. En los pacientes con este síndrome existe un aumento en la percepción de los estímulos cardíacos, aunque la causa de este trastorno se desconoce. Objetivo Explorar los tractos nerviosos sensitivos involucrados en la percepción anormal del dolor en mujeres que sufren de síndrome X. Material y métodos Estudio prospectivo que incluyó 24 mujeres: 12 con síndrome X, 6 con enfermedad coronaria documentada y 6 controles sanas. Se realizó el mapeo del tracto espinotalámico lateral mediante tractografía por difusión. Se analizaron las características anatómicas (líneas, vóxels, longitud) y físicas (anisotropía fraccional, coeficiente de difusión aparente, difusividad) de cada tracto. Resultados El haz espinotalámico lateral se pudo aislar en todas las pacientes evaluadas. No hubo diferencias en las características físicas de los tractos, pero existió una diferencia significativa en el número de vóxels de los tres grupos a expensas del grupo síndrome X (101,2 ± 46,9 vs. 83,2 ± 24 vs. 66 ± 16; p = 0,030), con una tendencia a presentar un número mayor de líneas en cada tracto. Conclusiones Se hallaron diferencias en las características anatómicas de los tractos de las pacientes con síndrome X respecto de los controles sanos y de las pacientes con enfermedad coronaria, con indemnidad en las características físicas de las fibras. Es probable que este estudio experimental sea el primero en demostrar que es posible evaluar in vivo los tractos neurológicos involucrados en la transmisión del dolor en este grupo de pacientes, lo cual abre un nuevo campo de investigación.

Background Syndrome X is associated with signs and symptoms of ischemia without significant coronary artery obstruction. There is an increased perception of cardiac stimuli in these patients, although the cause of this disorder is unknown. Objective The aim of this study was to analyze sensory nerve tracts involved in abnormal perception of pain in women with syndrome X. Methods This prospective study included 24 women: 12 with syndrome X; 6 with documented coronary heart disease, and 6 healthy controls. Lateral spinothalamic tract mapping by diffusion trac-tography was performed. The anatomic features (lines, voxels, and length) and physical features (fractional anisotropy, apparent diffusion coefficient, diffusivity) of each tract were analyzed. Results The lateral spinothalamic tract was isolated in all patients. No differences were found in the physical characteristics of the tracts, but there was a significant difference in the number of voxels of the syndrome X group when compared to the other two groups (101.2±46.9 vs. 83.2±24 vs. 66±16; p=0.030), with a tendency towards larger number of lines in each tract. Conclusions There were differences in the anatomic characteristics of tracts in syndrome X patients with respect to healthy controls and coronary artery disease patients, with indemnity in the physical characteristics of the fibers. This is probably the first experimental study to show that it is possible to evaluate "in vivo" neurological tracts involved in pain transmission in syndrome X patients, opening a new field of research.

Evaluación del haz espinotalámico mediante tractografía por resonancia magnética: nuevos aportes en la fisiopatología del dolor en pacientes con síndrome X / Spinothalamic Assessment by Magnetic Resonance Tractography: new Contributions in the Pathophysiology of Pain in Patients with Syndrome X

Introducción El síndrome X se asocia con signos y síntomas de isquemia, sin obstrucción significativa de las arterias coronarias. En los pacientes con este síndrome existe un aumento en la percepción de los estímulos cardíacos, aunque la causa de este trastorno se desconoce. Objetivo Explorar los tractos nerviosos sensitivos involucrados en la percepción anormal del dolor en mujeres que sufren de síndrome X. Material y métodos Estudio prospectivo que incluyó 24 mujeres: 12 con síndrome X, 6 con enfermedad coronaria documentada y 6 controles sanas. Se realizó el mapeo del tracto espinotalámico lateral mediante tractografía por difusión. Se analizaron las características anatómicas (líneas, vóxels, longitud) y físicas (anisotropía fraccional, coeficiente de difusión aparente, difusividad) de cada tracto. Resultados El haz espinotalámico lateral se pudo aislar en todas las pacientes evaluadas. No hubo diferencias en las características físicas de los tractos, pero existió una diferencia significativa en el número de vóxels de los tres grupos a expensas del grupo síndrome X (101,2 ± 46,9 vs. 83,2 ± 24 vs. 66 ± 16; p = 0,030), con una tendencia a presentar un número mayor de líneas en cada tracto. Conclusiones Se hallaron diferencias en las características anatómicas de los tractos de las pacientes con síndrome X respecto de los controles sanos y de las pacientes con enfermedad coronaria, con indemnidad en las características físicas de las fibras. Es probable que este estudio experimental sea el primero en demostrar que es posible evaluar in vivo los tractos neurológicos involucrados en la transmisión del dolor en este grupo de pacientes, lo cual abre un nuevo campo de investigación.(AU)

Background Syndrome X is associated with signs and symptoms of ischemia without significant coronary artery obstruction. There is an increased perception of cardiac stimuli in these patients, although the cause of this disorder is unknown. Objective The aim of this study was to analyze sensory nerve tracts involved in abnormal perception of pain in women with syndrome X. Methods This prospective study included 24 women: 12 with syndrome X; 6 with documented coronary heart disease, and 6 healthy controls. Lateral spinothalamic tract mapping by diffusion trac-tography was performed. The anatomic features (lines, voxels, and length) and physical features (fractional anisotropy, apparent diffusion coefficient, diffusivity) of each tract were analyzed. Results The lateral spinothalamic tract was isolated in all patients. No differences were found in the physical characteristics of the tracts, but there was a significant difference in the number of voxels of the syndrome X group when compared to the other two groups (101.2±46.9 vs. 83.2±24 vs. 66±16; p=0.030), with a tendency towards larger number of lines in each tract. Conclusions There were differences in the anatomic characteristics of tracts in syndrome X patients with respect to healthy controls and coronary artery disease patients, with indemnity in the physical characteristics of the fibers. This is probably the first experimental study to show that it is possible to evaluate "in vivo" neurological tracts involved in pain transmission in syndrome X patients, opening a new field of research.(AU)

Presencia de angiogénesis en placas vulnerables ateroscleróticas en corazones humanos aparentemente sanos / Angiogenesis in Vulnerable Atherosclerotic Plaques in Apparently Healthy Human Hearts / Angiogenesis in Vulnerable Atherosclerotic Plaques in Apparently Healthy Human Hearts

Introducción La angiogénesis o neovascularización involucra la formación de nuevos conductos en las adyacencias de vasos preexistentes. Esta proliferación vascular es frecuente en varias circunstancias clínicas, como es el caso de la aterosclerosis. Los microvasos de las placas ateroscleróticas coronarias pueden estar vinculados a la inestabilidad de la lesión. Objetivo Correlacionar la presencia de angiogénesis en placas ateroscleróticas con los criterios de vulnerabilidad de la clasificación de la American Heart Association (AHA). Material y métodos En 121 corazones de donantes no diabéticos aparentemente sanos y mayores de 40 años destinados para homoinjertos se examinaron las arterias coronarias y todas las áreas de estrechamiento luminal se sometieron a estudios histológicos, inmunohistoquímicos y morfométricos. Para el análisis de la angiogénesis se empleó un puntaje semicuantitativo (escala 0-3). Se realizó un análisis de regresión logística univariado y multivariado para identificar factores de riesgo relacionados con la angiogénesis. Resultados Se hallaron 143 lesiones de riesgo alto (AHA tipos IV, V y VI) en las arterias descendente anterior (46,3%), circunfleja (28,9%) y coronaria derecha (43%). La angiogénesis se asoció en forma estadísticamente significativa con el grado de oclusión vascular, la infiltración de células inflamatorias, la presencia de centro lipídico, la fibrosis, la periarteritis y, sólo en la descendente anterior, con el antecedente de hipertensión arterial (p < 0,006). Se detectó angiogénesis en 1 placa tipo II, en 5 tipo III, en 21 tipo IV, en 22 tipo V y en 7 placas tipo VI (AHA). Conclusiones La angiogénesis de placas vulnerables se asoció con el grado de oclusión vascular, la infiltración de células inflamatorias, la fibrosis, la presencia de núcleo lipídico y, sólo en la descendente anterior, con el antecedente de hipertensión arterial. No se encontró asociación con la hemorragia intraplaca o la calcificación, lo cual sugiere que la angiogénesis puede anticipar la rotura de las placas.

Background Angiogenesis or neovascularization involves the formation of new blood vessels adjacent to preexisting vessels. This vascular proliferation is prevalent in various clinical conditions, such as atherosclerosis. Microvessels in coronary artery atherosclerotic plaques may contribute to plaque instability. Objectives The aim of this study was to correlate the presence of angiogenesis in atherosclerotic plaques with the criteria of plaque vulnerability used by the American Heart Association (AHA). Methods One hundred and twenty one hearts from non-diabetic and apparently healthy transplant donors older than 40 years were selected. The coronary arteries were examined and all areas of cross-sectional luminal narrowing underwent histological, immunohistochemical and morphometric studies. A semi-quantitative score (scale 0-3) was used to identify of angiogenesis. Univariate and multivariate logistic regression analysis was performed to identify angiogenesisrelated risk factors. Results On hundred and forty three high-risk lesions (AHA type IV, V and VI) in the left anterior descending coronary artery (46.3%), the circumflex coronary artery (28.9%) and the right coronary artery (43%) were identified. Angiogenesis had a statistically significant association with the severity of vascular occlusion, inflammatory cell infiltration, presence of a lipid core, fibrosis and periarteritis. A history of hypertension (HT) was associated with angiogenesis only in lesions of the left anterior descending coronary artery (LAD). According to the AHA classification angiogenesis was detected in 1 Type II, 5 Type III, 21 Type IV, 22 Type V, and 7 Type VI plaques. Conclusions Angiogenesis in vulnerable plaques was associated with the severity of vascular occlusion, inflammatory cell infiltration, fibrosis and presence of a lipid core, and with a history of HT in LAD lesions. There was no association between angiogenesis and plaque hemorrhage or calcification, suggesting that angiogenesis may anticipate plaque rupture.

Presencia de angiogénesis en placas vulnerables ateroscleróticas en corazones humanos aparentemente sanos / Angiogenesis in Vulnerable Atherosclerotic Plaques in Apparently Healthy Human Hearts / Angiogenesis in Vulnerable Atherosclerotic Plaques in Apparently Healthy Human Hearts

Introducción La angiogénesis o neovascularización involucra la formación de nuevos conductos en las adyacencias de vasos preexistentes. Esta proliferación vascular es frecuente en varias circunstancias clínicas, como es el caso de la aterosclerosis. Los microvasos de las placas ateroscleróticas coronarias pueden estar vinculados a la inestabilidad de la lesión. Objetivo Correlacionar la presencia de angiogénesis en placas ateroscleróticas con los criterios de vulnerabilidad de la clasificación de la American Heart Association (AHA). Material y métodos En 121 corazones de donantes no diabéticos aparentemente sanos y mayores de 40 años destinados para homoinjertos se examinaron las arterias coronarias y todas las áreas de estrechamiento luminal se sometieron a estudios histológicos, inmunohistoquímicos y morfométricos. Para el análisis de la angiogénesis se empleó un puntaje semicuantitativo (escala 0-3). Se realizó un análisis de regresión logística univariado y multivariado para identificar factores de riesgo relacionados con la angiogénesis. Resultados Se hallaron 143 lesiones de riesgo alto (AHA tipos IV, V y VI) en las arterias descendente anterior (46,3%), circunfleja (28,9%) y coronaria derecha (43%). La angiogénesis se asoció en forma estadísticamente significativa con el grado de oclusión vascular, la infiltración de células inflamatorias, la presencia de centro lipídico, la fibrosis, la periarteritis y, sólo en la descendente anterior, con el antecedente de hipertensión arterial (p < 0,006). Se detectó angiogénesis en 1 placa tipo II, en 5 tipo III, en 21 tipo IV, en 22 tipo V y en 7 placas tipo VI (AHA). Conclusiones La angiogénesis de placas vulnerables se asoció con el grado de oclusión vascular, la infiltración de células inflamatorias, la fibrosis, la presencia de núcleo lipídico y, sólo en la descendente anterior, con el antecedente de hipertensión arterial. No se encontró asociación con la hemorragia intraplaca o la calcificación, lo cual sugiere que la angiogénesis puede anticipar la rotura de las placas.(AU)

Background Angiogenesis or neovascularization involves the formation of new blood vessels adjacent to preexisting vessels. This vascular proliferation is prevalent in various clinical conditions, such as atherosclerosis. Microvessels in coronary artery atherosclerotic plaques may contribute to plaque instability. Objectives The aim of this study was to correlate the presence of angiogenesis in atherosclerotic plaques with the criteria of plaque vulnerability used by the American Heart Association (AHA). Methods One hundred and twenty one hearts from non-diabetic and apparently healthy transplant donors older than 40 years were selected. The coronary arteries were examined and all areas of cross-sectional luminal narrowing underwent histological, immunohistochemical and morphometric studies. A semi-quantitative score (scale 0-3) was used to identify of angiogenesis. Univariate and multivariate logistic regression analysis was performed to identify angiogenesisrelated risk factors. Results On hundred and forty three high-risk lesions (AHA type IV, V and VI) in the left anterior descending coronary artery (46.3%), the circumflex coronary artery (28.9%) and the right coronary artery (43%) were identified. Angiogenesis had a statistically significant association with the severity of vascular occlusion, inflammatory cell infiltration, presence of a lipid core, fibrosis and periarteritis. A history of hypertension (HT) was associated with angiogenesis only in lesions of the left anterior descending coronary artery (LAD). According to the AHA classification angiogenesis was detected in 1 Type II, 5 Type III, 21 Type IV, 22 Type V, and 7 Type VI plaques. Conclusions Angiogenesis in vulnerable plaques was associated with the severity of vascular occlusion, inflammatory cell infiltration, fibrosis and presence of a lipid core, and with a history of HT in LAD lesions. There was no association between angiogenesis and plaque hemorrhage or calcification, suggesting that angiogenesis may anticipate plaque rupture.(AU)

Risk-prediction model for ischemic stroke in patients hospitalized with an acute coronary syndrome (from the global registry of acute coronary events [GRACE]).

The risk of stroke in patients hospitalized with an acute coronary syndrome (ACS) ranges from <1% to ≥ 2.5%. The aim of this study was to develop a simple predictive tool for bedside risk estimation of in-hospital ischemic stroke in patients with ACS to help guide clinicians in the acute management of these high-risk patients. Data were obtained from 63,118 patients enrolled from April 1999 to December 2007 in the Global Registry of Acute Coronary Events (GRACE), a multinational registry involving 126 hospitals in 14 countries. A regression model was developed to predict the occurrence of in-hospital ischemic stroke in patients hospitalized with an ACS. The main study outcome was the development of ischemic stroke during the index hospitalization for an ACS. Eight risk factors for stroke were identified: older age, atrial fibrillation on index electrocardiogram, positive initial cardiac biomarkers, presenting systolic blood pressure ≥ 160 mm Hg, ST-segment change on index electrocardiogram, no history of smoking, higher Killip class, and lower body weight (c-statistic 0.7). The addition of coronary artery bypass graft surgery and percutaneous coronary intervention into the model increased the prediction of stroke risk. In conclusion, the GRACE stroke risk score is a simple tool for predicting in-hospital ischemic stroke risk in patients admitted for the entire spectrum of ACS, which is widely applicable to patients in various hospital settings and will assist in the management of high-risk patients with ACS.

Diagnóstico y tratamiento paliativo endovascular de un angiosarcoma de arteria pulmonar / Endovascular diagnosis and palliative treatment of a pulmonary artery angiosarcoma

No disponible

Utilidad de la angiotomografía computarizada multidetector en patología aórtica / Usefulness of Multi-Detector Row Computed Tomography Angiography in Aortic Diseases

El propósito de esta revisión es demostrar mediante imágenes la utilidad de la angiotomografía computarizada multidetector (angio-TCMD) en el estudio de la patología aórtica. La elevada morbimortalidad de éstas exige precisión diagnóstica y rapidez al momento de evaluar al paciente con patología conocida o sospecha clínica. Una de las principales ventajas de la angio- TCMD es su carácter de no invasiva y la velocidad con la que se realiza, lo que la convierte en un método ampliamente aceptado por los pacientes. La angio-TCMD es el estándar de referencia para la evaluación de los aneurismas aórticos caracterizando su ubicación en los planos del espacio, extensión y diámetros además de las particulares de la pared. Los síndromes aórticos agudos: el aneurisma disecante, el hematoma intramural y la úlcera arteriosclerótica penetrante son de presentación clínica similar. La angio_TCMD constituye la herramienta de mayor eficacia para confirmar o descartar lesiones. Las múltiples técnicas de visualización y la posibilidad de reconstrucciones multiplanares y tridimensionales facilitan la elección del tratamiento quirúrgico o endovascular.

The goal of the present review is to demonstrate the usefulness of multi-detector row computed tomography (MDCT) angiography in the evaluation of diseases of the aorta. The high morbidity and mortality associated with this condition requires a rapid diagnostic tool with diagnostic accuracy at the moment of evaluating patients with known or clinically suspected disease of the aorta. The non-invasive nature of and the rapid evaluation provided by MDCT angiography are the main advantages of the method that is widely accepted by the patients. MDCT angiography is the reference-standard method for the evaluation of aneurysms of the aorta, describing its location in the spatial planes, extension, diameters and characteristics of the aortic wall. The clinical presentation of the acute aortic syndromes - aortic dissection, intramural hematoma and penetrating aortic ulcer - is similar. MDCT angiography is a diagnostic tool with the greatest efficacy to confirm or rule out aortic lesions. The multiple visualization techniques and the possibility of multiplanar and three-dimensional reconstructions make it easy to choose between surgical or endovascular treatment.

Tomografía Computada Multidetector en el diagnóstico de la pseudocoartación de aorta: Reporte de dos casos y revisión de la literatura / Multidetector CT in diagnosis of aortic pseudocoarctation: Two reported cases and revised literature

La pseudocoartación aórtica es una rara anomalía que consiste en una elongación tortuosa con acodadura de la arteria aorta que involucra la región distal del cayado y la porción descendente proximal, típicamente relacionada al sitio de inserción del ligamento arterioso. No suelen existir manifestaciones clínicas asociadas, por lo que el diagnóstico habitualmente es incidental mediante estudios de imágenes. Entre ellos, se destacan la angio Tomografía Computada Multidetector (angio TCMD) y la Resonancia Magnética (RM). Se diferencia de la verdadera coartación aórtica por su morfología y por la ausencia de obstrucción hemodinámicamente significativa. En el presente artículo revisamos los aspectos imagenológicos utilizando TCMD en dos pacientes a los cuales se les diagnosticó la pseudocoartación, sin ser ésta la patología sospechada al momento de indicar el estudio. La TCMD permite realizar un diagnóstico apropiado mostrando las características diferenciales con otras anomalías aórticas.

The aortic pseudocoarctation is a rare anomaly characterized by a tortuous elongation with kink aorta which compromises the distal portion of the aortic arch and the proximal descending portion, typically related to the insertion site of arterious ligament. Usually, there are no associated symptoms so the diagnosis is generally incidental with imaging such as Multidetector Computed Tomography (MDCT) or Magnetic Resonance Imaging (MRI). It differs from the true aortic coarctaction in their morphology and in the absence of hemodynamically significant obstruction. In this paper we review the imagenologic features using MDCT in two patients who were diagnosed with pseudocoartaction, which was not suspected before performing the study. MDCT allows a proper diagnosis showing differential characteristics with other aortic anomalies.

Estimation of coronary length-volume allometric relations of human arteries in vivo using CT.

Assessing the individual geometry of the coronary arteries in a patient can help to explain diffuse artery disease. Some allometric functions, relating arterial length and volume, were verified in porcine arteries and human autopsies but not in vivo. In this work we use skeletonization methods on MSCT images to render the whole coronary tree in healthy and cardiovascular patients. Twenty patients with and without coronary artery disease were recruited. The coronary was segmented with minimum user intervention. Vessels were separated and measured. A 3D coronary map was individually calculated. The allometric length-volume function L=k(v)V(ß) was evaluated in each patient and plotted in a Log-Log scale. The coefficient k(v) ranged 1.00 ± 0.35. Slopes ranged ß = 0.69-0.88 and seemed to overlap in the scatter Log plot. The analysis of covariance verified this perception and concluded that lines were parallel. In other words, the allometric function stood for all patients. Values were not different from other studies in humans and pigs. The combination of multislice CT with morphological extraction algorithms was effective to extract allometric functions from coronary arteries in patients and can be easily applied in the clinic.

Clínica y seguimiento de la pericarditis constrictiva crónica / Clinical finding and follow up of chronic constrictive pericarditis

El objetivo de este estudio fue describir la etiología, presentación clínica, métodos diagnósticos, tratamiento, evolución y pronóstico alejado de 35 pacientes con pericarditis constrictiva crónica que fueron evaluados prospectivamente de acuerdo a un protocolo de enfermedad pericárdica que se aplica en nuestra Institución. En 24 (68%) la pericarditis constrictiva fue idiopática y 11 (32%) presentaron etiología definida, realizándose pericardiectomía en 34 (97%). Hubo 4 (12%) muertes intrahospitalarias, todas con etiología definida. La mediana de seguimiento fue de 5.6 años (percentilos 25-75: 2.4-7.4 años). La supervivencia de acuerdo al método de Kaplan-Meier fue de 97% al año (IC 95% 80 - 99%), 83% a los 5 años (IC 95% 65 - 93%), 78% a los 7 años (IC 95% 60 - 90%), y 69% a los 10 años (IC 95% - 50% - 84%). En conclusión, la pericarditis constrictiva crónica es una enfermedad generalmente idiopática, de diagnóstico tardío, cuyo tratamiento es la pericardiectomía. Los pacientes con etiología específica presentaron mayor mortalidad intrahospitalaria. En el seguimiento a 10 años 2/3 de los pacientes están vivos y con mejoría de los síntomas.

The aim of this study was to describe the etiology, clinical findings, diagnostic methods, treatment, outcome and long-term prognosis of 35 patients with chronic constrictive pericarditis (CCP) that were prospectively analyzed according to a pericardial disease protocol performed in our Institution. Etiology of CCP was idiopathic in 24 patients (68%), and specific in 11 (32%). The majority (34 patients, 97%) underwent pericardiectomy. Perioperative mortality was 12% (4/33) no deaths were registered among patients with idiopathic CCP. Median follow-up was 5.6 years (percentile 25-75: 2.4-7.4 years). The cumulative actuarial survival probability was 97% at 1 year (confidence interval [CI] 80% to 99%); 83% at 5 years, (95% CI 65% to 93%); 78% at 7 years, (95% CI 60% to 90%), and 69% at 10 years (95% CI 50% to 84%). In conclusion, nowadays CCP is generally an idiopathic disease with late diagnosis. The clinical course of the disease produces severe symptoms of congestive heart failure. In a 10 years follow-up 2/3 of patients are alive and improved their quality of life. Idiopathic form of pericarditis did not show mortality during early postoperative period.

Age and sex differences, and changing trends, in the use of evidence-based therapies in acute coronary syndromes: perspectives from a multinational registry.

BACKGROUND: A limited number of studies have examined the age and sex differences, and potentially changing trends, in cardiac medication and procedure use in patients hospitalized with an acute coronary syndrome (ACS). METHODS: Using data from a large multinational study, we examined the age and sex differences, and changing trends (1999-2007) therein, in the hospital use of evidence-based therapies in patients hospitalized with an ACS using data from the Global Registry of Acute Coronary Events (n=50 096). RESULTS: After adjustment for several variables, in comparison with men below 65 years, patients in other age-sex strata had a significantly lower odds of receiving aspirin [odds ratios (ORs) for men 65-74, 75-84, and >or=85 years, women <65, 65-74, 75-84, and >or=85 years were 0.86, 0.84, 0.72, 0.80, 0.86, 0.68 and 0.46, respectively], angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ORs, 1.08, 1.01, 0,71, 0.83, 0.90, 0.89, and 0.63), beta blockers (ORs, 0.66, 0.52, 0.53, 0.67, 0.54, 0.53, and 0.52), statins (ORs, 0.72, 0.49, 0.29, 0.82, 0.68, 0.44, and 0.22), and undergoing coronary artery bypass graft surgery or a percutaneous coronary intervention (ORs, 0.79, 0.53, 0.21, 0.64, 0.57, 0.38, and 0.13) during their acute hospitalization. Age and sex differences in the receipt of these therapies remained relatively unchanged during the period under study. CONCLUSION: Although there were increasing trends in the use of evidence-based medications and cardiac procedures over time, important gaps in the utilization of effective cardiac treatment modalities persist in elderly patients and younger women.

Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events.

AIMS: To determine the incidence and factors associated with heart rupture (HR) in acute coronary syndrome (ACS) patients. METHODS AND RESULTS: Among 60 198 patients, 273 (0.45%) had HR (free wall rupture, n = 118; ventricular septal rupture, n = 155). Incidence was 0.9% for ST-segment elevation myocardial infarction (STEMI), 0.17% for non-STEMI, and 0.25% for unstable angina. Hospital mortality was 58 vs. 4.5% in patients without HR (P < 0.001). The incidence was lower in STEMI patients with primary percutaneous coronary intervention (PCI) than in those without (0.7 vs. 1.1%; P = 0.01), but primary PCI was not independently related to HR in adjusted analysis (P = 0.20). Independent variables associated with HR included: ST-segment elevation (STE)/left bundle branch block; ST-segment deviation; female sex; previous stroke; positive initial cardiac biomarkers; older age; higher heart rate; systolic blood pressure/30 mmHg decrease. Conversely, previous MI and the use of low-molecular-weight heparin and beta-blockers during first 24 h were identified as protective factors for HR. CONCLUSION: The incidence of HR is low in patients with ACS, although its incidence is probably underestimated. Heart rupture occurs more frequently in ACS with STE and is associated with high hospital mortality. A number of variables are independently related to HR.

Recurrent ischemia across the spectrum of acute coronary syndromes: prevalence and prognostic significance of (re-)infarction and ST-segment changes in a large contemporary registry.

BACKGROUND: There are limited recent data on the prevalence and potentially different adverse impact of the various types of recurrent ischemia (RI) in unselected patients with acute coronary syndromes(ACS). We examined the clinical features and treatment associated with, and the differential prognostic impact of, the various types of RI in unselected patients across the broad spectrum of ACS in the contemporary era. METHODS: The Global Registry of Acute Coronary Events (GRACE) was a prospective, multinational registry of patients hospitalized for ACS. Data were collected on standardized case report forms. RESULTS: Of the 29,400 ACS patients enrolled in May 2000-March 2007, 21% developed RI; 2.4%, 4.9%, and 16% had myocardial (re-)infarction [(re-)MI], RI with ST-segment changes, and RI without ST-segment changes (not mutually exclusive), respectively. Rates of in-hospital mortality and complications, and 6-month mortality were significantly higher among patients with RI compared to those without; the rates were highest for patients who developed (re-)MI, followed by those with RI and ST-segment changes. After adjusting for other validated prognosticators in the GRACE risk score, all three types of RI retained an independent association with both higher in-hospital and post-discharge 6-month mortality. Early revascularization was associated with lower in-hospital mortality only in the group with (re-)MI (P for interaction=0.003). CONCLUSIONS: Despite the current use of intensive medical therapies, RI remains a common and serious consequence across the spectrum of ACS. Different types of RI confer a variable adverse prognostic impact. Re-MI is associated with the worst outcome, which appears to be mitigated by early revascularization. Our findings underscore the persistent need to improve the treatment of ACS.

Presencia de placas coronarias vulnerables en mujeres de mediana edad que sufrieron muerte cerebral / Presence of Vulnerable Coronary Plaques in Middle-Aged Women Who Suffered Brain Death

Introducción Las placas vulnerables de las arterias coronarias se encuentran habitualmente en varones sin sintomatología previa que fallecieron súbitamente o debido a un síndrome coronario agudo. La frecuencia y las características de estas placas en la población femenina de mediana edad se desconocen. Objetivo Indagar acerca de la presencia de placas coronarias vulnerables en mujeres de mediana edad que sufrieron muerte cerebral. Material y métodos De un total de 652 corazones de donantes para trasplante obtenidos entre 1996 y 2007, se seleccionaron los provenientes de individuos aparentemente sanos y mayores de 40 años que murieron a causa de un accidente traumático o cerebrovascular. De los 160 órganos que cumplieron los criterios de selección, se estudiaron 70 corazones femeninos en los que se examinaron las arterias coronarias en cortes consecutivos a intervalos de 3 mm. Las áreas con estrechamiento luminal se procesaron para su posterior estudio histológico e inmunohistoquímico. Las placas se clasificaron según la American Heart Association (AHA). Resultados La edad promedio de las mujeres fue de 50,7 ± 5,7 años. El grado de oclusión vascular promedio fue del 28,66% ± 17,35%. Cuarenta y un corazones poseían sólo lesiones ateroscleróticas no avanzadas (tipos I, II y III de la clasificación de la AHA). En los 29 restantes se encontraron 58 placas consideradas de alto riesgo o vulnerables (AHA tipos IV, V y VI). Éstas fueron menos frecuentes que en los varones (p < 0,001) y se asociaron con el peso del órgano (OR 1,02, IC 95% 1,01-1,04; p < 0,001) y con la edad (OR 1,11, IC 95% 1,01- 1,23; p = 0,038). No se encontró una relación significativa con la causa de la muerte (p = 0,065). Conclusiones El 41,4% de las mujeres que sufrieron muerte cerebral presentaron placas vulnerables en los vasos coronarios no asociadas con una reducción significativa de la luz. De esta serie puede inferirse que existe un promedio de 0,82 lesiones propensas a generar trombosis en mujeres de mediana edad aparentemente sanas que sufrieron muerte cerebral.

Background The presence of vulnerable plaques is a common finding in the coronary arteries of previously asymptomatic men who died suddenly or due to an acute coronary syndrome. The prevalence and the characteristics of these plaques in middle-aged women are still unknown. Objective To evaluate the presence of vulnerable coronary plaques in middle-aged women who suffered brain death. Material and Methods From a total of 652 hearts from transplant donors collected between 1996 and 2007, we selected those from apparently healthy individuals older than 40 years old who died of head trauma or stroke. From a total of 160 elegible organs, the coronary arteries of 70 female hearts were examined by serial sectioning at 3-mm intervals. The areas with luminal narrowing were processed for subsequent histological and immuhistochemical studies. Plaques were classified according to the American Heart Association (AHA) report. Results Mean age was 50.7±5.7 years. The degree of average vascular obstruction was 28.66%±17.35%. A total of 41 hearts had no advanced coronary atherosclerotic lesions (Type I, II, and III of the AHA classification). In the remaining 29 hearts we found 58 plaques considered high-risk lesions (AHA type IV, V and VI). These plaques were less frequent in women than in men (p<0,001) and were associated with higher heart weight (OR 1.02, 95% CI 1.01-1.04; p<0.001) and with age (OR 1.11, 95% CI 1.01-1.23; p=0.038). No significant association with the cause of death was found (p = 0.065). Conclusions In 41.4% of women who suffered brain death, we found vulnerable plaques in the coronary arteries that were not associated with significant lumen obstructions. This series suggests the presence of 0.82 coronary lesions which are prone to develop thrombosis in apparently healthy middleaged women who suffered brain death.

Coronary arteries simplified with 3D cylinders to assess true bifurcation angles in atherosclerotic patients.

The geometry of coronary arteries affects regional atherogenic processes. Accurate images can be assessed using multislice computer tomography (MSCT) to estimate bifurcations angles. We propose a three-dimensional (3D) method to measure true bifurcation angles of coronary arteries and to determine possible correlations between plaque presence and angulations. The left main (LM) coronary artery, left anterior descendent (LAD) and left circumflex artery (LCX) were imaged in 40 atherosclerotic and 35 healthy patients, using 64-rows MSCT. This Y-junction was simplified fitting a 3D cylinder to each vessel to estimate true bifurcation angles and diameters. The method was tested in phantoms and interobserver variability was assessed. Geometrical results were compared between groups using an unpaired t-test. The cylinders fitted reasonably well with mean distances to measured points below 0.4 mm. LAD-LCX bifurcation angles were wider in the atherosclerotic group (p < 0.01). LAD (p < 0.01) and LCX (p < 0.05) diameters were also larger. In phantoms mean absolute difference between true and estimated angles (N = 27) was 0.44 +/- 0.54 degrees . Interobserver mean difference (N = 135) was 1.8 +/- 5.8 degrees . Simplifying coronary bifurcation with cylinders results in a reliable technique to assess coronary artery geometry in 3D, avoiding planar projections and decreasing interobserver variability. Geometrical risk factors should be incorporated to properly predict atherosclerosis processes.