[The prognostic factors after an acute myocardial infarct treated with fibrinolytics]. / Factores pronósticos tras el infarto agudo de miocardio tratado con fibrinolíticos.

BACKGROUND: The usefulness of the exercise test in evaluating patients with an acute myocardial infarction treated with fibrinolytics is controversial. On the other hand, the prognostic value of a patent infarct-related artery has not been clearly established. The objectives of this study were to assess the validity of the exercise test and to study the prognostic value of the artery patency after a myocardial infarction. MATERIAL AND METHODS: We studied 99 patients with a myocardial infarction treated with fibrinolytics, non-complicated. An exercise test and a cardiac catheterization were performed in the first month. The patients were followed-up for 2 years, recording the major cardiac events (death and reinfarction) and the minor events (angina class (II, left cardiac failure class (II or maintained ventricular tachycardia). RESULTS: On multivariate analysis with Cox regression, a workload < 4 METS at the exercise test was the only independent prognostic factor of major events (RR 5.6; CI 95% 1.68-19). The independent prognostic factors of minor events were: multivessel disease (RR 3.36; CI 95% 1.56-7.24), anterior infarction (RR 3.15; CI 95% 1.3-7.6), abnormal exercise test (RR 2.98; CI 95% 1.46-6.09) and ejection fraction < or = 40% (RR 2.48; CI 95% 1.07-5.74). The patency of the infarct-related artery was not a predictor of events. CONCLUSIONS: The exercise test is useful in predicting the prognosis in patients treated with fibrinolytics. An occluded infarct-related artery was not an independent predictor of cardiac events in 2 years of follow-up.

[The single coronary artery arising from the sinus of Valsalva. A rare cause of myocardial ischemia]. / Arteria coronaria única desde seno de Valsalva derecho. Una causa poco frecuente de isquemia miocárdica.

The presence of a congenital anomaly in coronary arteries can be the cause of a defective coronary flow and ischaemic symptoms. Although they are rare, we must suspect them in the presence of major cardiac events in young people. A single coronary artery is present if the entire coronary system arises from a solitary ostium. Its presence is regarded as having little clinical significance and it is usually a fortuitous finding on coronary angiography. We report the case of a patient with effort anginal symptoms, with a single coronary artery arising from the right sinus of Valsalva without obstructive atherosclerotic lesions.

[Evolution of the filling pattern of the left ventricle during the first year after an acute myocardial infarct. The influence of the infarct size]. / Evolución del patrón de llenado del ventrículo izquierdo durante el primer año tras un infarto agudo de miocardio. Influencia del tamaño del infarto.

OBJECTIVES: Acute myocardial infarction induces diastolic dysfunction as a result of the alteration of left ventricular relaxation and stiffness caused by ischemia and fibrosis. This study analyzes the association of infarct size with the diastolic filling pattern and the evolution of the latter during the first postinfarction year. PATIENTS AND METHODS: The study group consisted of 68 patients with a first acute myocardial infarction treated with thrombolytic agents. A Doppler echocardiography was performed at 8 +/- 2, 32 +/- 7 and 370 +/- 23 days after infarction. Five measurements of the ratio between E and A waves peak velocities (E/A ratio) and of the E deceleration time (EDT, ms) were averaged in each echocardiographic study. The patients were divided according to infarct size into a large infarct group (creatine kinase > 1,000 U/ml; 1,913 +/- 883; n = 26) and a small infarct group (creatine kinase < 1,000 U/ml; 556 +/- 227; n = 42). RESULTS: The large infarct group exhibited a greater E/A ratio and shorter EDT than the small infarct group in the first week (E/A ratio: 1.4 +/- 0.7 vs 0.8 +/- 0.3; p = 0.0001; EDT: 159 +/- 49 vs 192 +/- 56; p = 0.02) and at one month (E/A ratio: 1.2 +/- 0.7 vs 0.9 +/- 0.3; p = 0.01; EDT: 170 +/- 55 vs 207 +/- 40; p = 0.004); however no differences were observed between either group at one year in either E/A ratio (0.8 +/- 0.2 vs 0.9 +/- 0.4; NS) or EDT (207 +/- 44 vs 219 +/- 54; NS). In the large infarct group, E/A ratio decreased and EDT increased at one year compared to the first week (E/A ratio: p = 0.0004; EDT: p = 0.0001) and the first month (E/A: p = 0.02; EDT: p = 0.003); in contrast, in the small infarct group there were no significant differences in E/A ratio nor EDT during the first year postinfarction. CONCLUSIONS: In the first month postinfarction, large infarcts exhibit a greater E/A ratio and shorter EDT than small infarcts. The evolution of large infarcts is characterized by an attenuation of this pattern, with a progressive reduction of E/A ratio and prolongation of EDT during the first year post-infarction.

[Determination of ejection fraction and left ventricular fraction using isotopic ventriculography and bidimensional echocardiography. Comparison with contrast ventriculography]. / Determinación de la fracción de eyección y volúmenes del ventrículo izquierdo mediante ventriculografía isotópica y ecocardiografía bidimensional. Comparación con la ventriculografía de contraste.

OBJECTIVES: The aim of this study was to determine the correlation and agreement between the values of left ventricular ejection fraction and volumes assessed by echocardiography and radionuclide ventriculography with the results obtained by contrast angiography, as well as the variability of each method in these measurements. PATIENTS AND METHODS: In a group of 59 patients with a first acute myocardial infarction we have determined left ventricular ejection fraction and volumes by two-dimensional echocardiography, equilibrium radionuclide ventriculography and contrast angiography initially and six months after myocardial infarction. We also assess the variability in the determinations in these three methods. RESULTS: We found significant correlations in ejection fraction and volumes by radionuclide ventriculography and echocardiography with contrast angiography. The correlation was higher in ejection fraction and end-systolic volume by radionuclide ventriculography (r = 0.88 and r = 0.73) than by echocardiography (r = 0.55 and r = 0.63; p < 0.01), whereas the correlation of end-diastolic volume was moderate by both methods (r = 0.58 and r = 0.47), without significant differences. The agreement between contrast angiography and radionuclide ventriculography was higher, with narrower limits of agreement than between contrast angiography and echocardiography in ejection fraction as well as in ventricular volumes. We have found high and significant correlations between two determinations by each method in all parameters, although they were higher in ejection fraction by contrast angiography (r = 0.96) and radionuclide ventriculography (r = 0.98) than by echocardiography (r = 0.70; p < 0.01). The limits of agreement were always wider in echocardiography, narrower in contrast angiography and the narrowest in radionuclide ventriculography, showing its superior reproducibility. CONCLUSIONS: In this group of myocardial infarction patients, the variability in the measurements was lower by radionuclide ventriculography than by echocardiography, this could be the reason for overall better results found in correlation and agreement between radionuclide ventriculography and contrast angiography than between echocardiography and contrast angiography in the assessment of left ventricular ejection fraction and volumes.

[The significance of the elevation of basal and exercise segments on Q-leads after acute myocardial infarct]. / Significado de la elevación basal y al esfuerzo del segmento ST en derivaciones con onda Q tras un infarto agudo de miocardio.

INTRODUCTION: ST segment elevation on Q-leads has been related to a greater infarct size and to the existence of ventricular aneurysm. On the other hand, ST elevation during exercise testing has been related to the presence of myocardial viability. OBJECTIVES: In the present study we investigated the relation between ST segment elevation on infarct-related electrocardiographic leads at rest and during exercise with: a) the extension and severity of the regional dysfunction; b) the presence of myocardial viability (response to dobutamine), and c) the residual stenosis in the culprit artery. MATERIAL AND METHODS: The study group was composed of 51 patients; cardiac cathetherism (8 +/- 3 days) and exercise testing (8 +/- 2 days) were performed during the pre-discharge period. In contrast ventriculography (centerline method) we determined the circumferential extension (rads) and the severity (SD/rad) of the regional dysfunction at rest and after dobutamine (10 micrograms/kg/min). The minimal luminal diameter (MLD) in the culprit artery was also measured. Results are expressed as median [Q1-Q3] and the differences among the groups were assessed by Mann-Whitney U. RESULTS: Patients with ST segment elevation in two or more leads at rest (n = 36) showed a greater (41 [30-51] rads vs 20 [14-41] rads; p = 0.007) and more severe regional dysfunction (1.9 [1.5-2.5] SD/rad vs 0.6 [0.5-2.4] SD/rad; p = 0.01), less response to dobutamine (% of reduction of the dysfunction extension after dobutamine) (17 [0-42]% vs 50 [24-100]%; p = 0.004) and smaller MLD (0.5 [0-0.9] mm vs 0.8 [0.6-1.1] mm; p = 0.03). Likewise, patients with exercise-induced ST segment elevation (n = 28) showed less response to dobutamine (15 [0-45]% vs 40 [21-57]%; p = 0.03) and smaller MLD (0.5 [0-0.7] mm vs 0.9 [0.5-1] mm; p = 0.02). There were non significant differences between patients with and without ST elevation during exercise in the extension or severity of the regional dysfunction. ST segment elevation both at rest (RR 0.2; CI 95% 0.04-0.85) and during exercise (RR 0.19; CI 95%: 0.05-0.69) decreased the probability of improvement with dobutamine. CONCLUSIONS: We conclude that ST segment elevation on Q-leads at rest is related to a more extended and severe dysfunction. Patients with ST segment elevation (at rest or during exercise) show less response to dobutamine (myocardial viability less likely) and a more severe residual coronary stenosis.

[E wave deceleration time predicts left ventricular telediastolic pressure in acute myocardial infarction in patients with systolic dysfunction]. / El tiempo de deceleración de la onda E predice la presión telediastólica del ventrículo izquierdo tras un infarto agudo de miocardio en pacientes con disfunción sistólica.

OBJECTIVES: Left ventricular end-diastolic pressure (LVEDP) is a useful parameter for the management of postinfarction patients. As the current methods of estimating LVEDP are invasive, the existence of non-invasive methods would be of great practical value. This study investigates the relation between LVEDP and Doppler parameters such as E wave deceleration time (EDT) and E/A ratio, at one month following an acute myocardial infarction. METHODS: Eighty-nine patients with a first acute myocardial infarction treated with thrombolytic agents were studied. Doppler-echocardiography at 29 +/- 3 days and cardiac catheterization at 30 +/- 4 days postinfarction were performed. According to the ejection fraction (EF), the patients were divided into group 1 (n = 17) with EF < 45%, and group 2 (n = 72) with EF > 45%. RESULTS: Overall, the E/A ratio showed a weak correlation with LVEDP (r = 0.32; p = 0.007), and EDT did not correlate with LVEDP. When patients from group 2 were analyzed, no correlation was found between LVEDP and either E/A or EDT. However, in patients from group 1, LVEDP strongly correlated with both EDT (r = -0.83; p = 0.00001) and E/A (r = 0.70; p = 0.003). Moreover, the sensitivity and specificity of an EDT of less than 150 ms in predicting a LVEDP > 20 mmHg was 100%. CONCLUSIONS: We conclude that at the first month after a myocardial infarction EDT provides a non-invasive and useful parameter for estimating LVEDP in patients with systolic dysfunction.

[Anatomo-functional substrate of high risk arrhythmia after myocardial infarct]. / Sustrato anatomofuncional de las arritmias de alto riesgo tras el infarto de miocardio.

Ventricular arrhythmias detected in the late-hospital phase of myocardial infarction have been identified as a risk factor for sudden death, being their prognostic value independent of ventricular function. However, relations between both factors are not clarified. In order to study hypothetic associations between ventricular arrhythmias and some clinical, hemodynamic and angiographic variables, 60 patients (52 males, 8 females) underwent 24-hour Holter recordings and cardiac catheterization with left ventricular and coronary angiographies, 3-5 weeks after hospital admission. Past history data, acute phase complications and hemodynamic and angiographic results were compared between patients with and without significant ventricular arrhythmias during Holter monitoring (10 or more PVC's/hour and/or repetitive forms). No significant differences were found between both groups neither in mean age nor in the incidence of previous angina or infarction, cerebral ischemia, diabetes, lipid disorders or subjective feeling of being under psychological stress. Prior history of arterial hypertension was, however, significantly more frequent in patients with ventricular arrhythmias (53.3% vs 17.8%; p = 0.0183). No differences were observed in the localization of the infarct or in the complications during the acute phase (CPK peak, Killip's score, angina after 24 hours of evolution, intraventricular or A-V conduction disorders and supraventricular and ventricular arrhythmias). Among hemodynamic data, only left ventricular and aortic systolic pressures were different in both groups, being significantly higher in patients with ventricular arrhythmias. There were not differences in left ventricular segmentary contraction and in number of coronary vessels involved. To conclude, significant ventricular arrhythmias were recorded in 25% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Calculation of the mean pressure of the pulmonary artery and of the valve surface by ECG in mitral stenosis]. / Calcul de la pression moyenne de l'artère pulmonaire et de la surface valvulaire par l'E.C.G. dans le rétrécissement mitral

From a group of 50 patients affected by pure mitral stenosis with sinus rhythm, we have tried to obtain multiple correlation equations which enable in to calculate, in each particular case, the mean pressure of the pulmonary artery and mitral valvular area from purely electrocardiographic facts. In an additional group of 16 patients we have been able to verify the mentioned equations, placing all the calculated points within the presumed limits of tolerance. So it appears that the electrocardiographic calculation of these hemodynamic parameters is possible, with sufficient approximation for clinical requirements.

[QRS in mitral stenosis: Electrohemodynamic correlation]. / Estudio del QRS en la estenósis mitral: correlaciones electrohemodinámicas

The electrocardiograms of 50 patients with mitral stenosis in sinus rhythm were reviewed (axis of QRS and T in the frontal and horizontal planes, with each one of their modules, Lewis index and right Sokolow-Lyon, quotient R/R + S in V1, time of beginning of the intrinsecoide deflection of QRS), they were related with the hemodynamic data; and the existence of clear relations between both methods of exploration were confirmed. 1. The QRS axis in the frontal plane kept a good relation with the hemodynamic data (mainly thzontal axis there proved to be a closer relation than in this one. 2. The quotient R/R + S in V1 was the parameter that best correlated with the mean pressure of the pulmonary artery and with the pulmonar capillary pressure. 3. Although the right Sokolow-Lyon index is not a definite criterion for recognizing a right ventricular hypertrophy; it is very useful in correlating the total pulmonary resistances with the mean pulmonary arterial pressure, even if it did not reach pathologic values. The same can be said the Lewis index, although the dependence is less important. 4. The horizontalization of the frontal axis of T becomes more important with the increase in the hemodynamic repercution. 5. As an expression of the systemic hemodynamic alteration, the decrease in time of inscription of the intrinsecoid deflection, of the left ventricle in V6 became evident when the mitral area diminished or by increase of mean pressure of the pulmonary artery. 6. The electrocardiographic characteristics that allow to recognize the existence of a mitral area smaller than 0.8 cm2, with a possibility of error of less than 5% (false positives), are: -- a horizontal axis of QRS less or equal to + 9 degrees -- a right Sokolow-Lyon index of more than 21.56. 7. The existence of a mean pressure of more than 25 mm. Hg in the pulmonary artery can be acknowledged, with a possibility of false positives of less than 5%, by the apparition of one or more of the following data: -- a frontal axis of QRS more or equal to + 87 degrees -- a Lewis index of less than -7.44. 8. The diagnosis of mean pressures of the pulmonary artery of more than 35 mm. Hg can be established, with the same degree of possibility, by: -- a T frontal axis of less or equal to + 10 degrees -- a horizontal axis of QRS of less or equal to + 13 degrees -- a right Sokolow-Lyon index of more than 19.71 -- a quotient R/R + S in V1 more or equal to 0.88. 9. The only finding that permits to establish of a pulmonary capillary pressure higher of 25 mm. Hg, with false positives possibility of less of 5% is: -- quotient R/R + S in higher or equal to 0.07 in V1.