'2' much mitral tissue.

A 73-year-old female patient was referred for evaluation after suffering an atypical chest pain. Physical examination and ECG were normal. The echocardiogram showed a normal ventricular function. Attached to the anterior leaflet an accessory mitral valve tissue was identified. In systole, this mitral tissue creates an image that looks like the 'number 2'.

CD14 C(-260)T promoter polymorphism and prevalence of acute coronary syndromes.

BACKGROUND: Inflammation and infection have been implicated in atherosclerosis and its complications. The CD14 receptor mediates monocyte activation by lipopolysaccharide (LPS) of Gram-negative bacteria. The aim of this study was to assess whether the C(-260)T polymorphism in the promoter of the CD14 receptor gene is associated with a higher prevalence of acute coronary syndromes (ACS) and severity of coronary atherosclerosis. METHODS: We studied 428 patients (mean age: 63+/-10 years, 67% men) consisting of 334 patients with coronary artery disease (CAD) and 94 patients with normal coronary arteriogram. Patients with CAD were subdivided in two groups: (1) no previous history of ACS (n=140; 64+/-9 years; 79% men) and (2) patients with a history of ACS (n=194; 64+/-10 years; 80% men). CD14 genotypes were determined by a Polymerase Chain Reaction (PCR)-Restriction Fragment Length Polymorphism Analysis (RFLP) technique. RESULTS: Patients with a prior ACS had a significantly higher frequency of the T/T genotype than CAD patients without prior ACS (33% vs. 20%; P=0.009), even after multivariate analysis (odd ratio [OR] 1.8 [1.1-3.1]; confidence intervals [CI] 95%; P=0.023). T/T genotype was not significantly different in CAD patients without prior ACS compared to controls (20% vs. 22.3%; P=0.67), and there was no significant association between genotypes, or allele frequencies, and severity of CAD. CONCLUSIONS: The CD14 C(-260)T polymorphism is associated with a history of ACS and it may represent a genetically determined risk factor for the development of ACS and atheromatous plaque vulnerability in angina patients.

Angiotension-converting enzyme gene I/D polymorphism in patients with angina and normal coronary arteriograms.

A polymorphism of the human angiotensin-converting enzyme (ACE) gene has been identified in which the insertion (I) rather than the deletion (D) variant is associated with lower circulating and tissue ACE activity. ACE I allele is associated with resistance and endurance performance. Skeletal muscle metabolic efficiency is reduced in patients with heart failure and is improved by ACE inhibition. Profound muscle fatigue is a predominant and debilitating symptom in a proportion or patients with angina and normal coronary arteriograms (ANCA), and we postulated that the gene D allele might be associated with the presence of fatigue in ANCA patients. We studied 33 consecutive patients with typical ANCA who completed a validated fatigue questionnaire, and found an excess of the D allele frequency in patients with the highest fatigue scores compared to those with the lowest (64% vs. 36%; p=0.027).

Management of iatrogenic radial artery perforation.

The aim of this study was to evaluate a new protocol allowing coronary angiography to be performed transradially in spite of the occurrence of iatrogenic radial artery perforation during catheterization. Nine patients with iatrogenic radial artery perforation were managed conservatively by inserting a long arterial sheath in the damaged radial artery up to the brachial artery, after which the diagnostic and/or interventional procedures that had motivated transradial catheterization were completed via the protected radial artery. Radial angiography performed immediately thereafter showed no extravasation, and no major vascular complications developed during follow-up. The day after the procedure, two patients had asymptomatic radial occlusion, but the other seven patients had normal radial pulses and reversed Allen test responses showing normal perfusion. A conservative management technique, installation of a long arterial sheath not only promotes resolution of iatrogenic radial artery perforation but also allows the procedures motivating catheterization to be completed transradially.

[Transradial approach to coronary angiography and angioplasty: initial experience and learning curve]. / Coronariografía y angioplastia coronaria por vía radial: experiencia incial curva de aprendizaje.

INTRODUCTION: The transradial approach has emerged as an attractive alternative to the femoral approach for coronary angiography and interventions. We describe our experience with the transradial approach and analyze the influence of the learning curve. PATIENTS AND METHODS: The transradial approach was attempted in patients with a good radial pulse and normal Allen test. When feasible and clinically indicated, we attempted ad hoc intervention. We divided the study population into two groups: Group A (the first 200 cases) and B (all other patients). We compared the radial group with a matched femoral control group. RESULTS: We attempted the transradial approach in 526 patients (77.6% male; age 63.5 +/- 11.51), and obtained a success rate of 93.7%. We found differences between group A and B in the success rate (91.0 vs 95.4%, p = 0,04), duration of procedure [23 (16-29) vs. 19 (15-24) minutes; p < 0.001], and fluoroscopy time [6.4 (4.2-10) vs. 5.0 (3.0-7.7) minutes; p < 0,001]. At 24 h of follow-up, we found small hematomas in 9.4%, bleeding in 4.9%, and radial artery obstruction in 2.8%, with no cases of arteriovenous fistula, pseudoaneurysm, or need for vascular surgery. We attempted intervention in 169 patients with 258 lesions, achieving angiographic success in 96.1%. We found no differences in the characteristics of the lesions and patients, or in the angiographic success rate of the radial and femoral PTCA groups. CONCLUSIONS: The transradial approach is a safe and effective alternative to femoral catheterization. There is a significant learning curve associated with the successful performance of transradial procedures.

[Cardiovascular syndrome X and endothelial dysfunction]. / Síndrome X cardiovascular y disfunción endotial.

Up to 30% of patients with chest pain who undergo coronary arteriography, have completely normal coronary angiograms. The subgroup with typical angina and a positive response to stress testing is generally included under the diagnosis of cardiovascular syndrome X. Several causes and mechanisms have been investigated in the past twenty years, to explain both chest pain and ischemic angina-like ST segment depression that are commonly observed in these patients. Clinical and pathogenic heterogeneity appears to be the main features of the syndrome. Among the suggested pathophysiological mechanisms, endothelial dysfunction of the coronary microcirculation features prominently. In this review, we present the available evidence regarding endothelial dysfunction in cardiovascular syndrome X.

Coronariografía y angioplastia coronaria por vía radial: experiencia inicial y curva de aprendizaje / Transradial approach to coronary angiography and angioplasty: initial experience and learning curve

Introducción. La vía transradial ha surgido como una alternativa atractiva a la vía femoral para realizar coronariografías e intervenciones coronarias. Describimos nuestra experiencia y analizamos la influencia de la curva de aprendizaje. Pacientes y métodos. El abordaje transradial se intentó en pacientes con pulso radial y test de Allen normales. Cuando se consideró posible e indicado, se realizó una intervención coronaria en el mismo procedimiento. Dividimos a la población de estudio en 2 grupos: A (primeros 200 casos) y B (el resto de los pacientes). Comparamos el grupo radial con un grupo control femoral. Resultados. Intentamos el acceso radial en 526 pacientes (77,6 por ciento varones; edad, 63,5 ñ 11,51 años), con éxito en el 93,7 por ciento. Encontramos diferencias entre los grupos A y B en la proporción de procedimientos con éxito (91,0 frente a 95,4 por ciento; p = 0,04), los tiempos de procedimiento (23 [16-29] frente a 19 [15-24] min; p < 0,001) y de fluoroscopia (6,4 [4,2-10] frente a 5,0 [3,0-7,7] min; p < 0,001). A las 24 h, encontramos pequeños hematomas en el 9,4 por ciento, hemorragia en el 4,9 por ciento, obstrucción radial en el 2,8 por ciento, y ningún caso de fístula arteriovenosa, seudoaneurisma o necesidad de intervención quirúrgica. Se intentó realizar una angioplastia en 169 pacientes (258 lesiones), con éxito angiográfico en el 96,1 por ciento. No encontramos diferencias en las características de los pacientes, las lesiones y el resultado angiográfico entre los grupos de intervención radial y femoral. Conclusiones. La vía radial es una alternativa segura y eficaz a la femoral. Existe una curva de aprendizaje significativa asociada a los procedimientos por vía radial (AU)

Síndrome X cardiovascular y disfunción endotelial / Cardiovascular syndrome X and endothelial dysfunction

Hasta un 30 por ciento de los pacientes que son sometidos a una coronariografía tienen arterias coronarias angiográficamente normales. De estos pacientes, el subgrupo con dolor anginoso típico y ergometría positiva se engloba bajo el diagnóstico de síndrome X cardíaco. Durante años se han investigado múltiples posibles causas y mecanismos para explicar tanto el dolor torácico como las alteraciones electrocardiográficas indicativas de isquemia miocárdica que se observan en estos pacientes. Hoy día parece claro que la heterogeneidad es una de las características principales del síndrome, tanto en lo que se refiere a la fisiopatología como a las manifestaciones clínicas. Entre los posibles mecanismos patogénicos, la disfunción endotelial de la microcirculación coronaria aparece como uno de los más importantes. En esta revisión se resume la evidencia disponible en la actualidad acerca de la disfunción endotelial como uno de los mecanismos patogénicos implicados en el síndrome X cardíaco (AU)

[Exercise echocardiography to differentiate dilated cardiomyopathy from ischemic left ventricular dysfunction]. / Ecocardiografía de ejercicio para diferenciar la miocardiopatía dilatada de la disfunción ventricualr por cardiopatía isquémica.

OBJECTIVES: Previous studies have shown the usefulness of dobutamine echocardiography to differentiate dilated cardiomyopathy (DC) from ischemic left ventricular dysfunction (ILVD), but no studies have been made using exercise echocardiography (EE). We hypothesized that most patients with DC have some contractile reserve and experience an increase in left ventricular ejection fraction (LVEF) during exercise, as opposed to patients with ILVD. Differences in response to EE may be useful to clinically differentiate between these two entities. PATIENTS AND METHOD: Between 1 March 1995 and 1 March 2001, we performed 4,133 EE studies on 3,830 patients. Of 289 patients (8%) with moderate or severe LV dysfunction (biplane LVEF < 41% and left ventricular end-diastolic diameter > 5.2 cm), 207 were excluded: 111 for a history of myocardial infarction; 28 for scarring on echocardiography (regional akinesia/dyskinesia with thinning and/or increased brightness); 13 for previous revascularization procedures; 9 for aortic valve disease; 11 for a known cause of cardiomyopathy; and 35 for not undergoing angiography. The study group was therefore composed of 82 patients who were encouraged to perform maximal treadmill EE. EE criteria for ILVD were either impaired regional wall motion (RWM) or a decrease/no change in LVEF from baseline to peak exercise, while criteria for DC were RWM improvement/no change and LVEF increase. The ILVD group was formed by 39 patients with stenosis >/= 70% diameter stenosis of a major epicardial coronary artery or major branch vessel. The remaining 43 patients constituted the DC group. RESULTS: The number of coronary risk factors (ILVD 2.0 1.1; DC 1.9 1.1), baseline LVEF (ILVD 30 7; DC 30 8), and exercise-induced angina (ILVD 23%; DC 14%) did not differ between groups (p = NS). ILVD patients achieved less Mets (6.6 3.1 vs 8.3 2.8; p < 0.05), had a lower heart rate x systolic blood pressure product (22 5 vs 27 7; p < 0.001), and developed regional and/or global LV dysfunction more frequently (79 vs 28%; p < 0.001). Sensitivity, specificity, positive and negative predictive values and global accuracy for ILVD detection were 79% (95% CI: 70-88), 72% (95% CI: 63-81), 72% (95% CI: 63-81), 79% (95% CI: 67-85), and 76% (95% CI: 69-83), respectively. CONCLUSION: Global and/or regional LV function impairment with exercise is accurate in identifying patients with ILVD. This method could reduce the need for invasive procedures.

Ecocardiografía de ejercicio para diferenciar la miocardiopatía dilatada de la disfunción ventricular por cardiopatía isquémica / Exercise echocardiography to differentiate dilated cardiomyopathy from ischemic Left Ventricular Dysfunction

Objetivos. Aunque la ecocardiografía con dobutamina diferencia la miocardiopatía dilatada (MD) de la disfunción ventricular debida a cardiopatía isquémica (DVCI), no existen estudios al respecto con ecocardiografía de ejercicio (EE). Con la hipótesis de que los pacientes con MD pueden tener reserva contráctil, al contrario que aquellos con DVCI, hemos estudiado a enfermos con disfunción ventricular (DV) izquierda sometidos a EE. Entre 1995 y 2001 realizamos 4.133 EE a 3.830 pacientes. De 289 enfermos con DV (fracción de eyección ventricular izquierda [FEVI] por método biplano 5,2 cm) se excluyó a 207: 111 por historia de infarto de miocardio; 28 por necrosis (acinesia-discinesia con adelgazamiento o brillo aumentado); 13 por revascularización; 9 por valvulopatía aórtica; 11 por causa conocida de miocardiopatía, y 35 por ausencia de coronariografía. Pacientes y método. Por tanto, el grupo de estudio estaba formado por 82 pacientes que fueron estimulados a realizar EE máxima en cinta: 39 pacientes con estenosis > 69 per cent en una arteria epicárdica principal o una rama importante formaban el grupo de DVCI y el resto (n = 43), el de MD. El criterio para DVCI era empeoramiento de la motilidad segmentaria o descenso o igual FEVI con el ejercicio, mientras que el criterio para MD era mejoría o ausencia de cambio en la motilidad segmentaria y aumento de la FE. Resultado. El número de factores de riesgo coronario (DVCI, 2,0 ñ 1,1; MD, 1,9 ñ 1,2), FEVI basal (DVCI, 30 ñ 7; MD, 30 ñ 8) y porcentaje de aparición de angina (DVCI, 23 per cent; MD, 14 per cent) eran similares (p = NS), mientras que los pacientes con DVCI alcanzaron menos Mets (6,6 ñ 3,1 frente a 8,3 ñ 2,8; p < 0,05) y producto frecuencia cardíaca × presión arterial (22 ñ 5 frente a 27 ñ 7; p < 0,001), y desarrollaron disfunción regional o global más frecuentemente (79 frente a 28 per cent; p < 0,001). La sensibilidad, el especificidad, el valor predictivo positivo y negativo y la precisión diagnóstica para DVCI fueron del 79 per cent (IC del 95 per cent, 70-88), 72 per cent (63-81), 72 per cent (63-81), 79 per cent (6785) y 76 per cent (69-83).Conclusión. En conclusión, una respuesta de empeoramiento de la función ventricular con el ejercicio identifica a los pacientes con DVCI con razonable precisión diagnóstica. La EE puede reducir, por tanto, la necesidad de procedimientos invasivos (AU)