Ateromatosis compleja del cayado aórtico: estudio de 71 pacientes con infartos lacunares / Complex aortic atheroma plaques: study of 71 patients with lacunar infarcts

Fundamento y objetivo: Los infartos lacunares (IL) suelen asociarse a lipohialinosis o microateromatosis hipertensiva. Su asociación con la ateromatosis compleja de cayado aórtico (ACO) es desconocida. Pretendemos analizar su frecuencia de presentación y su perfil clínico.Pacientes y método: Muestra de 71 pacientes consecutivos con un primer IL (9 de causa esencial) incluidos en un registro de ictus durante un período de 4 años, estudiados mediante neuroimagen y ecocardiografía transtorácica supraesternal con tecnología de imagen armónica. Se analizan sus factores de riesgo, datos clínicos, de neuroimagen y pronósticos.Resultados: El estudio ecocardiográfico fue patológico en 20 pacientes (28,2%). Siete pacientes (9,9%) presentaron placas aórticas no complicadas y 13 (18,3%) presentaron ACO. Se trataba de 10 mujeres y 3 varones de 79 años de edad media (extremos 57-91). La hemiparesia motora pura fue el síndrome más habitual, presente en 5 casos (39%). La hipertensión arterial (69%), los accidentes isquémicos transitorios previos (39%) y la diabetes (31%) fueron los principales factores de riesgo. Solamente 3 pacientes con ACO (4,2% del total y 33% de los IL de causa esencial) no tenían ningún factor de riesgo. Presentaron infartos cerebrales silentes 7 casos (53,8%) (6 IL y un infarto no lacunar). Ningún paciente falleció durante el ingreso hospitalario.Conclusiones: La presencia de placas de ateroma complejas se observó en el 18,3% de los IL. En dichos pacientes predominó el sexo femenino. Presentaron criterios de alto riesgo de embolismo aórtico el 4,2% de IL. La ACO debe ser descartada en los IL de etiología esencial (AU)

Background and objectives: To characterize the frequency and the clinical factors of complex aortic atheroma plaques (CAA) in patients with a first-ever lacunar infarct (LI).Patients and methods: Sample of 71 consecutive patients with a first LI (9 of uncertain etiology) included in a stroke registry over a period of 4 years, studied by neuroimaging and suprasternal transthoracic echocardiography with harmonic imaging technology. We analyze the risk factors, clinical data and prognosis. Results: Echocardiography was abnormal in 20 patients (28.2%). Seven patients (9.9%) had simple aortic plaques and 13 (18.3%) had CAA. There were 10 women and 3 men of 79 (range 57-91) years of median age. Pure motor hemiparesis was the most common syndrome present in 5 cases (39%). Hypertension (69%), previous transient ischemic attack (39%) and diabetes (31%) were the main risk factors. Only 3 patients with CAA (4.2% of the total and 33% of LI of uncertain etiology) had no risk factors. Silent infarcts were present in 7 cases (53.8%) (6 LI and one non-LI). No patient died during hospitalization. Conclusions:The presence of complex aortic atheroma plaques was observed in 18.3% of first-LI patients, with a predominance of females. High risk criteria of aortic embolism was present in 4.2% of LI. CAA should be ruled out in essential LI patients (AU)

[Complex aortic atheroma plaques: study of 71 patients with lacunar infarcts]. / Ateromatosis compleja del cayado aórtico: estudio de 71 pacientes con infartos lacunares.

BACKGROUND AND OBJECTIVES: To characterize the frequency and the clinical factors of complex aortic atheroma plaques (CAA) in patients with a first-ever lacunar infarct (LI). PATIENTS AND METHODS: Sample of 71 consecutive patients with a first LI (9 of uncertain etiology) included in a stroke registry over a period of 4 years, studied by neuroimaging and suprasternal transthoracic echocardiography with harmonic imaging technology. We analyze the risk factors, clinical data and prognosis. RESULTS: Echocardiography was abnormal in 20 patients (28.2%). Seven patients (9.9%) had simple aortic plaques and 13 (18.3%) had CAA. There were 10 women and 3 men of 79 (range 57-91) years of median age. Pure motor hemiparesis was the most common syndrome present in 5 cases (39%). Hypertension (69%), previous transient ischemic attack (39%) and diabetes (31%) were the main risk factors. Only 3 patients with CAA (4.2% of the total and 33% of LI of uncertain etiology) had no risk factors. Silent infarcts were present in 7 cases (53.8%) (6 LI and one non-LI). No patient died during hospitalization. CONCLUSIONS: The presence of complex aortic atheroma plaques was observed in 18.3% of first-LI patients, with a predominance of females. High risk criteria of aortic embolism was present in 4.2% of LI. CAA should be ruled out in essential LI patients.

Importancia del perfil cardiovascular en la mortalidad hospitalaria de los infartos cerebrales / Importance of cardiovascular risk profile for in-hospital mortality due to cerebral infarction

Introducción y objetivos. Analizar el perfil cardiovascular y su pronóstico en los infartos cerebrales y sus subtipos etiológicos. Métodos. Se efectúa un análisis retrospectivo de una serie clínica de 2.704 pacientes con infartos cerebrales procedentes de un registro hospitalario de ictus ingresados entre 1986 y 2004 (770 trombóticos, 763 cardioembólicos, 733 lacunares, 324 indeterminados y 114 inhabituales). Se compara el perfil cardiovascular de cada subtipo etiológico y su influencia con la mortalidad hospitalaria mediante un análisis multivariable. Resultados. La hipertensión arterial (HTA) se presentó en el 55,5%, seguida por la fibrilación auricular (FA) (29,8%) y la diabetes mellitus (23,4%). La mortalidad hospitalaria fue del 12,9% y estaba relacionada con la FA (odds ratio [OR] = 2,33; intervalo de confianza [IC] del 95%, 1,84-2,96) y la insuficiencia cardiaca (OR = 1,96; IC del 95%, 1,33-2,89). El perfil cardiovascular asociado a la mortalidad estaba formado en los trombóticos, por la insuficiencia cardiaca (OR = 2,87; IC del 95%, 1,45-5,71), la FA (OR = 1,80; IC del 95%, 1,09-2,96) y la edad (OR = 1,06; IC del 95%, 1,04-1,08); en los cardioembólicos, por la enfermedad vascular periférica (OR = 2,18; IC del 95%, 1,17-4,05), el infarto cerebral previo (OR = 1,75; IC del 95%, 1,16-2,63), la insuficiencia cardiaca (OR = 1,71; IC del 95%, 1,01-2,90) y la edad (OR = 1,06; IC del 95%, 1,04-1,08), y en los infartos indeterminados, por la HTA (OR = 3,68; IC del 95%, 1,78-7,62) y la edad (OR = 1,05; IC del 95%, 1,01-1,09). Conclusiones. Cada subtipo etiológico de infarto cerebral presenta un perfil cardiovascular propio. El perfil cardiovascular asociado a la mortalidad también es diferente en cada subtipo de infarto cerebral. Palabras clave: Isquemia cerebral. Factores de riesgo. Mortalidad. Hipertensión arterial. Fibrilación auricular. Registros de ictus (AU)

Introduction and objectives. To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. Methods. The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined, and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. Results. Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). Conclusions. Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype (AU)

Importance of cardiovascular risk profile for in-hospital mortality due to cerebral infarction.

INTRODUCTION AND OBJECTIVES: To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. METHODS: The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. RESULTS: Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). CONCLUSIONS: Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype.

Mitral annular calcification as a marker of complex aortic atheroma in patients with stroke of uncertain etiology.

The aim of this study was to evaluate the presence of dense mitral annular calcification as a marker of complex aortic atherosclerosis in patients with stroke of uncertain etiology. One hundred twenty-one patients with stroke of uncertain etiology were evaluated for complex aortic atherosclerotic plaques; their presence and severity were correlated with transthoracic echocardiographic findings, demographic data, and cardiovascular risk factors. Complex plaques in the ascending aorta or aortic arch were found in 72 of the 121 patients (59.5%). The only difference seen in patients with or without plaques was the presence of dense mitral annular calcification (58.3 vs 16.3%; P < 0.001). Dense mitral annular calcification (n = 50) was associated with higher prevalence of complex aortic plaques (84.0% vs 42.3%; P < 0.001), mobile components (28.0% vs 9.9%; P < 0.01), and protruding (80.0% vs 36.6%; P < 0.001), ulcerated (16.0% vs 1.4%; P < 0.01), and multisite complex plaques (46.0% vs 9.0%; P < 0.001). Therefore, in patients with stroke of uncertain etiology dense mitral annular calcification is an important marker of aortic atherosclerosis with high risk of embolism, and this association may explain in part the high prevalence of stroke and peripheral embolism in patients with mitral annular calcification.

[Evaluation of a home-based intervention in heart failure patients. Results of a randomized study]. / Evaluación de una intervención domiciliaria en pacientes con insuficiencia cardíaca. Resultados de un estudio aleatorizado.

INTRODUCTION AND OBJECTIVES: Home-based interventions after hospital discharge in patients with heart failure (HF) have been shown to decrease readmission and mortality rates. The primary aim of this study was to determine the effect of a home-based educational intervention carried out by nursing staff on the readmission rate, emergency department visits, and healthcare costs. PATIENTS AND METHOD: Patients hospitalized with systolic HF were randomly assigned to receive either usual care or a single home-based educational intervention 1 week after discharge. RESULTS: Between July 2001 and November 2002, 70 patients entered the study: 34 in the intervention group and 36 in the control group. During the 6-month follow-up, there were fewer unplanned readmissions in the intervention group than in the control group (0.09 vs 0.94; P<.001), fewer emergency department visits (0.21 vs 1.33; P<.001), and fewer out-of-hospital deaths (2 vs 11; P<.01). Costs were also significantly lower in the intervention group (difference, ; 1190.9; P<.001). Moreover, patient-perceived health status, as indicated by scores on a quality-of-life questionnaire, increased significantly in the intervention group. CONCLUSIONS: In a cohort of patients with systolic HF who received a home-based educational intervention there were significant reductions in the unplanned readmission rate, mortality, and healthcare costs, and better quality of life. Some limitations of the study warrant validation of the resultats in further studies.

Evaluación de una intervención domiciliaria en pacientes con insuficiencia cardíaca. Resultados de un estudio aleatorizado / Evaluation of a home-based intervention in heart failure patients. Results of a randomized study

Introducción y objetivos. Conocida la eficacia de los programas domiciliarios para pacientes con insuficiencia cardíaca (IC), nos hemos propuesto evaluar las diferencias en los ingresos hospitalarios, las visitas al servicio de urgencias, los costes económicos y la calidad de vida tras una intervención educativa en el domicilio una semana después del alta, realizada por personal de enfermería. Pacientes y método. Los pacientes ingresados por IC sistólica en los servicios de cardiología y medicina interna fueron distribuidos, mediante tabla de números aleatorios, en un grupo que recibió intervención educativa y otro grupo control que fue atendido de forma convencional. Resultados. Desde julio de 2001 hasta noviembre de 2002 se distribuyó a 70 pacientes en los 2 grupos. A los 6 meses de seguimiento, el grupo de 34 pacientes que recibió la intervención educativa, comparado con el grupo de 36 pacientes que no la recibió, tuvo en promedio menos visitas a urgencias (0,21 frente a 1,33; p < 0,001), menos ingresos hospitalarios (0,09 frente a 0,94; p < 0,001) y con un menor coste por individuo (diferencia ajustada: 1.190,9 €; p < 0,001). La salud percibida mejoró de forma significativa en el grupo de intervención. También se observó una disminución significativa de la mortalidad (2 frente a 11; p < 0,01). Conclusiones. Los pacientes con IC sistólica que han recibido una intervención educativa domiciliaria tienen una significativa menor tasa de reingresos, mortalidad y coste, con una mejor calidad de vida. Algunas limitaciones del estudio hacen recomendable la replicación de las observaciones

Introduction and objectives. Home-based interventions after hospital discharge in patients with heart failure (HF) have been shown to decrease readmission and mortality rates. The primary aim of this study was to determine the effect of a home-based educational intervention carried out by nursing staff on the readmission rate, emergency department visits, and healthcare costs. Patients and method. Patients hospitalized with systolic HF were randomly assigned to receive either usual care or a single home-based educational intervention 1 week after discharge. Results. Between July 2001 and November 2002, 70 patients entered the study: 34 in the intervention group and 36 in the control group. During the 6-month follow-up, there were fewer unplanned readmissions in the intervention group than in the control group (0.09 vs 0.94; P<.001), fewer emergency department visits (0.21 vs 1.33; P<.001), and fewer out-of-hospital deaths (2 vs 11; P<.01). Costs were also significantly lower in the intervention group (difference, € 1190.9; P<.001). Moreover, patient-perceived health status, as indicated by scores on a quality-of-life questionnaire, increased significantly in the intervention group. Conclusions. In a cohort of patients with systolic HF who received a home-based educational intervention there were significant reductions in the unplanned readmission rate, mortality, and healthcare costs, and better quality of life. Some limitations of the study warrant validation of the resultats in further studies

[Role of complex aortic atheroma plaques in the recurrence of unexplained cerebral infarction]. / Papel de las placas complejas de ateroma aórtico en la recurrencia del infarto cerebral de etiología incierta.

INTRODUCTION AND OBJECTIVES: In a subgroup of patients with cerebral infarction, noninvasive diagnostic explorations fail to disclose the etiology. We studied the clinical course and the usefulness of transesophageal echocardiography to diagnose complex aortic atheroma plaques in patients with cerebral infarction of uncertain cause with recurrence of ischemia. PATIENTS AND METHOD: In a study population of 1840 consecutive patients with a first cerebral infarction evaluated with a screening protocol for transesophageal echocardiography, the etiology remained uncertain in 248 cases. These patients were followed during 1 year of treatment with antiplatelet agents, and transesophageal echocardiography was done if cerebral ischemia recurred. We compared the prevalence of complex aortic atheroma plaques in patients with recurrence and in patients with cerebral infarction of unknown etiology in the French Study of Aortic Plaques in Stroke, in whom there was no recurrence of cerebral infarction. RESULTS: Recurrent cerebral infarction was documented in 17 of our 248 patients with infarction of unknown etiology (6.9%). Transesophageal echocardiography established the etiology in 15 of these patients (88.2%) with complex aortic atheroma plaques being identified in 14 cases (82.4%). In contrast, in patients with cerebral infarction of unknown etiology in the French study without recurrent cerebral infarction during the first year of follow-up, the prevalence of complex plaques was 21.1% (P<.0001). CONCLUSIONS: During the first year of treatment with antiplatelet agents, most patients with cerebral infarction of unknown etiology had no recurrences. In the small subgroup with short-term recurrence, transesophageal echocardiography yielded the etiologic diagnosis in 88.2% of cases: the pathology most frequently involved was complex atherosclerotic disease of the aortic arch.

Papel de las placas complejas de ateroma aórtico en la recurrencia del infarto cerebral de etiología incierta / Role of complex aortic atheroma plaques in the recurrence of unexplained cerebral infarction

Introducción y objetivos. En un subgrupo de pacientes con infarto cerebral, las exploraciones diagnósticas no invasivas no permiten establecer un diagnóstico etiológico. Hemos estudiado su evolución y el valor del ecocardiograma transesofágico en el diagnóstico del ateroma complejo aórtico en pacientes con infarto cerebral de etiología incierta que presentan recurrencia. Pacientes y método. Al evaluar a 1.840 pacientes consecutivos con un primer infarto cerebral mediante un protocolo restrictivo para la ecocardiografía transesofágica, en 248 no pudo establecerse un diagnóstico etiológico. Durante 1 año de seguimiento con fármacos antiplaquetarios, se practicó un ecocardiograma transesofágico en caso de nuevo episodio isquémico cerebral. Se comparó la prevalencia de placas complejas aórticas en estos pacientes con recurrencia respecto a la de los infartos cerebrales de etiología incierta del French Study of Aortic Plaques in Stroke que no presentaron un segundo infarto cerebral. Resultados. Presentaron un segundo infarto cerebral 17 de los 248 pacientes con etiología incierta (6,9%). El ecocardiograma transesofágico estableció la etiología en 15 de ellos (88,2%), que fue atribuida a placas complejas de ateroma aórtico en 14 casos (82,4%). En cambio, entre los pacientes del French Study con infarto cerebral de etiología incierta que no presentaron reinfarto cerebral durante el primer año de seguimiento, la prevalencia de placas complejas aórticas fue del 21,1% (p < 0,0001). Conclusiones. Durante el primer año de seguimiento con antiagregantes, la mayoría de los pacientes con infarto cerebral de etiología incierta no presenta recurrencia. En el subgrupo con recurrencia isquémica cerebral, el ecocardiograma transesofágico permite establecer el diagnóstico definitivo en el 88,2% de los casos; la principal etiología implicada es la ateromatosis avanzada de la aorta torácica

Introduction and objectives. In a subgroup of patients with cerebral infarction, noninvasive diagnostic explorations fail to disclose the etiology. We studied the clinical course and the usefulness of transesophageal echocardiography to diagnose complex aortic atheroma plaques in patients with cerebral infarction of uncertain cause with recurrence of ischemia. Patients and method. In a study population of 1840 consecutive patients with a first cerebral infarction evaluated with a screening protocol for transesophageal echocardiography, the etiology remained uncertain in 248 cases. These patients were followed during 1 year of treatment with antiplatelet agents, and transesophageal echocardiography was done if cerebral ischemia recurred. We compared the prevalence of complex aortic atheroma plaques in patients with recurrence and in patients with cerebral infarction of unknown etiology in the French Study of Aortic Plaques in Stroke, in whom there was no recurrence of cerebral infarction. Results. Recurrent cerebral infarction was documented in 17 of our 248 patients with infarction of unknown etiology (6.9%). Transesophageal echocardiography established the etiology in 15 of these patients (88.2%) with complex aortic atheroma plaques being identified in 14 cases (82.4%). In contrast, in patients with cerebral infarction of unknown etiology in the French study without recurrent cerebral infarction during the first year of follow-up, the prevalence of complex plaques was 21.1% (P<.0001). Conclusions. During the first year of treatment with antiplatelet agents, most patients with cerebral infarction of unknown etiology had no recurrences. In the small subgroup with short-term recurrence, transesophageal echocardiography yielded the etiologic diagnosis in 88.2% of cases: the pathology most frequently involved was complex atherosclerotic disease of the aortic arch