[Usefulness of copeptin in discarding non-ST elevation acute myocardial infarction in patients with acute chest pain and negative first troponin I]. / Valor de la copeptina para la exclusión del infarto agudo de miocardio sin elevación del segmento ST en pacientes con dolor torácico y primera troponina negativa.

AIM: To evaluate the usefulness of copeptin as a rapid and reliable marker for discarding non-ST elevation acute myocardial infarction (NSTEMI) in patients attended in an Emergency Care Department due to acute chest pain with a normal or non-diagnostic electrocardiogram and a negative first troponin I result. DESIGN: A prospective observational study was carried out. SETTING: The Emergency Care Department of a university hospital. PATIENTS: The study comprised a total of 97 patients attended in the Emergency Care Department due to chest pain suggestive of acute coronary syndrome with an evolution of under 12h, a non-diagnostic electrocardiogram and a negative first troponin I result. INTERVENTIONS: None. VARIABLES OF INTEREST: Patient demographic data and baseline characteristics, copeptin upon admission, troponin I upon admission and after 6h, and final diagnosis. RESULTS: The final diagnosis was NSTEMI in 14 patients (14.4%) -no significant differences in copeptin concentration being observed between the 2 groups, though a tendency towards higher values was recorded in the NSTEMI group (median: 24.6pmol/l [interquartile range: 42.0] vs. 12.0pmol/l [16.1]; P=.06). The AUC ROC for copeptin upon admission was 0.657 (95%CI: 0.504-0.810), with a negative predictive value of 92% for a cutoff point of 14pmol/l. CONCLUSIONS: Copeptin determination upon admission to the Emergency Care Department in patients with chest pain for ≤12h, suggestive of acute coronary syndrome, with a non-diagnostic electrocardiogram and a negative first troponin I determination does not allow rapid and reliable exclusion of the presence of NSTEMI. Serial troponin I measurements are needed in this respect.

Effects of early use of atenolol or captopril on infarct size and ventricular volume: A double-blind comparison in patients with anterior acute myocardial infarction.

BACKGROUND: beta-Blockers and ACE inhibitors reduce early mortality when either one is started in the first hours after myocardial infarction (MI). Considering the close correlation between morphological changes and prognosis, we aimed to investigate whether the benefit of both beta-blockers and ACE inhibitors might reside in a similar protective effect on infarct size or ventricular volume. METHODS AND RESULTS: In a randomized, double-blind comparison between early treatment with captopril or atenolol in 121 patients with acute anterior MI, both drugs showed a similar reduction in mean blood pressure. However, only the atenolol-treated patients showed a significant early reduction in heart rate. Infarct size, obtained from the perfusion defect in resting single photon emission imaging, was higher in captopril-treated patients than in atenolol-treated patients: 29.8+/-12% versus 20.8+/-12% (P:<0.01) by polar map and 28.3+/-13% versus 20.0+/-13% (P:<0.01) by tomography. Changes from baseline to 1 week and to 3 months in ventricular end-diastolic volume, assessed by echocardiography, were as follows: 58+/-14 versus 64+/-19 (P<0.05) and 65+/-21 mL/m(2) (P<0.05), respectively, with captopril, and 58+/-18 versus 64+/-18 (P<0.05) and 69+/-30 mL/m(2) (P<0.05), respectively, with atenolol. Neither group showed significant changes in end-systolic volume. Among patients with perfusion defect >18% (n=51), those treated with atenolol showed a significant increase of end-systolic and end-diastolic ventricular volumes, whereas captopril-treated patients did not. CONCLUSIONS: Although early treatment with atenolol or captopril results in similar overall short- and medium-term preservation of ventricular function and volumes, in patients with larger infarctions, a beta-blocker alone does not adequately protect myocardium from ventricular dilatation.

[Echocardiography during transesophageal atrial pacing. Its applicability and diagnostic value]. / Ecocardiografía durante la estimulación auricular transesofágica. Aplicabilidad y valor diagnóstico.

INTRODUCTION AND OBJECTIVES: Atrial pacing has been proposed as an alternative method to the isotonic exercise, to induce ischemia, and, joined to two-dimensional echocardiography, as one of the main modalities in stress echo. In order to analyse its applicability and diagnostic value in assessing coronary artery disease this study was undertaken. PATIENTS AND METHODS: 52 patients referred to coronarography for suspicion or evaluation of ischemic disease, were submitted to this technique. RESULTS: The study was completed in 44 patients (applicability rate of 84,7%). The results obtained showed a sensitivity, specificity and diagnostic accuracy for the regional wall motion abnormalities echocardiographically detected, of 88%, 68% and 79%, respectively. When electrocardiographic changes or presence of angina during atrial pacing were added to echocardiographic data, sensitivity increased to 96%. In 41 patients in which a conventional stress test was available, sensitivity was 55% electrocardiographically, 33% clinically and 68% globally. CONCLUSIONS: It is concluded that transthoracic two-dimensional echocardiography during atrial pacing is a safe, highly sensitive method for coronary artery disease detection. The limitations of the method for its routine clinical application are also analysed.

Valor de la copeptina para la exclusión del infarto agudo de miocardio sin elevación del segmento ST en pacientes con dolor torácico y primera troponina negativa / Usefulness of copeptin in discarding non-ST elevation acute myocardial infarction in patients with acute chest pain and negative first troponin I

OBJETIVO: Evaluar la utilidad de la copeptina para descartar de forma rápida y segura el infarto agudo de miocardio sin elevación del segmento ST (IAMNST) en pacientes atendidos en un Servicio de Urgencias por dolor torácico agudo con electrocardiograma normal o no diagnóstico y primera determinación de troponina I (cTnI) negativa. DISEÑO: Estudio prospectivo y observacional. ÁMBITO: Servicio de Urgencias de un hospital universitario. PACIENTES: Un total de 97 pacientes atendidos en el Servicio de Urgencias por dolor torácico sugestivo de síndrome coronario agudo de menos de 12 h de evolución, con electrocardiograma no diagnóstico y primera cTnI negativa. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS: Datos demográficos y características basales, copeptina en admisión, cTnI en admisión y a las 6 h, diagnóstico final. RESULTADOS: El diagnóstico final fue de IAMNST en 14 pacientes (14,4%), no observándose diferencias significativas en las concentraciones de copeptina entre ambos grupos, aunque se observó una tendencia a valores superiores en aquellos con IAMNST (mediana: 24,6 pmol/L [amplitud intercuartil: 42,0] vs. 12,0 pmol/L [16,1]; p = 0,06). El AUC ROC para la medida al ingreso de copeptina fue de 0,657 (IC 95%: 0,504-0,810), con un valor predictivo negativo del 92% para un punto de corte de 14 pmol/L. CONCLUSIONES: La determinación de copeptina al ingreso en el Servicio de Urgencias en pacientes con dolor torácico ≤ 12 h sugestivo de síndrome coronario agudo, electrocardiograma no diagnóstico y primera TnI negativa no permite descartar de forma rápida y segura la presencia de IAMNST, siendo necesaria la realización de medidas seriadas de cTn

AIM: To evaluate the usefulness of copeptin as a rapid and reliable marker for discarding non- ST elevation acute myocardial infarction (NSTEMI) in patients attended in an Emergency Care Department due to acute chest pain with a normal or non-diagnostic electrocardiogram and a negative first troponin I result. Design: A prospective observational study was carried out. Setting: The Emergency Care Department of a university hospital. The study comprised a total of 97 patients attended in the Emergency Care Department due to chest pain suggestive of acute coronary syndrome with an evolution of under 12 h, a non-diagnostic electrocardiogram and a negative first troponin I result. Interventions: None. Variables of interest: Patient demographic data and baseline characteristics, copeptin upon admission, troponin I upon admission and after 6 h, and final diagnosis. Results: The final diagnosis was NSTEMI in 14 patients (14.4%) ---no significant differences in copeptin concentration being observed between the 2 groups, though a tendency towards higher values was recorded in the NSTEMI group (median: 24.6 pmol/l [interquartile range: 42.0] vs. 12.0 pmol/l [16.1]; P=.06). The AUC ROC for copeptin upon admission was 0.657 (95%CI: 0.504- 0.810), with a negative predictive value of 92% for a cutoff point of 14 pmol/l. Conclusions: Copeptin determination upon admission to the Emergency Care Department in patients with chest pain for ≤12 h, suggestive of acute coronary syndrome, with a non-diagnostic electrocardiogram and a negative first troponin I determination does not allow rapid and reliable exclusion of the presence of NSTEMI. Serial troponin I measurements are needed in this respect

Non-compliance with appointments amongst patients attending an Allergology Clinic, after implementation of an improvement plan.

BACKGROUND: Non-compliance is a common cause of failed medical action, contributing to absence of regular check-ups. Our group has already published studies that analyse the level of non-compliance with appointments amongst patients attending our Allergology clinic, and we have made proposals for improvement. OBJECTIVE: This article evaluates the results obtained three years after setting up and launching telephone reminders for patients' first appointments. METHODS: All patients who were given appointments for first and subsequent visits during 2005 were included. A total of 18215 appointments were studied (3115 first appointments and 15100 subsequent ones). Of these, there were 2479 missed appointments (438 first appointments and 2041 subsequent ones), corresponding to 2215 patients (412 first visits and 1803 subsequent ones), with a mean of 1.12 appointments/patient/year. RESULTS: The non-compliance rate was 13.61%. The most common non-compliers were men (14.11% missed appointments against 13.24% missed appointments in women) and in the age range 20-29 years and 30-39 years (16.46% and 15.28% non-compliance, respectively). The mean age of non-compliers was 34.55 +/- 14.73 years. We observed a significant number of patients who missed more than one appointment (5.12% of all non-compliers and 0.7% of all patients). Differences were found in the degree of non-compliance depending on the type of appointment (14.06% non-compliance with first visits and 13.52% with subsequent visits). We observed a significant increase in missed appointments during the Summer holidays; July and August showed the highest percentage of missed appointments for both the first visit (20.62% in July and 23.59% in August) and subsequent visits alike (16.14% in July and 14.23% in August). CONCLUSIONS: A slight reduction in non-compliance was observed after implementing the proposals made in our previous study. In view of the high costs incurred from missed appointments, the government should finance studies to reduce this problem. The causes of non-compliance may be difficult to control, including present access to the public health service. We must be alert to and/or take preventive measures in young patients and cases of previous non-compliance. The degree of non-compliance is a quality indicator, because it reduces the yield of appointments, and it evidences a lack of cohesion of patients with Primary Health Care Units for first appointments, and with Specialist Care Units for subsequent appointments. Once certain levels of attendance have been attained, it is difficult to achieve an effect on this point in order to improve attendance rates.

Congenital diverticulum of the right ventricle associated with coarctation of aorta, atrial and ventricular septal defect and ductus.

Congenital right ventricular muscular diverticula are extremely rare and are usually associated with other congenital cardiac anomalies, (in half of the cases tetralogy of Fallot). They functionally behave like an accessory ventricular chamber which contracts synchronously with the normal ventricles. Less than 30 patients with a right ventricular diverticulum have been reported in literature. An apical right ventricular diverticulum occurs in patients with thoraco-abdominal midline defects or abnormalities of the cardiac position([1]). However, an antero-superior diverticulum is usually associated with other congenital cardiac defects, such as a ventricular septal defect, tetralogy of Fallot, double outlet right ventricle and pulmonary stenosis([2--9]). We report an 11-year-old boy with an antero-superior diverticulum of the right ventricle associated with a coarctation of aorta, ductus arteriosus, and atrial and ventricular septum defects. To the best of our knowledge, such an association has not been reported before.

[The utility of color Doppler in dissecting aortic aneurysm]. / Utilidad del doppler codificado en color en los aneurismas aorticos con o sin diseccion.

We inform about the utility of Color-Doppler to identify dissection in aortic aneurysm. We studied five patients, fourth with dissection and one without dissection. All of them were in the fourth decade of life, except the patient without dissection, who developed symptoms at the age of 62. Two-dimensional echocardiography displayed the alterations of the aorta, such as dilatation of the walls, the presence or absence of dissection and in the cases with dissection the extension of it (three patients had DeBakey Type I, one DeBakey Type III an other DeBakey Type II). In all patients with dissection the Doppler study determined the presence or absence of flow through the false channel, in particular in the second and fifth patient and with Color-Doppler we observed that the flow was bidirectional. Also the degree of aortic incompetence could be quantified. It is concluded that with two-dimentional echocardiography it is possible to identify the anatomical features of aortic aneurysm and that Doppler study gives additional hemodynamic information which has importance in therapy and prognosis.

[Atypical chest pain with normal coronary vessels: clinical study and follow-up of 22 patients]. / Dolor torácico atípico con coronarias normales: estudio clínico y seguimiento de 22 pacientes.

22 patients with normal coronarography but with angina pectoris or angina-like chest pain without evidence of coronary spasms are reviewed. We studied clinical characteristics, basal and exercise electrocardiography and other tests used to obtain a diagnosis, although only in one patient were we able to find an esophageal pathology which caused the clinical picture. After 20.7 +/- 14.4 months follow-up no patients had myocardial infarction or acute coronary events. Most of them still experience chest pain, are physically limited and use antianginal drugs. The fact that their coronarograms were normal decreased significantly the number of admissions to hospital (2.4 +/- 3.3 vs 0.26 +/- 0.95, P less than 0.02) and the amount of drugs prescribed. The lack of improvement of most of them seems to justify the need for other studies looking for a positive diagnosis and other types of treatment.

[Immediate and long-term results of aortic valvulotomy in aortic valve stenosis]. / Resultados inmediatos y a largo plazo de la valvulotomía aórtica en la estenosis aórtica valvular.

Between April 1962 and December 1982 we performed valvulotomies on 68 patients to correct valvular aortic stenosis (VAoS). Forty-one were men and 27 women whose ages ranged from 20 months to 47 years (mean = 11.9 +/- 6.4 years). In 95% of cases VAoS was congenital. All patients underwent clinical preoperative evaluation with chest roentgenogram and electrocardiogram (ECG). Catheterization was done on 89.7%. Symptoms varied from none to syncope and stress angina. Symptoms bore no relation to the systolic aortic gradient, which oscillated between 31 and 200 mm Hg. There was a significant postoperative improvement in symptoms and less notable improvement in chest X-rays and ECG. Follow-up was from 1 to 22 years (mean = 7.12 +/- 4.43 years). Thirty-nine patients were followed for 5 or more years with serial clinical, radiological and electrocardiographic control. Fifty percent underwent postoperative catheterization. Seventeen patients continued with residual aortic regurgitation (AoR). Fourteen patients were again operated. A new valvulotomy was performed on 2 and valve replacement was done on the rest. Perioperative mortality was 2.9% and long-term survival 88% with 84.6% of the patients asymptomatic or in functional class I of the NYHA. Survival curves were plotted and the literature reviewed. The conclusion was that although this surgery constitutes a low risk, it should be considered palliative in the majority of the cases.

[Long-term follow up of Doppler parameters of ventricular diastolic function after myocardial infarct]. / Evolución a largo plazo de los parámetros Doppler de función diastólica ventricular tras un infarto del miocardio.

Forty-two survivors of a first transmural, noncomplicated myocardial infarction underwent mitral flow pulsed-Doppler studies both at predischarge time and 1 year later, in order to assess the long-term evolution of diastolic parameters in the absence of reinfarction or revascularization procedures. Results showed a decrease of mean value of E wave peak velocity (59.6 +/- 14 cm/sec vs 46.8 +/- 13 cm/sec, p < 0.001). Mean value of A wave peak velocity remained stable (59.4 +/- 16 cm/sec vs 58.8 +/- 13 cm/sec, p = 0.86). The mean value of the E/A ratio showed a significant decrease during follow-up from an initial value > or = 1 to a final value < 1 (1.08 +/- 0.4 vs 0.82 +/- 0.2, p < 0.01). From the point of view of individual results, only 8 of 22 patients with an E/A ratio > or = 1 before discharge presented the same ratio value 1 year later, whereas only 1 patient with a E/A ratio < 1 before discharge presented a > 1 value of this ratio in the late study. It is concluded that during the first year of evolution after transmural, nonrevascularized, noncomplicated infarction, the left ventricle filling pattern displays a significant change from predischarge phase (mainly protodiastolic with predominant E wave) to late follow-up (mainly telediastolic with predominant A wave). Different hypotheses to explain these results are discussed.

Non-compliance with appointments amongst patients attending an Allergology Clinic, after implementation of an improvement plan / Incumplimiento de citas concertadas en los pacientes de una consulta de alergología, tras la implantación de un ciclo de mejora

Background: Non-compliance is a common cause of failed medical action, contributing to absence of regular check-ups. Our group has already published studies that analyse the level of non-compliance with appointments amongst patients attending our Allergology clinic, and we have made proposals for improvement. Objective: This article evaluates the results obtained three years after setting up and launching telephone reminders for patients' first appointments. Methods: All patients who were given appointments for first and subsequent visits during 2005 were included. A total of 18215 appointments were studied (3115 first appointments and 15100 subsequent ones). Of these, there were 2479 missed appointments (438 first appointments and 2041 subsequent ones), corresponding to 2215 patients (412 first visits and 1803 subsequent ones), with a mean of 1.12 appointments/patient/year. Results: The non-compliance rate was 13.61 %. The most common non-compliers were men (14.11 % missed appointments against 13.24 % missed appointments in women) and in the age range 20-29 years and 30-39 years (16.46 % and 15.28 % non-compliance, respectively). The mean age of non-compliers was 34.55 ± 14.73 years. We observed a significant number of patients who missed more than one appointment (5.12 % of all non-compliers and 0.7 % of all patients). Differences were found in the degree of non-compliance depending on the type of appointment (14.06 % non-compliance with first visits and 13.52 % with subsequent visits). We observed a significant increase in missed appointments during the Summer holidays; July and August showed the highest percentage of missed appointments for both the first visit (20.62 % in July and 23.59 % in August) and subsequent visits alike (16.14 % in July and 14.23 % in August). Conclusions: A slight reduction in non-compliance was observed after implementing the proposals made in our previous study. In view of the high costs incurred from missed appointments, the government should finance studies to reduce this problem. The causes of non-compliance may be difficult to control, including present access to the public health service. We must be alert to and/or take preventive measures in young patients and cases of previous non-compliance. The degree of non-compliance is a quality indicator, because it reduces the yield of appointments, and it evidences a lack of cohesion of patients with Primary Health Care Units for first appointments, and with Specialist Care Units for subsequent appointments. Once certain levels of attendance have been attained, it is difficult to achieve an effect on this point in order to improve attendance rates

Fundamento: El incumplimiento es una causa frecuente de fracaso de las actuaciones médicas, contribuyendo a ello la ausencia a los controles periódicos. Nuestro grupo con anterioridad ha publicado estudios en los que se analizaba el grado de incumplimiento a citas concertadas, de los pacientes citados en nuestra consulta de Alergología y se realizaban propuestas de mejora. Objetivo: En el presente artículo se evalúan los resultados obtenidos tras tres años desde su puesta en marcha, e introducción de recordar telefónicamente la fecha de la cita a los pacientes de primera vez. Métodos: Se incluyeron los pacientes citados en consulta que acudían por primera vez o a una visita sucesiva, durante todo el año 2005. Fueron objeto del estudio un total de 2.479 citaciones (438 por primera vez y 2.041 sucesivas) que no acudieron a la consulta, correspondientes a 2.215 pacientes (412 de primera visita y 1803 sucesivas), con una media de 1,12 citas/paciente/año. Eran 1391 (56,11%) mujeres y 1088 (43,89%) hombres, con una edad media de 34,55 ± 14.73 años. Resultados: Existió incumplimiento al 13,61% de las consultas. Los pacientes que incurrieron en el incumplimiento con más frecuencia fueron los hombres (14,11% de los citados frente al 13,24%) y las franjas de edades de los 20 a 30 años y de 30 a 40 años (16,46% y 15,28% de incumplimiento respectivamente). Encontramos un número importante de pacientes reincidentes en el incumplimiento (5,12% del total de pacientes incumplidores y 0,7% del total de pacientes citados). Se evidenciaron diferencias en el grado de incumplimiento de las citas en función de la consulta (14.06% incumplimiento en la primera consulta y 13.52% en las consultas sucesivas). Hemos encontrado un aumento significativo de las ausencias en la consulta durante el período vacacional estival, siendo los meses de julio y de agosto los que registraron mayor porcentaje de ausencias, tanto los de primera visita (20,62% en julio y 23,59% en agosto) como los de visitas sucesivas (16,14% en julio y 14,23% en agosto). Conclusiones: Se evidenció un discreto descenso en el incumplimiento, tras poner en marcha las medidas propuestas a raíz de nuestro anterior estudio. Debido a los elevados costes que las inasistencias suponen, es necesario que la administración financie estudios que permitan la disminución de las mismas. Quizá en las inasistencias jueguen papel motivos de difícil control, entre los que cabe barajar la actual accesibilidad a los servicios sanitarios públicos. Es preciso estar alerta y/o tomar medidas anticipatorias en pacientes jóvenes y con incumplimientos previos. El nivel de incumplimiento es un indicador de calidad, al disminuir el rendimiento de las consultas, y poner en evidencia una falta de adherencia de los ciudadanos con los Equipos de Atención Primaria para las primeras consultas, y para la Atención Especializada en las consultas sucesivas. Sobre él, es difícil incidir con el fin de mejorar los índices, una vez obtenidas determinadas cuotas