Long-term follow-up assessment after the arterial switch operation for correction of dextro-transposition of the great arteries by means of exercise myocardial perfusion-gated SPECT.

The arterial switch operation (ASO) is the preferred technique for correcting transposition of the great arteries, but translocation and reimplantation of the coronary arteries can produce myocardial ischemia. This report aims to describe the authors' experience with exercise single-photon emission computed tomography (SPECT) used to evaluate myocardial perfusion. Exercise-rest gated-myocardial perfusion SPECT was performed for 69 patients (49 boys; median age, 9 years; 5th percentile [6.4 years] to 95th percentile [15.6 years]), 64 of whom were asymptomatic 9.98 ± 3.20 years after ASO. During exercise testing, the patients reached 9.85 ± 3.05 metabolic equivalents (METs) and a median heart rate of 160 beats per minute (bpm), 5th percentile (106 bpm) to 95th percentile (196 bpm). Whereas 61 patients (88.41 %) had normal myocardial perfusion, 2 patients (2.9 %) had reversible defects, and 6 patients (8.7 %) had fixed defects. All the patients with perioperative ischemic complications (4/4, 100 %) had myocardial perfusion defects, whereas four patients (4/65, 6.15 %) without ischemic complications had abnormal perfusion (p = 0.0005). Age at the time of surgery did not differ significantly (p = 0.234) between the patients with perfusion defects and those with normal study results. No significant difference was observed between the patients who had an A coronary pattern (left coronary artery originating from the left sinus and the right coronary artery originating from the right sinus, n = 47) and those who had a non-A coronary pattern (n = 22) (p = 1). The high rate for normality of exercise myocardial perfusion in our study suggests that myocardial perfusion gated-SPECT should be reserved for patients who have experienced perioperative ischemic complications or those with symptoms, at least during the first 10 years after the surgery.

Prophylactic treatment after myocardial infarction in primary care: how far can we go?

BACKGROUND: Despite best practice, it may not be achievable in some patients to reach the optimal goals of secondary prevention recommendations for various reasons, such as co-morbidity, contraindications for some drugs or side effects. OBJECTIVE: Our aim was to estimate the achievable standards for audit purposes in primary care for prophylactic treatment of secondary prevention of myocardial infarction. METHODS: We conducted a survey of consecutive patients with a hospital diagnosis of first acute myocardial infarction during 1997 who were identified from discharge books from four hospitals and interviewed at their primary health centre 2 years after admission. The achievable standard for a prophylactic drug was then defined as the proportion of patients that could benefit from the treatment excluding those that for one justified reason or another were off medication. RESULTS: Three hundred and sixty-nine patients were interviewed in the follow-up. Aspirin or another antiplatelet regimen was prescribed in 86.9 patients, beta-blockers in 50.2%, angiotensin-converting enzyme (ACE) inhibitors in 32.5% and lipid-lowering drugs in 52%. The estimated achievable standards for those prescribed drugs were 94.5, 71,8, 50.5 and 69.8%, respectively. CONCLUSIONS: There is an underuse of prophylactic drug therapies after myocardial infarction. The standards established in this study for secondary preventive drug treatment might be achieved through a reasonable effort by GPs working in primary care committed to improving the quality of care.

[Baseline characteristics and determinants of outcome in a patient population admitted for heart failure to a general hospital]. / Características basales y determinantes de la evolución en pacientes ingresados por insuficiencia cardíaca en un hospital general.

INTRODUCTION AND OBJECTIVES: To assess baseline characteristics, management patterns, and clinical outcomes after 18 months in patients diagnosed as heart failure in a tertiary hospital in Catalonia, Spain. METHODS: The records of all 265 patients admitted to the Hospital General Vall d'Hebron from July through December 1998 with a diagnosis of heart failure who met study criteria were identified and analyzed. Patients were interviewed by telephone 18 months later. RESULTS: The mean age of the study population was 75 12 years, 42% were male, 19% were admitted for causes other than heart failure, and 62% had significant comorbidity. Ventricular function was assessed in 68% (preferentially patients with a better prognosis), and was considered normal in 41%. Angiotensin-converting enzyme inhibitors or angiotensin II antagonists were used in 54%, and beta-blockers in 4%. The 18-month mortality was 46% (77% cardiac mortality). Multivariate predictors of death were older age, severe or previous heart failure, and serious comorbidity. At 18 months, 69% of survivors were in functional classes I or II. CONCLUSIONS: 1) As in other geographic areas, patients in this study were an older population with poor survival; 2) local patterns of care definitely need improvement; 3) comorbidity is important for prognosis, and 4) a significant proportion of survivors enjoy an acceptable quality of life long after discharge.

Características basales y determinantes de la evolución en pacientes ingresados por insuficiencia cardíaca en un hospital general / Baseline characteristics and determinants of outcome in a patient population admitted for heart failure to a general hospital

Introducción y objetivos. Analizar las características basales, los patrones de manejo y los resultados clínicos a los 18 meses del ingreso en pacientes diagnosticados de insuficiencia cardíaca en un hospital terciario de Cataluña. Métodos. Se identificaron y analizaron las historias clínicas de los 256 pacientes ingresados en el Hospital General Vall d'Hebron desde julio a diciembre de 1998, diagnosticados de insuficiencia cardíaca y que cumplieran los criterios del estudio. Se entrevistó a los pacientes telefónicamente 18 meses después. Resultados. La edad media de los pacientes era de 75 ñ 12 años, el 42 por ciento correspondía a varones, el 19 por ciento había ingresado por enfermedades distintas de la insuficiencia cardíaca y el 62 por ciento tenía comorbilidad significativa. Se estudió la función ventricular en el 68 por ciento (básicamente en pacientes con mejor pronóstico), y se consideró normal en un 41 por ciento. Se administraron inhibidores de la enzima conversiva o antagonistas de la angiotensina II en un 54 por ciento y bloqueadores beta en un 4 por ciento. La mortalidad a los 18 meses fue del 46 por ciento, siendo de causa cardíaca en el 77 por ciento de éstos. Los predictores independientes de mortalidad fueron la edad avanzada, la insuficiencia cardíaca grave o antigua y la comorbilidad. A los 18 meses, un 69 por ciento de los supervivientes se hallaba en clase funcional I o II. Conclusiones. 1) Al igual que sucede en otras áreas geográficas, los pacientes de este estudio constituyen, como media, una población anciana y con pobre supervivencia; 2) los patrones de manejo registrados son claramente mejorables; 3) la comorbilidad afecta significativamente al pronóstico, y 4) la calidad de vida después del alta es aceptable en una llamativa proporción de supervivientes. (AU)