Electrocardiographic findings in true acute left main coronary total occlusion a subanalisys from ATOLMA registry.

INTRODUCTION: Acute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12­leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients. METHODS: The admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI). RESULTS: Some ECG features at presentation can predict an ATOLMA: QRS left axis deviation (-61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5-21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4-52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02-1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01-0.81), p = 0.03). CONCLUSIONS: aVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry.

OBJECTIVES: To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients. BACKGROUND: ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce. METHODS: This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI). RESULTS: In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1-0.36), p < 0.001). CONCLUSIONS: Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Invasive assessment of coronary flow reserve impairment in severe aortic stenosis and ecochadiographic correlations.

OBJECTIVES AND BACKGROUND: Patients with aortic stenosis (AS) may have impaired coronary flow reserve (CFR) despite angiographically normal coronary arteries. This is the first report of invasive thermodilution-derived CFR and IMR in patients with AS and their associations with echocardiographic parameters for AS assessment. METHODS: Thirty-six consecutive severe AS patients and ten patients without AS underwent prospectively cardiac catheterization and coronary physiological parameters were determined in the left anterior descending (LAD). Mean transit time (Tmn), a surrogate of absolute coronary flow, was obtained from the coronary thermodilution curve. RESULTS: In AS patients we found a high LAD flow at rest (Tmn rest 0.55±0.3 vs 0.99±0.4, p=0.01) and a low flow at hyperemia (Tmnhyp 0.44±0.2 vs 27.7±0.1, p=0.02) and consequently a severe CFR impairment (1.4±0.4 vs 3.8±1.4, p<0.001) compared with controls. An elevated index of microvascular resistance (IMR) (32.7±16 vs 17.8±6.5, p=0.01) and a low baseline microvascular coronary resistance (48.1±29 vs 84±34, p=0.02) were also found. In AS patients there were significant correlations between CFR and left ventricular mass index (r=-0.32; p=0.02), and the ratio of acceleration time to ejection time (AT/ET) (r=-0.4; p=0.01) a non-flow dependent echocardiographic parameter for AS assessment. Multiple linear stepwise regression analysis showed that AT/ET (ß=-0.441, p=0.019) was the only independently variable associated with CFR CONCLUSIONS: In severe AS, invasive CFR shows a progressive decrease with AS severity and a good correlation with echocardiographic parameters of AS, especially with flow-independent ones.

Tratamiento precoz con estatinas en el infarto agudo de miocardio / Early statin therapy in acute myocardial infarction

OBJETIVOS: Evaluar el efecto de la administración precoz de estatinas durante la fase aguda del infarto de miocardio (IM). DISEÑO: Estudio de cohortes retrospectivo. Ámbito: Nacional. PACIENTES O PARTICIPANTES: Pacientes incluidos en el registro ARIAM desde enero de 1999 hasta diciembre de 2008 con diagnóstico de IM. INTERVENCIONES: Ninguna. Variables de interés principales: Se utilizaron análisis de regresión logística y de propensión para determinar si la administración de estatinas, durante las primeras 24h del IM, se comportaba como un factor protector frente a: 1) la mortalidad, 2) la incidencia de arritmias letales o 3) el shock cardiogénico. RESULTADOS: Se incluyeron 36.842 pacientes en el estudio. En un 50,2% de los pacientes las estatinas se administraron de forma precoz. Su administración se asoció a pacientes más jóvenes, con dislipidemia previa conocida, obesidad, antecedentes personales de cardiopatía isquémica, insuficiencia cardiaca, presencia de taquicardia inusal, uso de betabloqueantes, inhibidores de la enzima convertidora de angiotensina, trombolisis e intervencionismo coronario percutáneo. La mortalidad fue del 8,2% (13,2% sin estatinas vs. 3% con estatinas; p < 0,001). El análisis multivariante demostró que la administración de estatinas actuó como factor protector frente a la mortalidad (OR ajustada 0,518; IC 95% 0,447-0,601). La continuación de la administración de estatinas se asoció con una reducción en la mortalidad (OR ajustada 0,597; IC 95% 0,449-0,798), y el inicio del tratamiento fue un factor protector frente a la mortalidad (OR ajustada 0,642; IC 95% 0,544-0,757). El tratamiento con estatinas también fue factor protector contra la incidencia de arritmias letales y shock cardiogénico. CONCLUSIONES: Estos resultados sugieren que el tratamiento precoz con estatinas en los pacientes con IM se asocia con una reducción de la mortalidad

OBJECTIVES: To evaluate the effects of the early administration of statins during acute myocardial infarction (MI). DESIGN: A retrospective cohort study was carried out. Setting National (Spain). PATIENTS OR PARTICIPANTS: Patients included in the ARIAM registry from January 1999 to December 2008 with a diagnosis of MI. INTERVENTIONS: None MAIN VARIABLES: We used logistic regression analysis and propensity scoring to determine whether the administration of statins during the first 24h of MI acts as a protective factor against: 1) mortality, 2) the incidence of lethal arrhythmias, or 3) cardiogenic shock. RESULTS: A total of 36 842 patients were included in the study. Statins were administered early in 50.2% of the patients. Statin administration was associated with younger patients with known previous dyslipidemia, obesity, a history of ischemic heart disease, heart failure, presence of sinus tachycardia, use of beta-blockers, angiotensin-converting enzyme inhibitors, thrombolysis and percutaneous coronary intervention. Mortality was 8.2% (13.2% without statin versus without statin versus 3% with statin, P < .001). Multivariate analysis demonstrated that statin administration acted as a protective factor against mortality (adjusted OR 0.518, 95%CI 0.447 to 0.601). Continued use of statins was associated with a reduction in mortality (adjusted OR 0.597, 95%CI 0.449 to 0.798), and the start of treatment was a protective factor against mortality (adjusted OR 0.642, 95%CI 0.544 -0.757). Statin therapy also exerted a protective effect against the incidence of lethal arrhythmias and cardiogenic shock. CONCLUSIONS: These results suggest that early treatment with statins in patients with MI is associated with reduced mortality

[Early statin therapy in acute myocardial infarction]. / Tratamiento precoz con estatinas en el infarto agudo de miocardio.

OBJECTIVES: To evaluate the effects of the early administration of statins during acute myocardial infarction (MI). DESIGN: A retrospective cohort study was carried out. SETTING: National (Spain). PATIENTS OR PARTICIPANTS: Patients included in the ARIAM registry from January 1999 to December 2008 with a diagnosis of MI. INTERVENTIONS: None. MAIN VARIABLES: We used logistic regression analysis and propensity scoring to determine whether the administration of statins during the first 24h of MI acts as a protective factor against: 1) mortality, 2) the incidence of lethal arrhythmias, or 3) cardiogenic shock. RESULTS: A total of 36 842 patients were included in the study. Statins were administered early in 50.2% of the patients. Statin administration was associated with younger patients with known previous dyslipidemia, obesity, a history of ischemic heart disease, heart failure, presence of sinus tachycardia, use of beta-blockers, angiotensin-converting enzyme inhibitors, thrombolysis and percutaneous coronary intervention. Mortality was 8.2% (13.2% without statin versus 3% with statin, P<.001). Multivariate analysis demonstrated that statin administration acted as a protective factor against mortality (adjusted OR 0.518, 95%CI 0.447 to 0.601). Continued use of statins was associated with a reduction in mortality (adjusted OR 0.597, 95%CI 0.449 to 0.798), and the start of treatment was a protective factor against mortality (adjusted OR 0.642, 95%CI 0.544 -0.757). Statin therapy also exerted a protective effect against the incidence of lethal arrhythmias and cardiogenic shock. CONCLUSIONS: These results suggest that early treatment with statins in patients with MI is associated with reduced mortality.

Surgery of subacromial syndrome with application of plasma rich in growth factors.

BACKGROUND: Our objective was to evaluate clinical recovery of patients with subacromial syndrome, after administering them plasma rich in growth factors (PRGF) by means of the Constant, University of California Los Angeles (UCLA) and Dissabilities of Arm, Shoulder and Hand (DASH) tests. MATERIALS AND METHODS: Prospective cohort study involving two groups - group A, treated with PRGF (52 patients); and group B, without PRGF treatment (79 patients). We analyzed the clinical situation preoperatively (time 1), at 1 month (time 2) and after rehabilitation (time 3). RESULTS: We considered 131 patients (71.2% were men, with median age of 53.7 years). Different approaches were used - traditional (62.5%), mini-open (22.5%) and arthroscopic (15%), without significant differences (P= .71). We observed improvement in the Constant test results at time 2 (59.8 +/- 11.5 points in group A vs. 13.2 +/- 7.1 points in group B; P < .05) and at time 3 (79.3 +/- 11.6 points in group A vs. 59.7 +/- 20.1 points in group B; P (1/4) .05). We found improvement in the UCLA test results at time 2 (23.2 +/- 5.8 points in group A vs. 4.72 +/- 1.1 points in group B; P < .05) and at time 3 (32.1 +/- 5.3 points in group A vs. 22.1 +/- 7.35 points in group B; P < .05). We also observed improvement in the DASH test results at time 2 (45.2 +/- 17.2 points in group A vs. 118.3 +/- 7.6 points in group B, P < .05) and at time 3 (37.3 +/- 12.6 points in group A vs. 69 +/- 25.7 points in group B). Time of rehabilitation reduced significantly: 2.53 months in group A vs. 4.96 months in group B (P < .05). No significant differences were observed in surgical times: 88 minutes (group A) vs. 97 minutes (group B). CONCLUSION: In our experience, PRGF should be indicated in subacromial syndrome and cuff involvement, as shown by the improvement in our results in terms of better results of tests, reduction in rehabilitation time and no increase in operation time.

Eficacia clínica de la vacunación antineumocócica en pacientes con enfermadad pulmonar obstructiva crónica / Clinical efficacy of anti-pneumoccocal vaccination in patients with COPD

El objetivo ha sido valorar la eficacia clínica de la vacuna antineumocócica(VANP) en pacientes inmunocompetentes con diagnósticoespirométrico de enfermedad pulmonar obstructiva crónica(EPOC).Método: Ensayo clínico prospectivo, controlado y aleatorizadoen 596 pacientes con EPOC, (edad media 66.9±9,6 años). De éstos,298 recibieron la VANP. La variable principal fue el primer episodiode neumonía adquirida en la comunidad (NAC) de etiologíaneumocócica o desconocida. Seguimiento de 3 años (media 979días).Resultados: Hubo 67 primeros episodios de NAC, de etiologíaneumocócica o desconocida. La eficacia de la VANP en la prevenciónde NAC de etiología neumocócica o desconocida en el grupototal era del 24%(IC 95%, -24 a 54; p= 0,333). En el subgrupo delos pacientes menores de 65 años, la eficacia aumentó hasta un76% (IC 95%, 20 a 93; p=0,013). En los que tenían una obstrucciónbronquial con un FEV1 <40%, la eficacia era del 48% (IC95%, -7 a 80; p=0,076). En los pacientes menores de 65 años y conFEV1<40%, la eficacia aumentaba hasta el 91% (IC95%, 35 a 99;p=0,002). Hubo 5 casos de NAC neumocócica no bacteriémica,todas ellas en el grupo control (long rank test = 5,03; p=0,0250). Sehizo un análisis multivariante de regresión de Cox para ajustar lavacunación a la edad y a la obstrucción bronquial, con respecto apresentar NAC: RR, 0,20; (IC 95% 0,06 a 0,68; p=0,01).Conclusiones: La VANP es efectiva para prevenir NAC de etiologíaneumocócica o desconocida en pacientes EPOC menores de65 años y con FEV1<40% (AU)

Objective: The aim of this study is to evaluate the clinical efficacyof the 23-valent pneumococcal polysaccharide vaccine (PPV)in immunocompetent patients with chronic obstructive pulmonarydisease (COPD).Methods: A randomised controlled trial was carried out in 596patients with COPD (age 66.9±9.6 yr). 298 of whom received PPV.The main outcome was radiographically proven communityacquired pneumonia (CAP) of pneumococcal or unknown aetiologyafter a mean period of 3 yr.Results: There were 67 first episodes of CAP caused by pneumococcusor of unknown aetiology. The efficacy of PPV in allpatients was 24% (95%CI -24 to 54; p = 0.333). In the subgroupaged, 65 years the efficacy of PPV was 76% (95% CI 20 to 93; p =0.013), while in those with severe functional obstruction(FEV1<40%) it was 48% (95% CI -7 to 80; p = 0.076). In youngerpatients with severe airflow obstruction the efficacy was 91%(95%CI 35 to 99; p = 0.002). There were only five cases of non-bacteriemicpneumococcal CAP, all in the non-intervention group (logrank test = 5.03; p = 0.0250). Multivariate analysis gave forunknown and pneumococcal CAP in the vaccinated group,adjusted for age was HR 0.20 (95%CI 0.06 to 0.68; p = 0.01).Conclusions: PPV is effective in preventing CAP in patientswith COPD aged less than 65 years and in those with severe airflowobstruction. No differences were found among the othergroups of patients with COPD (AU)

Eficacia clínica de la vacunación antineumocócica en pacientes con enfermedad pulmonar obstructiva crónica / Clinical efficacy of anti-pneumoccocal vaccination in patients with COPD

El objetivo ha sido valorar la eficacia clínica de la vacuna antineumocócica (VANP) en pacientes inmunocompetentes con diagnóstico espirométrico de enfermedad pulmonar obstructiva crónica (EPOC).Método: Ensayo clínico prospectivo, controlado y aleatorizado en 596 pacientes con EPOC, (edad media 66.9±9,6 años). De éstos, 298 recibieron la VANP. La variable principal fue el primer episodio de neumonía adquirida en la comunidad (NAC) de etiología neumocócica o desconocida. Seguimiento de 3 años (media 979 días).Resultados: Hubo 67 primeros episodios de NAC, de etiología neumocócica o desconocida. La eficacia de la VANP en la prevención de NAC de etiología neumocócica o desconocida en el grupo total era del 24%(IC 95%, -24 a 54; p= 0,333). En el subgrupo de los pacientes menores de 65 años, la eficacia aumentó hasta un 76% (IC 95%, 20 a 93; p=0,013). En los que tenían una obstrucción bronquial con un FEV1 <40%, la eficacia era del 48% (IC95%, -7 a 80; p=0,076). En los pacientes menores de 65 años y con FEV1<40%, la eficacia aumentaba hasta el 91% (IC95%, 35 a 99; p=0,002). Hubo 5 casos de NAC neumocócica no bacteriémica, todas ellas en el grupo control (long rank test = 5,03; p=0,0250). Se hizo un análisis multivariante de regresión de Cox para ajustar la vacunación a la edad y a la obstrucción bronquial, con respecto a presentar NAC: RR, 0,20; (IC 95% 0,06 a 0,68; p=0,01).Conclusiones: La VANP es efectiva para prevenir NAC de etiología neumocócica o desconocida en pacientes EPOC menores de 65 años y con FEV1<40%

Objective: The aim of this study is to evaluate the clinical efficacy of the 23-valent pneumococcal polysaccharide vaccine (PPV) in immunocompetent patients with chronic obstructive pulmonary disease (COPD).Methods: A randomised controlled trial was carried out in 596 patients with COPD (age 66.9±9.6 yr). 298 of whom received PPV. The main outcome was radiographically proven community acquired pneumonia (CAP) of pneumococcal or unknown aetiology after a mean period of 3 yr. Results: There were 67 first episodes of CAP caused by pneumococcus or of unknown aetiology. The efficacy of PPV in all patients was 24% (95%CI -24 to 54; p = 0.333). In the subgroup aged, 65 years the efficacy of PPV was 76% (95% CI 20 to 93; p = 0.013), while in those with severe functional obstruction (FEV1<40%) it was 48% (95% CI -7 to 80; p = 0.076). In younger patients with severe airflow obstruction the efficacy was 91%(95%CI 35 to 99; p = 0.002). There were only five cases of non-bacteriemic pneumococcal CAP, all in the non-intervention group (log rank test = 5.03; p = 0.0250). Multivariate analysis gave for unknown and pneumococcal CAP in the vaccinated group, adjusted for age was HR 0.20 (95%CI 0.06 to 0.68; p = 0.01).Conclusions: PPV is effective in preventing CAP in patients with COPD aged less than 65 years and in those with severe airflow obstruction. No differences were found among the other groups of patients with COPD

Synthesis of fluorescent dendrimers with an oligo(phenylenevinylene) core.

Novel fluorescent dendrimers of first, second, and third generation bearing a conjugated oligo(phenylenevinylene) (OPV) core and peripherial allyl chains as dendrons have been synthesized by a convergent method. The compounds have been fully characterized by 1H, 13C NMR, FTIR, UV-vis, and fluorescence spectroscopy, MALDI-TOF or FAB+ mass spectroscopy and elemental analysis. All dendrimers showed in solution a blue fluorescence with a maximum wavelength at 444-446 nm and can be deposited as thin films emitting in the blue-green region. The most homogeneous films were obtained for the second generation dendrimer which also exhibits the higher quantum yield in solution. These properties make it a possible candidate for application in organic light emitting diodes (OLEDs).

[Aortic coarctation: different anatomo-clinical forms depending on the age of presentation]. / Coartación de aorta: diferentes formas anatomoclínicas según la edad de presentación.

OBJECTIVE: To analyse the anatomo-clinical characteristics of the coarctation of the aorta at different ages of presentation as well as the findings and results of its surgical correction at different periods. PATIENTS AND METHODS: We retrospectively studied the clinical and angiographic data, as well as the intraoperative findings and surgical outcomes of 82 consecutive patients (54 M and 28 F) with coarctation of the aorta. Mean age was 16.2 +/- 13.7 years (1 month to 63 years). The patients were divided into three groups according to age: Group A (n = 10) under 1 year; Group B (n = 30) from 1 to 12 years and Group C (n = 42) over 12 years. RESULTS: A preductal form was found in 20.7% cases (50.0%, 30.0% and 7.1% of groups A, B, and C respectively; p = 0.003). An associated left-to-right shunt was present in 19.5% (40.0%, 16.7% and 16.7% of groups A, B and C respectively; p = NS). The first manifestation of the disease was different in groups A, B and C. Among group A patients, congestive heart failure was the most frequent presentation (70.0%). In group B, the most frequent presentation (30%) was as an incidental finding in an asymptomatic patient. Finally, systemic hypertension or its complications predominated among group C patients (38.0%). Left ventricular hypertrophy on ECG was present in 0.0%, 30.0% and 54.7% of patients in groups A, B and C (p = 0.003) respectively. Postoperative complications including death, hypertensive crisis and re-coarctation were observed in 90.0%, 33.3% and 21.4% in groups A, B and C (p = 0.01) respectively. CONCLUSIONS: Among patients with coarctation of the aorta, the age of clinical presentation allows us to define groups of patients with different anatomical characteristics, clinical course and postoperative outcome.

[Prognostic evaluation of post-infarction patients using two-dimensional echocardiography, late ventricular potentials and baroreflex sensitivity]. / Valoración pronóstica pacientes postinfarto mediate la ecocardiografía bidimensional, los potenciales tardíos ventriculares y la sensibilidad barorrefleja.

BACKGROUND: Although many variables are useful predictors of post-infarction mortality, their predictive positive values are weak when applied individually. The aim of this study was to determine the prognostic value of the combination of left ventricular ejection fraction, ventricular late potentials and baroreflex sensitivity. PATIENTS AND METHODS: We studied 69 consecutive post-infarction patients. On the day of their discharge from the coronary unit, all patients underwent a two-dimensional echocardiography, to determine the ejection fraction as well as a high resolution electrocardiogram to detect late potentials. To a subset of 49 patients was carried out to learn their baroreflex sensitivity. The patients were followed for 14 +/- 7 months and the following cardiac end points were considered: sudden cardiac death, non sudden cardiac death and non-fatal episodes of sustained ventricular tachycardia or ventricular fibrillation. RESULTS: There were 8 end points: 3 sudden cardiac deaths, 3 non sudden cardiac deaths and 2 successfully resuscitated sustained ventricular tachycardia episodes. The rate of fibrinolysis was 55%. An ejection fraction < 45%, the presence of late potentials and a baroreflex sensitivity < 3.0 msec/mmHg were univariate predictors with predictive positive values of 33%, 24% and 16%, respectively. When ejection fraction < 45%, late potentials and baroreflex sensitivity < 3.0 were combined, we found a significant increase in the positive predictive value (50%). CONCLUSION: The combined determination of ejection fraction, ventricular late potentials and baroreflex sensitivity allows us to identify subset postinfarction patients with a high rate of cardiac complications.

[Ventricular functional changes following an episode of accidental electrocution]. / Alteraciones funcionales de ventrículo tras un episodio de electrocución accidental.

We present a case of accidental electrocution in a 62-years-old male. After the accident he referred a non-specific thoracic pain that disappeared in a week, remaining asymptomatic since then. On the other hand, he shows a permanent electrocardiographic pattern of anterolateral subepicardial ischaemia. Myocardial function revealed by echocardiography and pertechnectate gammagraphy, showed an early primary damage, with a posterior slow tendency to recovery. Exercise treadmill test and Tallium-Dipyridamole test were normal, so an ischaemic background could be rejected in this case. No other diseases were presented, so the changes observed could be exclusively connected with the electrical accident.