[Pulmonary arterial hypertension from the risk assessment to combined treatment]. / Hipertensión arterial pulmonar desde la evaluación del riesgo al tratamiento combinado.

This paper shows the importance of the guideline clinical practice as well as the centers for comprehensive care of pulmonary arterial hypertension. The current treatment of pulmonary arterial hypertension is analyzed according to its severity, stratified through the evaluation of the multiple parameters of risk and its mortality to 1 year. The prognosis of the disease is considered and the place of the combined treatment indicated in sequential manner or from the beginning.

En este trabajo se señala la importancia de las guías de actuación clínica, así como de los centros de atención integral de la hipertensión arterial pulmonar. Se analiza el tratamiento actual de la hipertensión arterial pulmonar de acuerdo a su severidad, estratificado a través de la evaluación de parámetros múltiples de riesgo y su mortalidad a 1 año. Además, se considera el pronóstico de la enfermedad y el lugar que tiene el tratamiento combinado indicado en forma secuencial o desde un inicio.

Left atrial longitudinal strain by speckle tracking as independent predictor of recurrence after electrical cardioversion in persistent and long standing persistent non-valvular atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia in humans. After successful cardioversion, there is a recurrence of 60% due to atrial remodeling, and it has been shown that the global peak atrial longitudinal strain (GPALS) is decreased in these subjects. The aim of this study was to evaluate the predictive value of GPALS for AF recurrence. A prospective cohort of patients with persistent (PnVAF) and long standing persistent non-valvular AF (LSPnVAF) which underwent electrical cardioversion was evaluated with standard echocardiographic variables and GPALS quantification. The primary endpoint was AF recurrence at 6 months. We included PnVAF (n = 50, aged 68.4 ± 10.2 years, female 46%, lasted AF 6 months) and LSPnVAF (n = 81, aged 66.5 ± 13.1 years, female 36%, lasted AF 18 months). At 6 months there were a 68% of recurrence of AF in PnVAF and 53% in LSPnVAF group. GPALS was lower in recurrence 7.8 ± 2.0% versus 21.2 ± 8.9% (p < 0.001) for PnVAF and 7.3 ± 2.7% versus 20.7 ± 7.6% (p < 0.001) in LSPnVAF. GPALS ≤ 10.75% discriminates recurrence at 6 months with a sensitivity of 85%, specificity 99%, PPV 85%, NPV 90%, LR + 8.5 and LR- 0.17. The independent predictors of recurrence in PnVAF were GPALS ≤ 10.75% HR 8.89 [(2.2-35.7), p < 0.01] meanwhile in LSPnVAF were age HR 1.039 [(1.007-1.071), p = 0.01], and GPALS ≤ 10.75% HR 28.1 [(7.2-109.1), p < 0.001]. In subjects with PnVAF and LSPnVAF with successful electrical cardioversion, GPALS ≤ 10.75% predicts arrhythmia recurrence at 6-month follow-up.

Oxidative Stress State Is Associated with Left Ventricular Mechanics Changes, Measured by Speckle Tracking in Essential Hypertensive Patients.

The oxidative stress state is characterized by an increase in oxygen reactive species that overwhelms the antioxidant defense; we do not know if these pathological changes are correlated with alterations in left ventricular mechanics. The aim was correlating the oxidative stress state with the left ventricular global longitudinal strain (GLS) and the left ventricular end diastolic pressure (LVEDP). Twenty-five patients with essential hypertension and 25 controls paired by age and gender were studied. All of the participants were subjected to echocardiography and biochemical determination of oxidative stress markers. The hypertensive patients, compared with control subjects, had significantly (p < 0.05) higher levels of oxidized proteins (5.03 ± 1.05 versus 4.06 ± 0.63 nmol/mg), lower levels of extracellular superoxide dismutase (EC-SOD) activity (0.045 ± 0.02 versus 0.082 ± 0.02 U/mg), higher LVEDP (16.2 ± 4.5 versus 11.3 ± 1.6 mm Hg), and lower GLS (-12% versus -16%). Both groups had preserved ejection fraction and the results showed a positive correlation of oxidized proteins with GLS (r = 0.386, p = 0.006) and LVEDP (r = 0.389, p = 0.005); we also found a negative correlation of EC-SOD activity with GLS (r = -0.404, p = 0.004) and LVEDP (r = -0.347, p = 0.014).

[Left main coronary artery aneurysm thrombosis in a young patient with acute myocardial infarction]. / Trombosis de aneurisma del tronco coronario izquierdo en paciente joven con infarto agudo de miocardio.

INTRODUCTION: The left main coronary artery aneurysm is rare, with an incidence of 0.1%, being the atherosclerosis its main etiology. Angiography is the gold standard for diagnosis and treatment. Depending on the severity of coexisting coronary stenosis, patients with left main coronary artery aneurysms can be effectively managed either surgical or pharmacologically. CLINICAL CASE: We present a case of a 44 year-old male with a history of obesity, smoking and dyslipidemia, complaining of oppressive chest pain, dyspnea and diaphoresis. An electrocardiogram showed an ST-segment elevation on the anterior and lateral wall and positive enzymatic curve for infarction. He was initially treated with streptokinase with no reperfusion evidence after 3 hours of the onset of symptoms, so he underwent to rescue angioplasty. Angiography reported left main coronary artery aneurysm thrombosis. Afterwards, he presented cardiogenic shock and was revascularized with a coronary artery bypass graft of the mammary artery to the left anterior descending artery and the saphenous vein to the obtuse marginal, however he did not survive. Determination for 4G/5G PAI-1 polymorphism, glycoprotein IIIa PLA1/A2 gene and Glu298Asp polymorphism of the endothelial nitric oxide synthase gene was performed. CONCLUSIONS: Left main coronary artery aneurysms are rare, finding ONE in an acute myocardial infarction is a serious situation because of the challenging reperfusion techniques that are implied, such as in this case. The search for genetic factors related with hypofibrinolysis could guide stratification and therapy towards medical surgical or interventional management.

Non-ST-elevation acute myocardial infarction secondary to antiphospholipid antibody syndrome in an adolescent female.

BACKGROUND: antiphospholipid antibody syndrome (APS) is characterized by the association among arterial or venous thrombosis, recurrent pregnancy loss, thrombocytopenia and the presence of circulating antiphospholipid antibodies. Antiphospholipid antibody-related thrombosis seems to constitute a significant proportion of childhood thrombosis. We present the case of an adolescent female with non-ST-elevation acute myocardial infarction secondary to APS. CLINICAL CASE: we present the case of a 14-year old female with a history of idiopathic thrombocytopenic purpura whose symptomatology initiated with oppressive chest pain, dyspnea, diaphoresis and nausea. During the physical exam she had tachycardia, accentuation of the second heart sound, a mesosystolic murmur in the pulmonary focus and pulmonary rales. Electrocardiogram showed ST-segment depression in anterior and lateral wall and positive enzymatic curve for infarction. Clinical study reported anterolateral and apical infarction, ostium secundum atrial septal defect and APS. CONCLUSIONS: many studies have demonstrated the diversity of clinical features associated with APS in children and teenagers including deep venous thrombosis, stroke, digital ischemia, pulmonary vasoocclusive disease and, more rarely, acute myocardial infarction. In pediatric patients with acute myocardial infarction we must consider the possibility of APS even though coronary thrombotic occlusion is one of the rarest manifestations.