[Utility of verapamil in the treatment of diastolic dysfunction in patients with acromegaly]. / Utilidad del verapamil en el tratamiento de la disfunción diastólica de pacientes acromegálicos.

INTRODUCTION: Diastolic dysfunction is a common complication in patients with acromegaly. By using the metabolic treatment for acromegaly, an improvement in diastolic function is not always achieved and a group of these patients could obtain some benefit from a specific treatment for such a condition. The objective of the present study was to evaluate the utility of verapamil therapy in acromegalic patients with diastolic dysfunction. METHODS: Fourteen patients (7 males and 7 females) with the diagnosis of acromegaly and diastolic dysfunction confirmed by echocardiogram were studied. After six months of treatment with verapamil (240 mg/day) the echo-cardiographic parameters and the functional class (NYHA) of patients were reevaluated. RESULTS: All patients showed an increased basal measurement of the cardiac mass (mean [percentiles 25-75]: 149 g/m2 [128-264]) and no improvement was observed after treatment (182 g/m2 [123-328]). Also, no improvement was found regarding the studied diastolic function parameters: E/A relationship of left ventricle (0.70 [0.54-0.83] versus 0.61 [0.54-0.86]) and isovolumetric relaxation time (146 [119-193] versus 120 [97-169]). A trend towards improvement was indeed found in the functional class, although no statistical differences were observed. CONCLUSION: Our results did not demonstrate a benefit derived from the treatment with verapamil upon the diastolic function in patients with acromegaly.

Utilidad delverapamil en el tratamiento de la disfunción diastólica de pacientes acromegálicos / Utility of verapamil in the treatment of diastolic dysfunction in patients with acromegaly

Introducción. La disfunción diastólica es una complicación frecuente en los pacientes acromegálicos. Mediante el tratamiento metabólico de la acromegalia no siempre se consigue una mejoría de la función diastólica y un grupo de estos pacientes se podría beneficiar de un tratamiento específico para dicha alteración. El objetivo del presente trabajo ha sido evaluar la utilidad del tratamiento con verapamil en pacientes acromegálicos con disfunción diastólica. Métodos. Se estudiaron 14 pacientes (7 hombres) diagnosticados de acromegalia y con disfunción diastólica confirmada mediante ecocardiografía. Tras 6 meses de tratamiento con verapamil (240 mg/día) se reevaluaron los parámetros ecocardiográficos y la clase funcional (NYHA) de los pacientes. Resultados. Todos los pacientes presentaban de forma basal un incremento de la masa cardíaca (media [percentiles 25-75]: 149 g/m2 [128-264]) sin que presentaran mejoría tras el tratamiento (182 g/m2 [123-328]). Tampoco se encontró mejoría en los parámetros de disfunción diastólica estudiados: relación E/A del ventrículo izquierdo (0,70 [0,54-0,83] frente a 0,61 [0,54-0,86]) y tiempo de relajación isovolumétrica (146 [119-193] frente a 120 [97-169]). Sí que se encontró una tendencia a la mejoría en la clase funcional, aunque sin diferencias estadísticas. Conclusión. Nuestros resultados no muestran un beneficio del tratamiento con verapamil sobre la función diastólica en los pacientes acromegálicos (AU)

Beta-blockade and exercise capacity in patients with mitral stenosis in sinus rhythm.

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine whether beta-blocker treatment (atenolol) improves cardiopulmonary exercise performance and ventilatory response in patients with mitral stenosis in sinus rhythm. METHODS: A prospective study comparing the results of cardiopulmonary exercise tests (CPETs) was performed before and after atenolol therapy in 17 patients in NYHA classes I and II with mitral stenosis in sinus rhythm. Transthoracic echocardiography was performed pre-study, and left ventricular diameters, ejection fraction and mitral valve area monitored. CPETs (Naughton protocol) were performed by two different investigators before and after one-week atenolol therapy (50 mg/day). The second investigator was blinded to the result of the baseline test. O2 consumption, CO2 production, ventilatory parameters and respiratory exchange ratios were measured on line. RESULTS: Maximal O2 uptake (VO2max) did not differ significantly before and after beta-blockade (median 16.8 and 15.0 ml/kg/min, respectively. Median heart rate at rest (72 versus 55 beats/min; p = 0.0003) and during peak exercise (153 versus 105 beats/min; p = 0.0003), and anaerobic threshold (10 versus 8.9 ml/kg/min; p = 0.02) were lower with beta-blockade compared with the baseline state. Minute ventilation at maximum exercise (41 versus 40 l/min) and ventilatory equivalent for CO2 (34 versus 35) were unchanged with atenolol therapy, indicating no improvement in ventilatory performance. When patients were grouped into those in whom VO2max was improved with atenolol therapy (n = 7) and those in whom it was impaired (n = 10), there were no inter-group differences with respect to age, left ventricular function, severity of mitral stenosis, NYHA class and grade of beta-blockade reached. Four patients felt symptomatically worse during atenolol treatment (lower NYHA functional class). CONCLUSION: Beta-blockade does not improve exercise tolerance in patients with mitral stenosis in sinus rhythm. In addition, ventilatory performance does not change with treatment.

[Thrombogenic and endothelial damage markers in patients with ischemic systolic impairment]. / Marcadores de hipercoagulabilidad y daño endotelial en pacientes con disfunción sistólica de origen isquémico.

INTRODUCTION: Anticoagulation is rarely indicated in patients with left ventricular dysfunction who show an increased risk for thromboembolism. In theory, the three arms of the Virchow' triad may be present: abnormal blood flow, endothelial damage and prothrombotic markers. The aim of this study was to identify the last two arms. PATIENTS AND METHOD: We studied 82 consecutive patients with demonstrated ischaemic heart disease and sinus rhythm, and compared them with a control group comprised of 32 healthy subjects matched for age and sex. None or the patients had had an acute coronary event or hemodynamic decompensation within the 3 months prior to inclusion in the study. The plasma concentration or von Willebrand factor and fibrin d-dimer and fibrinogen were determined as endothelial damage and prothrombotic markers, respectively. A fractional shortening less than 29% by echography was defined as ventricular systolic dysfunction. RESULTS: The patients showed significantly higher levels of von Willebrand factor with respect to the control group (109.2 31.9 vs 85.5 32.6%, p < 0.01), with no differences in fibrinogen and fibrin d-dimer values. Twenty-six patients fulfilled criteria of left ventricular systolic dysfunction. Patients with left ventricular dysfunction showed higher fibrinogen (386 118 vs 322 102 mg/dl, p = 0.03) and fibrin d-dimer (0.36 0.22 vs 0.26 0.10 g/ml; p = 0.04) levels, with no differences in von Willebrand factor levels. CONCLUSIONS: After acute coronary events, patients with ischaemic heart disease show markers of endothelial damage. However, patients with left ventricular dysfunction show a hypercoagulable state.

[The Influence of the growth hormone in the profile of blood pressure. Results in adult patients with deficiency in this hormone]. / Influencia de la hormona de crecimiento en el perfil de la presión arterial. Resultados en pacientes adultos con déficit de dicha hormona.

INTRODUCTION AND OBJECTIVES: There is an increasing interest in the relationship between the growth hormone (GH) and the heart since the GH has an important inotropic effect and its use has been tested in patients with severe systolic dysfunction. However, cardiovascular diseases are the main cause of increased morbimortality observed in patients with acromegaly. Growth hormone deficiency has been related to different clinical findings depending on the age of onset. Recent studies have demonstrated that GH deficiency in adults is associated with alterations in blood pressure. The aim of our study was to assess the influence of GH in blood pressure. PATIENTS AND METHODS: We studied 14 adult patients with GH deficiency and 15 healthy subjects, matched for sex and age. The diagnosis of GH deficiency was based on GH response to intravenous insulin tolerance test < 5 ng/ml and IGF-1 levels lower than the normal limit for each age group. In all the patients 24-hour Holter blood pressure monitorization was performed in addition to a treadmill test and echographic evaluation. RESULTS: All patients showed normal systolic and diastolic function in the echocardiographic study. Only one patient had an increased left ventricular mass. Blood pressure was lower in the patients than in the control subjects (p < 0.05). Moreover, the difference remained significant when analysis was based on the time of day. However, the patients showed normal blood pressure response to the effort test with a mean increase of 60%. The length of the exercise on the treadmill test was shorter in the subgroup of GH deficient patients. CONCLUSIONS: Lower systolic blood pressure was observed in GH deficiency patients. The patients studied did not show structural heart alterations. Blood pressure and chronotrophic response to the effort test were similar in both groups.

Dispersión del intervalo QT y variabilidad de la frecuencia cardíaca postinfarto. evolución temporal y relaciones con la función ventricular izquierda / QT interval dispersion and heart rate variability following myicardial infarction. Time course and relations with the left ventricular function

Introducción y objetivos. Se investigaron los cambios precoces en la dispersión del intervalo QT y variabilidad de la frecuencia cardíaca en un grupo de pacientes consecutivos hospitalizados por infarto de miocardio de cara anterior, así como el curso evolutivo de estos indicadores pronósticos durante un período de 6 meses y la relación entre estas variables y los parámetros de función ventricular izquierda. Métodos. Se estudiaron 42 pacientes consecutivos ingresados por infarto de miocardio de cara anterior con onda Q. Se llevaron a cabo en la primera semana y a los 6 meses postinfarto un análisis de la variabilidad de la frecuencia cardíaca (Holter de 24 horas) empleando el método de la demodulación compleja, una medida de la dispersión del intervalo QT en el electrocardiograma (ECG) estándar de 12 derivaciones (QT máximo - QT mínimo) y se obtuvieron los parámetros de función ventricular izquierda a partir de la ventriculografía de contraste y la extensión de la disfunción regional ventricular izquierda. Resultados. La dispersión del QT disminuyó significativamente entre la primera semana (0,07s [0,050,08]) y los 6 meses (0,06s [0,04-0,08], p =0,029); la extensión de la anormalidad de la motilidad parietal mostró una tendencia similar (desde 51 por ciento [27-56] hasta 33 por ciento [11-46], p<0,00001). En cambio, la desviación estándar de los ciclos RR aumenta entre la 1ª semana (31 ms [22-44]) y los 6 meses (43 ms [32-58], p< 0,00001). Sin embargo, la fracción de eyección ventricular izquierda, volumen telediastólico, y volumen telesistólico (46 ml/m2 [31-67] no mostraron cambios significativos en este período de tiempo. En la 1ª semana, la desviación estándar (r = 0,46, p< 0,01) y el ciclo RR medio (r = 0,59, p < 0,0001) se relacionaron con la fracción de eyección, Sin embargo, la dispersión de QT no se correlacionó con la variabilidad de la frecuencia cardíaca o los parámetros de función ventricular en la primera semana o a los 6 meses de evolución. No existieron diferencias en los parámetros autonómicos o hemodinámicos entre los pacientes que presentaron unos valores de dispersión del QT < 0,08 (n=15) o 0,08 ( n=16) segundos. Conclusiones. a) La dispersión del QT disminuye y la variabilidad de la frecuencia cardíaca aumenta en los primeros meses postinfarto; b) la disminución de la variabilidad de la frecuencia cardíaca tiende a ser mayor cuanto mayor es el deterioro de la función ventricular secundario al infarto; y c) no se han encontrado relaciones entre la dispersión del QT y las características clínicas, variabilidad de la frecuencia cardíaca o parámetros de función ventricular izquierda en la primera semana o a los 6 meses postinfarto (AU)

Hipercoagulabilidad y cardiopatía isquémica: potencial interacción entre los anticuerpos antifosfolípidos y elementos celulares implicados en la hemostasia / Hipercoagulability and ischemic cardiopathy: potential interaction between antiphospholipid antibodies and cellular elements related with haemosthasis

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[QT interval dispersion in hospital patients admitted with cardiac insufficiency. Determinants and prognostic value]. / Dispersión del intervalo QT en pacientes ingresados por insuficiencia cardíaca. Determinantes y valor pronóstico.

INTRODUCTION AND OBJECTIVES: The determinants and the prognostic value of the QT interval dispersion are analysed in a group of consecutive patients admitted to hospital with heart failure. METHODS: One hundred twenty-two consecutive patients admitted because of heart failure in whom a reliable measurement of QT dispersion in the first electrocardiogram was obtained (maximum QT-minimum QT) were studied. The main clinical, analytic and echocardiographic data were recorded. A control group (n = 35) matched in age and sex with the study group was also analysed. RESULTS: The study group showed a greater QT dispersion than the control group (62 +/- 30 vs 40 +/- 21 ms; p = 0.01). Those cases with a QT dispersion > 80 ms (n = 50; 41%) exhibited a lower natremia (138 +/- 6 vs 141 +/- 4 mEq/l; p = 0.01), a higher probability of ischemic aetiology (52 vs 33%; RR = 2.2; IC95% 1.05-4.7; p = 0.04), an increased mortality during the first year (20 vs 6%; RR = 4.7; IC95% 1.3-16; p = 0.01) and during the whole follow-up (38 vs 19%; RR = 3.4; IC95% 1.3 a 8.6; p = 0.01) than those patients with a QT dispersion < 80 (n = 72; 59%). There were no significant differences between both groups with regard to the clinical, analytic or echocardiographic data. In the multivariate analysis only the ischemic etiology (p = 0.002) and the NYHA grade (p = 0.02) were related to a greater mortality. CONCLUSIONS: Patients with heart failure show an increased QT interval dispersion. This parameter is a simple tool that suggests an ischemic etiology and can help in prognosis stratification.

[Tissue plasminogen activator as a prognostic factor in myocardial infarct patients]. / Activador tisular del plasminógeno como factor pronóstico en pacientes con infarto de miocardio.

Changes in hemostasis inducing hypercoagulability are pathogenic factors for the development of ischemic heart disease and myocardial infarction. Nevertheless, their role is unknown in the emergence of new coronary events in patients with infarction. A group of 58 patients who had survived to a first infarction episode were studied; the cardiovascular risk factors were determined and blood concentrations of fibrinogen, t-PA, PAI and FRW measured. These patients were followed for two years to observe the development of new ischemic problems. In the study only the t-PA concentration was found to be a factor for poor prognosis.

[Natural-valve endocarditis in patients wearing pacemakers]. / Endocarditis sobre válvula natural en pacientes portadores de marcapasos.

The presence of infective endocarditis with appearance of vegetations over the tricuspid valve in patients with permanent pacemaker is an uncommon complication. We report here three patients with permanent cardiac pacemakers who developed a picture of infective endocarditis over the electrode with appearance of vegetations over the native valve. The microorganism recovered from blood cultures in the three patients was Staphylococcus. The presence of retained pacemaker leads and repetitive surgical procedures over the pacemaker pouch are two risk factors reported in literature also present in our patients. Infective endocarditis is an uncommon difficult-to-diagnose complication, with a poor prognosis and which requires the removal of the whole infected material, with implantation of an epidermal pacemaker. Some diagnostic and therapeutic issues are discussed.

[Improvement in fibrinolytic function following anticoagulant treatment in chronic rheumatic atrial fibrillation]. / Mejoría de la función fibrinolítica tras el tratamiento anticoagulante en la fibrilación auricular reumática crónica.

INTRODUCTION AND OBJECTIVES: Patients with rheumatic atrial fibrillation are considered at high risk of systemic embolism and require oral anticoagulation. Fibrinolytic function has been little studied. We evaluated fibrinolytic activation markers before starting anticoagulation, at 1 and 6 months following the introduction of oral anticoagulation therapy. We analyzed the relationship with left atrial diameter and mitral area. METHODS: Tissue plasminogen activator (tPA), its inhibitor (PAI-1), plasmin-antiplasmin complexes (PAP) and D-dimer were measured in 13 patients with rheumatic atrial fibrillation. Basal levels were compared with those found in plasma of 20 healthy subjects matched by sex and age. Transthoracic echocardiography was made. RESULTS: A significant increase for PAI-1 and D-dimer levels were detected in patients with atrial fibrillation group (p < 0.05), with no differences in tPA and PAP concentrations. Significant correlation between left atrial diameter and basal t-PA levels was found. Levels of t-PA, PAI-1 and D-dimer decreased significantly under anticoagulation therapy, whereas PAP levels were significantly increased. CONCLUSIONS: Patients with rheumatic atrial fibrillation show a relative hypofibrinolytic state due to elevated PAI-1 levels with no increase in PAP concentration. At six months of anticoagulation therapy, an improvement of fibrinolytic function markers was observed. This is consistent with the prophylactic effect of oral anticoagulants therapy against thromboembolic risk.

[Safety of oral anticoagulation in aged patients with heart diseases]. / Seguridad en la anticoagulación oral en ancianos con cardiopatía.

BACKGROUND: Anticoagulation therapy in the elderly poses some doubts on the possible increase in hemorrhagic risk. The hemorrhagic complications in a population of patients over 70 years of age anticoagulated with acenocoumarol by heart disease were studied. MATERIALS AND METHODS: A study was made of seventy-two patients (43 females and 29 males; mean age: 73 years) anticoagulated for one year and controlled on an outpatient basis by means of INR (international normalized ratio) measurement with a maximal interval of four weeks. INR values above 4.5 or below 2.0 were considered out of range. RESULTS: Nineteen patients had an INR above the recommended value on one occasion and eleven patients on two or more occasions. Sixteen patients had hemorrhagic complications, five were admitted on account of hemorrhages although none of them required transfusional therapy. No cases of brain hemorrhage or peripheral embolism occurred. CONCLUSIONS: Most anticoagulated elderly patients were within their therapeutic range. The percentage of severe hemorrhagic complications was low. Advanced age had did not prove to be a factor against therapy with oral anticoagulants.

[Dual-chamber pacemakers in obstructive hypertrophic cardiomyopathy: gradient variation with stress echocardiography]. / Marcapasos bicameral en la miocardiopatía hipertrófica obstructiva: variación del gradiente con ecocardiografía de estrés.

INTRODUCTION: Permanent cardiac pacing with a dual chamber pacemaker has become a valid alternative in treatment of patients with obstructive hypertrophic cardiomyopathy and refractory symptoms to pharmacological treatment, with a significant decrease of left ventricular outflow tract gradient. AIM: To assess any modification of the gradient with dobutamine stress echocardiography. PATIENTS AND METHODS: We study 10 patients with obstructive hypertrophic cardiomyopathy and angina and/or dyspnea refractory to customary pharmacological treatment. A dual chamber pacemaker had been implanted 3-6 months previously. A dobutamine stress echocardiography was performed, beginning with a 10 microgram/kg/min infusion, with increases of 10 micrograms each 3 minutes until a maximum of 40. Modification of subaortic gradient, severity of systolic anterior motion of mitral valve (SAM, degree 0-3/3) and severity of mitral regurgitation (degree 0-4/4) were assessed. RESULTS: Subaortic gradient decreased in all patients after pacemaker implantation (90 +/- 15 vs 20 +/- 10 mmHg; p < 0.001). With stress echocardiography the gradient increased in all patients (20 +/- 10 to 101 +/- 13 mmHg; p < 0.001). After implant there were only two patients with a +1 SAM, while during stress echocardiography SAM developed in all patients in +2 or +3 degree. Three patients had +1 mitral regurgitation after pacemaker implantation but during stress echocardiography 2-4/4 mitral regurgitation developed in all patients. CONCLUSIONS: Permanent dual chamber pacing decreased left ventricular outflow tract gradient in patients with obstructive hypertrophic cardiomyopathy, but during dobutamine stress echocardiography obstruction echocardiographic signs appeared.