Blood Pressure, Congestion and Heart Failure with Preserved Ejection Fraction Among Patients with and Without Type 2 Diabetes Mellitus. A Cluster Analysis Approach from the Observational Registry DICUMAP.

INTRODUCTION: The association of patients with heart failure (HF) and preserved ejection fraction (HFpEF) and with type 2 diabetes mellitus (T2DM) is strong and related additionally to blood pressure (BP). AIMS: To analyze distinctive clinical profiles among patients with HFpEF both with and without T2DM. METHODS: The study was based on a Spanish National Registry (multicenter and prospective) of patients with HF (DICUMAP), that enrolled outpatients with HF who underwent an ambulatory BP monitoring (ABPM) and then were followed-up for 1 year. We categorized patients according to the presence/absence of T2DM then building different clusters based on K-medoids algorithm. RESULTS: 103 patients were included. T2DM was present in 44.7%. The patients with T2DM were grouped into two clusters and those without T2DM into three. All patients with T2DM had kidney disease and anemia. Among them, cluster 2 had higher systolic blood pressure and pulse pressure (PP) with a bad outcome (p = 0.03) regarding HF mortality and readmissions, influenced by eGFR (HR 0.93, 95% CI 0.97-0.87, p = 0.04), and hemoglobin (HR 0.65, 95% CI 0.71-0.63, p = 0.03). Among those without T2DM, cluster 3 had a pathological ABPM pattern with the highest PP, cluster 4 was slightly similar to cluster 2, and cluster 5 expressed a more benign pattern without differences on both, HF mortality and readmissions. CONCLUSIONS: Patients with HFpEF and T2DM expressed two different profiles depending on neurohormonal activation and arterial stiffness with prognostic implications. Patients without T2DM showed three profiles depending on ABPM pattern, kidney disease and PP without prognostic repercussion.

Síndrome de apneas-hipopneas del sueño, hipertensión y riesgo cardiovascular / Sleep apnea/hypopnea Syndrome, hypertension and cardiovascular risk

El síndrome de apneas-hipopneas del sueño (SAHS) es un trastorno que se caracteriza porepisodios recurrentes de limitación del flujo aéreo en la vía aérea superior que condicionandesaturaciones de oxígeno, microdespertares y desestructuración del sueño, conrepercusiones en la calidad de vida y en el riesgo cardiovascular. Esta enfermedad estácobrando especial interés por ser causa demostrada de hipertensión arterial independientementede la concurrencia de otros factores de riesgo. El SAHS produce, además,alteraciones en el patrón circadiano de la presión arterial, y los pacientes tienen tendenciaa un patrón non-dipper, más desfavorable. En la presente revisión, se abordan losmecanismos fisiopatológicos implicados en la relación SAHS-hipertensión arterial sistémica.También se abordan otros procesos paralelos por los cuales el SAHS produce lesiónvascular, como el aumento del estrés oxidativo, sus repercusiones desfavorables en elperfil lipídico y la adhesión plaquetaria. Todo ello contribuye a la aparición de lesionesateromatosas en los pacientes con SAHS y sus repercusiones en eventos. Asimismo, seabordan las evidencias que aportan los estudios clínicos que han relacionado el SAHScon un mayor riesgo de hipertrofia venticular izquierda, insuficiencia cardíaca sistólica ydiastólica, cardiopatía isquémica, arritmias y enfermedad cerebrovascular, así como unaumento de la morbimortalidad cardiovascular.El tratamiento recomendado es la aplicación de presión positiva continua en la vía aérea(CPAP). La CPAP se ha demostrado eficaz en reducir la presión arterial de los pacienteshipertensos con SAHS, un efecto que, aunque aparentemente moderado, es tanto másevidente cuanto más severo es el síndrome o mayor es el grado de hipertensión arterial.Paralelamente, estudios observacionales demuestran que la CPAP disminuye la morbimortalidadcardiovascular asociada al síndrome(AU)

Obstructive sleep apnea/hypopnea (OSAH) syndrome is a condition characterized byrecurrent episodes of restricted airflow through the upper airway that causes oxygendesaturation, microarousals and destructed sleep with negative repercussions for qualityof life and cardiovascular risk. This condition has been attracting special interest as it hasbeen shown to be a cause of arterial hypertension as well as its concurrence with otherrisk factors. OSAH also produces other modifications in the circadian rhythm of arterialpressure, resulting in a tendency for patients to exhibit a less favorable nondipperpattern. In the present review, we examine the pathophysiological mechanisms involvedin the relationship between OSAH and systemic arterial hypertension. We also considerother parallel processes through which OSAH may produce vascular lesions, including anincrease in oxidative stress, and its negative impact on both the lipid profile and plaqueadhesion. All of this contributes to the appearance of atheromatosis lesions in patientswith OSAH and their repercussions in terms of related events. Furthermore, the articleexamines evidence provided by clinical trials that associates OSAH with a higher risk ofleft ventricular hypertrophy, systolic and diastolic cardiac failure, ischemic heart disease,cardiac arrhythmias, cerebrovascular disease, and a greater incidence of cardiovascularmorbidity-mortality.The usual treatment recommended for this syndrome is continuous positive airwaypressure (CPAP). CPAP has been shown to be effective in reducing arterial pressure inhypertensive patients with OSAH. Although this effect is apparently moderate, its resultsare clearly as the cases become more severe or when the level of arterial hypertensionis greater. CPAP has also been shown in observational studies to be effective in reducingcardiovascular morbidity-mortality associated with the syndrome(AU)

Mujer de 67 años con artritis y ausencia de pulsos / A 67-year old woman with arthritis and absence of pulse

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RS3PE asociado a tuberculosis / RS3PE associated with tuberculosis

El síndrome de sinovitis simétrica seronegativa remitente del anciano con edema y fóvea (remitting seronegative symmetrical synovitis with pitting edema) (RS3PE), se caracteriza por la aparición de una poliartritis simétrica bilateral seronegativa asociada a edema con fóvea en el dorso de las manos, y factor reumatoide negativo. Su asociación a tuberculosis no se había descrito previamente. Se presenta el caso de un paciente de 89 años que consultó por anorexia de mes y medio de evolución acompañada de edema en manos y pies, con factor reumatoide negativo. Presentaba un infiltrado pulmonar, cuyo estudio microbiológico reveló la infección por Mycobacterium tuberculosis

The remitting seronegative symmetrical synovitis with pitting edema of the elderly patient with edema and fovea (RS3PE), characterizes for the appearance of one polyarthritis symmetrical with fovea in the back of the hands, and negative reumatoideal factor. The association to tuberculosis had not been described before. One presents the case of a 89-yearold patient who consulted for anorexia of month and a half of evolution accompanied of edema in hands and feet, with negative reumatoideal factor. He was presenting a pulmonary infiltrated, which microbiological study revealed the infection for Mycobacterium tuberculosis

Síndrome de apneas del sueño y riesgo cardiovascular / Sleep apnea syndrome and cardiovascular risk

El síndrome de apneas-hipopneas del sueño (SAHS) se caracteriza por la presencia de episodios repetidos de interrupción parcial o completa del flujo aéreo durante el sueño. En la actualidad constituye un problema de salud pública, debido fundamentalmentea su elevada prevalencia y morbi-mortalidad asociada.Cada evento respiratorio tiene como consecuencia la producción de un descenso en la saturación de oxihemoglobina (SaO2) y/o un arousal (despertar electroencefalográfico), así como un aumento de la presión negativa intratorácica que da lugar a la producción de cambios a nivel tanto autonómico como hemodinámico.Estos episodios repetidos de forma reiterada a lo largo de la noche se han asociado con la presencia de alteraciones en la coagulación, inflamación, síndrome metabólico, disfunción endotelial, estrés oxidativo y cambios en la actividad simpática.El conjunto de estas alteraciones se han relacionado directamente con un mayor riesgo de hipertensión arterial (HTA), accidentescerebrovasculares agudos (ACVA), cardiopatía isquémica (CI), aterosclerosis, hipertensión pulmonar (HTP) e insuficiencia cardíaca (IC). Por este motivo el SAHS se considera un potencial factor de riesgo cardiovascular.En la actualidad, el tratamiento de elección del SAHS es la CPAP (Continuous Positive Airway Pressure), que mejora tanto los síntomas relacionados con el SAHS como la calidad de vida de estos pacientes.Sin embargo, aún no está claro el papel de la CPAP en pacientes con SAHS y factores de riesgo cardiovascular (FRCV) con el fin de prevenir o tratar la aparición de nuevos eventos cardiovasculares.Son necesarios estudios a gran escala que definan elimpacto real del SAHS sobre el sistema cardiovascular y la eficacia de la CPAP como tratamiento del mismo con el fin de disminuir el riesgo cardiovascular

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[RS3PE associated with tuberculosis]. / RS3PE asociado a tuberculosis.

The remitting seronegative symmetrical synovitis with pitting edema of the elderly patient with edema and fovea (RS3PE), characterizes for the appearance of one polyarthritis symmetrical with fovea in the back of the hands, and negative reumatoideal factor. The association to tuberculosis had not been described before. One presents the case of a 89-year-old patient who consulted for anorexia of month and a half of evolution accompanied of edema in hands and feet, with negative reumatoideal factor. He was presenting a pulmonary infiltrated, which microbiological study revealed the infection for Mycobacterium tuberculosis.

[Atypical presentation of a clinical case of giant cell arteritis]. / Presentación atípica de un caso de arteritis de células gigantes.

We present a very unusual clinical case of giant cell arteritis with uterus involvement, in a women of 66 years old, that began clinical features of pain and functional limitation of shoulders and hip 3 mouth before been operated of uterus prolapse with hysterectomy. Biopsy of uterus found affected arterial vesels with wall sclerosis and granulomatous inflamation with giant cells, without necrosis, involving media and perivascular portions suggesting giant cell arteritis. In a previous reports review, we only found ten similar clinical cases. In that cases, clinical features were no suggestif of the disease. Although the well known tendency of arteritis to involve some specific vascular areas, the case we present is an example of the systemic course of the disease and his difficulty to diagnose.

[Pericarditis and giant cell arteritis]. / Pericarditis y arteritis de células gigantes.

Pericarditis is an unusual manifestation of gigantic cell arteritis. The following essay describes the case of a female patient who had been diagnosed, three years earlier, with several types of rheumatic myalgia, and because of this, she had had periodical tests in which no complications at all had been observed. At the age of 69, this female patient consulted the doctor for mild fever, dry cough, anorexia and diffuse abdominal pain. The echocardiography showed pericardium discharge and complementary explorations ruled out infectious or neoplasia processes. A corticoid treatment was started and the symptomatology improved in a few days, the pericardium discharge being solved in 3 months.

Pericarditis y arteritis de células gigantes / Pericarditis and giant cell arteritis

La pericarditis es una manifestación inusual de la arteritis de células gigantes. En este trabajo se describe el caso de una paciente diagnosticada 3 años antes de polimialgia reumática por la que había seguido controles periódicos en los que no que no se había observado ninguna complicación. A la edad de 69 años consultó por febrícula, tos seca, anorexia y dolor abdominal difuso y la ecocardiografía mostró un derrame pericárdico. Las exploraciones complementarias descartaron procesos infecciosos o neoplásicos. Se inició tratamiento corticoideo mejorando la sintomatología en pocos días, resolviéndose el derrame pericárdico en 3 meses

Pericarditis is an unusual manifestation of gigantic cell arteritis. The following essay describes the case of a female patient who had been diagnosed, three years earlier, with several types of rheumatic myalgia, and because of this, she had had periodical tests in which no complications at all had been observed. At the age of 69, this female patient consulted the doctor for mild fever, dry cough, anorexia and diffuse abdominal pain. The echocardiography showed pericardium discharge and complementary explorations ruled out infectious or neoplasia processes. A corticoid treatment was started and the symptomatology improved in a few days, the pericardium discharge being solved in 3 months

Presentación atípica de un caso de arteritis de células gigantes / Atypical presentation of a clinical case of a giant cell arteritis

Presentamos un caso muy poco frecuente de arteritis de células gigantes con afectación uterina, en una mujer de 66 años de edad, que inició clínica de dolor y limitación funcional en cintura escapular y pelviana 3 meses antes de ser operada de histerectomía por prolapso uterino. En la biopsia de cuerpo uterino se detecta vasos arteriales con esclerosis de pared e inflamación granulomatosa con células gigantes, sin necrosis, afectando capas media y perivascular, compatible con arteritis de células gigantes. En la revisión de la literatura tan solo hemos encontrado la publicación de una decena de casos similares. En ellos la clínica tampoco hacía sospechar la presencia de la enfermedad. A pesar del tropismo bien conocido de la arteritis de células gigantes por ciertos territorios vasculares, el caso que presentamos muestra el carácter sistémico de la enfermedad y la dificultad diagnóstica

We present a very unusual clinical case of giant cell arteritis with uterus involvement, in a women of 66 years old, that began clinical features of pain and functional limitation of shoulders and hip 3 mouth before been operated of uterus prolapse with hysterectomy. Biopsy of uterus found affected arterial vesels with wall sclerosis and granulomatous inflamation with giant cells, without necrosis, involving media and perivascular portions suggesting giant cell arteritis. In a previous reports review, we only found ten similar clinical cases. In that cases, clinical features were no suggestif of the disease. Althougt the well known tendency of arteritis to involve some specific vascular areas, the case we present is an example of the systemic course of the disease and his dificulty to diagnose

Nódulos pulmonares atípicos en paciente con artritis Reumatoide / Atypical pulmonary nodules in a patient with rheumatoid arthritis

La artritis reumatoide (AR) está asociada a una amplia variedad de manifestaciones pulmonares, entre las que se incluye la presencia de nódulos reumatoides. Aportamos el caso de una paciente diagnosticada de AR y que por cuadro de tos y disnea a esfuerzos se le realizó una tomografía computarizada (TC) torácica que informó de la presencia de pequeños nódulos pulmonares. Una vez biopsiados fueron diagnosticados como granulomas de colesterol(AU)

Rheumatoid arthritis (RA) is associated with a wide variety of lung manifestations, including rheumatoid nodules. We report the case of woman with a diagnosis of RA who underwent thoracic computed axial tomography (CAT) scan because of cough and effort dyspnea. The CAT scan revealed the presence of small lung nodules. After biopsy, these nodules were diagnosed as cholesterol Granulomas(AU)

[Atypical pulmonary nodules in a patient with rheumatoid arthritis]. / Nódulos pulmonares atípicos en paciente con artritis reumatoide.

Rheumatoid arthritis (RA) is associated with a wide variety of lung manifestations, including rheumatoid nodules. We report the case of woman with a diagnosis of RA who underwent thoracic computed axial tomography (CAT) scan because of cough and effort dyspnea. The CAT scan revealed the presence of small lung nodules. After biopsy, these nodules were diagnosed as cholesterol granulomas.

Paciente diabética con hipertensión acelerada que ingresa con clínica de insuficiencia cardíaca / Diabetic patient with accelerated hypertension admitted to hospital with clinical signs of heart failure

Presentamos el caso de una paciente de 48 años diabética que ingresó en nuestro centro con clínica de fallo biventricular e hipertensión acelerada. Un análisis superficial del cuadro orientaba a esta hipótesis, ya que la paciente presentaba retinopatía hipertensiva de grado III, derrame pleural bilateral, severa disfunción diastólica comprobada por ecocardiografía y proteinuria atribuible a nefropatía hipertensiva o diabética. La evidencia de la existencia de elementos inexplicados (derrame pleural exudativo, anemia inflamatoria, velocidad de sedimentación glomerular y PCR elevadas) nos llevan a sospechar un proceso de mayor complejidad inflamatorio-sistémico subyacente que finalmente se confirma con unos anticuerpos antinucleares positivos titulo 1/1.280 patrón homogéneo y la realización de biopsia renal que muestra nefropatía lúpica de grado IV. Todo ello nos lleva a cambiar todo el enfoque diagnóstico (AU)

[Ciliary changes with abscence of dynein arms in Kartagener's syndrome]. / Alteración ciliar con ausencia de los brazos de dineina en el síndrome de Kartagener.

A 33 years-old female with a diagnosis of Kartagener's syndrome was studied. She had a clinical history of chronic sinusitis with nasal obstruction and rhinorrea, and a chronic cough with mucopurulent sputum. A paranasal sinus CT showed hypertrophyc mucosa. A thoracic CT showed a situs inversus and chronic bronchitis with bronchiectasis. The saccharin test lasted 55 minutes. The electron microscopy study showed in a a cross-sectional axoneme a total absence of the outer and inner arm of the 9th outer doublet in over a 100 cilias studied. No others ultrastructure anormalities were observed.

Alteración ciliar con ausencia de los brazos de dineina en el síndrome de Kartagener / Ciliary changes with abscence of dynein arms in Kartagener's syndrome

Presentamos el caso de una mujer de 33 años diagnosticada de síndrome de Kartagener. La paciente refiere una historia de rinorrea y obstrucción nasal de larga evolución sugestiva de sinusitis crónica y de tos acompañada de expectoración mucopurulenta. En TC de senos paranasales se aprecia una mucosa sinusal hipertrófica. En TC de tórax de observa un situs inversus y bronquiectasias. El tiempo del test de la sacarina fue de 55 minutos. El estudio ciliar con microscopío electrónico mostró una ausencia completa de los dos brazos del doblete número nueve en más de 100 cilios estudiados. No se observaron otras alteraciones ultraestructurales (AU)

A 33 years-old female with a diagnosis of Kartagener's syndrome was studied. She had a clinical history of chronic sinusitis with nasal obstruction and rhinorrea, and a chronic cough with mucopurulent sputum. A paranasal sinus CT showed hypertrophyc mucosa. A thoracic CT showed a situs inversus and chronic bronchitis with bronchiectasis. The saccharin test lasted 55 minutes. The electron microscopy study showed in a a cross-sectional axoneme a total absence of the outer and inner arm of the 9th outer doublet in over a 100 cilias studied. No others ultrastructure anormalities were observed (AU)

[Psoas abscess caused by Salmonella enteritidis: presentation of a case]. / Absceso de psoas por Salmonella enteritidis: presentación de un caso.

The psoas abscess is an entity of infrequent occurrence in daily clinical practice. Many pathogens have been related with the genesis of this focal infections, but it can be said nowadays that the Staphylococcus aureus is more often involved in them. We present the case of a male aged 26, with a culture of purulent drained material, where Salmonella enteritidis, a microorganism of exceptional presentation in this pathology, was isolde. Moreover, some hypothesis have been proposed about the possible physiopathology and the current state of the diagnostic and therapeutic techniques in these processes is revised.