Varón joven con manchas "café con leche", valvulopatía y crisis hipertensiva / Young male with "coffee and milk" spots, valvulopathy and hypertensive crises

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[Utility of verapamil in the treatment of diastolic dysfunction in patients with acromegaly]. / Utilidad del verapamil en el tratamiento de la disfunción diastólica de pacientes acromegálicos.

INTRODUCTION: Diastolic dysfunction is a common complication in patients with acromegaly. By using the metabolic treatment for acromegaly, an improvement in diastolic function is not always achieved and a group of these patients could obtain some benefit from a specific treatment for such a condition. The objective of the present study was to evaluate the utility of verapamil therapy in acromegalic patients with diastolic dysfunction. METHODS: Fourteen patients (7 males and 7 females) with the diagnosis of acromegaly and diastolic dysfunction confirmed by echocardiogram were studied. After six months of treatment with verapamil (240 mg/day) the echo-cardiographic parameters and the functional class (NYHA) of patients were reevaluated. RESULTS: All patients showed an increased basal measurement of the cardiac mass (mean [percentiles 25-75]: 149 g/m2 [128-264]) and no improvement was observed after treatment (182 g/m2 [123-328]). Also, no improvement was found regarding the studied diastolic function parameters: E/A relationship of left ventricle (0.70 [0.54-0.83] versus 0.61 [0.54-0.86]) and isovolumetric relaxation time (146 [119-193] versus 120 [97-169]). A trend towards improvement was indeed found in the functional class, although no statistical differences were observed. CONCLUSION: Our results did not demonstrate a benefit derived from the treatment with verapamil upon the diastolic function in patients with acromegaly.

Utilidad delverapamil en el tratamiento de la disfunción diastólica de pacientes acromegálicos / Utility of verapamil in the treatment of diastolic dysfunction in patients with acromegaly

Introducción. La disfunción diastólica es una complicación frecuente en los pacientes acromegálicos. Mediante el tratamiento metabólico de la acromegalia no siempre se consigue una mejoría de la función diastólica y un grupo de estos pacientes se podría beneficiar de un tratamiento específico para dicha alteración. El objetivo del presente trabajo ha sido evaluar la utilidad del tratamiento con verapamil en pacientes acromegálicos con disfunción diastólica. Métodos. Se estudiaron 14 pacientes (7 hombres) diagnosticados de acromegalia y con disfunción diastólica confirmada mediante ecocardiografía. Tras 6 meses de tratamiento con verapamil (240 mg/día) se reevaluaron los parámetros ecocardiográficos y la clase funcional (NYHA) de los pacientes. Resultados. Todos los pacientes presentaban de forma basal un incremento de la masa cardíaca (media [percentiles 25-75]: 149 g/m2 [128-264]) sin que presentaran mejoría tras el tratamiento (182 g/m2 [123-328]). Tampoco se encontró mejoría en los parámetros de disfunción diastólica estudiados: relación E/A del ventrículo izquierdo (0,70 [0,54-0,83] frente a 0,61 [0,54-0,86]) y tiempo de relajación isovolumétrica (146 [119-193] frente a 120 [97-169]). Sí que se encontró una tendencia a la mejoría en la clase funcional, aunque sin diferencias estadísticas. Conclusión. Nuestros resultados no muestran un beneficio del tratamiento con verapamil sobre la función diastólica en los pacientes acromegálicos (AU)

[Thrombogenic and endothelial damage markers in patients with ischemic systolic impairment]. / Marcadores de hipercoagulabilidad y daño endotelial en pacientes con disfunción sistólica de origen isquémico.

INTRODUCTION: Anticoagulation is rarely indicated in patients with left ventricular dysfunction who show an increased risk for thromboembolism. In theory, the three arms of the Virchow' triad may be present: abnormal blood flow, endothelial damage and prothrombotic markers. The aim of this study was to identify the last two arms. PATIENTS AND METHOD: We studied 82 consecutive patients with demonstrated ischaemic heart disease and sinus rhythm, and compared them with a control group comprised of 32 healthy subjects matched for age and sex. None or the patients had had an acute coronary event or hemodynamic decompensation within the 3 months prior to inclusion in the study. The plasma concentration or von Willebrand factor and fibrin d-dimer and fibrinogen were determined as endothelial damage and prothrombotic markers, respectively. A fractional shortening less than 29% by echography was defined as ventricular systolic dysfunction. RESULTS: The patients showed significantly higher levels of von Willebrand factor with respect to the control group (109.2 31.9 vs 85.5 32.6%, p < 0.01), with no differences in fibrinogen and fibrin d-dimer values. Twenty-six patients fulfilled criteria of left ventricular systolic dysfunction. Patients with left ventricular dysfunction showed higher fibrinogen (386 118 vs 322 102 mg/dl, p = 0.03) and fibrin d-dimer (0.36 0.22 vs 0.26 0.10 g/ml; p = 0.04) levels, with no differences in von Willebrand factor levels. CONCLUSIONS: After acute coronary events, patients with ischaemic heart disease show markers of endothelial damage. However, patients with left ventricular dysfunction show a hypercoagulable state.

[The Influence of the growth hormone in the profile of blood pressure. Results in adult patients with deficiency in this hormone]. / Influencia de la hormona de crecimiento en el perfil de la presión arterial. Resultados en pacientes adultos con déficit de dicha hormona.

INTRODUCTION AND OBJECTIVES: There is an increasing interest in the relationship between the growth hormone (GH) and the heart since the GH has an important inotropic effect and its use has been tested in patients with severe systolic dysfunction. However, cardiovascular diseases are the main cause of increased morbimortality observed in patients with acromegaly. Growth hormone deficiency has been related to different clinical findings depending on the age of onset. Recent studies have demonstrated that GH deficiency in adults is associated with alterations in blood pressure. The aim of our study was to assess the influence of GH in blood pressure. PATIENTS AND METHODS: We studied 14 adult patients with GH deficiency and 15 healthy subjects, matched for sex and age. The diagnosis of GH deficiency was based on GH response to intravenous insulin tolerance test < 5 ng/ml and IGF-1 levels lower than the normal limit for each age group. In all the patients 24-hour Holter blood pressure monitorization was performed in addition to a treadmill test and echographic evaluation. RESULTS: All patients showed normal systolic and diastolic function in the echocardiographic study. Only one patient had an increased left ventricular mass. Blood pressure was lower in the patients than in the control subjects (p < 0.05). Moreover, the difference remained significant when analysis was based on the time of day. However, the patients showed normal blood pressure response to the effort test with a mean increase of 60%. The length of the exercise on the treadmill test was shorter in the subgroup of GH deficient patients. CONCLUSIONS: Lower systolic blood pressure was observed in GH deficiency patients. The patients studied did not show structural heart alterations. Blood pressure and chronotrophic response to the effort test were similar in both groups.

Hipercoagulabilidad y cardiopatía isquémica: potencial interacción entre los anticuerpos antifosfolípidos y elementos celulares implicados en la hemostasia / Hipercoagulability and ischemic cardiopathy: potential interaction between antiphospholipid antibodies and cellular elements related with haemosthasis

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[Natural-valve endocarditis in patients wearing pacemakers]. / Endocarditis sobre válvula natural en pacientes portadores de marcapasos.

The presence of infective endocarditis with appearance of vegetations over the tricuspid valve in patients with permanent pacemaker is an uncommon complication. We report here three patients with permanent cardiac pacemakers who developed a picture of infective endocarditis over the electrode with appearance of vegetations over the native valve. The microorganism recovered from blood cultures in the three patients was Staphylococcus. The presence of retained pacemaker leads and repetitive surgical procedures over the pacemaker pouch are two risk factors reported in literature also present in our patients. Infective endocarditis is an uncommon difficult-to-diagnose complication, with a poor prognosis and which requires the removal of the whole infected material, with implantation of an epidermal pacemaker. Some diagnostic and therapeutic issues are discussed.

[Improvement in fibrinolytic function following anticoagulant treatment in chronic rheumatic atrial fibrillation]. / Mejoría de la función fibrinolítica tras el tratamiento anticoagulante en la fibrilación auricular reumática crónica.

INTRODUCTION AND OBJECTIVES: Patients with rheumatic atrial fibrillation are considered at high risk of systemic embolism and require oral anticoagulation. Fibrinolytic function has been little studied. We evaluated fibrinolytic activation markers before starting anticoagulation, at 1 and 6 months following the introduction of oral anticoagulation therapy. We analyzed the relationship with left atrial diameter and mitral area. METHODS: Tissue plasminogen activator (tPA), its inhibitor (PAI-1), plasmin-antiplasmin complexes (PAP) and D-dimer were measured in 13 patients with rheumatic atrial fibrillation. Basal levels were compared with those found in plasma of 20 healthy subjects matched by sex and age. Transthoracic echocardiography was made. RESULTS: A significant increase for PAI-1 and D-dimer levels were detected in patients with atrial fibrillation group (p < 0.05), with no differences in tPA and PAP concentrations. Significant correlation between left atrial diameter and basal t-PA levels was found. Levels of t-PA, PAI-1 and D-dimer decreased significantly under anticoagulation therapy, whereas PAP levels were significantly increased. CONCLUSIONS: Patients with rheumatic atrial fibrillation show a relative hypofibrinolytic state due to elevated PAI-1 levels with no increase in PAP concentration. At six months of anticoagulation therapy, an improvement of fibrinolytic function markers was observed. This is consistent with the prophylactic effect of oral anticoagulants therapy against thromboembolic risk.

[Safety of oral anticoagulation in aged patients with heart diseases]. / Seguridad en la anticoagulación oral en ancianos con cardiopatía.

BACKGROUND: Anticoagulation therapy in the elderly poses some doubts on the possible increase in hemorrhagic risk. The hemorrhagic complications in a population of patients over 70 years of age anticoagulated with acenocoumarol by heart disease were studied. MATERIALS AND METHODS: A study was made of seventy-two patients (43 females and 29 males; mean age: 73 years) anticoagulated for one year and controlled on an outpatient basis by means of INR (international normalized ratio) measurement with a maximal interval of four weeks. INR values above 4.5 or below 2.0 were considered out of range. RESULTS: Nineteen patients had an INR above the recommended value on one occasion and eleven patients on two or more occasions. Sixteen patients had hemorrhagic complications, five were admitted on account of hemorrhages although none of them required transfusional therapy. No cases of brain hemorrhage or peripheral embolism occurred. CONCLUSIONS: Most anticoagulated elderly patients were within their therapeutic range. The percentage of severe hemorrhagic complications was low. Advanced age had did not prove to be a factor against therapy with oral anticoagulants.

[Dual-chamber pacemakers in obstructive hypertrophic cardiomyopathy: gradient variation with stress echocardiography]. / Marcapasos bicameral en la miocardiopatía hipertrófica obstructiva: variación del gradiente con ecocardiografía de estrés.

INTRODUCTION: Permanent cardiac pacing with a dual chamber pacemaker has become a valid alternative in treatment of patients with obstructive hypertrophic cardiomyopathy and refractory symptoms to pharmacological treatment, with a significant decrease of left ventricular outflow tract gradient. AIM: To assess any modification of the gradient with dobutamine stress echocardiography. PATIENTS AND METHODS: We study 10 patients with obstructive hypertrophic cardiomyopathy and angina and/or dyspnea refractory to customary pharmacological treatment. A dual chamber pacemaker had been implanted 3-6 months previously. A dobutamine stress echocardiography was performed, beginning with a 10 microgram/kg/min infusion, with increases of 10 micrograms each 3 minutes until a maximum of 40. Modification of subaortic gradient, severity of systolic anterior motion of mitral valve (SAM, degree 0-3/3) and severity of mitral regurgitation (degree 0-4/4) were assessed. RESULTS: Subaortic gradient decreased in all patients after pacemaker implantation (90 +/- 15 vs 20 +/- 10 mmHg; p < 0.001). With stress echocardiography the gradient increased in all patients (20 +/- 10 to 101 +/- 13 mmHg; p < 0.001). After implant there were only two patients with a +1 SAM, while during stress echocardiography SAM developed in all patients in +2 or +3 degree. Three patients had +1 mitral regurgitation after pacemaker implantation but during stress echocardiography 2-4/4 mitral regurgitation developed in all patients. CONCLUSIONS: Permanent dual chamber pacing decreased left ventricular outflow tract gradient in patients with obstructive hypertrophic cardiomyopathy, but during dobutamine stress echocardiography obstruction echocardiographic signs appeared.