[Guidelines of the Spanish society of cardiology on requirements and equipment of the coronary care unit]. / Guías de práctica clínica de la Sociedad Española de Cardiología sobre requerimientos y equipamiento de la unidad coronaria.

The conceptual change and the dynamic care of patients observed in coronary care units, in recent years are reported. The coronary care unit is increasingly conceived as an intensive care unit for patients with acute or chronic cardiopathies with severe complications. Criteria for rational planification, functional and hierarchic organization and basic medical care arguments are established. The coronary care unit can not be considered as an isolated facility, but should rather be integrated in the cardiology department, under the direction of a cardiologist. The authors point out the basic, physical structure and characteristics of the equipment in the coronary care unit and the intermediate cardiac care unit, as well as the newly created chest pain units. Finally, we comment on the human resources (medical, nursing and administrative) and the criteria for admission and discharge in the coronary care unit.

[Thrombolysis in the elderly with acute myocardial infarction. The PRIAMHO study]. / Trombólisis en el anciano con infarto agudo de miocardio. El estudio PRIAMHO.

INTRODUCTION: In the elderly with acute myocardial infarction the risks and benefits of thrombolytic therapy are not well defined due mainly to the lack of randomized trials. In the present study we examined the clinical profile of the aged treated with thrombolytic agents and the effects of that therapy on 28 day and 1 year mortality. PATIENTS AND METHODS: We studied 733 patients aged > 75 years (mean: 79.9) admitted to the Coronary Care Unit (CCU) of 24 Spanish hospitals with a confirmed diagnosis of Q-Wave myocardial infarction (MI). On admission, 293 patients were treated with thrombolytics and 440 patients received standard therapy. The difference between the two groups in the clinical profile of MI, treatments administered in CCU, evolutive course and 28 day and 1 year mortality were assessed. RESULTS: The independent predictors related to the use of thrombolytic therapy were age (OR: 0.93; 95% CI: 0.89-0.97), history of arterial hypertension (OR: 0.85; 95% CI: 0.71-1.01), delay time to admission (OR: 0.998; 95% CI: 0.997-0.999), anterior location of infarct (OR: 1.21; 95% CI: 1.01-1.24) and Killip Class III-IV (OR: 0.79; 95% CI: 0.64-0.97). During the evolution thrombolysis therapy was associated with lower rates of Killip III-IV (p < 0.00001), complete AV block (p = 0.037), intraventricular conduction defects (p = 0.046) and a higher incidence of stroke (p < 0.01). The 28-day mortality was also significantly lower in the group receiving thrombolytics (27 vs 31. 3%; p = 0.035). However, this difference disappeared when the analysis was adjusted with other variables such as age, administration of aspirin and Killip Class III-IV (OR: 1.29; 95% IC: 0.87-1.92). CONCLUSIONS: The results of this trial suggest that in the elderly with acute myocardial infarction thrombolysis is associated with a less complicated evolutive course and a lower 28-day mortality. However, these findings could be mediated by other covariables such as age, more frequent use of aspirin and a higher number of patients with Killip Class III-IV excluded from the thrombolytic therapy.

[Clinical practice guidelines of the Spanish Society of Cardiology on unstable angina/infarction without ST elevation]. / Guías de práctica clínica de la Sociedad Española de Cardiología en la angina inestable/infarto sin elevación ST.

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.

[Role of noninvasive examinations in the management of ischemic cardiopathy. V. Noninvasive examinations in the management of patients with chronic ischemic cardiopathy]. / Papel de las exploraciones no invasivas en el manejo de la cardiopatía isquémica. V. Las exploraciones no invasivas en el manejo de los pacientes con cardiopatía isquémica crónica. Recomendaciones para su utilización.

In the last few years the has been an enormous development in noninvasive testing in the field of clinical cardiology. In fact, excellent monographs on each one of these techniques have been published elsewhere, but fewer publications exist that treat the topic of their indications and use in an integrated way, except for in the most common clinical situations. In this paper, the treatment of patients who present chest pain, stable and unstable angina is discussed, including the study of postinfarction patients. Furthermore, the role of noninvasive tests in the detection of coronary heart disease in women and in patients with left bundle branch block is thoroughly analyzed; as well as their usefulness after surgical or percutaneous coronary revascularization and in patients with peripheral vascular disease.

[Usefulness of exercise Doppler in the diagnosis of severe mitral stenosis]. / Valor del Doppler de esfuerzo para el diagnóstico de la estenosis mitral severa.

BACKGROUND: Exercise in mitral stenosis produces an increase in cardiac output and heart rate which determines the increment in the transmitral gradient. However, it has not yet been established what level is reached by the gradients on exercise in severe mitral stenosis nor whether the rise in the gradient during such exercise is different to that occurring in non-severe stenosis. OBJECTIVE: To evaluate the effect of exercise in patients with severe mitral stenosis on the mitral valve gradients in absolute values and on the increment with respect to base values. METHODS: Forty-eight mitral stenosis patients (mean age: 48.8 +/- 11 years) underwent 50 exercise Doppler echocardiographic studies using supine bicycle ergometry in two stages with increases of 25 W every 3 minutes; from each of these we obtained the peak and mean mitral gradient using a non-imaging continuous-wave Doppler probe. We also conducted this procedure on 14 patients with a mean age of 50 +/- 6 who had Bjork mitral prostheses which were functioning normally. RESULTS: We defined a hemodynamic profile of severity based on the data from 18 patients whose basal mitral valve areas was < 1.2 cm2 (group I), and compared them with the data from the 32 studies of mitral stenosis patients with an area > 1.1 cm2 (group II) and with the patients with mitral prostheses (group III). The mean mitral gradient (mmHg) in group I was greater than in group II at rest (9.3 +/- 3.2 and 6.6 +/- 2.7; p < 0.001), at 25 W (20.6 +/- 4.8 and 14.1 +/- 5; p < 0.001) and at 50 W (25.9 +/- 5.4 and 17.3 +/- 5.8; p < 0.001). The increase in mean mitral gradient from the baseline to 50 watts was 16.7 +/- 4.5 mmHg in group I, which was greater than in group II and III (11.1 +/- 4.1 and 6.8 +/- 2.6 mmHg; p < 0.001). CONCLUSIONS: Exercise Doppler echocardiography enabled us to define a differential hemodynamic profile in patients with severe mitral stenosis which can be used in isolation as an indicator of severity in this condition.

[Stratification of arrhythmia risk and therapeutic options in survivors of acute myocardial infarction]. / Estratificación del riesgo arrítmico y opciones terapéuticas en los supervivientes a infarto agudo de miocardio.

A significant improvement in late survival of post-myocardial infarction patients has been observed during the last few years, even before the beginning of the thrombolytic era. However, about half of the fatality rate in these patients is related to arrhythmic sudden death. So, a discussion of the value of different diagnostic and therapeutic tools available for reducing arrhythmic risk seems pertinent. Several features are considered risk markers for sudden arrhythmic death: symptomatic ventricular arrhythmias, left ventricular disfunction, myocardial ischemia, frequent or complex premature ventricular contractions, late ventricular potentials in high-resolution ECG and autonomous nervous system disturbances. It seems reasonable to state that the risk markers whose value was established before the thrombolytic era maintain most of their clinical applicability to the present, but none of them has specificity enough as a sudden death predictor to warrant a general systematic strategy to trace such risk arrhythmic factors. Prophylactic administration of Type I antiarrhythmic drugs to patients with frequent or complex premature ventricular contractions can no longer be justified. There is probably a place for betablockers, mainly in patients with mild to moderate depression in left ventricular function. The final results of several trials currently in progress should contribute to establish the potential role of low dose amiodarone. There is not enough evidence to determine which post-myocardial infarction patients will be candidates for an Implantable Cardioverter Defibrillator Device. Patients with risk factors for sudden death, in particular those who have a severe impairment of left ventricular function and/or severe ischemia in the stress test, would be able to take advantage of a revascularization procedure when the culprit vessel remains occluded. In the intermediate risk patients (20-40% of the total population), tests attempting to more precisely evaluate the arrhythmic risk would be warranted, always in an individualized, sequential schedule. In some cases, like the high-resolution ECG or the heart rate variability indices, more clinical investigation is necessary to adequately establish their value in routine clinical practice.

[Myocardial revascularization in angina pectoris. Study Group on Angina Pectoris of the Ischemic Cardiopathy and Coronary Units Section of the Spanish Society of Cardiology]. / Revascularización miocárdica en la angina de pecho. Grupo de Estudio de Angina de Pecho de la Sección de Cardiopatía Isquémica y Unidades Coronarias de la Sociedad Española de Cardiología.

Ischemic pain relief and survival are the targets of the revascularization treatment in angina pectoris. The authors describe the clinical and anatomic indications for revascularization in angina and the reasons for the election between surgery and percutaneous transluminal coronary angioplasty.

[Rehabilitation of patients with chronic cardiac insufficiency. Immediate and midterm effects]. / Réadaptation des malades en insuffisance cardiaque chronique. Effets immédiats et à moyen terme.

OBJECTIVES: While physical training is known to improve cardiac performance in patients with chronic congestive heart failure, we conducted this study to evaluate the effect of such training programmes. METHODS: The study group included 48 untrained patients with stable chronic heart failure controlled with the same daily oral regimen including 0.25 mg digitoxin, 40 mg furosemide and 50 mg captopril. Halt of the patients (n = 24) entered a physical rehabilitation programme for a 3-week period. Each daily session included passive mobilization of the limbs (10 min), respiratory exercises (10 min) and endurance exercise on an ergometric cycle with a maximum work load of 50, 60 and 70% of the theoretical maximal load for weeks 1, 2 and 3 respectively. The other 24 patients did not change their physical activity level and served as controls. The immediate and medium term effects (3 months after the end of the training programme) were assessed using exercise tests, left ventricular isotopic ejection fraction and plethysmography of the lower limbs. The quality of life was compared using the NYHA functional classification and the Goldsman questionnaire. RESULTS: At the end of the 3-week training period, and compared with the control group, there was a moderate improvement of VO2max (p < 0.02) and a 10% improvement in the ejection fraction (p < 0.05) in the trained patients. There was a clearly significant improvement in the anaerobic threshold and arterial blood flow rate (p < 0.001) and lowered vascular resistance (p < 0.001) and venous tone (p < 0.001). The quality of life was also improved in the training group. However, 3 weeks after the end of the training period, these differences disappeared. CONCLUSION: Patients with chronic heart failure can benefit from physical training showing functional improvement and no deleterious effect on left ventricular function. This beneficial effect is nonetheless temporary and would appear to be due to improved skeletal muscle oxidative capacity and peripheral haemodynamics.