Additive value of diabetes and peripheral arterial disease in the risk stratification of patients admitted after an acute coronary syndrome: a subanalysis of the PAMISCA Study.

BACKGROUND: There is an increasing interest in the use of non-invasive methods for the detection of subclinical atherosclerosis to better identify patients with high risk of cardiovascular events The presence of diabetes mellitus (DM) and peripheral arterial disease (PAD) is associated with increased risk of events but their value in the acute coronary syndrome (ACS) patient has not been ascertained. METHODS: We performed a subanalysis of the PAMISCA study, designed to investigate the prevalence of PAD in patients admitted to Spanish hospitals with a diagnosis of an ACS. RESULTS: A total of 1410 patients were analysed (71.4% men, age 66 +/- 11.9 years, 35% DM). The prevalence of PAD was higher in DM vs. no-DM (41.5% vs. 30.6% respectively, p < 0.001). Patients with PAD and DM had more in-hospital cardiac complications such as atrial fibrillation/flutter, recurrent myocardial ischaemia and heart failure and a trend towards higher in-hospital mortality (p = 0.08). Non-DM patients with PAD and DM without PAD shared similar cardiac complications and the group without neither PAD nor DM had the best prognosis. In patients without PAD, DM was an independent predictor of three-vessel coronary disease (OR 1.6; 95% CI: 1.1-2.5, p < 0.05) after adjustment by age, sex, low density lipoproteins (LDL), smoking and the previous myocardial infarction. However, in PAD patients, DM failed to be an independent risk factor in the multivariate analysis (OR 1.0; 95% CI 0.6-1.6, p < 0.05). CONCLUSIONS: The concurrence of DM and PAD helps identify patients with an adverse risk profile.

Seguridad cardiovascular de los inhibidores de la ciclooxigenasa 2 / Cardiovascular safety of ciclooxigenase 2 inhibitors

Los inhibidores de la ciclooxigenasa 2 (celecoxib y rofecoxib) son fármacos antiinflamatorios no esteroideos potentes y con un excelente perfil de seguridad cardiovascular. Sin embargo, en un artículo reciente se sugiere que estos fármacos podrían presentar un incremento del riesgo de complicaciones cardiovasculares tromboembólicas. En el presente artículo analizamos los datos disponibles hasta la fecha sobre la seguridad cardiovascular de los inhibidores de la ciclooxigenasa 2 (AU)

[The clinical practice guidelines of the Sociedad Española de Cardiología on pericardial pathology]. / Guías de práctica clínica de la Sociedad Española de Cardiología en patología pericárdica.

The pericardium is a serous membrane consisting of two layers (parietal and visceral), which may be involved by different infectious, physical, traumatic, or inflammatory agents as well as in metabolic or systemic diseases. The reactions of the pericardium to these insults result in rather nonspecific clinical features, such as the characteristic inflammatory findings in acute pericarditis, the development of pericardial effusion with the possible complication of cardiac tamponade, and a fibrous retractile reaction that may lead to constrictive pericarditis. These phenomena are not mutually exclusive and can be simultaneous or consecutive in the same patient; however, for the sake of clarity they are independently discussed. The aim of the present guidelines is to provide orientation about the management of patients with pericardial disease. Such management should basically rest on the knowledge of the clinical and epidemiological features (such as disease frequency) of the different types of pericardial disease that determine the diagnostic and therapeutic yield of the different invasive pericardial procedures (pericardiocentesis, pericardial biopsy and pericardiectomy), and, therefore, their respective indications. In addition, the indication of the different types of medical therapy are discussed. On the other hand, emphasis is made on the possible limitation of the validity of these guidelines for patients belonging to geographical areas or socioeconomic contexts with different etiologic spectra.

[The hemodynamic effects of the combination of milrinone in heart failure refractory to treatment with dopamine, dobutamine and/or nitroprusside]. / Efectos hemodinámicos de la asociación de milrinona en la insuficiencia cardíaca refractaria al tratamiento con dopamina, dobutamina y/o nitroprusiato.

INTRODUCTION: Classical treatment of advanced heart failure is mainly based on the intravenous administration of inotropic drugs and vasodilators. Phosphodiesterase-III inhibitors, drugs whose effectiveness is not affected for the beta-receptor downgrading, may be particularly helpful in patients with severe heart failure refractory to conventional treatment with dopamine, dobutamine and/or nitroprusside. PATIENTS AND METHODS: We have analysed the hemodynamic effects of milrinone in 13 patients (11 men, 2 women, mean age 55 +/- 12 years) with advanced heart failure resistant to dopamine, dobutamine and/or nitroprusside. Basally, before milrinone was administered, mean cardiac index and pulmonary capillary wedge pressure were 1.9 +/- 0.4 l/min/m2 and 25 +/- 6 mmHg, respectively. Milrinone was administered intravenously with a initial dose of 50 micrograms/kg over 10 minutes and followed by and infusion of 0.75 micrograms/kg/min over 6 hours. RESULTS: During milrinone administration cardiac index and stroke volume index significantly increased (40% and 28%, respectively) (p < 0.05). Furthermore, systemic and pulmonary vascular resistance indexes significantly decreased (17% and 30%, respectively) (p < 0.05). Mean right atrial pressure and pulmonary capillary wedge pressure also decreased (36% and 20%, respectively), but differences did not reach statistical significance. Milrinone was well tolerated and no patient presented serious side-effects. CONCLUSION: Our results suggest that in patients with advanced heart failure refractory to conventional treatment with dopamine, dobutamine and/or nitroprusside, the addition of milrinone significantly improves parameters of systolic function.

[The differential characteristics of early ventricular arrhythmias following a myocardial infarct in patients with and without ventricular fibrillation]. / Características diferenciales de las arritmias ventriculares precoces tras un infarto de miocardio en pacientes con y sin fibrilación ventricular.

OBJECTIVE: To evaluate the characteristics of early ventricular arrhythmias in acute myocardial infarction and their predictive value of ventricular fibrillation. PATIENTS AND METHODS: We retrospectively compared 85 patients who presented ventricular fibrillation with a control group of 187 consecutively acute myocardial infarction patients recorded within the first 12 hours after onset of acute myocardial infarction symptoms. Patients in Killip class III-IV were excluded. RESULTS: In the ventricular fibrillation group we observed a high prevalence of inferior site of infarction (69 vs 56%; p < 0.05), sum of ST in 3 leads (ST-3 leads) with maximal elevation (13 +/- 17 vs 8 +/- 7 mm; p < 0.005), basic heart rate (97 +/- 23 vs 88 +/- 18 bpm; p < 0.01), R-on-T phenomenon (16 vs 2%; p < 0.001). In 22 patients in whom the ventricular fibrillation episode was registered, the basic heart rate preceding the ventricular fibrillation was fast (113 +/- 54 bpm), and the prematurity index (coupling interval/QT) shorter than in the other ventricular arrhythmias (0.9 +/- 0.2 vs 1.2 +/- 0.3 s respectively; p < 0.005). The prematurity index of ventricular arrhythmias in the ventricular fibrillation group was shorter than in the control group (1.2 +/- 0.3 vs 1.5 +/- 0.3 s respectively; p < 0.0001) and the heart rate during runs was faster (172 +/- 54 vs 126 +/- 40 bpm; p < 0.01). The logistic regression analysis showed that R-on-T phenomenon (odds ratio [OR] = 2.8), inferior site of infarct (OR = 3.65), sum of ST-3 leads > 10 mm (OR = 5.82), and basic heart rate > 100 bpm (OR = 2.33) were independent risk factors for ventricular fibrillation. CONCLUSION: Characteristic ventricular arrhythmias were found to precede ventricular fibrillation episodes: R-on-T phenomenon or short prematurity index and fast runs of ventricular tachycardia, with other parameters such a inferior site of infarct, sum of ST-3 leads > 10 mm and basic heart rate > 100 bpm.

Do silent myocardial ischemia and ventricular arrhythmias interact to result in sudden death?

The relationship between silent myocardial ischemia and sudden death depends on the severity and duration of the ischemia. Severe, transmural and persistent ischemia, as occurs in myocardial infarction, can trigger sudden death. When the ischemia is severe and transmural but not long-standing (e.g., Prinzmetal angina), ventricular arrhythmias appear frequently, but they are rarely malignant. In cases of subendocardial ischemia, there is no definitive proof of this relationship.

[The hemodynamic profile of the response to amrinone treatment in severe heart failure]. / Perfil hemodinámico de la respuesta al tratamiento con amrinona en la insuficiencia cardíaca severa.

The hemodynamic response to amrinone was analyzed in 19 patients with severe heart failure (NYHA III or IV). In 17 patients, 2 bolus of amrinone (0.75 mg/kg) were administered with an interval of 30 minutes, while a single bolus only was administered in 2 patients. In all patients the initial bolus was followed by continuous perfusion of Amrinone (10 micrograms/kg/min in 17 patients; 7 and 5 micrograms/kg/min in the remaining two). Cardiac index increased from 1.8 +/- 0.2 to 2.5 +/- 0.4 l/min/m2 (p less than 0.01), and pulmonary capillary wedge pressure and mean right atrial pressure decreased significantly (from 24 +/- 5.2 to 14 +/- 6 mmHg, p less than 0.01; and from 8.7 +/- 6.5 to 3.2 +/- 3.4, p less than 0.05 respectively). There were no significant changes in mean blood pressure (93 +/- 17 versus 88 +/- 13), heart rate (81 +/- 15 versus 84 +/- 14 beats per minute) and systolic work index (26.4 +/- 10.7 versus 37.7 +/- 12.3 g-m/m2). The maximum effect was obtained at 60 minutes and maintained throughout the period of monitoring (8 hours). In the 2 patients who received a single bolus of amrinone the maximum effect was reached at 30 minutes (cardiac index 1.3 +/- 0.1 versus 2.5 +/- 0.1 l/min/m2; pulmonary capillary pressure 24 +/- 5 versus 16.8 +/- 6.5 mmHg; mean right atrial pressure 11 +/- 1 versus 3.5 +/- 3.5 mmHg), and was followed by a progressive loss of efficiency, until effect had totally disappeared and situation basal returned, between the third and fourth hours.(ABSTRACT TRUNCATED AT 250 WORDS)