Resultados en España de la encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) / Spanish results of the Second European Cardiac resynchronization therapy survey (CRT-Survey II)

Introducción y objetivos: Se describen los resultados en España de la segunda encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) y se comparan con los de los demás países participantes. Métodos: Pacientes a los que se implantó un dispositivo de terapia de resincronización cardiaca entre octubre de 2015 y diciembre de 2016 en 36 centros participantes. Se recogieron datos sobre las características basales de los pacientes y del implante, y un seguimiento a corto plazo hasta el alta hospitalaria. Resultados: La tasa de éxito del implante fue del 95,9%. La mediana [intervalo intercuartílico] de implantes anuales/centro en España fue significativamente menor que en los demás países participantes: 30 [21-50] frente a 55 [33-100] implantes/año (p=0,00003). En los centros españoles hubo una menor proporción de pacientes de edad ≥ 75 años (el 27,9 frente al 32,4%; p=0,0071), una mayor proporción de pacientes en clase funcional II de la New York Heart Association (el 46,9 frente al 36,9%; p <0,00001) y un mayor porcentaje de pacientes con criterios electrocardiográficos de bloqueo de rama izquierda (el 82,9 frente al 74,6%; p <0,00001). La media de la estancia hospitalaria fue menor en los centros españoles (5,8+/-8,5 frente a 6,4+/-11,6; p <0,00001) y una mayor proporción de pacientes recibieron un cable de ventrículo izquierdo cuadripolar (el 74 frente al 56%; p <0,00001) y fueron seguidos a distancia (el 55,8 frente al 27,7%; p <0,00001). Conclusiones: La encuesta CRT-Survey II muestra que en España hay una menor proporción de pacientes de 75 o más años que reciben un dispositivo de terapia de resincronización cardiaca, una mayor proporción de pacientes en clase funcional II de la New York Heart Association, con bloqueo completo de la rama izquierda del haz de His y con seguimiento a distancia, con estancias hospitalarias significativamente menores

Introduction and objectives: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. Methods: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. Results: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in NYHA class II (46.9% vs 36.9%, P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8+/-8.5 days vs 6.4+/-11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%, P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). Conclusions: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring

Spanish Results of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II).

INTRODUCTION AND OBJECTIVES: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. METHODS: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. RESULTS: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in New York Heart Association functional class II (46.9% vs 36.9%; P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8±8.5 days vs 6.4±11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%; P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). CONCLUSIONS: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring.

A scoring algorithm for the accurate differential diagnosis of regular wide QRS complex tachycardia.

BACKGROUND: The differential diagnosis of regular wide QRS complex tachycardia (RWQRST) remains the subject of numerous publications, all of which aim at diagnosis during the acute phase. Although an accurate diagnosis is necessary to make long-term decisions, it often leads to invasive testing. METHODS: Criteria with high positive predictive values (PPVs) for diagnosis can be obtained by analyzing the electrocardiogram (ECG) data during RWQRST and comparing them with these data at baseline. By assigning points to these criteria, a scoring algorithm to accurately diagnose numerous patients can be obtained. A total of 352 consecutive patients with RWQRST were included. Two electrophysiologists blind to patient condition analyzed the 16 criteria considered as having high PPVs. RESULTS: A total of 149 (42.3%) cases were supraventricular tachycardia (SVT), and 203 (57.7%) cases were ventricular tachycardia (VT). A higher percentage of patients with VT had structural heart disease (86.7% vs 16.1%). Seven of the 16 criteria analyzed had PPVs > 95%, and each criterion was assigned a score. A final score of -1 was indicative of SVT (PPV 98%); a score of 1 was indicative of VT (PPV 98%); and a score of ≥2 was indicative of VT (PPV 100%). A score of ≠0 was obtained for 51.7% of all cases of tachycardia, making it possible to reach a highly accurate diagnosis in approximately half of all cases. No cases of VT scored -1, and no cases of SVT scored ≥2. CONCLUSIONS: The current scoring system stands out for its high PPV (98%) and specificity (98%), enabling an accurate diagnosis for more than half of the patients.

Comparative determination and monitoring of biomarkers of necrosis and myocardial remodeling between radiofrequency ablation and cryoablation.

BACKGROUND: Biomarkers of necrosis and inflammation have been found raised after radiofrequency ablation (RF). There is scarce information on biomarkers' behavior after cryoablation. Our aim was to study biomarkers of necrosis, inflammation, and interstitial remodeling after two different approaches: RF versus cryoablation. METHODS: We studied 22 consecutive patients with atrial flutter who underwent RF (10) or cryoablation (12). All patients underwent electrophysiological study and subsequent ablation. Peripheral samples were collected before the procedure, immediately after, the following day, 3 days, 1 week, 1 month, and 2 months after ablation. Samples were assayed for biomarkers of inflammation (high sensitive C-reactive protein [hs-CRP]) and tissue remodeling (C-propeptide of type I procollagen [CICP], matrix metalloproteinase 2 [MMP-2], matrix metalloproteinase 9 [MMP-9], and metallopeptidase inhibitor 1 [TIMP-1]). We also determined biomarkers of tissue necrosis (creatine kinase [CK], its MB isoenzyme, cardiac troponin I [TnI], and troponin T (TnT)] in samples obtained immediately after ablation, 6 hours postablation, and 12 hours postablation. RESULTS: Bidirectional isthmus block was achieved in all patients. We found significantly higher levels of CK, CK-MB, and TnI after cryoablation compared to RF ablation for all timing samples. These necrosis biomarkers showed significant differences depending on the time (all P < 0.001), and the interaction between the time and the used ablation approach (P = 0.005, P < 0.001, and P < 0.001, respectively). For patients who undergoing RF ablation, MMP-2 showed the greatest changes depending on the interaction between time and number of applications (P = 0.041), whereas for patients who undergoing cryoablation, CK was the most relevant biomarker depending on the interaction between time and number of applications (P = 0.006). CONCLUSIONS: We show higher levels of necrosis and myocardial injury biomarker after cryoablation versus RF. However, we found higher remodeling processes after RF. Our data support previous publications showing different lesion formation in cryoablation and RF.

Utilidad de la prueba de troponina T de alta sensibilidad en la detección de rechazo agudo en trasplante cardiaco / Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation

Introducción y objetivos. La detección del rechazo agudo en pacientes trasplantados cardiacos mediante métodos no invasivos representa un reto. La disponibilidad de un nuevo método de alta sensibilidad para la determinación de troponina T podría ayudar a su detección. Métodos. Estudio case-crossover, en el que cada paciente sirvió como control de sí mismo, mediante la selección de muestras obtenidas en episodios de rechazo agudo tratados (29 casos) y muestras sin rechazo obtenidas inmediatamente antes y/o después (38 controles). La determinación de alta sensibilidad de troponina T se realizó mediante un nuevo test precomercial (Elecsys Troponina T HS). Resultados. La troponina T fue detectable en todas las muestras: mediana, 0,068 [intervalo intercuartílico, 0,030-0,300] ng/l. Sus concentraciones se correlacionaron con la presión auricular derecha (r=0,37; p=0,002), la fracción aminoterminal del propéptido natriurético cerebral (r=0,67; p<0,001) y el tiempo transcurrido desde el trasplante (r=–0,81; p<0,001). Las concentraciones de troponina T fueron mayores en presencia de rechazo (0,155 frente a 0,047 ng/l; p=0,006). En el análisis operador-receptor, el área bajo la curva fue 0,67 (intervalo de confianza del 95%, 0,53-0,77) y el mejor punto de corte, 0,035 ng/l, que se asoció con mayor riesgo de rechazo (odds ratio=3,7; intervalo de confianza del 95%, 1,2-11,9; p=0,02). Durante los primeros 2 meses, el área bajo la curva aumentó hasta 0,86 (intervalo de confianza del 95%, 0,66-0,97), con un punto de corte óptimo de 1,1 ng/l (sensibilidad, 58% [28-85%]; especificidad, 100% [74-100%]). Conclusiones. El análisis de alta sensibilidad detectó troponina T en todas las muestras tras el trasplante, en mayor concentración en caso de rechazo agudo, si bien su utilidad en la monitorización se limitaría a servir como apoyo ante la sospecha clínica o histológica, especialmente en los primeros meses (AU)

Introduction and objectives. Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. Methods. We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). Results. In all samples, highly sensitive troponin was detectable, with a median of 0.068 ng/mL (IQR, 0.030-0.300 ng/mL). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=–0.81; P<.001). The highly sensitive troponin concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). Conclusions. Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period (AU)

[Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation]. / Utilidad de la prueba de troponina T de alta sensibilidad en la detección de rechazo agudo en trasplante cardiaco.

INTRODUCTION AND OBJECTIVES: Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. METHODS: We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). RESULTS: In all samples, highly sensitive troponin T was detectable, with a median of 0.068 ng/L (IQR, 0.030-0.300 ng/L). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=-0.81; P<.001). The highly sensitive troponin T concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). CONCLUSIONS: Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period.

Shoshin beriberi mimicking a high-risk non-ST-segment elevation acute coronary syndrome with cardiogenic shock: when the arteries are not guilty.

BACKGROUND: Cardiac acute beriberi (Shoshin syndrome) is a rare disease that may lead to a fatal outcome if not treated specifically. OBJECTIVES: We report a case of Shoshin syndrome with an unusual presentation of cardiogenic shock and an electrocardiographic pattern of severe myocardial ischemia suggesting left main coronary artery obstruction. CASE REPORT: A 35-year-old man presented with chest discomfort, diffuse ST-segment depression in the 12-lead electrocardiogram (ECG) with ST-segment elevation in aVR, and rapidly evolving congestive heart failure leading to cardiogenic shock. Intensive support was required, including mechanical ventilation, high doses of inotropics and vasopressors, intra-aortic balloon counterpulsation, and continuous renal replacement therapy. An emergency coronary angiogram was performed that showed normal coronary arteries. Right heart catheterization showed a high-output state with elevated filling pressures suggesting high-output heart failure. The echocardiography confirmed normal left and right ventricular contraction. Thiamine deficiency was suspected as the cause of the high-output heart failure. After a single dose of intravenous thiamine (100 mg), the patient's hemodynamic status improved dramatically within minutes, allowing a rapid discontinuation of hemodynamic support. Subsequent ECGs showed complete resolution of ST-segment abnormalities. Serial lactate measurements, red blood cell transketolase activity, and the thiamine pyrophosphate response test were concordant with a thiamine deficiency state. CONCLUSION: Shoshin syndrome may present as cardiogenic shock with an ECG mimicking severe myocardial ischemia, and if suspected, can be rapidly and effectively treated.

Systolic aortic regurgitation: a not-so-rare phenomenon.

In a normal cardiac cycle, aortic and pulmonary regurgitation are diastolic phenomena. Aortic regurgitation has been observed in ventricular systole in patients with arrhythmias, extracorporeal circulation and palliative surgical correction of complex congenital heart disease. Systolic aortic regurgitation is explained as the inability of the ventricular beat to overcome the aortic pressure in patients with valvular incompetence. Beyond its potential as an elegant quiz about heart physiology, clinical association of systolic aortic regurgitation with heart failure and syncope has been described. Illustrative examples of both aortic and pulmonary systolic regurgitation are presented, an image of "continuous" aortic regurgitation is displayed, and technical issues on its diagnosis are briefly commented.

An atypical presentation of Tako-Tsubo cardiomyopathy.

We present the case of a patient with Tako-Tsubo cardiomyopathy whose initial diagnosis, based on the location of shoulder and chest pain and electrocardiographic (ECG) changes, suggested that she was suffering from pericarditis. However, 24 h after admission, evolutionary changes of ECG and the echocardiogram performed suggested a Tako-Tsubo cardiomyopathy. In this context, we review the literature to discuss the clinical presentation and evolutionary ECG changes associated with Tako-Tsubo cardiomyopathy.

[The frequency of systolic aortic regurgitation and its relationship to heart failure in a consecutive series of patients]. / Frecuencia de la insuficiencia aórtica sistólica y su relación con la insuficiencia cardiaca en una serie consecutiva de pacientes.

Although aortic regurgitation is a diastolic phenomenon, it has been observed during systole in a few cases. Our aims were to determine the incidence of systolic aortic regurgitation in routine clinical practice and to investigate the clinical profiles of patients with the condition. An exhaustive prospective study of all investigations performed by a hospital echocardiographic unit over one month was carried out. Systolic aortic regurgitation was detected in five out of a total of 216 investigations (2.3%). In all cases, the patient had some degree of heart failure. Overall, the condition was present in 5.9% of patients with heart failure. In one patient with atrial fibrillation, systolic aortic regurgitation disappeared and the patient's clinical status improved after atrioventricular node modulation using a cryoablation catheter. Systolic aortic regurgitation was not an exceptional occurrence in hospitalized patients. Moreover, it tended to be specifically associated with heart failure.

Frecuencia de la insuficiencia aórtica sistólica y su relación con la insuficiencia cardiaca en una serie consecutiva de pacientes / The Frequency of Systolic Aortic Regurgitation and Its Relationship to Heart Failure in a Consecutive Series of Patients

La insuficiencia aórtica es un fenómeno diastólico, aunque ha sido descrita durante la sístole en casos aislados. Nos propusimos evaluar la incidencia en la práctica habitual del fenómeno de insuficiencia aórtica sistólica y el tipo de pacientes en que se presenta. Inclusión exhaustiva y prospectiva de todos los estudios realizados durante 1 mes en una agenda de ecocardiografía hospitalaria. Detectamos 5 casos de insuficiencia aórtica sistólica en un total de 216 estudios (2,3%). En todos los casos lospacientes tenían insuficiencia cardiaca de algún grado. El fenómeno estaba presente en el 5,9% de los pacientesingresados con insuficiencia cardiaca. En un pacientecon fibrilación auricular la insuficiencia aórtica sistólica desapareció y el estado clínico mejoró tras la modulación del nodo auriculoventricular con catéter de crioablación. La insuficiencia aórtica sistólica no se presenta de forma excepcional en los pacientes ingresados y muestra cierta especificidad para la insuficiencia cardiaca

Although aortic regurgitation is a diastolic phenomenon,it has been observed during systole in a few cases. Ouraims were to determine the incidence of systolic aorticregurgitation in routine clinical practice and to investigate the clinical profiles of patients with the condition. An exhaustive prospective study of all investigations performed by a hospital echocardiographic unit over one month was carried out. Systolic aortic regurgitation was detected in five out of a total of 216 investigations (2.3%). In all cases, the patient had some degree of heart failure. Overall, the condition was present in 5.9% of patients with heart failure. In one patient with atrial fibrillation, systolicaortic regurgitation disappeared and the patient’s clinical status improved after atrioventricular node modulation using a cryoablation catheter. Systolic aortic regurgitation was not an exceptional occurrence in hospitalized patients. Moreover, it tended to be specifically associated with heart failure

[Prognostic value of BNP and cardiopulmonary exercise testing in patients with systolic heart failure on beta-blocker therapy]. / Valor pronóstico del BNP y la prueba de esfuerzo cardiopulmonar en la insuficiencia cardiaca sistólica en tratamiento con bloqueadores beta.

INTRODUCTION AND OBJECTIVES: The long-term prognostic value of the B-type natriuretic peptide (BNP) level and cardiopulmonary exercise testing in patients with heart failure (HF) who are receiving beta-blocker therapy is not well established. METHODS: The study involved 80 outpatients (78% male, age 50 [11] years) with stable HF, severe systolic dysfunction (left ventricular ejection fraction 25 [9]%), and intermediate functional impairment (New York Heart Association functional class 2.4 [0.6]) who were receiving optimum therapy, including beta-blockers. Their BNP levels (pg/mL) were measured and cardiopulmonary exercise testing was carried out to determine maximal oxygen uptake (VO2max) and ventilatory efficiency (VE/VCO2 slope). Patients were followed up for 2.7 (0.8) years. The study endpoints were cardiovascular death, heart transplantation, and HF hospitalization. RESULTS: The BNP level and VE/VCO2 slope were greater in patients who died (n=7), at 211 pg/mL (51-266 pg/mL) vs. 46 pg/mL (16-105 pg/mL) (P=.017) and 39 (3) vs. 33.8 (5.5) (P=.018), respectively, or who had an adverse event (n=19), at 139 pg/mL (88-286 pg/mL) vs. 40 pg/mL (13-81 pg/mL) (P< .001) and 38.7 (4.3) vs. 32.9 (5.2) (P< .001), respectively. Only the combined endpoint was associated with a significant difference in VO2max (19.7 [5.4] vs. 16.8 [3.9] mL/kg per min, P=.016). On multivariate analysis, BNP >102 pg/mL (P=.002; hazard ratio [HR]=5.2; 95% confidence interval [CI], 1.8-14.8) and VE/VCO2 slope >35 (P=.012; HR =4.3; 95% CI, 1.4-13.2) were the best predictors of an adverse event. In patients who satisfied neither, one or both criteria, 36-month cumulative adverse event rates were 2%, 25% and 63%, respectively (log rank, P< .001). CONCLUSIONS: In ambulatory HF patients with intermediate functional impairment who are receiving optimum beta-blocker therapy, the persistence of a high BNP level (>102 pg/mL) combined with poor ventilatory efficiency (VE/VCO2 slope >35) identify those with a poor long-term prognosis.

Valor pronóstico del BNP y la prueba de esfuerzo cardiopulmonar en la insuficiencia cardiaca sistólica en tratamiento con bloqueadores beta / Prognostic value of BNP and cardiopulmonary exercise testing in patients with systolic heart failure on beta-blocker therapy

Introducción y objetivos. En pacientes con insuficiencia cardiaca y tratamiento con bloqueadores beta, el valor pronóstico a largo plazo del péptido natriurético tipo B (BNP) y la prueba de esfuerzo cardiopulmonar no está bien establecido. Métodos. Se estudió a 80 pacientes ambulatorios con insuficiencia cardiaca estable (el 78% varones; media de edad, 50 ± 11 años), disfunción ventricular severa (FEVI, 25% ± 9%), deterioro funcional intermedio (NYHA, 2,4 ± 0,6) y tratamiento optimizado que incluyera bloqueadores beta. Se midió el BNP (pg/ml) y se realizó una prueba de esfuerzo cardiopulmonar, en la que se midió el consumo máximo de oxígeno (VO2máx) y la ineficiencia ventilatoria (pendiente VE/VCO2). El seguimiento fue de 2,7 ± 0,8 años y se estudió la muerte cardiovascular, el trasplante y el ingreso hospitalario por insuficiencia cardiaca. Resultados. La concentración de BNP y la pendiente VE/VCO2 fueron mayores en los pacientes que fallecieron (n = 7) (211 [51-266] contra 46 [16-105], p = 0,017; 39 ± 3 contra 33,8 ± 5,5, p = 0,018) o presentaron cualquier evento adverso (n = 19) (139 [88-286] contra 40 [13-81], p < 0,001; 38,7 ± 4,3 contra 32,9 ± 5,2, p < 0,001). El VO2máx sólo alcanzó significación para el evento combinado (19,7 ± 5,4 contra 16,8 ± 3,9 ml/kg/min, p = 0,016). Tras el análisis multivariable, el BNP > 102 pg/ml (p = 0,002; hazard ratio [HR] = 5,2; intervalo de confianza [IC] del 95%, 1,8-14,8) y la pendiente VE/VCO2>35 (p = 0,012; HR = 4,3; IC del 95%, 1,4-13,2) fueron los mejores predictores de complicaciones. En presencia de ninguno, alguno o ambos predictores, la incidencia acumulada de eventos a 36 meses fue del 2, el 25 y el 63% respectivamente (log rank < 0,001). Conclusiones. En pacientes con insuficiencia cardiaca, deterioro funcional intermedio y tratamiento optimizado con bloqueadores beta, la persistencia de un BNP elevado (> 102 pg/ml) y la ineficiencia ventilatoria (pendiente VE/VCO2 > 35) identifican a los pacientes con peor pronóstico a largo plazo

Introduction and objectives. The long-term prognostic value of the B-type natriuretic peptide (BNP) level and cardiopulmonary exercise testing in patients with heart failure (HF) who are receiving beta-blocker therapy is not well established. Methods. The study involved 80 outpatients (78% male, age 50 [11] years) with stable HF, severe systolic dysfunction (left ventricular ejection fraction 25 [9]%), and intermediate functional impairment (New York Heart Association functional class 2.4 [0.6]) who were receiving optimum therapy, including beta-blockers. Their BNP levels (pg/mL) were measured and cardiopulmonary exercise testing was carried out to determine maximal oxygen uptake (VO2max) and ventilatory efficiency (VE/VCO2 slope). Patients were followed up for 2.7 (0.8) years. The study endpoints were cardiovascular death, heart transplantation, and HF hospitalization. Results. The BNP level and VE/VCO2 slope were greater in patients who died (n=7), at 211 pg/mL (51­266 pg/mL) vs. 46 pg/mL (16­105 pg/mL) (P=.017) and 39 (3) vs. 33.8 (5.5) (P=.018), respectively, or who had an adverse event (n=19), at 139 pg/mL (88­286 pg/mL) vs. 40 pg/mL (13­81 pg/mL) (P<.001) and 38.7 (4.3) vs. 32.9 (5.2) (P<.001), respectively. Only the combined endpoint was associated with a significant difference in VO2max (19.7 [5.4] vs. 16.8 [3.9] mL/kg per min, P=.016). On multivariate analysis, BNP >102 pg/mL (P=.002; hazard ratio [HR]=5.2; 95% confidence interval [CI], 1.8­14.8) and VE/VCO2 slope >35 (P=.012; HR =4.3; 95% CI, 1.4­13.2) were the best predictors of an adverse event. In patients who satisfied neither, one or both criteria, 36-month cumulative adverse event rates were 2%, 25% and 63%, respectively (log rank, P<.001). Conclusions. In ambulatory HF patients with intermediate functional impairment who are receiving optimum beta-blocker therapy, the persistence of a high BNP level (>102 pg/mL) combined with poor ventilatory efficiency (VE/VCO2 slope >35) identify those with a poor long-term prognosis

Transient global amnesia after dobutamine--atropine stress echocardiography.

Dobutamine-atropine stress echocardiography is a useful and relatively safe test for coronary artery disease assessment. However, possible complications should be recognized. We describe a case of transient global amnesia in a woman who underwent a standard-protocol dobutamine-atropine stress echocardiogram for coronary ischaemia detection, after having complained about chest pain. The test was not positive for coronary ischaemia, but a typical picture of transient global amnesia ensued. Symptoms shortly resolved spontaneously. Neurological work up was negative for organic disease. Transient global amnesia is a neurological syndrome of unknown origin and good prognosis. Dobutamine-atropine stress echocardiography can be added to the described precipitants of transient global amnesia. This neurological syndrome should be taken into account as a possible complication of dobutamine-atropine stress echocardiography.

Relation of B-type natriuretic peptide levels before and after exercise and functional capacity in patients with idiopathic dilated cardiomyopathy.

Although much is known about the value of B-type natriuretic peptide (BNP) at rest, the significance of the responsiveness of BNP during exercise in patients with chronic heart failure (HF) without coronary artery disease remains to be established. A role of BNP release during exercise in the functional disability of patients with chronic HF and idiopathic dilated cardiomyopathy (IDC) was hypothesized. One hundred five consecutive patients with an established diagnosis of HF and IDC who underwent symptom-limited cardiopulmonary exercise testing were studied. BNP was measured immediately before exercise and within 1 minute of the end of exercise. BNP at rest increased significantly at peak exercise (median from 66.5 (first, third quartiles 18, 168) to 72.0 pg/ml (26, 208), p <0.001), but BNP response was not uniform. BNP response increased in 63% of patients, did not change in 22%, and decreased in 15%. BNP at rest and BNP response showed an inverse correlation (p <0.001, r = -0.523). Aging and low left ventricular ejection fraction were independent predictors of higher BNP levels at rest, but lower BNP response. Beta-blocker therapy did not influence BNP response. BNP at rest correlated negatively with functional capacity (p <0.001, r = -0.516), whereas BNP response correlated positively (p = 0.002, r = 0.326). Patients with BNP release (vs patients without) had higher maximum oxygen consumption (19.2 +/- 5.1 vs 15.9 +/- 3.6, p <0.001), better functional capacity (59 +/- 13% vs 50 +/- 15%, p = 0.002), and lower minute ventilation/carbon dioxide production slope (33.6 +/- 4.8 vs 36.5 +/- 7.7, p = 0.026) independent of other clinical parameters. In conclusion, BNP release during exercise could be a determinant of functional capacity in patients with chronic HF and IDC.