Short- and long-term results of a programme for the prevention of readmissions and mortality in patients with heart failure: are effects maintained after stopping the programme?

UNLABELLED: The objective of the study was to evaluate whether improvements obtained during an intervention programme were maintained after the programme was stopped. 153 patients discharged with a diagnosis of heart failure (HF) were randomized to either usual care or an intervention programme, which included patient education, consultation with the cardiologist and monitoring in the Heart Failure Unit. After an average period of 16+/-8 months, the intervention programme was stopped. One year later, all the patients were re-examined to assess HF readmissions, all-cause mortality, quality of life, and prescribed medical treatment. During the 16+/-8-month treatment period, patients in the intervention group had a lower rate of HF readmissions (17% vs. 51%, p<0.01), less all-cause mortality (13% vs. 27%, p=0.03), improvement in quality of life (1.5+/-0.8 vs. 1.9+/-1, p=0.03) and optimisation of medical treatment was achieved. One year after stopping the intervention, there was no difference in HF readmissions (28% vs. 25%, p=0.72), all-cause mortality (14% vs. 17%, p=0.64) and quality of life (1.7+/-0.9 vs. 1.8+/-1, p=0.24) between the groups. Survival and the probability of not being readmitted due to HF were similar in both groups. There was also a reduction in the use of beta-blockers and spironolactone in the intervention group. CONCLUSIONS: The positive effects of an intervention programme are clearly reduced when it is stopped, due to less strict control of the patients and a decrease in the use of drugs with proven efficacy in HF.

[Short-term results with the ross procedure. Does the etiology of aortic valvulopathy affect the outcome?]. / Resultados a corto plazo en la técnica de Ross. Influye la etiología de la valvulopatía aórtica?

INTRODUCTION: The Ross procedure has become established as an appropriate method for aortic valve replacement in children and young adults. There is controversy regarding the results of this surgical technique depending on whether the aortic valve disorder is congenital or acquired. The objective of this study was to analyze the outcome of this technique in different etiologies. PATIENTS AND METHOD: We analyzed 61 patients who underwent the Ross procedure between November 1997 and November 2001. Age range was 6 to 54 years, and 44 patients (72%) were male. The mean duration of follow-up was 15.6 (10.6) months. The aortic valve lesion was stenosis in 17 patients, regurgitation in 22 and both in 22. The patients were divided into two groups: etiology was congenital in group I (40 patients) and acquired in group II (21 patients: 14 rheumatic, 2 degenerative, 2 endocarditis and 3 other). RESULTS: Pre-intervention data showed significant differences in age, functional class and percentage of patients with previous cardiac surgery. In the last follow-up examination, autograft gradient and homograft gradient were similar in both groups. Diastolic and systolic diameters and left ventricle ejection fraction were normal in both groups and did not differ between groups. Major events during follow-up were: 1 patient died, 1 patient had endocarditis, and 2 patients needed stent implantation in the homograft in group I; 2 patients in group II underwent reoperation because of severe autograft dysfunction. There were no statistically significant differences between groups. CONCLUSION: Short-term morbidity and mortality associated with the Ross procedure are low in patients with either congenital or acquired aortic valvulopathy.

[Prevalence of patent foramen ovale in young patients with cerebral ischemic accident of unknown origin]. / Prevalencia de foramen oval permeable en pacientes jóvenes con accidente isquémico cerebral de causa desconocida.

INTRODUCTION AND OBJECTIVE: Patent foramen ovale has been associated with stroke in young patients with cryptogenic stroke. The purpose of this study is to examine the prevalence of patent foramen ovale in this group of patients, as well as their anatomical and functional characteristics by contrast echocardiography, trying to determine ictus risk markers in young patients with acute ischemic stroke. PATIENTS AND METHOD: Prospective study of 90 patients under the age of 50 who were hospitalised consecutively due to a clinical presentation suggestive of stroke. No cause was found in 55 out of 90 (group I) and the rest, in which an stroke was finally disregarded, were used as the control group (group II). A transthoracic and transesophageal echocardiography examination with 2 types of contrast agents was performed in all patients to determine the presence of a patent foramen ovale and its anatomical and functional characteristics. RESULTS: Patent foramen ovale was observed more frequently in group I than in group II (43 versus 21%; p < 0.05). Among patients with a patent foramen ovale those with an ischemic stroke showed greater mobility of the oval membrane, more frequent large shunts of contrast in a single frame in the left heart, and more frequent shunts at rest. Transesophageal echocardiography without contrast showed a high sensitivity (90%) and specificity (93%) for detecting anatomically permeable foramen ovale whereas contrast transthoracic echocardiography showed a low sensitivity (13%). There were no differences between the two contrasts used. CONCLUSIONS: Near half of young patients with ischemic stroke of an unknown origin have a patent foramen ovale. A bigger mobility of the membrane of the oval cavity and a large degree of shunt contrast as well as shunt at rest detected by contrast transesophageal echocardiography, seem to identify patent foramen ovale patients with ischemic stroke. In these patients, transthoracic echocardiography has low sensibility for detecting permeability of the foramen ovale.

Prevalencia de foramen oval permeable en pacientes jóvenes con accidente isquémico cerebral de causa desconocida / Prevalence of patent foramen ovale in young patients with cryptogenic stroke

Introducción y objetivos. El foramen oval permeable se ha asociado a infartos cerebrales en pacientes jóvenes con ictus criptogénico. El objetivo de este estudio es determinar la prevalencia en este grupo de pacientes de foramen oval permeable, así como las características anatómicas y funcionales del mismo, mediante ecocardiografía con contraste, tratando de determinar los marcadores de riesgo de ictus en pacientes jóvenes con un foramen oval permeable. Pacientes y método. Estudio prospectivo en 90 pacientes menores de 50 años que ingresaron de forma consecutiva por sospecha clínica de accidente cerebrovascular. En 55 pacientes no se encontró ninguna causa (grupo I) y los restantes, en los que se descartó finalmente un ictus, fueron utilizados como grupo control (grupo II). A todos se les realizó un estudio ecocardiográfico transtorácico y transesofágico con 2 tipos de contrastes, para determinar la presencia de foramen oval y las características anatómicas y funcionales del mismo, comparando ambos grupos. Resultados. En el grupo de estudio existió un mayor número de foramen oval permeable que en el grupo control (43 frente a 21 por ciento; p < 0,05). Comparando a los pacientes con foramen permeable de ambos grupos existieron diferencias significativas en la mayor movilidad de la membrana de la fosa oval, en el mayor número de pacientes con paso amplio de contraste, así como con paso del mismo en situación de respiración basal, en el grupo de pacientes que habían tenido ictus. La ecografía transesofágica sin contraste demostró una alta sensibilidad (90 por ciento) y especificidad (93 por ciento) para detectar "foramen permeable anatómico", mientras que la ecografía transtorácica con contraste demostró una baja sensibilidad para detectarlo (13 por ciento). No hubo diferencias entre los 2 contrastes utilizados. Conclusiones. En casi la mitad de los pacientes jóvenes con ictus de origen desconocido se encuentra un foramen oval permeable. Una mayor movilidad de la membrana de la fosa oval y un paso amplio de contraste y en situación de respiración en reposo han resultado marcadores predictores de isquemia cerebral en estos pacientes. La ecografía transtorácica tiene una baja sensibilidad para detectar permeabilidad del foramen, y no existieron diferencias entre los dos contrastes utilizados (AU)

[Late recovery of coronary flow reserve in patients successfully treated with a percutaneous procedure]. / Recuperación tardía de la reserva coronaria en pacientes tratados con éxito mediante revascularización peructánea.

INTRODUCTION AND OBJECTIVES: Coronary angiograms are of limited value for the assessment of the results of percutaneous interventions. Intracoronary Doppler studies have been used to overcome these difficulties. The achievement of a coronary flow reserve (CFR) > 2-2.5 after the procedure is considered a good result and further optimization is generally not required. However, coronary flow reserve may not recover immediately, despite optimal procedural results. The aim of this study is to assess the temporal course of the recovery of coronary flow reserve after successful revascularization. PATIENTS AND METHOD: We studied 34 patients with coronary heart disease who were successfully treated by balloon angioplasty (n = 8) or stent implantation (n = 26). In all patients, serial observations were made by quantitative angiography and intracoronary Doppler (0.014 = flow-wire). Patients were studied: a) before treatment; b) immediately after, and c) 8 3 months later. RESULTS: The baseline coronary flow reserve was 1.3 0.4 and increased to 2.4 0.8 after the procedure (p < 0.01). At 8 months follow-up there was a significant increase (3 0.8; p < 0.01). This late improvement in coronary flow reserve was associated with a decline in average peak velocity at follow-up. Patients with impaired CFR immediately after treatment had a greater increase in CFR during followup than those with CFR > 2 after treatment (1.4 0.9 vs 0.4 0.6; p < 0.01). CONCLUSIONS: After a successful coronary intervention, CFR increases immediately, but some patients may experience additional improvement during follow-up. This increase was greater in patients who showed less improvement in coronary flow reserve immediately after treatment. Our findings suggest that the use of Doppler parameters in the immediate assessment of percutaneous coronary intervention results have limitations.

Recuperación tardía de la reserva coronaria en pacientes tratados con éxito mediante revascularización percutánea / Late recovery of coronary flow reserve in patients successfully treated with a percutaneous procedure

Introducción y objetivos. El estudio Doppler intracoronario es una de las técnicas propuestas para resolver algunas de las limitaciones de la angiografía. Una reserva coronaria > 2-2,5 después de un procedimiento de revascularización se considera un buen resultado fisiológico y, en general, no se recomienda una optimización adicional en el procedimiento. Sin embargo, la recuperación de la reserva coronaria podría no ser siempre inmediata y completa. El objetivo de nuestro estudio es evaluar la evolución de la recuperación de la reserva coronaria después de una revascularización realizada con éxito. Pacientes y método. Hemos incluido a 34 pacientes con enfermedad coronaria tratados con éxito mediante implantación de stent (n = 26) o angioplastia con balón (n = 8). En todos los pacientes obtuvimos un estudio angiográfico y otro de velocidades de flujo coronario en 3 condiciones: a) antes del tratamiento; b) inmediatamente después, y c) a los 8 ñ 3 meses del seguimiento. Resultados. La reserva coronaria basal fue de 1,3 ñ 0, 4 y aumentó a 2,4 ñ 0,8 tras el procedimiento (p < 0,01).A los 8 meses de seguimiento se produjo un aumento adicional significativo (3 ñ 0,8; p < 0,01). Esta mejoría tardía de la reserva coronaria se asoció a una disminución en la velocidad basal obtenida en el estudio de seguimiento. Los pacientes con reserva coronaria disminuida tras el tratamiento (< 2) fueron los que tuvieron un mayor incremento de la misma en el seguimiento (1,4 ñ 0,9 frente a 0,4 ñ 0,6; p < 0,01). Conclusiones. Después de una intervención coronaria percutánea realizada con éxito, la reserva coronaria aumenta de forma inmediata. Sin embargo, algunos pacientes presentan mejoras adicionales en el seguimiento. Esta mejoría resultó mayor en los pacientes en los que la reserva no se recuperó inmediatamente tras el tratamiento. Nuestros datos sugieren que el uso de estos parámetros en la valoración inmediata de un procedimiento percutáneo tiene un valor limitado (AU)