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La circulacion colateral coronaria aparece como consecuencia de la isquemia miocardica recurrente, generalmente debida a lesiones coronarias severas y fijas, y de manera excepcional puede desarrollarse en lesiones no significativas provocadas por un vasospasmo coronario severo. En esta situacion, la angina vasospastica puede manifestarse como una angina de esfuerzo con descenso del segmento ST. Presentamos el caso de un paciente con angina de esfuerzo, ergometria clinicamente positiva y descenso horizontal del segmento ST. En la angiografia se observo una estenosis critica en la arteria coronaria derecha y el desarrollo de circulacion colateral heterocoronaria. Tras la administracion de nitroglicerina intracoronaria, la lesion finalmente fue moderada con desaparicion de la circulacion colateral.

To determine whether mortality from acute myocardial infarction has reduced in Spain and the possibly related therapeutic factors.Nine thousand, nine hundred and forty-nine patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit were identified from PRIAMHO I, II and MASCARA registries performed in 1995, 2000 and 2005, with a 6 month follow-up.From 1995 to 2005 patients were increasingly more likely to have hypertension, hyperlipidemia and anterior infarction, but age of onset and the proportion of females did not increase. Twenty-eight-day mortality rates were 12.6%, 12.3% and 6% in 1995, 2000 and 2005 respectively, and 15.3%, 14.6% and 9.4% at 6 months (both P-trend.001). Multivariate analysis was performed and the adjusted odds ratio for 28-day mortality for an infarction occuring in 2005 (compared with 1995) was 0.62 (95% confidence interval: 0.44-0.88) whereas the adjusted hazard ratio for mortality at 6 months was 0.40 (95% confidence interval: 0.24-0.67). Other variables independently associated with lower mortality at 28 days were: reperfusion therapy, and the use of anti-thrombotic treatment, beta-blockers and angiotensin-converting enzyme inhibitors. The 28-day-6-month period had an independent protective effect on the following therapies: coronary reperfusion, and prescription of antiplatelet agents, beta-blockers and lipid lowering drugs upon discharge.Twenty-eight-day and six-month mortality rates fell among patients with ST-elevation myocardial infarction in Spain from 1995 to 2005. The possibly related therapeutic factors were the following: more frequent reperfusion therapy and increased use of anti-thrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors and lipid lowering drugs.

Objective To assess the long-term safety and antianginal efficacy of two doses of ivabradine, a novel selective and specific inhibitor of the sinus node I(f) current. Methods In a randomized double-blind, parallel-group study 386 patients with chronic stable angina were randomized to either ivabradine 5 mg b.i.d. (n = 198, group 1) or ivabradine 7.5 mg b.i.d. (n = 188, group 2) for 12 months. Concomitant medication included antithrombotic agents, lipid-lowering agents, long-acting nitrates and dihydropyridine calcium antagonists. Safety was assessed on the basis of reported adverse events at 1, 3, 6, 9 and 12 months. Antianginal efficacy was based on the reduction in the weekly number of angina attacks and in the consumption of short-acting nitrates from month 0 (baseline) to month 12. Results Ivabradine was well tolerated. Phosphene-like mild transient visual symptoms were the most frequently reported adverse events but led to treatment withdrawal in only 4 patients. Resting heart rate was reduced by 9 bpm in group 1 and 12 bpm in group 2. Sinus bradycardia caused treatment withdrawal in only three cases. The QTc (Bazett) interval did not increase. At month 12 relative to month 0 there was a significant reduction in the number of angina attacks per week. Conclusion Ivabradine at the recommended doses of 5 and 7.5 mg b.i.d. was well tolerated and demonstrated antianginal efficacy in patients with documented coronary artery disease treated with concomitant antianginal medications.

Even though atherosclerosis is a systemic disease, few prospective studies have evaluated in a thorough and systematic manner the whole vascular tree in patients with clinical damage of different territories.Prospective protocolized study of 269 consecutive patients younger than 70, attended because of symptomatic arteriosclerosis of any territory -53% coronary (CHD), 32% cerebrovascular (CVD), 15% peripheral (PVD)-. Patients underwent evaluation of risk factors and their control, systematic non-invasive study of the vascular tree (Doppler-ultrasound) and comparison between groups according to the index territory.Even though all risk factors were represented in the 3 groups, male sex, smoking and diabetes were more frequent in PVD and dyslipemia was more common in CHD (p0.05) Abdominal aortic diameter and carotid intima-media thickness were similar for all groups, while the number of carotid plaques was higher in PVD. CHD patients more often presented left ventricular hypertrophy and reduced ejection fraction. PVD patients showed a marked reduction of the ankle-brachial index as well as increased C-reactive protein and homocysteine (p0.05). Severe unsuspected vascular lesions were found in 13% of cases (95% confidence interval, 9.5-17.6%). Risk factor control was better for CHD, followed by CVD and PVD, but was globally poor.The systematic evaluation of the vascular tree detects generalized atherosclerotic lesions, in some cases severe and clinically unsuspected. New markers to identify patients at very high risk are necessary. Peripheral vascular disease identifies a group of patients of particular risk. Risk factor control is deficient, particularly among PVD patients.

Recently, the Mayo Clinic proposed criteria for the clinical diagnosis of the syndrome of left ventricular transient apical ballooning. This syndrome consists of the acute onset of transient, extensive akinesia of the apical and middle portions of the left ventricle without significant stenosis evident on the coronary angiogram, accompanied by chest symptoms, ECG changes, and limited release of cardiac markers disproportionate …

Peripheral arterial disease (PAD) frequently coexists with coronary artery disease. Our objective was to determine the prevalence of traditional and emergent cardiovascular risk factors in patients with acute coronary syndrome (ACS), with or without PAD.A prospective study of 141 consecutive patients (70 years old) admitted to our hospital with ACS was performed. PAD was diagnosed when the ankle-brachial index (ABI) wasor = 0.9. Traditional cardiovascular risk factors were evaluated. C-reactive protein, homocysteine, amyloid A, lipoprotein (a), fibrinogen, apolipoprotein A1, and apolipoprotein B100 serum levels, and microalbuminuria were measured. Specific genotypes were also determined.Patients were divided into two groups according to whether PAD was present (37 patients, 26% of total, ACS-PAD group) or absent (104 patients, ACS group). In the ACS-PAD group, patients were older, and diabetes and hypertension were significantly more common. Moreover, levels of C-reactive protein (3.1 mg/L vs 2.18 mg/L; P.05), homocysteine (11.45 mmol/L vs 9.4 mmol/L; P.01), amyloid A (5.2 mg/mL vs 3.7 mg/mL; P.05), and microalbuminuria (4.89 mg/L vs 3.1 mg/L; P.05) were significantly higher in this group. Logistic regression analysis showed that poorly controlled diabetes (OR = 6.3; 95% CI, 1.1-36.7), time-dependent tobacco exposure (OR = 1.5 per decade; 95% CI, 1.2-2.0), and high pulse pressure (OR = 1.9 per 10 mmHg; 95% CI, 1.3-2.7) were independent predictors of the presence of PAD.Several traditional and emergent cardiovascular risk factors were more prevalent in patients with acute coronary syndrome and peripheral arterial disease. Moreover, some factors were independent predictors of peripheral arterial disease.

Coronary collateral circulation usually develops as a consequence of recurrent ischemia associated with severe stenosis. In exceptional cases, it can develop with moderate coronary lesions if there is severe recurrent vasospasm. In this situation, the presenting clinical features of vasospastic angina (i.e., effort angina with ST-segment depression) can be identical to those of a severe permanent lesion. We present a patient who exhibited effort angina and ST-segment depression on treadmill testing. Angiography showed severe right coronary artery stenosis and the development of coronary collateral circulation from the other main artery. After repeated intracoronary bolus injection of nitroglycerin, only a moderate stenosis was still apparent and the collateral circulation had disappeared.

The description of the human genome has opened new venues for the study and understanding of pathophysiological phenomena. In the 20th century, individual cell components were studied. The 21st century began with a global analysis of cell components. Thanks to the development of new technologies such as DNA chips, or two-dimensional electrophoresis, we can now study the expression of thousands of genes, or the proteins they encode, in a few hours. Genomics has opened the way for proteomics. Improved knowledge of genes does not provide information about cell functions, because any cell expresses all genes simultaneously. Instead, there is selective gene expression depending on the cell type and the stimuli to which it is exposed. The result of this is the proteome, an ensemble of proteins that are responsible for cell functions at any given moment, which are the object of the study of proteomics. The description of the proteome of cardiac cells has begun and some new proteins have been found to be dysregulated in different cardiomyopathies. These proteins are involved either in energy production or in the stress response, or belong to the cell proteasome or cytoskeleton. They may be potential risk markers or new therapeutic targets in the future. In this sense, chemogenomics is a new methodology for the development of new drugs using genomic and proteomic data.

Therefore, it is of great interest to deter-mine whether such on-site availability improves pa-tient prognosis. The effect of on-site availability of acatheterization laboratory on 1-year survival after anAMI was evaluated in the Spanish National Myocar-dial Infarction Registry.•••The Proyecto de Registro de Infarto Agudo deMiocardio Hospitalario (PRIAMHO) study was de-signed by the Spanish Society of Cardiology to deter-mine the variability in AMI management in Spain.

Since the Spanish Society of Cardiology Clinical Practice Guidelines on Unstable Angina/Non-Q-Wave Myocardial Infarction were released in 1999, the conclusions of several studies that have been published make it advisable to update current clinical recommendations. The main findings are related to the developing role of Chest Pain Units in the management and early risk stratification of acute coronary syndromes in the emergency department; new information concerning the efficacy of glycoprotein IIb/IIIa inhibitors, clopidogrel and low-molecular-weight heparins in the pharmacological treatment of acute coronary syndromes without ST-segment elevation; and the role of early invasive strategy in improving the prognosis of these patients. The published evidence is reviewed and the corresponding clinical recommendations for the management of acute coronary syndromes without persistent ST-segment elevation are updated.

We have performed a proteomic analysis of peripheral blood monocytes from ACS patients in comparison with healthy subjects and stable coronary patients in order to search novel biomarkers of ACS in circulating monocytes. Monocytes were isolated from blood of patients with non-ST elevation ACS (n = 27) at day 0, 2 and 6 months, and from patients with stable coronary disease (n = 10) and matched healthy controls (n = 11). The proteomic analysis of monocytes from ACS patients at day 0 showed that cathepsin D is differentially expressed compared to healthy subjects and stable coronary patients. Western blot analysis indicated that the mature form of cathepsin D at day 0 was overexpressed in monocytes of ACS patients in relation to healthy subjects. In contrast, the precursor of this enzyme, absent at day 0 in ACS patients, was highly expressed in monocytes of healthy subjects. Furthermore, the upregulation of the mature form of cathepsin D diminished along the time, while the expression of the precursor increased. ACS patients also showed significantly increased plasma cathepsin D levels on admission compared to healthy subjects and stable patients. Cathepsin D plasma levels diminished at 2 and 6 months to control values. Finally, cathepsin D levels were independent of the existence of coronary risk factors and CRP levels, correlating only with CD40L. Since this protease participates in the genesis and rupture of atherosclerotic plaques, it could represent a potential marker of ACS.

Introduccion y objetivo En el estudio de la dimension del problema de las distintas formas de presentacion de la cardiopatia isquemica, la angina ha recibido escasa atencion. El objetivo de este estudio fue determinar la prevalencia de angina en la poblacion de 45 a 74 anos de las diferentes comunidades autonomas, asi como la prevalencia de factores de riesgo cardiovascular. Metodos Fueron seleccionados 10.248 individuos de 45 a 74 anos. El muestreo fue estratificado por sexos y por tres grupos de edad, y fue proporcional a la distribucion poblacional de las diferentes comunidades autonomas. Se realizo un muestreo polietapico; en primer lugar, se seleccionaron 200 municipios al azar, y posteriormente se eligieron tres ambientes socioeconomicos distintos y se utilizaron itinerarios. La unidad de muestreo fue la vivienda familiar. Se administro el cuestionario de angina de Rose y un cuestionario estructurado para recoger variables sociodemograficas y antecedentes de factores de riesgo. Resultados La prevalencia de angina en la poblacion espanola de 45 a 74 anos fue del 7,5%, siendo las comunidades autonomas con una prevalencia mayor y menor las Baleares (11,4%) y el Pais Vasco (3,1%), respectivamente. El coeficiente de correlacion entre la prevalencia de angina y la mortalidad por cardiopatia isquemica o por enfermedad cardiovascular en varones y mujeres fue 0,52 y 0,55 y 0,31 y 0,44, respectivamente. El 31,1% de los participantes declararon ser hipertensos, el 24,2% dislipemicos, el 14,3% diabeticos y el 34,6% fumadores. Conclusiones La prevalencia de angina varia significativamente entre comunidades autonomas y se asocia con la mortalidad por cardiopatia isquemica y por enfermedades cardiovasculares en las mismas, asi como con la prevalencia de factores de riesgo cardiovascular. La prevalencia de estos factores de riesgo varia significativamente entre comunidades autonomas.