[Guidelines of the Spanish Society of Cardiology for clinical practice in exercise testing]. / Guías de práctica clínica de la Sociedad Española de Cardiología en pruebas de esfuerzo.

Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain. This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.

Heart failure after aortic valve replacement for aortic regurgitation: prospective 20-year study.

BACKGROUND: The objective of this study was to assess the probability of development of heart failure during a long-term follow-up in patients submitted for aortic valve replacement for aortic regurgitation on the basis of preoperative findings. METHODS AND RESULTS: Eighty-seven consecutive patients with pure aortic regurgitation and normal coronary arteries were submitted for aortic valve replacement and prospectively followed up. Clinical examination, echocardiography, and radionuclide ejection fraction were performed before surgery and at 1, 2, 5, and 10 years after surgery. Operative mortality rate was 2.2% (2 patients). The follow-up period was 1 to 12 years (mean 6 years). Overall survival rate was 87% at 5 years and 81% at 10 years. During follow-up, 19 patients had heart failure develop, and there were 14 deaths (6 caused by heart failure). Probability of heart failure was 16% at 5 years and 24% at 10 years. Age was the single independent preoperative predictor of both death and heart failure. Age >50 years (relative risk [RR] 10.4), preoperative ejection fraction <40% (RR 10.6), and end-systolic diameter >50 mm (RR 74) were independently related to the postoperative development of heart failure. CONCLUSIONS: Aortic valve replacement can be performed safely in patients with severe aortic regurgitation by following current recommendations. Age >50, end-systolic diameter >50 mm, and radionuclide ejection fraction <40% were independent preoperative predictors of postoperative heart failure. The only independent predictor of both postoperative death and heart failure was age >50 years.

[Pathology of diseases of extracardiac origin. VI. Disease of the connective tissue and heart]. / Patología del corazón de origen extracardíaco (VI). Enfermedades del tejido conectivo y corazón.

Connective tissue diseases encompass a wide group of nosologic entities of unknown etiology, characterized by multisystemic organ involvement, sharing an immunologic pathogenetic mechanism, producing a variety of inflammatory manifestations, and whose primary lesion is always a diffuse vasculitis. Any part of the cardiovascular system may be involved, including the pericardium, the myocardium, the endocardium and valves, the coronary arteries, the aorta, the pulmonary vasculature, the peripheral arteries, veins, arterioles, venules, and the capillary beds of almost every organ subsystem. Pathologic studies disclose a high prevalence of heart involvement, but the presence and extent of pathologic findings correlate poorly with clinical manifestations. With the advent of echocardiography-Doppler, milder and earlier cases are now recognized. Although these patients continue under the care of rheumatologists and internists, when cardiac involvement arises, cardiologists must be aware of the characteristics, outcome and management of connective tissue diseases.

Survival prognostic factors and markers of morbidity in Spanish patients with systemic sclerosis.

OBJECTIVE: To identify survival prognostic factors and markers of morbidity among patients with systemic sclerosis (SSc). PATIENTS AND METHODS: The study included 72 patients diagnosed with SSc. According to the extent of skin involvement, three groups of patients were established: group 1, without sclerosis and with sclerosis of fingers and neck; group 2, with sclerosis of face and distal to elbows and knees; group 3, with generalised sclerosis including the trunk. All patients were included in a study protocol to determine visceral involvement. Cumulative survival after first symptom has been estimated according to the Kaplan-Meier method. The association between a hypothetical prognostic factor and cumulative survival after first symptom was assessed by log rank test. The association between a hypothetical risk factor and the prevalence of severe morbidity was assessed by the odds ratio. Multiple logistic regression models were used to identify the main predictors of severe morbidity. RESULTS: Survival was estimated to be 85% 10 years after first SSc symptom. Survival was higher among SSc patients with skin involvement distal to elbows and knees than among the rest of patients; a forced vital capacity (FVC) on spirometry lower than 70% of expected value was associated with a shorter survival, even after adjustment for diffuse SSc. Skin involvement proximal to elbows or knees was associated with a higher prevalence of severe morbidity (OR = 46.57; p < 0.001). According to a multiple logistic regression, severe morbidity was higher among patients with skin involvement proximal to knees or elbows (OR = 40.92; p < 0.001) or among patients with pulmonary hypertension detected by Doppler echocardiography (OR = 23.66 p < 0.001). CONCLUSIONS: In patients with SSc the extent of skin sclerosis was found to be a determining factor on the prognosis. According to skin sclerosis extent two main subsets of SSc patients with different survival incidence and degree of morbidity could be clearly established: limited SSc, formed by patients with no skin sclerosis or with sclerosis distal to elbows and knees and diffuse SSc, formed by patients with skin sclerosis distal and proximal to elbows and knees. Moreover, lung involvement (FVC < 70% on survival study and pulmonary hypertension on morbidity study) was an important and independent prognostic factor.

Clinical outcome of severe asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study.

One hundred one patients with asymptomatic chronic severe aortic regurgitation and normal ejection fraction were monitored for up to 10 years (mean 55.4 +/- 33.5 months). Predefined surgical indications were the development of cardiac symptoms or the documentation of impaired basal left ventricular function. During the follow-up period there were no cardiac deaths; 14 patients needed surgery, 8 because of development of symptoms and 6 because of left ventricular impairment. The risk of surgery was 12% at 5 years and 24% at 10 years. Baseline end-systolic diameter > 50 mm and radionuclide ejection fraction < 60% were independent predictors or either cardiac symptoms or left ventricular dysfunction. In patients needing surgery, a pattern of progressive left ventricular dilatation was demonstrated. There were no deaths during surgery, and echocardiographic and radionuclide parameters normalized in the first year of follow-up. Our data confirm that the prognosis of severe aortic regurgitation in patients with no symptoms is good and that the occurrence of asymptomatic left ventricular dysfunction is an uncommon event. Surgery can be safely postponed until the appearance of cardiac symptoms or the documentation of left ventricular dysfunction at rest.

[Extrinsic compression of the pulmonary artery by a mediastinal lymphoma. Diagnosis by Doppler echocardiography]. / Compresión extrínseca de la arteria pulmonar por un linfoma mediastínico. Diagnóstico por ecocardiografía-Doppler.

A patient with an anterior mediastinal tumor and cardiomegaly observed by plain chest roentgenogram is presented. The echocardiographic-Doppler examination showed massive pericardial efussion with hemodynamic compromise, and external compression of the right atrium and pulmonary artery. A pericardiocentesis was performed, and a mediastinoscopy with biopsy was diagnostic of lymphoblastic lymphoma.

Pericardial and myocardial localization of antimyosin in a case of acute myocarditis.

A 60-yr-old immunodepressed woman presented with acute perimyocarditis and cardiac tamponade complicating meningococcic infection. We had the opportunity to study her cardiac condition by injecting antimyosin during the acute phase. Images at 48 hr showed unexpected findings, with obvious localization of the tracer in the pericardial fluid, as well as myocardial uptake. Possible mechanisms for pericardial activity are discussed.

[The usefulness of Doppler echocardiography in the preoperative assessment of valvulopathies. A comparison with the hemodynamic and surgical findings]. / Utilidad de la ecocardiografía-Doppler en la evaluación prequirúrgica de las valvulopatías. Comparación con los hallazgos hemodinámicos y quirúrgicos.

The Doppler echocardiography and cardiac catheterization studies of all patients who underwent valvular surgery in a three-year period were reviewed to assess the correlation between the estimated severity of valvular disease by both methods. Two-hundred and thirty-five patients (group I: 140 male, age 58 +/- 12; 95 female, age 60 +/- 13) underwent both studies within 6 months. There was agreement on estimation of severity of valve lesions in 140 of 162 patients with aortic valve disease (93% of stenosis, 82% of regurgitations and 79% of mixed lesions), in 58 of 80 patients with mitral valve disease (83% of stenosis, 76% of regurgitations and 33% of mixed lesions) and in 10 of 16 patients with prosthetic valve disfunction. The correlation between both methods was significantly lower in mixed mitral lesions than in the remaining native valve lesions (p < 0.05). Significant disagreement occurred in 4 cases of aortic valve disease, four of mitral valve disease and five of prosthetic disfunction. When disagreement was present, Doppler often underestimated the severity of the disease. Disagreement was more frequent in patients with combined aortic and mitral disease. According to the surgical conclusions cardiac catheterization provided a diagnostic profit in the assessment of the disease severity in 8, 11 and 22% of cases of aortic and mitral valve disease and prosthetic valve disfunction, respectively. Coronary artery disease was present in 19% of patients who underwent coronary arteriography. One-hundred and two patients (group II: 44 m, 48 +/- 15; 58 f, 53 +/- 11) underwent surgery without previous cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac and hematological involvement in idiopathic hypereosinophilic syndrome. Study of 12 cases]. / Afección cardíaca y hematológica en el síndrome hipereosinofílico idiopático. Estudio de 12 casos.

BACKGROUND: The idiopathic hypereosinophilic syndrome (IHS) is a rare entity of unknown etiology. Hematological and cardiac involvement is predominant. A series of 12 patients with this syndrome, initiated in 1982, is described. METHODS: Cardiological study by repeated echocardiograms and hematological study in peripheral blood and bone marrow upon initiation of the disease were performed. RESULTS: Median follow up was of 48 +/- 31 months. Males predominated (75%) with mean age being 55 +/- 15 years. The principal organs or systems involved were the heart (50%) and the nervous system (41%). Of the 6 cases with cardiac involvement only 2 had clinical manifestations. The remaining 4 patients were diagnosed from echocardiographic changes with the principal alterations observed being: atypical occupation of the ventricles, endocardial thickening and mitral and tricuspid subvalvular cumulus. Echocardiographic follow-up only showed changes in one case. Hematological involvement was characterized by moderate leukocytosis with hypereosinophilia formed by mature eosinophils, conservation of other hematopoietic series, absence of blasts in peripheral blood, finding suggestive of diseosinophilopoiesis and appearance of myelofibrosis and cytogenetic alterations. Survival at four years was 58%. CONCLUSIONS: In the series studied cardiac involvement is frequent, being principally diagnosed in a subclinical phase and with a very slow echocardiographic evolution. At a hematological level changes typical in myelodysplastic syndromes and myeloid leukemia were observed.

Silver stains for identification of neuroendocrine cells. A study of the chemical background.

The chemical background of silver stains used for visualization and characterization of peripheral neuroendocrine cells in the gastrointestinal tract and pancreas, and of their corresponding tumours, was studied in tissue sections and by a dot-blot technique. Sequential staining of pancreatic islets with an immunohistochemical procedure and silver staining of the same tissue section revealed that chromogranin A immunostained cells also displayed an argyrophil reaction with the Grimelius method, but no argentaffin reaction with the Masson technique. Accordingly, purified chromogranin A (15 micrograms or less) treated in formalin and applied to nitrocellulose did not show any argentaffin reaction but displayed a dose-related argyrophil reaction. Equal quantities of other polypeptide components did not give rise to any silver reaction. Further dot-blot studies showed that the tryptophan and tyrosine metabolites, dopamine, norepinephrine, 5-hydroxytryptamine and 5-hydroxinodole caused strongly argentaffin and argyrophil reactions while epinephrine, 5-hydroxyindole-3-acetic acid and 5-hydroxytryptophan gave only the former reaction. Among other chemical components studied, only guanine displayed weak silver staining. The results indicate that the reaction products between aldehydes and the granular content of biogenic amines synthesized from tryptophan and tyrosine display an argentaffin reaction and that the granular chromogranin A caused an argyrophil but no argentaffin reaction.

[Spontaneous echocardiographic contrast in the left ventricle related to aortic insufficiency]. / Contraste ecocardiográfico espontáneo en el ventrículo izquierdo en relación con insuficiencia aórtica.

A case of spontaneous echocardiographic contrast in the left ventricle of a patient with severe aortic insufficiency is presented. This contrast appeared through the mitral valve which opened mainly during tele-diastole. Pulsed Doppler showed the blood flow responsible was laminar and of normal velocity. The mechanism of spontaneous intraventricular contrast cannot be attributed to poor left ventricle function or to high-velocity turbulent flow. We believe that spontaneous contrast was triggered by the decrease in proto-diastolic mitral flow secondary to aortic insufficiency. Transient stagnation of blood in the left atrium might modify the echogenic characteristics of the blood which persist during the passage of the flow through the left ventricle.

Clinical evaluation of a prospective protocol for the timing of surgery in chronic aortic regurgitation.

Out of 160 prospectively followed patients with aortic regurgitation, the clinical courses of 53 patients with pure, severe, and chronic aortic regurgitation and without coronary artery disease who were selected for surgery on the basis of predefined criteria is discussed. Surgical criteria were either unequivocal symptoms or documentation of impaired left ventricular dysfunction (defined as angiographic ejection fraction of less than 50% plus and end-systolic volume index greater than 60 ml/m2). According to preoperative status, patients were divided as follows: 11 asymptomatic patients (group A), 30 patients with moderate (classes II to III) symptoms (group B), and 12 patients with dyspnea at rest and pulmonary edema when first seen (group C). Surgical mortality was one patient (from group C). Late death occurred in four patients (one from group B, three from group C). At the end of follow-up (minimum 1 year, mean 3.6 years) 41 patients were in functional class I, four patients in class II, and one patient in class III. All patients except one in functional classes II and III belonged to group C. Before surgery, patients from groups A and B had similar ventricular dimensions and ejection fractions, whereas patients from group C had larger end-systolic diameters and volumes and lower ejection fractions. End-diastolic and end-systolic diameters decreased significantly at 1 and 2 years after surgery. Patients from group C continued to have dilated hearts as did those patients from groups A and B who had preoperative end-systolic diameters greater than 55 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of DDD and VVIR pacemakers with gated radionuclide ventriculography]. / Valoración del marcapasos DDD y VVIR mediante la técnica de la ventriculografía isotópica en equilibrio.

Gated radionuclide ventriculography was performed in 53 patients, with 29 DDD and 24 VVIR pacemakers. Ejection fraction and regional contractility was studied in three conditions: a) At rest. b) With tachycardia after exercise. And c) With induced tachycardia at rest. At a rate similar to the one reached with the exercise. Stimulation in different parts of the right ventricule did not show any differences in the ejection fraction. Induced ventricular stimulation in comparison with natural ventricular contractions did not alter or change ejection fraction if the reached rate was the same an not too high in both cases. Induced stimulation at rest with a rate of 110-120/min, decreased the ejection fraction in 10% (p less than 0.001). Induced stimulation by exercise (VVIR. DDD) increased the ejection fraction in 10% (p less than 0.003) and if there were zones of dyskinesia they improved or disappeared. There were no statistical differences between VVIR and DDD pacemakers. It seems that a limited tachycardia is convenient for patients with rate response pacemakers (VVIR).