Influence of the previous use of ß-blockers on the early clinical course of acute coronary syndromes.

Recent studies have recently questioned the current role of ß-blockers in myocardial infarction. Our purpose is to analyze the influence of the previous use of ß-blockers on the early course of patients admitted because of acute coronary syndrome (ACS). We analyzed the data of 37.359 patients included in the ARIAM-Andalucia Registry. Of them, 7759 (20.8%) were previously receiving ß-blockers. BB patients were older, more often female, had more risk factors and vascular disease, and less often had an ST-elevation myocardial infarction. In the unadjusted analysis, BB patients less often had ventricular fibrillation or atrioventricular block, and more often a Killip classification >1, and no difference of in-hospital mortality (5.7 vs 5.6%). After logistic regression analysis and propensity score matching, no differences in complications or mortality (odds ratio 0.997, 95% confidence interval 0.882-1.128) were found in relationship to previous ß-blockers. In conclusion, we find that the previous administration of ß-blockers is not an independent predictor of the early prognosis of ACS.

The previous use of digoxin does not worsen early outcome of acute coronary syndromes: an analysis of the ARIAM Registry.

The aim of the study was to determine the influence of the previous use of digoxin on the hospital mortality and complications of patients admitted because of acute coronary syndrome (ACS). We analyzed the data of patients included in the ARIAM-Andalucia Registry, which involves 49 hospitals in Andalucia, Spain, from 2007 to 2012. Patients on digoxin treatment prior to their admission because of ACS constituted the digoxin group (DG), and were compared with the group of patients not on digoxin. Logistic regression and propensity score matching were used to analyze the differences. We included 20,331 patients, of whom 244 (1.2%) were on digoxin. DG patients were older (73.1 vs 63.7 years old), more often women, and had more diabetes, hypertension, previous myocardial infarction, heart failure, stroke, atrial fibrillation, peripheral vascular disease, obstructive pulmonary disease or kidney disease. On univariate analysis, DG patients had significantly higher hospital mortality (13.5 vs 5.3% P < 0.001), and more cardiogenic shock, but less ventricular fibrillation, and no differences in atrioventricular block, stroke or reinfarction. After the multivariate analysis, DG had no significant influence on hospital prognosis [odds ratio (OR) 1.21, 95% confidence interval 0.79-1.86]. The analysis of a propensity-matched cohort of 464 patients (232 DG and 232 NoDG) did not find differences in hospital mortality (13.4 vs 13.4%) nor other complications. In our cohort of ACS patients, the previous treatment with digoxin was not associated with an increase in dysrhythmic complications nor was an independent predictor of mortality during hospitalization.

Ablación de extrasistolia ventricular del tracto de salida ventricular derecho con sistema de cartografía sin contacto / Ablation of premature ventricular contractions originating in the right ventricular outflow tract using non-contact mapping

La extrasistolia ventricular originada en el tracto de salida de ventrículo derecho puede tener una respuesta pobre a fármacos y ser compleja de ablacionar mediante un sistema convencional con guía fluoroscópica debido a la dificultad en la inducibilidad. Describimos la ablación de extrasistolia ventricular de difícil inducibilidad originada en el tracto de salida de ventrículo derecho, mediante un sistema de cartografía sin contacto. Se realizó ablación de cinco focos extrasistólicos originados en tracto de salida de ventrículo derecho en una serie prospectiva de 4 pacientes. Los pacientes presentaban pobre calidad de vida y falta de respuesta a antiarrítmicos. Se realizó una media de tres aplicaciones de radiofrecuencia por foco, con un tiempo medio de aplicación de 113±15 s. Se obtuvo un 100% de éxito agudo y no hubo complicaciones. En un seguimiento medio de 30±16 meses, los pacientes se mantienen asintomáticos sin tratamiento farmacológico. El sistema de cartografía sin contacto permite una alta eficacia en la eliminación de extrasistolias ventriculares aisladas de difícil inducibilidad (AU)

Premature ventricular contractions originating in the right ventricular outflow tract may respond poorly to pharmacological treatment, and ablation using conventional fluoroscopically-guided systems may be complicated by the difficulty in inducing arrhythmias. We describe the use of a non-contact mapping system to ablate difficult-to-induce premature ventricular contractions originating in the right ventricular outflow tract. Five premature ventricular contractions sites in the right ventricular outflow tract were ablated in a prospective series of 4 patients. Patients had a poor quality of life and had not responded to antiarrhythmic drugs. A mean of 3 radiofrequency pulses per site was applied and mean application time was 113±15s. We achieved a 100% acute success rate and there were no complications. Patients were asymptomatic without drug therapy after a mean of 30±16 months of follow-up. The noncontact mapping system is highly effective in eliminating difficult to induce, isolated premature ventricular contractions (AU)

[Ablation of premature ventricular contractions originating in the right ventricular outflow tract using non-contact mapping]. / Ablación de extrasistolia ventricular del tracto de salida ventricular derecho con sistema de cartografía sin contacto.

Premature ventricular contractions originating in the right ventricular outflow tract may respond poorly to pharmacological treatment, and ablation using conventional fluoroscopically-guided systems may be complicated by the difficulty in inducing arrhythmias. We describe the use of a non-contact mapping system to ablate difficult-to-induce premature ventricular contractions originating in the right ventricular outflow tract. Five premature ventricular contractions sites in the right ventricular outflow tract were ablated in a prospective series of 4 patients. Patients had a poor quality of life and had not responded to antiarrhythmic drugs. A mean of 3 radiofrequency pulses per site was applied and mean application time was 113±15s. We achieved a 100% acute success rate and there were no complications. Patients were asymptomatic without drug therapy after a mean of 30±16 months of follow-up. The noncontact mapping system is highly effective in eliminating difficult to induce, isolated premature ventricular contractions.

Disección auricular izquierda que simula un síndrome coronario agudo / No disponible

No disponible

Functional anatomy of aortic regurgitation. Role of transesophageal echocardiography in aortic valve-sparing surgery.

INTRODUCTION AND OBJECTIVES: The aim was to evaluate the usefulness of transesophageal echocardiography (TEE) for the preoperative functional anatomical assessment of patients with aortic regurgitation (AR) to identify those eligible for valve-sparing surgery (VSS). METHODS: We determined the accuracy and diagnostic value of TEE for identifying underlying lesions and mechanisms in 66 patients who underwent surgery for severe AR by comparing TEE findings with those obtained on surgical inspection. The usefulness of TEE for predicting the feasibility of VSS was determined. RESULTS: The overall diagnostic accuracy of TEE was excellent (87%, kappa=0.82), with valve prolapse being the principle cause of discrepancy between the methods (in 23/27 cases; 85%). Three anatomical forms of dilatation of the ascending aorta (AA) were correctly classified (accuracy >88%; kappa 0.83): supratubal aneurysm (19 patients), aortic root aneurysm (4), and annuloaortic ectasia (24). The mechanism underlying AR was identified with an accuracy of 85% (kappa 0.8) and there was a significant association between the type of mechanism identified by TEE and the success of VSS (P< .001): VSS was successful in 73% of patients with dilatation of a functional annulus (i.e. with tethering), but aortic valve replacement was required in 78% with prolapses, 90% with thickened leaflets with restricted movement, and 100% with perforation. There was also a relationship between the type of aneurysm and the technique required for AA replacement (P=.004). CONCLUSIONS: Use of TEE enabled the mechanism underlying AR to be accurately identified. There was a high level of agreement with surgical inspection and the technique was useful for predicting the feasibility of VSS and the surgical procedure for AA replacement.

Anatomía funcional de la insuficiencia aórtica. Papel de la ecocardiografía transesofágica en la cirugía conservadora de válvula aórtica / Functional anatomy of aortic regurgitation. Role of transesophageal echocardiography in aortic valve-sparing surgery

Introducción y objetivos. Intentamos determinar el papel de la ecocardiografía transesofágica (ETE) en la descripción preoperatoria de la anatomía funcional de la insuficiencia aórtica (IAo) para identificar candidatos a cirugía conservadora (CCVAo). Métodos. En 66 pacientes intervenidos de IAo severa se determinan precisión y valores diagnósticos de la ETE en la descripción de lesiones y mecanismos, empleando la observación quirúrgica como referencia. Se valora la utilidad de la ETE para predecir aplicabilidad de técnicas de CCVAo. Resultados. La exactitud diagnóstica general de la ETE es excelente (87%, índice kappa = 0,82); el prolapso presenta la principal discrepancia (23/27 casos; 85%) entre los métodos. Tres formas anatómicas de dilatación de aorta ascendente (AA) fueron correctamente clasificadas (precisión, > 88%; kappa = 0,83): aneurisma de AA supratubular (19), aneurisma de raíz (4) o anuloectasia aórtica (24). La precisión en el diagnóstico del mecanismo fue del 85% (kappa = 0,8) y éste presentó una asociación significativa con el éxito de la CCVAo (p < 0,001) en el 73% de los casos de dilatación de los anillos funcionales (tethering). El 78% de prolapsos, el 90% de movimiento restrictivo de velos engrosados y el 100% de perforaciones requirieron sustitución valvular aórtica. Las formas de aneurisma también se relacionaron con el procedimiento de sustitución de AA (p = 0,004). Conclusiones. La ETE permite una descripción precisa de los mecanismos de la IAo, tiene una elevada tasa de acuerdo con las observaciones quirúrgicas y predice adecuadamente la aplicabilidad de la CCVAo y el procedimiento de sustitución de AA (AU)

Introduction and objectives. The aim was to evaluate the usefulness of transesophageal echocardiography (TEE) for the preoperative functional anatomical assessment of patients with aortic regurgitation (AR) to identify those eligible for valve-sparing surgery (VSS). Methods. We determined the accuracy and diagnostic value of TEE for identifying underlying lesions and mechanisms in 66 patients who underwent surgery for severe AR by comparing TEE findings with those obtained on surgical inspection. The usefulness of TEE for predicting the feasibility of VSS was determined. Results. The overall diagnostic accuracy of TEE was excellent (87%, kappa=0.82), with valve prolapse being the principle cause of discrepancy between the methods (in 23/27 cases; 85%). Three anatomical forms of dilatation of the ascending aorta (AA) were correctly classified (accuracy >88%; kappa 0.83): supratubal aneurysm (19 patients), aortic root aneurysm (4), and annuloaortic ectasia (24). The mechanism underlying AR was identified with an accuracy of 85% (kappa 0.8) and there was a significant association between the type of mechanism identified by TEE and the success of VSS (P < .001): VSS was successful in 73% of patients with dilatation of a functional annulus (i.e. with tethering), but aortic valve replacement was required in 78% with prolapses, 90% with thickened leaflets with restricted movement, and 100% with perforation. There was also a relationship between the type of aneurysm and the technique required for AA replacement (P=.004). Conclusions. Use of TEE enabled the mechanism underlying AR to be accurately identified. There was a high level of agreement with surgical inspection and the technique was useful for predicting the feasibility of VSS and the surgical procedure for AA replacement (AU)

[Imbalance between the supply and demand for cardiologists in Spain. Analysis of the current situation, future prospects, and possible solutions]. / Desequilibrio entre la oferta y las necesidades de cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución.

Planning cardiology provision in Spain requires knowledge of the resources available and the demand, both now and in the future. In this report, we present the results of a study carried out by the Spanish Society of Cardiology on the availability of and demand for cardiologists in the country. The current situation is characterized by an imbalance of around 14% between the number of active cardiologists and the estimated number required. The demographic distribution of cardiologists shows that they are predominantly male and middle-aged. Expectations are that the situation will get worse until the year 2020. To correct this imbalance, alternative forms of training or clinical department organization, or both, are required. Some possible alternatives are presented in the final part of this document, as proposals for open discussion.

Desequilibrio entre la oferta y las necesidades de cardiólogos en España. Análisis de la situación actual, previsiones futuras y propuestas de solución / Imbalance between the supply and demand for cardiologists in Spain. Analysis of the current situation, future prospects, and possible solutions

La planificación de la cardiología en España requiere el conocimiento de los recursos disponibles y las necesidades, no sólo presentes, sino también futuras. En el presente informe se recogen los resultados de un estudio llevado a cabo por la Sociedad Española de Cardiología sobre la necesidad y la disponibilidad de cardiólogos. La situación actual en España presenta un desequilibrio entre el número de cardiólogos en activo y los que serían necesarios, desequilibrio que oscila en torno al 14%. La pirámide poblacional refleja una población envejecida y mayoritariamente masculina. Las previsiones futuras indican que la situación empeorará desde ahora hasta el año 2020. La corrección de este desequilibrio requiere el desarrollo de alternativas diferentes de las actuales en formación y/o organización de los servicios asistenciales. Algunas de estas alternativas se recogen en la parte final de este documento, en forma de propuestas abiertas al debate

Planning cardiology provision in Spain requires knowledge of the resources available and the demand, both now and in the future. In this report, we present the results of a study carried out by the Spanish Society of Cardiology on the availability of and demand for cardiologists in the country. The current situation is characterized by an imbalance of around 14% between the number of active cardiologists and the estimated number required. The demographic distribution of cardiologists shows that they are predominantly male and middle-aged. Expectations are that the situation will get worse until the year 2020. To correct this imbalance, alternative forms of training or clinical department organization, or both, are required. Some possible alternatives are presented in the final part of this document, as proposals for open discussion

El estudio SIESTA

No disponible

[Inflammation markers and risk stratification in patients with acute coronary syndromes: design of the SIESTA Study (Systemic Inflammation Evaluation in Patients with non-ST segment elevation Acute coronary syndromes)]. / Marcadores de inflamación y estratificación de riesgo en pacientes con síndorome coronario agudo: diseño del estudio SIESTA (Systemic Inflammation Evaluation in patients with non-ST segment elevaton Acute coronary syndromes).

BACKGROUND AND OBJECTIVE: Evidence is growing regarding the prognostic value of markers of inflammation in unstable angina/non-ST segment elevation myocardial infarction (UA/NSTEMI). However, the independent value of these variables has not been systematically investigated in prospective studies. The main objective of the SIESTA study is to assess the relative prognostic roles of C-reactive protein, fibrinogen, neopterin, interleukins 6, 8, 10 and 18, tumor necrosis factor, e-selectin, endothelin 1, tissue factor, VCAM-1, ICAM-1, pregnancy-associated plasma protein-A, B-type natriuretic peptide, leukocytes, troponin I or T and serum creatine kinase-MB (CKMB) in UA/NSTEMI patients. PATIENTS AND METHOD: SIESTA is a prospective, multicenter trial involving patients with chest pain suggestive of acute coronary syndrome (ACS) within 48 hours of enrolment and at least one of the following: abnormal troponin levels, electrocardiographic signs of ischaemia or previously documented vascular disease. Clinical outcome data and serial biochemical determinations will be assessed during hospital admission and at 30, 180 and 365 days of follow-up. The TIMI (Thrombolysis In Myocardial Infarction) and PEPA (Proyecto de Estudio del Pronóstico de la Angina) risk scores will be also validated. Study variables will include death due to any cause, cardiac death, non-fatal myocardial infarction, unstable angina requiring re-admission, emergency revascularization and a composite of death, myocardial infarction and need for emergency hospitalization or myocardial revascularization. Each of these conditions will be treated as secondary end-points when assessed individually. This study will provide valuable prospective information about the prognostic value of inflammatory markers in real life ACS patients of Mediterranean origin.

[Utility of cardiac event recorders in diagnosing arrhythmic etiology of palpitations in patients without structural heart disease]. / Utilidad de un grabador de acontecimientos en el diagnóstico de la etiología arrítmica de las palpitaciones en pacientes sin cardiopatía estructural.

OBJECTIVE: To determine the diagnostic yield of transtelephonic event monitors for identifying the reason for palpitations in patients with no structural heart disease. PATIENTS AND METHOD: For 20 months we enrolled all patients reporting palpitations in whom heart disease had been ruled out by medical history, physical examination, ECG and transthoracic echocardiography. All patients underwent 24 h Holter monitoring, which did not provide diagnostic information. Later, a Cardiotest 4DM transtelephonic event monitor was provided to each patient for a mean of 15 3 days. We used SPSS V 10 for statistical analysis. RESULTS: Two hundred twenty-seven consecutive patients were enrolled. Mean age was 45 3 years (range 12-85); 167 were females (74%). Two hundred twelve of the 227 patients (93.3%) experienced palpitations while wearing the device, and 210 (92.5%) used the monitor correctly, recording the cardiac rhythm during palpitations. Fifteen patients (6.6%) had no palpitations during the days of study. In 125 (55%) the Cardiotest 4DM correctly recorded and transmitted arrhythmia that justified the patients' reference to palpitations. In 35 (15.4%) significant arrhythmia was detected: paroxysmal supraventricular tachycardia in 21, atrial fibrillation in 9, atrial flutter in 5, runs of ventricular extrasystoles in 4 and right outflow tract ventricular tachycardia in 1. Sinus rhythm was recorded during palpitations in 85 patients (37%), and arrhythmia as the cause could be ruled out. CONCLUSIONS: Cardiotest 4DM identifies arrhythmia in a very high proportion of patients with palpitations and no structural heart disease.

Utilidad de un grabador de acontecimientos en el diagnóstico de la etiología arrítmica de las palpitaciones en pacientes sin cardiopatía estructural / Utility of Cardiac Event Recorders in Diagnosing Arrhythmic Etiology of Palpitations in Patients without Structural Heart Disease

Introducción y objetivos. El objetivo del presente trabajo es determinar cuál es el rendimiento de la utilización del grabador de acontecimientos en el diagnóstico de la etiología de las palpitaciones como síntoma en pacientes sin cardiopatía estructural. Pacientes y método. Durante 20 meses se han incluido en el estudio a todos los pacientes que consultaban por palpitaciones y en los que se descartaba mediante historia clínica, exploración, ECG y ecocardiografía la existencia de cardiopatía estructural. A todos se les realizó un Holter de 24 h que no resultó diagnóstico. Posteriormente se les proporció un registrador de acontecimientos Cardiotest 4DM® durante una media de 15 ñ 3 días. Utilizamos el paquete estadístico SPSS V.10.Resultados. Se incluyeron en el estudio 227 pacientes consecutivos. La edad media fue de 45 ñ 3 años (rango, 12-85 años) y 167 eran mujeres (74 por ciento). Un total de 212 de los 227 pacientes incluidos (93,3 por ciento) tuvieron palpitaciones durante los 15 días que dispusieron del monitor, y 210 (92,5 por ciento) utilizaron correctamente el monitor, grabando el ritmo cardíaco coexistente con dichas palpitaciones. Quince pacientes (6,6 por ciento) no tuvieron palpitaciones durante los días de estudio. En 125 (55 por ciento) el Cardiotest 4DM® grabó y transmitió por vía transtelefónica correctamente arritmias que justificaban las palpitaciones referidas por los pacientes. En 35 pacientes (15,4 por ciento) se detectaron arritmias significativas: 21 taquicardias paroxísticas supraventriculares, 9 fibrilaciones auriculares, 5 aleteos auriculares, 4 tripletes de extrasístoles ventriculares y una taquicardia ventricular de tracto de salida de ventrículo derecho. En 85 pacientes (37 por ciento), durante las palpitaciones no se detectó arritmia alguna que las justificara, excluyendo así las arritmias como etiología de la misma. Conclusiones. El Cardiotest 4DM® permite identificar arritmias en una proporción muy elevada de pacientes con palpitaciones y sin cardiopatía estructural conocida (AU)