[Early percutaneous revascularization in patients with unstable angina. Current results and comparison with conservative medical treatment]. / Revascularización precoz percutánea en los pacientes con angina inestable. Resultados actuales y comparación con el tratamiento médico conservador.

In patients with ongoing angina, despite optimal medical therapy, the best therapeutic alternative is coronary angiography followed by emergency coronary revascularization with surgery or angioplasty. However, whether or not all patients should have early angiography and revascularization is a matter of debate. This paper reviews the advantages of modern medical therapy in this setting and the problems associated with early coronary revascularization. In particular, it analyses the data from the main clinical trials that have specifically compared an early invasive procedure with a conservative strategy in unstable coronary syndromes. Finally, it assesses the impact of the new antithrombotic agents, such as glycoprotein IIb/IIIa receptor blockers, particularly during coronary percutaneous interventions. The data reviewed suggest that early invasive intervention should be reconsidered, and that patients should be controlled (if possible) under medical treatment until non invasive stratification tests allow the identification of those patients who would benefit most from revascularization.

[An assessment of myocardial ischemia in women with the exercise test validated by coronary angiography]. / Evaluación de la isquemia miocárdica en mujeres con la prueba de esfuerzo validada mediante coronariografía.

Ischemic heart disease has been studied in men and women only as a group. We studied the sensitivity and specificity of the exercise stress testing in women. The exercise stress testing (EST) was validated with the coronary arteriography. We studied 72 women and 129 men, the mean age was 55 years for women and 51 years for men. We found in women 83.2% of estimated maximal heart rate; the rate pressure product was 2.4, no different from the values recorded in men (p greater than 0.06). The blood pressure response to exercise was higher in women, and the maximal work capacity was more elevated in men (p less than 0.006). We found normal coronary arteries in 41 women, 70.7% with a positive (EST) compared with a 87.07% in men. The sensitivity and specificity of the exercise stress testing for the diagnosis of ischemic heart disease is smaller in women.

[Dynamic intracavitary echoes studied by transthoracic and transesophageal echocardiography]. / Ecos dinámicos intracavitarios estudiados con ecocardiografía transtorácica y transesofágica.

One hundred consecutive echocardiograms performed on adults using transthoracic and transesophageal (TEE) transducers were analyzed in order to determine the prevalence of spontaneous contrast (SC) and the factors associated with it. Indications for study included complex congenital cardiopathy, evaluation of valve lesions or prosthetic valves, dissecting aortic aneurysm, cardiac masses and evaluation of ventricular function. SC was observed only with TEE and appeared in 25% of cases, most frequently in left atrium. Factors associated with contrast included mitral valve disease and replacement, ventricular dysfunction, left atrial dilatation and atrial fibrillation. An important relationship existed between SC and presence of thrombi. Atrioventricular valvular regurgitation was not associated with SC. Results are compared with those of previous series.

[The clinical features of myocardial infarct via "normal" coronary angiography. The experience of the Instituto Nacional de Cardiología]. / Rasgos clínicos del infarto del miocardio con coronariografía "normal". Experiencia del Instituto Nacional de Cardiología.

The end-point of our study was to find clinical differences between patients with myocardial infarction and evident obstructions in coronary angiography, and patients without coronary obstructions. In a 10 years follow-up period, 48 patients with diagnosis of myocardial infarction and normal coronary arteries by angiography (group A) where admitted al hospital. We compared this group with 80 patients (group B), randomly selected from all patients with myocardial infarction and evident obstructions in coronarography. Patient age at the ischemic event, familiar history of ischemic heart disease or sudden death, obesity, drug habits, contraception drugs use, and history of migraine and Raynaud's phenomenon were pointed out. Thirty patients from group A were admitted with acute myocardial infarction, and we also analysed in these patients prodromal symptoms, precipitating factors, AMI localisation, serum enzymatic levels, rhythm and/or conduction disturbances, clinical condition, treatment and new ischemic events. Group A patients showed lower age-average, smoking habit, prodromal symptoms and serum CPK levels. They have better ventricular performance parameters and a greater incidence of women. The only different risk factor for ischemic heart disease between both groups was smoking.

[Postoperative course of prosthetic valve replacement]. / Evolución postoperatoria en el recambio valvular protésico.

In order to know the post-operative outcome of patients with valvular replacement due to prosthetic dysfunction, we reviewed the clinical charts of 94 patients operated at the Instituto Nacional de Cardiología "Ignacio Chávez" between January 1986 and December 1988. Eighty four cases were replaced by the first time the remaining 10 by a second time. Diagnosis of prosthetic dysfunction was made by clinical, radiological, echocardiographic and haemodynamic parameters. The most frequent causes of dysfunction were the rupture of prosthetic leaflets, stenosis with calcific deposition and paravalvular leaks. The global mortality rate was 19.15%, higher than the native valve replacement group. The most important predictors of surgical mortality were: 1) poor ventricular function (functional classes III and IV), 2) aortic clamping period, 3) the need of a second prosthetic replacement and 4) the time of prosthetic dysfunction. Thus, we conclude that it is of great importance the early recognition of prosthetic valve dysfunction. The need of special surgical procedures in these cases should be evaluated in order to reduce morbidity and mortality.

[Partial pericardial tamponade immediately after cardiac surgery]. / Taponamiento pericárdio parcial en el postoperatorio inmediato de cirugía cardíaca.

Partial pericardial tamponade is a critical situation frequently misdiagnosed. We describe five patients with this entity during an urgent surgical reintervention performed few hours after the initial one. We found clots compressing cardiac cavities in all, usually in the right atrium. In one of them we found also a clot compressing the left atrium. None of the patients studied had the classical clinical features of cardiac tamponade (Kussmaul's sign: pulsus paradoxus) and we found no difference in blood pressure, quantity of bleeding or pulmonary capillary pressure, considering the reinterventional moment in comparison to the values taken immediately after the initial surgery and the ones registered during the surgical reintervention. There was significative increase in the central venous pressure value, decreased urine output and drop in the cardiac index. Based on this observation, we believe it is possible to have a presumptive diagnosis of partial pericardial tamponade by bidimensional echocardiographic studies just before the surgical reintervention.

[Myocardial infarct immediately after a normal exercise test]. / Infarto de miocardio inmediatamente después de una prueba de esfuerzo normal.

Two cases of myocardial infarction immediately following a normal stress testing, are described. The incidence and possible pathophysiological mechanisms are discussed. In one of the patients it was difficult to establish the pathophysiological mechanism which was the cause of the ischemic event. In the other, the coronary arteriography revealed only minimal obstructive disease. Therefore, coronary vasospasm with thrombus formation as a cause of the infarction ia an interesting speculative possibility in view of the angiographic findings. Acute myocardial infarction after a normal electrocardiographic response to maximal exercise testing is extremely rare, and the precise pathophysiologic mechanism that leads to his complication is not clear.

[Cardiovascular abnormalities in Ehlers-Danlos syndrome. Report of a case]. / Anormalidades cardiovasculares en el síndrome de Ehlers-Danlos. Informe de un caso.

This is the case of a 34-year-old woman with Ehlers-Danlos syndrome whose cardiopulmonary manifestations are the following: Prolapse of mitral and tricuspid valves. Aneurysmal dilatation of main arteries without aortic or pulmonary insufficiency. Disturbances in pulmonary function tests and pulmonary arterial hypertension. The diagnosis was verified by skin biopsy and an electron microscopic study. Due to the clinical and histopathological characteristics, we have considered this case to be a non-specified type of the 10 varieties described up to now, and have decided to report it also because of the interesting findings in the hemodynamic and pulmonary function tests.