Long-Term Radiotherapy-Induced Cardiac Complications: A Case Report.

BACKGROUND Tumor disease has improved survival due to therapeutic advances and early diagnosis. However, anti-neoplastic treatment involves generating harmful side effects in the body, both in the short-term and in the long-term. One of the most important side effects is cardiovascular disease after radiotherapy, which in addition to being influenced by classic cardiovascular risk factors, can be also be influenced by anti-neoplastic therapy, and represents the main cause of death after a second cancer. We present a case that synthesizes the most relevant and determining aspects of radiotherapy-induced heart disease. CASE REPORT We present the case of a 48-year-old male with a personal history of mediastinal Hodgkin lymphoma who was treated with local radiotherapy 20 years ago, and who was admitted to hospital due to dyspnea and oppressive chest pain with efforts. He was diagnosed with severe aortic stenosis, and a coronary angiography confirmed the existence of coronary disease. Two years before, he had been admitted to hospital due to syncope and a pacemaker had been implanted. This patient experienced several cardiovascular complications that could be attributed to the radiotherapy treatment received in his past. CONCLUSIONS Radiotherapy shows multiple cardiological complications, especially when applied at the thoracic level. This fact is very relevant, and this report can help determine the aspects of radiotherapy-induced heart disease affecting the mortality and morbidity of these patients.

Síncopes en un paciente con antecedente de radioterapia: la importancia de una valoración global de la afección cardiaca. Respuesta / Syncopes in a patient with a history of radiotherapy: the importance of a comprehensive assessment of cardiac involvement. Response

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Síncope de repetición inducido por radioterapia / Radiotherapy-induced recurrent syncope

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Levosimendan improves hemodynamic status in critically ill patients with severe aortic stenosis and left ventricular dysfunction: an interventional study.

AIMS: To study the hemodynamic effect of levosimendan administration in acute heart failure patients with severe aortic stenosis (AS) and reduced left ventricular ejection fraction (LVEF). METHODS: Hemodynamic response to 24 h intravenous levosimendan infusion (0.1 µg/kg/min without a loading dose) in patients with severe AS (aortic valve area ≤1 cm(2) , time-velocity integral between left ventricular out-flow tract and aortic valve <0.25), reduced LVEF (≤40%), and a depressed cardiac index (CI) <2.2 L/min/m(2) was determined in a sequential group of nine patients aged 76 ± 10 years (5 men). RESULTS: Baseline mean ejection fraction was 33 ± 0.7%; mean aortic valve area was 0.37 ±0.11 cm(2) /m(2) ; peak and mean gradients of 63.6 ± 20.53 and 36.7 ± 12.62 mmHg, respectively; and mean CI was 1.65 ± 0.20 L/min/m(2) . At 6 and 12 h of levosimendan therapy, mean CI had increased to 2.00 ± 0.41 L/min/m(2) (P = 0.02) and 2.17 ± 0.40 L/min/m(2) (P = 0.01), respectively. At 24 h, mean CI had increased further to 2.37 ± 0.49 L/min/m(2) (P = 0.01). A significant beneficial effect was also observed in pulmonary capillary wedge pressure, pulmonary artery mean pressure, central venous pressure, systemic vascular resistances, pulmonary vascular resistances, stroke volume index, left ventricular stroke work index. NTproBNP levels decreased at 24 h of levosimendan treatment. Levosimendan infusion was also well tolerated. Five patients subsequently underwent aortic valve surgery replacement. One died (of postoperative multiorgan failure). At 30 days, overall survival was 75%. CONCLUSIONS: Levosimendan administration improves hemodynamic parameters in critically ill patients with severe AS and reduced LVEF. In our study, it provides a safe and effective bridge to aortic-valve replacement or oral vasodilator therapy in surgical contraindicated patients. A controlled study is needed to confirm these preliminary findings.

Unusual etiology of acute lung injury in a patient with acute myocardial infarction.

BACKGROUND: The known etiology of acute lung injury (ALI) is immensely varied and includes severe burns and trauma. Electrical and multiple defibrillation shocks can cause cutaneous burns and blunt chest trauma. The literature contains no reference to the association between ALI and cutaneous burns or blunt chest trauma secondary to defibrillation. OBJECTIVE: To report a patient with Acute Myocardial Infarction (AMI) who developed ALI possibly due to multiple defibrillation shocks. CASE REPORT: A 51 year-old man with AMI presenting with multiple episodes of ventricular fibrillation (VF) treated with defibrillation and subsequently cutaneous burns. He developed soon afterward respiratory failure due to ALI. Cardiac failure or any known etiology of ALI was ruled out. Medical treatment included oxygen therapy, cardiac frequency control with betablockers, in addition to antiplatelet therapy. Clinical and oxymetric evolution was favourable, with resolution of the radiological infiltrates. The patient was discharged alive and in good condition at the 19th day after admission. The authors discuss possible mechanisms of ALI development by multiple defibrillation shocks. CONCLUSIONS: In the absence of any other known etiology, multiple defibrillation shocks may have played a role in the genesis of ALI in our patient, but this remains speculative.

Renal dysfunction is an independent predictor of in-hospital mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty.

BACKGROUND: Patients with baseline renal dysfunction (BRD) have an increased cardiovascular risk and a worse prognosis after an acute myocardial infarction (AMI). Besides, the appearance of worsening renal failure (WRF) after an AMI is an independent predictor of worse prognosis too. The aim of the present study was to determine the in-hospital prognostic significance of BRD and WRF in patients with ST-segment elevation myocardial infarction (STEMI) who underwent successful primary angioplasty (PA). METHODS: Seventy-six consecutive patients with STEMI diagnosis were admitted to our department and treated with PA successfully. Two groups were established in relation to the presence of BRD on admission (defined by a ClCr<60 ml/min/1.73 m2, estimated by the modification of diet in renal disease equation). We compared their baseline characteristics and their in-hospital mortality and developing of WRF. RESULTS: BRD was associated to a greater in-hospital mortality (11.5% vs. 2.7%, p=0.009) and a higher incidence of WRF (12.2% vs. 2.5%, p<0.001). After adjusting by confounding factors, the multiple logistic regression analysis demonstrated that BRD was an independent predictor of in-hospital mortality (OR 2.5, CI 95% 1.5-3.8, p<0.001). Besides, WRF was associated to a greater in-hospital mortality too, independent of the presence of BRD (OR 1.9, CI 95% 1.3-2.4, p<0.001). CONCLUSIONS: BRD was an independent predictor of in-hospital mortality in patients with STEMI who underwent successful PA. Likewise, WRF occurring in these patients was an independent predictor of in-hospital mortality too.

[Influence of diabetes mellitus on the management and prognosis of non-ST-elevation acute coronary syndrome]. / Influencia de la diabetes mellitus en el tratamiento y el pronóstico del síndrome coronario agudo sin elevación del segmento ST.

The presence of diabetes mellitus worsens prognosis in acute coronary syndromes. The aim of our study was to analyze retrospectively the influence of diabetes mellitus on the management and prognosis of patients with non-ST-segment elevation acute coronary syndrome. We compared the baseline clinical characteristics of 273 patients (93 diabetic and 180 non-diabetic) admitted consecutively to our department with the diagnosis of non-ST-segment elevation acute coronary syndrome. In both groups, we assessed the medical treatment given during hospitalization and the use of coronary angiography, percutaneous coronary intervention, and coronary artery bypass grafting. Finally, we determined the incidence of heart failure during hospitalization and mortality at 28 days and 6 months in both groups. Multifactorial analysis revealed that diabetes was an independent risk factor for mortality during the study period. Data from our registry indicate that these findings were not associated with more extensive use of interventions in diabetic patients.

Influencia de la diabetes mellitus en el tratamiento y el pronóstico del síndrome coronario agudo sin elevación del segmento ST / Influence of diabetes mellitus on the management and prognosis of non-ST-elevation acute coronary syndrome

La diabetes mellitus condiciona un peor pronóstico del síndrome coronario agudo. Presentamos un estudio retrospectivo cuyo objetivo fue analizar la influencia de la presencia de diabetes en el pronóstico y el tratamiento de pacientes con síndrome coronario agudo sin elevación del segmento ST. Se compararon las características clínicas de 273 pacientes (93 pacientes diabéticos frente a 180 no diabéticos) ingresados en nuestro centro con el diagnóstico de síndrome coronario agudo sin elevación del segmento ST. Durante la hospitalización analizamos en ambos grupos el tratamiento médico y la realización de coronariografía, intervencionismo y cirugía coronaria. Finalmente, analizamos la incidencia acumulada de insuficiencia cardiaca intrahospitalaria y la mortalidad a los 28 días y 6 meses en ambos grupos. El análisis multifactorial demostró que la diabetes fue un predictor independiente de mortalidad durante el período de seguimiento. Estos hallazgos no se acompañaron en nuestro registro de un tratamiento más intervencionista en el grupo de pacientes diabéticos

The presence of diabetes mellitus worsens prognosis in acute coronary syndromes. The aim of our study was to analyze retrospectively the influence of diabetes mellitus on the management and prognosis of patients with non-ST-segment elevation acute coronary syndrome. We compared the baseline clinical characteristics of 273 patients (93 diabetic and 180 non-diabetic) admitted consecutively to our department with the diagnosis of non-ST-segment elevation acute coronary syndrome. In both groups, we assessed the medical treatment given during hospitalization and the use of coronary angiography, percutaneous coronary intervention, and coronary artery bypass grafting. Finally, we determined the incidence of heart failure during hospitalization and mortality at 28 days and 6 months in both groups. Multifactorial analysis revealed that diabetes was an independent risk factor for mortality during the study period. Data from our registry indicate that these findings were not associated with more extensive use of interventions in diabetic patients

Cardiogenic shock after primary percutaneous coronary intervention: Effects of levosimendan compared with dobutamine on haemodynamics.

BACKGROUND: Levosimendan is a new calcium sensitizer with positive inotropic properties. Cardiac power output (CPO) has been shown to be instrumental in the diagnosis of cardiogenic shock (CS) and is an important determinant of outcomes. AIMS: To evaluate the haemodynamic effects of levosimendan compared to dobutamine in acute myocardial infarction (AMI) patients revascularised by primary percutaneous coronary intervention (PCI), who developed CS. METHODS AND RESULTS: Twenty two consecutive AMI patients revascularised by PCI, who developed CS, were randomly assigned to levosimendan (24 microg kg(-1) bolus plus 24-h continuous infusion 0,1 microg kg(-1) min(-1)) or dobutamine (initial dose 5 microg kg(-1) min(-1), with a maximum dose adjustment in order to reach the desired haemodynamic effect). Evaluations were performed from baseline to 30 h. The primary end-point was an increase > or =30% in CPO, after 24 h of therapy. The baseline clinical and haemodynamic characteristics were similar in both groups. Levosimendan had a consistently better effect on CPO than dobutamine, while the decrease in PCWP was similar. CONCLUSION: The primary objective of our study was achieved better by the end of the 24 h infusion of levosimendan than by dobutamine.

¿Es la homocisteína es un factor de riesgo independiente para enfermedad cardiovascular? / Is homocysteine an independent risk factor for cardiovascular disease?

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[Association between serum interleukin 10 level and development of heart failure in acute myocardial infarction patients treated by primary angioplasty]. / Asociación entre concentraciones séricas de interleucina 10 y desarrollo de insuficiencia cardíaca en pacientes con infarto agudo de miocardio tratados con angioplastia primaria.

INTRODUCTION AND OBJECTIVES: Interleukin 10 (IL-10) is an anti-inflammatory cytokine that inhibits the synthesis of proinflammatory cytokines. It has been shown that IL-10 is released into the circulation during post-ischemic myocardial reperfusion. The objective of this study was to determine whether the serum IL-10 concentration in patients with acute myocardial infarction who were undergoing primary angioplasty was related to the subsequent presence or absence of heart failure. PATIENTS AND METHOD: The study included 65 patients who underwent successful primary angioplasty. During their subsequent stay in the coronary unit, their maximum degree of heart failure was recorded. Patients were then divided into 2 groups: group A patients were in Killip class I and group B patients in Killip classes II-IV. The serum IL-10 concentration was measured during the 24 hours following admission to the coronary unit. RESULTS: The 2 groups were similar with regard to age, sex, and coronary risk factors. The IL-10 concentration was significantly higher in the group of patients with acute myocardial infarction without heart failure than in the group with heart failure (30.4+/-10.8 vs 19.8+/-7.9 pg/mL; P<.001). CONCLUSIONS: In patients with acute myocardial infarction who had undergone successful primary angioplasty, the serum IL-10 concentration measured during the following 24 hours was significantly higher in those who did not develop heart failure. These findings suggest that this anti-inflammatory cytokine has a protective effect on the myocardium during ischemia or reperfusion, or both.

Asociación entre concentraciones séricas de interleucina 10 y desarrollo de insuficiencia cardíaca en pacientes con infarto agudo de miocardio tratados con angioplastia primaria / Association between serum interleukin 10 level and development of heart failure in acute myocardial infarction patients treated by primary angioplasty

Introducción y objetivos. La interleucina 10 (IL-10) es una citocina con propiedades antiinflamatorias capaz de inhibir la síntesis de citocinas proinflamatorias. Se ha demostrado que la IL-10 se libera al torrente sanguíneo durante la reperfusión miocárdica postisquémica. El objetivo de este estudio fue determinar las concentraciones séricas de IL-10 en pacientes con infarto agudo de miocardio (IAM) tratados con angioplastia primaria y relacionarlas con la presencia o ausencia posterior de insuficiencia cardíaca (IC). Pacientes y método. Se incluyó en el estudio a 65 pacientes a los que se realizó angioplastia primaria con éxito. Posteriormente, durante su estancia en la unidad coronaria, se registró el máximo grado de IC. La población de estudio fue dividida en 2 grupos: grupo A (clase Killip I) y B (clases Killip II, III y IV). Las concentraciones séricas de IL- 10 se determinaron durante las primeras 24 h posteriores a su admisión en la unidad coronaria. Resultados. Ambos grupos fueron similares en edad, sexo y factores de riesgo coronario. En el grupo de pacientes con IAM sin IC, las concentraciones de IL-10 fueron mayores que en el grupo de pacientes con IC (30,4 ± 10,8 frente a 19,8 ± 7,9 pg/ml; p < 0,001). Conclusiones. En los pacientes con IAM en los que se realiza con éxito una angioplastia primaria, la concentración sérica de IL-10, determinada en las primeras 24 h del evento, está más elevada cuando no se desarrolla IC. Estos hallazgos sugieren que esta citocina antiinflamatoria ejerce un efecto protector del miocardio durante la isquemia y/o la reperfusión

Introduction and objectives. Interleukin 10 (IL-10) is an anti-inflammatory cytokine that inhibits the synthesis of proinflammatory cytokines. It has been shown that IL-10 is released into the circulation during post-ischemic myocardial reperfusion. The objective of this study was to determine whether the serum IL-10 concentration in patients with acute myocardial infarction who were undergoing primary angioplasty was related to the subsequent presence or absence of heart failure. Patients and method. The study included 65 patients who underwent successful primary angioplasty. During their subsequent stay in the coronary unit, their maximum degree of heart failure was recorded. Patients were then divided into 2 groups: group A patients were in Killip class I and group B patients in Killip classes II-IV. The serum IL-10 concentration was measured during the 24 hours following admission to the coronary unit. Results. The 2 groups were similar with regard to age, sex, and coronary risk factors. The IL-10 concentration was significantly higher in the group of patients with acute myocardial infarction without heart failure than in the group with heart failure (30.4±10.8 vs 19.8±7.9 pg/mL; P<.001). Conclusions. In patients with acute myocardial infarction who had undergone successful primary angioplasty, the serum IL-10 concentration measured during the following 24 hours was significantly higher in those who did not develop heart failure. These findings suggest that this anti-inflammatory cytokine has a protective effect on the myocardium during ischemia or reperfusion, or both