Impacto pronóstico de la enfermedad pulmonar obstructiva crónica y el asma bronquial en pacientes con insuficiencia cardiaca / Prognostic impact of chronic obstructive pulmonary disease and bronchial asthma in patients with heart failure

Propósito Analizar el impacto de la enfermedad pulmonar obstructiva crónica (EPOC) y el asma bronquial sobre el manejo terapéutico y el pronóstico de los pacientes con insuficiencia cardiaca (IC). Métodos Análisis de la información contenida en un registro clínico de pacientes remitidos a una unidad especializada de IC entre enero de 2010 y junio de 2022. Se compararon su perfil clínico, el tratamiento y el pronóstico en base a la presencia de EPOC o asma bronquial. El análisis de supervivencia se realizó mediante los métodos de Kaplan-Meier y Cox. La mediana de seguimiento fue de 1.493 días. Resultados Se estudiaron 2.577 pacientes, de los cuales 251 (9,7%) presentaban EPOC y 96 (3,7%), asma bronquial. Observamos diferencias significativas entre los tres grupos con respecto a la prescripción de betabloqueantes (EPOC=89,6%; asma=87,5%; no broncopatía=94,1%; p=0,002) e inhibidores del cotransportador de sodio-glucosa tipo2 (EPOC=35,1%; asma=50%; no broncopatía=38,3%; p=0,036). Además, los pacientes con patología bronquial recibieron con menor frecuencia un desfibrilador (EPOC=20,3%; asma=20,8%; no broncopatía=29%; p=0,004). La presencia de EPOC se asoció de forma independiente con mayor riesgo de muerte por cualquier causa (HR=1,64; IC95%: 1,33-2,02), muerte u hospitalización por IC (HR=1,47; IC95%: 1,22-1,76) y muerte cardiovascular o trasplante cardiaco (HR=1,39; IC95%: 1,08-1,79) en comparación con la ausencia de broncopatía. La presencia de asma bronquial no se asoció a un impacto significativo sobre los desenlaces analizados. Conclusiones La EPOC, pero no el asma bronquial, es un factor pronóstico adverso e independiente en pacientes con IC. (AU)

Purpose To analyze the impact of chronic obstructive pulmonary disease (COPD) and bronchial asthma on therapeutic management and prognosis of patients with heart failure (HF). Methods Analysis of the information collected in a clinical registry of patients referred to a specialized HF unit from January-2010 to June-2012. Clinical profile, treatment and prognosis of patients was evaluated, according to the presence of COPD or asthma. Survival analyses were conducted by means of Kaplan-Meier and Cox's methods. Median follow-up was 1493 days. Results We studied 2577 patients, of which 251 (9.7%) presented COPD and 96 (3.7%) bronchial asthma. Significant differences among study groups were observed regarding to the prescription of beta-blockers (COPD=89.6%; asthma=87.5%; no bronchopathy=94.1%; P=.002) and SGLT2 inhibitors (COPD=35.1%; asthma=50%; no bronchopathy=38.3%; P=.036). Also, patients with bronchial disease received less frequently a defibrillator (COPD=20.3%; asthma=20.8%; no broncopathy=29%; P=.004). COPD was independently associated with increased risk of all-cause mortality (HR=1.64; 95%CI: 1.33-2.02), all-cause death or HF admission (HR=1.47; 95%CI: 1.22-1.76) and cardiovascular death or heart transplantation (HR=1.39; 95%CI: 1.08-1.79) as compared with patients with no bronchopathy. Bronchial asthma was not significantly associated with increased risk of adverse outcomes. Conclusions COPD, but not asthma, is an adverse independent prognostic factor in patients with HF. (AU)

Prognostic impact of chronic obstructive pulmonary disease and bronchial asthma in patients with heart failure.

PURPOSE: To analyze the impact of chronic obstructive pulmonary disease (COPD) and bronchial asthma on therapeutic management and prognosis of patients with heart failure (HF). METHODS: Analysis of the information collected in a clinical registry of patients referred to a specialized HF unit from January-2010 to June-2012. Clinical profile, treatment and prognosis of patients was evaluated, according to the presence of COPD or asthma. Survival analyses were conducted by means of Kaplan-Meier and Cox's methods. Median follow-up was 1493 days. RESULTS: We studied 2577 patients, of which 251 (9.7%) presented COPD and 96 (3.7%) bronchial asthma. Significant differences among study groups were observed regarding to the prescription of beta-blockers (COPD=89.6%; asthma=87.5%; no bronchopathy=94.1%; p=0.002) and SGLT2 inhibitors (COPD=35.1%; asthma=50%; no bronchopathy=38.3%; p=0.036). Also, patients with bronchial disease received less frequently a defibrillator (COPD=20.3%; asthma=20.8%; no broncopathy=29%; p=0.004). COPD was independently associated with increased risk of all-cause mortality (HR=1.64; 95% CI 1.33-2.02), all-cause death or HF admission (HR=1.47; 95% CI 1.22-1.76) and cardiovascular death or heart transplantation (HR=1.39; 95% CI 1.08-1.79) as compared with patients with no bronchopathy. Bronchial asthma was not significantly associated with increased risk of adverse outcomes. CONCLUSIONS: COPD, but not asthma, is an adverse independent prognostic factor in patients with HF.

Clinical profile and causes of death according to ejection fraction in patients with heart failure cared for in a specialized Cardiology unit.

BACKGROUND AND OBJECTIVE: Patients with heart failure are classified into three phenotypes based on left ventricular ejection fraction. This work aimed to compare the clinical profile, treatment, prognosis, and causes of death of patients with heart failure and reduced (<40%, HF-rEF), preserved (≥50%, HF-pEF), or mid-range (40-49%, HF-mrEF) left ventricular ejection fraction. METHODS: An analysis was conducted on the clinical data included in a prospective registry of patients with heart failure who were referred to a specific Cardiology unit from 2010 to 2019. RESULTS: A total of 1404 patients with HF-rEF, 239 patients with HF-mrEF, and 266 patients with HF-pEF were analyzed. Significant differences were observed among the groups in regard to several clinical characteristics and the frequency of prescription of neurohormonal blocking drugs. A multivariate Cox regression revealed an increased risk of all-cause mortality in patients with HF-pEF (hazard ratio 1.36; 95% confidence interval 1.03-1.80; p = 0.028) and patients with HF-mrEF (hazard ratio 1.36; 95% confidence interval 1.03-1.78; p = 0.029) as compared to patients with HF-rEF. Heart failure was the most frequent cause of death in the three subgroups. A higher relative weight of sudden death as a cause of death was observed among patients with HF-rEF while the relative weight of non-cardiovascular causes of death was higher among patients with HF-pEF and HF-mrEF. CONCLUSIONS: This study confirms the existence of significant differences among patients with HF-rEF, HF-mrEF, and HF-pEF with regard to their clinical profile, therapeutic management, prognosis, and causes of death.

Perfil clínico y causas de muerte de los pacientes con insuficiencia cardíaca atendidos en una unidad especializada de Cardiología según su fracción de eyección / Clinical profile and causes of death according to ejection fraction in patients with heart failure cared for in a specialized Cardiology unit

Antecedente y objetivo: Los pacientes con insuficiencia cardíaca se caracterizan en 3 fenotipos en función de su fracción de eyección ventricular izquierda. El propósito de este estudio fue comparar el perfil clínico, el tratamiento, el pronóstico y las causas de muerte de los pacientes con insuficiencia cardíaca y fracción de eyección ventricular izquierda reducida (<40%, IC-FEr), preservada (≥50%, IC-FEp) o en rango medio (40-49%, IC-FErm). Metodología: Análisis de la información clínica recogida en un registro prospectivo de pacientes con insuficiencia cardíaca remitidos a una consulta monográfica de Cardiología entre 2010 y 2019. Resultados: Se estudiaron 1.404 pacientes con IC-FEr, 239 pacientes con IC-FErm y 266 pacientes con IC-FEp. Se observaron diferencias significativas entre los 3 grupos en relación con diversas características clínicas, y en cuanto a la tasa de prescripción de fármacos moduladores de la respuesta neurohormonal. La regresión de Cox multivariante reveló un incremento del riesgo de muerte por cualquier causa en los pacientes con IC-FEp (hazard-ratio 1,36; intervalo de confianza al 95% 1,03-1,80; p=0,028) e IC-FErm (hazard-ratio 1,36; intervalo de confianza al 95% 1,03-1,78; p=0,029) en comparación con los pacientes con IC-FEr. La insuficiencia cardíaca fue la causa más frecuente de muerte en los 3 grupos; se observó un mayor peso relativo de la muerte súbita en los pacientes con IC-FEr, mientras que las causas no cardiovasculares de muerte tuvieron un peso relativo mayor en los pacientes con IC-FEp e IC-FErm. Conclusiones: El estudio confirma la existencia de diferencias significativas en el perfil clínico, manejo terapéutico, pronóstico y causas de muerte de los pacientes con IC-FEr, IC-FErm e IC-FEp (AU)

Background and objective: Patients with heart failure are classified into three phenotypes based on left ventricular ejection fraction. This work aimed to compare the clinical profile, treatment, prognosis, and causes of death of patients with heart failure and reduced (<40%, HF-rEF), preserved (≥50%, HF-pEF), or mid-range (40–49%, HF-mrEF) left ventricular ejection fraction. Methods: An analysis was conducted on the clinical data included in a prospective registry of patients with heart failure who were referred to a specific Cardiology unit from 2010 to 2019. Results: A total of 1,404 patients with HF-rEF, 239 patients with HF-mrEF, and 266 patients with HF-pEF were analyzed. Significant differences were observed among the groups in regard to several clinical characteristics and the frequency of prescription of neurohormonal blocking drugs. A multivariate Cox regression revealed an increased risk of all-cause mortality in patients with HF-pEF (hazard ratio 1.36; 95% confidence interval 1.03-1.80; p=0.028) and patients with HF-mrEF (hazard ratio 1.36; 95% confidence interval 1.03–1.78; p=0.029) as compared to patients with HF-rEF. Heart failure was the most frequent cause of death in the three subgroups. A higher relative weight of sudden death as a cause of death was observed among patients with HF-rEF while the relative weight of non-cardiovascular causes of death was higher among patients with HF-pEF and HF-mrEF. Conclusions: This study confirms the existence of significant differences among patients with HF-rEF, HF-mrEF, and HF-pEF with regard to their clinical profile, therapeutic management, prognosis, and causes of death (AU)

The effect of age and sex on the diagnostic yield of the echocardiogram in patients with syncope.

INTRODUCTION: Syncope is the motivation for numerous diagnostic tests, among them transthoracic echocardiography (TTE); however, previous evidence suggests there is little utility in this test. Our objective was to assess its diagnostic yield in syncope, analysing the effect of age and sex. MATERIAL AND METHODS: We conducted an observational study that included patients with syncope and who underwent TTE between 1990 and 2015. We defined diagnostic findings related to syncope and performed a descriptive analysis, assessing the diagnostic yield (overall and according to age and sex). RESULTS: The study included 3302 patients and measured a diagnostic yield of 8.8%; the most common finding was ventricular dysfunction (4.5%). The probability of a diagnostic TTE significantly increased with age (p<.001) but was low for patients younger than 50 years (2.3%). The male sex was significantly related with a diagnostic TTE (p<.001), mostly due to the higher rate of ventricular dysfunction. CONCLUSIONS: The diagnostic yield of TTE in patients with syncope is moderate, low in patients younger than 50 years and lower in women than in men. These factors should be considered when conducting a diagnostic study of patients with syncope.

Efecto de la edad y el sexo en el rendimiento diagnóstico del ecocardiograma en pacientes con síncope / The effect of age and sex on the diagnostic yield of the echocardiogram in patients with syncope

Introducción El síncope es motivo de numerosas pruebas diagnósticas, entre las que está el ecocardiograma transtorácico (ETT). Existe evidencia previa que sugiere escasa utilidad de esta prueba. Nuestro objetivo fue evaluar su rendimiento diagnóstico en el síncope, analizando el efecto de la edad y el sexo. Materiales y métodos Estudio observacional en el que se incluyeron pacientes con síncope y ETT entre 1990 y 2015. Se definieron hallazgos diagnósticos relacionados con el síncope. Realizamos un análisis descriptivo evaluando el rendimiento diagnóstico en global, y en función de edad y sexo. Resultados Se incluyeron 3.302 pacientes, siendo el rendimiento diagnóstico del 8,8%; el hallazgo más frecuente fue disfunción ventricular (4,5%). La probabilidad de ETT diagnóstico aumentó significativamente con la edad (p<0,001), siendo baja en menores de 50 años (2,3%). El sexo masculino se relacionó significativamente con ETT diagnóstico (p<0,001), a expensas de mayor frecuencia de disfunción ventricular. Conclusiones El rendimiento diagnóstico del ETT en pacientes con síncope es moderado, siendo bajo en edades inferiores a 50 años, y menor en mujeres que en hombres. Estos factores deben ser tenidos en cuenta a la hora del estudio diagnóstico de los pacientes con síncope (AU)

Introduction Syncope is the motivation for numerous diagnostic tests, among them transthoracic echocardiography (TTE); however, previous evidence suggests there is little utility in this test. Our objective was to assess its diagnostic yield in syncope, analysing the effect of age and sex. Material and methods We conducted an observational study that included patients with syncope and who underwent TTE between 1990-2015. We defined diagnostic findings related to syncope and performed a descriptive analysis, assessing the diagnostic yield (overall and according to age and sex). Results The study included 3,302 patients and measured a diagnostic yield of 8.8%; the most common finding was ventricular dysfunction (4.5%). The probability of a diagnostic TTE significantly increased with age (p<.001) but was low for patients younger than 50 years (2.3%). The male sex was significantly related with a diagnostic TTE (p<.001), mostly due to the higher rate of ventricular dysfunction. Conclusions The diagnostic yield of TTE in patients with syncope is moderate, low in patients younger than 50 years and lower in women than in men. These factors should be considered when conducting a diagnostic study of patients with syncope (AU)

Presence of bacterial DNA in thrombotic material of patients with myocardial infarction.

Infectious agents have been suggested to be involved in etiopathogenesis of Acute Coronary Syndrome (ACS). However, the relationship between bacterial infection and acute myocardial infarction (AMI) has not yet been completely clarified. The objective of this study is to detect bacterial DNA in thrombotic material of patients with ACS with ST-segment elevation (STEMI) treated with Primary Percutaneous Coronary Intervention (PPCI). We studied 109 consecutive patients with STEMI, who underwent thrombus aspiration and arterial peripheral blood sampling. Testing for bacterial DNA was performed by probe-based real-time Polymerase Chain Reaction (PCR). 12 probes and primers were used for the detection of Aggregatibacter actinomycetemcomitans, Chlamydia pneumoniae, viridans group streptococci, Porphyromonas gingivalis, Fusobacterium nucleatum, Tannarella forsythia, Treponema denticola, Helycobacter pylori, Mycoplasma pneumoniae, Staphylococus aureus,  Prevotella intermedia and Streptococcus mutans. Thus, DNA of four species of bacteria was detected in 10 of the 109 patients studied. The most frequent species was viridans group streptococci (6 patients, 5.5%), followed by Staphylococus aureus (2 patients, 1.8%). Moreover, a patient had DNA of Porphyromonas gingivalis (0.9%); and another patient had DNA of Prevotella intermedia (0.9%). Bacterial DNA was not detected in peripheral blood of any of our patients. In conclusion, DNA of four species of endodontic and periodontal bacteria was detected in thrombotic material of 10 STEMI patients. Bacterial DNA was not detected in the peripheral blood of patients with bacterial DNA in their thrombotic material. Bacteria could be latently present in plaques and might play a role in plaque instability and thrombus formation leading to ACS.

The effect of age and sex on the diagnostic yield of the echocardiogram in patients with syncope. / Efecto de la edad y el sexo en el rendimiento diagnóstico del ecocardiograma en pacientes con síncope.

INTRODUCTION: Syncope is the motivation for numerous diagnostic tests, among them transthoracic echocardiography (TTE); however, previous evidence suggests there is little utility in this test. Our objective was to assess its diagnostic yield in syncope, analysing the effect of age and sex. MATERIAL AND METHODS: We conducted an observational study that included patients with syncope and who underwent TTE between 1990-2015. We defined diagnostic findings related to syncope and performed a descriptive analysis, assessing the diagnostic yield (overall and according to age and sex). RESULTS: The study included 3,302 patients and measured a diagnostic yield of 8.8%; the most common finding was ventricular dysfunction (4.5%). The probability of a diagnostic TTE significantly increased with age (p<.001) but was low for patients younger than 50 years (2.3%). The male sex was significantly related with a diagnostic TTE (p<.001), mostly due to the higher rate of ventricular dysfunction. CONCLUSIONS: The diagnostic yield of TTE in patients with syncope is moderate, low in patients younger than 50 years and lower in women than in men. These factors should be considered when conducting a diagnostic study of patients with syncope.

Prevalence of donor-transmitted coronary artery disease and its influence on heart transplant outcomes.

BACKGROUND: It is uncertain whether donor-transmitted coronary artery disease (DTCAD) affects heart transplant (HT) recipients. METHODS: This retrospective analysis includes records of all patients who underwent a HT at our center over an 8-year period, who survived for at least 1 month, and who were examined by coronary angiography within 2 months post-HT. We distinguished angiographically from keep ultrasonography (IVUS) detected DTCAD. Major adverse cardiovascular events (MACE) comprised death, myocardial infarction, unstable angina, coronary revascularization, and admission because of heart failure not due to an acute rejection episode. RESULTS: Among the 171 patients of mean age 53±13 years and including 83% men, 65 (38%) were evaluated by IVUS. Donors were aged 40±14 years (range=14-73). Angiographic DTCAD affected seven patients (4.1%), and IVUS-detected DTCAD, 35 (53.8% of those examined by IVUS). DTCAD donors were older than non-DTCAD donors, by an average of 13 years (P=.001) for angiographic DTCAD and 18 years (P<.0001) for IVUS-detected DTCAD. Two patients underwent percutaneous revascularization upon detection of angiographic DTCAD. The angiographic- and IVUS-detected DTCAD groups did not differ significantly from the corresponding non-DTCAD groups as regards MACE incidence during 54±41 and 38±20 months follow-up, respectively. Cox regression analysis with adjustment for relevant confounders confirmed that IVUS-detected DTCAD was not a predictor of MACE (hazard ratio 1.2, 95% confidence interval 0.2-8.1). CONCLUSIONS: Among HT patients surviving≥1 month, angiographic- and IVUS-detected DTCAD showed prevalences of <10% and >50%, respectively. Neither detection method was associated with a greater long-term incidence of MACE.

Neither acute rejection nor immunosuppressant drug therapy (cyclosporine or tacrolimus) correlates with expression of either CD40 or CD154 on peripheral blood cells among human cardiac transplant patients.

Acute allograft rejection (AAR) is an important cause of graft loss following heart transplantation (HT). Increasing evidence shows that CD40-CD154 interactions play a central role in the immune processes leading to AAR. In this study we investigated the expression of CD40 and CD154 on peripheral blood cells from HT patients so as to determine possible association with AAR. Using two-color flow cytometry, we determined the expression of CD40 and CD154 in 102 samples of peripheral blood taken from 53 adult HT patients and in 17 samples from healthy adult volunteers. Samples from patients were obtained at the same time as endomyocardial biopsy was performed. We analyzed the relationships between the expression of these molecules and the following parameters: immunosuppressive treatment (cyclosporine vs tacrolimus), gender, age, time post-HT, and AAR (indicated by an ISHLT rating > or =3A). The percentages of HT patients' blood samples showing above-normal CD40 or CD154 expression did not differ significantly from those of controls. The percentage of patients' samples showing above-normal CD40 expression decreased with time after HT. Expression of these molecules was not above normal during rejection episodes, and for neither was there any statistically significant correlation between expression level and the immunosuppressor drug.

[The electrocardiogram in apical hypertrophic myocardiopathy. A case report with unique manifestations]. / El electrocardiograma en la miocardiopatía hipertrófica apical. Presentación de un caso con manifestaciones únicas.

We report the case of a 63-year-old female patient with apical hypertrophic cardiomyopathy, diagnosed by the presence of localized apical hypertrophy in the echocardiogram and a typical "spade like" left ventricular angiographic image, but with unique electrocardiographic features, characterized by chronic ST segment elevation, and T wave inversion, in the anterolateral leads. These changes were initially interpreted as a manifestation of acute ischemic heart disease. Chronic ST segment elevation has been occasionally described in patients with hypertrophic cardiomyopathy complicated with apical necrosis and aneurysm formation, but not in uncomplicated cases of apical hypertrophic cardiomyopathy. Its knowledge by the physician could allow avoidance of problems of differential diagnosis with more frequent heart diseases, especially acute atherosclerotic ischaemic heart disease.

Angiotensin-converting enzyme insertion/deletion polymorphism and restenosis after coronary angioplasty in unstable angina pectoris.

We studied the relation between angiotensin-converting enzyme insertion/deletion gene polymorphism and restenosis in Caucasian patients who underwent coronary angioplasty for management of unstable angina pectoris. Our results indicate that, in contrast to previous reports in Japanese patients, no association exists between angiotensin-converting enzyme gene polymorphism and the development of restenosis in Caucasian patients with acute coronary syndromes.)

[The diagnosis of myocardial damage during coronary angioplasty by the analysis of the isoforms of the enzyme creatine kinase MB]. / Diagnóstico de daño miocárdico durante la angioplastia coronaria mediante el análisis de las isoformas de la enzima creatincinasa MB.

BACKGROUND: The existence of myocardial damage during percutaneous transluminal coronary angioplasty (PTCA) is controversial. Mild elevations in creatine kinase (CK) activity and its isoenzyme MB (CKMB) in patients who underwent PTCA have been reported. However, other authors failed to confirm these elevations. The low sensitivity of total CK and CKMB activity for the detection of myocardial damage in different settings other than myocardial infarction might account for the controversial findings. Measurement of CKMB isoforms has been shown to have a higher sensitivity than the assessment of CK or CKMB activity for early diagnosis of myocardial infarction. Its sensitivity for the diagnosis of myocardial damage in settings other than infarction is not well described. OBJECTIVES: The aim of our study was two-fold: 1) to assess the incidence of myocardial damage after PTCA and 2) to compare the sensitivity of total CK and CKMB activity and measurement of CKMB isoforms for the detection of myocardial damage. METHODS: 14 patients (11 men and 3 women) with chronic stable angina underwent PTCA. Two electrocardiographic leads were monitored from the beginning of the procedure until 30 minutes after the PTCA. ST segment shifts of at least 1 mm, lasting for more than 1 minute, were considered indicative of myocardial ischemia. The duration of ischemic episodes was measured from the onset of the ST shift until its return to baseline. Total ischemic time, in minutes, was the sum of the duration of every ischemic episode. Blood samples were drawn before PTCA and serially during the first 24 hours post PTCA. CK (normal < 200 U/l) and CKMB (normal < 14 U/l) activities were measured. The CKMB isoforms were separated by electrophoresis, measured by densitometric scanning and their ratio calculated (CKMB2/CKMB1 normal < 1.5). RESULTS: Vessels which underwent PTCA were: the left anterior descending artery (LDA) in 5 patients, the circumflex coronary artery (Cx) in 3 patients, right coronary artery (RCA) in 3 patients, LDA and Cx in 1 patient and Cx and RCA in 2 cases. Eleven patients underwent balloon dilatation, 1 underwent atherectomy (Rotablator) and two patients had treatment with both Rotablator and balloon angioplasty. Ischemic ST segment shifts were found in ten patients and the median of total ischemic time was 13.5 minutes (interquartile range: 2-15 minutes). Total CK and CKMB activities were within the normal range in every patient whereas in 7 patients (50%) the peak ratio CKMB2/CKMB1 was above the normal range. There were no differences in age, sex, number of vessels or lesions treated or in the time of balloon inflation between patients with and without abnormal CKMB2/CKMB1 peak. However, the ischemic time was significantly higher in patients with CKMB2/CKMB1 > 1.5 (median 15 vs 0 minutes; p = 0.023). CONCLUSIONS: Myocardial damage during PTCA is not an uncommon finding. The CKMB isoforms are more sensitive markers of myocardial damage during PTCA than total CK or CKMB activities.

[Corticoid-resistant rejection and humoral rejection. The diagnostic criteria and therapeutic management]. / Rechazo corticorresistente y rechazo humoral. Criterios diagnósticos y manejo terapéutico.

The standard treatment of rejection episodes post-heart transplantation is based on high dose of steroids followed by monoclonal or policlonal antibodies directed against T lymphocytes like ATG or OKT3. When this treatment is insufficient it can be used other drugs like metothrexate, ciclofosfamide and another procedures such as total lymphoid irradiation, plasmapheresis or photopheresis. Cardiac allograft rejection is defined by histologic features that include the presence of lymphocytic infiltration of the myocardium with or without necrosis and this histologic pattern is termed cellular rejection. However there is a second form of acute rejection, associated with capillary injury, usually mediated by humoral immune response and without interstitial infiltrates which has been named vascular or humoral rejection. Vascular allograft rejection is commonly resistant to standards forms of immunosuppressive therapy and may result in irreversible allograft dysfunction and reduced patient survival.

[The relationship between clinical events and the angiographic lesions in coronary atherosclerosis. Hypolipemic treatment and plaque stabilization]. / Relación entre eventos clínicos y lesiones angiográficas en la aterosclerosis coronaria. Tratamiento hipolipemiante y estabilización de placa.

Secondary prevention studies have shown that lipid-lowering therapy improve angiographic outcome and reduce mortality and incidence of ischemic clinical events in patients with coronary artery disease. The mechanism responsible for the improvement in prognosis seem to be subtle as this improvement cannot be explained by changes in the angiographic diameter of coronary arteries. Atherosclerotic plaque rupture and subsequent thrombosis are the central features in the pathogenesis of acute coronary events: unstable angina, myocardial infarction and sudden death. Cholesterol lowering might decrease the risk of plaque rupture and its thrombogenicity, as well as normalise the impaired endothelial function in hypercholesterolemic patients. In this report, the effects of lipid-lowering therapy on angiographic outcome and incidence of clinical events, in patients suffering from coronary artery disease, are reviewed, and the mechanisms that might explain these findings are discussed.

Spontaneous coronary artery dissection.

Spontaneous coronary artery dissection is a rarely identified entity whose exact incidence, etiology, pathogenesis, medium-term evolution, and optimal treatment have not yet been firmly established. This article describes five new cases with additional specific characteristics. Five of 2,241 coronary arteriograms taken between September 1989 and November 1992 showed angiographic signs of coronary dissection. Three of the patients were treated pharmacologically, and two were operated on. All were evaluated angiographically 10-18 months after diagnosis and followed up clinically for > or = 20 months. Three patients exhibited acute myocardial infarction, one showed effort angina and the fifth unstable angina. In four cases, coronary dissection was associated with coronary atherosclerosis, but in the fifth the coronary tree was apparently healthy except for the dissection. Dissection affected the right coronary artery in three cases and the left in two. Angiographic evolution varied among the five and was uncorrelated with treatment. Dissection disappeared in three; it persisted, with total obstruction of the artery in the middle of the dissected segment in one case; and advanced to affect the whole left coronary tree in the fifth. After an 18-month follow-up, none of the five patients experienced symptoms. These cases provide a good illustration of the variability of spontaneous coronary dissection as regards etiology, clinical presentation, treatment, and evolution. Coronary dissection is always caused by hemorrhage in the media of the arterial wall; its variability in evolution and in optimal treatment may be derived from the cause of the hemorrage, which possibly was not the same in all cases.