Un protocolo prospectivo de anticoagulación oral en los pacientes con fibrilación auricular crónica no valvular: efectividad y seguridad en la práctica clínica diaria / A prospective protocol of oral anticoagulation in patients with chronic nonvalvular atrial fibrillation: effectiveness and safety in daily clinical practice

Introducción: Nuestro trabajo pretende valorar si un protocolo prospectivo de anticoagulación en la fibrilación auricular no valvular, basado en las Guías de Práctica Clínica de la Sociedad Española de Cardiología, es efectivo y seguro en la práctica clínica diaria. Pacientes y métodos: Desde el 1.2.2000 hasta el 1.2.2002 se han incluido en el protocolo todos los pacientes con fibrilación auricular no valvular crónica revisados en dos consultas de cardiología y se han seguido prospectivamente, analizando los eventos mayores (muerte, embolismos sistémicos o hemorragia severa) por grupo de tratamiento. Resultados: De 624 pacientes incluidos, fueron anticoagulados 425 (68%). Los pacientes anticoagulados presentaron una mayor frecuencia de hipertensión (75% versus 53%, p < 0.001), diabetes (28% versus 15%, p < 0.001), embolismo previo (19% versus 5%, p < 0.001) y cardiopatía isquémica (11% versus 4%, p = 0.003), un mayor número de factores de riesgo cardioembólicos (2.2 ± 1.1 versus 1.6 ± 1.2, p < 0.001) y una menor frecuencia de fibrilación auricular aislada (15% versus 40%, p < 0.001) que los pacientes no anticoagulados. Éstos últimos fueron antiagregados en el 93% de los casos (92% con aspirina). Tras un seguimiento de 22 ± 14 meses (95% de pacientes seguidos) la tasa anual de eventos embólicos (0.82% versus 7.17%, p < 0.001) y la de mortalidad (1.98% versus 5.18%, p = 0.007) fueron menores en los pacientes nticoagulados que en el resto, sin un aumento significativo en la tasa anual de hemorragias severas (1.37% versus 1.36%, p = 0.82). Conclusión: El tratamiento anticoagulante en la fibrilación auricular no valvular es efectivo y seguro en la práctica clínica diaria (AU)

Introduction: Our objective is to evaluate if a prospective protocol of oral anticoagulation in patients with nonvalvular atrial fibrillation, based in ClinicalPractice Guidelines of the Spanish Society of Cardiology, is effective and safe in daily clinical practice. Patients and method: From February 1st, 2000 until February 1st, 2002, we enrolled all patients with chronic nonvalvular atrial fibrillation visited in two outpatient cardiology clinics and we prospectively followed them, analysingmajor events (death, systemic embolism and severe haemorrhage) by group of treatment. Results: 624 patients fulfilled inclusion criteria, and 425 were anticoagulated (68%). Anticoagulated patients showed a higher frequency of hypertension (75% versus 53%, p < 0.001), diabetes (28% versus 15%, p < 0.001), previous embolism (19% versus 5%, p < 0.001) and ischaemic heart disease (11% versus 4%, p = 0.003), a greater number of cardioembolic risk factors (2.2±1.1 versus 1.6±1.2, p < 0.001) and a lower frequency of lone atrial fibrillation (15% versus 40%, p < 0.001) than non-anticoagulated patients. These latter ones were antiagregated in 93% of cases (92% with aspirin). After a mean follow-up of 22 ± 14 months (95% of patients with follow-up completed) embolic event rate for year (0.82% versus 7.17%, p < 0.001) and yearly mortality (1.98% versus 5.18%, p = 0.007) were lower in anticoagulated patients than in the rest of the series, without a significant increase in severe haemorrhage rate for year (1.37% versus 1.36%, p = 0.82). Conclusions: Oral anticoagulation in nonvalvular atrial fibrillation is effective and safe in daily clinical practice (AU)

[Short and long-term prognosis of prosthetic valve endocarditis in non-drug addicts]. / Pronóstico a corto y largo plazo de la endocarditis sobre prótesis en pacientes no drogadictos.

INTRODUCTION AND OBJECTIVES: Prosthetic valve infective endocarditis is a complication of valvular replacement surgery with a high morbimortality during the in-hospital phase and an important risk of complications during follow-up. The objective of the present study is to assess the clinical features and the short and long-term prognosis of this disease. PATIENTS AND METHODS: A prospective study of 43 consecutive cases of prosthetic valve endocarditis in non-addict patients from January 1987 to March 1997. RESULTS: The mean age was 51 +/-16 years. Eight patients (19%) had early prosthetic valve endocarditis (two months following heart surgery), fourteen patients (32%) had intermediate (between 2 and 12 months post surgery) and twenty-one (49%) had late prosthetic valve endocarditis (more than one year after heart surgery). Transesophageal echocardiography was performed in 32 patients with a sensibility of 81%. Complications occurred in 86% of patients and 53% of patients underwent surgery during the active phase (25% was emergency surgery). Inpatient mortality was 23% (50% in early prosthetic valve endocarditis). After a mean follow-up of 56 months there were 5 cases of recurrence, four patients required late surgery and 5 patients died. Survival (excluding early mortality) was 82% at 5 years with no significant differences among patients who received only medical treatment and those who underwent surgery in the active phase. CONCLUSIONS: Early mortality of prosthetic valve endocarditis is, according to our experience of 20%. The prognosis of survivors to the active phase is favourable in the majority. Early prosthetic valve endocarditis still causes a high mortality rate despite the use of combined medical surgical treatment in most cases.

[The general characteristics and short- and long-term results of infective endocarditis in non-drug addicts]. / Características generales y resultados a corto y largo plazo de la endocarditis infecciosa en pacientes no drogadictos.

INTRODUCTION AND OBJECTIVES: Infective endocarditis is a disease with a high morbimortality during the active phase and a considerable risk of complications during follow-up. The aim of our study is to describe the clinical and prognostic features of infective endocarditis in non-drug addict patients in short and long terms. PATIENTS AND METHODS: A prospective study of 138 cases of infective endocarditis in non-drug addict patients through the parenteral pathway treated in our institution from 1987 to 1997. RESULTS: The mean age was 44 +/- 20 years. Ninety-five patients (69%) had native valve infective endocarditis and forty-three (31%) had prosthetic valve endocarditis. Streptococci were the causal microorganism in 34% and staphylococci in 33%. 83% of patients developed some type of complications during hospital stay. 51% of patients were operated on during the active phase (22% were urgent). The in-hospital mortality rate was 21%. 10 patients (9%) needed late cardiac surgery and seven patients (5%) died during follow-up. Global survival at 10 years was 71%. There were no statistical differences in survival in as much as the type of treatment received during the hospital stay in the active phase (medical alone or combined medical-surgical). CONCLUSIONS: A high early surgery rate in the active phase related to good long-term results and does not increase early in-hospital mortality. Medical treatment also offers good long-term results in cases of infectious endocarditis with absence of bad prognostic factors and good clinical outcome.

[Isolated left ventricular myxoma discovered incidentally by echocardiography]. / Mixoma ventricular izquierdo aislado descubierto casualmente por ecocardiografía.

We describe the case of a young patient in whom two-dimensional echocardiography, performed because of episodes of palpitations, discovered the presence of a small mass in the left ventricle, attached to the posterior wall. Transesophageal echocardiography was performed to further assess the mass's attachments and to verify the lack of involvement of the mitral valve and its associated structures. The patient had a cardiopulmonary bypass, surgery and the mass was removed approaching into the left ventricular cavity through the atrial septum via a right atriotomy, without any complication during the postoperative period. In the histologic study the mass appeared to be a typical myxoma. This case has a great interest because the ventricular location of the myxoma is unusual; and because the use of two-dimensional echocardiography, even in the absence of significant symptoms and/or signs, avoided dangerous embolic complications, which often represent the first sign of this neoplastic pathology.

[Mobile thrombus in the right cardiac cavities in patients with severe pulmonary thromboembolism. Importance of echocardiography]. / Trombos móviles en cavidades cardíacas derechas en pacientes con tromboembolismo pulmonar grave. Importancia de la ecocardiografía.

The pulmonary thromboembolism is a frequent and severe disease, usually difficult to recognize, specially in patients with thrombotic material trapped within right heart cavities. We present our experience in three patients with severe pulmonary thromboembolism where echocardiographic study demonstrated the presence of huge mobile thrombus in right heart cavities, which demanded urgent therapy with excellent results. We would like to stress that echocardiographic study in these patients could be elective diagnostic procedure, avoiding the realization of pulmonary arteriography, which could bring risk of possible thrombus mobilization.

[Abscess of the mitral-aortic confluence and perforation of the mitral valve in a patient with Brucella endocarditis]. / Absceso de la confluencia mitroaórtica y perforación de la válvula mitral en un paciente con endocarditis por Brucella.

We report a case of Brucella aortic valve endocarditis in a 36 year-old patient with no underlying heart disease who required urgent surgery. In the postoperative follow-up, he suffered from congestive heart failure due to an anterior mitral valve rupture. In the echocardiogram, a periprosthetic abscess was seen and a second intervention was necessary. This report suggests that treating Brucella endocarditis requires a combined medical and surgical approach.

[Acute pericarditis as the initial manifestation in Still's disease in an adult]. / Pericarditis aguda como manifestación inicial de la enfermedad de Still del adulto.

Almost 90% of primary acute pericarditis are idiopathic. Between specifics forms, a very low percentage of cases are due to chronic rheumatic diseases. A case of adult Still's disease (juvenile chronic rheumatoid arthritis) with acute pericarditis being the first clinical manifestation (besides fever and general syndrome) is presented. Therapy with oral prednisone was rapidly effective, and pericardial effusion resolved after 3 weeks of treatment, as echocardiography showed.