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Introduction and objectives: Coronary lesions with stent overlapping are associated with higher neointimal proliferation that leads to more restenosis. Furthermore, the tapering of coronary arteries is a major challenge when treating long coronary lesions. This study attempted to assess the safety and clinical level of performance of long nontapered sirolimus-eluting coronary stent systems (> 36 mm) to treat long and diffused de novo coronary lesions in real-world scenarios. Methods: This was a prospective, non-randomized, multicentre study that included 696 consecutive patients treated with the long nontapered BioMime sirolimus-eluting coronary stent system in long and diffused de novo coronary lesions. The safety endpoint was major adverse cardiovascular events defined as a composite of cardiac death, myocardial infarction, clinically driven target lesion revascularization, stent thrombosis, and major bleeding at the 12-month follow-up. Results: Of a total of 696 patients, 38.79% were diabetic. The mean age of all the patients was 64.6 ± 14 years, and 80% were males. The indication for revascularization was acute coronary syndrome in 63.1%. A total of 899 lesions were identified out of which 742 were successfully treated with long BioMime stents (37 mm, 40 mm, 44 mm, and 48 mm). The cumulative incidence of major adverse cardiovascular events was 8.1% at the 12-month follow-up including cardiac death (2.09%), myocardial infarction (1.34%), and total stent thrombosis (0.5%). Conclusions: This study confirms the safety and good performance of long nontapered BioMime coronary stents to treat de novo coronary stenosis. Therefore, it can be considered a safe and effective treatment for long and diffused de novo coronary lesions in the routine clinical practice.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a very contagious virus, has led to the coronavirus disease 2019 (COVID-19) pandemic. The clinical manifestations of this virus in humans vary widely, from asymptomatic to severe, with diverse symptomatology and even death. The substantial transmission from asymptomatic people has facilitated the widespread transmission of SARS-CoV-2, hampering public health initiatives to identify and isolate infected people during the pre-symptomatic contagious period. COVID-19 is associated with cardiac complications that can progress from mild to life-threatening. The aim of this article is to analyse the present knowledge of COVID-19 and cardiac involvement, the development of arrhythmia risk and its treatment.

Resumen La fibrilacion auricular es la arritmia cardiaca mas frecuente en la practica clinica diaria. Ademas de las alteraciones hemodinamicas que ocasiona —consecuencia de la perdida de la contraccion auricular y la frecuencia cardiaca habitualmente elevada, que pueden causar la aparicion de insuficiencia cardiaca—, el principal riesgo de la fibrilacion auricular es que la estasis circulatoria en la auricula cause una embolia arterial. Se sabe que la fibrilacion auricular se asocia a un marcado aumento del riesgo de accidentes tromboembolicos arteriales, asociados a elevadas mortalidad y morbilidad y alto riesgo de recurrencia. Esta demostrado que el tratamiento antitrombotico con anticoagulantes orales se asocia a un drastico descenso del riesgo de accidentes tromboembolicos. Sin embargo, los anticoagulantes orales incrementan significativamente el riesgo de hemorragias mayores, de las que es especialmente devastadora la hemorragia intracraneal. Por lo tanto, al iniciar el tratamiento anticoagulante de un paciente con fibrilacion auricular, resulta imprescindible valorar adecuadamente el beneficio/riesgo del tratamiento segun sus caracteristicas clinicas. Multiples estudios han mostrado una serie de variables que determinan los riesgos emboligeno y de sangrado asociados al tratamiento anticoagulante, y con base en ellas se han desarrollado diversos sistemas de estratificacion para calcular el riesgo de embolia secundaria a la fibrilacion auricular y el riesgo de hemorragia relacionado con el tratamiento antitrombotico. En la practica clinica diaria, la aplicacion de estas escalas de riesgo es de gran ayuda para elegir la mejor alternativa terapeutica para un paciente concreto.

Resumen La fibrilacion auricular es una arritmia que se caracteriza por la contraccion de las fibras auriculares de modo caotico e impredecible. Esta disincronia origina la perdida funcional de contractilidad. Por ello, se favorece la coagulacion intraauricular y, consecuentemente, se aumenta la probabilidad de sufrir un ictus por tromboembolia. Es bien conocido que esta arritmia aumenta la mortalidad y la morbilidad. Por lo tanto, su prevencion y manejo son de gran importancia tanto para los pacientes como para el sistema sanitario. Este articulo analiza los datos epidemiologicos de la fibrilacion auricular en Espana.

Impaired interatrial conduction or interatrial block is well documented but is not described as an individual electrocardiographic (ECG) pattern in most of ECG books, although the term atrial abnormalities to encompass both concepts, left atrial enlargement (LAE) and interatrial block, has been coined. In fact, LAE and interatrial block are often associated, similarly to what happens with ventricular enlargement and ventricular block. The interatrial blocks, that is, the presence of delay of conduction between the right and left atria, are the most frequent atrial blocks. These may be of first degree (P-wave duration > 120 milliseconds), third degree (longer P wave with biphasic [+/-] morphology in inferior leads), and second degree when these patterns appear transiently in the same ECG recording (atrial aberrancy). There are evidences that these electrocardiographic P-wave patterns are due to a block because they may (a) appear transiently, (b) be without associated atrial enlargement, and (c) may be reproduced experimentally. The presence of interatrial blocks may be seen in the absence of atrial enlargement but often are present in case of LAE. The most important clinical implications of interatrial block are the following: (a) the first degree interatrial blocks are very common, and their relation with atrial fibrillation and an increased risk for global and cardiovascular mortality has been demonstrated; (b) the third degree interatrial blocks are less frequent but are strong markers of LAE and paroxysmal supraventricular tachyarrhythmias. Their presence has been considered a true arrhythmological syndrome. (C) 2012 Elsevier Inc. All rights reserved.

Introduccion y objetivos La presencia de enfermedad arterial periferica se asocia con un peor pronostico cardiovascular en el paciente coronario; sin embargo, la mayor parte de ellos estan asintomaticos e infradiagnosticados. El indice tobillo-brazo (ITB) es un metodo sencillo para el diagnostico de esta entidad. El objetivo del presente estudio es determinar el papel de un ITB patologico en la identificacion de enfermedad coronaria multivaso en pacientes con sindrome coronario agudo (SCA). Metodos Se analizaron todos los pacientes con SCA del registro multicentrico PAMISCA (94 centros participantes) a los que se les habia realizado un cateterismo durante su ingreso. Se considero enfermedad coronaria multivaso la afectacion de dos o mas vasos mayores epicardicos y/o enfermedad de tronco coronario izquierdo. Se considero patologico un ITB > 1,4 o ≤ 0,9. Resultados Se incluyeron 1.031 pacientes, con una edad media de 67,7 anos. De ellos, 542 pacientes presentaron afectacion multivaso (52,6%). Respecto a los pacientes sin afectacion multivaso, este grupo presentaba una mayor edad (66,6 frente a 62,6; p Conclusiones En el paciente con SCA, un ITB patologico se asocia de manera independiente con la probabilidad de padecer enfermedad coronaria multivaso.

Observational studies report poor prognosis of patients after acute coronary syndrome (ACS) in the presence of previous peripheral arterial disease (PAD), but data on subclinical PAD are scarce. This study was designed to assess the predictive value of clinical and subclinical PAD in the follow-up of patients after an ACS. We included 1,054 patients hospitalized for an ACS who survived the acute phase. Patients were divided into 3 groups: clinical PAD (previously diagnosed PAD or intermittent claudication), subclinical PAD (defined as ankle-brachial indexor=0.9 or1.4), and no PAD. Clinical PAD was present in 150 patients (14.2%) and 298 cases of subclinical PAD were detected (28.3%). Patients with PAD (clinical and subclinical PAD) were significantly older and had a higher prevalence of hypertension and diabetes mellitus than those without PAD. During the 1-year follow-up, 59 patients died (5.6%). Previous PAD (hazard ratio 4.38, 95% confidence interval 1.96 to 9.82, p0.001) and subclinical PAD (hazard ratio 2.35, 95% confidence interval 1.05 to 5.23, p0.05) were associated with increased cardiovascular mortality. Moreover, patients with clinical PAD had higher rates of major cardiovascular events (myocardial infarction, angina, and heart failure) than patients with subclinical PAD or without PAD. In conclusion, beyond clinical PAD, measurement of ankle-brachial index after ACS provides substantial information on intermediate-term prognosis.

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year.

Debido a la elevada prevalencia de la enfermedad arterial periferica (EAP), que con frecuencia es asintomatica, y sus graves repercusiones pronosticas, se recomienda la criba diagnostica de los pacientes con alto riesgo de sufrirla: a) pacientes de edad > 70 anos; b) pacientes de 50-69 anos con historia de tabaquismo o diabetes mellitus; c) pacientes de 40-49 anos con diabetes mellitus y al menos otro factor de riesgo de arteriosclerosis; d) sintomas compatibles con claudicacion al esfuerzo o dolor isquemico en reposo; e) pulsos anormales en las extremidades inferiores; f) enfermedad arteriosclerosa en otros territorios, o g) pacientes con un score de Framingham entre el 10 y el 20%. Tanto la anamnesis como la exploracion fisica tienen un valor para el diagnostico de la enfermedad limitado porque, aunque son muy especificos, su sensibilidad es muy baja. Existen multiples pruebas diagnosticas para valorar la presencia y la severidad de la enfermedad vascular periferica, entre las que cabe destacar el indice tobillo-brazo, las determinaciones de la presion segmentarias, los estudios de ecografia-Doppler y la angiografia mediante resonancia megnetica, tomografia computarizada o de sustraccion digital. En la actualidad se considera que el indice tobillo-brazo es el metodo no invasivo que presenta mejor rendimiento diagnostico, ya que se trata de una prueba incruenta, facil de realizar a la cabecera del paciente y con una elevada sensibilidad (superior al 90%).

ObjectiveA significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes.MethodsThe PAMISCA register is a prospective, multicenter study involving patients ≥40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event.Results1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03–1.06; p

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1-9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover.

La Seccion de Cardiopatia Isquemica y Unidades de la Sociedad Espanola ha considerado necesario el desarrollo de este documento sobre la necesidad, la estructura y la organizacion de las unidades coronarias de cuidados intermedios (UCCI). Los registros de sindrome coronario agudo (SCA) realizados en Espana indican que una proporcion importante de pacientes recibe una atencion suboptima, en parte debido a una organizacion inadecuada de los recursos asistenciales o a la falta de estos. Las UCCI surgen de la necesidad de corregir estos aspectos y gestionar con eficiencia unos recursos escasos y costosos. Sus objetivos son: a) proporcionar a cada paciente el grado de cuidados que requiere; b) optimizar los recursos estructurales, tecnicos y humanos, y c) facilitar el continuo asistencial y el gradiente de cuidados. Las UCCI se deben constituir en una parte esencial del servicio de cardiologia destinada a la atencion de enfermos cardiologicos que requieren monitorizacion, cuidados y capacidad de respuesta medica superiores a los disponibles en una planta de hospitalizacion convencional de cardiologia, pero cuyo riesgo no justifica la utilizacion de los recursos tecnicos y humanos de una unidad coronaria. Este documento describe la infraestructura (equipamiento, dotacion de personal y organizacion) que se precisa para cumplir los objetivos descritos anteriormente y contiene recomendaciones sobre las indicaciones de ingreso en estas unidades intermedias. Estas incluyen a determinados pacientes con: a) SCA sin elevacion del segmento ST de riesgo intermedio o alto pero estables hemodinamicamente, y b) infarto agudo de miocardio con elevacion del segmento ST no de alto riesgo, o bien, de alto riesgo, pero estabilizado despues de una fase inicial complicada en la unidad coronaria. Tambien se contempla el ingreso de algunos pacientes despues de determinados procedimientos invasivos y de algunas formas de cardiopatias agudas no coronarias.

La enfermedad cardiovascular es la principal causa de morbilidad y mortalidad en los pacientes con diabetes mellitus. Se ha demostrado que los pacientes diabeticos presentan una mayor incidencia de enfermedad coronaria multivaso, con mayor frecuencia de lesiones complejas, pobres lechos distales y una progresion de la enfermedad mas rapida que la poblacion general no diabetica. La revascularizacion coronaria percutanea (ICP) ha demostrado su utilidad en los pacientes diabeticos. Sin embargo, aunque los resultados angiograficos iniciales son buenos, hay una mayor incidencia de reestenosis, un riesgo mas elevado de complicaciones y una menor supervivencia a largo plazo. Los stents farmacoactivos han reducido notablemente el riesgo de reestenosis y complicaciones tardias. En espera de los resultados de los estudios actualmente en marcha, en los pacientes diabeticos con enfermedad multivaso, la cirugia de derivacion aortocoronaria sigue siendo el tratamiento de primera eleccion. Sin embargo, hay que destacar que, desde un punto de vista practico, a la hora de indicar cirugia de derivacion aortocoronaria o ICP deberemos basarnos en las caracteristicas particulares del paciente (p. ej., comorbilidad asociada) y en la experiencia del propio centro, ya que hay notables diferencias en funcion de la experiencia del equipo quirurgico y de cardiologia intervencionista. Por ultimo, es muy importante destacar que, en los pacientes diabeticos en los que se realiza revascularizacion coronaria, con independencia del metodo utilizado, es de trascendental importancia establecer un tratamiento medico energico que incluya modificaciones en el estilo de vida (tabaquismo, sindrome metabolico, etc.), ntiagregacion plaquetaria, tratamiento con estatinas en las dosis adecuadas (objetivo terapeutico con un valor de colesterol unido a lipoproteinas de baja densidad

Background Vasospastic angina usually responds well to medical treatment. Hypothesis The present study describes our experience in patients who received a coronary stent because of recurrent variant angina refractory to medical treatment and evaluates stent implantation as an alternative treatment. Materials and methods Between March 1998 and February 2005, recurrent variant angina was diagnosed in 22 patients admitted to our coronary care unit. Of these, five patients (22.7%), were refractory to pharmacologic treatment. Coronary angiography and coronary stents were indicated. Clinical follow-up was 29 ± 6 months. Results Stenting was performed during diagnostic coronary angiography in two patients. In the other three patients, the stent was implanted 24–48 h later. We observed coronary spasm recurrences proximal or distal to the stent in four patients—two during the stent implantation procedure and the other two in the coronary care unit within 48 h post angioplasty. Three patients where treated with additional stenting and the fourth patient improved with pharmacologic treatment. During follow-up three patients remained asymptomatic. The fourth patient had diffuse in-stent restenosis in the third month, and the fifth patient showed a de novo lesion in the treated segment 2 years later. Conclusions Stent implantation in patients with recurrent variant angina refractory to medical treatment may be an alternative treatment in carefully selected, clinically unstable patients. Spasm recurrences may occur in other segments of the treated artery, probably due to the diffuse nature of the disease. Immediate and continued surveillance is recommended because of the risk of adverse clinical events. Copyright © 2006 Wiley Periodicals, Inc. Wiley Periodicals, Inc.

New biological markers of myocardial injury have improved the management of patients with acute coronary syndromes. Among these markers, the most relevant are the cardiac troponins (troponin I and troponin T) because of their cardiospecificity, and myoglobin because of its combination of diagnostic sensitivity and usefulness for an early diagnosis. The serial analysis and combined use of both markers fulfill all diagnostic and prognostic requirements, and are helpful in indicating therapeutic strategies for acute coronary syndromes. However, these markers also have limitations, and their concentrations should always be interpreted in the light of the patient's clinical status.

Introduction -There is scant information about the effects of thrombolysis in the evolution of right bundle-branch block (RBBB) in the setting of acute anterior myocardial infarction.The aim of this study has been to analyse these effects and its impact on prognosis. Methods -We studied 54 patients who presented a RBBB related to an acute anterior myocardial infarction. We defined two groups: those who received thrombolytic treatment and those who did not.We analysed the evolution of RBBB (transience, moment of onset, moment of disappearance) and its relationship with in-hospital mortality. Twenty-one patients (39%) received thrombolytic treatment (group T) and 33 patients (61%) (group NT) did not. Results - The incidence of late appearance (> 6 h) of RBBB was less frequent in group T compared with group NT (10% vs. 33%, p = 0.04). The incidence of transient block was similar in the two groups (57% vs. 45%, p ns). However, early disappearance of RBBB (in < 6 hours) was more common in group T than in group NT (33% vs. 9%, p = 0.04). Mortality was higher in patients with RBBB present at 24 h after admission) than in those with RBBB resolved in less than 24 hours (in group NT, 55% vs. 8%, p = 0.02 and in group T 50% vs. 0%, p = 0.02, respectively). Conclusions -Thrombolysis seems to influence the moment of onset and disappearance of RBBB by promoting its early disappearance and avoiding its late appearance. Disappearance of RBBB is associated with a better prognosis.

This study was designed to determine the value of automatic corrected QT-interval measurement in Holter tapes in patients after myocardial infarction as a marker of life-threatening ventricular arrhythmias. We compared the corrected QT interval, automatically measured in 24-hour Holter recordings, in two groups of patients after myocardial infarction: group I was composed of 14 patients admitted consecutively to our hospital for documented sustained ventricular tachycardia or out-of-hospital cardiac arrest. Group II consisted of 28 patients with previous myocardial infarction with characteristics similar to those of group I, but without malignant ventricular arrhythmias in the follow-up. The global mean 24-hour corrected QT interval was longer in group I (425 +/- 20 msec) than in those patients after myocardial infarction without arrhythmias (group II) (405 +/- 17 msec; p0.01). Furthermore, a significant proportion of patients of group I (seven of 14) exhibited more peaks of corrected QT longer than 500 msec compared with patients of group II (two of 28; p0.005). A circadian rhythm of corrected QT peaks was observed in group I, having a significantly higher incidence from 11 PM to 11 AM (p0.05). We conclude that automatic corrected QT-interval measurement on Holter electrocardiogram is now available and feasible. Our results suggest that this is a marker for risk assessment of life-threatening ventricular arrhythmias. Large-scale trials are needed to confirm these results and to determine the predictive value of this technique for risk stratification.

The following images belong to a 86-year-old woman with severe aortic stenosis in whom a transcatheter aortic valve replacement (TAVR) was performed ([Figure 1][1], [Online Videos 1][2], [2][3], and [3][4]). Pre-procedural angiography revealed an anomalous origin of the left circumflex coronary

Left ventricular hypertrophy (LVH) is the adaptative mechanism of the heart to systolic overload of the left ventricle. Nevertheless, LVH plays a role in some complications, such as cardiac arrhythmias. Patients with LVH are more likely to develop ventricular arrhythmias than the hypertensive population without LVH. Further, the relation between left ventricular mass and ventricular arrhythmias is graded and continuous. The arrhythmias described in hypertensive patients with LVH are usually isolated premature ventricular contractions. The presence of electrocardiographic criteria of LVH represents a risk of higher incidence of sudden death, especially in men. The risk is even greater in the presence of ventricular arrhythmias. The presence of late potentials has been recently characterized as more related to ventricular arrhythmias than LVH. Antihypertensive drugs that can reduce LVH also have a beneficial effect on cardiovascular morbility and mortality.

The relationship between silent myocardial ischemia and sudden death depends on the severity and duration of the ischemia. Severe, transmural and persistent ischemia, as occurs in myocardial infarction, can trigger sudden death. When the ischemia is severe and transmural but not long-standing (e.g., Prinzmetal angina), ventricular arrhythmias appear frequently, but they are rarely malignant. In cases of subendocardial ischemia, there is no definitive proof of this relationship.

Peripheral arterial disease (PAD) is associated with an increased risk of cardiovascular morbidity and mortality. Nevertheless, many patients are asymptomatic, and this condition frequently remains underdiagnosed. An ankle-brachial index (ABI) of less than 0.9 is a noninvasive and simple marker in the diagnosis of PAD and is also predictive of target organ damage in hypertension. The prognostic value of such measurements in hypertensive patients with acute coronary syndrome (ACS) is unknown.The Prevalence of Peripheral Arterial Disease in Patients with Acute Coronary Syndrome registry is a multicentre, observational and prospective study that aims to describe the prevalence of and prognosis for PAD, diagnosed by ABI in hypertensive patients with ACS.One thousand one hundred and one hypertensive patients with ACS and at least 40 years of age were prospectively studied. Mean age of the population was 67.4 (11.4) years, and 67.7% were men. The prevalence of ABI less than 0.9 was 42.6% (469 patients). This subgroup was significantly older, had a higher prevalence of diabetes, previous coronary heart disease or stroke, left ventricular hypertrophy and more severe coronary lesions. Hospital mortality was higher in hypertensive patients with ABI less than 0.9 (2.3 vs. 0.2%; P0.01). An ABI less than 0.9 was associated with an increased risk of heart failure after ACS (odds ratio, 1.4; P=0.04), higher hospital mortality (odds ratio, 13.0; P=0.03) and the composite endpoint of mortality, heart failure and angina (odds ratio, 1.4; P=0.03).Asymptomatic PAD is highly prevalent in hypertensive patients with ACS. An ABI less than 0.9 identifies a subset of patients with more extensive target organ damage and higher risk of hospital cardiovascular complications after an ACS.

The best therapeutic approach to the therapy of potentially malignant ventricular arrhythmias is still unknown, particularly in view of the increased mortality with flecainide and encainide shown in the CAST study. Various ongoing studies, particularly with amiodarone, will show whether better results can be obtained with other agents. Flecainide and encainide do, however, have a restricted place when other agents cannot be used. Low-dose amiodarone with low-dose flecainide may be worth trying.

El diagnostico clinico de los tumores cardiacos es, a menudo, dificil. Presentamos el caso de un paciente de 17 anos en el que se diagnostico un tumor del ventriculo izquierdo a partir del estudio de un sincope. El estudio anatomopatologico confirmo el diagnostico de mixoma. Clinical diagnosis of cardiac tumours is often difficult. We present the case of a 17 year-old boy inwhom a left ventricular tumour was discovered duringon diagnostic work-up for a syncope. The tumourwas removed and histology confirmed thediagnosis of myxoma.

Transient left ventricular apical ballooning (TAB) is a condition that mimics acute coronary syndrome typically without coronary angiographic stenosis. Patients present with typical chest pain, ECG changes suggesting ischemia, and a slight elevation of myocardial injury markers such as creatine kinase and troponines. Ballooning during ventricular systole of the cardiac apex is a characteristic feature of this entity. It is transient and it usually resolves after a few days together with normalization of ECG changes. Initially, apical dyskinesis can be diagnosed by any cardiac imaging technique that allows myocardial wall motion assessment. Recent advances in cardiovascular magnetic resonance imaging (CMR) have made this technique to become the gold-standard method to assess myocardial infarction. CMR provides an excellent and reproducible assessment of segmental wall motion abnormalities and, more importantly, it allows an accurate depiction of myocardial necrotic area by means of delayed contrast-enhancement method. Therefore, it may be particularly useful in the assessment of TAB by demonstrating segmental dysfunction in the absence of myocardial irreversible damage. We report three cases of TAB in which contrast- enhanced CMR emerged as an excellent diagnostic tool.

Primary ventricular fibrillation (VF) is an early complication of acute myocardial infarction (AMI), which was recently associated with high in-hospital mortality. 1 The usefulness of preventive antiarrhythmic drugs in patients with symptoms of acute coronary ischemia has been addressed in different studies, 2,3 but less attention has been given to the identification of AMI patients with a high risk for VF. Admission data for predicting VF in AMI have been assessed by Flugelman et al 4–5 and Molstad 6 using multiple logistic regression formulas. In the first study, however, ventricular tachycardia was included as the end point for analysis, and no distinction was made between primary and secondary VF, whereas in the second study, only variables of doubtful value in clinical practice were considered. We investigated the usefulness of routine clinical, electrocardiographic and laboratory parameters for predicting the development of VF in patients with AMI in Killip's functional class I and II.

Background Chest pain is a frequent symptom in the emergency department and often presents a diagnostic challenge. Because coronary thrombosis is a hallmark of acute ischemic syndromes, the substrates of the coagulation and fibrinolysis cascades may be markers of coronary ischemia. The objective of this study was to determine the diagnostic value of several hemostatic markers in patients presenting to the emergency department (ED) with chest pain syndromes. Methods Two hundred fifty-seven consecutive patients with acute chest pain were studied in this prospective study conducted in an urban ED. D- Dimer levels were measured at admission to the ED in all patients. We also measured thrombin-antithrombin complexes, prothrombin fragment 1+2, activated factor VII, and fibrinogen. We used regression analysis to estimate the likelihood of myocardial infarction and the diagnostic value of D -dimer. Results D -Dimer and fibrinogen levels were significantly higher in patients with acute ischemic events (myocardial infarction and unstable angina) than in nonischemic patients ( P P =.02, respectively). The other hemostatic markers were not significantly elevated in patients with ischemic events. D -Dimer level >500 μg/L had an independent diagnostic value for myocardial infarction and increased the diagnostic sensitivity of the electrocardiogram and history from 73% to 92%. Conclusion D -Dimer, an expression of ongoing thrombus formation and lysis, is a marker of substantial incremental value for the early diagnosis of acute coronary syndromes presenting with chest pain. It adds independent information to the traditional assessment for myocardial infarction. D -Dimer can be incorporated into clinical decision models in the ED. (Am Heart J 2000;140:379-84.)

Ventricular fibrillation is the final event in the majority of cases of sudden death. The ECG and clinical precursors of ventricular fibrillation are discussed in this article. Ventricular fibrillation usually appears as a consequence of a chain of events that leads to the appearance of this lethal arrhythmia. We review the markers of the vulnerable myocardium prone to ventricular fibrillation, the triggers and modulators that act on this vulnerable myocardium, and the event(s) that constitute the final step preceding this arrhythmia. The final step may be as unique as a sudden waterfall or present as a cascade of successive phenomena.

The problem of risk stratification after myocardial infarction is reviewed. There are three major complications: new ischemic events, congestive heart failure, and malignant arrhythmias and sudden death, related to the presence of residual ischemia, left ventricular dysfunction, and electrical instability. The bidirectional interactions among these three factors is analyzed. The risk is in the middle of a triangle, the three angles of which are the above-mentioned factors. All the “satellite” factors that appear from all three angles are presented. Furthermore, the most important parameters and techniques employed to detect risk, multifactorial approach of risk stratification, and changes of risk stratification in the thrombolytic era are briefly reviewed.

Thrombosis of the superior vena cava and other central venous trunks is a complication that is associated with the implantation of pacemakers and central venous catheters that are used for chemotherapy or total parenteral nutrition. This complication occurs somewhat more frequently than expected because many of these thrombi are clinically unnoticed and are finally diagnosed at autopsy. Phlebographic studies have shown that thrombosis is related to central venous catheters in up to 52 “;# of patients who have not received anticoagulation therapy.l This complication may be treated satisfactorily with fibrinolytic agents such as streptokinase (SK), urokinase (UK), and tissue plasminogen activator. We report a patient with ischemic heart disease who had a catheter-related superior vena cava thrombosis with protrusion of the thrombus t,owards the right atrium, successfully treated with SK. Diagnosis and follow-up examinations were carried out by transthoracic and biplane transesophageal echocardiography. The patient was a 59-year-old man who had antecedents

There is conclusive experimental and clinical evidence that severe, transmural and persistent acute ischemia (silent or symptomatic), the maximum exponent of which is myocardial infarction, can trigger malignant ventricular arrhythmias and sudden cardiac death. 1 Furthermore, a relation between severe acute transmural but transient ischemia appearing during Prinzmetal's angina 2 or during percutaneous transluminal angioplasty 3 and ventricular arrhythmias is well known, although such arrhythmias are rarely malignant. However, the relation between ventricular arrhythmias and subendocardial ischemia (silent or symptomatic) has only been partially studied, and results are contradictory. 4–7

We describe the criteria for differential diagnosis between 3:2 sinoatrial block from atrial bigeminy due to an ectopic focus in the sinus or parasinus zone. In the 3:2 sinoatrial block the RR interval of the basic rhythm is similar to the short R-R interval of the paired rhythm. In atrial bigeminy, the R-R interval of the basic rhythm is similar to the long R-R interval of the paired rhythm. (Chest 1991; 99:735–36)

Recurrence is one of the major complications of pericarditis. Treatment of recurrence is often difficult, and immunosuppressive drugs or surgery may be necessary. We conducted an open-label prospective study of nine patients (seven men and two women; age, 18-64 years; mean age, 41.7 +/- 13.7 years). Patients were treated with colchicine (1 mg/day) to prevent recurrences. All patients had suffered at least three relapses despite treatment with acetylsalicylic acid, indomethacin, prednisone, or a combination. Pericarditis was classified as idiopathic in five patients, postpericardiotomy in two, post-myocardial infarction in one, and associated with disseminated lupus erythematosus in one. For statistical analysis, we conducted a paired comparison design (Student's t test). All patients treated with colchicine responded favorably to therapy. Prednisone was discontinued in all patients after 2-6 weeks (mean, 26.33 +/- 10.9 days), and colchicine alone was continued. After a mean follow-up of 24.3 months (minimum, 10 months; maximum, 54 months), no recurrences were observed in any patient; there was a significant difference between the symptom-free periods before and after treatment with colchicine (p less than 0.002). Our study suggests that colchicine may be useful in avoiding recurrence of pericarditis, although these results need to be confirmed in a larger, double-blind study.

On the basis of our reported experience with colchicine for recurrent pericarditis, we administered colchicine to two patients with large pericardial effusions complicating idiopathic pericarditis. The first was a 26‐year‐old male who showed clinical deterioration following emergency pericardiocentesis and aspirin (3 g/day) for 10 days; the second was a 2‐year‐old girl who was unsuccessfully treated with aspirin (100 mg/kg/day) for 2 weeks, followed by corti‐costeroids for 7 months. Administration of colchicine (1 mg/ day) instead of aspirin in the first case, and with a rapid tapering‐off of the corticosteroids in the second case, led to complete regression of the pericardial effusion on echocardiography within 1 week and 1 month, respectively. Colchicine was discontinued after 1 month in the first patient and was continued for 6 months in the child. Neither has had a recurrence at 24 and 6 months of follow‐up, respectively. No side effects of colchicine were observed. We conclude that colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti‐inflammatory drugs and/or corticosteroids fails.

Masked bifascicular block (MBB) (absent or minimal S in I and VL, high R in Vi and AQRS approximately -60 degrees) is a rare condition. We have found 16 such cases in the last 12 years, thirteen male and three female, mean age 70 +/- 9 years. The conventional electrocardiogram was tabulated and the clinical features and evolution of the patients were followed over 39.1 +/- 32 months. Ten patients required pacemakers, nine because of complete atrioventricular (AV) block or increase in the previous AV block. Seven patients died (follow-up 27.3 +/- 32 months), five from heart failure. This study shows: (1) MBB is a subgroup of patients with a high risk of advanced atrioventricular block; (2) a pacemaker implant does not significantly reduce the high mortality in this group because of the severity of the underlying disease; (3) these results should be evaluated in a larger series of patients in order to confirm our provisional results.