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INTRODUCTION AND OBJECTIVES To analyze the percutaneous revascularization strategy for severe lesions in the secondary branches (SB) (diameter ≥ 2mm) of major epicardial arteries compared with conservative treatment. METHODS This study analyzed patients with severe SB lesions who underwent percutaneous revascularization treatment compared with patients who received pharmacological treatment. The study examined the percentage of branch-related events (cardiovascular death, myocardial infarction attributable to SB, or the need for revascularization of the SB). RESULTS We analyzed 679 SB lesions (662 patients). After a mean follow-up of 22.2±10.5 months, there were no significant differences between the 2 treatment groups regarding the percentage of death from cardiovascular causes (1.7% vs 0.4%; P=.14), nonfatal acute myocardial infarction (AMI) (1.7% vs 1.7%; P=.96), the need for SB revascularization (4.1% vs 5.4%; P=.45) or in the total percentage of events (5.1% vs 6.3%; P=.54). The variables showing an association with event occurrence on multivariate analysis were diabetes (SHR, 2.87; 95%CI, 1.37-5.47; P=.004), prior AMI (SHR, 3.54; 95%CI, 1.77-7.30; P

Introduction and objectives Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by progressive fibrofatty replacement of predominantly right ventricular myocardium . This cardiomyopathy is a frequent cause of sudden cardiac death in young people and athletes. The aim of our study was to determine the incidence of pathological or likely pathological desmosomal mutations in patients with high-risk definite ARVC. Methods This was an observational, retrospective cohort study , which included 36 patients diagnosed with high-risk ARVC in our hospital between January 1998 and January 2015. Genetic analysis was performed using next-generation sequencing . Results Most patients were male (28 patients, 78%) with a mean age at diagnosis of 45 ± 18 years. A pathogenic or probably pathogenic desmosomal mutation was detected in 26 of the 35 index cases (74%): 5 nonsense, 14 frameshift, 1 splice, and 6 missense. Novel mutations were found in 15 patients (71%). The presence or absence of desmosomal mutations causing the disease and the type of mutation were not associated with specific electrocardiographic, clinical, arrhythmic, anatomic, or prognostic characteristics. Conclusions The incidence of pathological or likely pathological desmosomal mutations in ARVC is very high, with most mutations causing truncation. The presence of desmosomal mutations was not associated with prognosis.

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INTRODUCTION Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited cardiomyopathy characterized by ventricular arrhythmias and heart failure. The variable phenotype suggesting that determined environmental factors may have an influence. The aim of our study was to discover the impact of the dynamic physical activity on patients with high-risk definite ARVC/D. METHODS AND RESULTS Collection of data on physical activity at the time of diagnosis was conducted at an in-person clinical interview. The intensity of the activity was classified in accordance with the mean frequency of weekly physical exercise sessions in the 10 years before diagnosis and into the following three groups of dynamic activity: high/competitive (>3 h/wk), moderate (1 to 3 h) and minimal/inactive (

Aim: To evaluate the possible relationship between high levels of CA-125 and long-term prognosis in chronic heart failure patients after they undergo a cardiac transplantation (CT). Materials & methods: We retrospectively studied all patients who underwent a CT and had a previous determination of CA-125. Congestive patients and those whose survival was 35 U/ml). After CT, survival was significantly inferior in this group (96.3 vs 81%, 84.9 vs 64%, 70.7 vs 32.9% at 2, 5 and 8 years, p = 0.014). CA-125 >35 U/ml was the only factor independently associated to long-term mortality (OR: 3.94; 95% CI: 1.2–12.82; p = 0.023). Conclusion: Noncongestive patients with high levels of CA-125 had inferior long-term survival after CT.

The use of noninsulin antihyperglycaemic drugs in the hospital setting has not yet been fully described. This observational study compared the efficacy and safety of the standard basal-bolus insulin regimen versus a dipeptidyl peptidase-4 inhibitor (linagliptin) plus basal insulin in medicine department inpatients in real-world clinical practice. We retrospectively enrolled non-critically ill patients with type 2 diabetes with mild to moderate hyperglycaemia and no injectable treatments at home who were treated with a hospital antihyperglycaemic regimen (basal-bolus insulin, or linagliptin-basal insulin) between January 2016 and December 2017. Propensity score was used to match patients in both treatment groups and a comparative analysis was conducted to test the significance of differences between groups. After matched-pair analysis, 227 patients were included per group. No differences were shown between basal-bolus versus linagliptin-basal regimens for the mean daily blood glucose concentration after admission (standardized difference = 0.011), number of blood glucose readings between 100&ndash, 140 mg/dL (standardized difference = 0.017) and &gt, 200 mg/dL (standardized difference = 0.021), or treatment failures (standardized difference = 0.011). Patients on basal-bolus insulin received higher total insulin doses and a higher daily number of injections (standardized differences = 0.298 and 0.301, respectively). Basal and supplemental rapid-acting insulin doses were similar (standardized differences = 0.003 and 0.012, respectively). There were no differences in hospital stay length (standardized difference = 0.003), hypoglycaemic events (standardized difference = 0.018), or hospital complications (standardized difference = 0.010) between groups. This study shows that in real-world clinical practice, the linagliptin-basal insulin regimen was as effective and safe as the standard basal-bolus regimen in non-critical patients with type 2 diabetes with mild to moderate hyperglycaemia treated at home without injectable therapies.

Background Marfan syndrome (MFS) is a disorder of autosomal dominant inheritance, in which aortic root dilation is the main cause of morbidity and mortality. Fibrillin-1 (FBN-1) gene mutations are found in more than 90% of MFS cases. The aim of our study was to summarise variants in FBN-1 and establish the genotype-phenotype correlation, with particular interest in the onset of aortic events, in a broad population of patients with an initial clinical suspicion of MFS. Material and methods This single centre prospective cohort study included all patients presenting variants in the FBN-1 gene who visited a Hereditary Aortopathy clinic between September 2010 and October 2016. Results The study included 90 patients with FBN-1 variants corresponding to 58 non-interrelated families. Of the 57 FBN-1 variants found, 25 (43.9%) had previously been described, 23 of which had been identified as associated with MFS, while the the remainder are described for the first time. For 84 patients (93.3%), it was possible to give a definite diagnosis of Marfan syndrome in accordance with Ghent criteria. 44 of them had missense mutations, 6 of whom had suffered an aortic event (with either prophylactic surgery for aneurysm or dissection), whereas 20 of the 35 patients with truncating mutations had suffered an event (13.6% vs. 57.1%, p

BackgroundAcute kidney injury (AKI) after cardiac surgery is associated with increased mortality, but few data exist on the occurrence and clinical impact of AKI associated with transcatheter aortic valve implantation (TAVI). The objective of this study was to determine the incidence and prognosis of AKI after percutaneous implantation of the CoreValve® (Medtronic, Minneapolis, MN, USA) prosthesis.MethodsA total of 357 patients with severe aortic stenosis and 9 patients with pure native aortic regurgitation were treated with the CoreValve prosthesis. AKI was defined according to Valve Academic Research Consortium criteria as the absolute increase in serum creatinine ≥0.3mg/dl at 72h post percutaneous procedure.ResultsAKI was identified in 58 patients (15.8%), none of whom required renal replacement therapy. In patients with AKI, the mortality at 30 days was 13.5% compared with 1.6% of patients without AKI, [odds ratio (OR)=12.2 (95% CI 3.53–41.9); p

Aims Hypertrophic cardiomyopathy is one of the main causes of sudden death in young people. Recent clinical practice guidelines include a risk prediction model for sudden death (HCM Risk-SCD), which facilitates the decision of whether to implant a defibrillator. The aim of our study was to ascertain the percentage of events in our series of primary prevention implantable cardioverter-defibrillator recipients with hypertrophic cardiomyopathy and whether HCM Risk-SCD predicts the onset of arrhythmic events. Methods and results This was an observational, retrospective cohort study, which included 48 primary prevention defibrillator recipient patients with HCM. We compiled their demographic and clinical characteristics, estimated 5-year risk using HCM Risk-SCD, and collected the documentation on arrhythmias during follow-up. The majority was male (66.7%) and mean age at implantation was 44.44 ± 14.46 years. Non-sustained ventricular tachycardia was the most prevalent risk factor (66.67%), followed by a family history of sudden death (47.92%). Mean HCM Risk-SCD was 6.15 ± 5.01%. HCM Risk-SCD was the only factor independently associated with the onset of ventricular tachyarrhythmia, above any other classic risk factor or association [odds ratio = 1.46 (95% confidence interval 1.051–2.013); P = 0.02]. None of the 11 patients estimated as low risk using HCM Risk-SCD suffered any appropriate events ( P < 0.05). Conclusions During an average follow-up of 4 years, 16.67% presented appropriate events (4.16%/year). HCM Risk-SCD predicted the onset of events more suitably than classic risk factors.

Aims We aimed to determine whether treatment with sildenafil improves outcomes of patients with persistent pulmonary hypertension (PH) after correction of valvular heart disease (VHD). Methods and results The sildenafil for improving outcomes after valvular correction (SIOVAC) study was a multricentric, randomized, parallel, and placebo-controlled trial that enrolled stable adults with mean pulmonary artery pressure ≥ 30 mmHg who had undergone a successful valve replacement or repair procedure at least 1 year before inclusion. We assigned 200 patients to receive sildenafil (40 mg three times daily, n = 104) or placebo (n = 96) for 6 months. The primary endpoint was the composite clinical score combining death, hospital admission for heart failure (HF), change in functional class, and patient global self-assessment. Only 27 patients receiving sildenafil improved their composite clinical score, as compared with 44 patients receiving placebo; in contrast 33 patients in the sildenafil group worsened their composite score, as compared with 14 in the placebo group [odds ratio 0.39; 95% confidence interval (CI) 0.22–0.67; P

This study analyzed the potential associations of 7 myocardial fibrosis-related microRNAs with the quality of the collagen network (e.g., the degree of collagen fibril cross-linking or CCL) and the enzyme lysyl oxidase (LOX) responsible for CCL in 28 patients with severe aortic stenosis (AS) of whom 46% had a diagnosis of chronic heart failure (HF). MicroRNA expression was analyzed in myocardial and blood samples. From the studied microRNAs only miR-19b presented a direct correlation (p in vitro studies miR-19b inhibition increased (p

IntroductionCardiac adipose tissue is a source of progenitor cells with regenerative capacity. Studies in rodents demonstrated that the intramyocardial delivery of cells derived from this tissue improves cardiac function after myocardial infarction (MI). We developed a new reparative approach for damaged myocardium that integrates the regenerative properties of cardiac adipose tissue with tissue engineering. In the adipose graft transposition procedure (AGTP), we dissect a vascularised flap of autologous pericardial adipose tissue and position it over the myocardial scarred area. Following encouraging results in acute and chronic MI porcine models, we performed the clinical trial (NCT01473433, AdiFLAP trial) to evaluate safety in patients with chronic MI undergoing coronary artery bypass graft. The good safety profile and trends in efficacy warranted a larger trial.Study designThe AGTP II trial (NCT02798276) is an investigator initiated, prospective, randomised, controlled, multicentre study to assess the efficacy of the AGTP in 108 patients with non-revascularisable MI. Patients will be assigned to standard clinical practice or the AGTP. The primary endpoint is change in necrotic mass ratio by gadolinium enhancement at 91 and 365 days. Secondary endpoints include improvement in regional contractibility by MRI at 91 and 365 days; changes in functional MRI parameters (left ventricular ejection fraction, left and right ventricular geometric remodelling) at 91 and 365 days; levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) at 7, 91 and 365 days; appearance of arrhythmias from 24 hour Holter monitoring at 24 hours, and at 91 and 365 days; all cause death or re-hospitalisation at 365 days; and cardiovascular death or re-hospitalisation at 365 days.Ethics and disseminationThe institutional review board approved the trial which will comply with the Declaration of Helsinki. All patients will provide informed consent. It may offer a novel, effective and technically simple technique for patients with no other therapeutic options. The results will be submitted to indexed medical journals and national and international meetings.Trial registration numberClinicalTrials.gov:NCT02798276, pre-results.

[Abstract] Epicardial adipose tissue has been proposed to participate in the pathogenesis of heart failure. The aim of our study was to assess the expression of thermogenic genes (Uncoupling protein 1 (UCP1), peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α), and PR-domain-missing 16 (PRDM16) in epicardial adipose tissue in patients with heart failure, stablishing the difference according to left ventricular ejection fraction (reduced or preserved). Among the 75 patients in our study, 42.7% (n=32) had reduced left ventricular ejection fraction. UCP1, PGC1α and PRDM16 mRNA in EAT were significantly lower in patients with reduced left ventricular ejection fraction. Multiple regression analysis showed that age, male gender, body max index, presence of obesity, type-2-diabetes mellitus, hypertension and coronary artery disease and left ventricular ejection fraction were associated with the expression levels of UCP1, PGC1α and PRDM16 mRNA. Thermogenic genes expressions in epicardial adipose tissue (UCP1: OR 0.617, 95%CI 0.103-0.989, p=0.042; PGC1α: OR 0.416, 95%CI 0.171-0.912, p=0.031; PRDM16: OR 0.643, 95%CI 0.116-0.997, p=0.044) were showed as protective factors against the presence of heart failure with reduced left ventricular ejection fraction, and age (OR 1.643, 95%CI 1.001-3.143, p=0.026), presence of coronary artery disease (OR 6.743, 95%CI 1.932-15.301, p

Introduction and Objectives Mortality from left-sided infective endocarditis remains very high. The aim of this study was to assess the impact of a multidisciplinary alert strategy (AMULTEI), based on clinical, echocardiographic and microbiological findings, implemented in 2008 in a tertiary hospital. Methods Cohort study comparing our historical data series (1996-2007) with the number of patients diagnosed with left-sided endocarditis from 2008-2011 (AMULTEI). Results The AMULTEI cohort included 72 patients who were compared with 155 patients in the historical cohort. AMULTEI patients were significantly older (62.5 vs 57.9 years in the historical cohort; P=.047) and had higher comorbidity (Charlson index, 3.33 vs 2.58 in the historical cohort; P=.023). There was also a trend toward more enterococcal etiology in the AMULTEI group (20.8% vs 11.6% in the historical cohort; P=.067). In the AMULTEI group, early surgery was more frequently performed (48.6% vs 23.2%; P

Objective Determine whether remote ischaemic postconditioning (RIP) protects against percutaneous coronary intervention-related myocardial infarction (PCI-MI). Design Single-centre, randomised, blinded to the researchers, clinical trial. ClinicalTrials.gov (NCT 01113008). Setting Tertiary hospital centre. Patients 232 patients underwent elective PCI for stable or unstable angina. Interventions Patients were randomised to RIP (induction of three 5-min cycles of ischaemia in the arm after the PCI) versus placebo. Main outcome measures The primary outcome measure was the peak 24-h troponin I level. PCI-MI was defined by an elevation of troponin values >3 or >5 of the 99th percentile according to the classical or the new definition. The secondary outcome measure was hospital admission, PCI for stable angina or acute coronary syndrome and mortality after 1 year of follow-up. The use of RIP in diabetic patients was specifically studied. Results The mean age was 64.6 years, and 42% were diabetic. The peak troponin in the RIP patients was 0.476 vs 0.478 ng/mL (p=0.99). PCI-MI occurred in 36% of the RIP patients versus 30.8% in the placebo group (p=0.378). Diabetic RIP patients had more PCI-MI (new definition): OR 2.7; 95% CI 1.10 to 6.92; p=0.027. The secondary outcome measure was seen in 11.7% of the RIP patients versus 10.8% in the placebo group (p=0.907). Conclusions RIP did not reduce the damage associated with elective PCI or cardiovascular events during the follow-up. The diabetic population who underwent RIP had more PCI-MI.

Aims Our aim was to describe the electrocardiographic findings of a large sample of Spanish workers from several different employment sectors. Methods and results Between May 2008 and November 2010, 13 495 consecutive 12-lead resting electrocardiograms (ECGs) were obtained during health examinations of working adults aged 16–74 years in 5 cities in different regions of Spain. Of those, 13 179 ECGs suitable for interpretation were included in this study. All tracings were classified by the same cardiologist, according to the Minnesota Code criteria. The mean age of the sample was 40 years, and 73.4% were male. Frequencies of complete right bundle branch block, complete left bundle branch block, and left ventricular hypertrophy were 1.1, 0.2, and 3.6%, respectively. Major Q wave abnormalities were observed in 1.7% of the subjects, T wave abnormalities in 0.7%, early repolarization in 2.4%, and other ST segment abnormalities in 0.2%. Atrial fibrillation was present in 0.08% of the workers and atrial flutter in 0.02%. Frequencies of the Wolff–Parkinson–White pattern, Brugada pattern, long QT pattern, and short QT pattern were 0.2, 0.068, 0.038, and 0.015%, respectively. Conclusion This study shows the electrocardiographic findings of a large sample of Spanish workers from several different employment sectors. The frequencies of many ECG patterns related to an adverse prognosis (left ventricular hypertrophy, complete left bundle branch block, T wave abnormalities, ST segment abnormalities, and atrial fibrillation) were low.

The purpose of this study was to evaluate the need for a permanent pacemaker after transcatheter aortic valve implantation with the CoreValve prosthesis (Medtronic, Inc., Minneapolis, Minnesota) using the new Accutrak delivery system (Medtronic, Inc.).The need for a permanent pacemaker is a recognized complication after transcatheter aortic valve implantation with the CoreValve prosthesis.Between April 23, 2008 and May 31, 2011, 195 consecutive patients with symptomatic aortic valve stenosis underwent transcatheter aortic valve implantation using the self-expanding CoreValve prosthesis. In 124 patients, the traditional delivery system was used, and in 71 patients, the Accutrak delivery system was used.There were no significant differences in baseline electrocardiographic characteristics between the traditional system and the Accutrak patients: PR interval: 153 ± 46 mm versus 165 ± 30 mm, p = 0.12; left bundle branch block: 22 (20.2%) versus 8 (12.7%), p = 0.21; right bundle branch block: 21 (19.3%) versus 8 (12.7%), p = 0.26. The depth of the prosthesis in the left ventricular outflow tract was greater with the traditional system than with the Accutrak system (9.6 ± 3.2 mm vs. 6.4 ± 3 mm, p0.001) and the need for a permanent pacemaker was higher with traditional system than with Accutrak (35.1% vs. 14.3%, p = 0.003). The predictors of the need for a pacemaker were the depth of the prosthesis in the left ventricular outflow tract (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 1.08 to 1.34, p0.001), pre-existing right bundle branch block (HR: 3.5, 95% CI: 1.68 to 7.29, p = 0.001), and use of the traditional system (HR: 27, 95% CI: 2.81 to 257, p = 0.004).The new Accutrak delivery system was associated with less deep prosthesis implantation in the left ventricular outflow tract, which could be related to the lower rate of permanent pacemaker requirement.

Eur J Clin Invest 2011; 41 (11): 1220–1226 Abstract Background Preinfarction angina, a possible form of ischaemic preconditioning, improves the prognosis in patients who experience a major ischaemic event; though the associated pathophysiology is not yet fully understood. The aim of this study was to determine the possible involvement of endothelial progenitor cells (EPC), the vascular endothelial growth factor (VEGF) and the hepatocyte growth factor (HGF) in the development of preinfarction angina. Methods and results We studied 41 patients (60·5 ± 12 years; 34% women) and 14 healthy controls; 43·9% of the patients had preinfarction angina. No differences were found in the baseline characteristics of the two groups. Although the EPC, VEGF and HGF were raised as compared with the control group, no significant differences were found according to the presence or absence of preinfarction angina in the levels of EPC (baseline, P = 0·25; day 3, P = 0·11; day 7, P = 0·32), VEGF (baseline, P = 0·96; day 3, P = 0·06; day 7, P = 0·57) or HGF (baseline, P = 0·18; day 3, P = 1; day 7, P = 0·86). An association was seen in the patients who had preinfarction angina between the EPC levels at baseline and on days 3 and 7 and the HGF on admission with the time from the angina to the STEMI (β = −0·070; β = −0·066; β = −0·081; β = −80·16; P

Recently, percutaneous aortic valve replacement has emerged as a therapeutic option for patients with severe symptomatic aortic stenosis and a high surgical risk. We report our initial experience in four patients with percutaneous implantation of a CoreValve aortic prosthesis to treat aortic bioprosthesis dysfunction involving aortic stenosis or regurgitation. In-hospital and medium-term outcomes were analyzed. The procedure was performed under local anesthesia and guided by angiography. The prosthesis was implanted successfully in all patients, although a second prosthesis was required in one case because the first was positioned too high. There were no major complications. After a mean follow-up of 7 months (SD, 4.7), all patients remained asymptomatic.

Thepresenceoflategadoliniumenhancement(LGE)incardiacmag-netic resonance (CMR), that enables quantification of myocardialfibro-sis[1],iscommoninpatientswithnonischemicdilatedcardiomyopathy(NIDC). LGE has been related to adverse clinical outcomes in patientswith NIDC, mainly in those with idiopathic dilated cardiomyopathy[1,2]. This study pretends to assess the long-term prognostic signifi-cance of LGE in an unselected population of patients with NIDC. Everyunderlying possible cause was included.Weperformed aretrospective cohortstudyinwhich64consecutiveoutpatients with heart failure secondary to NIDC were included. Allunderwent a CMR between August 2005 and November 2011. Thepresence and location of LGE were evaluated.Diagnosis was established according to the World HealthOrganization/International Society and Federation of Cardiology'sdefinition [3]. None of the patients presented previous history ofsignificant valvular disease, hypertrophic cardiomyopathy, restrictivecardiomyopathy, congenital heart disease, or coronary artery disease.PatientsunderwentCMRjustafterthediagnosisofNIDCtocompletethe diagnostic evaluation. Exclusion criteria were: cardiac pacemaker/implantable cardioverter defibrillator (ICD)/cardiac resynchronizationtherapy, renal insufficiency and severe obesity or claustrophobia.Patientswerefollowedviaclinicalvisits.Theprimaryoutcomewasacomposite endpoint of three events: cardiac death, hospitalization forheart failure and appropriate ICD firing. ICD devices were implanted insome patients after they underwent CMR.CMRimagingwasperformedona1.5Teslascanner(PhilipsMRSys-tem Achieva Release 2.6.3.7). Delayed contrast-enhanced images wereacquired 10 min after intravenous administration of 0.2 mmol/kg ofgadolinium-diethylenetriaminepentaacetate, using inversion-recoveryfast gradient-echo pulse sequences in sequential short- and long-axisslices of the left ventricle.Allstudies were analyzedby aradiologistand acardiologist usinga workstation (Extended MR Work Space 2.6.2.4.). The presence andlocation of LGE were visually assessed.Qualitativevariableswereexpressedaspercentagesandquantitativeasmean±SD.Qualitativevariableswerecomparedwiththeχ

Although changes in atrioventricular conduction frequently occur after percutaneous implantation of an aortic valve prosthesis, little is known about the mechanisms involved or how these changes progress. We investigated ECG abnormalities and predictors of pacemaker need after percutaneous implantation of the CoreValve® aortic valve prosthesis.Between April 2008 and October 2009, 65 patients with symptomatic severe aortic stenosis received a CoreValve® prosthesis. Clinical and ECG parameters were recorded and predictors of pacemaker need due to advanced atrioventricular block were investigated. The analysis excluded three patients because they had pacemakers and a fourth who died during the procedure.The patients' mean age was 79 ± 7.8 years and their logistic EuroSCORE was 20 ± 14%. Implantation was successful in 98.4%. After implantation, 47.5% had left bundle branch block and 21 patients (34.4%) required a permanent pacemaker. The need for a pacemaker was associated with a greater depth of prosthesis implantation in the left ventricular outflow tract (LVOT): 13 ± 2.5 mm vs. 8.8 ± 2.8 mm (P.001). Moreover, depth was the only predictor: odds ratio 1.9, 95% confidence interval 1.19-3.05 (P.007). A cutpoint of 11.1 mm for the prosthesis depth in the LVOT had a sensitivity of 81% and a specificity of 84.6% for predicting the need for a pacemaker.After CoreValve® aortic valve prosthesis implantation, a high percentage of patients needed a permanent pacemaker for advanced atrioventricular block. The only independent predictor was the depth of the prosthesis in the LVOT, which could serve as an early indicator of pacemaker need.

Aims Cardiac resynchronization therapy (CRT) improves survival and quality of life in advanced heart failure (HF). Although mitral regurgitation (MR) reduction has been reported, its presence has been associated with non-response to CRT. This study was undertaken to assess the potential role of significant mitral regurgitation (SMR) persistence after CRT on clinical outcome, major arrhythmic events, and echocardiographic response in the mid-long term. Methods and results Seventy-six patients (28.9% women, 63 ± 11 years) with dilated cardiomyopathy in advanced HF were included. SMR, defined as regurgitant orifice area ≥0.20 cm2, was assessed at baseline and its evolution 6 months after CRT. Clinical outcome (cardiovascular death/HF readmission), major arrhythmic events, and echocardiographic response (reverse remodelling) were recorded on follow-up. Thirty-two patients (42.1%) presented baseline SMR, becoming non-significant in 11 of the 32 patients (34.3%) 6 months after CRT. Its persistence was associated with higher rates of clinical events (46.4 vs. 18.7%, P = 0.011), arrhythmic events (35.7 vs. 14.5%, P = 0.034), and less reverse remodelling (28.5 vs. 83.3%, P < 0.001). Conclusion CRT can reduce moderate or severe baseline MR to non-significant in one-third of patients. However, its persistence was associated with worse clinical evolution, greater incidence of arrhythmic events, and less reverse remodelling.

BACKGROUND AND HYPOTHESIS: Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against in‐hospital complications, this effect has not been well documented after initial hospitalization, especially in older or diabetic patients. We examined whether angina 1 week before a first MI provides protection in these patients. METHODS: A total of 290 consecutive patients, 143 elderly (>64 years of age) and 147 adults (

The influence of sex on the prognosis of patients undergoing aortic valve replacement for severe stenosis is unclear. Nevertheless, a number of studies have regarded sex as an independent risk factor. The aim of this study was to evaluate the influence of sex on perioperative outcomes in patients undergoing valve replacement for severe aortic stenosis.This retrospective study involved 577 consecutive patients who underwent aortic valve replacement surgery for severe aortic stenosis between 1996 and April 2007.Women (44% of patients) were older than men (70.3+/-7.9 years vs. 66.8+/-9.8 years; P.001), had a smaller body surface area (1.68+/-0.15 m(2) vs. 1.83+/-0.16 m(2); P.001), more often had arterial hypertension (73% vs. 49%; P.001), diabetes mellitus (33.5% vs. 24.5%; P=.001) and ventricular hypertrophy (89.1% vs. 83.1%; P.001), and less often had coronary artery disease (19.1% vs. 31.8%; P.001) and severe ventricular dysfunction (7.9% vs. 17.4%; P.001). Nevertheless, women more often suffered acute myocardial infarction perioperatively (3.9% vs. 0.9%; P=.016), had a low cardiac output in the postoperative period (30.3% vs. 22.3%; P=.016) and experienced greater perioperative mortality (13% vs. 7.4%; P=.019) than men. However, after adjustment for various confounding factors, female sex was not a significant independent risk factor for mortality (odds ratio = 2.40; 95% confidence interval, 0.79-7.26; P=.119).Perioperative mortality in women with severe aortic stenosis who underwent valve replacement was high. However, after adjustment for potential confounding factors, particularly body surface area, female sex was not an independent risk factor for mortality.

Adiponectin can suppress atherogenesis by inhibiting the adherence of monocytes, reducing their phagocytic activity, and suppressing the accumulation of modified lipoproteins in the vascular wall. Contradictory data have been reported about the effect of statins on adiponectin plasma levels. In this work, adiponectin plasma levels were measured in 102 statin-free subjects from the Spanish population of the Achieve Cholesterol Targets Fast with Atorvastatin Stratified Titration (ACTFAST) study, a 12-week, prospective, multi-centre, open-label trial which enrolled subjects with coronary heart disease, coronary heart disease-equivalent or a 10-year coronary heart disease risk >20%. Subjects were assigned to atorvastatin (10-80 mg/day) based on low-density lipoprotein (LDL)-cholesterol concentration at screening. For comparison, age and gender-matched blood donors (N=40) were used as controls. Control subjects did not present hypertension, hypercholesterolemia, diabetes, metabolic syndrome and history of cardiovascular diseases. Adiponectin levels were diminished in patients at high cardiovascular risk compared with control subjects [4166 (3661-4740) vs 5806 (4764-7075) ng/ml respectively; geometric mean (95% CI); P

Background Drug-eluting stents (DES) have been shown in randomized trials to reduce clinical events in diabetic patients. Our aim was to determine whether these clinical results are applicable in an unselected population of patients with non-insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM). Methods We studied 440 consecutive patients (271 NIDDM and 169 IDDM) who underwent percutaneous coronary intervention, divided into 2 cohorts: Group A (1998–2000): 220 patients with bare metal stents, and Group B (2002–2004): 220 patients with drug-eluting stents. We analyzed major coronary adverse events (death, nonfatal acute myocardial infarction, and target lesion revascularization) over a mean follow-up of 18 ± 15 months. Results Group B had more patients who were insulin-dependent (44.5 versus 32.3% p

Introduction and objectives. The fractional flow reserve (FFR) has been shown to be a valid and useful measure in the functional assessment of coronary stenoses of intermediate severity. Our aim was to determine the usefulness of FFR assessment in diabetic patients, in whom determination of the FFR can be influenced by microvascular dysfunction. Methods. Between 1997-2004, FFR assessment was used to evaluate 222 consecutive coronary lesions judged by an interventional cardiologist to be of intermediate severity (ie, 40%-70%). Intravenous adenosine (140 µg/kg per min) was used to achieve maximum hyperemia. The occurrence of cardiac events (ie, death, non-fatal acute myocardial infarction, and target lesion revascularization) was compared in diabetics and nondiabetics in whom FFR assessment gave a negative result and intervention was deferred. The mean follow-up period was 30 (21) months. Results. Revascularization was deferred for 144 lesions (in 136 patients) in which the FFR was ≥0.75. Of these, 42 lesions (29.2%) were in diabetics (40 patients). The proportion of patients who were female or who had hypertension, dyslipidemia, or multivessel disease was greater in the diabetic group. There was no difference in indications for coronary angiography. In both groups, the most frequently investigated vessel was the left anterior descending coronary artery. The mean FFR was 0.87 (0.06), and there was no difference between the groups. On long-term follow-up, there was no difference in the rate of death or acute myocardial infarction. Overall, 8.8% of nondiabetics and 14.3% of diabetics with a negative FFR test result required target lesion revascularization (P=.32). Conclusions. Our results indicate that deferring percutaneous coronary intervention in diabetics with a

The occurrence of angina in the week preceding myocardial infarction is associated with a reduction in cardiovascular complications in the acute phase. However, little is known about it relationship with prognosis after hospitalization (e.g., cardiovascular death and the development of heart failure or ischemic cardiomyopathy). The study included 290 consecutive patients admitted for a first myocardial infarction: 107 (36.9%) had preceding angina while 183 did not. Those with a history of ischemic cardiomyopathy of more than 1 week or structural cardiopathy were excluded. There was no difference in baseline characteristics between the two groups. Moreover, there was no difference in the rates of cardiovascular complications after hospital discharge: cardiovascular death (7% vs. 12.6%; P=.3), heart failure (7.4% vs. 11.6%; P=.2), and myocardial ischemia, including myocardial infarction and unstable angina, requiring hospitalization (41.2% vs. 31.3%; P=.3). The occurrence of angina in the week before a first myocardial infarction did not influence cardiovascular complications after hospital discharge (odds ratio = 0.75 [0.51-1.11]; P=.15).

The aim of this study was to compare the effects of cardiac resynchronization therapy on left ventricular function and reverse remodeling in patients in sinus rhythm with the effects in patients with atrial fibrillation who have not undergone atrioventricular node ablation. Echocardiographic and clinical parameters were evaluated at baseline and after 6 months of cardiac resynchronization therapy in 55 patients: 15 had atrial fibrillation and 40 were in sinus rhythm. Device programming was similar in the 2 groups, as were the reductions in QRS interval and echocardiographic measures of asynchrony observed after implantation. However, although significant improvements in end-systolic volume and ejection fraction were seen in both groups, reverse remodeling was greater in patients in sinus rhythm (reduction in end-systolic volume 30.9%+/-24.6% vs 12.5%+/-18.6%; P=.024), as was the relative increase in ejection fraction (15.4%+/-12.6% vs 5.0%+/-7.2%; P=.010). Cardiac resynchronization therapy in patients with atrial fibrillation who had not undergone atrioventricular node ablation resulted in significant improvements in ejection fraction and reverse remodeling, but these were less than those observed in patients in sinus rhythm.

Aims Cardiac resynchronization therapy (CRT) reduces the degree of functional mitral regurgitation (FMR). However, FMR has also been associated with a lack of clinical response to CRT. We undertook this study to determine whether the presence of FMR influences the reverse remodelling induced by CRT. Methods and results We used Doppler echocardiography to assess 20 patients with dilated cardiomyopathy before and 6 months after undergoing CRT. We evaluated the effect of reverse remodelling (reduction ≥ 10% in end-systolic volume) according to the presence or absence of important FMR, defined as a regurgitant orifice area (ROA) of ≥ 0.20 cm2. Of the 20 patients (mean age, 64.7 ± 8.2 years, eight women), 9 had marked FMR (ROA 0.40 ± 0.12 cm2), 6 mild FMR (ROA 0.15 ± 0.02 cm2), and 5 had trivial or no FMR. CRT reduced the presence of mitral regurgitation by 33.3% and induced reverse remodelling in 60% of the patients. A ROA ≥ 0.20 cm2 was associated with a lack of reverse remodelling, despite presenting similar baseline characteristics and a reduction in asynchrony to the other patients. Reverse remodelling was produced in all the other patients, with a significant reduction in end-systolic volume (41.7 ± 21%; P = 0.003), accompanied by improvement in the ejection fraction ( P = 0.003) and myocardial performance index ( P = 0.027). Conclusion CRT improved FMR, although the baseline presence of important mitral regurgitation, with a ROA ≥ 0.20 cm2, in patients undergoing CRT was associated with a lack of response in reverse remodelling.

Plasma levels of soluble intercellular adhesion molecule 1 (sICAM-1) and monocyte chemoattractant protein 1 (sMCP-1) are associated with increased risk for future coronary events. However, the effect of statins on these inflammatory markers has hardly been studied. We analyzed whether treatment with the different doses of atorvastatin affects sICAM-1 and sMCP-1 plasma levels in subjects at high cardiovascular risk.Achieve Cholesterol Targets Fast with Atorvastatin Stratified Titration was a 12-week, prospective, multicenter, open-label trial that enrolled a total of 2117 subjects with coronary heart disease (CHD), CHD equivalent (defined as diabetes, peripheral vascular disease, or cerebrovascular disease), or a 10-year CHD risk20%. Subjects with low-density-lipoprotein cholesterol between 100 and 220 mg/dL (2.6-5.7 mmol/L) and triglycerides600 mg/dL (6.8 mmol/L) were assigned to atorvastatin (10-80 mg/d) based on low-density-lipoprotein cholesterol at screening. The Atorvastatin on Inflammatory Markers study included statin-free patients (N = 1078).At baseline, 52%, 14%, 12%, and 22% of subjects were assigned to doses of 10, 20, 40, and 80 mg, respectively. Levels of sICAM-1 [geometric mean (95% confidence interval); 283.8 (278.1-289.6) vs 131.9 (127.2-136.6) ng/mL, P.0001] and sMCP-1 [164.1 (159.9-168.2) vs 131.1 (123.1-139.6 pg/mL, P.0001] were increased in subjects at high cardiovascular risk compared to healthy subjects (n = 130). In the whole population, sICAM-1 and sMCP-1 levels were reduced by atorvastatin [% change (95% confidence interval); -2.2 (-3.8 to -0.6); -4.1 (-6.1 to -2); P = .006 and P = .0002, respectively]. All doses of atorvastatin diminished sICAM-1 and sMCP-1 levels in the highest quartile.Short treatment with atorvastatin reduced sICAM-1 and sMCP-1 plasma levels showing anti-inflammatory effects in subjects at high cardiovascular risk.

Aims Right ventricular (RV) pacing has been shown to cause heart failure symptoms in patients with and without previous systolic left ventricular (LV) dysfunction. The aim here was to evaluate the preventive effect of biventricular pacing vs. RV apical pacing in patients with indication for permanent ventricular pacing. Methods PREVENT-HF is an ongoing multicentre randomized controlled pilot study designed to assess whether biventricular pacing is superior to RV pacing in patients receiving a bradycardia pacemaker for standard indications. Patients with Class I or IIa indication according to ACC/AHA guidelines for cardiac pacing judged likely to require high (⩾80%) ventricular pacing are randomized to receive either RV or biventricular stimulation. Patients are ineligible if younger than 18 years, have Class III or IV heart failure, or experienced a recent myocardial infarction or cardiac surgery. Echocardiographic parameters of LV function are assessed at baseline, 6 months, and 12 months. The primary endpoint is change in LV end diastolic volume. Secondary outcomes include LV ejection fraction, mortality, morbidity, and mitral regurgitation. In subsets of patients, NT-pro-BNP and oxygen uptake are analysed. Centres in Spain (five), Italy (four), and Germany (seven) will enrol 100 patients. Conclusion PREVENT-HF will contribute to better define the role of chronic biventricular pacing for advanced atrioventricular block.

The development of dynamic left ventricular outflow tract (LVOT) obstruction (DLVOTO) during effort in patients without hypertrophic cardiomyopathy has been described only a few times and its clinical significance has not been established. This study was undertaken to determine DLVOTO during exercise in patients with angina and normal coronary arteries, and to analyze the potential mechanism involved. The study included 23 patients (60.7 +/- 7.2 years), with effort angina and normal coronary arteries who underwent exercise echocardiography. DLVOTO during exercise appeared in 7 patients (30.4%), with gradients ranging from 31.1 to 67.2 mm Hg (mean 41.3 +/- 12.6). These patients showed more symptoms (effort angina) during testing than the remaining patients (100% vs 47.3%; P = .014). LVOT size was the only predictive factor of DLVOTO (9.1 +/- 0.5 vs 10.3 +/- 1.2 mm/m(2); P = .017). In patients with angina and no epicardical coronary artery disease DLVOTO is associated with a lower LVOT size.

Objectives— Increasing evidence indicates that the Fas/Fas ligand interaction is involved in atherogenesis. We sought to analyze soluble Fas (sFas) and soluble Fas ligand (sFasL) concentrations in subjects at high cardiovascular risk and their modulation by atorvastatin treatment. Methods and Results— ACTFAST was a 12-week, prospective, multicenter, open-label trial which enrolled subjects (statin-free or statin-treated at baseline) with coronary heart disease (CHD), CHD-equivalent, or 10-year CHD risk >20%. Subjects with LDL-C between 100 to 220 mg/dL (2.6 to 5.7 mmol/L) and triglycerides ≤600 mg/dL (6.8 mmol/L) were assigned to a starting dose of atorvastatin (10 to 80 mg/d) based on LDL-C at screening. Of the 2117 subjects enrolled in ACTFAST, AIM sub-study included the 1078 statin-free patients. At study end, 85% of these subjects reached LDL-C target. Mean sFas levels were increased and sFasL were reduced in subjects at high cardiovascular risk compared with healthy subjects. Atorvastatin reduced sFas in the whole population as well as in patients with metabolic syndrome or diabetes. Minimal changes were observed in sFasL. Conclusions— sFas concentrations are increased and sFasL are decreased in subjects at high cardiovascular risk, suggesting that these proteins may be novel markers of vascular injury. Atorvastatin reduces sFas, indicating that short-term treatment with atorvastatin exhibits antiinflammatory effects in these subjects.

Left ventricular reverse remodeling (LVRR) in dilated cardiomyopathy is poorly known within the context of current therapeutic approach. Our goal is to describe the present incidence of LVRR, the factors able to predict it and the long term prognosis of these patients.We performed a retrospective analysis of a cohort or 387 consecutive outpatients. Mean follow-up was 50.4 ± 28.4 months. Sustained LVRR occurred in 57.6% of patients. The number of coronary arteries with severe stenosis (HR 0.69, 95% CI 0.55-0.86; p=0.001), New York Heart Association Functional Class (NYHA FC) (HR 0.39, 95% CI 0.27-0.54; p0.001) as well as the severity of mitral regurgitation (MR) at the end of follow-up (HR 0.42, 95% CI 0.30-0.58; p0.001) and the time until first event (HR 1.02, 95% CI 1.01-1.03; p0.001) were independent predictors of left ventricular ejection fraction improvement. LVRR was tightly related to prognosis due to the fact that both improvement in cardiac function achieving normal or slightly impaired LVEF (HR 0.31, 95% CI 0.17-0.56; p0.001) and shorter time to achieve LVRR (HR 0.99, 95% CI 0.98-0.99; p=0.017) formed part of the best model for predicting events in DCM.More than half of the patients showed sustained LVRR associated with a significantly better prognosis. Fewer numbers of coronary arteries with severe stenosis, milder NYHA FC and the absence of significant MR at the end of follow-up as well as longer event free period formed a simple model to prognosticate LVRR. LVRR and the time to achieve it were strongly related to long term prognosis in patients with DCM.

Natriuretic peptides are extremely useful in the diagnosis and prognosis of patients with heart failure. However, it is not clear whether their values are stable. We carried out a prospective study of 30 consecutive ambulatory patients (mean age, 62.6 [12.2] years) with stable systolic heart failure, as determined by the 6minute walk test, who were in New York Heart Association class II or III and who had a left ventricular ejection fraction

Background: Calculation of myocardial fractional flow reserve (FFR) enables coronary stenoses to be evaluated. Objectives: We determined the usefulness of measuring the FFR in multivessel coronary artery disease, reflected in changes in the therapeutic options for patients with moderate coronary stenosis. Methods: We studied 38 patients (30 men, 8 women; mean age: 59.8 ± 10 years) with multivessel coronary artery disease with 41 moderate lesions. Indications for coronary angiography were unstable angina in 24 patients (60%), acute myocardial infarction in 10 (27%), and stable angina in 4 (13%). We studied the FFR (in nonactive lesions) in the left anterior descending artery in 23 patients (56%), the left coronary trunk in 8 (19.5%), the circumflex artery in 5 (12.2%), the right coronary artery in 3 (7.3%), and the left internal mammary artery and diagonal branch in 1 patient each. Results: Twelve patients had a positive FFR, which resulted in no change in the mode of revascularization; 26 patients had a negative FFR, in 20 (77%) of whom the revascularization approach was changed, especially those with moderate lesions of the left coronary trunk or anterior descending artery. No differences were detected in the angiographic characteristics of the lesions examined. Cardiac events during follow-up were few. Conclusions: The results of FFR may influence the decision-making process after diagnostic coronary angiography in multivessel coronary artery disease with moderate lesions, especially in patients with a negative FFR in nonculprit lesions of the left trunk or left anterior descending artery.

The frequent occurrence of ventricular tachycardia can be a serious problem for patients with an implantable defibrillator, and may necessitate adjuvant antiarrhythmic therapy or radiofrequency catheter ablation. We analyzed the long-term results obtained with this latter therapy in patients suffering from frequent or continuous ventricular tachycardia.Eighteen ablation procedures were performed in 11 patients who had a defibrillator implanted because of previous syncopal ventricular tachycardia. All were men, aged 67.64 (5.87) years; 10 patients had had a myocardial infarction 15.50 (5.08) years earlier, and one suffered from arrhythmogenic right ventricular dysplasia.Electrophysiologically, treatment was initially successful in 8 patients (72.73%). After a follow-up period of 39.10 (24.70) months, the number of defibrillator discharges decreased significantly in all patients, from 52.82 (35.73) to 0.64 (1.03) (P=.001). During follow-up, ventricular tachycardia occurred in nine patients. In five, it took the same form as the ablated ventricular tachycardia. Six patients needed additional ablation procedures: two because of initial failure, three because of recurrence, and one because a different ventricular tachycardia occurred. In addition to the good electrophysiological results obtained, long-term clinical evolution was favorable in all patients.Radiofrequency ablation successfully disrupts frequent or continuous ventricular tachycardias and significantly reduces the defibrillator discharge rate even when ablation has failed electrophysiologically. It is particularly useful in these latter critical situations, in which other therapies are not sufficiently effective. Because our patients mainly had ischemic heart disease and were highly susceptible to new arrhythmias during follow-up, ablation complemented rather than replaced the implantable defibrillator.

Identification of clinical factors associated with coronary artery disease could obviate the need for coronary angiography in selected patients with severe aortic stenosis. We studied 315 patients (68 [8] years) with severe aortic stenosis without previous infarction who underwent coronary angiography. In the univariate analysis, age (P = .001), dyslipidemia (P = .003), angina (P = .018), aortic gradient (P = .001) and reduced ejection fraction (P = .006) were predictors of coronary artery disease. After multivariate analysis, age (OR = 1.079, P = .01), ejection fraction < 40% (OR = 2.685, P = .02), angina (OR = 2.518, P = .04) and dyslipidemia (OR = 2.34, P = .008) were the factors independently associated with coronary artery disease. Left ventricular dysfunction correlated independently with the presence of coronary artery disease.

Introduction and objectives. The PREVESE Study reported the situation of secondary prevention after myocardial infarction in Spain. Similar surveys conducted in Europe have also shown that the implementation of secondary prevention is not adequate. The aim of this second PREVESE study was to compare the situation in Spain four years after the first study. Patients and method. We included retrospectively 2,054 patients discharged after myocardial infarction from 74 Spanish hospitals. We studied the available information recorded in medical records after discharge, the prevalence of risk factors, procedures performed, and medical treatment before admission and at discharge. We compared the data collected with those from the first PREVESE study because the data collection methodology was similar. Results. The information recorded in the hospital medical records was satisfactory in relation to the most important risk factors (hypertension 94.8%; dyslipidemia and diabetes 97.9%; and smoking 89.2%). Compared with the previous study, there was a significant decrease in the percentage of smokers (46.1 vs. 35.4%). The echocardiogram was performed more frequently (60.1 vs. 85.6%) and there were also significant differences related to drug treatment at discharge, with an important increase in the prescription of beta-blockers (33.5 vs. 45.1%), ACE inhibitors (32.5 vs. 46.4%), and lipid-lowering drugs (6.7 vs 30.5%). Conclusions. This study shows some improvement in the management of myocardial infarction patients after a four-year period, mainly due to more prescription of cardioprotective drugs at hospital discharge.

Background aims Endothelial progenitor cells (EPCs) are known to play a beneficial role by promoting postnatal vasculogenesis in pathological events, such as ischemic heart disease and peripheral artery disease. However, little is known about the potential of EPCs to restore heart damage tissue. We compared the cardiac differentiation capacity of EPCs isolated from peripheral blood of patients with acute myocardial infarction (AMI) with EPCs obtained from umbilical cord blood (UCB). Methods EPCs from both origins were isolated by density gradient centrifugation and characterized through the use of endothelial markers (UEA-1lectin, CD133 and KDR) and endothelial cell colony-forming unit assay. Cardiac differentiation capacity of EPCs was assessed by immunofluorescence and reverse transcriptase–polymerase chain reaction after 5-azacytidine (5-aza) induction. Results No significant differences were observed between the number of endothelial cell colony-forming units in peripheral blood of patients with AMI and samples from UCB. Moreover, 5-aza induced the appearance of myotube-like structures and the positive expression of sarcomeric α-actinin, cardiac troponin I and T and desmin in a similar pattern for both cell sources, which indicates a comparable acquisition of a cardiac-like phenotype. Conclusions For the first time, we have compared, in vitro, the cardiomyogenic potential of EPCs derived from patients with AMI with UCB-derived EPCs. Our data indicate that EPCs obtained from both origins have similar plasticity and functions and suggest a potential therapeutic efficacy in cardiac cell therapy.

Background: Clinical practice guidelines recommend ad hoc screening of diabetes in patients admitted for macrovascular disease; however, these recommendations are rarely followed in real practice. This study was undertaken to assess whether impaired glucose metabolism, newly diagnosed after percutaneous coronary intervention (PCI) or known diabetes, provides prognostic information. Methods : We studied 374 patients who underwent PCI. An oral glucose tolerance test was carried out in the known non-diabetic patients with fasting glucose < 7 mmol/L. Results : Eighty-one percent of the patients presented impaired glucose metabolism, from which 35.3% were previously diagnosed with diabetics, 21.4% were newly detected diabetics, and 24.3% were pre-diabetics. After a mean follow-up of 35.8 ± 13.4 months, only a known history of diabetes was an independent predictor of revascularization (OR = 2.03, p = 0.025), non-fatal acute myocardial infarction (OR = 2.70, p = 0.029) and readmission due to heart failure during the follow-up (OR = 3.82, p = 0.022). Conclusions: Screening for impaired glucose metabolism after PCI permits the detection of a high proportion of patients with abnormal glucose regulations. However, previously known diabetes remains the only independent predictor of cardiovascular events in the follow-up.

Stent thrombosis is a feared complication of percutaneous coronary intervention due to its catastrophic consequences. We analysed the incidence of angiographically-confirmed thrombosis in 5011 consecutive patients treated with drug-eluting stents or bare-metal stents. Although the incidence of thrombosis was similar between the two groups (0.8%), angiographically-documented late thrombosis was a relatively unusual complication after implantation of either stent, though it was more common with drug-eluting stents than bare-metal stents (0.25 vs. 0.06%, P=.03).

Vasoespastic angina usually respondswell to treatmentwith vasodilator coronary agents: calcium antagonists and nitrates. However, there are patients resistant to classical therapy. We report a case of a patient with primary Raynaud phenomenon and eosinophilia, refractory to intensive treatment with high doses of calcium antagonist and nitrates who was controlled after treatment with low doses of oral corticosteroids. A 52 years old man, smoker without other cardiovascular risk factors, who has been studied because of Raynaud phenomenon, with negative rheumatoid factor and antinuclear antibodies and no history of asthma or allergic disease, suffered an acute inferior myocardial infarction. Primary angioplasty was performed to dominant distal circumflex coronary and a bare metal stent was implanted. There were no significant lesions in other coronary arteries. Left ventricular ejection fraction was slightly reduced. Five month later he was admitted on hospital because unstable angina and STelevation in II, III, aVF leads normalized after intravenous nitrates. Coronariography showed stent patency and no coronary artery lesions. Treatment with amlodipine 10 mg/day and topic nitroglycerine (15 mg/day) was started. Angina persists with nocturnal and at rest attacks, and repeated hospital admissions with transient ST elevation in inferior leads (Figs. 1 and 2) without coronary stenosis in angiogram, but with propensity to coronary vasospasm in non dominant right coronary and circumflex artery in

The occurrence of exercise-induced dynamic obstruction of the left ventricular outflow tract in patients without cardiomyopathy has recently been reported. However, it is not known if this phenomenon is a normal response to exercise in healthy adults. We studied 23 healthy adults using exercise Doppler echocardiography. We measured the left ventricular outflow velocity at rest and after maximum tolerated exercise. After a mean exercise duration of 12 min 45 s (2 min 32 s), the heart rate was 97.61 (6.71)% of the theoretical maximum. Left ventricular outflow velocity increased from 1.07 (0.18) m/s (range: 0.77-1.44 m/s) to 1.58 (0.35) m/s (range: 1.09-2.4 m/s). In healthy adults, exercise increased the left ventricular outflow velocity by 50%, though in no subject was it greater than 2.5 m/s. This observation appears to rule out the possibility that a high intraventricular pressure gradient is a normal response to exercise in healthy adults.

Congestive heart failure is an increasing cause of mortality among the aging population. The current management approaches have increased the survival of patients with congestive heart failure, although the mortality rate remains high. Thus, any effort to reduce mortality in this condition seems justified. Beta-adrenergic blocking agents have shown to improve functional class and the ventricular function of heart failure patients; the use of these agents should be considered in congestive heart failure patients unless an increase in mortality with betablockers can be demonstrated. In fact, beta-blockers reduce mortality, as the recent study of carvedilol has demonstrated. Therefore, beta adrenergic blocking agents should be incorporated into the strategies of management of patients with congestive heart failure.

Aims Previous studies showed unfavourable effects of right ventricular (RV) pacing. Ventricular pacing (VP), however, is required in many patients with atrioventricular (AV) block. The PREVENT-HF study explored left ventricular (LV) remodelling during RV vs. biventricular (BIV) pacing in AV block without advanced heart failure. The pre-specified PREVENT-HF German Substudy examined exercise capacity and N-terminal pro-brain natriuretic peptide (NT-proBNP). Methods and results Patients with expected VP ≥80% were randomized to RV or BIV pacing. Endpoints were peak oxygen uptake (pVO2), oxygen uptake at the anaerobic threshold (VO2AT), ventilatory efficiency (VE/VCO2), and logNT-proBNP. Considering crossover, intention to treat (ITT), and on-treatment (OT) analyses of covariance (ANCOVA) were performed. For exercise testing 44 (RV: 25, BIV: 19), and for NT-proBNP 53 patients (RV: 29, BIV: 24) were included. The ITT analysis revealed significant differences in pVO2 [ANCOVA effect 2.83 mL/kg/min, confidence interval (CI) 0.83–4.91, P = 0.007], VO2AT (ANCOVA effect 2.14 mL/min/k, CI 0.14–4.15, P = 0.03), and VE/VCO2 (ANCOVA effect −5.46, CI −10.79 to −0.13, P = 0.04) favouring BIV randomization. The significant advantage in pVO2 persisted in OT analysis, while VO2AT and VE/VCO2 showed trends favouring BIV pacing. LogNT-proBNP did not differ between groups. (ITT: ANCOVA effect 0.008, CI –0.40 to +0.41, P = 0.97; OT: ANCOVA effect –0.03, CI −0.44 to 0.30, P = 0.90). Conclusion Our study suggests that BIV pacing produces better exercise capacity over 1 year compared with RV pacing in patients without advanced heart failure and AV block. In contrast, we observed no significant changes of NT-proBNP. Larger trials will allow appraising the clinical usefulness of BIV pacing in AV block. ClinicalTrials.gov Identifier: [NCT00170326][1] [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00170326&atom=%2Feuropace%2F16%2F1%2F63.atom

Introduction and objectives There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation . The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. Methods Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. Results A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty ( P=.04). Conclusions Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement.