[Cardiomyopathy (X). Clinical approach to the patient with hypertrophic cardiomyopathy]. / Miocardiopatías (X). Actitud clínica ante el paciente con miocardiopatía hipertrófica.

Hypertrophic cardiomyopathy is a clinical and anatomofunctional entity that determines a series of hemodynamic consequences closely related to sintomatology. Left ventricular hypertrophic, subaortic stenosis, diastolic dysfunction and myocardial ischemia are the different pathophysiology mechanisms that generate similar clinical manifestations. Sintomatology defines two groups of patients with different profiles and clinical management. Ventricular arrhythmias are not uncommon and the forms that imply a darkest prognosis are supported symptomatic ventricular tachycardia and the induced ventricular tachycardia in patients that have suffered a cardiac arrest or have had syncopes. Basic explorations in all patients, in addition to physical examination, chest radiography and rest electrocardiogram, are Doppler echocardiography and Holter. Other explorations, such as Tallium-201 stress test, tilt test, electrophysiological and hemodynamic studies, are rationalized according to risk profile, sintomatology and responses to indicated treatment. In general, prognosis in asymptomatic patients is good and complex explorations are not justified nor are preventive character treatments. Symptomatic patients who have a higher risk must be studied more closely, and frequently require complex and invasive explorations. They also need pharmacological treatment and often more invasive therapeutical options, DDD pacemakers or surgery, if those fail.

[Study of heart rate variability in acute myocardial infarction and its relationship with ventricular function and other clinical variables]. / Estudio de la variabilidad de la frecuencia cardíaca en el infarto agudo de miocardio y su relación con la función ventricular y otras variables clínicas.

BACKGROUND: The influence of ventricular function (VF) on prognosis in acute myocardial infarction (AMI) is well known. Heart rate variability (HRV), as a neurohumoral parameter could predict VF after discharge in AMI patients. Our goal is to investigate the possible relation among HRV, VF and another clinical variables in AMI. PATIENTS AND METHODS: We studied 37 patients with AMI after hospital discharge. Age, AMI type, location, enzymes, treatment (thrombolysis versus no thrombolysis) were evaluated. The left ventricular ejection fraction (LVEF) was assessed by radionuclide ventriculography in 27 subjects. Twenty nine subjects without cardiopathy were the control group. Twenty four hour electrocardiographic recordings were obtained and a proper software was used to measure HRV. This was evaluated with time domain measures: RR interval, standard deviation of the mean RR interval (SDNN), standard deviation of the average of the RR intervals measured every 5 minutes during 24 hours (SDANN) and number of two consecutive RR intervals with a variability > 50 ms (pNN50). We considered a decreased variability if SDANN was less than 100 ms. Two groups were established: 1) low heart rate variability (LHRV) if SDANN was less than 100 ms, and 2) normal heart rate variability (NHRV) if SDANN was larger than 100 ms. Continuous variables were examined by the t-test, chi square for discrete ones and linear regression analysis was used to assess the relation among variables. A p < 0.05 was considered significant. RESULTS: The percentage of infarcted patients in the group of LHRV is 75%, whereas it is 14% in the control group (p < 0.05). SDANN, SDNN and pNN50 values are significantly lower (p < 0.05) in the AMI than in the control group. LHRV was more frequent in patients with complicated AMI with congestive heart failure. LVEF was significantly lower (35% vs 56%) in the LHRV than in the NHRV group. No significant differences were found among: site, type infarct, treatment or ventricular ectopy in the Holter before discharge. There is good correlation (r = 0.635; p < 0.05) between LVEF and HRV measures. No correlation was found between HRV and age, or the enzymatic size of infarction. CONCLUSIONS: 1) LHRV is frequent in the late phase of AMI, and 2) LHRV can be an indirect index of left ventricular failure.

[Permanent endocardial pacemaker. Review of 116 implantations (author's transl)]. / Marcapaso endocavitario permanente. A propósito de 116 implantaciones.

A retrospective study on the results of 116 permanent ventricular pacemaker implantations performed in the Service of Cardiology of the Hospital Clinico Universitario in Salamanca is reported. In the majority of cases the indication for a pacemaker was a complete atrioventricular block (53 cases). Sixteen cases had a "sick-sinus syndrome". An apparent cardiopathy was not found in 84 percent of the cases. In the group of patients with cardiopathy that of ischemic type was the most common. The technique of endocardiac catheter pacing was employed in all cases. An 18 percent of global complications occurred, but in no case an early electrode displacement was registered. Complications appeared at a later time included erosion of the pacemaker in ten cases, and displacement and/or deinsertion in seven. The mean life for 18 displaced generators was 41.3 months. A sudden equipment malfunction occurred in two cases, and an inhibition by potentials of the pectoralis major muscle in another. Morbidity rate was lower to that of other published series, may be due to the use of modern generators with a progressive reduction of its diameter and weight and more flexible electrodes which allow a better implantation. The mortality rate was zero.

[Changes in exercise capacity and in induced ischemia with an oral dose of 5 isosorbide mononitrate in patients with stable angina pectoris]. / Modificaciones en la capacidad de ejercicio y en la isquemia inducida con una dosis oral de 5-mononitrato de isosorbide en pacientes con angina de pecho estable.

In order to establish the effects of 5-isosorbide mononitrate on: the exercise capacity, the onset period of angina and ischemia along with the degree and on whether the duration time was prolonged up to 5 hours after the oral administration of 20 mg of this drug, we compare this drug against a placebo in a group of 15 patients with stable angina pectoris developed by effort who performed an exercise test using a bicycle ergometer. After the administration of 20 mg of 5-isosorbide mononitrate it was observed that onset time of angina (p less than 0.001), the onset time of ST decrease (p less than 0.002) and total time of exercise attained were significantly superior to those found in patients with placebo administration. Moreover, for the same degree of EKG ischemia (ST decrease) showed a superior exercise time was registered (p less than 0.002) after the administration of 5-isosorbide mononitrate (5-IM). Our results show that an oral dosage of 20 mg of 5-IM given to patients with stable angina pectoris increased the capacity and exercise tolerance delaying significantly the onset time of angina, the onset time of EKG ischemia and its decree induced by the effort up to 5 hours after its administration.

Tratamiento de la angina de pecho / Treatment of angor pectoris

La angina de pecho es la forma más común de manifestarse la cardiopatía isquémica. El paciente que presenta dolor anginoso es afortunado porque dentro del amplio abanico de manifestaciones de la cardiopatía isquémica, cualquiera de las otras como infarto de miocardio, muerte súbita, insuficiencia cardíaca y arritmias ventriculares, son más graves y porque, además, la presencia del dolor torácico permite poner en marcha todo el sistema diagnósticoterapéutico que redundará finalmente en una reducción del infarto de miocardio y la muerte. El tratamiento de la angina de pecho, tanto en su forma crónica y estable como en la forma aguda e inestable, tiene como objetivos inmediatos controlar el síntoma y prevenir la muerte y el infarto agudo, y como objetivos a medio y largo plazo el control de la enfermedad aterosclerótica coronaria. El plan terapéutico siempre deberá diseñarse según el perfil de riesgo de cada paciente.La angina inestable frecuentemente se estabiliza con tratamiento médico, pero puede presentar inicialmente predictores de mal pronóstico o en la fase pre-alta hospitalaria una prueba de isquemia moderada o severamente positiva, que determinarán una actitud agresiva con angiografía coronaria y eventualmente revascularización. En la angina crónica, el tratamiento médico, que se dirige a controlar síntomas pero también a prevenir infarto y muerte, debe también configurarse atendiendo a tres variables de significación pronóstica, grado de isquemia, estado de la función ventricular y extensión angiográfica de la enfermedad coronaria. Según el perfil pronóstico de cada paciente se decidirá el tipo de tratamiento definitivo. Los casos con mayor riesgo se beneficiarán de un tratamiento revascularizador y la técnica a proponer se establecerá en función de la localización y extensión de las lesiones anatómicas, la severidad de la i quemia y el grado de disfunción ventricular. (AU)