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We investigated if the correlation between the amount of ST elevation (STE) and myocardial ischemia could be altered by variables such as hypertension or body mass index (BMI).A 12-lead electrocardiogram and a technetium-99m tetrofosmin injection were performed during balloon coronary occlusion in 34 patients with single-vessel disease.The sum of STE correlated with scintigraphic extent of ischemia (r = 0.441; P = .009), but this correlation improved significantly in men and patients with BMI of 28 kg/m2 or less and was highest in nonhypertensive patients (r = 0.763; P.001). In contrast, it was poor in women and patients with BMI greater than 28 kg/m2 or arterial hypertension, being lowest in the latter subset (r = 0.110; P = .664). Moreover, 8 (80%) of 10 patients with extensive hypoperfusion but with low SigmaSTE (or =20 mm) were hypertensive.If confirmed by larger studies, electrocardiographic underestimation of transmural ischemia during coronary occlusion in patients with hypertension or increased BMI may lead to adjustments in STE criteria for reperfusion therapy.

We investigated to what extent patients with variant angina and significant coronary stenosis (or=70%) present a clinical and angiographic profile similar to patients with ST elevation myocardial infarction. Thus, the clinical and angiographic features as well as follow-up events of 200 patients were prospectively analyzed and were compared with those of 422 patients with a first ST elevation myocardial infarction survivors of the early phase (3 days) and those of 70 patients with variant angina and non significant stenosis. Age and incidence of smoking, systemic hypertension, diabetes and maximum ST elevation were similar in the 2 groups. Furthermore, among patients with significant coronary stenosis, stenosis severity and the proportion of eccentric lesions were also comparable. Incidence of recent-within 30 days prior to admission-angina at rest was higher in variant angina patients with significant stenosis (67% vs. 27%, p0.001) than in those with myocardial infarction but long standing angina at rest (30 days) was low and comparable in these 2 groups (15% vs. 11%, ns). Also, in a 5-year follow-up most patients from these 2 groups were free from angina at rest (86% vs. 84%) which in variant angina patients was largely attributable to a high revascularization rate (72%). Moreover, the rate of myocardial infarction/cardiac death (20% vs. 19%) was also similar. Patients with variant angina and non-significant stenosis, however, had longer antecedent angina, more frequent follow-up angina and a lower incidence of cardiac events than the other 2 groups. Thus, these findings suggest that patients with variant angina and significant coronary stenosis generally behave as an acute coronary syndrome-likely associated with an acutely complicated plaque-rather than as recurrent vasospastic angina, and should be managed accordingly.

Objectives The purpose of this study was to compare postoperative outcome in two groups of patients with chronic severe aortic regurgitation (AR): those operated on early and those operated on late according to the guidelines. Background The impact of earlier surgery for chronic severe AR as defined in guidelines has not been evaluated. Methods A total of 170 patients with chronic severe AR submitted to aortic valve replacement were prospectively followed up. Patients were divided in two groups depending on the clinical situation at the time of surgery. Group A were 60 patients who were operated on following guidelines advice of earlier surgery, and group B were 110 patients who were operated on late with regard to guideline recommendations. Results Follow-up was 10 ± 6 years (1 to 22 years). During follow-up 44 patients died, 7 patients (12%) from group A and 37 (37%) from group B (p = 0.001). The cause of death was non-cardiac in 11 patients, 2 (3%) in group A and 9 (8%) in group B. Cardiac deaths occurred in 33 patients, 5 (9%) from group A and 28 (28%) from group B (p = 0.002). Causes of death differed between groups A and B: heart failure or sudden death were significantly more frequent in group B (20 patients vs. 1 patient, p = 0.001). Overall survival in groups A and B was 90 ± 4% vs. 75 ± 8% at 5 years, 86 ± 5% vs. 64 ± 5% at 10 years, and 78 ± 7% vs. 53 ± 6% at 15 years, respectively (p = 0.009). Conclusions Early operation as defined in the guidelines improves long-term survival in patients with chronic AR.

El mal pronostico que tiene la insuficiencia cardiaca obliga al uso apropiado de los farmacos que han demostrado beneficio. Para obtener el mejor resultado es necesaria la asociacion de varios de ellos, pero el pronostico sombrio que, en el mejor de los casos, sigue teniendo la insuficiencia cardiaca justifica la creacion de nuevos farmacos. Estos deberan tener unas acciones terapeuticas distintas de los farmacos actualmente recomendados, y actuar sobre alteraciones distintas de las neurohumorales dependientes del sistema renina-angiotensina-aldosterona y del sistema simpatico. En cualquier caso, el tratamiento de un determinado enfermo requerira de un juicio clinico personalizado, sobre todo cuando la mayor parte de ellos (mayores de 70 anos, funcion sistolica conservada y con morbilidad asociada importante) no estan representados (y probablemente, por limitaciones metodologicas, no lo estaran nunca) en los ensayos controlados sobre los que se basan las guias de practica clinica actuales.

Several studies have demonstrated a correlation between myocardial ischemia and severity of coronary lesions as determined by intravascular ultrasound (IVUS) and fractional flow reserve (FFR) measurements. However, their value for the assessment of mild coronary stenoses that are associated with myocardial perfusion abnormalities has not been well studied. The objective of this study was to prospectively compare the results of myocardial perfusion as determined by exercise/dipyridamole myocardial single-photon emission computed tomography with IVUS and FFR measurements in patients who had angiographically mild coronary stenosis (50% diameter stenosis by quantitative coronary angiography). Forty-eight patients who had stable coronary disease (61 +/- 11 years of age; 6 women) were included. All had mild coronary stenosis in the proximal/middle segment ofor = 1 coronary artery and had undergone maximal exercise myocardial technetium-99m tetrofosmin single-photon emission computed tomography within 48 hours before coronary angiography. IVUS measurements included lesion lumen area, external elastic membrane area, lesion plaque burden (calculated as external elastic membrane minus lumen area, divided by external elastic membrane, and multiplied by 100), and lumen area stenosis (calculated as reference lumen area minus lesion lumen area, divided by reference lumen area, multiplied by 100). Fifty-three coronary lesions were studied, with a mean percent diameter stenosis of 34.9 +/- 7.9% on angiography. Myocardial perfusion defects were demonstrated by single-photon emission computed tomography in 11 patients (12 myocardial regions) with no differences in lesion percent diameter stenosis compared with those without perfusion defects. The presence of reversible perfusion defects was associated with a higher lesion plaque burden as evaluated by IVUS (67.4 +/- 8.1% vs 60.2 +/- 9.3%, p = 0.01). FFR values did not differ in the presence or absence of perfusion defects (0.90 +/- 0.06 vs 0.92 +/- 0.07, respectively; p = NS). In conclusion, plaque burden as determined by IVUS may partly explain the presence of myocardial perfusion defects in cases of angiographically nonsignificant coronary lesions. However, the high FFR values associated with these lesions suggest that other mechanisms, such as endothelial/microvascular dysfunction, might also account for perfusion abnormalities in these patients.

The frequency distribution and severity of the cardiac disease underlying acute cardiogenic pulmonary edema (APE) to define appropriate subsequent diagnostic and management strategies were investigated in 216 consecutive patients. To this effect, the clinical, electrocardiographic, ecocardiographic and angiographic characteristics were analyzed. Coronary artery disease was identified in 185 patients (86%)—146 with acute myocardial infarction—as the underlying cause, isolated valvular disease in 10 (5%) and other causes in 21 (11%). Most patients were elderly (≥70 years, 72%), hypertensive (71%) and diabetic (44%). Among coronary disease (CAD) patients, however, 105 (57%) showed conduction disturbances in the ECG (QRS>0.10 s) and 84 (45%) had no anginal pain during pulmonary edema. A 2D echocardiogram showed a 30% incidence of moderate–severe mitral regurgitation in coronary disease and non-coronary disease patients, and a 67% incidence of reduced ejection fraction ( Therefore, these findings demonstrate that coronary disease is the most common cause of acute pulmonary edema and it is associated with a distinctly high prevalence of multivessel and left main disease. This diagnosis, however, may often be overlooked if no serial enzymatic sampling is performed given the increased frequency of conduction abnormalities and lack of anginal pain.

Deep negative T waves (NTW) are a frequent finding following acute ST-segment elevation coronary syndromes but its possible relation with the status of regional contractility remains unclear. We studied 52 patients with a first ST-elevation acute coronary syndrome with or without NTW in anterior leads (≥3 mm in ≥3 leads) and assessed the ejection fraction and regional myocardial contractility by contrast left ventriculography at baseline and during a low-dose dobutamine test (10 μ g/kg per minute). Ejection fraction and regional contractility tended to be more preserved in patients with NTW, but dobutamine increased regional contractility in the jeopardized area in most patients with or without NTW and the improvement was similar in those either with or without enzyme elevation. In conclusion, deep NTW after ST-elevation acute coronary syndromes tends to be associated with a more preserved myocardium but it is neither a sensitive nor a specific marker of viable myocardium.

Los sindromes pericardicos agudos incluyen basicamente la pericarditis aguda y el taponamiento cardiaco. El presente trabajo esta dedicado fundamentalmente al manejo diagnostico y terapeutico de la pericarditis aguda. En nuestro medio, la gran mayoria de pericarditis cuya causa no es evidente en la presentacion clinica inicial corresponde a pericarditis idiopaticas o virales, que tienen un curso benigno y autolimitado (aunque algunos pacientes pueden desarrollar taponamiento cardiaco). Esta nocion de prevalencia es fundamental para establecer un protocolo de manejo logico que evite, por un lado, el excesivo uso de procedimientos invasivos del pericardio, pero que permita, por otro lado, diagnosticar los casos de pericarditis especificas (tuberculosa, purulenta y neoplasica). Segun estas consideraciones y nuestra propia experiencia proponemos un protocolo de estudio y manejo de las enfermedades agudas del pericardio que difieren sustancialmente de las recientes «Guias de practica clinica para el diagnostico y tratamiento de las enfermedades del pericardio» de la Sociedad Europea de Cardiologia. Tambien se comentan aspectos del taponamiento cardiaco y de las formas de constriccion aguda y subaguda que se pueden presentar en la fase de resolucion de las pericarditis agudas.

We investigated the relationship between clinical, electrocardiographic and angiographic characteristics with development of refractory angina and acute myocardial infarction (AMI) in 976 consecutive patients with unstable angina (UA). AMI occurred in 63 (6%) and recurrent angina in 384 (39%), 201 of whom had >2 episodes (refractory, 21%). Patients with AMI were older (P

Introduccion y objetivos Analizar la extension y distribucion del miocardio en riesgo en los mapas polares de la tomografia computarizada por emision de fotones simples (SPECT) de perfusion miocardica correspondientes a las arterias descendente anterior (DA), coronaria derecha (CD) y circunfleja (CX), obtenidos mediante la inyeccion de un radiotrazador tecneciado durante su oclusion en el curso de una angioplastia. Pacientes y metodo Se estudio a 50 pacientes (24 de la DA, 15 de la CD y 11 de la CX) a los que, inmediatamente despues del inicio del inflado del globo de angioplastia, se inyecto por via intravenosa un compuesto tecneciado manteniendo ocluida la arteria durante unos 90 s. Posteriormente, se procedio a captar los mapas polares con la distribucion y extension de la zona isquemica (captacion Resultados El porcentaje de extension media del territorio isquemico con relacion a todo el ventriculo izquierdo durante las oclusiones de la DA proximal fue del 49,8 ± 10,3% (minimo 35%, maximo 67%); para la DA media, del 39,8 ± 8,3% (minimo 20%, maximo 51%); para la CD, del 20,3 ± 7,6% (minimo 8,3%, maximo 35%), y para la CX, del 21,3 ± 10,8% (minimo 10,2%, maximo 30%). Conclusiones Los contornos y la extension de la isquemia obtenidos en los mapas polares durante la oclusion de las arterias coronarias permiten definir el area en riesgo real de cada arteria con una distribucion y extension diferentes de las de los mapas polares clasicos utilizados habitualmente en la mayoria de los programas de cuantificacion del SPECT de perfusion miocardica.

ESC Committee for Practice Guidelines (CPG), Silvia G. Priori (Chairperson) (Italy), Maria Angeles Alonso Garcia (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), Martin Cowie (UK), Veronica Dean (France), Jaap Deckers (The Netherlands), Enrique Fernandez Burgos (Spain), John Lekakis (Greece), Bertil Lindahl (Sweden), Gianfranco Mazzotta (Italy), Joao Morais (Portugal), Ali Oto (Turkey), Otto A. Smiseth (Norway)

Objetivo Analizar la utilidad de la gated-SPECT precoz de perfusion miocardica de reposo en los pacientes con dolor toracico y electrocardiograma no diagnostico en urgencias. Pacientes y metodo Se estudio a 222 pacientes (el 49% de mujeres, edad de 61 ± 13 anos) con dolor toracico y electrocardiograma no diagnostico que fueron distribuidos aleatoriamente en 2 grupos: grupo A, con 111 pacientes a los que se practico una gated-SPECT antes de las 6 h de la finalizacion del dolor ademas del manejo estandar (determinaciones de la fraccion MB de la creatincinasa masa y troponina I a las 0, 4 y 8 h), y grupo B, con 111 pacientes que solo recibieron el manejo estandar en urgencias. Resultados En los 8 pacientes del grupo A con criterios bioquimicos de infarto agudo de miocardio, la SPECT precoz de reposo fue positiva: sensibilidad y valor predictivo negativo del 100%. La especificidad fue del 84% y el valor predictivo positivo del 33% cuando los resultados dudosos fueron considerados como negativos. El numero de pacientes ingresados (el 18,4 frente al 32,7%; p Conclusiones En los pacientes con dolor toracico y electrocardiograma no diagnostico en urgencias, la sensibilidad y el valor predictivo negativo de la SPECT precoz de reposo son muy elevados para el diagnostico de infarto agudo de miocardio, pero el valor predictivo positivo es bajo. La practica de esta exploracion permite reducir el numero de pacientes ingresados y el tiempo de estancia en urgencias.

24 Introduction and objectives. Systolic function and myocardial perfusion are evaluated before hospital dis- charge and can change during follow-up. The purpose of this study was to evaluate these parameters by gated- SPECT in the first year after acute myocardial infarction. Patients and method. We studied 74 consecutive pa- tients with a first uncomplicated acute myocardial infarc- tion (49 infero-lateral and 25 anterior) by stress-rest 99m Tc-tetrofosmin and rest-gated-SPECT before hospital discharge (6-8 days after admission) and one year after myocardial infarction. Results. The ejection fraction (EF) increased > 5% in 51% of infero-lateral infarcts and 28% of non-revasculari- zed anterior infarcts. EF increased significantly (48.4 ± 8% to 54.6 ± 8.7%; P 5% in half of these patients, as opposed to only a quarter of anterior infarctions. This improvement was associated to increased myocardial perfusion at rest.

Left ventricular free wall rupture (FWR) usually develops within the first days of acute myocardial infarction (AMI) without warning, but it is uncertain whether a mild pericardial effusion might herald this complication.A 2-dimensional echocardiogram (2DE) was performed in patients with first AMI with (1149) or without (324) ST-segment elevation within 2 days. A second 2DE was performed 2 to 4 days later in 300 patients, 100 with and 200 without an initial mild PE (3-9 mm), and in those with initial moderate-severe PE (or =10 mm) (MSPE) or who developed hypotension or died.The first 2DE showed mild PE in 177 patients and MSPE in 51 patients, whereas a late (2 days) MSPE occurred in 27 with a second routine 2DE, 15 (15%) with and 12 (6%) without initial mild PE (P =.01). Fourteen additional patients, 5 of 77 (6%) with and 9 of 1045 (1%) without initial PE, presented with hypotension and late MSPE (P.002). Of 92 patients with MSPE, 90 had ST-segment elevation (98%), 60 had tamponade (65%), and 38 died of FWR or were operated on (41%). Results of pericardiocentesis performed in 64 patients were positive in 58, with hemopericardium in 57 (98%). Multivariant analysis showed mild PE on first 2DE and age of60 years as the only independent predictors of late MSPE or late tamponade.Mild PE within the first 2 days in patients aged60 years with a first ST-segment elevation AMI is associated with an increased risk of late MSPE. Moreover, in this setting MSPE is most frequently associated with hemopericardium, and two thirds of these patients may develop tamponade/FWR.

Objetivos Evaluar la influencia de los metodos de presentacion de los resultados sobre la percepcion cuantitativa de la eficacia de farmacos utilizados en prevencion primaria y secundaria de la enfermedad coronaria y la probabilidad de comenzar el tratamiento con dichos farmacos. Metodo Estudio realizado en 1.408 cardiologos espanoles a los que se asigno, de forma aleatoria, tres cues-tionarios en los que se utilizaban diferentes medidas de efecto de ensayos clinicos publicados. Resultados Se pudo aplicar 559 cuestionarios (40%). A partir de las respuestas a los cuestionarios se estimo, en una escala del 0 al 10 (valor este maximo de eficacia), la percepcion de la eficacia media de diferentes farmacos utilizados en ensayos clinicos cuyos resultados fueron expresados en terminos de reduccion relativa del riesgo, reduccion absoluta del riesgo y numero necesario de pacientes a tratar para evitar un caso, respectivamente, obteniendose: prevencion primaria con estatinas: 6,79, 6,38 y 5,43; prevencion primaria con aspirina: 6,84, 5,06 y 4,25; prevencion secundaria con estatinas: 8,16, 7,76 y 7,54; prevencion secundaria con inhibidores de la enzima conversiva de la angiotensina (IECA): 7,11, 7,81 y 7,19, y prevencion secundaria con bloqueadores beta: 7,22, 7,43 y 6,98. Sin embargo, la probabilidad de iniciar el tratamiento con los farmacos considerados se vio poco influida debido a la forma de presentacion de los resultados en los ensayos clinicos. Conclusiones La presentacion de resultados en los ensayos clinicos en forma de reduccion relativa del riesgo, en comparacion con su presentacion en forma de reduccion absoluta del riesgo o numero necesario de pacientes a tratar, dio lugar globalmente a una percepcion de mayor eficacia de la intervencion, sin influir, sin embargo, en la probabilidad de iniciar el tratamiento con los farmacos.

Introduction. Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood. Aim. To evaluate the incidence of DIG and determine risk factors and associated morbimortality. Patients and method. One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity ≥ 2.5 m/s. Results. Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, P

Prolongation of the QT interval is associated with a high risk of serious ventricular tachyarrhythmias, usually torsade de pointes (TdP) polymorphic ventricular tachycardia, although monomorphic ventricular tachycardia may also develop. Both congenital and acquired forms have been reported, acquired forms being much more prevalent. An association between human immunodeficiency virus (HIV) infection and a higher rate of dilated cardiomyopathy has also been recognized. The severity of immunodeficiency seems to influence both the incidence and severity of cardiomyopathy. A higher prevalence of QT prolongation has been reported among hospitalized HIV-positive patients with HIV infection, possibly related to drugs prescribed for such patients or to an acquired form of long QT syndrome arising from HIV infection. We report a case of QT prolongation and development of ventricular arrhythmia in one HIV patient that started with intravenous clarithromycin and cotrimoxazole therapy.

Objectives We sought to assess the effect of glycoprotein (GP) IIb/IIIa blockade on myocardial platelet and polymorphonuclear leukocyte accumulation and on infarct size after coronary injury and transient coronary occlusion (CO) in pigs. Background It has been suggested that platelet GP IIb/IIIa blockade might reduce the severity of microvascular damage after reperfusion. Methods Sixteen thiopental-anesthetized, open-chest pigs, in whom platelets had been labeled with technetium-99m (99mTc) on the previous day, were submitted to catheter-induced left anterior descending coronary artery (LAD) injury followed by 55 min of CO and 5 h of reperfusion. Five minutes before reflow, the animals were blindly allocated to receive lamifiban (intravenous bolus of 250 μg/kg body weight and continuous infusion of 3 μg/kg per min) or saline. Results Lamifiban had a rapid and potent platelet anti-aggregatory effect, as demonstrated by significant prolongation of the bleeding time and profound (∼90%) inhibition of ex vivo platelet aggregation, and completely prevented the development of cyclic flow reductions of the LAD (0 vs. 5 ± 1, one of them followed by re-occlusion, in control animals, p = 0.005). However, compared with animals receiving placebo, those treated with lamifiban had a similar (p = NS) content of 99mTc platelets in the reperfused myocardium (288 ± 40% vs. 205 ± 27% of the value in the control region, respectively) and similar myeloperoxidase activity (0.50 ± 0.17 U/g vs. 0.47 ± 0.17 U/g, respectively) and infarct size (46.8 ± 12.0% vs. 49.8 ± 10.5% of the area at risk, respectively). Arteriolar platelet thromboemboli were very rarely seen on histologic analysis. Lamifiban did not modify platelet P-selectin expression in additional studies. Conclusions Platelet GP IIb/IIIa blockade has a potent antithrombotic effect at the culprit lesion, but does not significantly reduce the magnitude of microvascular platelet accumulation or myocardial damage after transient CO.

Introduccion y objetivos La aparicion de un bloqueo de rama izquierda inducido por el ejercicio no siempre significa presencia de enfermedad coronaria subyacente. El motivo de este estudio fue analizar las caracteristicas clinicas y evolutivas de los pacientes con bloqueo de rama izquierda dependiente de la frecuencia. Pacientes y metodo Se revisaron 9.318 estudios ergometricos de esfuerzo practicados de forma consecutiva y se estudiaron las caracteristicas clinicas y evolutivas (seguimiento medio: 6,9 anos) de los 20 pacientes que presentaron bloqueo de rama izquierda dependiente de frecuencia y en los que se disponia de coronariografia. Resultados Un total de ocho de los 20 pacientes tenian coronarias normales (grupo A) y 12 tenian enfermedad coronaria (grupo B). El consumo maximo de O2, el consumo miocardico de O2 y la frecuencia cardiaca en el momento de aparicion del bloqueo (132 ± 20 frente a 95,4 ± 23 lat/min; p = 0,002) fueron significativamente superiores en el grupo A. Siete de los 8 pacientes del grupo A presentaron dolor precordial coincidiendo con el primer latido en que aparecio el bloqueo. No hubo ningun caso de fallecimiento en el grupo A, y en cinco de los 8 pacientes de este grupo se observo evolucion a bloqueo de rama izquierda permanente con desaparicion del dolor inducido por el esfuerzo. En el grupo B, 3 pacientes fallecieron y dos presentaron un infarto durante el seguimiento. Un paciente de cada grupo evoluciono a bloqueo auriculoventricular completo. Conclusiones A diferencia de los pacientes con bloqueo de rama izquierda dependiente de frecuencia y enfermedad coronaria, el pronostico de los pacientes con bloqueo de rama izquierda doloroso y coronarias normales es muy bueno en cuanto a mortalidad, aunque pueden evolucionar a bloqueo de rama izquierda permanente y, excepcionalmente, a bloqueo auriculoventricular.

Introduccion y objetivos Analizar las caracteristicas basales, los patrones de manejo y los resultados clinicos a los 18 meses del ingreso en pacientes diagnosticados de insuficiencia cardiaca en un hospital terciario de Cataluna. Metodos Se identificaron y analizaron las historias clinicas de los 256 pacientes ingresados en el Hospital General Vall d’Hebron desde julio a diciembre de 1998, diagnosticados de insuficiencia cardiaca y que cumplieran los criterios del estudio. Se entrevisto a los pacientes telefonicamente 18 meses despues. Resultados La edad media de los pacientes era de 75 ± 12 anos, el 42% correspondia a varones, el 19% habia ingresado por enfermedades distintas de la insuficiencia cardiaca y el 62% tenia comorbilidad significativa. Se estudio la funcion ventricular en el 68% (basicamente en pacientes con mejor pronostico), y se considero normal en un 41%. Se administraron inhibidores de la enzima conversiva o antagonistas de la angiotensina II en un 54% y bloqueadores beta en un 4%. La mortalidad a los 18 meses fue del 46%, siendo de causa cardiaca en el 77% de estos. Los predictores independientes de mortalidad fueron la edad avanzada, la insuficiencia cardiaca grave o antigua y la comorbilidad. A los 18 meses, un 69% de los supervivientes se hallaba en clase funcional I o II. Conclusiones 1) Al igual que sucede en otras areas geograficas, los pacientes de este estudio constituyen, como media, una poblacion anciana y con pobre supervivencia; 2) los patrones de manejo registrados son claramente mejorables; 3) la comorbilidad afecta significativamente al pronostico, y 4) la calidad de vida despues del alta es aceptable en una llamativa proporcion de supervivientes.

The clinical, angiographic and therapeutic features of eight patients who developed a left ventricular pseudoaneurysm (PA) after an acute myocardial infarction (AMI) and those of 25 who did not develop this complication following a medically managed left ventricular free wall rupture (FWR) were compared. These 25 patients were treated with pericardiocentesis, extended rest and strict blood pressure control. Most patients with FWR or PA had a first AMI and absence of overt heart failure. Both groups had a comparable age, frequency of systemic hypertension and extent of coronary disease. Pericardial effusion (> or =10 mm) was documented in all patients with FWR and in two of the three with PA with this information. Twenty four patients with FWR were hospitalized within the first 48 h (96%) but only three of those with PA (37.5%, P

Introduccion y objetivos El objetivo del presente estudiofue analizar el valor pronostico y la evolucion delecocardiograma-Doppler en una poblacion hospitalariaadulta con miocardiopatia hipertrofica (MH). Metodos Se estudiaron 119 pacientes consecutivosdiagnosticados de MH (52 ± 12 anos, 60 mujeres) duranteun seguimiento medio de 9,7 ± 6,7 anos. La evolucionecocardiografica se analizo en los 104 pacientes (67 conobstruccion dinamica) en quienes se disponia al menosde 2 ecocardiogramas con un intervalo de 3,7 ± 3 anos(uno a 7 anos) entre ambas exploraciones. Resultados Durante el seguimiento 7 pacientes fallecierony 31 presentaron complicaciones severas (siete fallecimientos,15, sincope, cuatro, angina grado IV, tres,disnea grado IV y dos, infarto). La presencia de insuficienciamitral (p = 0,001) y un gradiente dinamico superior a50 mmHg (p = 0,02) fueron predictores de mortalidad, yun indice de auricula izquierda superior a 25 mm/m2 (p =0,028), de complicaciones severas. En un 15% de los pacientescon MH no obstructiva en el primer registro estapaso a ser obstructiva en el ultimo registro. Tambien seobservo un incremento del numero de pacientes con insuficienciamitral (el 80 frente al 66%; p = 0,01) y en su severidad(p = 0,038) durante el seguimiento. Conclusiones La presencia de insuficiencia mitral, degradiente dinamico superior a 50 mmHg, y un indice deauricula izquierda superior a 25 mm/m2 son variablesde mal pronostico en los pacientes adultos con MH. Duranteel seguimiento se observa la evolucion a formasobstructivas en un 15% de las MH no obstructivas y unatendencia a la progresion de la insuficiencia mitral.

Resumen —Objetivos: Valorar el papel del SPET miocardico de perfusion y de la ventriculografia isotopica en la miocardiopatia hipertrofica (MH). Material y Metodos A una serie consecutiva de 101 pacientes (54 ± 15 anos de edad, 50 mujeres, 55 obstructivos), diagnosticados por ecocardiograma-Doppler de MH, se les practico un SPET miocardico de perfusion con 99mTctetrofosmina y una ventriculografia isotopica. El seguimiento medio desde el momento del diagnostico fue de 9,9 ± 6,7 anos (entre 1 y 28 anos). Resultados El 36% de los pacientes presentaron defectos de perfusion (15 defectos fijos y 21 defectos reversibles). En las MH no obstructivas se observo un mayor numero de pacientes con defectos fijos (p = 0,01) y en los pacientes con defectos fijos se observo una mayor incidencia de ondas Q patologicas en el ECG (p = 0,01), mayores volumenes ventriculares (p Conclusiones Ni la tomogammagrafia miocardica de perfusion ni la ventriculografia isotopica aportan informacion pronostica en la MH, aunque en los pacientes con sincope se observan valores de fraccion de eyeccion mas elevados. Los pacientes con defectos fijos presentan mayor proporcion de ondas Q patologicas en el ECG, mayores volumenes ventriculares y fraccion de eyeccion mas baja en la ventriculografia isotopica, lo cual indica una evolucion hacia la forma dilatada de la MH.

We retrospectively analyzed the response to fibrinolytic treatment in a group of 5 patients with prosthetic thrombosis, one of whom was a pregnant woman. All the patients were in functional class IV (NYHA), and the risk of surgery was considered very high for the following reasons: cardiogenic shock in 2 cases, severe depression of ventricular function in 1 case, and 3 and 4 prior interventions in 2 patients. The treatment was effective in 4 cases and the fifth patient died in cardiogenic shock. There were no major hemorrhagic complications and one case of peripheral embolism was detected. The treatment was effective and no obstetric or fetal complications were observed in the pregnant woman. We believe that fibrinolytic treatment is a good alternative for patients with prosthetic thrombosis and very high surgical risk and it may even be effective during pregnancy.

OBJECTIVESThe goal of this study was to investigate possible differences in thrombin generation or fibrinolytic capacity in patients with unstable angina (UA) or acute myocardial infarction (AMI) with or without recurrent angina at rest.BACKGROUNDAngina at rest in patients with AMI or UA is generally produced by a reduction in coronary flow, but it is unclear whether patients with or without this event differ in their thrombin generation or in their fibrinolytic capacities, which might influence the course of the culprit lesion.METHODSThrombin-antithrombin complex (TAT), D-dimer, fibrinogen and plasminogen activator inhibitor (PAI-1) antigen plasma levels were determined in 40 patients with AMI and in 23 with UA on admission, at 10 days and at three months.RESULTSFirst day values for TAT, fibrinogen and D-dimer were comparable in patients with AMI and in those with UA. At 10 days they increased significantly in each group, and at 3 months they decreased to a similar extent. First day PAI-1 levels, however, were highest in both groups and declined in AMI patients at 10 days and at three months, whereas they also decreased at 10 days in UA patients but not any further at three months. Ten patients with AMI (25%) and 12 with UA (52%) developed in-hospital angina at rest. First day values for TAT, fibrinogen and D-dimer were similar in patients with or without angina, but PAI-1 levels were higher in the former subset (p < 0.008). At 10 days, however, TAT (p < 0.013) and D-dimer (p < 0.013) were higher in patients who developed angina than in those who did not.CONCLUSIONSThe higher inhibition of fibrinolytic activity in the first day in patients with AMI or UA who will develop recurrent angina suggests that maintenance of a prothrombotic status may contribute to its mechanisms, perhaps by preventing passivation of the culprit thrombus/plaque. This is consistent with greater thrombin generation and greater levels of fibrynolitic products at 10 days observed in these patients compared with those who attain early stability.

OBJECTIVESWe sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation.BACKGROUNDST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear.METHODSIn 432 patients with a first acute MI without Q waves or ≥0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death.RESULTSThe presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V5, or V6) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 ± 96 vs. 122 ± 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 ± 12% vs. 66 ± 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001).CONCLUSIONSIn patients with a first non–ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.

Although different Doppler methods have been validated for aortic regurgitation quantification, the benefit of combining information from different methods has not been defined.Our study included 2 phases. In the initial phase (60 patients), Doppler parameters (jet width, short-axis jet area, apical jet area, regurgitant fraction from pulmonary and mitral flow, and deceleration slope) were correlated with angiography; range values for each severity grade were defined and intraobserver and interobserver and intermachine variability were studied. In the validation phase (158 patients), defined value ranges were prospectively tested and a strategy based on considering as the definitive severity grade that in which the two best methods agreed was tested.Jet width had the best correlation with angiography (r = 0.91), and its ratio with the left ventricular outflow diameter did not improve the correlation (r = 0.85) and decreased reproducibility. Apical jet area and regurgitant fraction from pulmonary flow permitted acceptable quantification (r = 0.87 and 0.86, respectively) but with worse reproducibility. The other methods were not assessable in 20% to 30% of studies. Concordance with angiography decreased in jet width when the jet was eccentric (90% vs 77%, P.01), in apical jet area when mitral valve disease was present (84% vs 65%, P.02), and in short-axis jet area and regurgitant fraction from pulmonary flow with concomitant aortic stenosis (77% vs 44%, P.002 and 77% vs 53%, P.02, respectively). Agreement with angiography was very high (94 [95%] of 99) when severity grade coincided in both jet width and apical jet area. In 59 cases without concordance, regurgitant fraction from pulmonary flow was used as a third method. Overall, this strategy permitted concordance with angiography in 146 patients (92%).Jet width is the best predictor in aortic regurgitation quantification by Doppler echocardiography. However, better results were obtained when a strategy based on concordance between jet width and another Doppler method was established, particularly when the jet was eccentric.

To demonstrate that the administration of dipyridamole at the end of an insufficient maximal subjective exercise test can improve the diagnostic accuracy of single-photon emission computed tomography in patients with previous myocardial infarction, 209 consecutive patients were studied with technetium-99m methoxyisobutyl isonitrile single-photon emission computed tomography and coronary angiography. Patients were divided in 3 groups: group 1, 107 patients with sufficient exercise testing; group 2, 55 patients with insufficient exercise testing; group 3, 47 patients with insufficient exercise testing in whom intravenous dipyridamole (0.56 mg/kg over 4 minutes) was administered at the end of exercise. In groups 1 and 3 the sensitivity values for the diagnosis of multivessel disease were significantly higher (80% and 76%, respectively) than those in group 2 (59% [p = 0.009 and p = 0.02, respectively]). Specificity and predictive values were not different among the 3 groups. Thus, in patients with previous infarction in whom adequate levels of exercise could not be achieved, dipyridamole administration at the end of exercise significantly increased the sensitivity for diagnosing multivessel disease.

Introduccion y objetivos La ergometria convencional presenta limitaciones en la valoracion de la permeabilidad de los injertos aortocoronarios. El motivo del presente estudio fue determinar la eficacia de la tomogammagrafia miocardica de esfuerzo con compuestos tecneciados para el diagnostico de la enfermedad de los injertos aortocoronarios poscirugia cardiaca. Pacientes y metodos Se analizo de forma retrospectiva el estado de 67 injertos coronarios (31 de arteria mamaria, 36 de vena safena, 35 a la arteria descendente anterior, 15 a la circunfleja y 17 a la coronaria derecha) pertenecientes a 38 pacientes (63 ± 8,7 anos; 35 varones). El tiempo medio entre la intervencion quirurgica y la tomogammagrafia de esfuerzo fue de 9,7 anos. De las 38 tomogammagrafias, 16 fueron realizadas con 99mTc-MIBI y las restantes 22 con 99mTc-tetrofosmina. En 6 de los casos se administro dipiridamol intravenoso durante la realizacion de una prueba de esfuerzo insuficiente. Resultados La sensibilidad (73,1%), especificidad (93%), valor predictivo positivo (86,3%), valor predictivo negativo (84,4%), valor global (85%), coeficiente de probabilidad positivo (10,4) y coeficiente de probabilidad negativo (0,29) de la tomogammagrafia fueron significativamente mejores (p Conclusiones La tomogammagrafia miocardica de esfuerzo con componentes tecneciados es una exploracion de alta eficacia para el diagnostico de la enfermedad de los injertos coronarios.

Introduccion y objetivos . El objetivo de este estudio es valorar si existen diferencias en el espectro etiologico y el curso clinico del derrame pericardico en pacientes ancianos, como se ha sugerido, lo que implicaria un manejo clinico distinto en funcion de la edad del paciente. Metodos . Todos los ecocardiogramas practicados en nuestro hospital entre 1990 y 1996 fueron revisados para seleccionar aquellos con derrame pericardico moderado o severo. Los pacientes con edad inferior a 66 anos fueron incluidos en el grupo I, y aquellos con edad superior a 65 anos fueron asignados al grupo II. Resultados . Se seleccionaron 322 pacientes con derrame moderado (122) o severo (200). En el grupo I fueron incluidos 221 pacientes (edad 15-65 anos; media, 47) y 101 pacientes fueron asignados al grupo II (edad 66-88 anos; media, 72,5). El derrame era severo en el 60% del grupo I y en el 66% del grupo II (p = NS), y se produjo taponamiento en 36% del grupo I y 38,6% del grupo II (p = NS). Las infecciones pericardicas especificas (pericarditis tuberculosa y purulenta) fueron mas frecuentes en el grupo I (el 5,9 frente al 0,9%; p Conclusiones . Este estudio sugiere que el derrame pericardico tiene, en general, una etiologia, curso clinico y pronostico similares en pacientes ancianos respecto a los de la poblacion general. Por tanto, su manejo deberia ser similar y cualquier posibilidad etiologica debe ser considerada en el diagnostico diferencial, con independencia de la edad del paciente.

Introduccion y objetivos El proposito de este estudio ha sido comparar los diferentes tipos morfologicos de miocardiopatia hipertrofica observados mediante tomogammagrafia miocardica de perfusion con los del ecocardiograma. Material y metodos En 76 de 119 pacientes (64%) con miocardiopatia hipertrofica, el ecocardiograma permitio una aceptable visualizacion de todos los segmentos del ventriculo izquierdo en la proyeccion paraesternal transversal y la asignacion de los pacientes a alguno de los 6 tipos morfologicos clasicos: tipo I (hipertrofia septal anterior), tipo II (hipertrofia septal anterior y septal posterior), tipo III (hipertrofia septal y anterolateral), tipo IV (hipertrofia septal posterior y/o anterolateral), tipo V (hipertrofia concentrica) y tipo VI (hipertrofia apical). Sin conocimiento de los datos ecocardiograficos, dos observadores experimentados intentaron asignar con las imagenes del eje corto de la tomogammagrafia miocardica de perfusion en reposo con 9 9 mTc-tetrofosmina a alguno de estos tipos. Resultados La concordancia global entre las dos tecnicas fue del 75%. El tipo III fue el mas frecuente, tanto en el ecocardiograma (76%) como en la tomografia miocardica de perfusion (74%), aunque tambien fue el que origino la mayoria de discrepancias. Con la tomogammagrafia miocardica de perfusion se observo en 4 pacientes una hipertrofia localizada en la region septal e inferior que no correspondia a ninguno de los 6 tipos de la clasificacion ecocardiografica clasica y que por ecocardiograma habia sido clasificada como tipo III en 3 casos y en 1 como tipo V. Conclusiones Se observo concordancia entre el ecocardiograma y la tomogammagrafia miocardica de perfusion en la clasificacion morfologica de la mayoria (75%) de los pacientes con miocardiopatia hipertrofica, aunque se hallaron discrepancias con respecto al ecocardiograma, sobre todo en el tipo III.

Introduction and objectives. The aim of this study was to evaluate the diagnostic accuracy of myocardial SPET in patients with hypertrophyc cardiomyopathy (HC). Patients and methods. One hundred and six consecutive patients (aged 53 ± 12 years, 50 women, 66 with dynamic obstruction) with an echocardiographic diagnosis of HC were studied with exercise-rest myocardial SPET with 99m Tc-tetrofosmin. Forty-six (43%) of these patients had chest pain and in 31 (29%) a coronary angiography was performed. Fifty-six per cent of the patients were treated with beta-blockers and 23% with verapamil. Results. Angina during the exercise test was observed in only 8% of the patients. Perfusion defects were observed in 35% of the patients. Only 8 (26%) out of the 31 patients with angiography had coronary artery disease (stenosis > 50%). When fixed and reversible defects were considered as positive, the sensitivity was 50%, the specificity was 65%, the positive predictive value was 33% and the negative predictive value was 79%. Conclusions. Myocardial perfusion defects can be observed in more than one third of medically treated patients with HC. Only a quarter of catheterized patients, even with chest pain, have associated coronary artery disease. The accuracy of SPET for the diagnosis of coronary artery disease in hypertrophic cardiomyopathy is low. Thus, the value of this technique is limited in these patients.

To validate the AHCPR classification for the prognosis of unstable angina, 225 consecutive patients were recruited with a suspected diagnosis of that condition attending a tertiary hospital from November 1994 through April 1995 and followed for one year. One-hundred fifty-six (69.3%) patients were considered at high risk, 37 (16.5%) at intermediate, and 32 (14.2%) at low risk of cardiac complications. All of the patients with major in-hospital cardiac complications (8 patients) had at least one of the features of the high risk group. The high to intermediate-low hazard ratio (HR) for one-year cardiac complications after the onset of unstable angina was 4.03. Predictors of major complications (myocardial infarction or death) after the follow-up were age > 65 (HR, 5.69); diabetes (HR, 4.94); heart failure (HR, 2.65); and prolonged angina (HR, 2.55). AHCPR classification correctly identified patients with risk of severe outcomes at the hospital. Also, the classification predicted outcomes one year after hospitalization, diabetes being an important determinant of adverse cardiac events.

The aim of this study was to assess the prognosis of medically treated patients with “clandestine” myocardial ischemia (perfusion defect without angina and no ST depression >1 mm during exercise test) compared to those with silent myocardial ischemia (ST-segment depression >1 mm, without angina) and those with angina pectoris. One hundred twelve patients without previous myocardial infarction were included. All patients underwent a symptom-limited exercise test on a bicycle ergometer, myocardial perfusion technetium-99m-methoxy-isobutyl-isonitrile single-photon emission computed tomography (SPECT), and coronary angiography. They were classified into 3 groups (angina group, 34 patients; silent group, 20 patients; and the clandestine group, 58 patients). The mean follow-up was 3.6 years (range 6 months to 5.5 years). Patients with clandestine ischemia had a lower scintigraphic and angiographic score than patients with silent ischemia (25 ± 8 vs 31 ± 9 and 24 ± 8 vs 29 ± 7, p = 0.008, respectively), but the prognosis was similar. Only angina and severe reversible SPECT defects were predictive for cardiac events: death + myocardial infarction + revascularization. We conclude that in medically treated patients without previous myocardial infarction, angina and severe reversible SPECT defects are predictive for cardiac events only when the need for revascularization is included as a cardiac event.

Objectives. We analyzed the possible relation between the presence of a hospital admission delay (≥24 h), undue physical effort or recurrence of anginal pain, alone or in combination, with the development of free wall rupture (FWR), septal rupture (SR) or papillary muscle rupture (PMR) in patients with an acute myocardial infarction (AMI).Background. Physical activity as a trigger of FWR in AMI remains controversial, and its contribution to SR or PMR remains unknown. Moreover, the role of ischemia or reinfarction as an additional cause of rupture has not been explored.Methods. The incidence of hospital admission delay ≥24 h with maintenance of some ambulatory activity and the incidence of postinfarction angina were analyzed in consecutive patients with a first AMI with (n = 225) or without rupture (n = 1,012 [control group]) over different time periods.Results. An admission delay ≥24 h occurred in 27 (27.6%) of 98 patients with FWR, 47 (47.0%) of 100 with SR and 14 (51.9%) of 27 with PMR but in only 81 (8%) of 1,012 control patients (p < 0.0001). Information on undue in-hospital effort preceding rupture was available for 111 patients and was present in 17 (32.7%) of 52 with FWR, 9 (18.4%) of 49 with SR and 3 (30%) of 10 with PMR versus only 76 (7.5%) of 1,012 control patients (p < 0.001). Information on postinfarction anginal pain was available for 114 patients with rupture and occurred in 30 (56.6%) of 53 with FWR, 30 (60%) of 50 with SR and 4 (36.4%) of 11 with PMR versus 120 (11.9%) of 1,012 control patients (p < 0.0001). Mean age and incidence of male gender, hypertension, absence of heart failure, single-vessel disease or occlusion of the infarct-related artery were comparable among the groups with FWR, SR or PMR.Conclusions. Delayed hospital admission or undue in-hospital physical activity appears to increase the risk of rupture in patients prone to this complication (i.e., a first transmural AMI, absence of overt heart failure and advanced age); recurrence of ischemia/infarction emerges as a potential additional trigger in a proportion of these patients.

Las enfermedades del tejido conectivo comprenden un amplio grupo de entidades cuya etiologia es desconocida, caracterizadas por afectar a multiples organos y sistemas, que comparten una patogenia inmunologica y dan lugar a manifestaciones de tipo inflamatorio de todo tipo, aunque su lesion basica es siempre una vasculitis difusa. Cualquier estructura cardiovascular puede verse afectada, desde el pericardio, el miocardio, el endocardio y las valvulas a las arterias coronarias, la aorta, las arterias pulmonares las arterias perifericas, venas, arteriolas, venulas y lechos capilares de casi todos los organos y sistemas. Los estudios anatomopatologicos ponen de manifiesto una alta prevalencia de afeccion cardiaca, pero existe una escasa correlacion entre los hallazgos patologicos y las manifestaciones clinicas. La incorporacion de la ecocardiografia Doppler ha permitido el reconocimiento de casos de menor entidad y mas precozmente. Aunque este tipo de pacientes continuan siendo controlados por reumatologos e internistas, la frecuente afeccion cardiaca requiere que los cardiologos conozcan sus caracteristicas, evolucion y tratamiento.

Introduccion y objetivos Analizar la eficacia de la tomogammagrafia miocardica de esfuerzo con compuestos tecneciados para el diagnostico de re estenosisen pacientes con angioplastia previa. Pacientes y metodos Se ha analizado retrospectivamente a 71 pacientes con angioplastia previa(16 mujeres, edad media: 60 anos, 35 con enfermedad multivaso y 78 angioplastias en total) y comprobacioncoronariografica. A todos se les habiapracticado, por motivos asistenciales, una tomogammagrafiamiocardica de esfuerzo con 99mTc (53con MIBI y 18 con tetrofosmina) entre 1 mes y 4anos despues de la angioplastia. A 16 pacientes se les administro dipiridamol intravenoso simultaneo con el ejercicio puesto que este fue insuficiente. Resultados La sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y valor global de la tomogammagrafia fueron significativamentesuperiores a los de la prueba de esfuerzo (80% frente al 63%; p = 0,05; 83% frente al 37%;p = 0,001; 91% frente al 69%; p = 0,007; 64% frenteal 31%; p = 0,009, y 81% frente al 55%; p = 0,0006 respectivamente). Al comparar los resultados de los pacientes con enfermedad multivaso respecto a los de un solo vaso observamos que fue en estos donde la eficacia diagnostica de la tomogammagrafia fue significativamente superior a la de la ergometria. Conclusiones La tomogammagrafia miocardicade esfuerzo con compuestos tecneciados es una exploracioncon una elevada eficacia para el diagnosticode la reestenosis postangioplastia, sobre todo en los pacientes con enfermedad de un solo vaso.

Introduccion y objetivos El proposito de este estudio es valorar la isquemia miocardica en las regiones dependientes de arterias coronarias ocluidas de pacientes sin infarto previo. Pacientes y metodos Se han estudiado 149 pacientes con enfermedad coronaria demostrada y sin infarto previo mediante tomogammagrafia miocardica de esfuerzo cuantitativa con 99mmetoxi-isobutil- isonitrilo (MIBI) (protocolo largo) y coronariografia. Se cuantifico la extension de la reversibilidad de captacion en 3 regiones (anteroseptal, inferior y lateral) de los mapas polares, valorandose el porcentaje de cada region que tuviera una diferencia entre la captacion en reposo menos la captacion en esfuerzo superior al 10%. Se compararon las regiones dependientes de una arteria ocluida con las dependientes de arterias con estenosis entre el 50 y el 99%, y tambien entre las que no tenian y las que tenian buena circulacion colateral. Resultados Cincuenta y cuatro de 149 pacientes (36%) tenian al menos una arteria coronaria ocluida (20 descendente anterior, 22 derecha y 27 circunfleja). En el analisis visual se observaron defectos reversibles en todos los pacientes con oclusion de la descendente anterior y de la derecha pero solo en la mitad de las oclusiones de la circunfleja. La extension de esta reversibilidad fue significativamente superior en las regiones dependientes de arterias ocluidas, tanto para la descendente anterior como para la derecha y la circunfleja. La extension de esta reversibilidad fue muy variable, aunque inferior cuando existia una buena circulacion colateral. Conclusiones En las oclusiones de la descendente anterior y de la derecha se observan siempre defectos reversibles en la 99mTc-MIBI SPET, mientras que en las de la circunfleja solo se detectan en la mitad de los casos. La extension de la isquemia es superior en las regiones dependientes de una arteria coronaria ocluida, sobre todo en ausencia de una buena circulacion colateral.

Objetivo El proposito del presente estudio fuedeterminar la utilidad pronostica en la deteccion deenfermedad multivaso de la ecocardiografia de esfuerzopracticada antes del alta hospitalaria de uninfarto agudo de miocardio no complicado. Pacientes y metodos Se han estudiado 65 pacientesconsecutivos afectados de un primer episodiode infarto agudo de miocardio no complicado, confuncion ventricular normal o ligeramente deprimida(FE > 40%). Se practico una prueba de esfuerzosubmaxima (60% VO2max) a los 7-10 dias del infartorealizando un ecocardiograma antes e inmediatamentepostesfuerzo. El seguimiento fue de 15 ± 8meses presentando 15 pacientes angina y 9 revascularizacion.Un paciente fallecio. Resultados La aparicion de isquemia en el electrocardiogramatuvo una baja sensibilidad y valorpredictivo negativo respecto a la presencia decomplicaciones durante la evolucion (44 y 73%, respectivamente),pero su especificidad y su valor predictivopositivo fueron altos (97 y 92%, respectivamente).Por el contrario, la deteccion de isquemiaen el ecocardiograma presento mucha mejor sensibilidady valor predictivo negativo (72 y 83%, respectivamente),con una ligera disminucion de la especificidady del valor predictivo positivo (87 y78%, respectivamente). Tanto la evidencia de isquemiaa distancia como el incremento del indicede contractilidad segmentaria global superior a0,25 durante el esfuerzo tuvieron una alta significacionpronostica (p Conclusiones La ecocardiografia de esfuerzo esde gran utilidad en la estratificacion pronostica delos pacientes antes del alta hospitalaria despuesde un infarto de miocardio no complicado. La respuestaisquemica, a nivel submaximo de esfuerzo,valorada por ecocardiografia, fue mucho mas sensibleque la electrocardiografica en la prediccionde nuevos episodios coronarios y enfermedad multivaso.

Introduccion y objetivos Aunque en diferentes publicaciones se ha comparado la extension de la isquemia entre los pacientes que presentan angina durante la prueba de esfuerzo y los que no la presentan, existen pocos estudios que hayan valorado la importancia pronostica de este hecho. El motivo de este trabajo ha sido analizar el valor pronostico de la presencia de angina durante la practica de una tomogammagrafia de esfuerzo con 99mTc-MIBI en pacientes con cardiopatia isquemica demostrada pero sin infarto previo. Pacientes y metodos Se ha realizado un estudio prospectivo en el que se han incluido de forma consecutiva 82 pacientes con al menos una estenosis coronaria superior al 70% en la coronariografia y con defectos reversibles de perfusion en la tomogammagrafia de esfuerzo con 99mTc-MIBI (protocolo largo). Veintidos enfermos (edad 57 ± 8 anos, 3 mujeres) presentaron angina y 60 (edad 57 ± 9 anos, 7 mujeres) no presentaron angina durante la practica de la prueba de esfuerzo. Se cuantifico la extension de la isquemia en la tomogammagrafia de perfusion y la severidad de la enfermedad coronaria en la coronariografia valorando las complicaciones aparecidas en ambos grupos durante un seguimiento medio de 3,2 anos. Resultados En el examen inicial, los pacientes con angina presentaron una reserva coronaria significativamente menor (duracion del ejercicio 6,3 frente a 8 min; p = 0,03), un menor consumo de oxigeno (5,8 frente a 6,2 MET; p = 0,04), una mayor frecuencia de descenso del segmento ST superior a 1 mm (64 frente a 19%; p = 0,006) y una mayor depresion de este (0,9 frente a 0,4 mm; p = 0,01) que los pacientes sin angina. No se hallaron diferencias significativasen cuanto a la extension de la isquemia en la tomogammagrafia y en cuanto a la severidad de la enfermedad coronaria entre ambos grupos. Durante el seguimiento, la presencia de complicaciones mayores (fallecimiento o infarto) tendio a ser superior en los pacientes con angina (27 frentea 17%; NS) y la necesidad de revascularizacion quirurgica fue significativamente superior (50 frente a 17%; p = 0,002). Conclusiones La presencia de angina durante una gammagrafia de esfuerzo positiva implica un mayor riesgo de complicaciones a medio-largo plazo, principalmente debido a la necesidad de revascularizacion quirurgica.

Introduccion y objetivos Conocer los determinantes del pronostico a corto plazo y a un ano de toda la poblacion atendida por el cardiologo de guardia del servicio de urgencias de un hospital de tercer nivel con sospecha de sindrome coronario agudo durante un periodo de seis meses. Pacientes y metodos Fueron identificados 153 pacientes consecutivos con diagnostico de infarto agudo de miocardio, 225 con diagnostico de angina inestable y 89 con diagnostico de dolor toracico atipico, estudiandose prospectivamente sus datos hospitalarios y su pronostico a largo plazo. Resultados La edad era superior a 65 anos en el 53% de pacientes con infarto agudo de miocardio y en el 54% con angina inestable. El 35% de los pacientes con infarto agudo de miocardio y el 16% de los pacientes con angina inestable sufrieron muerte o reinfarto al ano. Las caracteristicas basales, patrones de manejo y pronostico de los pacientes ingresados con infarto agudo de miocardio en el servicio de cardiologia, otras areas del hospital u otros centros diferian de forma importante, siendo el ingreso fuera del servicio de cardiologia un predictor independiente de mortalidad. En la angina inestable, las complicaciones se observaron en pacientes mayores de 75 anos, o previamente revascularizados, o tratados con revascularizacion, o con lesiones consideradas no revascularizables. Conclusiones a ) en la poblacion estudiada predominan los pacientes de edad avanzada y con una proporcion de mal pronostico considerablemente alta; b ) una significativa proporcion de los pacientes con complicaciones graves esta escasamente representada en los grandes ensayos clinicos, y c ) se tiende a concentrar el mayor esfuerzo terapeutico en los pacientes con un buen pronostico.

Objectives. We attempted to demonstrate that simultaneous dipyridamole administration and maximal subjective exercise in patients who are unable to achieve a good exercise level can improve the diagnostic efficacy of technetium-99m methoxy isobutyl isonitrile (99mTc-MIBI) myocardial single-photon emisson computed tomography (SPECT).Background. The results of myocardial perfusion scintigraphy are unsatisfactory if the level of exercise achieved by the patient is insufficient. The use of dipyridamole with maximal subjective stress testing has been shown to improve the quality of the thallium-201 myocardial perfusion images, but there are no studies demonstrating that this combination improves the diagnostic accuracy of myocardial perfusion SPECT.Methods. Two hundred thirty-one consecutive patients, without a previous myocardial infarction, were classified into three groups: group 1, 91 patients with an adequate exercise test; group 2, 68 patients with an inadequate exercise test; group 3, 72 patients with an inadequate exercise test who then received intravenous dipyridamole (0.56 mg/kg body weight over 4 min) simultaneously with exercise.Results. Results for sensitivity (89%) and negative predictive value (83%) in group 3 were significantly better than those in group 2 (71% [p = 0.03] and 56% [p = 0.002], respectively) and not significantly different from those in group 1. The polar maps of 20 patients studied with and without dipyridamole at the same exercise level revealed a significantly greater extent of ischemia in each territory and in a global assessment (19 + 20% vs. 8 + 11%, p < 0.0001) when dypiridamole was administered during physical exercise.Conclusions. Intravenous dipyridamole administration during exercise testing is advisable in all patients who are unable to achieve an adequate exercise level. This approach permits physicians to avoid missing ergometric information while optimizing myocardial SPECT results.(J Am Coll Cardiol 1997;29:531–6)

Introduccion y objetivos Estudiar el rendimientodiagnostico de la tomogammagrafia miocardicacon tecnecio-99m-metoxi-isobutil isonitrilo en ladeteccion de enfermedad individualizada de las arteriascoronarias epicardicas y su valor en la prediccionde enfermedad multivaso. Metodo Se han estudiado 231 pacientes (58 ± 10anos, 26% mujeres) consecutivos sin infarto previoen los que se disponia de una tomogammagrafiamiocardica de esfuerzo y reposo y coronariografia(104 multivaso, 45 monovaso y 82 sin lesiones coronarias).Los resultados de la tomogammagrafiase evaluaron de forma semicuantitativa medianteuna puntuacion proporcional a la extension y severidadde los defectos postesfuerzo (puntuacion maxima:65). Se realizo un analisis bi y multivariableentre los pacientes con enfermedad multivaso ycon enfermedad de un vaso. Resultados La sensibilidad y especificidad de latomogammagrafia para la deteccion de estenosis > 50% en la arteria descendente anterior fuerondel 74% y 85%, para la coronaria derecha del 79% y85% y para la arteria circunfleja del 45% y 96%respectivamente. La tomogammagrafia mostro unasensibilidad del 65%, especificidad del 87%, un valorpredictivo positivo del 81% y un valor predictivonegativo del 76% para la deteccion de enfermedadmultivaso. El analisis bivariable mostro diferencias significativasentre los pacientes de un vaso y multivasoen cuatro parametros: descenso del ST > 1 mm (p =0,01), descenso del ST corregido por la frecuenciacardiaca (p = 0,005), defectos reversibles en masde una region (p = 0,009), y puntuacion de la tomogammagrafia(p = 0,002). En el analisis multivariable la probabilidad de enfermedadmultivaso fue del 90% cuando se asociabadescenso del ST > 1 mm y una puntuacion > 20 en la tomogammagrafia. Cuando estos dos criteriosno se cumplian esta probabilidad fue del 16%. Conclusion Los resultados de la tomogammagrafiamiocardica en la deteccion de enfermedad coronariapor vasos son globalmente buenos exceptopara la circunfleja que presenta una menor sensibilidad.La interpretacion conjunta del ECG de esfuerzoy de la tomogammagrafia permitio una mejordiscriminacion de los pacientes con enfermedadmultivaso.

La oclusion total cronica del tronco comun es unhallazgo angiografico poco frecuente. Tras revisarlas coronariografias realizadas en nuestro centroentre 1986 y 1995, encontramos una prevalenciadel 0,04%. Estos pacientes presentaron una clinicainespecifica no diferenciable de otros grados de enfermedadcoronaria, existiendo en todos ellos unaarteria coronaria derecha dominante con ampliacirculacion colateral hacia la coronaria izquierda.La funcion ventricular estaba conservada en el 50%de los casos. Probablemente, en estos infrecuentescasos, la mejor alternativa terapeutica sea la cirugiade revascularizacion.

Objectives. This study sought to assess the reliability of biplanar transesophageal echocardiography in the diagnosis of ascending aortic dissection and to test the utility of M-mode information in the differential diagnosis of ascending aortic ultrasound artifacts and intimal flap images. Background. Transesophageal echocardiography is a useful technique in the diagnosis of aortic dissection. However, ultrasound artifacts in the ascending aorta are an important limitation. Methods. Transesophageal echocardiography was performed in 132 consecutive patients with clinically suspected aortic dissection. Two-dimensional and M-mode echocardiography and color Doppler were used to diagnose intimal flap and artifact images. Diagnoses were validated either anatomically or with reference techniques. Results. The sensitivity and specificity of transesophageal echocardiography in the diagnosis of ascending aortic dissection were 96.8% and 100%, respectively. Ninety-three artifacts were observed in 56 (55%) of 101 patients without ascending aortic dissection. Two-dimensional echocardiography easily identified 74 artifacts (80%). Color Doppler showed no ascending flow abnormalities in 71% of artifact images. M-mode echocardiography showed three location and mobility artifact patterns related to the posterior wall of the aorta or the right pulmonary artery. In contrast, intimal flap movement showed no relation to the aortic wall movement in 25 cases (83%). Blind analysis of transesophageal echocardiographic study tapes underlined the utility of M-mode in the differential diagnosis. Ranges of sensitivity, specificity and positive predictive value (established by including doubtful results as either positive or negative) improved from 87.1–93.5% to 93.5- to 96.8%, from 85.1–94.1% to 99–100% and from 65.9–81.8% to 96.8–100%, respectively, with the inclusion of M-mode data. Conclusions. Biplanar transesophageal echocardiography permits reliable diagnosis of ascending aortic dissection. Ultrasound artifacts are common, but assessment of the location and mobility of intraluminal images by M-mode echocardiography definitely improves diagnostic accuracy.

We describe a patient with disseminated metastases from malignant melanoma manifested as symptomatic tachycardia and bradycardia that mimicked sick sinus syndrome. Autopsy showed extensive invasion of the right atrium by nodular disease.