Anaemia is associated with higher mortality among patients with heart failure with preserved systolic function.

OBJECTIVE: To investigate the prevalence of anaemia and its influence on mortality among hospitalised patients with congestive heart failure (CHF) with preserved left ventricular systolic function (LVSF). METHOD AND RESULTS: 210 patients with preserved LVSF admitted to the cardiology department of a tertiary hospital for CHF between 1 January 2000 and 31 December 2002 were analysed. Anaemic patients, who constituted 46% of the whole group, were older (75 v 72 years, p = 0.036); were in hospital longer (mean (SD) 13 v 11 days, p = 0.007); had a higher prevalence of ischaemic heart disease (54% v 35%, p = 0.009), left bundle branch block (12% v 4%, p = 0.018), and kidney failure (56% v 34%, p = 0.003); and had faster erythrocyte sedimentation rates (mean (SD) 50 v 26 mm in the first hour, p < 0.001), a tendency to lower serum cholesterol concentration (mean (SD) 4.65 v 5.22 mmol/l, p = 0.073), and smaller body mass index (mean (SD) 27 v 29 kg/m2, p = 0.126) than their non-anaemic counterparts. Kaplan-Meier analysis showed the anaemic group to have significantly poorer survival (p = 0.0001), with a one year survival rate of 72.2% versus 90.5% in the non-anaemic group. Multivariate analysis showed anaemia to be the most powerful independent predictor of mortality, increasing the risk of death by a factor of 2.7 (p = 0.007). CONCLUSION: Anaemia is a very prevalent condition in hospitalised patients with CHF with preserved LVSF and is independently associated with higher mortality. Appropriately designed randomised studies are needed to determine whether the prevention or treatment of anaemia can improve survival of these patients.

Disección coronaria espontánea: aspectos diagnósticos y terapéuticos / Spontaneous coronary dissection: diagnostic and therapeutic approach

Presentamos dos casos de disección espontánea coronaria, que corresponden a dos mujeres sin factores de riesgo que presentaron un síndrome coronario agudo que cursó con importantes cambios electrocardiográficos. Se realizó en ambos casos una coronariografía urgente, que demostró una disección del tronco de la coronaria izquierda en el primer caso y una disección del segmento proximal de la arteria descendente anterior en el segundo. Ambos casos fueron revascularizados quirúrgicamente. (AU)

Role of transesophageal echocardiography in the assessment of patients with blunt chest trauma: correlation of echocardiographic findings with the electrocardiogram and creatine kinase monoclonal antibody measurements.

OBJECTIVES: This study was designed to evaluate the usefulness of transesophogeal echocardiography (TEE) for detecting cardiac damage after blunt chest trauma (BCT). BACKGROUND: Multiple methods have been used to detect cardiac damage after a BCT, but none has been demonstrated to be sensitive, specific, and feasible enough. METHODS: This multicenter prospective trial was designed to evaluate the usefulness of TEE in the assessment of patients with BCT and to compare the TEE findings with those provided by the electrocardiogram (ECG) and cardiac isoenzymes assay. One hundred seventeen consecutive patients with a significant BCT were enrolled. A TEE was performed in each patient. Serial ECGs and plasma profiles of creatine kinase (CK) and CK-monoclonal antibody (MB) were obtained. RESULTS: Sixty-six (56%) patients had pathologic findings in the TEE attributed to the BCT (group A). In the remaining 51 (44%) patients the TEE was normal (group B). An abnormal ECG was more frequent in group A (59% vs 24%; p < 0.001), and the serum CK-MB peak level was also higher in group A (174 +/- 30 U/L vs 93 +/- 21 U/L; p = 0.05). Relative to pathologic TEE findings, the sensitivity and specificity of an abnormal ECG were 59% and 73% and of high CK-MB with CK-MB/CK > 5% were 64% and 52%, respectively. CONCLUSIONS: We conclude that TEE can be routinely and safely performed for diagnosing cardiac injuries after a BCT and plays an important role in the evaluation and treatment of these patients. EGG and CK-MB assay are not good methods for detecting cardiac damage in this setting.

[Activity of leukocyte elastase in coronary disease diagnosed by coronarography]. / Actividad de la elastasa leucocitaria en la enfermedad arterial coronaria determinada por coronariografía.

OBJECTIVE: To evaluate the clinical usefulness of leukocyte elastase concentration for diagnosis of coronary artery disease. BACKGROUND: Recent research has shown the important role elastase, a proteolytic enzyme released by neutrophils, in the pathogenesis of coronary atherosclerotic disease. METHODS: 95 patients underwent coronary angiography during investigation of chest pain and/or heart valve disease; 38 had normal coronary arteriograms (Group I) and 57 had coronary lesions (Group II). The patients were characterized as regards presence or absence of stable or unstable angina, family history of coronary artery disease, smoking, diabetes mellitus, hypertension, leukocyte counts, plasma lipid and elastase concentrations. Among Group II patients, those with simple atheromatous plaques were distinguished from those with complex plaques. RESULTS: Elastase concentrations were greater in the Group II than in the Group I (41 +/- 21 vs 27 +/- 14 micrograms/L) (p < 0.001), and greater among complex plaque patients than among simple plaque patients (53 +/- 27 vs 33 +/- 12 micrograms/L) (p < 0.001). Logistic regression analysis showed than elastase concentration, angina, age and sex had independent value for prediction of coronary artery disease and that the risk increased by 7% for every 1 microgram/L increase in elastase concentration. Among Group II patients, the risk of complex plaque was greatest for those with unstable angina and high elastase concentration, increasing by 6% for every 1 microgram/L increase in elastase concentration. CONCLUSIONS: Peripheral blood leukocyte elastase concentration is a sensitive diagnostic marker of coronary artery disease. High values suggest the presence of complex atheromatous plaques.

[Regression of left ventricular mass in arterial hypertension. Efficacy of 3 different treatment protocols]. / Regresión de la masa ventricular izquierda en la hipertensión arterial. Eficacia de tres diferentes pautas de tratamiento.

BACKGROUND: To evaluate the antihypertensive efficacy, at rest and under exercise, in patients treated with three different antihypertensive drugs and the modifications induced on the left ventricular mass. METHODS: Fifty hypertensive males, mean age 51 years, 15 received 50 mg/day of chlorthalidone, 20 atenolol (100 mg/day) and 15 enalapril (20-40 mg/day). Baseline pressure control and echocardiogram, and 3, 6 and 9 months after starting therapy were performed. Thickness of the interventricular septum and posterior left ventricular wall in mm, left ventricular mass index in g/m2 were determined. RESULTS: The baseline septum in the diuretic group was 15 +/- 3 mm and 14 +/- 3 mm at 9 months, in the atenolol group was 16 +/- 3 mm and 12 +/- 2 mm (p less than 0.001), and in the enalapril group 15 +/- 2 mm and 12 +/- 3 mm (p less than 0.01). The posterior wall was 14 +/- 3 mm and 13 +/- 2 mm in the diuretic group, in the atenolol group 15 +/- 2 mm and 12 +/- 2 mm (p less than 0.001) and in the enalapril group 15 +/- 2 mm and 12 +/- 3 mm (p less than 0.01). The left ventricular mass index was in he diuretic group 153 +/- 45 g/m2 and 146 +/- 36 g/m2, in the atenolol group 167 +/- 34 g/m2 and 128 +/- 24 g/m2 (p less than 0.001) and in the enalapril group 156 +/- 36 g/m2 and 131 +/- 26 g/m2 (p less than 0.05). CONCLUSIONS: The antihypertensive efficacy at rest was similar with the three drugs, being under exercise superior atenolol and enalapril. Only atenolol and enalapril induced regression of left ventricular mass.

[Clinical and prognostic implications of age in acute myocardial infarct]. / Implicaciones clínicas y pronósticas de la edad en el infarto agudo de miocardio.

The purpose of this study was to evaluate the clinical characteristics and the factors related to early mortality in the acute myocardial infarction of the geriatric population. We studied 814 consecutive patients with their first acute myocardial infarction admitted to the coronary care unit at tha Hospital General de Galicia. 401 patients were older than 65 years (Group A) and 413 were younger (Group B). Group A was found a significantly lower percentage of males (64.7% versus 88.4%; p less than 0.001) and smokers (46.7% versus 72.7%; p less than 0.001; and older patients showed a greater incidence of diabetes mellitus (28.1% versus 15.2%; p less than 0.001) and arterial hypertension (45.6% versus 31.7%; p less than 0.01). In the geriatric population, the clinical course of the acute myocardial infarction is characterized by a greater incidence of heart failure (35.3% versus 11.1%; p less than 0.001), cardiogenic shock (18% versus 5.7%; p less than 0.001) and post-acute myocardial infarction angina pectoris (18.3% versus 12.2%; p less than 0.05). Early mortality (first month) was significantly higher in elderly patients (22.7% versus 6.3%; p less than 0.001). The multivariate analysis by stepwise logistic regression identified cardiogenic shock, age and heart failure as the only independent predictive variables for early mortality. We conclude that early mortality in the acute myocardial infarction is high and related to severe degrees of pump failure and age.

[Images of magnetic resonance and computerized axial tomography in a case of subacute post-myocardial infarct heart rupture]. / Imágenes de resonancia magnética y tomografía axial computadorizada en un caso de rotura cardíaca subaguda postinfarto de miocardio.

In a patient with clinical and hemodynamic criteria of cardiac tamponade, during the acute phase of myocardial infarction, a two dimensional echocardiographic study showed pericardial effusion with an echo-dense mass in the pericardial space. Subacute ventricular free-wall rupture diagnosis was suspected. A cardiac computerized tomography (CT) and magnetic resonance (MR) study was made. CT showed an elevated density (32 HU) of pericardial effusion suggesting hemopericardium. RM imaging showed a very high and homogeneous signal in the pericardial space consistent with a methemoglobin phase clot. Anatomic confirmation was not possible.

[40 years' experience in the surgical treatment of constrictive pericarditis]. / Cuarenta años de experiencia en el tratamiento quirúrgico de la pericarditis constrictiva.

In order to know early and late results of pericardiectomy on the treatment of chronic constrictive pericarditis in the Instituto Nacional de Cardiología Ignacio Chávez, we review the records of 58 patients with the diagnosis of constrictive pericarditis who underwent surgical treatment between 1947 to 1987. Tuberculosis was the most frequent cause (68.3%) followed by idiopathic cases (24.1%). Preoperatively 3.4% were in New York Heart Association Class I, 31% in Class II, 48.3% in Class III and 17.2% in Class IV. There were 4 in-hospital deaths (overall operative mortality 6.89%). Operative mortality in the last ten years was 0%. Low output was the most common nonfatal complication of pericardiectomy (15.5%). Accidental right atrial tear happened in 8.6%. Mean post-operative follow-up was 5.6 +/- 6.3 years (longest 25.6 years). Mortality per patient year was 2.04%. Actuarial survival estimates were 82% and 71% at 5 to 10 years respectively. Postoperatively 76% were in New York Heart Association Class I (p less than 0.001), 16% in Class II (p less than 0.001), 8% in Class III (p less than 0.001) and none in Class IV (p less than 0.05). Operative mortality, long-term survival and post-operative functional Class were not significantly influenced by preoperative functional Class nor by the duration of symptoms. We conclude that pericardiectomy is an effective treatment of symptomatic chronic constrictive pericarditis because it provides an important and durable improvement in symptoms and functional Class, and it has a low operative mortality.

[Electrocardiographic aspects of right ventricular repolarization in interauricular septal defect]. / Aspectos electrocardiográficos de la repolarización ventricular derecha en la comunicación interauricular.

In order to know the value of a peculiar right ventricular repolarization in the diagnosis of atrial septal defect. We studied-one hundred patients with main right bundle branch block and atrial septal defect confirmed by cardiac catheterization. The peculiar right ventricular repolarization consist in a straight and long S-T segment (longer than 160 msc) that form a 60 degrees or greater angle with the ascendent branch of the T wave. This electrocardiographic sign was found in 82 patients (sensitivity 82%). There were no differences between the age groups or the pulmonary pressure levels. In sixty five patients with main right bundle branch block without atrial septal defect, this peculiar right ventricular repolarization was investigated. It was found in fourteen cases (specificity 78.4%). Positive predictive value was 85.4%, negative predictive value 73.9% and diagnostic efficiency 80.6%. When the atrial septal defect was repaired (76 patients), the peculiar right ventricular repolarization disappeared in 87.7% of the cases (p less than 0.0001). It can be concluded that the peculiar right ventricular repolarization, in presence of main bundle branch block supports the diagnosis of atrial septal defect.

[Value of the DI and AVL leads in the diagnosis of infarction of the right ventricle]. / Utilidad de las derivaciones DI y AVL en el diagnóstico del infarto del ventrículo derecho.

The present study attempts to analyze the sensitivity and specificity of the S-T segment depression in I and a VL leads in the diagnosis of postero-inferior myocardial infarction with right ventricular extension. Thirty four specimens from autopsies performed in the Instituto Nacional de Cardiología Ignacio Chávez with histopathological evidence of postero-inferior myocardial infarction, with an adequate clinical, enzymatic and electrocardiographic documentation were studied. In 23 the postero-inferior myocardial infarction had extended to the right ventricle (group I) and in ll only left ventricle was involved (group II). There were not significative differences in severity and extension of coronary obstructions between the two groups studied. Sensitivity of S-T segment depression in DI lead ad diagnosis of right ventricular extension had 82.6%, specificity 90.9%, positive predictive value 95%, negative predictive value 71.4% and diagnostic efficiency 85.2%. Sensitivity of S-T segment depression in a VL lead as diagnostic of right ventricular extension was 91.3%, specificity 81.8%, positive predictive value 91.3%, negative predictive value 81.8% and diagnostic efficiency 88.2%.

[Long-term course of infarct of the right ventricle]. / Evolución a largo plazo del infarto del ventrículo derecho.

The long-term evolution of 36 patients surviving the phase of hospitalization after a postero-inferior infarction with extension to the right ventricle was studied. Patients included 7 women and 29 men with a mean age of 55 years. Follow-up time averaged 39 months (range: 4 to 78 months). The evolution of acute phase was analyzed and correlated with mortality, complications and long-term evolution of functional capacity. Mortality at the end of follow-up period was 5.5%. Five patients developed another myocardial infarctions (16%). No patient manifested right heart failure; in one case tricuspid regurgitation was evident. The majority of the patients (55.5%) were in functional class I of the NYHA, while 36.6% were in class II and 8.3% in class III. We conclude that long-term mortality of those patients with right ventricular infarction is not greater than that of other patients with myocardial infarction, and that the great majority have a favorable evolution in regard of functional capacity. Impared function is generally due to left ventricular failure secondary to the severity and extension of coronary lesions. The subgroup of patients with severe right ventricular dysfunction during the acute phase of the infarction did not have a worse long-term prognosis.