Trombo en tránsito / Thrombus in transit

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Creation and validation of the acute heart failure risk score: AHFRS.

Our aims were to create and validate a clinical decision rule to assess severity in acute heart failure. We conducted a prospective cohort study of patients with symptoms of acute heart failure who attended the emergency departments (EDs) of three hospitals between April 2011 and April 2013. The following data were collected on arrival to or during the stay in the ED: baseline severity of symptoms; presence of decompensated comorbidities; number of hospital admissions/visits to EDs for acute heart failure during the previous 24 months; triggers of the exacerbation; clinical signs and symptoms; results of ancillary tests requested in the ED; treatments prescribed; and response to the initial treatment in the ED. The main outcome was poor course during the acute phase, in-hospital for admitted patients and during the first week following the ED visit for discharged patients, this being a composite endpoint that included death, admission to an intensive care unit, need for invasive mechanical ventilation, cardiac arrest and use of non-invasive mechanical ventilation. Multivariate logistic regression models were developed. Predictors of poor course in acute heart failure were oedema on chest radiography, visits to the ED and/or admissions in the previous two years, and levels of glycemia and blood urea nitrogen (areas under the curve of 0.83 in the derivation sample, and 0.82 in the validation sample). Four clinical predictors available in the ED can be used to create a simple score to predict poor course in acute heart failure.Clinical Trials.gov ID: NCT02437058.

Utilidad de la resonancia magnética cardiaca en el diagnóstico de los pacientes con síndrome coronario agudo y coronarias normales / The value of cardiac magnetic resonance in patients with acute coronary syndrome and normal coronary arteries

Introducción y objetivos. Diferentes enfermedades pueden presentar síntomas similares a los del síndrome coronario agudo (SCA): dolor torácico, cambios en el ECG y elevación de marcadores de daño miocárdico. Incluso después de realizar una coronariografía, a veces es difícil establecer el diagnóstico. El objetivo del estudio fue valorar la utilidad de la resonancia magnética cardiaca (RMC) en el diagnóstico de los procesos que se presentan como un SCA y tienen coronarias normales. Métodos. Estudiamos a 80 pacientes con sospecha de SCA y coronarias normales. La media de edad fue 48 ± 15 años. La troponina T media fue 1,8 ± 0,9 ng/ml. Realizamos un estudio de RMC incluyendo secuencias potenciadas en T2 para detectar edema y secuencia I-R de realce tardío (RT) a los 10 min de la administración de gadolinio. Resultados. El diagnóstico final fue miocarditis aguda en 51 pacientes (63%). En todos estos casos observamos RT localizado en el subepicardio y las porciones medias de miocardio. En 12 pacientes (15%) el diagnóstico final fue infarto agudo de miocardio, todos ellos con RT subendocárdico o transmural. En 9 pacientes (11%) con alteraciones de la contractilidad en el ecocardiograma basal y normalización posterior, el estudio con RMC no mostró RT de contraste y se les diagnosticó síndromes de tako-tsubo. En 4 pacientes el diagnóstico final fue pericarditis aguda y en 4 no se pudo establecer un diagnóstico. Conclusiones. La miocarditis aguda y el síndrome de tako-tsubo pueden presentarse en la clínica de forma similar al SCA. La presencia y el patrón de RT de contraste en el estudio de RMC nos ayudan de forma importante a establecer el diagnóstico (AU)

Introduction and objectives. A number of different conditions can present with symptoms similar to acute coronary syndrome (ACS): chest pain, electrocardiographic changes, and elevated levels of markers of myocardial damage. Even after coronary angiography has been performed, differential diagnosis can be challenging. The aim of this study was to evaluate the usefulness of cardiac magnetic resonance (CMR) for diagnosing conditions that present like ACS but in which the coronary arteries are normal. Methods. The study involved 80 patients with suspected ACS and normal coronary arteries. Their mean age was 48 (15) years and their mean troponin-T (TnT) level was 1.8 (0.9) ng/mL. A CMR study, which involved T2 weighted imaging to detect edema and delayed contrast-enhancement (DCE) imaging 10 minutes after gadolinium administration, was performed. Results. In 51 patients (63%), the final diagnosis was acute myocarditis. In all these cases, DCE was observed in subepicardial and middle segments of the myocardium. The final diagnosis was acute myocardial infarction in 12 patients (15%), all of whom exhibited subendocardial or transmural DCE. In the 9 (11%) who exhibited abnormal contractility on baseline echocardiography with subsequent normalization, CMR did not show DCE, a finding that is characteristic of Takotsubo cardiomyopathy. In addition, 4 patients had a final diagnosis of pericarditis, while no diagnosis could be established in another 4. Conclusions. The clinical presentation of acute myocarditis and Takotsubo syndrome can be similar to that of ACS. The presence and distribution of DCE on CMR are of great help in establishing a diagnosis (AU)

The value of cardiac magnetic resonance in patients with acute coronary syndrome and normal coronary arteries.

INTRODUCTION AND OBJECTIVES: A number of different conditions can present with symptoms similar to acute coronary syndrome (ACS): chest pain, electrocardiographic changes and elevated levels of markers of myocardial damage. Even after coronary angiography has been performed, differential diagnosis can be challenging. The aim of this study was to evaluate the usefulness of cardiac magnetic resonance (CMR) for diagnosing conditions that present like ACS but in which the coronary arteries are normal. METHODS: The study involved 80 patients with suspected ACS and normal coronary arteries. Their mean age was 48+/-15 years and their mean troponin-T (TnT) level was 1.8+/-0.9 ng/ml. A CMR study, which involved T2-weighted imaging to detect edema and delayed contrast-enhancement (DCE) imaging 10 minutes after gadolinium administration, was performed. RESULTS: In 51 patients (63%), the final diagnosis was acute myocarditis. In all these cases, DCE was observed in subepicardial and middle segments of the myocardium. The final diagnosis was acute myocardial infarction in 12 patients (15%), all of whom exhibited subendocardial or transmural DCE. In the 9 (11%) who exhibited abnormal contractility on baseline echocardiography with subsequent normalization, CMR did not show DCE, a finding that is characteristic of Takotsubo cardiomyopathy. In addition, 4 patients had a final diagnosis of pericarditis, while no diagnosis could be established in another 4. CONCLUSIONS: The clinical presentation of acute myocarditis and Takotsubo syndrome can be similar to that of ACS. The presence and distribution of DCE on CMR are of great help in establishing a diagnosis.

Papel de los nitratos en el tratamiento de la enfermedad cardiovascular / Role of nitrates in the treatment of cardiovascular diseases

Los nitratos orgánicos, en sus diferentes presentaciones, han constituido uno de los pilares para el tratamiento de las enfermedades cardiovasculares durante más de 100 años. Los nitratos son donadores de óxido nítrico; por tanto, su efecto primordial es el de la relajación del músculo liso endotelial. Producen dilatación venosa y arterial, por lo que reducen la precarga y la poscarga. Sus principales indicaciones son el tratamiento sintomático de la angina de esfuerzo estable, el síndrome coronario agudo, y la insuficiencia cardíaca aguda y crónica. Asimismo, añadidos a la terapia convencional en pacientes afroamericanos con insuficiencia cardíaca crónica, en asociación con la hidralazina, producen una reducción de la mortalidad. Su papel actual en pacientes de otras razas aún se desconoce. La principal limitación de esta terapia es el desarrollo de tolerancia, que conduce a la atenuación de los efectos farmacológicos antiisquémicos, antianginosos y hemodinámicos con la utilización continuada. En la práctica clínica, lo más conveniente para reducir al mínimo la tolerancia es utilizar la menor dosis necesaria y dejar un intervalo libre de nitratos, para permitir la recuperación del endotelio (AU)

For more than 100 years, organic nitrates, in one form or another, have formed one the central pillars of the treatment of cardiovascular disease. As nitrates are nitric oxide donors, their main effect is to induce endothelial smooth muscle relaxation. Nitrates induce both venous and arterial dilatation, thereby reducing both preload and afterload. They are principally indicated for the symptomatic treatment of stable angina, acute coronary syndromes, and acute and chronic heart failure. Moreover, nitrates also reduce mortality in Afro-americans when given with hydralazine as an addition to conventional therapy. Their role in other ethnic groups is unknown. The main limitation of nitrate therapy is that its continued use leads to the development of tolerance, with reductions in anti-ischemic and hemodynamic effects. Clinically, the most appropriate way of minimizing tolerance is to use the lowest acceptable dose and to introduce nitrate-free periods to enable recovery of the endothelium (AU)