Prevalencia de disfunción diastólica de acuerdo con las guías diagnósticas de 2009 y 2016. Relación con la valoración hemodinámica no invasiva / Prevalence of diastolic dysfunction (DD) according to the diagnostic guidelines of 2009 and 2016. Relationship with non-invasive hemodynamic assessment

Resumen Objetivos: Evaluar la prevalencia de DD de acuerdo con los criterios de las guías del 2009 y 2016, y su relación con la distensibilidad arterial sistémica (DAS) y la resistencia vascular periférica (RVP). Material y métodos: Se analizó a 306 pacientes ≥ 40 años de edad, con fracción de expulsión ≥ 50%. Se calcularon en todos DAS y RVP. Resultados: La prevalencia de DD fue de 32.7% y 22.9% según las guías de 2009 y 2016, respectivamente (p = < 0.0001). De acuerdo con las guías del 2009, los pacientes con DD presentaron una media de DAS menor que aquéllos con función normal (p = 0.0001), de modo similar a las guías del 2016 (p = 0.0007). La DD, según las guías de 2009 y 2016, mostró valores más altos de RVP que los normales (p = 0.005 y p = 0.018, respectivamente). Asimismo, la DD fue predictora, en el análisis univariado, de DAS < 0.60 ml.mm Hg-1 y RVP > 1,400 mmHg.min.l-1 según ambas guías. En el análisis multivariado, la DD, de acuerdo con las guías del 2009, persistió como predictor independiente de RVP > 1,400 mmHg.min.l-1. Conclusión: Las guías del 2016 reducen la prevalencia de DD. Ésta, tanto en las guías del 2009 como en las del 2106, fue predictor univariado de DAS < 0.60 ml.mmHg-1 y RVP > 1,400 mmHg.min.l-1. La DD, de acuerdo con las guías de 2009, resultó predictora independiente de RVP > 1,400 mmHg.min.l-1.

Abstract Objectives: To assess the prevalence of developmental disabilities (DD) according to the criteria of the 2009 and 2016 guidelines, and its association with systemic arterial compliance (DAS) and peripheral vascular resistance (RVP). Material and methods: 306 patients aged ≥ 40 years, with ejection fraction ≥ 50% were analyzed. It was estimated in all DAS and RVP. Results: The prevalence of DD was 32.7% and 22.9% according to the 2009 and 2016 guidelines, respectively (p ≤ 0.0001). Patients with DD according to the 2009 guideline had a lower average of DAS than those with normal function (p = 0.0001). Similar with the 2016 guide (p = 0.0007). The presence of DD according to the 2009 and 2016 guideline showed higher RVP values than normal values (p = 0.005 and p = 0.018, respectively). The DD according to both guidelines was a predictor, in the univariate analysis, of DAS < 0.60 ml.mmHg−1 and RVP > 1400 mmHg.min.l−1. The DD according to the 2009 guideline persisted as an independent predictor, in the multivariate analysis, of RVP > 1400 mmHg.min.l−1. Conclusion: The 2016 guide decreases the prevalence of DD. The DD, both from the 2009 and 2106 guidelines, were univariate predictors of DAS <0.60 ml.mmHg−1 and RVP > 1400 mmHg.min.l−1. The DD according to the 2009 guide, was an independent predictor of RVP > 1400 mmHg.min.l−1.

Estimulación eléctrica permanente en región septal en pacientes con insuficiencia cardíaca secundaria a estimulación en ápex de ventrículo derecho / Permanent septal pacing in patients suffering secondary heart failure compared to right ventricular apical pacing

Resumen Introducción: Independientemente de la modalidad de estimulación (VVI o DDD), el mayor porcentaje de estimulación ventricular derecha deteriora la función contráctil izquierda. Por ello se han estudiado diferentes sitios de estimulación. Objetivo: Describir las diferencias electrocardiográficas y ecocardiográficas entre la estimulación en la región apical y la región septal del ventrículo derecho (VD)0. Métodos: Se estudió a 24 pacientes, 2 mujeres y 22 hombres, con fracción de eyección deprimida (≤ 35%) secundaria a estimulación en punta de VD. Se realizó electrocardiograma durante estimulación en ápex de VD y en seguimiento de estimulación septal. También ecocardiografía en ambos momentos. Resultados: La fracción de eyección se incrementó desde 31 ± 3.1% hasta 45 ± 12% (p = 0.0041) con estimulación septal; esta mostró mejor grado de sincronía mecánica. Conclusiones: La estimulación septal puede constituir un sitio de elección en pacientes con disfunción sistólica de ventrículo izquierdo secundaria a estimulación en ápex de VD, los cuales presenten QRS estrecho en su conducción intrínseca, pues en la muestra estudiada produce una mejoría en la sincronía electromecánica, demostrándose incrementos significativos en la fracción de eyección.

Abstract Introduction: Regardless of the type of electrical stimulation (VVI or DDD) the highest percentage of right ventricular apical pacing can cause left ventricular failure. For this reason, studies have been performed in different sites on right ventricle pacing. Objective: To describe differences between electrocardiography and echocardiography variables during right ventricular apical pacing and septal pacing. Methods: A total of 24 patients were studied, 2 women and 22 men, with heart failure due to conventional pacing on right ventricular (ejection fraction ≤ 35%). An electrocardiogram as well as an echocardiogram, was performed during right ventricular apical pacing and when patients were paced on septal area. Results: The ejection fraction increased from 31 ± 3.1% to 45 ± 12% (P=.0041) on septal pacing, showing higher degree of mechanic synchronisation. Conclusions: Pacing on septal area could be a good site for those patients that suffer heart failure due to right ventricular apical pacing. These must show narrow QRS on their intrinsic electrocardiographic conduction. This kind of pacing can produce an improvement in electro- mechanical synchronisation, as well as show an increased left ventricular ejection fraction.

Prevalence of Left Ventricular Diastolic Dysfunction in Patients with Normal Systolic Function and its Relation with Other Risk Factors from Eastern India.

Impaired diastolic filling of left ventricle may be the important cause of symptoms ranging from mild to severe form of dyspnea with overt features of pulmonary edema which may be wrongly imparted to systolic failure. To study prevalence and severity of diastolic dysfunction and its relation with various risk factors. Methods: Patients from in and out patients department were subjected to detail history, estimation of BMI, blood sugar levels, BP measurement, echocardiographic assessment of cardiac function. Patients of isolated diastolic dysfunction were identified and the degree of diastolic dysfunction was correlated with functional class (NYHA grade) of the patients as well as various risk factors. Results: Out of 400 patients 16 (12.5%) asymptomatic patients had diastolic dysfunction (DD). Severity of diastolic dysfunction increased as the presenting NYHA grade was higher. In NYHA grades III and IV, 59% and 57% of the patients respectively had diastolic dysfunction .DD was significantly associated with diabetes (p<.0001), BMI (p =0.0002), dyslipidemia (p =0.0491), hypertension (p=0.0489). Conclusion: DD is a significant cardiac morbidity. Hypertension, diabetes, dyslipidemia and obesity have significant association with diastolic dysfunction. There is no randomized control trials for treatment for DD. Whether asymptomatic DD needs treatment is not known.

Smoking and Hypertension: A Study in Subjects Admitted to Hospital for Cardiovascular Diseases.

Aims: There is a general consensus in considering cigarette smoking as a major risk factor for cardiovascular diseases: a direct causal association between smoking and hypertension however is questioned. The present paper reports a study on the effect of cigarette smoking and of other clinical parameters on hypertension in a sample of subjects admitted to Hospital for Cardiovascular Diseases (CVD). Study Design: Observational study. Place and Duration of Study: Department of Cardiology Valmontone Hospital and Department of Biomedicine and Prevention, University of Rome Tor Vergata, between April 2007- December 2013. Methodology: We have studied 335 subjects admitted to the Hospital for Cardiovascular Diseases. Statistical analyses were in the study that was approved by the Ethical Committee. We have considered hypertension in relation to smoking, diabetes, age and sex. Results: Multivariate statistical analyses have shown a high significant effect of age (P<.001) and diabetes (P<.01) on hypertension and a border line effect of smoke (P=.05). No effect of sex has been detected (P=.47). The proportion of subjects with hypertension is positively correlated with the number of risk factors examined. Conclusion: Our data indicate that an independent effect of smoking on blood pressure is relatively small and suggest an additive effect of the variables considered on the risk of hypertension.

β-blockers in Post ST Elevation Myocardial Infarction Patient with Low Left Ventricular Systolic Function: A Retrospective Study at Shahid Gangalal National Heart Centre, Kathmandu, Nepal.

Aims: Despite well developed guidelines in the management of ST elevation myocardial infarction with low left ventricular ejection fraction, β-blockers remain an underutilized therapy. We aim to assess the adherence of β-blocker use during the discharge in Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Study Design: Retrospective, Observational study. Place and Duration of Study: Department of cardiology, Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Between January 2012 to December 2012. Methodology: Medical records of 160ST elevation myocardial infarction patients with left ventricular ejection fraction ≤40% and discharged from our centre were retrospectively reviewed regarding the use of β-blocker. Results: Among the 160 patients, 112 (70%) were males and 48 (30%) were females, mean age was 59.1±13.4 years. Anterior wall myocardial infarction followed by extensive anterior wall was the common in patient with low left ventricular ejection fraction after ST elevation myocardial infarction. Only in 67.5% patients β-blockers were prescribed. Metoprolol tartrate was the most commonly used β-blocker. Conclusion: β-blocker use in patients ST elevation myocardial infarction patients with low left ventricular ejection fraction in our study is comparable to international studies. We still need some more effort to improve our prescription rate.

Impacto de la hiperinsulinemia sobre la función del ventrículo izquierdo en sujetos hipertensos / Differential impact of hyperinsulinemia on left ventricular function in hypertense subjects

Introducción: La hiperinsulinemia asociada a hipertensión arterial activa el proceso inflamatorio/reparador y deteriora la función ventricular. Objetivo: Determinar los efectos de la hiperinsulinemia sobre la masa la ventricular y función diastólica del ventrículo izquierdo (VI) en hombres y mujeres no diabéticos con hipertensión. Método: 52 pacientes con curva de tolerancia a la glucosa normal fueron estratificados según la relación glucosa/insulina (rG/I): Grupo 1, hiperinsulinémico (rG/I < 1.6); Grupo 2, normoinsulinémico (rG/I > 1.6). Se realizó historia clínica, análisis de laboratorio, ECG y ecografía Doppler cardíaca. Resultados: En condición basal no hubo diferencias entre los grupos en cuanto a edad, valores de glucemia y presión arterial, pero sí en los de insulina (32.5 vs. 8.78 mU/ml), masa ventricular (131.6 vs. 92.7 g/m2), fracción de eyección del VI (73.5 vs. 69.3%), índice de masa corporal (31.2 vs. 29 kg/m2), relación E/A mitral (0.92 vs. 1.35), tiempo de relajación isovolumétrica del VI (126.3 61 ms) y tiempo de hemipresión transmitral (T1/ 2; 206 vs. 244.4 ms). En las mujeres hiperinsulinémicas se incrementaron más los niveles de insulina a 60' que en los hombres (12.5 vs. 6.7 veces), rG/I de 0.54 vs. 0.99, masa ventricular (61.4 vs. 30.7%), disfunción diastólica del VI (E/A 0.87 vs. 0.93 y T1/2; 191.7 vs. 220.3 ms). Conclusión: La hiperinsulinemia incrementa la masa ventricular y deteriora la función diastólica del VI en pacientes hipertensos no diabéticos, con mayor gravedad en las mujeres.

AIDS in childhood: cardiac involvement with and without triple combination antiretroviral therapy / AIDS na infância: acometimento cardíaco com e sem a terapia anti-retroviral tríplice combinada

OBJETIVO: Descrever a prevalência de alterações cardíacas ao ecocardiograma em crianças com AIDS acompanhadas em serviço de referência aos 18±6 meses do diagnóstico confirmado de AIDS. MÉTODOS: Estudo transversal, com corte aos 18±6 meses do diagnóstico de AIDS. Incluídas 93 crianças com diagnóstico confirmado de AIDS por transmissão vertical, sem doença maligna, que, na avaliação cardiológica, realizaram ecocardiograma (eco). De forma exploratória avaliaram-se as alterações cardíacas nos pacientes sem uso (G1) e com uso (G2) de terapia combinada anti-retroviral. RESULTADOS: Quando do diagnóstico de AIDS, as crianças tinham em média 3,07 anos e 50,50 por cento eram do sexo feminino. Esquema de terapia combinado com anti-retrovirais foi utilizado por 47 pacientes (G2). O acometimento cardíaco esteve presente em 40 crianças (43,00 por cento). A presença de disfunção ventricular esquerda (G1:39,10 por cento;G2:10,60 por cento) e o aumento isolado de ventrículo esquerdo (G1:6,60 por cento;G2:14,90 por cento) foram os achados mais freqüentes. Observou-se associação significativa entre os grupos sem e com terapia anti-retroviral combinada quanto à presença de disfunção ventricular esquerda (RP=3,42; [1,41-8,26]; p =0,02) e de desnutrição (RP=1,79; [1,00-3,20]; p=0,04). CONCLUSÃO: O acometimento cardíaco foi freqüente nas crianças com AIDS, sendo a disfunção ventricular esquerda a alteração mais observada ao ecocardiograma. Houve diferença estatisticamente significativa entre os grupos com e sem tratamento tríplice combinado quanto à presença de disfunção ventricular esquerda e de desnutrição.

OBJECTIVE: To describe the prevalence of cardiac abnormalities in the echocardiogram of children with AIDS followed up in a reference service at 18±6 months of AIDS confirmed diagnosis. METHODS: A cross-section study with a cohort after 18±6 months of AIDS diagnosis. The study included a total of 93 children with a confirmed diagnosis of AIDS with vertical transmission, with no malignancies and who underwent echocardiogram (echo) during cardiologic evaluation. Cardiac abnormalities were assessed in patients who were not treated (G1) and patients who were treated (G2) with combination antiretroviral therapy. RESULTS: When diagnosed with AIDS, the children were on average 3.07 years old and 50.50 percent were female. The combination regimen with antiretroviral agents was used by 47 patients (G2). Cardiac involvement was present in 40 children (43.00 percent). The presence of left ventricular dysfunction (G1: 39.10 percent; G2: 10.60 percent) and the isolated enlargement of left ventricle (G1: 6.60 percent; G2: 14.90 percent) were the most frequent findings. We observed a significant association between the groups without and with combination antiretroviral therapy asregards the presence of left ventricular dysfunction (PR= 3.42; [1.41-8.26]; p = 0.02) and malnutrition (PR = 1.79; [1.00-3.20]; p = 0.04). CONCLUSION: Cardiac involvement was frequent in children with AIDS and left ventricular dysfunction was the most common abnormality on echocardiogram. There was a statistically significant difference between the groups with and without triple combination treatment as regards the presence of left ventricular dysfunction and malnutrition.

Early detection of cardiac involvement in beta-thalassemia children.

BACKGROUND: Beta-thalassemia major and beta-thalassemia/HbE are the important causes of chronic hemolytic anemia in Thailand. The objectives of the study were to determine variables associated with cardiac involvement in asymptomatic beta-thalassemia patients. PATIENTS AND METHOD: The authors studied beta-thalassemia major and beta-thalassemia/HbE patients who came to the clinic between July 1st 1999 and July 31st 2000. There were 211 asymptomatic patients included in study. Their ages ranged from 2.6 to 18.2 years. Previous clinical history including blood transfusion and iron chelation were recorded. All patients received a thorough physical examination, chest X-ray, electrocardiogram and echocardiogram. Patients who had abnormal systolic or diastolic function detected by echocardiogram were identified as having cardiac involvement. RESULTS: Cardiac involvement was found in 26 patients (12.3%). There was no difference in physical examination between patients who had and did not have cardiac involvement. Abnormal chest X-Ray defined as cardiothoracic (CT) ratio>0.55 and electrocardiogram (ECG) findings of left or right ventricular hypertrophy were associated with cardiac involvement. Other associated findings were older age and lower average pretransfusion hematocrit (23 +/- 6.6%). CONCLUSIONS: In asymptomatic beta-thalassemia children, chest X-ray and ECG should be used for screening patients for the detection of cardiac involvement.

Should we screen for asymptomatic left ventricular dysfunction in glaucoma patients

The aim of the study was to assess the frequency of asymptomatic left ventricular dysfunction in primary open-angle glaucoma patients. Patients and Two-dimensional and pulsed Doppler echocardiography of transmitral flow was performed on 31 glaucoma patients and 27 controls. No significant difference was found in early [E] and late [A] transmitral filling velocity, velocity time integral E wave [VTIE] and A wave [VTIA], left ventricular end-diastolic pressure, pulmonary capillary wedge pressure, left ventricular ejection fraction [EF] and fractional shortening [FS]. A significant difference was found in ratio E/A [P=0.04] and ratio VTIA/VTIE [P=0.05], although all obtained values were within the 95% confidence limit for the corresponding age. Our study tends to indicate the possibility of dysfunction of myocardial relaxation in glaucoma patients, which might be partially attributed to systemic vascular dysregulation

Aplicación clínica de la ecocardiografía transesofágica para la evaluación intraoperatoria de la función ventricular izquierda

La imagen directa del ventrículo izquierdo a través del ciclo cardíaco provee información acerca del grosor de la pared ventricular izquierda, tamaño de la cavidad y actividad contractil. Esta información puede ser usada para diagnosticar disfunciones en la actividad cardiaca, detectar isquemia miocárdica agudao monitorizar la precarga ventricular izquierda, la contractilidad y las poscarga. Aunque la ETE es potencialmente una herramienta útil en el diagnóstico y la monitorización, se acepta que depende de la experiencia del ecocardiografista, la metodología utilizada y la habilidad para reconocer algunas limitaciones inherentes a la técnica

Coronary artery reoperations using arterial conduits: immediate and early results.

This study deals with results of coronary artery reoperations in 21 males aged 54.4 +/- 6.6 years. Native vessel coronary disease at first and second operation was nearly the same (2.7 +/- 0.6 vs 2.8 +/- 0.4 vessel, p = NS). Graft attrition and deterioration in left ventricular ejection fraction (55.9 +/- 9.2 initial vs 36 +/- 15 at reoperation, p < 0.001) necessitated reoperation in majority. Recurrence of angina (71%) and left ventricular failure (23.8%) were the clinical indicators for reoperation. Procedure was successful in 20 (95%) and had to be abandoned in 1 due to severe pericardial and sternal adhesions. Arterial grafts were utilised in 90% (18 cases, Group A and B). Total arterial revascularisation (Group A) was done in 9 (45%) using Y graft 6, combination of both mammary arteries 2, and by both mammary and inferior epigastric artery in 1. Group B patients had arterial grafts (bilateral IMA 1, Y graft 1, bilateral IMA + gastroepipolic 1, RIMA 4, and LIMA 2) in addition to a venous graft. Two patients (group C, 10%) had only venous grafts. There was no in hospital mortality or morbidity and at 10 +/- 5.2 months follow up, all are asymptomatic with negative stress test at 3 months followup in 8 cases. We conclude that coronary artery reoperations using arterial conduits can be performed safely with excellent immediate and early results.

Determinación ecocardiográfica de la masa ventricular izquierda, valores en una población normal / Echocardiographic determination of left ventricular mass, in a normal population

La determinación de la masa ventricular izquierda (MVI), es importante en la voloración de la función cardiaca y en la identificación de la Hipertrofia Ventricular Izquierda (HVI). En este sentido consideramos prioritario el conocimiento de los valores de normalidad en nuestra población tanto de la MVI como el Indice de MVI (IMVI). La determinación de la MVI por el método de la ASE-CUBO corregida y el IMVI fue realizada en 660 pacientes sin cardiopatía con ecocardiogramas normales en el Hospital Militar Central (Lima - Perú), de los cuales 432 eran varones y 228 mujeres; encontrándose diferencias estadísticamente significativas de la MVI e IMVI entre ambos sexos. (IMVI para hombres; 100.10 11.71 ñ, mujeres: 88:94 ñ 16.78) p <0.05. Se estratificó la edad en 3 grupos etarios: 1) <30 años, 2) 31-60 años y 3)> 60 años; se encontró diferencia significativa al estudiar el género masculino entre el 1§ y 2§ grupo (94.73 ñ 14.07 y 100.84 ñ 12.31) p <0.05, y entre el 1§ y 3§ (94.73 ñ 14.07 y 104.74 ñ 8.76) p <0.05. En el sexo femenino se encontró diferencias significativas entre el 1§ y 2§ grupo (79.69 ñ 17.90 y 90.47 ñ 15.91) con p <0.05. Al realizar el análisis global se encontró diferencias significativas para la MVI (ASE-CUBO corregida) entre el 1§ y 2§ grupo etario (147.26 ñ 26.68 y 163.84 ñ 25.69) y entre el 1§ y 3§ (147.26 ñ 26.68 y 174.76 ñ 27.83) p <0.05; y cuando se consideró el IMVI sólo se encontró significancia entre los de 60 años (87.21 ñ 15.98 y 100.71 ñ 12.65) p <0.05. Consideramos que la MVI y el IMVI deben ser parte del estudio ecocardiográfico habitual en todo paciente con cardiopatía conocida o sospechosa.