Valor pronóstico de la hiperuricemia en la insuficiencia cardiaca crónica / Prognostic value of hyperuricemia in chronic heart failure

BACKGROUND: Hyperuricemia has been proposed as a risk marker in chronic heart failure, but its value as an independent prognostic is not well established. AIM: To determine the prognostic value of hyperuricemia, in patients with chronic stable heart failure. PATIENTS AND METHODS: Forty six male patients with chronic heart failure, aged 62 +/- 13 years, were studied. Their election fraction was less than 40% and their serum creatinine was less than 2 mg/dl. Serum uric acid and catecholamines, maximal oxygen consumption (VO2 max) and left ventricular ejection fraction were measured. Mortality and the need for cardiac transplant were recorded as endpoints during a mean follow up of 39 +/- 18 months. The relationship between basal measures and the occurrence of events was analyzed using univariate and multivariate methods. RESULTS: Basal VO2 max and left ventricular ejection fraction were 16 +/- 4.6 ml/kg/min and 22 +/- 7% respectively. Eighteen patients died and three required transplantation during the follow up. Patients reaching these endpoints had a lower VO2 max and left ventricular ejection fraction and higher uric acid levels. Multivariate analysis accepted left ventricular ejection fraction (relative risk 0.89, 95% CI 0.82-0.97) and serum uric acid (relative risk 1.335 95% CI 1.02-1.74) as significant predictors of events. The relative risk for cardiac transplantation was 7.07 times higher among those with a serum uric acid over 7 mg/dl. CONCLUSIONS: A high serum uric acid is an independent predictor of bad prognosis in patients with stable chronic heart failure.

Trombosis en el infarto agudo del miocardio en hospitales chilenos: la experiencia del grupo GEMI / Thrombolysis in the acute myocardial infarction in chilean hospitals: the gemi group experience

Antecedentes: La trombolisis es uno de los métodos de reperfusión coronaria que permite reducir la mortalidad del infarto agudo del miocardio (IAM). Lamentablemente no todos los pacientes con indicación de trombolítico reciben el tratamiento. Objetivo: Evaluar los cambios en el empleo de trombolíticos a través del tiempo en pacientes con IAM y supradesnivel ST y analizar las variaciones en mortalidad según el período de registro. Método: Se compara la información de tres registros efectuados los años 93-95 (R1), 97-98 (R2), y los pacientes incluidos en el año 2001 del registro GEMI actualmente en curso (R3), en el que participan 23 hospitales de Santiago y regiones. Se recolecto información sobre latencia en administración del trombolítico, motivo de la no utilización y evolución intrahospitalaria de los pacientes que ingresaron con el diagnóstico de IAM Q o con supradesnivel ST (SDST). Resultados: En R1 se recolectaron 2.155 pacientes con IAM y SDST, en R2: 1.436 pacientes y en R3: 789 pacientes. El porcentaje que recibió trombolíticos fue de 37,8 por ciento, 41,4 por ciento y 45,1 por ciento, respectivamente. La mortalidad global en cada uno de los registros fue de R1: 11,2 por ciento, R2: 9,9 por ciento y R3: 8,9 por ciento ( p para tendencias: NS). Cuando se analiza según sexo, la mortalidad en hombres fue de 8,1 por ciento 7,4 por ciento y 7,1 por ciento (p para tendencias: NS). En mujeres estas proporciones fueron 23,6 por ciento 19,2 por ciento y 14,8 por ciento, respectivamente (p para tendencias: <0,05). El motivo de no uso trombolítico, dato consignado en R2 y R3, se debió a: ingreso tardío (45 por ciento y 38 por ciento respectivamente), contraindicación (9,5 y 12,5), no disponibilidad de él (1,5 por ciento y 0,23 por ciento). En el resto de los pacientes se consignó como “otro” el motivo de no uso. (De este análisis se excluyeron los pacientes sometidos a angioplastia primaria). Se observa un aumento en la proporción de pacientes sometidos a trombosis, asociado a una reducción en la mortalidad global en ellos. Conclusión: La reducción de la mortalidad en mujeres es determinante en la mejoría del pronóstico intrahospitalario en la población de trombolisados. Estos hallazgos pueden reflejar una mejor indicación y oportunidad del empleo de trombolíticos, así como de los fármacos de eficacia demostrada para el tratamiento de IAM con SDST...

Association of noninvasive markers of coronary artery reperfusion to assess microvascular obstruction in patients with acute myocardial infarction treated with primary angioplasty.

Early restoration of coronary artery patency through primary angioplasty limits infarct size and improves survival. Increasing evidence, however, suggests that microvascular obstruction is often present despite coronary artery recanalization. This may limit the benefits of reperfusion therapy. We studied the use of noninvasive markers of coronary artery reperfusion as indicators of microvascular obstruction and determinants of prognosis in 98 patients with acute myocardial infarction (AMI) who were successfully treated with primary angioplasty (Thrombolysis In Myocardial Infarction grade 3 flow and residual stenosis <30%). Plasma creatine kinase (CK) levels and 12-lead electrocardiograms were performed on admission, at 90 minutes, and at 6, 12, and 24 hours after treatment. We defined: (1) reperfusion as resolution of ST-segment elevation >50% at 90 minutes, with peak CK levels within 12 hours, and T-wave inversion within 24 hours; and (2) failed reperfusion, as the absence of these parameters. Of the 98 patients studied, 87 (88.8%) had reperfusion and 11 (11.2%) had failed reperfusion. Infarct location was anterior (versus inferior) in 9 patients in the failed reperfusion group (81.8%) compared with 41 patients in the reperfusion group (47.1%) (p <0.01). Congestive heart failure >24 hours after presentation or in-hospital death occurred in 11 patients (12.6%) in the reperfusion group versus 5 (45.5%) in the failed reperfusion group (p <0.01). One-year survival was 96.1% for the reperfusion group and 60.6% for the failed reperfusion group (p <0.0001). We conclude that the association of noninvasive markers of reperfusion better identifies patients with microvascular obstruction among those who had a "successful" primary angioplasty. Evidence of impaired microvascular reperfusion is associated with a poor in-hospital and 1-year outcome.

[Changes in the patterns of drug prescription for acute myocardial infarct. Comparison of 2 periods]. / Cambios en los patrones de prescripción de medicamentos en el infarto agudo del miocardio. Comparación de dos períodos.

BACKGROUND: Pharmacotherapy of Chilean patients with acute myocardial infarction has been recorded in 37 hospitals since 1993. AIM: To compare pharmacotherapy for acute myocardial infarction in the period 1993 to 1995 with the period 1997-1998. PATIENTS AND METHODS: Drug prescription during hospital stay was recorded in 2957 patients admitted to Chilean hospitals with an acute myocardial infarction in the period 1993-1995 and compared with that of 1981 subjects admitted in the period 1997-1998. RESULTS: When compared with the former period, in the lapse 1997-1998 there was an increase in the frequency of prescription of aspirin (93 and 96.1% respectively) beta blockers (37 and 55.2% respectively) and angiotensin converting enzyme inhibitors (32 and 53%). The prescription of thrombolytic therapy did not change (33 and 33.7% respectively). There was a reduction in the prescription of calcium antagonists and antiarrhythmic drugs. CONCLUSIONS: During the period 1997-1998, the prescription of drugs with a potential to reduce the mortality of acute myocardial infarction, increased. The diffusion of guidelines for the management of this disease may have influenced this change.

[Hyperuricemia as a marker for anaerobic threshold in chronic cardiac failure]. / La hiperuricemia es un marcador del umbral anaeróbico en la insuficiencia cardíaca crónica.

BACKGROUND: Patients with chronic cardiac failure often have elevated plasma uric acid levels, that are associated to a dismal prognosis. AIM: To investigate possible metabolic mechanisms to explain elevated uric acid levels in these patients. PATIENTS AND METHODS: Eighteen patients with chronic cardiac failure aged 61 +/- 10 years old, without gout or renal failure and not using high doses of diuretics (equal or less than 80 mg/day furosemide or 50 mg/day hydrochlorothiazide) were studied. Plasma uric acid levels were correlated with anaerobic threshold, maximal oxygen uptake, plasma noradrenaline and creatinine and left ventricular ejection fraction, measured radioisotopically. RESULTS: Mean maximal oxygen uptake was 16.6 +/- 4.2 ml/kg/min. There was a negative correlation between uric acid levels and maximal oxygen uptake or maximal oxygen uptake/body surface area (r = 0.521 and -0.533 respectively, p < 0.05). Patients with uric acid levels over 7 mg/dl had a lower anaerobic threshold than patients with lower levels (9.81 +/- 2.41 and 13.08 +/- 3.28 ml/kg/min respectively, p < 0.05). No significant differences in maximal oxygen uptake were observed in these two groups of patients (15.5 +/- 4.24 and 18.08 +/- 3.86 ml/kg/min respectively). Uric acid levels did not correlate with plasma noradrenaline, creatinine or left ventricular ejection fraction. CONCLUSIONS: These results suggest that a defect in cellular oxygenation contributes to the elevation of plasma uric acid levels in patients with chronic cardiac failure.

[Selective training of respiratory muscles in patients with chronic heart failure]. / Entrenamiento selectivo de los músculos respiratorios en pacientes con insuficiencia cardíaca crónica.

BACKGROUND: Patients with chronic heart failure have a lower inspiratory muscle strength and fatigue endurance. AIM: To assess the effects of selective training of respiratory muscles in patients with heart failure. PATIENTS AND METHODS: Twenty patients with stable chronic heart failure, aged 58.3 +/- 3 years with an ejection fraction of 28 +/- 9%, were subjected to respiratory muscle training with threshold valves. The load was fixed in 30% of maximal inspiratory pressure (PImax) in 11 and in 10% of PImax in nine. Two sessions of 15 minutes, 6 days per week, during 6 weeks were done. Degree of dyspnea (Mahler score), maximal oxygen uptake, distance walked in 6 minutes, respiratory muscle function and left ventricular ejection fraction were measured before and after training. RESULTS: Both training loads were associated to an improvement in dyspnea (+2.7 +/- 1.8 and +2.8 +/- 1.8 score points with 30% PImax and 10% PImax respectively), maximal oxygen uptake (from 19 +/- 3 to 21.6 +/- 5 and from 16 +/- 5 to 18.6 +/- 7 ml/kg/min with 30% PImax and 10% PImax respectively, p < 0.05), PImax (from 78 +/- 22 to 99 +/- 22 and from 72 +/- 34 to 82.3 cm H20 with 30% PImax and 10% PImax respectively), sustained PImax (from 63 +/- 18 to 90 +/- 22 and from 58 +/- 3 to 69 +/- 3 cm H20 with 30% PImax and 10% PImax respectively), and maximal sustained load (from 120 +/- 67 to 195 +/- 47 and from 139 +/- 120 to 192 +/- 154 g with 30% PImax and 10% PImax respectively). The distance walked in 6 min only increased in subjects trained at 30% PImax (from 451 +/- 78 to 486 +/- 68 m). CONCLUSIONS: Selective training of respiratory muscles results in a functional improvement of patients with chronic heart failure.

[Infective endocarditis: short and long-term results in 261 cases managed by a multidisciplinary approach]. / Endocarditis infecciosa: análisis de 261 casos y resultados del tratamiento con un enfoque multidisciplinario.

BACKGROUND: Early diagnosis, an effective treatment and prompt recognition of complications are essential to improve the prognosis of infective endocarditis (IE). AIM: To report the results of a multidisciplinary approach to diagnosis and management of patients with IE at the Universidad Católica de Chile Hospital. PATIENTS AND METHODS: The clinical history, diagnosis, treatment and outcome of 261 episodes (Duke criteria) of IE admitted between January 1980 and January 1999 were analyzed. These included 185 episodes of native, 73 of prosthetic valve and 3 of nonvalvular IE. RESULTS: Sixty nine percent of patients were men and the mean age was 49 +/- 16 years. Seventy five percent had a definite diagnosis of IE (Duke). S. viridans, staphylococci and enterococci together constituted 85% of the isolated bacterial strains. Twenty seven had culture-negative IE, related to a high incidence of antibiotic therapy prior to diagnosis. Transesophageal echocardiography was performed in 102 cases and it detected vegetations in 91% of aortic and 96% of mitral IE, rupture or prosthesis dehiscence in 67% of aortic and 52% of mitral IE and abscesses in 51% of aortic and 15% of mitral IE. Fifty one percent developed heart failure and 34% had embolic events. S. aureus IE was associated to a higher incidence of embolic events, complications which contraindicated surgery and increased mortality rate (27%). Of all patients, 40% were treated exclusively with antibiotics, 52% were operated on and 8% had surgical indication but were nonoperable because of serious complications. The overall mortality was 16.3%: 13% in the medical, 9% in the surgical and 81% in the non-operable groups. The type of treatment and mortality rates did not differ between IE of native valves and prosthetic valves. Long term follow up showed survival rates of 73% at 5 years and 66% at 10 years. CONCLUSION: A multidisciplinary approach may be very helpful to improve the prognosis of IE.

Bedside markers of coronary artery patency and short-term prognosis of patients with acute myocardial infarction and thrombolysis.

BACKGROUND: In this study we have evaluated the prognostic power of noninvasive markers of coronary artery reperfusion in patients with acute myocardial infarction who were treated with intravenous streptokinase. METHODS: In 967 consecutive patients with acute myocardial infarction who were treated within 6 hours of symptoms, we analyzed the prognostic power of resolution of chest pain and ST-segment elevation >50% at 90 minutes, abrupt creatine kinase rise before 12 hours, and T-wave inversion in infarct-related electrocardiographic leads within the first 24 hours after thrombolysis. RESULTS: Global in-hospital mortality rate was 12.0%. Each reperfusion marker was associated with improved outcome. Multivariate logistic regression analysis showed that 3 of the 4 markers of coronary artery reperfusion were significantly and independently associated to low in-hospital mortality rate. The presence of early T-wave inversion was associated with the lowest in-hospital mortality rate (odds ratio 0.25, confidence interval 0. 10-0.56). When all markers of coronary artery reperfusion were included in the regression model, T-wave inversion (odds ratio 0.29, confidence interval 0.11-0.68) and abrupt creatine kinase rise (odds ratio 0.36, confidence interval 0.16-0.77) continued to be significantly associated with better outcome. CONCLUSION: A systemic analysis of noninvasive markers of coronary artery reperfusion can provide the clinician with an excellent tool to predict clinical outcomes when treating myocardial infarction.

[Acute myocardial infarction in Chilean hospitals. Final results of the GEMI study]. / Infarto agudo del miocardio en hospitales chilenos. Resultados finales del estudio GEMI. Grupo de Estudio Multicéntrico del Infarto (GEMI).

BACKGROUND: Acute myocardial infarction is the leading cause of death in Chile. AIM: To report the main features, hospital evolution, complications and pharmacological treatment of patients admitted to Chilean hospitals with the diagnosis of acute myocardial infarction. PATIENTS AND METHODS: Between 1993 and 1995, the GEMI group registered 2,957 patients admitted to 37 hospitals with the diagnosis of acute myocardial infarction. RESULTS: Mean age of patients was 62 +/- 2 years old and 74% were male. Forty six percent had a history of hypertension and 40% were smokers. During the first five days of admission, 93% of patients received aspirin, 95% received intravenous nitrates, 59% intravenous heparin, 56% oral nitrates, 37% beta blockers, 32% angiotensin-converting enzyme inhibitors, 33% thrombolytic agents, 29% antiarrhythmics and 23% calcium antagonists. Coronary angiograms were performed in 28% of patients, angioplasty in 9% and 8% were subjected to a coronary bypass. Global hospital mortality was 13.4% (19.5% in women and 11.1% in men, p < 0.001). CONCLUSIONS: This work gives a picture of myocardial infarction in Chilean hospitals. Pharmacological treatment is similar to that used abroad, but certainly it can be optimized.

[Treatment of atrial fibrillation: a persistent dilemma]. / Tratamiento de la fibrilación auricular: un dilema permanente.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Increased life expectancy will result in a higher prevalence of AF. Treatment of AF constitutes a persistent medical dilemma. Different multicenter trials have confirmed that oral anticoagulant therapy is the best choice for the prevention of systemic embolism. It must be recognized, however, that the incidence of systemic embolism in patients with AF varies according to the presence and type of underlying heart disease. Advanced age increases the risk of emboli in patients with AF. At the same time, older patients have a higher risk of hemorrhage when treated with oral anticoagulants. Thus, careful titrated individual oral anticoagulant therapy targeted to a safe and effective INR must be considered in patients with AF. Another dilemma in AF patients is the convenience of restoring sinus rhythm and indicating permanent antiarrhythmic therapy versus the alternative of heart rate control plus oral anticoagulants. Several multicenter trials now in progress have addressed this issue and most likely will answer these questions. Identification of patients with paroxysmal AF and risk of systemic embolism constitutes another dilemma, since only a small proportion of these patients evolve to chronic arrhythmia. Advanced age, history of hypertension and left atrial enlargement in 2D Echo are well recognized risk factors for embolism in patients with non valvular paroxysmal AF. A history of previous embolism constitutes another risk factor and supports the hypothesis that AF may activate systemic coagulation factors and left atrial thrombus formation in some patients.

[Cardiac rhythm and systemic embolism in long-term follow up of patients with non-valvular paroxysmal atrial fibrillation]. / Ritmo cardíaco y embolias sistémicas en la evolución alejada de pacientes con fibrilación auricular paroxística no valvular.

BACKGROUND: Paroxysmal atrial fibrillation may predispose to systemic embolism. There is little information about the evolution of cardiac rhythm and the occurrence of new embolic events in these patients. AIM: To report the results of a long term follow up of patients with paroxysmal atrial fibrillation. PATIENTS AND METHODS: Patients consulting for non valvular paroxysmal atrial fibrillation were followed for a mean period of 5 years. An EKG, 2D echocardiogram and brain CT scans were performed on admission and at the end of the follow up period to all patients. RESULTS: Sixty eight patients aged 65 +/- 1.5 years were studied. Thirty two had an idiopathic atrial fibrillation, 28 had a history of mild hypertension and 8 had a history of coronary artery disease. Evidence of systemic emboli was found in 17 patients at entry (to the brain in 14 patients). During the follow up 87% of patients required antiarrhythmics, 27% were anticoagulated and 28% received aspirin. Five patients had new embolic episodes. Of these, four had a history of prior embolism. Forty one percent of patients continued in sinus rhythm and remained asymptomatic, 32% had at least one recurrence of paroxysmal atrial fibrillation and nine patients evolved to chronic atrial fibrillation. Five patients required a permanent pacemaker due to symptomatic bradycardia. CONCLUSIONS: Most patients with non valvular paroxysmal atrial fibrillation remain in sinus rhythm but one third have recurrences of the arrhythmia. A main risk factor for embolism is the history of previous embolic episodes.

[Comparison of low-molecular-weight heparin and unfractionated heparin in the treatment of unstable angina]. / Heparina de bajo peso molecular versus heparina no fraccionada en el tratamiento de la angina inestable.

BACKGROUND: Low molecular weight heparin can be administered by the subcutaneous route and has a stable and prolonged antithrombotic effect. These features have prompted clinical essays about its use as an alternative to unfractionated heparin in the treatment of unstable angina. AIM: To compare the clinical effects of low molecular weight heparin and unfractionated conventional heparin in patients with unstable angina or non Q infarction. PATIENTS AND METHODS: Seventy patients (47 male) admitted to the hospital with the diagnosis of unstable angina or non Q acute myocardial infarction were randomly assigned to receive unfractionated intravenous heparin or subcutaneous low molecular weight heparin bid. All received aspirin p.o. and i.v. nitroglycerin. The incidence of recurrent angina, acute myocardial infarction or a need for emergency surgical revascularization during hospital stay were assessed in both groups. RESULTS: Compared to patients with low molecular weight heparin, patients receiving unfractionated heparin had a higher incidence of recurrent resting angina (23 and 47.5% respectively, p < 0.04) and higher need for emergency surgical revascularization (3.3 and 17.5% respectively, p < 0.06). Patients treated with unfractionated conventional heparin had a 3 times higher risk of having an adverse cardiovascular event than patients receiving low molecular weight heparin (O.R. 0.33, confidence intervals 0.11-0.58). CONCLUSIONS: Low molecular weight heparin is superior to unfractionated conventional heparin in the treatment of unstable angina and non Q acute myocardial infarction.

Selective increase in cardiac IGF-1 in a rat model of ventricular hypertrophy.

There is evidence that insulin-like growth factor-1 (IGF-1) plays a role in the development of left ventricular hypertrophy, but it is uncertain whether cardiac IGF-1 changes before or after hypertension is established, and whether circulating IGF-1 are involved in cardiac hypertrophy. We have investigated changes in circulating and left ventricular IGF-1 and in the expression of the IGF-1 gene in the left ventricles of rats during the development of hypertensive left ventricular hypertrophy (Goldblatt model; 2 kidney-1 clamped). Our results show that the left ventricular contents of IGF-1 and its mRNA were increased at one and four weeks of hypertension and hypertrophy, and that both returned to control values after nine weeks. These changes were unrelated to the seric concentration of IGF-1 in the blood. These results show that local rather than circulating IGF-1 levels contributed to the development of renovascular hypertensive left ventricular hypertrophy.

[Effects of ramipril and spironolactone on ventricular remodeling after acute myocardial infarction: randomized and double-blind study]. / Ramipril vs espironolactona en el remodelamiento ventricular izquierdo post-infarto: estudio randomizado y doble ciego.

BACKGROUND: Studies have shown that angiotensin converting enzyme (ACE) inhibition prevents left ventricular remodeling and cardiovascular events after an acute myocardial infarction. The role of aldosterone in ventricular remodeling after a myocardial infarction has not been addressed. AIM: To compare the effects of an ACE inhibitor, an aldosterone receptor antagonist and placebo on left ventricular remodeling after a first episode of transmural acute myocardial infarction. PATIENTS AND METHODS: Patients hospitalized for a first episode of acute myocardial infarction were blindly and randomly assigned to receive ramipril (2.5 mg bid), spironolactone (25 mg tid) or placebo. Ejection fraction, left ventricular end diastolic and end systolic volumes were measured by multigated radionuclide angiography, at baseline and after six months of treatment. RESULTS: Twenty four patients were assigned to placebo, 31 to ramipril and 23 to spironolactone. Age, gender, Killip class, treatment with thrombolytics, revascularization procedures and use of additional medications were similar in the three groups. After six months of treatment, ejection fraction increased from 34.5 +/- 2.3 to 40.2 +/- 2.4% in patients on ramipril, from 32.6 +/- 2.9 to 36.6 +/- 2.7% in patients on spironolactone, and decreased from 37 +/- 3 to 31 +/- 3% in patients on placebo (ANOVA between groups p < 0.05). Basal end systolic volume was similar in all three groups, increased from 43.4 +/- 3.4 to 61.4 +/- 6.0 ml/m2 in patients on placebo and did not change in patients on spironolactone or ramipril (ANOVA p < 0.05). End diastolic volume was also similar in the three groups, increased from 70.6 +/- 4.3 to 92.8 +/- 6.4 ml/m2 in patients on placebo and did not change with the other treatments. CONCLUSIONS: Ramipril and spironolactone had similar effects on ventricular remodeling after acute myocardial infarction, suggesting that aldosterone contributes to this phenomenon and that inhibition of its receptor may be as effective as ACE inhibition in its prevention.

[Vasodilator hormonal agents in chronic heart failure: effect of angiotensin-converting enzyme inhibitors]. / Hormonas vasodilatadoras en la insuficiencia cardíaca crónica: efecto de la inhibición de la enzima convertidora de angiotensina.

BACKGROUND: Administration of angiotensin converting enzyme (ACE) inhibitors to patients with congestive heart failure (CHF) is associated to a decrease in the abnormal vasoconstrictor neurohormonal activity. This contributes to the sustained benefits of these drugs on symptoms and survival of patients with CHF. There is little information, however, regarding the effects of ACE inhibition on vasodilator and natriuretic hormones. AIM: To evaluate the chronic effects of enalapril, in addition to digitalis and diuretics in patients with chronic cardiac failure. PATIENTS AND METHODS: Nine patients with an idiopathic dilated cardiomyopathy (8 male, aged 48 to 76 years old) under treatment with digitalis and diuretics, received enalapril 20 mg bid during eight weeks. Before and after this treatment period resting left ventricular ejection fraction, functional class, plasma levels of atrial natriuretic factor and bradykinins (BK) and urinary excretion of kalikreins (BK) and prostaglandin E2 (PGE2) were measured. RESULTS: After enalapril therapy, there was a significant increase in maximal O2 consumption (14.8 +/- 1.2 to 18.6 +/- 1.5 ml/kg/min, p < 0.05) and radionuclide LV ejection fraction (27.4 +/- 1.1 to 31.4 +/- 0.9% p < 0.05). This was associated with a significant decrease in plasma ANP levels (559 +/- 158 to 178 +/- 54.8 pg/ml) and UK (391 +/- 112 to 243 +/- 92 Cu/24 h). CONCLUSIONS: The decrease in ANP levels, which is a well known marker of prognosis in CHF, could contribute to explain the sustained clinical benefits observed with ACE inhibitors in patients with CHF.

[Growth hormone deficiency in patients with chronic heart failure]. / Déficit de hormona de crecimiento en pacientes con insuficiencia cardíaca crónica.

BACKGROUND: Experimental and preliminary clinical data in patients with dilated cardiomyopathy show that growth hormone has a positive inotropic effect and contributes to peripheral vasodilatation. However, there is little information about the activity of growth hormone-IGF-1 axis in patients with chronic heart failure. AIM: To measure growth hormone and IGF-1 levels in patients with chronic heart failure. PATIENTS AND METHODS: Nine patients, aged 49 to 76 years old, 7 male, were studied. Seven had an idiopathic dilated cardiomyopathy and 2 a coronary heart disease. All had a stable cardiac failure, in functional capacity II or III and were receiving digoxin, furosemide and potassium supplements. Thyroid hormone levels, basal and exercise growth hormone and IGF-1 levels were measured and compared with reference values for American populations. Left ventricular ejection fraction was measured with an isotopic technique and nutritional status using anthropometry and indirect calorimetry. RESULTS: Anthropometric measures, basal and post-prandial oxygen consumption were within normal limits. Thyroid hormone levels were normal. During maximal exercise, growth hormone levels were 2.56 +/- 4.1 ng/ml and IGF-1 levels were 0.56 +/- 0.61 mU/ml. These values were significantly lower than expected for age and sex. CONCLUSIONS: These patients with chronic cardiac failure have lower than normal growth hormone and IGF-1 levels.

[Prognostic value of noninvasive makers of coronary reperfusion in patients with acute myocardial infarction treated with thrombolysis]. / Valor pronóstico de los índices no invasivos de reperfusión coronaria en pacientes con infarto agudo del miocardio tratados con trombolisis.

BACKGROUND: The immediate prognosis of patients with acute myocardial infarction treated with thrombolysis primarily depends on obtaining a satisfactory coronary reperfusion. AIM: To assess the prognostic power of four markers of coronary artery patency in patients with acute myocardial infarction treated with Streptokinase 1.5 million U within the first six hours of symptoms. PATIENTS AND METHODS: In 807 consecutive patients from the Chilean National Registry of Acute Myocardial Infarction we analyzed the resolution of chest pain and ST segment elevation over 50% within the first 90 min, abrupt CK rise within 8 h and T wave inversion in infarct related EKG leads within the first 24 h after thrombolysis. RESULTS: Global in-hospital mortality was 12.1%. Mortality of patients with the presence of 3 or 4 markers of coronary artery patency was 5.1%, in those with resolution of ST elevation and abrupt CK rise was 6.25% and in those with T wave inversion it was 3.9% (p < 0.001). Multivariate analysis, adjusted by age, gender, risk factors, Killip class and infarct location showed that early T wave inversion was the better predictor of a low in-hospital mortality and that its combination with other markers of coronary artery patency did not increase its prognostic power. Early CK rise and the presence of 3 out of 4 reperfusion criteria were also independent predictors of a low mortality. CONCLUSIONS: Non invasive markers of coronary artery patency are associated with a lower in-hospital mortality and may serve as surrogate end points in clinical trials.

[Acute myocardial infarction in Chile: differences between men and women in its evolution and prognosis. Multicenter Study Group on Infarction] (GEMI)]. / Infarto agudo del miocardio en Chile: diferencias entre hombres y mujeres en su evolución y pronóstico. Grupo de Estudios Multicéntrico de Infarto (GEMI).

BACKGROUND: Gender may be a prognostic factor for the evolution of acute myocardial infarction and women may have higher mortality and complication rates. AIM: To study if there are differences in the evolution of acute myocardial infarction between men and women. PATIENT AND METHODS: We have recorded information on risk factors, clinical evolution, treatment and complications of 2,052 patients hospitalized for acute myocardial infarction in 36 Chilean hospitals. The odds ratio for female sex and mortality was calculated using a logistic regression analysis adjusted for risk factors, treatment, invasive procedures and complications. RESULTS: Twenty six percent of analyzed patients were female. Mortality rates among females and males were 11.8 and 20.2% respectively (p < 0.01). Women had higher frequency of smoking, diabetes, obesity and hypertension. Blood lipid levels were similar in both sexes. Compared to men, a lesser proportion of women were treated with thrombolytic agents (25 and 35% respectively), intravenous heparin (54 and 61% respectively), beta blockers (31 and 42% respectively) and intravenous nitrates (53 and 61% respectively). Also, women were subjected to less invasive procedures. The odds ratio for mortality and sex was 1.72 (confidence interval from 1.13 to 2.62). CONCLUSIONS: Female sex is an independent risk factor for acute myocardial infarction mortality.

[Noncardiogenic pulmonary edema associated with hydrochlorothiazide use]. / Edema pulmonar no-cardiogénico relacionado con la hidroclorotiazida.

A 54 years old female patient with a mitral valve prolapse and a rheumatoid arthritis treated with steroids was admitted with dyspnea and hypotension, that started 30 min after taking a pill containing enapril and hydrochlorothiazide. Hemodynamic monitoring with a Swan-Ganz catheter showed a pulmonary capillary pressure of 5 mm Hg, a systemic vascular resistance of 887 (dyn sec)/cm5 and a cardiac output of 10 l/min. The patient had a history of adverse reactions to thiazides and responded to volume replacement, dopamine and steroids.

Cyclic AMP-dependent protein kinase and mechanical heart function in ventricular hypertrophy induced by pressure overload or secondary to myocardial infarction.

The role of cyclic AMP-dependent protein kinase (PKA) and systolic function during the development of left ventricular hypertrophy (LVH) still remain uncertain. The aim of this work is to study PkA activity and mechanical heart function in two experimental heart hypertrophy models: specifically, one induced by pressure overload (Goldblatt model: two kidneys, one clamped, Gb); and another secondary to myocardial infarction (MI) generated by ligation of the left coronary artery. Hypertension in the Gb group becomes evident by the third and fourth week after surgery without any significant change in the corresponding sham group. The myocardial infarction group did not show any change in systolic pressure. Different degrees of LVH for the two experimental models were observed. Relative cardiac mass (RCM) and relative ventricular mass (RVM) increased 23 and 16%, respectively, above the sham-operated rats in MI group (P < 0.05). For the pressure overload model, the increase values were 42 and 44%, respectively (P < 0.05). Left ventricular hypertrophy was also evaluated through quantitative changes in cardiac beta-myosin heavy chain which agreed with morphometric studies in Goldblatt rats. Ventricular PKA activity did not show any significant difference with respect to the sham-operated group after induction of pressure overload. For the MI model, ventricular PKA activity changed only at day 7 post-infarction with a 289% increase above the sham-operated group (P < 0.05). The absence of activation of ventricular PKA after constriction of renal artery or myocardial infarction was also corroborated by the patterns of PKA-dependent phosphorylated proteins. While force-generating capacity was increased, there was no change in ventricular PKA activity, indicating that there is no relation between this enzyme and systolic stress-strain regression lines in either pressure overload or myocardial infarction conditions. Cyclic AMP-dependent protein kinase activity had no relation with development of cardiac hypertrophy in the two experimental models of LVH. These findings contribute to the hypothesis for a multifactorial interaction of different intracellular biochemical and molecular mechanisms in the genesis of cardiac hypertrophy.