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Varón de 72 años que, tras sufrir un infarto agudo de miocardio sin elevación del segmento ST (IAMSEST), es sometido a intervención coronaria percutánea (ICP) en etapas por presentar estenosis significativa de las arterias descendente anterior (DA) media y circunfleja (Cx) media (figura 1A; flecha roja). Después de colocar una guía intracoronaria hidrofílica y de alto torque en la Cx, se implantó sin complicaciones un stent farmacoactivo (SFA) (figura 1B y figura 1C). Sin embargo, a continuación no se logró extraer la guía, probablemente por atrapamiento en placa calcificada. La mayor tracción ejercida provocó la fractura parcial de la guía con deshilachamiento de los coils (figura 1D, flechas blancas; la flecha roja apunta a la segunda guía insertada). Se intentó recuperarla sin éxito empleando diferentes técnicas, como la extracción mediante lazo y la de la guía retorcida o trenzada (twisting wires) (vídeo 1 del material adicional).

Background Pacing in vasovagal syncope remains controversial. Objectives The authors evaluated dual-chamber pacing with closed loop stimulation (DDD-CLS) in patients with cardioinhibitory vasovagal syncope. Methods This randomized, double-blind, controlled study included Canadian and Spanish patients age ≥40 years, with high burden syncope (≥5 episodes, ≥2 episodes in the past year), and a cardioinhibitory head-up tilt test (bradycardia 3 s). Patients were randomized to either DDD-CLS pacing for 12 months followed by sham DDI mode pacing at 30 pulses/min for 12 months (group A), or sham DDI mode for 12 months followed by DDD-CLS pacing for 12 months (group B). Patients in both arms crossed-over after 12 months of follow-up or when a maximum of 3 syncopal episodes occurred within 1 month. Results A total of 46 patients completed the protocol; 22 were men (47.8%), and mean age was 56.30 ± 10.63 years. The mean number of previous syncopal episodes was 12 (range 9 to 20). The proportion of patients with ≥50% reduction in the number of syncopal episodes was 72% (95% confidence interval [CI]: 47% to 90%) with DDD-CLS compared with 28% (95% CI: 9.7% to 53.5%) with sham DDI mode (p = 0.017). A total of 4 patients (8.7%) had events during DDD-CLS and 21 (45.7%) during sham DDI (hazard ratio: 6.7; 95% CI: 2.3 to 19.8). Kaplan-Meier curve was significantly different between groups in time to first syncope: 29.2 months (95% CI: 15.3 to 29.2 months) versus 9.3 months (95% CI: 6.21 months, NA; p Conclusions DDD-CLS pacing significantly reduced syncope burden and time to first recurrence by 7-fold, prolonging time to first syncope recurrence in patients age ≥40 years with head-up tilt test–induced vasovagal syncope compared with sham pacing. (Closed Loop Stimulation for Neuromediated Syncope [SPAIN Study]; NCT01621464)

One 72-year-old male who recently suffered from a non–ST-segment elevation myocardial infarction (NSTEMI) underwent a staged percutaneous coronary intervention (PCI) due to significant stenosis of his mid left anterior descending (LAD) and mid left circumflex (LCX) arteries (figure 1A; red arrow). After placing one hydrophilic Hi-Torque intracoronary guidewire into the LCX, one drug-eluting stent (DES) was deployed uneventfully (figure 1B and figure 1C). However, we were unable to extract the guidewire afterwards probably due to entrapment with a calcified plaque. The stronger traction resulted in the partial fracture of the guidewire followed by the disruption of the coils (figure 1D, white arrows; the red arrow points to a second inserted guidewire). Retrieval was unsuccessfully attempted using different techniques like the snare loop technique and the twisting wire technique (video 1 of the supplementary data). After the uncomplicated stenting of the mid LAD, we conducted an optical coherence tomography (OCT). A three-dimensional reconstruction showed remains of the broken wire (figure 2; blue arrows) coming out of the LCX (figure 2; yellow asterisk) and into the left main stem (LMS) and proximal LAD with presence of adhered and free-floating thrombotic material as shown in the cross-sectional views (figure 3A and figure 3B; blue arrows point to the wire remains; the yellow arrow points to the thrombotic material; MLA, minimal lumen area; video 2 of the supplementary data). We immediately proceeded to eliminate the uncoiled filaments from the circulation by deploying one DES into the distal LMS and the proximal LAD. The control OCT conducted showed the wire remains trapped by the struts of the stent against the vessel wall (figure 3C; white arrow: wire remains, highlighted in red-framed box; red asterisks: stent struts).

Misoprostol is widely used for the medical management of incomplete abortion. Few serious adverse events have been reported, so it is considered a safe drug. We present a case of a 40-year-old woman in which misoprostol preceded coronary artery spasm.

The soluble isoform of ST2 (sST2) represents a powerful prognostic biomarker in patients with heart failure and acute coronary syndromes. In patients with ST-segment elevation myocardial infarction (STEMI), concentrations of sST2 are elevated early and identify a higher risk of death, adverse

Background: The implantable loop recorder (ILR) is a useful tool for diagnosis of syncope or palpitations. Its easy use and safety have extended its use to secondary hospitals (those without an Electrophysiology Lab). The aim of the study was to compare results between secondary and tertiary hospitals. Methods: National prospective and multicenter registry of patients with an ILR inserted for clinical reasons. Data were collected in an online database. The follow-up ended when the first diagnostic clinical event occurred, or 1 year after implantation. Data were analyzed according to the center of reference; hospitals with Electrophysiology Lab were considered Tertiary Hospi­tals, while those hospitals without a lab were considered Secondary Hospitals. Results: Seven hundred and forty-three patients (413 [55.6%] men; 65 ± 16 year-old): 655 (88.2%) from Tertiary Centers (TC) and 88 (11.8%) from Secondary Centers (SC). No differences in clinical characteristics between both groups were found. The electrophysi­ologic study and the tilt table test were conducted more frequently in Tertiary Centers. Fol­low-up was conducted for 680 (91.5%) patients: 91% in TC and 94% in SC. There was a higher rate of final diagnosis among SC patients (55.4% vs. 30.8%; p < 0.001). Tertiary Hospital patients showed a trend towards a higher rate of neurally mediated events (20% vs. 4%), while bradyarrhythmias were more frequent in SC (74% vs. 60%; p = 0.055). The rate of deaths and adverse events was similar in both populations. Conclusions: Patients with an ILR in SC and TC have differences in terms of the use of complementary tests, but not in clinical characteristics. There was a higher rate of diagnosis in Secondary Hospital patients.

Pacing in vasovagal syncope remains controversial.The authors evaluated dual-chamber pacing with closed loop stimulation (DDD-CLS) in patients with cardioinhibitory vasovagal syncope.This randomized, double-blind, controlled study included Canadian and Spanish patients age ≥40 years, with high burden syncope (≥5 episodes, ≥2 episodes in the past year), and a cardioinhibitory head-up tilt test (bradycardia 40 beats/min for 10 s or asystole3 s). Patients were randomized to either DDD-CLS pacing for 12 months followed by sham DDI mode pacing at 30 pulses/min for 12 months (group A), or sham DDI mode for 12 months followed by DDD-CLS pacing for 12 months (group B). Patients in both arms crossed-over after 12 months of follow-up or when a maximum of 3 syncopal episodes occurred within 1 month.A total of 46 patients completed the protocol; 22 were men (47.8%), and mean age was 56.30 ± 10.63 years. The mean number of previous syncopal episodes was 12 (range 9 to 20). The proportion of patients with ≥50% reduction in the number of syncopal episodes was 72% (95% confidence interval [CI]: 47% to 90%) with DDD-CLS compared with 28% (95% CI: 9.7% to 53.5%) with sham DDI mode (p = 0.017). A total of 4 patients (8.7%) had events during DDD-CLS and 21 (45.7%) during sham DDI (hazard ratio: 6.7; 95% CI: 2.3 to 19.8). Kaplan-Meier curve was significantly different between groups in time to first syncope: 29.2 months (95% CI: 15.3 to 29.2 months) versus 9.3 months (95% CI: 6.21 months, NA; p 0.016); odds ratio: 0.11 (95% CI: 0.03 to 0.37; p 0.0001).DDD-CLS pacing significantly reduced syncope burden and time to first recurrence by 7-fold, prolonging time to first syncope recurrence in patients age ≥40 years with head-up tilt test-induced vasovagal syncope compared with sham pacing. (Closed Loop Stimulation for Neuromediated Syncope [SPAIN Study]; NCT01621464).

Resumen Antes de la implantacion del programa, la intervencion coronaria percutanea primaria era la excepcion en el tratamiento del infarto agudo de miocardio, a pesar de que se reperfundia con fibrinoliticos a menos del 40% de los pacientes. Desde 1998 se comenzo a tratar con intervencion coronaria percutanea primaria a todos los pacientes que acudian al Hospital Universitario Virgen de la Arrixaca. En el ano 2000, se diseno un programa de tratamiento del infarto agudo de miocardio con intervencion coronaria percutanea primaria para toda la Region de Murcia, al que se denomino APRIMUR, estableciendo una primera fase que solo incluia los tres hospitales de la capital. El programa se hizo extensible al resto de la Region en 2001. Se describe del programa sus primeras fases, el transporte, la metodologia de trabajo, los objetivos primarios y secundarios, lo que consideramos puntos clave y su sostenibilidad. Se han realizado mas de 3.500 intervenciones coronarias percutaneas primarias, con una media mensual actual de 40–45 casos. La mortalidad ha ido variando desde cifras anuales superiores al 10% a las mas actuales del 6% en 2007 y el 6,6% en 2009. Hemos conseguido que, al menos en la mitad de la Region, las cifras de reperfusion superen el 90% y vayan aumentando anualmente en el resto de las comarcas.

Introduccion y objetivos. El intervencionismo coronario percutaneo (ICP) de la enfermedad de tronco coronario izquierdo (TCI) no protegido puede ser necesaria en el infarto agudo de miocardio (IAM). Sin embargo, la evidencia del ICP urgente en el TCI fuera de ensayos clinicos no es muy amplia. El objetivo del estudio es evaluar la mortalidad intrahospitalaria, sus predictores y su asociacion con shock, asi como eventos a largo plazo en pacientes con enfermedad de TCI tratado con ICP urgente debido a un IAM. Metodos. Se incluyo a 71 pacientes consecutivos en los que se realizo una angioplastia urgente sobre el TCI y seguimiento clinico posterior. Resultados. Presentaron IAM con elevacion del ST 42 (59%) y presentaban shock cardiogenico o lo desarrollaron durante el procedimiento 47 (66%). Murieron en la sala de hemodinamica 11 (16%) y 33 (47%) durante la hospitalizacion. La mortalidad intrahospitalaria fue independiente de la elevacion del ST en el ECG (el 45 frente al 48%; p = 1). Los predictores multivariables de mortalidad intrahospitalaria fueron el shock cardiogenico (4,5; intervalo de confianza [IC], 1,1-18) y la revascularizacion incompleta (odds ratio [OR] = 5,1; IC, 1-26). Tras el alta hospitalaria se siguio a 39 pacientes durante una mediana de 32 meses. La mortalidad durante el primer ano de seguimiento fue del 10%. Conclusiones. El ICP es una opcion terapeutica en el seno del IAM debido a enfermedad de TCI. Sin embargo, la mortalidad intrahospitalaria es elevada independientemente de la elevacion del ST en el ECG y especialmente cuando se asocia a shock cardiogenico y no se logra una revascularizacion completa.

Introduccion y objetivos Las mujeres presentan, con respecto a los varones, una mayor mortalidad y morbilidad tras un infarto agudo de miocardio con elevacion del segmento ST (IAMEST). Hay controversia sobre si la angioplastia primaria (ACTPp) como tratamiento de eleccion logra contrarrestar el peor pronostico de las mujeres en esta situacion. El objetivo fue determinar la influencia del sexo en las caracteristicas clinicas y en el pronostico intrahospitalario y a largo plazo de un grupo de pacientes con IAMEST tratados con ACTPp como metodo de reperfusion. Metodos Estudio observacional prospectivo de una cohorte de 838 pacientes consecutivos, de ellos 183 (22%) mujeres, con IAMEST tratados con ACTPp en un unico centro. Resultados Las mujeres fueron mayores (70 frente a 62 anos; p Conclusiones A pesar de los recientes avances en el tratamiento del IAMEST, las mujeres presentan una mayor mortalidad hospitalaria ajustada por caracteristicas basales. Las mujeres supervivientes tras el alta hospitalaria tuvieron una similar mortalidad a largo plazo cuando se ajusto por la edad.

Introduction and objectives. Mortality and morbidity after ST-elevation myocardial infarction (STEMI) are higher in women than men. It is not clear whether reperfusion by elective treatment with primary angioplasty can improve the poor prognosis in women with this condition. The objective of this study was to determine the effect of sex on clinical characteristics, and on in-hospital and long-term outcomes in patients with STEMI undergoing reperfusion by primary angioplasty. Methods. A prospective observational study was performed in 838 consecutive patients with STEMI treated by primary angioplasty at a single hospital. Of these, 183 (22%) were women. Results. Women were older (70 years vs 62 years; P

Introduction and objectives. Numerous variations of the head-up tilt-table test potentiated with nitrates have been reported. After the administration of nitroglycerin, between 10 and 25 min of continued tilting have been recommended. The aim of this study was to assess the optimal duration of the pharmacological phase of the headup tilt-table test potentiated with sublingual administration of nitroglycerin spray (NTG-TT). Method. The records of 498 consecutive NTG-TT were reviewed. Our protocol consisted of a 20-min drug-free phase at a 60 o angle. If syncope does not develop, 400 µg of sublingual nitroglycerin spray is administered and the patient continues to be tilted for a further 25 min. The test results and time to a positive response were analyzed. Results. The result of NTG-TT was positive in 288 procedures, most of them after nitroglycerin administration (255, 88.5%). The mean time to a positive response was 10.7 ± 6.7 and 5.0 ± 2.4 min during the control and pharmacological phases respectively. Most positive responses were concentrated in the 3 to 5 min after drug administration. The time to syncope after nitroglycerin administration was over 10 min in 9 patients and 15 min in only 2 patients. Conclusions. The duration of the pharmacological phase of NTG-TT using the described protocol can be reduced to 15 min without loss of sensitivity. A further reduction to 10 min would decrease the rate of positive responses by a small amount and might be considered clinically acceptable.

Background The implantable loop recorder (ILR) is a useful tool for diagnosing paroxysmal conditions potentially related to arrhythmias. Most investigations have focused on selected clinical studies or high-volume centers. The aim of this study was to evaluate the indications and outcomes of the ILR in real clinical practice. Methods and results This was a prospective, multicenter registry of patients undergoing ILR implantation for clinical indications (April 2006-December 2008). Clinical characteristics (symptoms, arrhythmias, treatments) were recorded in a database. Follow-up data at 1 year or after the occurrence of the first episode were also recorded. Total enrollment: 743 patients (male, 413, 55.6%; 64.9 ± 16 years); 228 (30.7%) had structural heart disease (SHD), and 183 (24.6%), bundle branch block (BBB). Recurrent syncope (76.4%) was the most common indication for implantation. Complete follow-up was obtained for 680 patients (91.5%). Three hundred and twenty-five patients (48%) presented 414 events, with a final diagnosis in 230 patients (70.8% of patients with events; 33.1% of patients with follow-up). Syncope secondary to bradyarrhythmia was the most frequent diagnosis. Similar rates of final diagnoses were noted in subgroups of SHD, BBB and normal heart. Regarding the cause of implantation, higher event rates were registered among patients with recurrent syncope. Conclusions One-third of patients obtained a final diagnosis with the ILR, independent of the baseline characteristics. Only the cause of implantation provided different rates of final diagnosis.

Rotational atherectomy allows plaque remodeling in severely calcified lesions and, prior to the adoption of clopidogrel as standard therapy, small trials showed that abciximab reduces transient hypoperfusion associated with the procedure. However, no studies have evaluated it among patients receiving dual antiplatelet therapy. This study aimed to evaluate whether abciximab reduces procedure-related myocardial injury in a non-selected population of patients receiving dual antiplatelet therapy. The study comprised a retrospective review of a nonselected cohort of 139 consecutive procedures of rotational atherectomy performed in patients pre-treated with dual antiplatelet therapy. Abciximab was administered in 48 (34.5%) patients, whereas 91 (65.5%) did not receive it. The only difference between groups was a higher rate of diabetes mellitus in the abciximab group (89% vs. 51%, p=0.001). The rate of procedural complications was 10.5% for patients with abciximab vs. 6.2% for patients without (p=0.537). After 24 hours, the peak of biomarkers of myocardial damage (CKmb and TnT) did not differ, and the rate of procedure-related myocardial injury was 23.9% with abciximab and 20.7% without (p=0.664). In a restricted analysis to diabetic patients (n=84), the rate of myocardial injury was 27.5% with abciximab vs. 18.6% without, (p=0.435). After adjusting by clinical and procedural parameters in a logistic regression model, abciximab use did not confer any significant reduction on procedure-related myocardial injury. In conclusion, in a non-selected cohort of patients receiving dual antiplatelet therapy, the administration of abciximab in the setting of rotational atherectomy did not reduce the incidence of procedure related myocardial injury.

Introduction and objectives Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease may be essential following acute myocardial infarction (AMI). However, few data are available on the use of emergency PCI in unprotected LMCAs outside of clinical trials. The objective of this study was to determine the frequency of in-hospital mortality, its predictors, and its association with cardiogenic shock, and long-term outcomes in patients with unprotected LMCA disease who undergo emergency PCI because of AMI. Methods The study included 71 consecutive patients who underwent emergency angioplasty of the LMCA and who were followed up clinically. Results Overall, 42 patients (59%) had ST-elevation AMI and 47 (66%) had cardiogenic shock or developed it during PCI. Eleven patients (16%) died in the catheterization laboratory and 33 (47%) died during hospitalization. Inhospital mortality was similar in those with and without evidence of ST-segment elevation on ECG (48% vs 45%; P =1). Multivariate analysis showed that the predictors of in-hospital mortality were cardiogenic shock (odds ratio [OR] =4.5; 95% confidence interval [CI], 1.1-18) and incomplete revascularization (OR=5.1; 95% CI, 1.0-26). After discharge, 39 patients were followed up for a median of 32 months. Mortality in the first year was 10%. Conclusions Emergency PCI is a viable therapeutic option for AMI due to unprotected LMCA disease. However, in-hospital mortality is high, regardless of STsegment elevation, particularly if there is cardiogenic shock or complete revascularization has not been achieved.

Introduction and objectives. The magnitude of the change in heart rate during the first few minutes of the head-up tilt test has been used to predict the test’s result. The aim of this study was to investigate whether the heart rate increase during the head-up tilt test potentiated with nitroglycerin is related to the development of syncope. Patients and method. The study included 158 consecutive patients with syncope, with stable sinus rhythm, and without structural cardiac disease who were undergoing a head-up tilt test with nitroglycerin. The heart rate increment induced by the tilt maneuver and by nitroglycerin administration was calculated, and its relationship to clinical variables and to the test’s results was analyzed. Results. The head-up tilt test gave positive results in 117 patients (74%). The heart rate was 68.7 (11.3) bpm in the decubitus position and 85.1 (15.4) bpm during the first 6 min of tilting. There was strong inverse correlation between the heart rate increase induced by tilting and age (r=‐0.63; P

Introduccion y objetivos. El incremento acentuado de la frecuencia cardiaca en los primeros minutos de la prueba de basculacion ha sido utilizado como predictor del resultado final de esta, en protocolos sin potenciacion farmacologica o con isoproterenol. El objetivo del estudio es evaluar si este incremento se relaciona con la aparicion de sincope durante la prueba de basculacion potenciada con nitroglicerina. Pacientes y metodo. Analisis retrospectivo de 158 pacientes consecutivos sometidos a prueba de basculacion potenciada con nitroglicerina por sincope, sin cardiopatia y en ritmo sinusal. Se calculo el incremento de la frecuencia cardiaca secundario a la basculacion y el debido a la nitroglicerina, relacionandolos con las variables clinicas y el resultado de la prueba. Resultados. La prueba de basculacion fue positiva en 117 pacientes (74%). La frecuencia cardiaca paso de 68,7 ± 11,3 lat/min en decubito a 85,1 ± 15,4 lat/min en los primeros 6 min posbasculacion. El incremento de frecuencia presento una fuerte correlacion negativa con la edad (r = ­-0,63; p < 0,001), pero no se relaciono significativamente con el resultado (16,8 ± 9,3 lat/min en el grupo con prueba positiva frente a 14,9 ± 11,3 en el negativo; p = 0,3). El aumento de la frecuencia cardiaca inducido por la nitroglicerina (27,3 ± 12,6 y 26,7 ± 13,4 lat/min, respectivamente; p = 0,8) tampoco predijo el resultado del test durante la fase farmacologica. Conclusiones. Los incrementos de frecuencia cardiaca en los primeros minutos despues de la basculacion y la administracion del farmaco se relacionan fundamentalmente con la edad y no tienen utilidad para predecir el resultado de la prueba de basculacion potenciada con nitroglicerina.

The propensity for spontaneous and tilt-induced neurocardiogenic syncope may exhibit temporal variations. Therefore the diagnostic performance of the head-up tilt test could be improved if it were performed soon after the occurrence of spontaneous syncope. The objective of this study was to assess whether the time interval between the last syncopal episode and tilt table testing influenced the outcome of the test.Three hundred and fifteen patients undergoing diagnostic tilt table testing potentiated with nitroglycerin for suspected neurocardiogenic syncope were included in the study. The time between the last spontaneous syncope and the tilt table test was recorded and its relationship with the results of the test was analyzed.The tilt table test was positive in 211 patients (67.0%). The time from syncope to test was similar for patients with positive and negative tilt table test results: 28 (1-500) vs 32 (2-700) days (NS). No significant relation was observed between the results of the test and the occurrence of spontaneous syncope during the week, the month or the three months previous to the procedure. However, in men and in patients older than 50 years a higher rate of positive tests was observed if the tilt test was performed within the first month after the last spontaneous syncope.The time from the last previous spontaneous syncope to the head-up tilt test does not have a significant impact on test outcome in the overall population with suspected neurocardiogenic syncope. However, the rate of positivity might decrease in men and patients older than 50 years if the test is performed later than one month after the spontaneous syncopal episode.

Numerous variations of the head-up tilt-table test potentiated with nitrates have been reported. After the administration of nitroglycerin, between 10 and 25 min of continued tilting have been recommended. The aim of this study was to assess the optimal duration of the pharmacological phase of the head-up tilt-table test potentiated with sublingual administration of nitroglycerin spray (NTG-TT).The records of 498 consecutive NTG-TT were reviewed. Our protocol consisted of a 20-min drug-free phase at a 60o angle. If syncope does not develop, 400 microgram of sublingual nitroglycerin spray is administered and the patient continues to be tilted for a further 25 min. The test results and time to a positive response were analyzed.The result of NTG-TT was positive in 288 procedures, most of them after nitroglycerin administration (255, 88.5%). The mean time to a positive response was 10.7 6.7 and 5.0 2.4 min during the control and pharmacological phases respectively. Most positive responses were concentrated in the 3 to 5 min after drug administration. The time to syncope after nitroglycerin administration was over 10 min in 9 patients and 15 min in only 2 patients.The duration of the pharmacological phase of NTG-TT using the described protocol can be reduced to 15 min without loss of sensitivity. A further reduction to 10 min would decrease the rate of positive responses by a small amount and might be considered clinically acceptable.

We present the case of a 74-year-old man with diabetes and hypertension who had to be rescued owing to a near-drowning syndrome at sea. When he was rescued, he complained of dyspnea and chest pain. An electrocardiogram (ECG) suggested acute coronary syndrome (ACS) affecting the left main coronary artery. Therefore, he was referred to our hospital for urgent coronary angiography. Arriving at our hospital, the patient was asymptomatic, but his blood pressure and saturation were normal. The ECG (Figure 1) showed normalization of previous anomalies. Besides, an echocardiogram showed nothing abnormal, and a blood sample was normal and served as a cardiac marker. Angiogram showed normal coronary arteries. After the procedure, the patient remained asymptomatic without an increase of cardiac enzymes, and he was discharged from the hospital after three days. Figure 1 First ECG, with the patient complaining of chest pain and dyspnea, showing ST depression in inferior and left precordial leads and elevation in V1 and VR (A). Second ECG, during the transfer to the hospital, showing minimal changes in ST segment (B). ... The initial response to immersion is apnea and aspiration of water, provoking a syndrome of respiratory failure and changes in serum electrolytes. This is frequently associated with hypothermia, which can lead to cardiac damages, mainly, conduction disturbance and ventricular arrhythmia.[1] A study[2] showed that the appearance of ECG changes in dogs subjected to experimental aspiration of fresh or sea water provoked bradycardia, tall T waves and ventricular fibrillation or ventricular asystole as the cause of death. Another study found[3] ECG changes in 37 patients who suffered from a near-drowning syndrome at the Dead Sea in addition to important changes in electrolyte levels, namely, hypercalcemia and hypermagnesemia. The most common findings were sinus tachycardia, prolongation of PR interval, widening of QRS complex and inversion of T waves. Nearly 35% of the 37 patients presented with ST segment depression. Besides, cases of Tako-Tsubo cardiomyopathy and corresponding ECG changes after near-drowning have also been reported.[4] Our case illustrates the importance of differential diagnosis in cases of near-drowning, since the associated symptoms can easily be mistaken with those of ACS. ECG changes could be confusing, leading to the mismanagement of the patient. In our case, clinical evolution and coronary angiogram of the patient were conducive to the correct diagnosis and treatment of the condition. In conclusion, the ECG findings of patients suffering from near-drowning may be similar to those of the patients affected by ACS with left coronary artery involvement. Hence, the patients should be managed with caution and a differential diagnosis should be made. An accurate medical history and additional examinations such as coronary angiogram are also necessary so as to make a final diagnosis and choose an appropriate treatment.

We have read with great interest the article published by Liu et al .1 about the duration of the tilt test in patients with suspected vasovagal syncope. We would like to highlight that a very similar paper (Head-up Tilt Test Potentiated with Nitroglycerin. What is the Optimal Duration of the Test after Administration of the Drug?2) was published by our group in 2002 in Rev Esp Cardiol , with an English …

A 66-year-old woman was admitted to our hospital with chest pain. Three months earlier, she underwent implantation of a mechanical mitral prosthesis with normal findings on preoperative angiography. The electrocardiogram obtained in the emergency department showed negative T waves in leads V2 to