ABSTRACT
The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to evaluate the benefits of percutaneous coronary intervention in reducing the risk of cardiovascular events in patients with chronic stable coronary artery disease. The results reinforce the prior evidence regarding the importance of medical treatment which should be a universal goal. The study population enrolled was quite average for a routine cardiology clinic. However, the results of cardiac intervention are center-dependent and therefore need to be analyzed as such. Patients should initially receive the optimal medical treatment. Patients with symptom persistence, intolerance to medical treatment, and moderate to severe ischemia should be considered candidates for combined treatment. Treatment needs to be individualized and discussed with the patient. New studies, without the limitations of the COURAGE trial, enrolling high-risk patients treated with new interventional technologies, are needed to assess the impact of ischemia in long-term prognosis.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Artery Disease/therapy , Chronic Disease , Clinical Trials as Topic , HumansSubject(s)
Cardiology , Cardiology/trends , Heart Diseases/therapy , Humans , Physician's Role , SpainABSTRACT
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Subject(s)
Humans , Cardiology/trends , Cardiovascular Diseases/epidemiology , Medicine/trends , Models, Cardiovascular , Risk Adjustment/methods , Myocardial Ischemia , Endocarditis, Bacterial , Heart Failure , Arrhythmias, CardiacABSTRACT
INTRODUCTION AND OBJECTIVES: Calculation of the effective regurgitant orifice (ERO) is regarded as the most accurate way of assessing the severity of mitral regurgitation (MR), but the technique's complexity limits its use. Our objective was to modify and validate a previously published semiquantitative method of assessment based on measurement of the proximal isovelocity surface area (PISA) in order to adapt it to recent recommendations from American and European cardiology societies. METHODS: In the PISA method, maximum regurgitant flow (MRF) is a function of the radius and aliasing velocity (AV). Using this relationship, it is possible to construct a nomogram formed by lines of different MRF value, which can be easily derived by looking for radius values on the graph and observing where they cross with AV values. The MR severity limits on the nomogram were set to reflect the different severity grades and limits recommended for use with ERO measurements by American and European cardiology societies. RESULTS: We studied 76 patients with MR using Doppler echocardiography. There was an excellent correlation between MRF and ERO (r=0.98, P< .001). Estimates of MR severity made using the new nomogram were in good agreement with those derived from the ERO: for a scale with three severity grades, kappa was 0.951 and the standard error was 0.11; for four grades, kappa was 0.969 and the standard error, 0.11. CONCLUSIONS: Estimates of MR severity derived semiquantitatively from MRF using the nomogram proposed here were in excellent agreement with quantitative estimates obtained using the ERO, and the method was faster and easier to use.
Subject(s)
Echocardiography, Doppler , Mitral Valve Insufficiency/diagnosis , Adult , Aged , Aged, 80 and over , Blood Flow Velocity , Data Interpretation, Statistical , Female , Humans , Male , Middle Aged , Mitral Valve/diagnostic imaging , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/physiopathology , Models, Cardiovascular , Severity of Illness IndexABSTRACT
Introducción y objetivos. El cálculo del orificio regurgitante efectivo (ORE) se considera el método más fiable para estimar la severidad de la insuficiencia mitral (IM), pero es poco usado por su complejidad. El objetivo fue modificar y validar un método semicuantitativo basado en la proximal isovelocity surface area (PISA), previamente publicado, para adaptarlo a las recientes recomendaciones de las sociedades americana y europea de cardiología. Métodos. Cuando usamos el método PISA, el flujo regurgitante máximo (FRM) es una función del radio y la velocidad de aliasing (Va). Esta relación permite la creación de un normograma formado por líneas de diferentes valores de FRM que se pueden obtener con facilidad al buscar en el gráfico los valores del radio y su cruce con los de Va. Los límites de severidad en esa tabla se han adaptado para que reflejen los grados y los límites de severidad recomendados por las sociedades americana y europea de cardiología según el valor de ORE. Resultados. Estudiamos a 76 pacientes con IM mediante eco-Doppler. Se encontró una correlación excelente entre FRM y ORE (r = 0,98; p < 0,001). La estimación de severidad mediante el nuevo normograma mostró una concordancia excelente con la determinada mediante el ORE, con un valor de kappa de 0,951 y un error estándar de 0,11 para una escala en 3 grados, y un valor de kappa de 0,969 y error estándar de 0,11 para la escala en 4 grados. Conclusiones. La estimación semicuantitativa de la severidad de la IM mediante el FRM mediante el normograma propuesto tiene un acuerdo excelente con la estimación cuantitativa por ORE, pero es mucho más simple y rápida
Introduction and objectives. Calculation of the effective regurgitant orifice (ERO) is regarded as the most accurate way of assessing the severity of mitral regurgitation (MR), but the technique's complexity limits its use. Our objective was to modify and validate a previously published semiquantitative method of assessment based on measurement of the proximal isovelocity surface area (PISA) in order to adapt it to recent recommendations from American and European cardiology societies. Methods. In the PISA method, maximum regurgitant flow (MRF) is a function of the radius and aliasing velocity (AV). Using this relationship, it is possible to construct a nomogram formed by lines of different MRF value, which can be easily derived by looking for radius values on the graph and observing where they cross with AV values. The MR severity limits on the nomogram were set to reflect the different severity grades and limits recommended for use with ERO measurements by American and European cardiology societies. Results. We studied 76 patients with MR using Doppler echocardiography. There was an excellent correlation between MRF and ERO (r=0.98, P<.001). Estimates of MR severity made using the new nomogram were in good agreement with those derived from the ERO: for a scale with three severity grades, kappa was 0.951 and the standard error was 0.11; for four grades, kappa was 0.969 and the standard error, 0.11. Conclusions. Estimates of MR severity derived semiquantitatively from MRF using the nomogram proposed here were in excellent agreement with quantitative estimates obtained using the ERO, and the method was faster and easier to use
Subject(s)
Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Humans , Mitral Valve Insufficiency , Echocardiography, Doppler, Color , Cardiac Catheterization , Prospective Studies , Sensitivity and Specificity , Reproducibility of Results , Severity of Illness IndexABSTRACT
UNLABELLED: Endomyocardial biopsy is an invasive procedure, often performed on children for the diagnosis of myocarditis, and is not without risk. Therefore, a noninvasive test of adequate diagnostic accuracy is highly desirable. We evaluated the role of antimyosin scintigraphy in infants and children with clinically suspected myocarditis. METHODS: Forty patients (age range, 2 mo to 14 y) with suspected myocarditis underwent (111)In-antimyosin scintigraphy. All patients were clinically followed for 29 +/- 17 mo; 21 patients underwent serial antimyosin scans (3.8 +/- 1.7 per patient). The antimyosin uptake was assessed by heart-to-lung ratio (HLR). The scan results were compared with endomyocardial biopsy results in 22 patients. RESULTS: Thirty-five of the 40 patients showed abnormal antimyosin findings; 17 patients showed intense myocardial antimyosin uptake (HLR > 2). The HLR was higher in patients presenting within the first 2 mo of illness (2.09 +/- 0.43 vs. 1.74 +/- 0.34, P = 0.01). Of 22 patients with endomyocardial biopsy, 17 demonstrated myocarditis. All 9 patients who had an HLR > 2 and underwent endomyocardial biopsy had histologic evidence of myocarditis. Of the remaining 13 patients with HLR < 2, 8 had biopsy-verified myocarditis (62%). The intensity of antimyosin uptake was the major determinant of survival in children, with a relative risk of 18 (confidence interval, 1.34-242; P = 0.027). High antimyosin uptake (HLR > 2) seen within 2 mo of the onset of symptoms was associated with a higher mortality rate. The survivors with an HLR > 2 and those with an HLR < 2 showed a high likelihood of complete functional recovery. Furthermore, the patients with serial antimyosin scans having persistently positive findings showed a poor clinical outcome. CONCLUSION: Intense myocardial uptake of antimyosin antibody is a reliable indicator of myocarditis in infants and children. Severe myocardial damage detected in the early phase of disease is associated with a higher mortality rate. The persistence of antimyosin uptake is associated with poor clinical outcomes.
Subject(s)
Immunoglobulin Fab Fragments , Myocarditis/diagnostic imaging , Myocarditis/mortality , Pentetic Acid/analogs & derivatives , Ventricular Dysfunction, Left/diagnostic imaging , Ventricular Dysfunction, Left/mortality , Adolescent , Child , Child, Preschool , Comorbidity , Disease Progression , Female , Humans , Infant , Male , Myocarditis/pathology , Prognosis , Radionuclide Imaging , Radiopharmaceuticals , Reproducibility of Results , Sensitivity and Specificity , Spain/epidemiology , Survival Analysis , Ventricular Dysfunction, Left/pathologyABSTRACT
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Humans , Myocardial Revascularization , Treatment Outcome , Quality of Life , Coronary DiseaseABSTRACT
Introducción y objetivos. Se realizó este estudio con el objetivo de valorar el rendimiento y la utilidad de la ecocardiografía transtorácica (ETT) con sonda de alta frecuencia para detectar y analizar el flujo de la descendente anterior en pacientes con lesiones de la misma y en pacientes con infarto anterior. Material y métodos. Se estudiaron 11 pacientes con lesiones mayores del 75 por ciento y 10 pacientes con infarto anterior previo. Los resultados se compararon con un grupo control de 18 sujetos. Se intentó localizar la descendente anterior en el surco interventricular anterior partiendo de una proyección apical de 4 cámaras. Se consideró que se detectaba la descendente anterior cuando se registraba con Doppler pulsado un flujo predominante diastólico. Resultados. La arteria fue detectada en 37/39 (94,9 por ciento) pacientes. Los pacientes con lesiones coronarias presentaron una disminución en el límite de la significación del cociente velocidad pico diastólica/sistólica: 2,5 (desviación estándar [DE], 0,7) frente a 1,8 (DE, 0,3) (p = 0,024). Los pacientes con infarto anterior presentaron un cociente velocidad pico diastólica/sistólica más disminuido respecto a los controles: 2,5 (DE, 0,7) frente a 1,4 (DE, 0,3) (p = 0,001). Conclusiones. El flujo de la descendente anterior se puede analizar con ETT y sonda de alta frecuencia en más del 90 por ciento de los casos. Los pacientes con lesiones coronarias y aquellos con infarto tienen disminución del cociente de velocidad pico diastólica/sistólica (AU)
