Clinical scores and patient risk stratification in non-ST elevation acute coronary syndrome.

BACKGROUND: Risk stratification of patients with unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI) is problematic given the heterogeneous presentation of the condition. This study was undertaken to compare, in UA/NSTEMI patients, the prognostic value of two clinical risk scores (RS) (i.e. Thrombolysis in Myocardial Infarction (TIMI) and physician's risk assessment (PRA)) and to assess whether serum biomarkers can increase the prognostic accuracy of these RS. METHODS: We prospectively assessed 610 consecutive UA/NSTEMI patients, 217 (36%) UA and 393 (64%) NSTEMI. In all patients RS, high sensitivity C-reactive protein, CD40 ligand, IL6, IL10, IL18, E-selectin, P-selectin, white blood cell count, neopterin, myeloperoxidase, fibrinogen and NT proBNP were assessed at study entry. The primary study endpoint was death and non-fatal MI at 30 and 360 days of follow-up. RESULTS: At 1 year, 54 patients (8.9%) had reached the primary study endpoint (26 suffered a cardiac death (4.3%) and 34 (5.6%) a non-fatal MI). For both RS, the study endpoint occurred more commonly in patients at a "higher risk" compared to those classified as being at a "lower risk". Moreover, TIMI and PRA RS had similar discriminatory accuracy. TIMI RS, however, was a better predictor of events than PRA at both 30- and 360-day follow-up. The inflammatory biomarkers assessed in the study did not improve significantly the predictive value of RS. CONCLUSIONS: Our study suggests both that TIMI RS is a better marker of risk than PRA RS and inflammatory biomarkers do not increase the predictive value of these clinical risk scores.

[Angiographic correlates of the high-risk criteria for conventional exercise testing and the Duke treadmill score]. / Correlación angiográfica de los criterios de alto riesgo para ergometría convencional y el índice de Duke.

OBJECTIVE: To compare the sensitivity, the specificity, the positive and negative predictive value and the predictive accuracy of the Duke Treadmill Score, the Spanish Society of Cardiology (SEC) and American College of Cardiology/American Heart Association (ACC/AHA) high-risk criteria for exercise testing in the detection of left main disease, three vessel disease and two vessel disease involving the proximal left anterior descending artery. PATIENTS AND METHOD: A cohort of 199 patients (age 75 years) consecutively admitted to hospital for unstable angina was studied. All patients underwent an exercise stress test and coronariography. RESULTS: The SEC high-risk Criteria showed a sensitivity of 69.2% and a specificity of 49.0%. The ACC/AHA high-risk Criteria demonstrated a sensitivity of 98.1% and a specificity of 23.8% and the Duke Treadmill Score presented a sensitivity of 30.8% and a specificity of 90.5%. In patients with moderate risk in the Duke Treadmill Score we found a sensitivity of 62.9% and a specificity of 39.8% for the SEC high-risk criteria, while the ACC/AHA high-risk Criteria presented a sensitivity of 100.0% and a specificity of 5.8%. CONCLUSIONS: The ACC/AHA high-risk Criteria showed a higher sensitivity while the Duke Treadmill Score presented a higher specificity for the detection of left main disease, three vessel disease and two vessel disease involving the proximal left anterior descending artery. The ACC/AHA and SEC high-risk Criteria were found to be very useful in the group of patients with moderate risk in the Duke Treadmill Score.

[Adult congenital anomalies of the coronary arteries described over 31 years of angiographic studies in the Asturias Principality: main angiographic and clinical characteristics]. / Anomalías congénitas de las arterias coronarias del adulto descritas en 31 años de estudios coronariográficos en el Principado de Asturias: principales características angiográficas y clínicas.

OBJECTIVE: The aim of this study was to determine the incidence of adult congenital anomalies of the coronary arteries over 31 years of angiographic studies, describing their angiographic and clinical characteristics. The results have been compared with the main series published. METHODS: The diagnostic angiographic reports done in the Principado de Asturias from 1968 to 1999 are reviewed. In those in which a congenital anomaly was diagnosed, the clinical report and the angiography were studied. The initial course of the anomaly was defined following angiographic criteria. RESULTS: Thirteen thousand five hundred reports were reviewed describing 75 patients with 75 anomalies (0.5%) including: anomalous origin of the left circumflex coronary artery (n = 24), coronary artery fistulae (n = 21), both coronary arteries arising from the left coronary sinus (n = 15), single coronary arteries (n = 6), both coronary arteries arising from the right coronary sinus (n = 2), separated origin of anterior descending and left circumflex coronary arteries (n = 3), anterior descending artery arising from the right coronary sinus (n = 2), and others (n = 1). Angiographic studies were done because of: angina (59%), dysnea (25%), atypical chest pain (7%), syncope (3%), dizziness (3%) and palpitations (3%). The initial course was retroaortic in all the circumflex arteries, interarterial in the right coronaries, anterior in the anterior descending arteries and retroaortic, septal and combined, in the left coronaries. CONCLUSIONS: Adult congenital anomalies of the coronary arteries are not very common and are usually casual findings of diagnostic angiographic studies. Left circumflex coronary artery anomalies are the most frequently diagnosed.

Etiología y factores de riesgo en una muestra de 200 pacientes consecutivos con insuficiencia cardiaca / Etiology and risk factors in a serie of 200 consecutive patients with heart failure

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[Complete transitory atrioventricular block in Lyme disease]. / Bloqueo auriculoventricular completo transitorio en la enfermedad de Lyme.

Cardiac manifestations in Lyme disease are uncommon and could generate myocarditis and/or pericarditis, but the most frequent and typical cardiac manifestation is in the form of conduction system disorders, causing blocks, which, according to their location and degree, could be intraventricular, intraatrial or atrioventricular of first, second or third degree. We report a case of transient atrioventricular block in a patient with frequent tick bites and with a positive serologic test for Borrelia burgdorferi.

[Atrioventricular block secondary to topical ophthalmic beta blockers]. / Estudio del bloqueo auriculoventricular secundario a betabloqueantes oculares tópicos.

It is known that ophthalmic beta-blockers can induce atrioventricular block. In our series of 243 patients with atrioventricular block, 12 were treated with topic ophthalmic timolol. None of them recognized the eye-drops as a treatment. In 7 cases the sinus rhythm was recovered and in 5 a pacemaker was implanted. There is a significant percentage of atrioventricular blocks produced by the ophthalmic beta-blockers that the patient does not recognize as treatment, and 60% of them are reversible. It is important to ask about the use of eye-drops in patients with bradycardia or atrioventricular block.

[The etiology and associated risk factors in a sample of 300 patients with atrial fibrillation]. / Estudio de la etiología y factores de riesgo asociados en una muestra de 300 pacientes con fibrilación auricular.

PURPOSE: To analyze the etiology and the prevalence of risk factors in patients with atrial fibrillation. PATIENTS AND METHODS: Applying an unpaired case controlled study, we examined 300 consecutive patients (143 men) with atrial fibrillation and a mean age of 66 +/- 8 years. This group is compared with a control group of 700 patients (mean age 64 +/- 12 years). RESULTS: In the group with atrial fibrillation the etiology in 32% was arterial hypertension, in 20% coronary heart disease, in 13% valvular heart disease, in 11% heart failure, in 4% hyperthyroidism and in 20% idiopathic. 50% presented hypertension, 29% tobaccoism, 26% left ventricular hypertrophy, 20% consumption of alcohol, 19% hypercholesterolemia and 16% diabetes. Compared with the control group, patients with atrial fibrillation had coronary heart disease (p < 0.05), VHD (p < 0.01), myocardiopathy (p < 0.05), HT (p < 0.001), left ventricular hypertrophy (p < 0.001), diabetes (p < 0.01) and alcohol consumption (p < 0.01) more frequently. In the multivariant analysis heart failure (odds ratio 2.1 [1.2-3.3]), the valvular heart disease (odds ratio 2.2 [1.4-3.5]), the coronary heart disease (odds ratio 1.8 [1.2-2.6]), the arterial hypertension (odds ratio 1.7 [1.2-2.3]), the left ventricular hypertrophy (odds ratio 2.6 [1.7-3.8]), the diabetes (odds ratio 1.9 [1.2-2.9]) and alcoholic habits (odds ratio 2 [1.3-3.9]) were independent risk factors for atrial fibrillation in our population. CONCLUSIONS: Atrial fibrillation in our study, is more frequent in patients with arterial hypertension, coronary heart disease or valvular heart disease. There are other risk factors such as arterial hypertension, diabetes and consumption of alcohol too, the modification of which could diminish the risk of the appearance of atrial fibrillation.

[A thrombus in the right atrium secondary to a fistulated aortic paravalvular abscess: apropos a case]. / Trombo en aurícula derecha secundario a absceso paravalvular aórtico fistulizado: a propósito de un caso.

This report describes the two-dimensional echocardiographic and autopsy findings in a patient with aortic valve endocarditis complicated by a posterior aortic root abscess with rupture into the right atrium, creating an aortic-right atrial fistula, with a later development from the root of the fistula of a pediculated thrombus inside the cavity.

Estudio de los factores de riesgo asociados y la prevalenciade cardiopatía en varones consumidores habituales de alcohol / Study of associated risk factors and prevalence of heart disease in men with alcoholic habit

Fundamento: Se estudia la prevalencia de cardiopatía y la asociación con otros factores de riesgo cardiovascular. Método: En una muestra prospectiva de 166 varones consumidores excesivos de alcohol (>60 grs/etanol/día) con edad media de 60ñ10 años (Grupo A). Este grupo se compara con 367 varones no bebedores y con edad media de 61ñ9 años (Grupo C). Resultados: En nuestro medio el 89 % de los varones con hábito etílico eran fumadores, el 36 porciento tenían hipertensión arterial, el 25 porciento niveles altos de colesterol total y el 17 porciento de triglicéridos, el 19 porciento hiperuricemia, el 13 porciento diabetes y el 15 porciento hipertrofia ventricular izquierda. La cifra media de HDL-Col fue de 67ñ12 mgrs/dl en el grupo A y de 58ñ10 en el grupo C con p<0,001. El 48 porciento del grupo A presentaba algún tipo de cardiopatía, isquémica en el 15 porciento, insuficiencia cardíaca en el 18 porciento y fibrilación auricular en el 15 porciento. Comparados con el grupo control se encontraron diferencias significativas para el tabaquismo (89 % A y 50 porciento C, p<0,001), la diabetes (13 % A y 7 porciento C, p<0,05), la hiperuricemia (19 % A y 8 % C, p<0,001), la hipertrigliceridemia (17 % A y 8 porciento C, p<0,01) y número total de factores de riesgo (2,9ñ1,2 A y 1,5ñ1,2 C, p<0,001). El porcentaje de individuos con cardiopatía es mayor en los varones bebedores (69 porciento C y 52 % A, p<0,05), siendo mayor también la prevalencia de insuficiencia cardíaca (18 % A y 10 porciento B, p<0,05) y fibrilación auricular (15 % A y 9 porciento C, p<0,05). Conclusiones: Los varones consumidores excesivos de alcohol en nuestro medio presentan habitualmente otros factores de riesgo coronario, fundamentalmente tabaco, diabetes, hiperuricemia e hipertrigliceridemia. En este grupo es más frecuente la presencia de cardiopatía, siendo el alcohol un factor de riesgo importante para el desarrollo de fibrilación auricular e insuficiencia cardíaca (AU)

[Spontaneous echocardiographic contrast in the left ventricle: apropos of 2 cases]. / Contraste ecocardiográfico espontáneo en el ventrículo izquierdo: a propósito de dos casos.

Two cases of spontaneous echocardiographic contrast in the left ventricle, using transthoracic echocardiography, are presented. One is due to a low-flow state in a patient with a dilated myocardiopathy. In the other we observed the echogenicity of a turbulent intracardiac blood flow across a mitral prosthesis. We considered the different theories that tried to explain the multiple origin of this "smoke".

Spontaneous coronary artery dissection.

Spontaneous coronary artery dissection is a rare coronary pathology whose precise incidence, etiology, pathogenesis, treatment and evolution have not been clearly established. Sudden death accounts for the majority of presentations. It occurs most commonly in young women in the left anterior descending coronary artery. We report the case of a 48-year-old male with asymptomatic spontaneous dissection in the anterior descending coronary artery.

[Colchicine treatment for recurrent pericarditis]. / Tratamiento con colchicina de la pericarditis recidivante.

The treatment of the recurrent pericarditis is difficult habitually. The colchicine, antiinflammatory drug used in gouty arthritis, is effective in preventing the recurrences of acute pericarditis. We review the literature about the efficacy of colchicine in the prevention of recurrent pericarditis.

[Primary cardiac tumors: a review of 29 cases]. / Tumores cardíacos primários: revisión de 29 casos.

A series of 29 cardiac tumors were operated in Asturias Central Hospital between 1974 and 1994. There were 23 benign and 6 malignant tumors. Among the benign neoplasms, 22 were myxomas and 1 lipoma; there were 6 remalignant tumors, one pulmonary artery sarcoma, two rhabdomyosarcoma, one mesothelioma and two lymphomas. We review the clinical findings of these patients. Long-term results were excellent in patients with benign lesions, and only one recurrence was found. In patients with malignant tumors, surgical procedures were only palliative and aimed at prolonging life; hence, prognosis remained unchanged.