Heart diseases during pregnancy

Improvements in health care services in recent decades have permitted more frequent identification of pregnant women with congenital and acquired heart disease. Normal pregnancy and the peripartum period are associated with considerable cardiocirculatory changes, which are usually well tolerated by the mother. However, the increased cardiac demands imposed by those changes may at times unmask cardiac disease in presumably normal women or increase morbidity and mortality in women with established heart disease. A recognition and understanding of these changes is essential for providing optimal care to obstetrical patients with cardiac disorders. This article offers a brief review of those cardiocirculatory changes during pregnancy and of the main features of various congenital and valvular heart disorders frequently referred for advice to our cardiology practice, along with recommendations for their management and follow up.

Review of clinical characteristics and management of patients with ST segment elevation myocardial infarction at atertiary care center

BACKGROUND: Information from recent multiple trials on the pathophysiology and outcome of ST-segment elevation myocardial infarction (STEMI) has changed its clinical perspective and strategic management, leading to a revision of the 1999 ACC/AHA practice guidelines for that condition. OBJECTIVE: Analyze the clinical characteristics, management strategies, the timing of therapeutic interventions and outcome of patients with STEMI referred to the Cardiovascular Center of Puerto Rico (CVCPR). METHODS: Retrospective review of medical records of all patients admitted to the CVCPR with a diagnosis of STEMI from January 1, 2003 to December 31, 2003. RESULTS: A total of 184 medical records were reviewed. Seventy-six percent of patients were men, mean age was 62.1 +/- 11.8 years. A high prevalence of coronary risk factors was present: systemic hypertension (64), diabetes mellitus (40), dyslipidemia (35), smoking (33) and previous CAD (32). Less than 1/4 of referral forms contained data indicative of whether patients had received antiplatelet therapy, beta-blockers, ACE inhibitors or statins. Fifty percent of patients arrived to the CVCPR more than 48 hours after diagnosis. Only forty-two patients (23) arrived within 12 hours. Thrombolytic therapy had been used in 27of them. 179 (97) patients underwent coronary angiography, 69.2of which had multivessel disease. 114 (62) patients underwent percutaneous coronary interventions (PCI) with stenting. Patients submitted to PCI and stenting of the culprit lesion had a better outcome and survival than the ones not exposed to those procedures (p = 0.02). Approximately two-third of patients received secondary prevention medications upon discharge. CONCLUSIONS: Relevant findings of this review were that in spite of high prevalence of CAD major risk factors, the use of medications of proven benefit for prevention and treatment of CAD at referral centers was less than that recommended by current guidelines, a significant delay in the transfer of patients to the tertiary care facility (in most cases that period exceeded more than 48 hours after diagnosis) and a reduced utilization of thrombolytic therapy. Intensification of the education of physicians throughout the island regarding these matters is to be encouraged. Additional measures should include, development of written protocols at referral centers to assure a more expedite clinical assessment of patients, an enhancement of their capability for utilizing fib

Acute heart failure in adults

Heart failure (CHF) is one of the most important health problems of our population and surprisingly the only cardiovascular disorder whose prevalence, incidence and mortality is steadily rising in spite of extraordinary advances in the diagnosis and management of other forms of cardiac disease. Management of chronic CHF has been the focus of recently published guidelines by cardiovascular societies both in the United States and Europe. However, no analogous guidelines have so far addressed the management of acute CHF. This presentation aims to review current knowledge regarding the diagnosis and management of acute CHF, to promote a more accurate identification of this clinical disorder and an optimization of the care received by patients afflicted with this condition in our community.

The hyperlipidemias

Despite clear and consistent clinical-trial evidence establishing a causal link between lipid disorders and coronary heart disease and that cholesterol-lowering therapy dramatically reduces the risk for that disease and its complications, many patients for whom such treatment is indicated remain either unidentified or untreated. Our objective is to present updated, practical information for primary-care physicians on the evaluation and management of lipid disorders, particularly those related to the primary and secondary prevention of coronary heart disease, the leading cause of morbidity and mortality in our population. A pertinent summary of the guidelines contained in the Third Report of the National Cholesterol Expert Panel on Detection, Evaluation and Treatment of Cholesterol in Adults (Adult Treatment Panel III), commonly known as ATP III, is utilized to better fulfill that objective

Effect of right atrial pacing, intravenous amiodarone and beta blockers for suppression of atrial fibrillation after coronary artery bypass surgery: a pilot study

OBJECTIVE: This pilot study aimed to compare right atrial pacing, intravenous amiodarone and oral beta-blockers in the prevention, time to onset, duration and effect on hospital stay of postoperative atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) at our center. BACKGROUND: AF is the most common arrhythmic complication after CABG and is related to increased morbidity, length of hospital stay and costs. Trials with different drugs and other therapeutic modalities including beta-blockers, intravenous amiodarone and override suppression of automatic atrial foci by atrial pacing have shown partial success as preventive measures. However, a comparison between those three interventions has not been reported. METHODS: Thirty-six consecutive patients that underwent CABG at our institution were randomly assigned to atrial pacing (18 patients) and intravenous amiodarone (18 patients) after baseline clinical, electrocardiographic and hemodynamic assessment. All patients received concomitant oral metoprolol or atenolol right after extubation. Thirty-three patients who had CABG at our center in the previous two months and that only received beta-blockers during their perioperative period served as a control group. RESULTS: The majority of baseline clinical and hemodynamic characteristics were similar in all groups. Only one patient (5.6 per cent) developed AF in the atrial pacing group versus five (27.8 per cent) on amiodarone and six (18.2 per cent) who only received beta-blockers. That finding, however, did not attain statistical significance (p > 0.05). After adjusting for potential confounders, the odds of occurrence of AF was 77 per cent lower in atrial pacing patients (OR = 0.23; 95 per cent CI: 0.02, 2.20; p = 0.09) and 2.36 times higher in those on amiodarone (95 per cent CI: 0.55, 10.24; P = 0.053) when compared to patients which only received beta blockers. Since only one patient on right atrial pacing developed atrial fibrillation, the analysis of the median time to onset and median duration of atrial fibrillation was restricted to those assigned to amiodarone and those who only received beta-blockers showing no statistically significant differences (p > 0.05)...

Immunology of cardiac diseases. A review

Se presenta un repaso de los mecanismos inmunologicos establecidos hasta el presente en relacion a varias enfermedades cardiacas. Excluye las lesiones cardiacas y/o complicaciones que se asocian a las llamadas enfermedades de autoinmunidad. Nuestro proposito ha sido el proveer un repaso organizado y actualizado de la literatura mas relevante sobre la funcion de las reacciones inmunologicas en la patogenesis de condiciones cardiacas primarias