Una extraña etiología para el QT largo / An unusual etiology for long QT

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Aneurisma gigante de fístula coronariopulmonar / No disponible

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[Randomized controlled clinical trial of a home care unit intervention to reduce readmission and death rates in patients discharged from hospital following admission for heart failure]. / Ensayo clínico aleatorizado y controlado para valorar una intervención por una unidad de hospitalización domiciliaria en la reducción de reingresos y muerte en pacientes dados de alta del hospital tras un ingreso por insuficiencia cardiaca.

INTRODUCTION AND OBJECTIVES: To determine the effectiveness of a primarily educational intervention in heart failure (HF) patients implemented in a home care unit. METHODS: This randomized controlled clinical trial involved 279 HF patients who were discharged from a tertiary-care hospital between February 2001 and June 2002. Patients with dementia, terminal non-cardiac disease, or chronic obstructive pulmonary disease were excluded. Data collected included the cause of cardiac decompensation. A primarily educational intervention was implemented in the patient's home for up to 15 days after hospital discharge. Treatment was adjusted during the first week if necessary. The primary outcome measure was the 1-year cumulative incidence of readmission or death. Secondary measures were the incidence of readmission, mortality, and emergency department admission. Telephone interviews were carried out 3, 6 and 12 months after discharge, and clinical records were updated when necessary. Emergency department admission in the first 6 months was monitored. RESULTS: At 1-year follow-up, 62 of the 137 patients (45.3%) in the intervention group had been readmitted or died, compared with 75 of the 142 (52.8%) in the control group, (relative risk=0.86, P=.232). Among patients who suffered decompensation because failure to adhere to treatment, 16 of the 45 (35.6%) in the intervention group were readmitted or died, compared with 34 of the 56 (60.7%) control group patients (relative risk=0.59, P=.016). CONCLUSIONS: This intervention is feasible but, when applied indiscriminately to every discharged heart failure patient, the best that can be expected is only a modest reduction in readmission and death rates, which, in this study in particular, did not achieve statistical significance.

Ensayo clínico aleatorizado y controlado para valorar una intervención por una unidad de hospitalización domiciliaria en la reducción de reingresos y muerte en pacientes dados de alta del hospital tras un ingreso por insuficiencia cardiaca / Randomized controlled clinical trial of a home care unit intervention to reduce readmission and death rates in patients discharged from hospital following admission for heart Failure

Introducción y objetivos. Evaluar la eficacia de una intervención de educación en pacientes con insuficiencia cardiaca (IC) realizada por hospitalización a domicilio. Métodos. Ensayo clínico aleatorizado y controlado. Se incluyó a 279 pacientes con diagnóstico clínico de IC dados de alta de un hospital terciario entre febrero de 2001 y junio de 2002. Se excluyó a los pacientes con demencias, enfermedad terminal no cardiológica o enfermedad pulmonar obstructiva crónica. La información recogida incluyó las causas de la descompensación. La intervención fue fundamentalmente de tipo educativo, en el domicilio del participante, y se extendió hasta 15 días después del alta. Se realizaron ajustes de tratamiento durante la primera semana cuando fue necesario. El objetivo principal fue determinar la incidencia acumulada de reingreso o muerte. Los objetivos secundarios fueron la incidencia de reingreso y la mortalidad, así como la utilización de los servicios de urgencia. Se llevó a cabo un seguimiento telefónico a los 3, 6 y 12 meses, y una revisión de las historias clínicas si era necesario. Asimismo, se valoró la utilización de servicios de urgencias los primeros 6 meses. Resultados. Al año, 62 pacientes de 137 (45,3%) ingresaron o murieron en el grupo de intervención, en comparación con 75 de 142 (52,8%) en el grupo control (p = 0,232; riesgo relativo [RR] = 0,86). En los pacientes que se descompensaron por incumplimiento terapéutico, 16 de 45 (35,6%) ingresaron o murieron en el grupo de intervención, en comparación con 34 de 56 (60,7%) en el grupo control (p = 0,016; RR = 0,59). Conclusiones. Esta intervención es factible pero, administrada de manera indiscriminada a todo paciente dado de alta por IC, en el mejor de los casos sólo podemos esperar un beneficio modesto, que en este estudio en particular no llegó a alcanzar significación estadística (AU)

Introduction and objectives. To determine the effectiveness of a primarily educational intervention in heart failure (HF) patients implemented in a home care unit. Methods. This randomized controlled clinical trial involved 279 HF patients who were discharged from a tertiary-care hospital between February 2001 and June 2002. Patients with dementia, terminal non-cardiac disease, or chronic obstructive pulmonary disease were excluded. Data collected included the cause of cardiac decompensation. A primarily educational intervention was implemented in the patient's home for up to 15 days after hospital discharge. Treatment was adjusted during the first week if necessary. The primary outcome measure was the 1-year cumulative incidence of readmission or death. Secondary measures were the incidence of readmission, mortality, and emergency department admission. Telephone interviews were carried out 3, 6 and 12 months after discharge, and clinical records were updated when necessary. Emergency department admission in the first 6 months was monitored. Results. At 1-year follow-up, 62 of the 137 patients (45.3%) in the intervention group had been readmitted or died, compared with 75 of the 142 (52.8%) in the control group, (relative risk=0.86, P=.232). Among patients who suffered decompensation because failure to adhere to treatment, 16 of the 45 (35.6%) in the intervention group were readmitted or died, compared with 34 of the 56 (60.7%) control group patients (relative risk=0.59, P=.016). Conclusions. This intervention is feasible but, when applied indiscriminately to every discharged heart failure patient, the best that can be expected is only a modest reduction in readmission and death rates, which, in this study in particular, did not achieve statistical significance (AU)

[Exercise echocardiography to differentiate dilated cardiomyopathy from ischemic left ventricular dysfunction]. / Ecocardiografía de ejercicio para diferenciar la miocardiopatía dilatada de la disfunción ventricualr por cardiopatía isquémica.

OBJECTIVES: Previous studies have shown the usefulness of dobutamine echocardiography to differentiate dilated cardiomyopathy (DC) from ischemic left ventricular dysfunction (ILVD), but no studies have been made using exercise echocardiography (EE). We hypothesized that most patients with DC have some contractile reserve and experience an increase in left ventricular ejection fraction (LVEF) during exercise, as opposed to patients with ILVD. Differences in response to EE may be useful to clinically differentiate between these two entities. PATIENTS AND METHOD: Between 1 March 1995 and 1 March 2001, we performed 4,133 EE studies on 3,830 patients. Of 289 patients (8%) with moderate or severe LV dysfunction (biplane LVEF < 41% and left ventricular end-diastolic diameter > 5.2 cm), 207 were excluded: 111 for a history of myocardial infarction; 28 for scarring on echocardiography (regional akinesia/dyskinesia with thinning and/or increased brightness); 13 for previous revascularization procedures; 9 for aortic valve disease; 11 for a known cause of cardiomyopathy; and 35 for not undergoing angiography. The study group was therefore composed of 82 patients who were encouraged to perform maximal treadmill EE. EE criteria for ILVD were either impaired regional wall motion (RWM) or a decrease/no change in LVEF from baseline to peak exercise, while criteria for DC were RWM improvement/no change and LVEF increase. The ILVD group was formed by 39 patients with stenosis >/= 70% diameter stenosis of a major epicardial coronary artery or major branch vessel. The remaining 43 patients constituted the DC group. RESULTS: The number of coronary risk factors (ILVD 2.0 1.1; DC 1.9 1.1), baseline LVEF (ILVD 30 7; DC 30 8), and exercise-induced angina (ILVD 23%; DC 14%) did not differ between groups (p = NS). ILVD patients achieved less Mets (6.6 3.1 vs 8.3 2.8; p < 0.05), had a lower heart rate x systolic blood pressure product (22 5 vs 27 7; p < 0.001), and developed regional and/or global LV dysfunction more frequently (79 vs 28%; p < 0.001). Sensitivity, specificity, positive and negative predictive values and global accuracy for ILVD detection were 79% (95% CI: 70-88), 72% (95% CI: 63-81), 72% (95% CI: 63-81), 79% (95% CI: 67-85), and 76% (95% CI: 69-83), respectively. CONCLUSION: Global and/or regional LV function impairment with exercise is accurate in identifying patients with ILVD. This method could reduce the need for invasive procedures.