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Hypolipemic treatment is a matter of controversy. The objective of this paper is to analyze how Spanish cardiologist knows the lipid role in ischemic heart disease and their intention of treatment hypercholesterolemia in ischemic cardiomiopathy patients. We also evaluate the grade of control and treatment of hypercholesterolemia in patients with ischemic heart disease who belong to a primary care center.Two inquests were done to 1,850 Spanish cardiologist using a question paper in 1993 and 1996. At the Primary Care Center of Fuencarral (Madrid) we made a transversal study from February till March 1996.In 1993, 11% answered the questionnaire and 25% in 1996. Cardiologists who considered the ideal level of cholesterol lower than 200 mg/dl raised from 62% in 1993 to 86% in 1996 (p0.001). Cardiologists who considered that cholesterol linked to low density lipoproteins should be lower than 100 mg/dl raised from 0% in 1993 to 28% in 1996 (p0.001). Drug treatment was prescribed by 68% when total cholesterol levels were higher than 300 mg/dl in 1993 and 14% of cardiologists never prescribed drugs. In 1996, 71% prescribed drug treatment when total cholesterol was between 200 and 250 mg/dl (p0.001). Cardiologists who worked at hospitals began with drugs with a lower cholesterol levels than out-hospital cardiologists. Hypercholesterolemia was considered as the most important risk factor in secondary prevention. We review 94 patients with ischemic heart disease; 37 did not receive hypolipemic treatment, though they had more than 200 mg/dl of cholesterol. Just 12 of the 45 treated reached figures below 200 mg/dl. 32% of the patients where controlled by family doctor's.Results of the two surveys in 1993 and 1996 have produced a change in Spanish cardiologist attitude about indication of hypolipemic treatment for patients suffering from ischemic cardiomiopathy. Family doctor's and cardiologists must assume secondary prevention. Indeed, it is necessary to make them both become aware of the importance of a correct treatment of those patients.

The technique of coronary endarterectomy, in coronary artery surgery, has been controversial and alternatively indicated or contraindicated by different authors. In this paper coronary endarterectomy is reviewed, including its definition, history and development of different techniques. Early and late results of the main papers in the literature are commented on as well as our results. The surgical technique of endarterectomy in the different coronary artery territories is described with the primary indications and contraindications. Coronary endarterectomy is a valid and well established technique that can provide possibilities of revascularization in patients with extended and diffused coronary artery obstructions, which are unable to be treated with conventional coronary artery bypass grafts. Operative mortality and morbidity are slightly higher, but long-term results, as far as survival and functional class are concerned, are similar to standard coronary artery surgical procedures.

A B S T R A C T Ventricular arrhythmias are important contributors to morbidity and mortality in patients with coronary artery disease. Ventricular fibrillation accounts for the majority of deaths occurring in the acute phase of ischemia, whereas sustained, monomorphic ventricular tachycardia due to reentry generated in the scar tissue develops most often in the setting of healed myocardial infarction, especially in patients with lower left ventricular ejection fraction. Despite determinant advances in population education and myocardial infarction management, the ventricular tachycardia risk in the overall population with coronary artery disease continues to be a major problem in clinical practice. The initial evaluation of a patient presenting with ventricular tachycardia requires a 12-lead electrocardiogram, which can be helpful to confirm the diagnosis, suggest the presence of potential underlying heart disease, and identify the location of the ventricular tachycardia circuit. An invasive electrophysiologic study is usually crucial to determine the mechanism of the arrhythmia once induced and to provide guidance for ablation. The approach for ventricular tachycardia ablation depends on several factors, including inducibility, sustainability, and clinical tolerance of ventricular tachycardia. The paper also reviews other therapeutic options for patients with ventricular tachycardia associated with coronary artery disease, including antiarrhythmic drug therapy, surgical ablation, and current implantable cardioverter-defibrillator indications.

Introduction and objectives: The increasing incidence of abdominal aortic aneurysm (AAA), mainly due to the aging population, and its mortality of 85-90% in the event of rupture justify opting for early diagnosis and elective treatment to repair it. The main aim of this paper is to analyze the utility of transthoracic echocardiography (TTE) in the study of infrarenal aorta and AAA screening. Methods: The study included 512 patients (309 men and 203 women) consecutively assessed by TTE and, where possible, abdominal ultrasound for any reason in a cardiology department. Results: An AAA was detected in 25 patients (5.1%), the minimum age at diagnosis was 55 years, the ratio of men to women was 7.3:1 and the mean diameter of the aneurysms was 39.5 12.2 mm. Risk factors associated with AAA were to current and former smoking, age, and presence of femoral murmur. The TTE results were equivalent to those of abdominal ultrasound. All patients with AAA studied by coronary angiography showed significant coronary lesions. Conclusions: It is feasible and useful to complement conventional TTE with the study of the infrarenal aorta for AAA screening in patients visited at the department of cardiology. This study should be performed mainly in patients 55 years old or with risk factors to develop an AAA.

Introduction and objectives: Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal

Despite diastolic dysfunction is recognized to play a major role in the pathophysiology of heart failure, the importance of an accurate diagnosis and treatment of this syndrome in clinical practice is poorly established. Recent publications suggest that diastolic dysfunction is the primary cause of heart failure in 30-50% of patients. Several studies also show that, in a significant number of patients with systolic dysfunction, diastolic function is the major determinant of their symptomatic status, their response to treatment and their outcome. Other preliminary data suggest that diastolic dysfunction is an important cause of exercise intolerance in patients with chronic hypertension. This paper discusses the most recent concepts related to the mechanisms, the diagnosis and the treatment of diastolic dysfunction based on diagnostic imaging techniques.

The clinical relevance of cardiac embolism a potential cause of stroke is progressively increasing, mainly due to the recent progress in diagnostic imaging. In the present paper, we update and review the state of the art of the different etiologies currently accepted of a cardiac source of stroke. Furthermore, we review the clinical role of different image techniques, emphasizing the doubts and realities of each particular approximation.

Contrast angiography has been used for nearly five decades to evaluate the severity of coronary lesions. However, when attempting to distinguish between intermediate coronary lesions able or unable to produce ischemia, the technique has several limitations. A large number of patients undergo cardiac catheterization without prior evaluation of coronary perfusion by non-invasive tests. This number is likely to increase in the coming years, because current recommendations favor the invasive treatment of acute coronary syndromes. This has triggered marked interest in new diagnostic techniques capable of assessing the physiological significance of intermediate lesions in the catheterization room. This paper reviews the different techniques currently available for scientifically assessing the significance of such lesions. The advantages and limitations of each are discussed.

Background. Recurrent symptomatic pericardial effusion can complicate different cardiac and extracardiac diseases. When recurrent pericardial effusion after drainage with conventional catheter techniques occurred the creation of a pericardial window by open surgery used to be the unique treatment available until the recent development of percutaneous balloon pericardiotomy. Objective. The aim of this paper is to review our initial experience with percutaneous balloon pericardiotomy for the treatment of patients with recurrent pericardial effusion. Patientes and method. Five patients with recurrent pericardial effusion have been treated with percutaneous pericardiotomy until now. Four patients had malignant pericardial effusion secondary to metastasis of extracardiac tumors, in one patient recurrent pericardial effusion was idiopathic. In all patients percutaneous balloon pericardiotomy was performed with a pediatric valvuloplasty balloon catheter, through a subxiphoid approach. Results. Successful drainage and balloon pericardiotomy was achieved in all patients without severe complications. In all cases only one pericardial site was dilated. Minor complications were registered, which included mainly mild pleural effusion occurring in all patients with spontaneous resolution. During a mean follow-up period of 8.6 ± 6.5 months (range 2 to 18 months) there were no recurrences of effusion or tamponade. Two patients died, 1 month and 9 months after the procedure, due to their malignant condition. Conclusions. Percutaneous balloon pericardiotomy is an easy and useful technique to manage patients with large recurrent pericardial effusion with a low rate of complications.

Received Accepted for publication For many years, the evaluation of the extent and severity of coronary artery disease has been mainly anatomical, carried out by coronary angiography. However, this technique has methodological limitations and interobserver variability is considerable. Quantification of coronary reserve with pressure guidewires and intracoronary Doppler now provides more precise physiologic evaluation of coronary circulation. Myocardial perfusion single proton emission computed tomography and echocardiography, combined with stress and/or pharmacological challenge testing, though they are only semiquantitative techniques, also offer appropriate complements to coronary angiography in the functional evaluation of coronary patients. The aim of this paper is to discuss the clinical value of these techniques.

Introduction and objectives. Mitral valve disease often is accompanied by chronic atrial fibrillation, especially when the left atrium is enlarged. Mitral valve surgery alone cannot resolve the arrhythmia in most cases. Several surgical techniques have been proposed. We have used surgical left atrial reduction and pulmonary vein isolation to eliminate chronic atrial fibrillation associated with mitral valve disease. The aim of this paper is to report our experience with this new surgical concept. Patients and method. Twenty-three patients (18 women and 5 men, mean age 44.1 ± 14.7 years) with mitral valve disease and chronic atrial fibrillation for more than 3 months underwent surgery. Mitral valvuloplasty was performed in 11 cases, and mitral valve replacement in 12. Left atrial reduction was used to eliminate chronic atrial fibrillation in all cases. Results. There was no operative mortality. Three patients (13%) had recurrent atrial fibrillation between postoperative days 6 and 8. No atrioventricular conduction disturbances were observed. An important reduction in left atrial size was evident on echocardiography (4.8 ± 0.77 vs. 8.1 ± 1.47 cm, p < 0.01). In 3 to 36 months of follow-up (13.9 ± 11 months), all patients preserved sinus rhythm. Conclusions. Left atrial reduction seems to be an effective and easily applied alternative method for treating mitral valve disease with chronic atrial fibrillation.

Introduction and objectives. Multiple clinical and echocardiographic parameters have been shown to have prognostic value in cases of left ventricular dysfunction. The purpose of this paper was to evaluate the relative predictive power of such parameters. Methods. Ninety-one patients with systolic dysfunction were prospectively studied. Functional status was evaluated using the New York Heart Association classification and the 6-minute walking test. Other clinical and biochemical parameters were assessed, and an anatomic and functional echocardiographic study was performed. Results. Mean follow-up was 16.5 months (SD: 6.95). Eighteen patients died and two underwent heart transplantation (cardiac death 22%). Multiple regression analysis showed that the only independent predictor of death was functional status. Functional classes I and II showed a 16-month mortality rate of 10%, class III 40% and class IV 83%. The mortality rate was 67% for patients who walked 500 meters. When echocardiographic results were analyzed separately, the only independent predictors of outcome were left atrial diameter and the E wave deceleration time. Deceleration times 5 cm were associated with a mortality rate of 46%. The correlation between E wave deceleration time and the walking test was r = 0.55, p < 0.0001. Conclusions. Functional status is the main predictor of outcome in patients with systolic dysfunction, whether assessed subjectively or estimated objectively by a walking test. Among echo-Doppler parameters, the deceleration time of the E wave and left atrial diameter gave similar prognostic information, although with less statistical significance. They can confirm or substitute the prognosis obtained by the functional classification.

Acute aortic pathology is an urgent clinical situation, of which prognosis mainly related to prompt and accurate diagnosis as well as a quick treatment. In this paper we review the aortic pathology, specially focused on aortic dissection. We review its etiology, clinical presentation and diagnostic methods. In addition the medical therapy and the surgical indications of aortic aneurysm, dissection and aortic intramural haematoma are described.

During the last 20 years, the principal objective in hypertrophic cardiomyopathy research has been the refinement of algorithms for the identification and treatment of patients at risk of sudden death. Sudden death is an important problem in hypertrophic cardiomyopathy, with an incidence of 4-6% in referral populations and approximately 1% in non-referral centers and because it affects young and often asymptomatic patients. We now know that hypertrophic cardiomyopathy is not a single disease, but a group of diseases caused by mutations in genes encoding different sarcomeric proteins. The phenotypic expression depends on multiple modifying genetic and environmental factors. Even though genetic testing is not presently a practical approach in hypertrophic cardiomyopathy risk stratification, it is important to consider new genetic data in the prognostic evaluation of patients. In this paper, we review the published data on risk stratification in hypertrophic cardiomyopathy and we set forth our opinion with regard to the available therapeutic options and their indications in the prevention of sudden death.

The 1998 Nobel Prize in Physiology and Medicine has been awarded jointly to North-American scientists, Dr Robert F. Furchgott, Louis J. Ignarro and Ferid Murad, for their discoveries in relation to "nitric oxide as a signalling molecule in the cardiovascular system". This has raised an important polemic because of the exclusion the South-American scientist, now nationalized British, Dr. Salvador Moncada. This short historical review examines some of the fundamental contributions to the knowledge in this field. It shows the sequence of the discoveries and the communication of them to the scientific community by the rewarded scientists and by Dr. Moncada. It is based on some fundamental publications in order to better understand this story, which does not coincide with the writing in 1996 by the Lasker Prize Committee, and which in 1998 was re-written again by the Nobel Committee of the Swedish Academy. More than 90 universities, academies and societies have acknowledged Dr. Moncada up to now with priority in the discovery of the fact that nitric oxide is released by endothelial cells, and the revealing of its metabolic way. More than 20,000 citations of their fundamental papers endorse in the scientific community his primacy in this field. Even Robert Furchgott, author of the brilliant discovery of the endothelium derived relaxing factor, that opened this field to the science, declared about the award of the 1998 Nobel Prize: "I feel that the Nobel Prize Committee could have made an exception this year and chosen a fourth person, Salvador Moncada (to share the prize)".

Changes in health systems are determining new hospital organization forms. The patient focused hospital suppose a new radical design of hospital processes from the patient's viewpoint. This paper defines the re-engineering process of the Cardiology and Cardiovascular Surgery Services of the Hospital Clinic of Barcelona in order to develop and Institute. The change consists fundamentally in a reorganization of the direction organs, creating a staff commission and director. The chief nursing and chief management report to the director. Also, a patients admission and management unit, that manage the beds infrastructure of both services has been developed. The first year results show a reduction of the length of stay and an increase in the in-hospital and external activity.

Randomization of treatment assignment in experiments generates treatment groups with approximately balanced baseline covariates. However, in observational studies, where treatment assignment is not random, patients in the active treatment and control groups often differ on crucial covariates that are related to outcomes. These covariate imbalances can lead to biased treatment effect estimates. The propensity score is the probability that a patient with particular baseline characteristics is assigned to active treatment rather than control. Though propensity scores are unknown in observational studies, by matching or subclassifying patients on estimated propensity scores, we can design observational studies that parallel randomized experiments, with approximate balance on observed covariates. Observational study designs based on estimated propensity scores can generate approximately unbiased treatment effect estimates. Critically, propensity score designs should be created without access to outcomes, mirroring the separation of study design and outcome analysis in randomized experiments. This paper describes the potential outcomes framework for causal inference and best practices for designing observational studies with propensity scores. We discuss the use of propensity scores in two studies assessing the effectiveness and risks of antifibrinolytic drugs during cardiac surgery.

Many patients with severe aortic stenosis never undergo surgical treatment for various reasons. Apart from the standard risks, some patients face an additional problem: their carrying of a mechanical mitral valve. In these patients, transcatheter aortic valve implantation is a therapeutic option. The literature contains only few reports of this procedure being performed (usually transapically) in such patients. This paper reports the cases of 3 patients with severe aortic stenosis, all carrying a mechanical mitral valve and at high surgical risk, all of whom were implanted by transcatheter aortic valve implantation with an Edwards aortic valve prosthesis. All procedures were successful with no complications encountered.

The increasing incidence of abdominal aortic aneurysm (AAA), mainly due to the aging population, and its mortality of 85-90% in the event of rupture justify opting for early diagnosis and elective treatment to repair it. The main aim of this paper is to analyze the utility of transthoracic echocardiography (TTE) in the study of infrarenal aorta and AAA screening.The study included 512 patients (309 men and 203 women) consecutively assessed by TTE and, where possible, abdominal ultrasound for any reason in a cardiology department.An AAA was detected in 25 patients (5.1%), the minimum age at diagnosis was 55 years, the ratio of men to women was 7.3:1 and the mean diameter of the aneurysms was 39.5 ± 12.2mm. Risk factors associated with AAA were to current and former smoking, age, and presence of femoral murmur. The TTE results were equivalent to those of abdominal ultrasound. All patients with AAA studied by coronary angiography showed significant coronary lesions.It is feasible and useful to complement conventional TTE with the study of the infrarenal aorta for AAA screening in patients visited at the department of cardiology. This study should be performed mainly in patients ≥55 years old or with risk factors to develop an AAA.

Introduction and objectives Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal circulation. Methods 20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4 ± 3.62 years (range 3-13) and 23.5 ± 8.74 Kg (range 12-38) in the submammary group, and 5.5 ± 2.04 years (range 3-9) and 19.7 ± 5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports. Results No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups ( P >.05). Conclusions 1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent.

This paper describes the general situation regarding heart transplantation in Spain and the results obtained using the technique, incorporating data for the year 2004. In 2004, 294 heart transplants were carried out, which brings the total number of procedures performed since 1984 to 4680. Clinically, the typical heart transplant recipient in Spain is male, aged around 50 years, has blood group A, has non-revascularizable coronary artery disease, and is in NYHA functional class IV/IV. The percentage of emergency heart transplantations was 35%, which is higher than in the previous year (29%), and higher than the mean for the preceding 5 years (22%). The early mortality rate was 10%, which is lower that the mean for the preceding 5 years (13%). After combining the results for 2004 with those of previous years, the probability of survival at 1, 5 and 10 years was 80%, 70% and 60%, respectively. When the survival rates for different time periods were analyzed, a significant improvement could be seen in the last 5 years, with recent survival rates being 85% and 72% at 1 and 5 years, respectively. The most frequent cause of death in the first month was acute graft failure; in the first year, infection and rejection; and, over the long term, tumors and a combination of graft vasculopathy and sudden death. A comparative analysis of survival rates showed that long-term results in Spain are slightly better than those published in the world literature. Moreover, survival has tended to improve gradually in recent years.

The history of rapamycin dates from 1965, when it was isolated from a microorganism in soil and its antibiotic properties were confirmed. Since its discovery, many scientific papers have demonstrated its antifungal and immunosuppressive properties. Our team pioneered in the study of the mechanism of action of rapamycin, motivated by its enormous promise as a therapeutic agent in atherosclerotic disease. We reported how it can inhibit the proliferation and migration of smooth muscle cells after a mechanical aggression, and demonstrated that this effect is mediated by p27 activation by rapamycin. The participation of p27, a key cyclin in the modulation of cell replication, in rapamycin's molecular signaling also spurred expectations in the field of oncological research because it involves a non-redundant system of regulation of the cell cycle susceptible to mutatio. The interesting characteristics of this active principle suggested that it would be worthwhile to investigate its protective effect in an experimental porcine model of angioplasty. Rapamycin showed that it can notably reduce vascular wall thickening, thus helping to preserve patency after angioplasty. Shortly after this study, the use of rapamycin-coated stents designed to release the active principle into the area of the atherosclerotic lesion was accompanied by an effective preservation of the arterial lumen in experimental models. It also produced a highly significant reduction in the rate of post-stent restenosis in various clinical studies in humans. However, the potential of this type of stent in diabetic patients is still unknown and we are on the point of beginning a large clinical trial (the FREEDOM study) to investigate its impact on the management of diabetic patients. Experimental and clinical evidence indicates that the development of oral agents capable of modifying the progression of atherosclerotic disease by acting on molecular targets involved in the control of the cell cycle will be a challenge in the coming years.

The aim of this paper is to present the bibliometric indicators for Revista Española de Cardiologíathat were obtained from the "Potential impact factor of Spanish medical journals in 2001" study financed by the Spanish Ministerio de Educacion, Cultura y Deporte. Citations to Revista Española de Cardiología, its national and international impact factor, and its immediacy index were calculated with methods similar to those used by the Institute for Scientific Information. National indicators were based only on citations from 87 Spanish journals considered source journals, whereas international indicators were calculated on the basis of citations from both national journals and foreign source journals in the Science Citation Index. Revista Española de Cardiologíaobtained a national impact factor of 0.719 and an international impact factor of 0.837, placing it at the head of the ranking of Spanish medical journals.

Contrast angiography has been used for nearly five decades to evaluate the severity of coronary lesions. However, when attempting to distinguish between intermediate coronary lesions able or unable to produce ischemia, the technique has several limitations. A large number of patients undergo cardiac catheterization without prior evaluation of coronary perfusion by non-invasive tests. This number is likely to increase in the coming years, because current recommendations favor the invasive treatment of acute coronary syndromes. This has triggered marked interest in new diagnostic techniques capable of assessing the physiological significance of intermediate lesions in the catheterization room. This paper reviews the different techniques currently available for scientifically assessing the significance of such lesions. The advantages and limitations of each are discussed.

The clinical relevance of cardiac embolism a potential cause of stroke is progressively increasing, mainly due to the recent progress in diagnostic imaging. In the present paper, we update and review the state of the art of the different etiologies currently accepted of a cardiac source of stroke. Furthermore, we review the clinical role of different image techniques, emphasizing the doubts and realities of each particular approximation.

Acute aortic dissection is a clinical emergency. Its prognosis is related mainly with prompt and accurate diagnosis, as well as rapid treatment. In this paper we review the importance of different imaging techniques in the diagnosis of patients with acute aortic syndrome. Aortic dissection, intramural haematoma, and penetrating aortic ulcer are discussed.

Despite diastolic dysfunction is recognized to play a major role in the pathophysiology of heart failure, the importance of an accurate diagnosis and treatment of this syndrome in clinical practice is poorly established. Recent publications suggest that diastolic dysfunction is the primary cause of heart failure in 30-50% of patients. Several studies also show that, in a significant number of patients with systolic dysfunction, diastolic function is the major determinant of their symptomatic status, their response to treatment and their outcome. Other preliminary data suggest that diastolic dysfunction is an important cause of exercise intolerance in patients with chronic hypertension. This paper discusses the most recent concepts related to the mechanisms, the diagnosis and the treatment of diastolic dysfunction based on diagnostic imaging techniques.

Mitral valve disease often is accompanied by chronic atrial fibrillation, especially when the left atrium is enlarged. Mitral valve surgery alone cannot resolve the arrhythmia in most cases. Several surgical techniques have been proposed. We have used surgical left atrial reduction and pulmonary vein isolation to eliminate chronic atrial fibrillation associated with mitral valve disease. The aim of this paper is to report our experience with this new surgical concept.Twenty-three patients (18 women and 5 men, mean age 44.1 14.7 years) with mitral valve disease and chronic atrial fibrillation for more than 3 months underwent surgery. Mitral valvuloplasty was performed in 11 cases, and mitral valve replacement in 12. Left atrial reduction was used to eliminate chronic atrial fibrillation in all cases.There was no operative mortality. Three patients (13%) had recurrent atrial fibrillation between postoperative days 6 and 8. No atrioventricular conduction disturbances were observed. An important reduction in left atrial size was evident on echocardiography (4.8 0.77 vs. 8.1 1.47 cm, p0.01). In 3 to 36 months of follow-up (13.9 11 months), all patients preserved sinus rhythm.Left atrial reduction seems to be an effective and easily applied alternative method for treating mitral valve disease with chronic atrial fibrillation.

Multiple clinical and echocardiographic parameters have been shown to have prognostic value in cases of left ventricular dysfunction. The purpose of this paper was to evaluate the relative predictive power of such parameters.Ninety-one patients with systolic dysfunction were prospectively studied. Functional status was evaluated using the New York Heart Association classification and the 6-minute walking test. Other clinical and biochemical parameters were assessed, and an anatomic and functional echocardiographic study was performed.Mean follow-up was 16.5 months (SD: 6.95). Eighteen patients died and two underwent heart transplantation (cardiac death 22%). Multiple regression analysis showed that the only independent predictor of death was functional status. Functional classes I and II showed a 16-month mortality rate of 10%, class III 40% and class IV 83%. The mortality rate was 67% for patients who walked300 meters and 0% for those who reached500 meters. When echocardiographic results were analyzed separately, the only independent predictors of outcome were left atrial diameter and the E wave deceleration time. Deceleration times100 ms or atrial diameters5 cm were associated with a mortality rate of 46%. The correlation between E wave deceleration time and the walking test was r = 0.55, p0.0001.Functional status is the main predictor of outcome in patients with systolic dysfunction, whether assessed subjectively or estimated objectively by a walking test. Among echo-Doppler parameters, the deceleration time of the E wave and left atrial diameter gave similar prognostic information, although with less statistical significance. They can confirm or substitute the prognosis obtained by the functional classification.

The large amount of information on rates of acute coronary syndrome accumulated in Spain over the last two decades is summarized in this paper, which also estimates the number of cases expected in 2002 and the trend for 1997 to 2005.Published information on the situation in the 90's was reviewed and summarized. We present the incidence of acute myocardial infarction (AMI), and an estimate of the absolute number of patients expected for various acute coronary syndromes in each autonomous community in Spain in 2002, along with the trend for 1997 to 2005.Approximately 68,500 patients will suffer AMI in 2002 and 40,989 of them will be hospitalized, while the rest will die before admission. A further 24.9% of admitted patients will not survive 28 days. Slightly less than half will be younger than 75 years old, an age with a better prognosis (28-day mortality 38.8%). Approximately 33,500 patients with unstable angina will be admitted, and 4.5% of them will die within 3 months of admission. Assuming the incidence of AMI remains stable, the absolute number of cases will increase by 2.28% yearly (9,847 cases in total) and hospitalizations for acute coronary syndromes will increase by 1.41% (8,817 cases in total) between 1997 and 2005.Ischaemic heart disease generates increasing demand for health care in Spain. Case fatality is high among the approximately 68,500 AMI patients, given that scarcely two thirds will have been hospitalized in 2002.

For many years, the evaluation of the extent and severity of coronary artery disease has been mainly anatomical, carried out by coronary angiography. However, this technique has methodological limitations and interobserver variability is considerable. Quantification of coronary reserve with pressure guidewires and intracoronary Doppler now provides more precise physiologic evaluation of coronary circulation. Myocardial perfusion single proton emission computed tomography and echocardiography, combined with stress and/or pharmacological challenge testing, though they are only semiquantitative techniques, also offer appropriate complements to coronary angiography in the functional evaluation of coronary patients. The aim of this paper is to discuss the clinical value of these techniques.

Recurrent symptomatic pericardial effusion can complicate different cardiac and extracardiac diseases. When recurrent pericardial effusion after drainage with conventional catheter techniques occurred the creation of a pericardial window by open surgery used to be the unique treatment available until the recent development of percutaneous balloon pericardiotomy.The aim of this paper is to review our initial experience with percutaneous balloon pericardiotomy for the treatment of patients with recurrent pericardial effusion.Five patients with recurrent pericardial effusion have been treated with percutaneous pericardiotomy until now. Four patients had malignant pericardial effusion secondary to metastasis of extracardiac tumors, in one patient recurrent pericardial effusion was idiopathic. In all patients percutaneous balloon pericardiotomy was performed with a pediatric valvuloplasty balloon catheter, through a subxiphoid approach.Successful drainage and balloon pericardiotomy was achieved in all patients without severe complications. In all cases only one pericardial site was dilated. Minor complications were registered, which included mainly mild pleural effusion occurring in all patients with spontaneous resolution. During a mean follow-up period of 8.6 6.5 months (range 2 to 18 months) there were no recurrences of effusion or tamponade. Two patients died, 1 month and 9 months after the procedure, due to their malignant condition.Percutaneous balloon pericardiotomy is an easy and useful technique to manage patients with large recurrent pericardial effusion with a low r

This paper outlines the general characteristics and results obtained with heart transplantation in Spain after including the data for the year 2000. In the course of last year 353 transplants were performed; along with the operations performed since 1984, this represents an overall total of 3445 transplants. The year 2000 was the first year in which the limit of 350 yearly operations was exceeded. The average clinical profile of the Spanish heart transplant patient corresponds to a male of about 50 years of age, with an A blood group, coronary disease that is not amenable to revascularization, and NYHA functional status IV/IV. In order to evaluate and compare this data register with others, it is important to take into account that on one hand it includes absolutely all the transplants performed in this country -thereby reliably reflecting the true situation of the technique in Spain- while on the other the analyses made are global and include high-risk transplants (urgent, recipients of advanced or paediatric age, retransplanted patients, heterotopic transplants, combined with lung, kidney and liver, etc.). The percentage of urgent heart transplants was 16%, a figure considerably lower than in previous years (20-25%). The mean early mortality in the past 10 years was 15%.Long-term survival has increased with respect to the records for last year, with a mean patient survival of 10.6 years. The probability of survival after 1, 5 and 10 years is 75, 63 and 51%, respectively. The most frequent causes of early death are infection and graft failure, while long-term survival is limited by tumors and vascular graft disease. In conclusion, we can say that our overall survival rate is slightly superior to that reported from other data records in the world literature. Nevertheless, a persisting challenge is to improve our results in the early phases of heart transplantation.

This paper aimed to study the usefulness of the Statistical Bulletin of Deaths (SBD) for identifying extrahospital deaths due to acute coronary ischaemia, and to determine the most efficient strategy in the selection of death causes that appear in the SBD, which are the most efficient for the identification.Those extrahospital deaths, which, among the causes of death, recorded a diagnostic code indicating that they might have been caused by coronary ischaemia, were included. To study the usefulness of the death certificate we calculated the sensitivity and the positive predictive value of cardiac ischaemia. To determine the most efficient strategy for selecting causes of death we compared two selection strategies: the first, using only the basic cause of death; and the second using all the causes appearing in the SBD.Of the 395 SBD selected, 161 were classed as acute heart attacks. In those SBD in which cardiac ischaemic disease was given as the basic cause of death, we obtained a sensitivity of 82.6% (CI 95%: 75.9-88.1) and a positive predictive value of 72.7% (CI 95%: 65.6-79). The most efficient strategy in SBD selection proved to be the investigation of death certificates in which cardiac ischaemia appeared as one of all the causes of death, and death certificates in which the basic cause of death was coded as diabetes mellitus, essential arterial hypertension, hypertensive heart disease, cardiac dysrhythmia, and cardiac insufficiency.The information provided by death certificates for extrahospital deaths due to coronary ischaemia is reliable. A sensitive and efficient SBD selection strategy is proposed for the detection of cases.

Renewed interest for aortic valve disease has evolved in recent years. Aortic valve replacement has become the second most frequent cause of cardiac surgery, following coronary bypass surgery. In addition, the etiologic and physiopathologic knowledge of this disorder has improved. In the present paper we analyze three aspects of the disease which are, at present, the subject of study and controversy: first, we discuss the possible relationship between degenerative aortic stenosis and atherosclerosis; second, the involvement of the aortic root in cases of bicuspid aortic valve; and third, the surgical indications in asymptomatic patients with either aortic stenosis or regurgitation.

Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain. This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.

Geographical differences in hospitalizations and mortality for heart failure serve to estimate the potential for reducing the associated hospital and demographic burden on the population. Accordingly, the objective of this paper is to analyze the geographic variation in heart failure hospitalizations and mortality in Spain during the period of 1980-1993, and to examine their potential determinants.Data on the primary diagnosis of heart failure were taken from the National Hospital Morbidity Survey and National Vital Statistics. Information on determinants of heart failure were obtained from large-scale nationally representative surveys conducted by the National Statistics Office.The period of 1980-1993 witnessed a decrease in geographical differences in heart failure hospitalizations and mortality. Theoretically, however, heart failure hospitalizations and mortality among persons agedor = 45 years could still be further reduced by 60% and 30% respectively. In the period of 1989-1993 heart failure hospitalizations were correlated (p0.05) with ischaemic heart disease hospitalizations and the number of beds/1,000 inhabitants. Heart failure mortality showed a statistically significant correlation (p0.05) with ischaemic heart disease mortality, illiteracy and unemployed status.There is a great potential for a reduction in the hospital and demographic burden of heart failure in Spain. Control of ischaemic heart disease and a reduction in the geographical differences in socio-economic status would probably contribute to lessening the healthcare burden of heart failure in Spain.

Acute aortic pathology is an urgent clinical situation, of which prognosis mainly related to prompt and accurate diagnosis as well as a quick treatment. In this paper we review the aortic pathology, specially focused on aortic dissection. We review its etiology, clinical presentation and diagnostic methods. In addition the medical therapy and the surgical indications of aortic aneurysm, dissection and aortic intramural haematoma are described.

Cardiac glucoside intoxication is a frequent medical problem given the following: the very narrow therapeutic range, its use in advanced aged patients, in patients with altered renal function, and because of interaction with other drugs. There are two types of digitalis intoxication: one that appears as a complication of the treatment with digitalis, and the other as a result of an accidental ingestion or in suicide attempt. The objective of this study was to review and assess the level of scientific evidence on the effectiveness and the indications of use of Fab fragments of antidigoxine antibodies.A systematic bibliographic search in the following databases was made: MEDLINE, The Cochrane Library, The Iowa Drug Information Service, Embase, LMS/RD Insight, and Indice Médico Español. The selected papers were classified according to their level of scientific evidence.Abstracts of 252 references were reviewed. In the reviewed bibliography no controlled, randomized trials were found. Most of the studies found are descriptions of case series or single cases that were treated with antidigoxin Fab fragments. These types of studies provide little or no scientific evidence to speak of. None of the treatment regimes with antidigoxin antibody Fab fragments so far proposed have proven to be valid in a controlled, randomized clinical trial.There is a very high level of concordance among the studies reviewed with regards to the efficacy and the indications for the use of Fab fragments in severe acute accidental digitalis intoxication and in suicide attempts. Regarding those intoxications that result in patients undergoing digitalis therapy, usual therapeutic approach is traditional treatment and the monitorization of the severity of the intoxication.

The information concerning stroke mortality is limited in Spain, and the information on morbidity is even scarcer similarly to other countries. This is true also for the decrease of frequency observed in the last decades. The objective of this paper is to provide data in the incidence, mortality and cardiovascular risk factors associated to stroke in our surrounding through by the prolonged observation of a working population.In the Manresa Study, which began in 1968, a cohort of 1,059 men, from 30 to 59 years old, was followed for 28 years. We recorded new cases of fatal and nonfatal stroke and the relationship between stroke incidence and risk factors of cardiovascular disease found in the initial examination.Incidence rate for stroke was 183 x 100,000 per year, 64% of the cases were registered after they turned 60 years of age. Mortality rate due to stroke was 88 x 100,000 per year, 91.6% of fatal cases were over 60 years old. Factors associated to the stroke morbimortality incidence were age, high blood pressure and overweight. In a bivariate regression model, stroke mortality was found significantly associated to the presence of atrial fibrillation, diabetes, hypercholesterolemia and tobacco smoking.Stroke frequency rates in the Manresa cohort are ranged at a medium level compared to data from other general population studies. The role of atrial fibrillation in the stroke morbimortality has been confirmed. The associated factors, age, high blood pressure and overweight, are similar role to that which was found in other research studies. The priorities in the cerebrovascular disease prevention in our surroundings are discussed.

During the last 20 years, the principal objective in hypertrophic cardiomyopathy research has been the refinement of algorithms for the identification and treatment of patients at risk of sudden death. Sudden death is an important problem in hypertrophic cardiomyopathy, with an incidence of 4-6% in referral populations and approximately 1% in non-referral centers and because it affects young and often asymptomatic patients. We now know that hypertrophic cardiomyopathy is not a single disease, but a group of diseases caused by mutations in genes encoding different sarcomeric proteins. The phenotypic expression depends on multiple modifying genetic and environmental factors. Even though genetic testing is not presently a practical approach in hypertrophic cardiomyopathy risk stratification, it is important to consider new genetic data in the prognostic evaluation of patients. In this paper, we review the published data on risk stratification in hypertrophic cardiomyopathy and we set forth our opinion with regard to the available therapeutic options and their indications in the prevention of sudden death.

In the present paper, a historical review and a clinical up-date are done on two procedures of great medical interest: Holter electrocardiography and ambulatory blood pressure monitoring. Technical and methodological characteristics of each procedure are carefully exposed, emphasizing each the lack of an international agreement in order to establish regulations that make all the equipment homogeneous and reliable in order to increase both accuracy and reliability in diagnosis. Based on published international scientific documents and the personal experience of the authors, guidelines for clinical applications, indications and limitations of each technique are analyzed in relation to capacities of the Spanish political and social public health system profile. New concepts and dynamics of developments such as; dynamic QT, RR variability or pulse wave velocity are exposed, in the frame of the present time and future for improving efficiency and clinical application.

The quick and accurate diagnosis of acute coronary heart disease in the emergency department constitutes a first line medical challenge. About 5% of patients attending to the emergency department present chest pain or symptoms suggesting myocardial ischemia. A prompt diagnosis contributes to patient survival while an incorrect one can be associated to an increased risk of unfavorable outcome. On the other hand, unnecessary admissions into high technology hospital areas determine important expenses unacceptable from a cost-benefit point of view. In the present paper, the usefulness of different diagnostic tools used in emergency department (case history, electrocardiogram, nuclear perfusion imaging, echocardiography, exercise test) is reviewed, their advantages and limitations reviewed, with special emphasis on the importance of having an electrocardiogram as soon as possible, and based on the electrocardiographic findings the most appropiate management is discussed.