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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.

Since the first implantation in man in 1980 implantable cardioverter defibrillator technology has greatly improved and the number of devices implanted has increased considerably every year. Non thoracotomy lead systems and biphasic shocks are now the approach of choice, offering an almost 100% success rate. This document reviews the recommendations for qualification of personnel and for the centres implanting and carrying out follow-ups on defibrillators. The current indications for the implantation of implantable cardioverter defibrillator are also addressed.

Most of the prognostic information on patients with unstable angina is obtained from the initial clinical assessment and the patient's subsequent course over the first few days of management. In recently stabilized patients noninvasive stress testing with exercise or pharmacologic testing provide additional useful risk assessment. Noninvasive stress testing should be part of the outpatient evaluation of low-risk patients with unstable angina and should be done within 72 hours. Unless cardiac catheterization is indicated, noninvasive stress testing should be performed in low- or intermediate-risk patients hospitalized with unstable angina who have been free of symptoms for a minimum of 48 hours. Choice of stress testing modality should be based on an evaluation of the patient's resting ECG, his or her physical ability to perform exercise, and the local expertise and technologies available. The standard ECG treadmill test should be the standard test employed in most patients with no contraindications for doing so. Provocation of ischemia at a low workload (< 5 to 6 METs) signifies a high-risk patient (cardiac mortality > or = 4%/year) who should generally merit referral to cardiac catheterization. Attainment of a higher workload (> 5 to 6 METs) without ischemia is associated with a better prognosis (cardiac mortality < 1%/year), and many such patients can be managed conservatively. Those who tolerate only a low workload but have no evident ischemia or those who develop ischemia at a high workload, represent an intermediate-risk group (cardiac mortality 2 to 3%/year) for whom several reasonable strategies can be proposed.

Many epidemiological studies have shown that moderate alcohol intake, from 10 to 30 g of ethanol a day, decreases cardiovascular mortality from atherosclerotic ischaemic heart disease and ischaemic stroke as compared to non-drinkers. This beneficial effect outweighs the risks of alcohol consumption in subgroups of people with a higher risk of atherosclerosis: the elderly, people with coronary risk factors and patients with previous coronary events. It has not been demonstrated that alcohol intake, even in moderate amounts, is beneficial for the general population, in particular, men under the age of 40 and women under 50, because it raises mortality due to other causes, especially injury, cirrhosis of the liver and some types of cancer, thereby outweighing the benefits for coronary artery disease. Thus, alcohol consumption should not be recommended as a prophylaxis for the general population. Guidelines on alcohol drinking habits--whether to continue, to start, to modify or to stop--must be given on an individual basis, taking into account the relative risks and benefits for each patient. The benefits of moderate alcohol consumption on the cardiovascular system seem to be exerted fundamentally through its effects on plasma lipoproteins, principally by raising high density lipoprotein (HDL) cholesterol and to a lesser degree, by decreasing low density lipoprotein (LDL) cholesterol. It appears to exert additional beneficial effects on the heart by decreasing platelet aggregability and by bringing about changes in the clotting-fibrinolysis system. Although there has been some debate about the relative superiority of different types of alcoholic beverages (wine, beer or hard liquor), and to a greater extent, about different types of wine, there is no current evidence of any kind of beneficial effect from other components of the beverage besides ethanol. Thus, it does not seem appropriate to recommend any particular type of alcoholic drink, except for sociocultural reasons. The added benefits from some components of different types of wine with a high antioxidant activity on plasma lipoproteins remain only an interesting hypothesis. Meanwhile, encouraging a healthy diet, flavonoid rich and with a predominance of natural ingredients (fruit, legumes, cereals and seeds), in the general population should stop the current tendency of Southern European countries from abandoning the Mediterranean diet. Because of the multifactorial nature of coronary heart disease, it is necessary to remember that atherosclerotic risk reduction is achieved by behavior modification of multiple risk factors present in individual patients and in the general population. Therefore, guidelines regarding alcohol intake should always be linked to pertinent recommendations about other atherosclerotic risk factors.

Diagnosis and risk stratification in angina pectoris is supported on clinical evaluation, rest electrocardiogram, exercise stress test and coronary angiography. Use and timing application of that diagnostic methods depend on coronary artery disease prevalence and on clinical situation. This review describe diagnostic and prognostic value of the tests in angina pectoris.

We have performed 2 implantations of transvenous automatic cardioverter defibrillator in a cardiac laboratory devoted to electrophysiology and pacemaker implantation. This is a preliminary experience with a novel implant strategy. Cardiologists were the primary operators. The automatic cardioverter defibrillator were placed in a subcutaneous pectoral region, with a non-thoracotomy lead system. The automatic cardioverter defibrillator were two Medtronic 7219D PCD Jewel, with a Transvene system. There were no perioperative complications. Acceptable defibrillation threshold were obtained in both patients, 12 and 20 J, respectively. Leads were inserted percutaneously through the left subclavian vein. After 8 months of follow-up the patients continue to tolerate the device satisfactorily. Implantation of automatic cardioverter defibrillator systems by trained cardiologists in an electrophysiology laboratory is safe and feasible. Moreover, its cost-effectiveness is superior, the saving includes the surgeons, and the reduction of stay in unit of intensive care and hospitalization.

Unlabelled: INTRODUCTION AND PURPOSES: Autonomic nervous system plays an important role in the pathogenesis of vasovagal/vasodepressor syncope and may also be assessed by the RR variability analysis. Head up tilt test (HUT) is a currently established tool to evaluate patients with neuromediated syncope. However, the relationship between heart rate variability and tilt induced syncope is not established. The purpose of this study was to assess the differences in heart rate variability among patients with syncope and negative or positive tilt test., Methods: Fifty patients (mean age 33 +/- 17 years, 24 female, 26 male) with syncope underwent tilt test (20 min, 80 degrees tilt and 20 min more under isoproterenol infusion). Twenty-three patients have a negative tilt, the rest had a positive test. There were not significant differences in age or sex. Immediately after the HUT a 24-hour ambulatory electrocardiogram was performed (Marquette system 8000, 002A program). The parameters measured during Holter monitoring were: SDANN, SD, rMSSD, pNN50 and frequency analysis of heart rate spectrum (low frequency 0.04-0.15 Hz, high frequency 0.15-0.4 Hz and the relation low/high). No significant differences were detected in age and sex in patients with and without positive HUT., Results: pNN50 and rMSSD were the best predictors of the results of tilt (p = 0.006). SDANN and SDNN were not useful parameter. The finding of a value of pNN50 > 25% (value significantly different between patients with HUT--and +) have a specificity for predicting a positive HUT of 82.6%, with a sensibility of 51.8%. Positive predictive value was 77%. As can be easily understood, if the cut value of pNN50 is lowered, its sensibility increased and the specificity. decreased. In the frequency analysis only the relation low/high (L/H) was significantly different between both populations., Conclusions: Heart rate variability is a useful tool in the evaluation of patients with vasovagal syncope, that may identify patients with chronically elevated vagal tone and thus may predict tilt test results.

Unlabelled: INTRODUCTION AND PURPOSES: Propafenone is an antiarrhythmic drug with well known electrophysiological effects. We performed this prospective non comparative study, in order to evaluate its efficacy and safety to terminate spontaneous episodes of monomorphic sustained ventricular tachycardia., Methods: Thirty-two episodes of sustained monomorphic ventricular tachycardia in 32 consecutive patients were treated with intravenous propafenone. Twenty-five were male and 7 female, mean age of 62 +/- 12 years; 23 suffered chronic ischemic heart disease, 2 dilated cardiomyopathy, 1 arrhythmogenic dysplasia of the right ventricle and 6 no organic heart disease. Patients with overt heart failure, acute myocardial infarction or a systolic blood pressure less than 90 mmHg were excluded. The ventricular origin of the tachycardia was assessed by clinical and electrocardiographic criteria and by the presence of AV dissociation in intraesophageal recording. The dose of propafenone was 0.2 mg/kg/min until interruption of ventricular tachycardia, or maximal dose of 2.5 mg/kg in 10 min., Results: In 23 episodes (72%) sinus rhythm was restored in less than 10 minutes (mean time and dose, 398 +/- 97 s and 95 +/- 42 mg, respectively). Two patients developed proarrhythmia with acceleration of the ventricular tachycardia. A significant decrease in blood pressure was noted in 6 patients. Presence of organic heart disease, advanced age and poor functional class were the best predictors of inefficacy to convert to sinus rhythm and of the presence of acute adverse effects (p < 0.05)., Conclusions: Propafenone is an effective drug for the acute conversion of spontaneous monomorphic sustained ventricular tachycardia, especially in patients without organic heart disease. Age, functional class and presence of organic heart disease could predict the response to propafenone and the incidence of complications.

We comment the results with non pharmacological treatment in 23 patients (mean age 11 +/- 4 years) with multiple episodes of palpitations, most of them required intravenous drugs for interrupting it. Twenty-eight procedures were performed, 17 catheter ablation and 11 surgical interventions. The energy source employed for fulguration until 1990 was DC and since 1991 radiofrequency. The best results with catheter ablation were obtained with accessory pathways. Interruption was achieved in all patients after a mean of 1.2 sessions per patient, but it was definitive in only 72%. Most of the patients (81%) remained asymptomatic without antiarrhythmic drugs. Nine patients with accessory pathways underwent surgery interruption, it was achieved in all; only one patient had arrhythmia recurrence, due to a second pathway in a different localization. We could not ablate a ectopic atrial tachycardia, that underwent surgery. There was only one indication for surgery in a patient with ventricular tachycardia. Catheter ablation does not present technical problem in children and teenagers, different from adults. The presented results lead us to suppose that the indications for non pharmacological treatment in the young will become more common.

Percutaneous transluminal coronary angioplasty is a useful therapeutic tool in the treatment of ischemic heart disease. Nowadays this procedure presents acute complications of different severity in 10% of the cases. The rupture of the guide wire is a very uncommon complication that may produce important consequences as occlusion of the artery of systemic embolism. The management of this event may be interventional or conservative, depending on the clinical situation of the patient and the position of the guide wire inside the vessel. We report the 2 cases of rupture of the guide wire observed in our center in 1,000 consecutive procedures; in one case it was decided to leave the fragment in the distal portion of the artery, and in the other case the fragment was extracted surgically. We review the literature about this rare complication.

Catheter ablation of the atrioventricular node is a therapeutic technique for the treatment of patients with drug-refractory supraventricular tachyarrhythmias. In our Arrhythmia Unit 25 patients (8 women, 17 men) aged (mean +/- DE) 56 +/- 10 years have undergone fulguration of the atrioventricular junction since 1986. The more frequent treated rhythm disturbance was atrial flutter or fibrillation, with uncontrolled rapid ventricular response. Absence of organic heart disease was diagnosed in 9 patients; the remainder had valvular heart disease (2), cor pulmonale (2), cardiomyopathy (7), hypertensive heart disease (2) and Wolff-Parkinson-White syndrome (3). Under general anesthesia 1.8 +/- 0.8 shocks/patients were delivered along 1.2 +/- 0.7 sessions/patient. In 23 of 25 patients (92%) complete atrioventricular block was achieved, and a pacemaker was implanted. There were no complications. The other 2 patients were referred to surgery for cryoablation of the atrioventricular junction. Patients were followed for an average of 21 +/- 12 months. Four patients have died: two due to congestive heart failure, which was present prior to the ablation procedure, the third because of a metastatic carcinoma, and the fourth had a sudden death 14 months after the procedure (he had dilated cardiomyopathy and Wolff-Parkinson-White syndrome). The remainder in chronic stable complete atrioventricular block are asymptomatic for arrhythmias and without antiarrhythmic medication.

Unlabelled: To evaluate the reliability of Holter monitoring in reproducing myocardial ischemic changes, 110 patients (90 males, 20 females; age range: 14-74 years) underwent a Bruce protocol treadmill exercise test. An electrocardiogram was recorded simultaneously with a two-channel modulated Holter recorder (frequency response: 0.05-100 Hz) with bipolar CM-V3 and CM-V5 leads and by a conventional 12-lead system. An ischemic ST-segment change was defined as 1 mm or more ST-segment depression lasting more than 0.08 sec after the J point. Results were concordant in 101 patients, 36 with both positive and 65 with both negative responses. Eight false negative and one false positive Holter ischemic episodes occurred. This yielded an accuracy (expressed as sensitivity, specificity, positive and negative predictive values) of 81.8%, 98.5%, 97.3% and 89.0%, respectively. There was a good correlation between the maximal ST-segment depression (r = 0.57; p less than 0.001), duration of ischemia (r = 0.89; p less than 0.001), heart rate at the onset of the ischemic episode (r = 0.91; p less than 0.001) and maximal heart rate (r = 0.98; p less than 0.001)., Conclusions: Two-channel amplitude modulated Holter recording system with bipolar CM-V3 and CM-V5 leads can reliably reproduce ST-segment changes.

We present the case of a patient with a dilated cardiomyopathy in which an anomaly in the origin of the left coronary artery, that arose from the right sinus of Valsalva through an own ostium and followed a retro aortic course, was recognized as an angiographic finding. The possible pathways the anomalous artery may follow, and their different clinical significances are reviewed. The angiographic sign of the aortic root, described for the identification of the anomalous origin of circumflex artery, is reviewed and its utility in the case of anomalous left coronary artery is demonstrated. In our case, Thallium-201 didn't show myocardial ischemia with the exercise and that justified, beside the doubtful efficacy of surgery as prophylaxis of sudden death when the anomalous course is retro-aortic, to maintain a conservative attitude.

To evaluate the prognostic significance of silent ischemia during exercise testing, 152 consecutive patients (143 males, 9 females) with a mean SD of 55 +/- 7 years (age range 32-73) who underwent exercise testing and coronary arteriography within 3 months were studied. All patients had the following characteristics: 1) a positive electrocardiographic exercise test response; 2) significant coronary artery disease on the arteriography; 3) uninterrupted clinical follow-up for a minimum of 6 months. The 152 patients were divided in 2 groups: group I: 56 patients (37%) with ischemic ST-segment depression during exercise testing without angina (silent ischemia); group II: 96 patients (63%) with ischemic ST-segment depression and angina (symptomatic ischemia). Patients in group I and group II showed similar time to ST-segment depression (3.6 +/- 1.5 min vs 3.2 +/- 1.4 min; p = NS), maximal ST-segment depression and peak heart rate-systolic pressure product (21,151 +/- 7,124 vs 20,456 +/- 6,024; p = NS). Exercise duration was longer in group I than in group II (5.6 +/- 2.1 min vs 4.8 +/- 1.5 min; p less than 0.001). The extent of coronary artery disease defined by the number of significant narrowed coronary vessels, left ventricular end diastolic pressure and ejection fraction were similar in the 2 groups. Sixty six patients who underwent coronary bypass surgery were not included in the analysis. The remaining 86 patients (40 in group I and 46 in group II) were medically treated. The mean follow-up period was 43,5 +/- 25 months (range 6-101).2+ myocardial ischemia during exercise testing.

Unlabelled: To evaluate the prevalence and characteristics of silent myocardial ischemia in asymptomatic patients with non insulin dependent diabetes mellitus, 50 diabetic patients (24 males, 26 females; mean age +/- SD = 58.3 +/- 6.4 years) with a normal resting electrocardiogram were prospectively studied. The total group underwent 48 hours electrocardiographic Holter monitoring, medical history, physical examination an a test for cardiac autonomic neuropathy. Serum levels of total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides and Hb A1c were determined. An ischemic episode was defined as asymptomatic ST-segment depression greater than or equal to 1 mm, greater than or equal to 1 min. Day-to-day variability was studied. Six hundred and forty one episodes with a total duration of 1,014 minutes of ischemia were recorded in 29 patients (58%). The mean number of episodes in 48 hours per patients was 19.2 +/- 21.9 and the mean time of ischemia over this period was 149 +/- 374 minutes. The average heart rate at the onset of the episodes was 95.2 +/- 8.4 beats per minute. Two hundred and ninety two (45.6%) episodes occurred without heart rate changes and in 349 (54.4%) episodes an increase in heart rate was detected at the onset of the episode. An important day-to-day variability in the number of episodes (73.8 +/- 29.5%) and ischemia duration (76.9 +/- 88.8%) was found. Fifteen patients had no ischemic episodes in either the first or second monitoring day. Silent ischemia was related to higher levels of total cholesterol (p less than 0.05), LDL-cholesterol (p less than 0.05) and Hb A1c (p less than 0.01) and was associated to diabetes complications: retinopathy (p less than 0.001), peripheral vascular disease (p less than 0.01), polyneuropathy (p less than 0.05), nephropathy (p less than 0.05), and impotence (p less than 0.01). Silent ischemia was not associated to abnormal test for cardiac autonomic neuropathy., Conclusions: prevalence of silent myocardial ischemia during daily activities in asymptomatic diabetic patients is very high (58%). Both an increase in oxygen demand and a decrease in oxygen supply may be involved in its pathophysiology. In diabetic patients silent ischemia is related to the presence of other risk factors for coronary artery disease and to diabetes complications and shows a marked day-to-day variability.