Search

[EN] The European Society of Cardiology guidelines recommend electrical cardioversion (ECV) as a rhythm control strategy in persistent atrial fibrillation (AF). Although being able to initially restore sinus rhythm in most patients, mid- and long-term AF recurrence rates are high. In this context, anticipation of ECV outcome is interesting to rationalize the management of AF patients. To this end, several parameters have been recently proposed for atrial activity (AA) characterization, such as fibrillatory wave amplitude (FWA), dominant frequency (DF) and sample entropy (SEn). These indices have revealed promising results, but have been mainly computed from lead V1, thus discarding spatial information from the remaining leads. Hence, this work explores whether a multidimensional extension of these parameters can improve ECV outcome prediction. Results showed that multidimensional parameters provided more balanced values of sensitivity and specificity than unidimensional ones. While FWA and DF showed similar discriminant ability among both approaches, multivariate SEn improved the discriminant ability of its univariate version by 5%, thus predicting 80% of the ECV procedures correctly. Consequently, whereas multivariate extension of linear parameters did not reveal new predictive information, multidimensional entropy analysis was able to quantify novel AA dynamics, which have been helpful in improving ECV outcome prediction., This research was funded by projects DPI2017-83952-C3 from MINECO/AEI/FEDER EU, SBPLY/17/180501/000411 from "Junta de Castilla la Mancha" and AICO/2019/036 from "Generalitat Valenciana".

Objective The objective was to assess the role of office and ambulatory blood pressure (BP) on the development of end-stage renal disease (ESRD) in nondiabetic chronic renal failure. Design and method Seventy-nine patients [mean age 57 (standard deviation 11) years, 47 men, BMI 28 (4), office BP 151 (25)/92 (14) mmHg, estimated glomerular filtration rate 28 (14) ml/min per 1.73 m3] were included. The causes of renal disease were nephrosclerosis (n = 33), glomerulonephritis (n = 19), interstitial (n = 12) and others (n = 15). The average follow-up was 44 months (range 9-72 months). The primary outcome was a composite of death, from any cause, or the development of ESRD that require initiation of renal replacement therapy. In all patients, 24-h ambulatory BP monitoring and left ventricular mass assessment were performed at the beginning of the study. Results During the follow-up period, 41 (52%) patients progressed to ESRD. In addition, nine (11%) patients died, four before reaching ESRD. Then the combined endpoint rate, 45 patients, was 6.3/100 patients per year. In a multivariate Cox proportional hazard model, which includes age, sex, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker status and the estimated glomerular filtration rate, office BP still provided no further prognostic information on risk of the primary outcome. In addition, daytime ambulatory BP and the no-dipper status did not further discriminate in terms of predicting endpoint. Nocturnal SBP more than 130 mmHg was associated with a doubling of risk [heart rate 2.07 (95% confidence interval 1.01-4.25)] on top of the other significant factors. Conclusion Glomerular filtration rate and nocturnal SBP values, but not nondipper pattern, were associated with risk to develop ESRD.

Introduction and objectives. The best therapeutic approach for persistent atrial fibrillation has yet to be defined. Our aim was to investigate the effects of cardioversion in unselected patients with persistent atrial fibrillation who were treated according to a strict protocol involving pretreatment, cardioversion, and follow-up. Methods. Consecutive patients with persistent atrial fibrillation of at least 1 months’ duration were included prospectively in a cardioversion protocol that involved standard antiarrhythmic pretreatment, with amiodarone being offered first, and follow-up. Results. The study included 295 patients, 87.5% of whom were taking the antiarrhythmic drug amiodarone. Sinus rhythm was restored in 92.5%, with pharmacologic cardioversion occurring in 9.5%. The recurrence rate was 33.5% in the first month and 54.9% by month 12. Antiarrhythmic treatment had to be modified in 10.8% of patients. Independent risk factors for recurrence during the first year after cardioversion were an atrial fibrillation duration greater than 1 year, previous cardioversion, and left ventricular dilatation. A simple risk scoring system was able to differentiate between subgroups of patients with a low, intermediate or high risk of recurrence in the first year after cardioversion. Conclusions. Sinus rhythm was maintained for 1 year after effective cardioversion in 45.1% of patients who received homogeneous antiarrhythmic pretreatment. There were few side effects. Recurrence can be predicted using clinical variables such as left ventricular dilatation, arrhythmia duration, and previous cardioversion.

Objectives We sought to prospectively assess the diagnostic yielding of a protocol in which electrophysiologic studies (EPS), tilt-table tests (TTTs), and loop recorder implantation are selectively used. Background The optimal strategy in the diagnosis of patients with syncope of unknown cause has not been defined. Methods A total of 184 consecutive patients with syncope of unknown cause were classified into two groups. Group A consisted of 72 patients fulfilling any of the following criteria: 1) presence of structural heart disease or family history of sudden death; 2) abnormal electrocardiogram; 3) significant non-symptomatic arrhythmia on Holter monitoring; and 4) paroxysmal palpitations immediately before or after syncope. These patients initially underwent an EPS and, if this study was negative, TTT. In the remaining 112 patients (group B), TTT was performed Results The EPS was positive in 32 patients (44%) in group A. The TTT was positive in 80 patients (71%) in group B. An additional patient had carotid sinus hypersensitivity. In patients of group A with a negative EPS, the TTT was positive in 23 (57%). A loop recorder was implanted in 15 patients from group A with negative conventional testing, and diagnostic activation was obtained in seven patients. Overall, a positive diagnosis was achieved in 143 patients (78%). Conclusions In patients with syncope of unknown cause, selective use of EPS or TTT leads to a positive diagnosis in >70% of the cases. An implantable loop recorder can be useful in non-diagnosed cases.

Introduccion y objetivos Antes de incluir la troponina I en la practica diaria de nuestro hospital, realizamos un estudio prospectivo para determinar su utilidad real y el mejor punto de corte. Metodos Estudiamos a 82 pacientes consecutivos ingresados por angina inestable en un hospital comarcal. Se determino la troponina I (> 10 h del episodio de dolor toracico). Los pacientes fueron remitidos a un hospital terciario para cateterismo/revascularizacion en caso de algun acontecimiento clinico. Resultados Durante el ingreso se detectaron acontecimientos en 25 casos (31%): angina recurrente en 23 (28%), insuficiencia cardiaca en 5 (6%), infarto en 1 (1%) y muerte en 3 (4%). El mejor punto de corte de la troponina I para predecir acontecimientos fue 0,1 ng/ml. Los 34 pacientes (42%) con troponina I > 0,1 presentaron mas acontecimientos (47 frente a 19%; OR = 3,8 [1,4-10,4]; p = 0,01), angina recurrente (42 frente a 19%), insuficiencia cardiaca (12 frente a 2%) y fallecimiento (9 frente a 0%). Los pacientes con cambios ECG y troponina I > 0,1 sufrieron mas acontecimientos (63%; p 0,1 (15%), o aquellos sin cambios ECG y troponina I Conclusiones La troponina I es de utilidad para predecir el riesgo hospitalario en pacientes con angina inestable en un hospital comarcal. Un punto de corte bajo (0,1 ng/ml) predice la aparicion de acontecimientos. La asociacion de cambios ECG y troponina I positiva identifica a un grupo de alto riesgo; sin embargo, la ausencia de ambas variables en pacientes con un diagnostico de angina inestable no asegura una buena evolucion.

Introduction: We analysed QT dispersion within the first 6 months postinfarction, its relationship with the main established risk stratifiers and its clinical value. Methods and results: In 55 patients with a first Q-wave myocardial infarction the 12-lead electrocardiogram was scanned and digitised for analysis of QT dispersion (QT maximum–QT minimum) at first day (72 [61–96] ms), first week (69 [47–90] ms), first month (67 [46–88] ms) and sixth month (47 [40–74] ms; P Conclusion: QT dispersion decreases progressively during the first months after myocardial infarction. These changes should be taken into account to define cut-off values of clinical interest in this phase. This variable does not seem related to the classic prognosis predictors. In a nonselected postinfarction population it has a low clinical value.

The best therapeutic approach for persistent atrial fibrillation has yet to be defined. Our aim was to investigate the effects of cardioversion in unselected patients with persistent atrial fibrillation who were treated according to a strict protocol involving pretreatment, cardioversion, and follow-up.Consecutive patients with persistent atrial fibrillation of at least 1 months' duration were included prospectively in a cardioversion protocol that involved standard antiarrhythmic pretreatment, with amiodarone being offered first, and follow-up.The study included 295 patients, 87.5% of whom were taking the antiarrhythmic drug amiodarone. Sinus rhythm was restored in 92.5%, with pharmacologic cardioversion occurring in 9.5%. The recurrence rate was 33.5% in the first month and 54.9% by month 12. Antiarrhythmic treatment had to be modified in 10.8% of patients. Independent risk factors for recurrence during the first year after cardioversion were an atrial fibrillation duration greater than one year, previous cardioversion, and left ventricular dilatation. A simple risk scoring system was able to differentiate between subgroups of patients with a low, intermediate or high risk of recurrence in the first year after cardioversion.Sinus rhythm was maintained for 1 year after effective cardioversion in 45.1% of patients who received homogeneous antiarrhythmic pretreatment. There were few side effects. Recurrence can be predicted using clinical variables such as left ventricular dilatation, arrhythmia duration, and previous cardioversion.

Before including troponin I detection in the daily practice of our hospital we performed a prospective study to determine its real usefulness and to establish the best cut-off point.We studied 82 consecutive patients admitted with unstable angina to a community hospital. Troponin I was determined (10 h after chest pain). Patients were referred to a tertiary hospital for catheterization/revascularization if clinical events developed.Twenty-five patients (31%) suffered events during admission: recurrent angina in 23 cases (28%); heart failure in 5 (6%); exitus in 3 (4%); myocardial infarction in 1 (1%). The cut-off point for troponin I that best predicted events was 0.1 ng/ml. Patients with troponin I0.1 (34 patients, 42%) experienced more events [47 vs. 19%; OR = 3.8 (1.4-10.4); p = 0.01] and had higher rates of recurrent angina (42 vs. 19%), heart failure (12 vs. 2%) and exitus (9 vs 0%). Patients with ECG changes and troponin I0.1 showed a significantly higher percentage of events (63%) than those with ECG changes alone (23%) or troponin I0.1 alone (15%) or those without ECG changes and troponin I0.1 (17%) (p0.0001).Troponin I elevation is useful for predicting in-hospital risk for unstable angina patients admitted to a community hospital. A low cut-off value (0.1 ng/ml) predicts events. The association of ECG changes and high troponin I identifies a population at very high risk; however, the absence of both variables in patients with a diagnosis of unstable angina does not preclude the development of events.

A 26-year-old man was admitted to our hemodynamic laboratory because of an anterior AMI and post myocardial infarction angina. He is an active smoker (10 cigarettes/day) and consumes inhaled cocaine during weekends (the last consumption of cocaine was 1 week ago). No others risk factors were recorded. Initial electrocardiogram shows sinus rhythm and anterior QS complex (V1–V3) with anterolateral ST segment elevation (V1–V5, D1 and aVL). Creatine-kinase isoenzyme MB and Troponin I were elevated at arrival. Upon admission, the patient was normotensive but with signs of pulmonary congestion. Ventriculography showed anterolateral and apical hypokinesia with an ejection fraction of 21%. Coronariography revealed a massive thrombosis and distal vasoconstriction of the left anterior descending coronary artery. Circumflex and right coronary artery were angiographically normals (Fig. 1). Recombinant tissue plasminogen activator was started by intracoronary infusion (50 mg) with additional 50 mg via systemic. Clinical evolution was satisfactory without new