Resultados a largo plazo de la valvuloplastía mitral con balón / Long term results of mitral balloon valvuloplasty

Background: Mitral balloon valvuloplasty (MBV) is the therapy of choice for the treatment of symptomatic mitral stenosis with suitable anatomy. Although its short and mid-term results are favorable, there is a paucity of information about long-term follow-up. Aim: To assess the late results of MBV. Material and Methods: A cohort of 225 patients aged 8 to 20 years who were subjected to a MBV from 1989 to 2001, was studied. All variables at the time of the procedure, short and long-term results and major events during follow-up (new mitral intervention and mortality) were recorded. Uni and multivariate analysis were used to assess prognosis. Results: The mean follow-up lapse was 13.5 years (range 8 to 20 years). During this period, 88 patients (39.1%) remained event-free and in acceptable functional capacity. Eight percent died, 8% required a second MBV and 43.5% required a surgical mitral valve replacement. A post-procedural area equal or greater to 1.9 cm² was associated with a greater likelihood of free-event survival (log rank test: p = 0.02/Cox proportional regression model: coefficient 0.54, p = 0.04). Conclusions: MBV is effective, although there is a high chance of new interventions in the long-term follow-up. A larger post-procedure mitral area is associated with a better prognosis.

Utilidad del cierre del foramen oval permeable en pacientes con AVE criptogénico / Closure of patent foramen ovale in patients with cryptogenic stroke

Antecedentes: El foramen oval permeable (FOP) es un hallazgo frecuente en pacientes con accidente vascular encefálico criptogénico (AVEC), y se discute la utilidad de su cierre percutáneo (CP). Objetivo: Evaluar el riesgo de recurrencia de eventos neurológicos en pacientes con AVEC y FOP, y compararlos entre aquellos tratados médicamente y los sometidos a CP. Métodos: Entre los 106 pacientes admitidos por AVEC y FOP, en el período 2003 a 2006, determinamos la aparición de nuevos eventos neurológicos isquémicos (NEN), y estudiamos sus factores determinantes y comparamos los que se sometieron a CP versus lo que continuaron con tratamiento médico, según criterio del tratante. Se consignaron las características clínicas y de la antomía del FOP en el ecocardiograma Los NEN se confirmaron por examen neurológico y/o neuro-imágenes. Para el análisis de los datos se utilizó chi-cuadrado y regresión logística.Resultados: Entre los 106 pacientes evaluados, 87 siguieron tratamiento médico y 19 CP. Los pacientes sometidos a CP presentaban mayor asociación de FOP con aneurisma del septum interauricular (ASI) (57,9% versus 35,6%, p=0,05). El seguimiento fue de 27 +/-13 meses. En este período se demostró un 12,6% de nuevo evento neurológico entre los tratados médicamente, mientras que ninguno lo presentó entre los sometidos al CP (NS). El único predictor independiente para NEN fue el ASI asociado con FOP; OR: 8,45 (1,56-60,46). Conclusiones: De acuerdo a nuestros resultados, los pacientes con AVEC y FOP tienen alto riesgo de recurrencia cuando el FOP se asocia a ASI y aparentemente se benefician con CP.

Background: Patent Foramen Ovale (PFO) is a frequent finding in patients with cryptogenic stroke (CS). Theeffect of closing the PFO in this setting is debated. Aim: to evaluate de risk of stroke recurrence in patients with CS and PFO; to compare this risk in patients followed under medical treatment with those undergoing percutaneous closure of PFO. Methods: From 2003 to 2006, 106 patients were admitted with a CS and the presence of PFO was documented by echocardiography. New ischemic strokes and risk factors were compared between those who weresubmitted to percutaneous closure of PFO and those treated in a conventional way. The decision to close thePFO was taken by the physician in charge. Clinical findings and echocardiographic characteristics of thePFO were recorded. New ischemic events were diagnosed by neurologic assessment and/or imaging techniques. Data was analyzed by chi square testing and logistic regression. Results: 87 patients were followed under medical treatment and 19 had closure of the PFO. The latter group had a greater incidence of atrial septal aneurysm (57.9% vs. 35.6%, p=0.05). The mean follow up was 27 +/- 13 months.New ischemic stroke occurred in 12.6% in the medically treated group while none was observed in the PFO closure group (NS). The sole independent predictor of new stroke was the presence of atrial septal aneurysm (OR: 8.45, 95% C.I. 1.56 - 60.46) Conclusion: Patients with CS and PFO are at considerable risk of developing new strokes, especially those with concomitant atrial septal aneurysm. Closure of PFO was apparently useful to prevent this risk.

Valor del autoreporte como método para estimar la prevalencia de factores de riesgo en prevención primaria: resultados del proyecto RICAR / Accuracy of the self report method for establishing the prevalence of cardiovascular risk factors in healthy adults: results of the RICAR project

Antecedentes: El autoreporte se ha utilizado frecuentemente como método para estudiar la prevalencia de los factores de riesgo cardiovascular (FRCV), por lo que es crucial conocer su grado de certeza. Objetivos: Determinar en una población de adultos aparentemente sanos la validez del autoreporte como método paraestimar la prevalencia de hipertensión arterial, hipercolesterolemia e hiperglicemia, comparando estos resultados con los obtenidos a través de la medición objetiva de estos parámetros. Método: En el proyecto RICAR, un total de 12.190 adultos sanos (6.320 mujeres, 5.870 hombres, edad 47,6 +/- 12 años) respondieron un cuestionario acerca de su presión arterial sistólica y diastólica (PAS, PAD), colesterol total (CT) y glicemia(GL). Conocían su PA 2.430, su CT 1.163 y su GL 1.556 personas. A ellos se les preguntó si los valores que estaban reportando eran normales o anormales, y se compararon estas apreciaciones con mediciones objetivas de estos parámetros. Resultados: Un 18,2 por ciento y un 15,6 por ciento refirió incorrectamente su PAS y su PAD como normales, mientras que el error fue de 44,9 por ciento y 15,8 por ciento respecto de CT y GL, respectivamente. Las mujeres tuvieron autoreportes de valores normales significativamente más precisos que los hombres para PAS, PAD y GL: 84,3 vs 77,6 por ciento, 88,7 vs 77 por ciento y 97,5 vs 94 por ciento respectivamente (p<0,0001), a pesar de tener un nivel educacional inferior a los hombres. El VP Positivo para el reporte de valores anormales de la PAS, PAD, CT y GL fue 54.3 por ciento, 46.7 por ciento, 75.1 por ciento y 41.8 por ciento respectivamente. El VP Negativo de los mismos parámetros fue 81.7 por ciento, 84.4 por ciento, 55.1 por ciento y 96.4 por ciento, respectivamente. La prevalencia verdadera versus la aparente en hipertensión sistólica fue de 30 vs 32,6 por ciento, hipertensión diastólica de 25,7 vs 32,6 por ciento y GL elevada de 10 vs 16,7 por ciento (índice de Kappa < 0.6)...

Background: Accuracy and validity of self reported data is a crucial aspect as massive populations´ surveys had become a common method of establishing population’s cardiovascular risk factors (CVRF) prevalence. Objective: To determine in a healthy adult population the accuracy of their self reported normal or abnormal values of Blood Pressure (BP), Total Cholesterol (TC) and Blood Sugar (BS), compared with clinical findings. Methods: A questionnaire about their own BP, TC and BS was answered by 12,190 healthy adults from the RICAR Project, (6320 women and 5870 men, mean age 47.6 +/- 12 y). Those who knew their parameters (BP n= 2,430, TC n= 1,163 and BS n = 1,556) were asked if they had normal or abnormal values. Using standardized methods we measured Systolic (SBP) and Diastolic Blood Pressure (DBP), Total Cholesterol and Blood Sugar (BS) and compare the referred data of normality/abnormality with clinical findings. Results: SBP and DBP were respectively uncorrectly reported as normal in 18,2 percent and 15,6 percent of the population. For TCand BS the mistaken reported normal values were 44,9 percent y 15,8 percent respectively. Women had significant more accurate selfreported normal values than men for SBP, DBP and BS: 84,3 vs 77,6 percent; 88,7 vs 77 percent y 97,5 vs 94 percent respectively (p<0,0001), eventhough they had a significant less educational level than men. Positive PV for abnormal SBP, DBP, TC and BS were 54.3 percent, 46.7 percent, 75.1 percent and 41.8 percent respectively. Negative PV for the same parameters were 81.7 percent, 84.4 percent, 55.1 percent and 96.4 percent respectively. True versus apparent prevalences evidenced differences with an overestimation of systolic hipertension 30 vs 32,6 percent, diastolic hipertension 25,7 vs 32,6 percent and high BS 10 vs 16,7 percent. Kappa index was low between these methods...

Coronariografía no invasiva mediante tomografía axial computada multicorte / 16 detector computed tomagraphy for coronary angiography

Antecedentes: La tomografía axial computada de 16 detectores de las arterias coronarias (TAC Coronario) ha emergido recientemente como una alternativa diagnóstica a la coronariografía invasiva (CI). Objetivo: Estudiar la exactitud del TAC coronario de 16 detectores para pesquisar la presencia o ausencia de estenosis coronaria en distintos tipos de pacientes, mediante su comparación con la CI. Métodos: A un total de 55 pacientes (46 hombres, 9 mujeres, promedio 57 +/-12 años) en quienes se realizó una CI electiva, se les realizó un TAC coronario. Se analizó específicamente la presencia de lesiones 50 por ciento y se compararon estos resultados con los obtenidos mediante la CI cuantitativa. Resultados: Cincuenta pacientes requirieron beta bloqueo, obteniéndose una FC promedio de 57 lpm. En los segmentos principales se objetivaron 61 lesiones significativas por CI, de las cuales 52 (85,2 por ciento) fueron correctamente detectadas por el TAC coronario. La sensibilidad, especificidad, LH(+) y LH(-) del examen fueron 85 por ciento, 97 por ciento, 33 y 0.15, respectivamente. La presencia o ausencia de enfermedad coronaria significativa fue correctamente diagnosticada en 50 de los 55 pacientes (91 por ciento). Conclusión: El TAC coronario de 16 detectores es un examen sensible y específico para el diagnóstico de estenosis significativas de los segmentos principales del árbol coronario.

Background: Invasive coronary arteriography (ICA) is the gold standard to assess coronary artery stenosis. Sixteen detector computed tomography (Coronary CT) has recently been introduced as a less invasive diagnostic alternative. Aim: To assess the reliability of Coronary CT in detecting coronary stenosis among different types of patients by comparing the results with those obtained by ICA. Methods: 55 patients (age 57+/-12 years, 46 males) who underwent ICA had also a coronary CT. Beta blockade was used to obtain a heart rate < 65 beats per min. The presence of significant stenosis (•'3d50 percent of luminal diameter measured by quantitative angiography) was compared between methods.Results: Adequate coronary images were obtained in 53 of 55 patients with coronary CT; a total of 715 coronary segments were available for analysis. Fifty patients required beta blockade and the mean heart rate was 57 beats per min. Fifty-two out of 61 main segment stenosis were detected by coronary CT (85.2 percent). Sensitivity, specificity, LH+ and LH- of coronary CT were 85 percent, 97 percent, 33 and 0.15, respectively. The presence or absence of significant lesions was correctly diagnosed in 50 of the 55 patients (91 percent). Conclusion: 16 detector coronary CT is a sensitive and specific method to diagnose main segment significant coronary stenosis.

Prevensión cardiovascular y actitud de cambio frente a los factores de riesgo: un análisis crítico del estado actual / Cardiovascular prevention and attitude of people towards behavior changes: state of the art

In recent years the main focus of cardiovascular prevention has been to identify people without clinical evidence of coronary disease, but with a high risk of developing a clinical event. Long term follow up studies show that a young person with a high "Relative Risk" of presenting a cardiovascular event becomes an adult with a high "Absolute Risk" of suffering it. The aim of primary prevention is to avoid the appearance of cardiovascular diseases, delaying the development of atherosclerosis and its consequences. In this scenario, the first step is to increase awareness among healthy people of their own cardiovascular risk, enhancing their knowledge of their risk parameter values and generating a correct perception of the risk burden that those values mean. Literature review reveals that significant percentages of healthy individuals are unaware of their own values of blood pressure, total cholesterol and blood glucose. Furthermore, people aware of having abnormal parameters have low treatment compliance rates or evidence inconsistency between knowledge and behavior. This paper reviews educational strategies and other factors that influence this knowledge-behavior gap, such as the stages of behavior changes of the Prochaska and Diclemente Model. Evidence has shown that knowledge about cardiovascular risk factors is not enough to influence behavior and that the degree of preparation of people towards behavior changes is a strong predictor of the success of educational and counseling interventions. Local Chilean data from the RICAR project also shows that the profile of behavior change is different for each modifiable cardiovascular risk factor.

Insuficiente control de factores de riesgo en prevención secundaria cardiovascular / Prevalence of cardiovascular risk factors among patients suffering vascular events on admission and one year later

Background: International studies show a low compliance with norms for the management of cardiovascular risk factors. Aim: To assess the prevalence of risk factors in patients admitted for a coronary or vascular event and to evaluate the proportion of patients that normalize these factors after one year of follow up. Material and Methods: Three hundred and fifty seven patients aged 64±13 years (264 males), admitted to a University Clinical Hospital for a coronary or vascular event were studied. They were educated about cardiovascular risk factors and followed by their treating physicians for a mean of 11.9±2 months. During this period, smoking habits, body mass index. blood pressure, serum lipid levels, blood glucose and the appearance of new cardiovascular events were registered. Results: One year survival was 96% (all 13 deaths were of cardiac origin). Eighty seven percent of patients were free of major cardiovascular events. At discharge from hospital and at the end of follow up 49% and 44% had a total cholesterol over 200 mg/dl respectively, 9,6% and 20,8% had systolic pressure over 140 mmHg. There was no diastolic hypertension in these patients, 27% and 31% had a body mass index over 25 kg/m2 and 2% smoked (versus 32% before the event). Conclusions: After one year of follow up, the prevalence of risk factors in patients that had suffered a cardiovascular event, continues to be high.

Riesgo precoz y alejado de los pacientes con diabetes mellitus sometidos a angiosplastía primaria en las primeras horas de un IAM / Early and late risk of diabetic patients undergoing primary angioplasty in the initial hours of an acute myocardial infarction

Introducción: La angioplastía primaria (AP) disminuye la mortalidad del infarto agudo del miocardio (IAM), pero en los pacientes diabéticos esto está en investigación. Objetivo: Evaluar el rol de la diabetes mellitus como factor pronóstico en el IAM reperfundido por AP. Métodos: Se incluyeron 304 pacientes ingresados por IAM con SDST de menos de 12 horas de evolución tratados con AP en el período 2000-2003. Se consideraron factores de riesgo y parámetros clínicos y angiográficos. Los pacientes fueron controlados hasta 12 meses luego del alta. Se estudiaron mortalidad precoz (1 mes post evento) y 12 meses, y los eventos combinados de muerte, infarto y revascularización al año (MACE). Resultados: La edad promedio de los pacientes fue 62 ± 14 años; 234 eran hombres (77 por ciento), y 46 pacientes eran diabéticos (15 por ciento). No hubo diferencias significativas entre diabéticos y no diabéticos en edad, presencia de hipertensión, dislipidemia, tabaquismo, antecedentes de IAM o revascularización previa, FE, Killip, Flujo TIMI alcanzado o número de vasos comprometidos. Hubo menos mujeres en el grupo de diabéticos. La mortalidad precoz y al año fue de 9,3 por ciento y 16,3 por ciento en diabéticos y de 5,3 por ciento y 9,4 por ciento en no diabéticos (pNS). Los eventos combinados al año ocurrieron en un 37,2 por ciento en diabéticos vs. 23,4 por ciento en no diabéticos, p=0,06. La incidencia de MACE al año fue significativa en un modelo multivariado que incluyó DM, sexo femenino, HTA, dislipidemia, tabaquismo y fracción de eyección por ventriculografía. Conclusión: La presencia de DM se asocia a mayor incidencia MACE en el seguimiento al año en pacientes sometidos a AP por IAM.

Enfermedad periodontal en pacientes con síndrome coronario agudo / Periodontal disease among patients with acute coronary syndrome

Background: Epidemiological studies suggest an association between periodontal disease and coronary heart disease. It is possible that periodontal disease may contribute to plaque destabilization in patients with acute coronary syndrome. Aim: To assess the association between severity of periodontal disease, the number of acute plaques and extension of coronary artery disease in patients with acute coronary syndrome. Patients and methods: The severity of periodontal disease was assessed by skilled independent observers in patients with acute coronary syndrome subjected to coronary angiography. The periodental disease was classified as mild or severe. Acute plaques were defined on angiography as those with thrombi, ulcers or flow alterations. The extension of coronary disease was analyzed using the Sullivan score. Results: Forty three patients (35 males) aged 41 to 83 years, were studied. Mild and severe periodontal disease was present in 18 (42percent) and 25 (58percent) patients respectively. Seventy six percent of those with severe disease had two or more acute plaques, compared with 17percent of those with mild disease (p<0.001). Median Sullivan score was 80.6 and 57.2 in patients with severe or mild periodontal disease respectively (p=0.001). Conclusions: Severe periodontal disease was associated with a higher number of acute coronary plasques and a higher extension of coronary artery disease, in patients with acute coronary syndromes.

Metaloproteinasas en placas de endarterectomía carotídea: actividad aumentada en áreas de estenosis crítica / Metalloproteinase in carotid endarterectomy plaques: increased activity in critical stenosis zones

The presence of metalloproteinases in etherosclerotic plaques has been described but their role is not well understood. An increased secretion of these proteolytic enzymes could explain plaque instability and distal embolization. Plaque were divided in 1 segment with and 1 segement without stenosis, the latter being used as control. Both segments were incubated in culture media for 48 h or were fixed for histology. The conditioned medium was studied using gelatin zimography and digital densitometry. Melloproteinases were identified by their molecular weight, inhibition with EDTA or Western blot. Standard histologic study and immunohistochemistry were done. In stenotic areas, metalloproteinase 9 (92kD) secretion was 269 percent higher than in regular plaques (191 and 73 kilopixels/ug protein respectively p<0.02). The histological study of stenotic areas showed macrophage infiltration and neoformation of blood vessels. The increased secretion of cellular matrix degrading enzyme metalloproteinase 9 in stenotic areas of atherosclerotic plaques could axplain plaque instability and subsequent embolization

Pepsanurina en la insuficiencia cardíaca congestiva / Pepsanurin in congestive heart failure

We have identified a plasmatic substance, "pepsanurin" (PU) obtained by pepsin hydrolysis which inhibits the renal effects of the atrial natriuretic factor (ANF). To investigate whether patients with congestive heart failure (CHF) have increased plasma levels of PU we prepared PU from 10 patients with CHF class IV (NYHA), 9 patients with CHF class II or III and 16 healthy controls. Anesthetized rats were used to test the effects of ANF, 0.5 ug/100 g body weight i.v., before and following the intraperitoneal injection of 0.5 ml of PU. The inhibition of the diuretic and natriuretic effects of ANF was 40.9 ñ 11.9% and 49.8 ñ 12% respectively for control subjects. Corresponding figures for clas CHF patients were 62.3 ñ 3.1% and 73.8 ñ 3.5% (p < 0.02) and for class II-III patients 39.2 ñ 7.0% and 53.1 ñ 8.2% (NS). Accordingly, an increased capacity to generate PU may underlie the decreased sensitivity to ANF in patients with advanced CHF