Search

Background: A definition of myocardial infarction with non-obstructive coronary arteries (MINOCA) was published by European Society of Cardiology in 2016. The aim of this study is to analyze the clinical profile and prognosis of these patients in a prospective single-center study and compare it with the literature data. Methods: During a 3-year period, information from every consecutive MINOCA patient was gathered (n = 109). It was then compared with 412 contemporaneous patients with myocardial infarction and obstructive coronary arteries (MIOCA). Univariate and multivariate analyses were performed. Prognosis analysis was adjusted by age and cardiovascular risk factors (CVRF). Results: MINOCA represented 16.9% of the total of patients admitted for myocardial infarction. Compared with MIOCA, they had more psychosocial disorders (22.9% vs. 10.7%; p < 0.01) and more pro-inflammatory conditions (34.9% vs. 14.0%; p < 0.01). Atrial fibrillation was twice as frequent in MINOCA (14.7% vs. 7.3%; p = 0.016). Predictors of MINOCA were as follows: female gender, absence of diabetes, absence of tobacco use, tachycardia, troponin above 10 times the 99 th percentile, and pro-inflammatory conditions. Median follow-up was 17.3 ± 9.3 months. Major adverse cardiovascular events (MACE; a composite of a recurrence of acute myocardial infarction, transient ischemic attack/stroke, or death from cardiovascular cause and death from any cause) occurred in 10.8% of the MINOCA group as compared with 10.7% in the MIOCA group (hazard ratio [HR] 1.19, 95% confidence interval [CI] 0.58–2.45; p = 0.645). Cardiovascular re-admission rates were higher in the MINOCA group: 19.8% vs. 13.9% (HR 1.85; CI 1.06–3.21; p = 0.030). Conclusions: The frequency of MINOCA is high, with fewer CVRF, and it is linked to atrial fibrillation, psychosocial disorders, and pro-inflammatory conditions. Mid-term prognosis is worse than previously thought, with a similar proportion of MACE as compared to MIOCA, and even a higher rate of cardiovascular re-admissions.

Introduction and objectives Episodes of extreme heat are associated with increased morbidity and mortality in chronically-ill patients but there is a need to clearly establish the relationship between extreme heat and myocardial infarction. The aim of this study was to analyze the relationship between the incidence of ST-segment elevation myocardial infarction (STEMI) and maximum temperature, in particular during heat wave alert periods (HWAP). Methods The population studied consisted of confirmed STEMI cases registered in the Infarction Code of the Community of Madrid between June 2013 and June 2017. Incidence rate ratios (IRR) adjusted for trend and seasonality and 95%CI were estimated using time series regression models. Results A total of 6465 cases of STEMI were included; 212 cases occurred during the 66-day period of HWAP and 1816 cases during the nonalert summer period (IRR, 1.14; 95%CI, 0.96-1.35). The minimum incidence rate was observed at the maximum temperature of 18 °C. Warmer temperatures were not associated with a higher incidence (IRR,1.03; 95%CI, 0.76-1.41), whereas colder temperatures were significantly associated with an increased risk (IRR, 1.25; 95%CI, 1.02-1.54). No effect modification was observed by age or sex. Conclusions We did not find an increased risk of STEMI during the 66 days of HWAP in the Community of Madrid between June 2013 and June 2017. However, an increased risk was found during colder temperatures. No extra health resources for STEMI management are required during periods of extreme heat, but should be considered during periods of cold weather. Resumen Introducción y objetivos Los episodios de calor extremo se asocian con una mayor morbimortalidad de los enfermos crónicos, pero su relación con el infarto de miocardio no está claramente establecida. El objetivo es analizar una posible relación entre la incidencia de infarto agudo de miocardio con elevación del segmento ST (IAMCEST) y la temperatura máxima, especialmente durante los periodos de alerta por ola de calor (PAOC). Métodos La población estudiada son los casos de IAMCEST confirmado registrados en Código Infarto Madrid entre junio de 2013 y junio de 2017. Se estimaron las razones de tasa de incidencia (RTI) ajustadas por tendencia y estacionalidad y sus IC95% asociadas con los PAOC y con la temperatura máxima, utilizando modelos de regresión de series temporales. Resultados Se incluyó a 6.465 casos de IAMCEST. En 66 días de PAOC hubo 212 casos y 1.816 casos durante los días de verano sin alerta (RTI = 1,14; IC95%, 0,96-1,35). La tasa de incidencia mínima se observó con temperatura máxima de 18 °C. Las temperaturas más cálidas no se asociaron con mayor incidencia (RTI = 1,03; IC95%, 0,76-1,41); por el contrario, hubo un incremento significativo con las temperaturas más frías (RTI = 1,25; IC95%, 1,02-1,54). No hubo modificación por sexo o edad. Conclusiones Durante los PAOC entre junio de 2013 y junio de 2017 en la Comunidad de Madrid, no se observó un aumento de la incidencia de IAMCEST, pero sí durante periodos de bajas temperaturas. No cabe esperar un mayor uso de los recursos sanitarios para el IAMCEST en periodos de calor extremo, pero sí durante los periodos fríos., A. Tobías received support from the Japanese Society for the Promotion of the Science (JSPS) in its grant invitation program for research in Japan (S18149).

INTRODUCTION AND OBJECTIVES To analyze differences between sexes in the clinical management of patients presenting with symptoms of chest pain and/or palpitations within a population-based study. METHODS The OFRECE study included a random sample of 8400 individuals from the Spanish population aged 40 years and older; 1132 (13.5%) had previously consulted for chest pain and 1267 (15.1%) had consulted for palpitations and were included in the present study. We calculated both the crude and adjusted odds ratios (OR) of undergoing certain tests and the results of consultations by sex. Adjustment was performed by classic cardiovascular risk factors, a personal history of cardiovascular disease, and a diagnosis of stable angina or atrial fibrillation confirmed in the OFRECE study in each case. RESULTS No differences were observed in history of consultation for chest pain between women and men (13% vs 14.1%; P=.159) but differences were found in palpitations (19% vs 10.4%, respectively; P

Resumen Introduccion y objetivos En un estudio de base poblacional, se analizaron las posibles diferencias en funcion del sexo en la atencion al dolor toracico o las palpitaciones como motivo de consulta. Metodos El estudio OFRECE incluyo una muestra aleatoria de la poblacion espanola de 8.400 participantes de edad ≥ 40 anos, de los que 1.132 (13,5%) tenian antecedentes de consulta por dolor en el pecho y 1.267 (15,1%), por palpitaciones y se incluyen en este estudio. Se calculo la odds ratio (OR) de que se practicaran determinadas pruebas y se comunicaran los resultados de las consultas en relacion con el hecho de ser mujer, tanto brutas como ajustadas por los factores de riesgo cardiovascular clasicos, antecedentes de enfermedad cardiovascular y diagnostico de angina estable o fibrilacion auricular confirmado en este estudio en cada caso. Resultados No se observaron diferencias en los antecedentes de consulta por dolor toracico entre mujeres y varones (el 13 y el 14,1%; p = 0,159) y si en las consultas por palpitaciones (el 19,0 y el 10,4% respectivamente; p Conclusiones Este trabajo no confirma un sesgo en razon del sexo en la atencion a estos sintomas, aunque no es descartable completamente un sesgo de genero en el diagnostico confirmado en el estudio que limite su capacidad para identificar diferencias en la atencion a las pacientes.

Resumen Introduccion y objetivos Las anomalias electrocardiograficas son muy comunes. El proposito de este estudio es analizar la prevalencia de hallazgos electrocardiograficos anormales y su significado clinico en la poblacion general espanola de 40 o mas anos. Metodos Subanalisis del estudio OFRECE; se selecciono una muestra representativa de la poblacion espanola de 40 o mas anos. Se dispuso de datos clinicos y electrocardiograma de todos los participantes. La lectura de los electrocardiogramas fue centralizada, los evaluaron de manera independiente 2 cardiologos expertos y se consulto con un tercero en caso de desacuerdo, para llegar al diagnostico final por consenso. Antes de iniciarse la lectura de los electrocardiogramas, se establecieron estrictamente los criterios diagnosticos de cada una de las anomalias analizadas. Se estudiaron la prevalencia y los factores clinicos asociados con: crecimiento de cavidades, trastornos de conduccion, anomalias de la repolarizacion, ondas Q patologicas, extrasistolia auricular y ventricular y preexcitacion. Resultados Se evaluo a 8.343 individuos (media de edad, 59,2 anos; el 52,4% mujeres). Solo 4.074 (51,2%) presentaron un electrocardiograma rigurosamente normal. Las anomalias mas frecuentes fueron las alteraciones inespecificas de la repolarizacion (16%) asociadas con enfermedad coronaria y fibrilacion auricular; el bloqueo de rama derecha (8,1%) asociado con enfermedad pulmonar obstructiva cronica; el hemibloqueo anterosuperior izquierdo (6,5%) relacionado con la hipertension y la insuficiencia cardiaca y el intervalo PR largo (3,7%) se asociaron con enfermedad coronaria. Conclusiones Las anomalias electrocardiograficas son muy comunes en la poblacion general de 40 o mas anos. Tan solo la mitad de la poblacion tenia un electrocardiograma rigurosamente normal.

Resumen «La Cardiologia del Futuro» es un proyecto de la Sociedad Espanola de Cardiologia (SEC) que tiene como objetivos definir hacia donde, desde la posicion actual, deben dirigirse las politicas de accion de la SEC, analizar las tendencias y los cambios del entorno que influiran en la practica de la cardiologia en Espana, definir el perfil de los cardiologos necesarios en el futuro, proponer las politicas para alcanzar los objetivos que se deriven de las necesidades identificadas, y establecer el papel que ha de desempenar la SEC en el desarrollo y la implantacion de esas politicas. En este articulo se presentan la metodologia y los hallazgos mas relevantes del informe final de este proyecto y las lineas estrategicas de actuacion de la SEC en el futuro inmediato, derivadas del analisis realizado.

BackgroundPrevious studies investigating the relationship of influenza with acute myocardial infarction (AMI) have not distinguished between AMI types 1 and 2. Influenza and cold temperature can explain the increased incidence of AMI during winter but, because they are closely related in temperate regions, their relative contribution is unknown. Methods and ResultsThe temporal relationship between incidence rates of AMI with demonstrated culprit plaque (type 1 AMI) from the regional primary angioplasty network and influenza, adjusted for ambient temperature, was studied in Madrid region (Spain) during 5 influenza seasons (from June 2013 to June 2018). A time‐series analysis with quasi‐Poisson regression models and distributed lag‐nonlinear models was used. The incidence rate of type 1 AMI according to influenza vaccination status was also explored. A total of 8240 cases of confirmed type 1 AMI were recorded. The overall risk ratio (RR) of type 1 AMI during epidemic periods, adjusted for year, month, and temperature, was 1.23 (95% CI, 1.03–1.47). An increase of weekly influenza rate of 50 cases per 100 000 inhabitants resulted in an RR for type 1 AMI of 1.16 (95% CI, 1.09–1.23) during the same week, disappearing 1 week after. When adjusted for influenza, a decrease of 1ºC in the minimum temperature resulted in an increase of 2.5% type 1 AMI. Influenza vaccination was associated with a decreased risk of type 1 AMI in subjects aged 60 to 64 years (RR, 0.58; 95% CI, 0.47–0.71) and ≥65 years (RR, 0.53; 95% CI, 0.49–0.57). ConclusionsInfluenza and cold temperature were both independently associated with an increased risk of type 1 AMI, whereas vaccination was associated with a reduced risk among older patients., This work has been partially funded by unrestricted research grants from the Fundación para la Investigación Biomédica, University Hospital “Príncipe de Asturias” (Servicio Madrileño de Salud, Madrid, Spain) (to Drs García‐Lledó and de Abajo) and funding from Sanofi‐Pasteur S.A., a manufacturer of influenza vaccines (to Dr de Abajo). The funders had no role in the study design, data collection, data analysis, data interpretation, or writing the report. Dr Tobías received support from the Japanese Society for the Promotion of Science in its invitation‐to‐research fellowship program in Japan (S18149).

Background: There is an emerging field underlying the myocardial infarction (MI) with non-obstruc­tive coronary arteries (MINOCA). The aim of this study was to evaluate the impact of psycho-emotional disorders and social habits in MINOCA patients. Methods: The study included 95 consecutive patients diagnosed of MINOCA and 178 patients with MI and obstructive lesions. MINOCA patients were included when they fulfilled the three main criteria: accomplishment of the Third Universal Definition of Myocardial Infarction, absence of obstructive coronary arteries and no clinically overt specific cause for the acute presentation. Results: MINOCA patients had a higher frequency of previous psychiatric illnesses than the obstructive coronary arteries group (29.7% vs. 12.9%, p = 0.001). MINOCA patients recognized emotional stress in 75.7% of the cases, while only 32.1% of the obstructive related group did (p < 0.001). The relation­ship remained after excluding takotsubo syndrome from the analysis (26 cases, 27.4%): psychiatric diseases (27.9% vs. 12.9%, p < 0.01) and recognition of emotional stress (70.8% vs. 32.1%, p < 0.001). Social habits which could act as stress modulating showed no significant relation with MINOCA. Conclusions: Psycho-emotional disorders are related to MINOCA and they could act as risk fac­tor. This relationship is maintained after excluding takotsubo from the analysis. (Cardiol J 2018; 25, 1: 24–31)

The Cardiology of the Future is a project of the Spanish Society of Cardiology (SEC) whose objectives are as follows: to define the action policies of the SEC; to analyze the trends and changes in the environment that will influence the practice of cardiology in Spain; to define the profile of the cardiologists needed in the future; to propose policies to achieve the objectives resulting from the identified needs; and to identify the role of the SEC in the development and implementation of these policies. This article describes the methodology and the most relevant findings of the final report of this project and the strategic lines to be developed by the SEC in the immediate future, resulting from the analysis performed. The project Cardiologists and the Cardiology of the Future and the creation of this article have been financed through the resources of the SEC. Sí

Background: Anthracycline cardiotoxicity (AC) may manifest years after treatment (long-term cardiotoxicity). There is little data on the incidence and natural history of AC in the current context, with protocols including lower anthracycline doses. The present study prospectively evaluated the incidence, time of occurrence and clinical correlates of long-term cardiotoxicity and the evolution of systolic function in patients with breast cancer treated with anthracyclines. Methods: This study prospectively included 85 consecutive patients undergoing chemotherapy (CHT) with anthracyclines without trastuzumab. All patients underwent evaluation at baseline, at the end of CHT, 3 months after the end of CHT and 1 and 4 years subsequent to the beginning of CHT. Clinical data and echocardiographic parameters were evaluated in all examinations. Results: The mean dose of doxorubicin used was 243.53 mg/m 2 . Median follow-up of the current cohort was 4.5 years. At 1 year the incidence of AC was 1% and at the end of the follow-up 16.5% (14 of 85 patients). Therefore, the incidence of long-term cardiotoxicity was 15%. Of these 14 patients with AC, 12 had asymptomatic systolic dysfunction, 1 had heart failure and 1 suffered sudden death. Fifteen percent developed systolic dysfunction during follow–up. An early decline in strain was observed in patients who developed long-term AC. Conclusions: The incidence of long-term cardiotoxicity in patients treated with low-cumulative dose of anthracyclines is high, 16.5% at 4.5 years. This was observed in almost all cases after the first year of follow-up. Therefore, long-term monitoring may be advisable.

Anthracycline cardiotoxicity (AC) may manifest years after treatment (long-term AC). There are few data on the incidence and natural history of AC in the current context. We evaluated incidence, onset time and clinical correlates of long-term AC and the evolution of systolic function in patients (

Introduction and objectives Abnormal electrocardiographic findings are highly common. The aim of this study was to analyze the prevalence of abnormal electrocardiographic patterns in the general Spanish population aged 40 years or older. Methods This subanalysis of the OFRECE study selected a representative sample of the Spanish population aged 40 years or older. Clinical data and electrocardiograms were available in all participants. The electrocardiograms were read centrally. Each electrocardiogram was independently assessed by 2 trained cardiologists and, if there was disagreement, a third was consulted to reach a consensus-based diagnosis. Prior to reading the electrocardiograms, diagnostic criteria were strictly defined for each of the abnormalities analyzed. We analyzed the prevalence and clinical factors associated with cavity enlargement, conduction disorders, repolarization abnormalities, pathological Q waves, atrial and ventricular premature beats, and pre-excitation. Results A total of 8343 individuals were evaluated, (mean age, 59.2 years; 52.4% women). Only 4074 (51.2%) participants had a completely normal electrocardiogram. The most frequent abnormalities were nonspecific repolarization abnormalities (16%) associated with coronary heart disease and atrial fibrillation; right bundle-branch block (8.1%) associated with chronic pulmonary obstructive disease; left anterior hemiblock (6.5%) related to hypertension and congestive heart failure; and long PR interval (3.7%), which was associated with coronary heart disease. Conclusions Electrocardiographic abnormalities are very common in the general population aged 40 years or older. Only about half of the population had a completely normal electrocardiogram.

[Resumen] Introducción y objetivos: Hay patrones electrocardiográficos asociados a mayor riesgo de muerte súbita por arritmias ventriculares. En España no existe información acerca de su prevalencia en la población. El objetivo es estudiar la prevalencia de estos patrones, así como los factores clinicoepidemiológicos asociados a su presencia. Métodos: Subanálisis del estudio OFRECE en el que se estudió la prevalencia de patrones electrocardiográficos de síndrome de Brugada o anomalías del intervalo QT en una muestra representativa de la población española ≥ 40 años. Se dispuso de datos clínicos y electrocardiogramas de todos los participantes. Los electrocardiogramas fueron evaluados de forma independiente por 2 cardiólogos y, en caso de desacuerdo, se consultó con un tercero. Se analizaron las prevalencias ponderadas y los factores clínicos asociados a patrones tipo Brugada o a anomalías del segmento QT. Resultados: Se evaluó a 8.343 individuos (59,2 años, 52,4% mujeres) y se detectaron 12 casos de patrón Brugada (tipo 1, 2 casos; tipo 2, 10 casos; prevalencia ponderada, 0,13%). Para el análisis del QT corregido (QTc) se excluyó a los participantes con bloqueo de rama izquierda o ritmos no sinusales. Las prevalencias ponderadas fueron: QTc corto (< 340 ms) 0,18%, QTc borderline (441-469 ms) 8,33%, QTc largo (criterio ≥ 470 ms) 1,01% y QTc largo (criterio ≥ 480 ms) 0,42%. Conclusiones: El 0,6-1,1% de la población española de edad ≥ 40 años presenta un patrón electrocardiográfico de riesgo de muerte súbita (síndrome de Brugada, QT largo o QT corto). [Abstract] Introduction and objectives: Some electrocardiographic patterns are associated with an increased risk of sudden cardiac death due to ventricular arrhythmias. There is no information on the prevalence of these patterns in the general population in Spain. The objective of this study was to analyze the prevalence of these patterns and associated clinical and epidemiological factors. Methods: This subanalysis of the OFRECE study selected a representative sample of the Spanish population aged ≥ 40 years. We studied the presence or absence of electrocardiographic patterns of Brugada syndrome and QT interval abnormalities. Clinical data and electrocardiograms were available in all participants. Electrocardiograms were evaluated by 2 cardiologists and a third cardiologist was consulted if there was disagreement in the diagnosis. We calculated the weighted prevalence and clinical factors associated with the presence of Brugada-type patterns or QT segment abnormalities Results: Overall, 8343 individuals were evaluated (59.2 years, 52.4% female). There were 12 Brugada cases (type 1, 2 cases; type 2, 10 cases; weighted prevalence, 0.13%). For corrected QT (QTc) analysis, we excluded participants with left bundle branch block or without sinus rhythm. Weighted prevalences were as follows: short QTc ( < 340 ms) 0.18%, borderline QTc (441-469 ms) 8.33%, long QTc ( ≥ 470 ms criterion) 1.01% and long QTc ( ≥ 480 criterion) 0.42%. Conclusions: A total of 0.6% to 1.1% of the Spanish population aged ≥ 40 years has an electrocardiographic pattern associated with a higher risk of sudden death (Brugada syndrome, long QT, or short QT).

Resumen Introduccion y objetivos La fibrilacion auricular se asocia con elevadas morbilidad y mortalidad, y tanto su incidencia como su prevalencia son altas. No obstante, hay escasos datos poblacionales sobre su epidemiologia en Espana. El objetivo de este estudio es estimar la prevalencia de fibrilacion auricular en Espana. Metodos Estudio transversal en poblacion espanola de 40 o mas anos. Se realizo un muestreo en dos etapas, una primera seleccion aleatoria de medicos de atencion primaria de cada provincia espanola y, en segundo lugar, se selecciono aleatoriamente a 20 individuos de la poblacion asignada a cada medico participante. La prevalencia se pondero por edad, sexo y area geografica. Se realizo una lectura centralizada de los registros electrocardiograficos. Resultados Se evaluo a 8.343 personas (media de edad, 59,2 [intervalo de confianza del 95%, 58,6-59,8] anos; el 52,4% mujeres). La prevalencia total de fibrilacion auricular fue del 4,4% (intervalo de confianza del 95%, 3,8-5,1). La prevalencia fue similar en varones (4,4% [3,6-5,2]) y mujeres (4,5% [3,6-5,3]) y se incrementa progresivamente a partir de los 60 anos de edad. En los mayores de 80 anos, la prevalencia fue del 17,7% (14,1-21,3). En un 10% de pacientes se diagnostico una fibrilacion auricular no conocida. Conclusiones La prevalencia de fibrilacion auricular en la poblacion general espanola mayor de 40 anos es elevada, del 4,4%. La prevalencia es similar en varones y mujeres y se incrementa escalonadamente a partir de los 60 anos. Se estima en mas de 1 millon de pacientes con fibrilacion auricular en la poblacion espanola, de los que mas de 90.000 estan sin diagnosticar.

Background and objectives The principal objective was to assess the prevalence of left ventricular hypertrophy (LVH) in hypertensive, never treated patients, depending on adjustment for body surface or height. Secondary objectives were to determine geometric alterations of the left ventricle and to analyze the interdependence of hypertension and obesity to induce LVH. Patients and methods Cross-sectional study that included 750 patients (387 men) aged 47 (13, SD) years who underwent ambulatory blood pressure (ABPM) monitoring and echocardiography. Results The prevalence of LVH was 40.4% (303 patients), adjusted for body surface area (BSA, LVHBSA), and 61.7% (463 patients), adjusted for height2.7 ( LV H height 2.7 ). In a multivariate logistic analysis, systolic BP24h, gender and presence of elevated microalbuminuria were associated with both LVHBSA and LV H height 2.7 . Increased waist circumference was the strongest independent predictor of LV H height 2.7 , but was not associated with LVHBSA. We found a significant interaction between abdominal obesity and systolic BP24h in LV H height 2.7 . Concentric remodelling seems to be the most prevalent alteration of left ventricular geometry in early stages of hypertension (37.5%). Conclusions The impact of obesity as predictor of LVH in never treated hypertensives is present only when left ventricular mass (LVM) is indexed to height2.7. Obesity interacts with systolic BP24h in an additive but not merely synergistic manner. Systolic BP24h is the strongest determinant of LVH when indexed for BSA.

Resumen Introduccion y objetivos Valorar la posible relacion de la presion arterial central con la masa ventricular izquierda. Metodos Estudio observacional transversal en 392 pacientes con hipertension arterial sin tratamiento farmacologico previo. Se valoraron las presiones clinicas, ambulatorias de 24 h y centrales (medidas por tonometria de aplanamiento) y se calculo el indice de masa del ventriculo izquierdo por ecocardiografia. Resultados Todos los valores de presion de 24 h tienen mejor relacion en el analisis de regresion multiple con el indice de masa del ventriculo izquierdo que los respectivos de presion clinica y central tras corregir por edad, sexo y sindrome metabolico. La correlacion fue siempre mayor con las cifras de presion sistolicas que con las diastolicas en las tres determinaciones. La correlacion del indice de masa del ventriculo izquierdo con la presion sistolica de 24 h fue superior a la que presentaba con las presiones sistolicas clinica (p Conclusiones El indice de masa del ventriculo izquierdo se correlaciona mas con los valores de presion sistolica ambulatoria de 24 h que con las demas medidas de la presion arterial, incluidas todas las medidas de presion central. La medicion de la presion arterial central no permite identificar mejor a los pacientes con hipertrofia del ventriculo izquierdo.

A B S T R A C T Introduction and objectives: The purpose of the present study was to assess the relationship of central and peripheral blood pressure to left ventricular mass. Methods: Cross-sectional study that included 392 never treated hypertensive individuals. Measurement of office, 24-h ambulatory, and central blood pressure (obtained using applanation tonometry) and determination of left ventricular mass by echocardiography were performed in all patients. Results: In a multiple regression analysis, with adjustment for age, gender and metabolic syndrome, 24-h blood pressure was more closely related to ventricular mass than the respective office and central blood pressures. Systolic blood pressures always exhibited a higher correlation than diastolic blood pressures in all 3 determinations. The correlation between left ventricular mass index and 24-h systolic blood pressure was higher than that of office (P

A B S T R A C T Cardiovascular disease is the main health problem in developed countries. Prevention is presented as the most effective and efficient primary care intervention, whereas cardiac rehabilitation programs are considered the most effective of secondary prevention interventions; however, these are underused. This literature review examines the effectiveness and the levels of evidence of cardiac rehabilitation programs, their components, their development and role in developed countries, applications in different fields of research and treatment, including their psychological aspects, and their application in heart failure as a paradigm of disease care under this type of intervention. It is completed by a review of the impact of such programs on measures of health-related quality of life, describing the instruments involved in studies in recent scientific literature.

There is controversy whether Takotsubo Syndrome (TTS) should be classified as a Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). The aim of this study is to compare the clinical profile and prognosis of TTS and non-TTS MINOCA patients. Analytical and observational study

There is a growing interest concerning MINOCA in the clinical practice. The aim of this study is to analyze the clinical profile and prognosis of MINOCA patients compared to those with myocardial infarction with obstructive lesions. Analytical and observational study developed in a University

La revascularizacion coronaria es una intervencion terapeutica plenamente consolidada y, por tanto, incluida en todas las estrategias de tratamiento de los pacientes con enfermedad coronaria. A pesar de sus mas de 40 anos de desarrollo, los continuos avances tecnicos, tanto de la revascularizacion quirurgica como de la percutanea, hacen que cada vez haya mas grupos de pacientes en los que se ha demostrado su utilidad. Por tanto, es necesario actualizar periodicamente sus indicaciones y limitaciones. El objetivo de la revascularizacion es mejorar el pronostico o la sintomatologia y calidad de vida de los pacientes con cardiopatia isquemica. La revascularizacion comprende 2 aspectos: 1) la indicacion y seleccion del tipo de revascularizacion y 2) la intervencion revascularizadora. En el primero, la participacion del cardiologo clinico es fundamental. Su mision consiste en detectar y seleccionar, sobre la base de datos clinicos, funcionales y anatomicos, a los pacientes que se pueden beneficiar de la revascularizacion, asi como ayudar en la seleccion de la tecnica. En este articulo de «Puesta al Dia» sobre revascularizacion se revisaran, referidos a la cardiopatia isquemica estable y al sindrome coronario agudo sin elevacion del ST: 1) los aspectos clinicos mas relevantes que es necesario considerar en la valoracion de la necesidad o el tipo de revascularizacion (edad, genero, diabetes, funcion renal, alteraciones electrocardiograficas, funcion ventricular, cuantificacion de la importancia funcional de la enfermedad coronaria o el grado de viabilidad de areas acineticas); 2) las indicaciones, tanto de la cirugia como de la angioplastia coronaria, y la estrategia terapeutica de acuerdo con las ultimas evidencias y recomendaciones de las sociedades cientificas, y 3) los datos disponibles en el momento actual sobre la controversia de la seleccion del tipo de revascularizacion en los pacientes con enfermedad multivaso

Los estudios publicados desde 1999 que compararon una estrategia invasiva moderna (con disponibilidad de stent y nuevos antitromboticos) y conservadora (invasive selectiva) en los pacientes con sindrome coronario agudo sin elevacion del ST han demostrado que la estrategia invasive disminuye, a largo plazo, la incidencia de muerte o infarto y mejora la evolucion clinica en los pacientes de alto riesgo, aunque durante la hospitalizacion aumenta levemente las complicaciones isquemicas. El momento de realizar la coronariografia es controvertido, aunque la mayoria de las guias recomiendan que se haga en las primeras 48 h. Los pacientes que mas se benefician son los que presentan cambios en el ST, elevacion de troponinas o diabetes. Los de bajo riesgo con ambas estrategias tienen resultados similares. El beneficio de la estrategia invasiva se atribuye a la revascularizacion mecanica, pero tambien al uso de los nuevos antitromboticos (clopidogrel e inhibidores de la glucoproteina IIb/IIIa). La utilizacion de clopidogrel esta recomendada por la mayoria de las guias, aunque el momento de su aplicacion es objeto de controversia y los datos mas recientes indican que parece preferible la heparina no fraccionada si se planifica una estrategia invasiva. La administracion precoz de inhibidores de la glucoproteina IIb /IIIa (tirofiban o eptifibatida) esta indicada. En los casos en que la coronariografia se realiza tempranamente (menos de 2,5-6 h), el uso de abciximab o eptifibatida en el laboratorio de hemodinamica, una vez conocida la anatomia coronaria, parece una estrategia razonable.

Introduction and objective. To assess the reliability of early analysis of the most frequently used cardiac magnetic resonance (CMR)-derived indexes for predicting systolic function recovery and ventricular remodeling in patients after a first acute myocardial infarction with a patent culprit artery. Patients and method. 17 patients were studied with an initial CMR protocol that included regional assessment of wall thickness and wall thickening, low-dose dobutamine response, first-pass gadolinium myocardial perfusion imaging and delayed enhancement. These results were compared with those obtained for segmental and global function in a second CMR study 6 months later. Results. Of the 272 myocardial segments evaluated in the initial study, 73 showed severe systolic dysfunction. The findings were used to calculate sensitivity and specificity of each of the indexes mentioned above for predicting myocardial viability. The sensitivities and specificities for each index were wall thickness ≥5.5 mm, 100% and 12%; low-dose dobutamine response, 41% and 93%; normal myocardial perfusion, 78% and 68%; delayed enhancement, 81% and 95%. Multivariate analysis showed that delayed enhancement was the only independent predictor of contractility (r=‐0.83, P=.0001), ventricular volumes (enddiastolic: r=0.61, P=.009, end-systolic: r=0.67, P=.003) and ejection fraction (r=‐0.73, P=.001) at 6 months. Conclusions. Delayed enhancement seen in CMR is a reliable, quantifiable index for predicting recovery of systolic function and ventricular remodeling in patients after a first infarction with a patent culprit artery.

Introduccion y objetivo. Analizar la fiabilidad del analisis precoz de los indices mas ampliamente utilizados en resonancia magnetica cardiaca (RMC) para predecir la recuperacion de la funcion sistolica y el remodelado ventricular en pacientes con un primer infarto agudo de miocardio y arteria causante del infarto permeable. Pacientes y metodo. Se estudio a 17 pacientes mediante RMC en la que se valoro el grosor de la pared, la respuesta a bajas dosis de dobutamina, la perfusion miocardica de primer paso con gadolinio y el porcentaje de captacion tardia de contraste. Los hallazgos de la RMC inicial se correlacionaron con la funcion segmentaria y global obtenida en la RMC al sexto mes. Resultados. De los 272 segmentos de la RMC inicial, 73 mostraron disfuncion sistolica severa, a partir de los cuales se calcularon la sensibilidad y especificidad de cada unos de los indices para predecir viabilidad miocardica. Un grosor diastolico = 5,5 mm obtuvo una sensibilidad del 100% y una especificidad del 12%; en la respuesta a la dobutamina, estas fueron del 41 y el 93%; en una perfusion normal, del 78 y el 68%, y en una captacion tardia < 50%, del 81 y el 95%, respectivamente. La captacion tardia fue el unico predictor independiente de la contractilidad (r = ­-0,83; p = 0,0001), de los volumenes ventriculares (telediastolico, r = 0,61; p = 0,009; telesistolico, r = 0,67; p = 0,003) y la fraccion de eyeccion (r = ­-0,73, p = 0,001) al sexto mes. Conclusiones. La captacion tardia mediante RMC es un indice cuantificable y fiable para predecir la mejoria de la funcion sistolica y el remodelado ventricular en pacientes tras un primer infarto con arteria abierta.

We appreciate the interest shown by Vidal-Pérez et al. in our article published recently in Revista Española de Cardiología,1 which provides us with an opportunity to present some interesting additional information not included in the article itself. We agree on the importance of knowing the thromboembolic risk of the population included in the OFRECE study, both for patients with a diagnosis of atrial fibrillation and for the general population. In our study, the mean (standard deviation) CHADS2 and CHAD2DS2-VASc of patients with atrial fibrillation was 2.3 (1.3) and 3.8 (1.6), respectively. In the general population, the mean (standard deviation) CHADS2 and CHAD2DS2-VASc of patients with atrial fibrillation was 0.8 (1) and 1.8 (1.5), respectively. The distribution of both scales is in agreement with that of the Val-FAAP and AFABE studies,2, 3 although the similarity is greater in the 2 population-based studies (Figure). These data are, we believe, relevant because they show that the level of risk in the population with atrial fibrillation is very similar to that of the populations included in clinical trials with new oral anticoagulants. In addition, an increasing body of evidence suggests that thromboembolic risk, as measured with these scales in the population without a diagnosis of atrial fibrillation, is associated with the onset of events. Yes Nos complace el interés mostrado por Vidal-Perez et al en relación con nuestro articulo publicado recientemente en Revista Española de Cardiología (1) y que nos da la oportunidad de ampliar la información recogida en el articulo con resultados de mucho interés. Coincidimos en que es relevante conocer el riesgo tromboembólico de la población incluida en OFRECE tanto enlos pacientes con diagnóstico defibrilación auricular como en la población general. En nuestro estudio, el CHADS2 y el CHAD2DS2-VAScmedio (y desviación estándar) en los pacientes con fibrilación auricular fue de 2,3±1,3 y 3,8±1,6 respectivamente. El dato del CHADS2 y el CHAD2DS2-VASc en la población general sin evidencia de fibrilación auricular fue de 0,8±1 y 1,8±1,5 respectivamente.Si comparamos la distribución de ambas escalas con las del estudio Val-FAAP y el estudio AFABE, todas en población con fibrilación auricular, podemos apreciar que son datos concordantes (2)(3) aunque con mas similitud en los dos estudios de base poblacional. Tabla 1. Estos datos pensamos que son relevantes porque, por un lado,podemos apreciar que el nivel de riesgo en la población con fibrilación auricular es muy parecido a las poblaciones incluidas en los ensayos clínicos de los nuevos anticoagulantes orales y, por otro lado, cada vez hay más información relativa a que niveles elevados de riesgo tromboembólico, medidos por estas escalas en población sin fibrilación auricular diagnosticada, pueden estar relacionados con la aparición de eventos.

Este informe refleja el interes de la Seccion de Hemodinamica y Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia en incrementar la calidad, seguridad y aplicabilidad del intervencionismo cardiaco, proporcionando claves cientificas que contribuyan a optimizar las funciones de planificacion o formacion en este campo y que ayuden a reforzar la capacidad y el prestigio de los cardiologos intervencionistas espanoles. El documento ha sido redactado con el proposito de describir la verdadera dimension de la cardiologia intervencionista actual, identificar referencias de calidad y establecer los niveles minimos aceptables para actuar o impartir ensenanza avanzada en esta disciplina. Para ello, se ha buscado un marcador solido de calidad global dentro de las distintas tecnicas percutaneas y se han analizado los resultados de las intervenciones, asi como su relacion con circunstancias de diversa indole. Dicho analisis ha identificado a la angioplastia coronaria como el patron de referencia en el que deben basarse los requerimientos tecnicos o cognitivos del intervencionismo cardiaco de cualquier tipo, los estandares de calidad y las recomendaciones sobre capacitacion o formacion. Por otra parte, se ha constatado la influencia crucial que ejercen la experiencia y el conocimiento sobre los resultados, especialmente en los escenarios anatomoclinicos mas desfavorables o tecnicamente mas complejos. Sobre esta base, el informe establece recomendaciones concretas sobre requisitos de cualificacion o formacion. Tambien aboga por la consideracion de la cardiologia intervencionista como una subespecialidad de la cardiologia que deberia requerir una acreditacion especifica.

Introduccion y objetivos Las necesidades asistenciales de las unidades coronarias obligan a acelerar el alta de los pacientes menos graves y esto podria influir sobre su pronostico. Nuestro objetivo ha sido: a) analizar las caracteristicas y la evolucion durante el primer mes de los pacientes con infarto de miocardio dados de alta de la unidad coronaria muy precozmente, y b) definir el perfil de un grupo de pacientes con bajo riesgo de complicaciones que podrian ser dados de alta precozmente. Pacientes y metodos Estudio de 978 pacientes consecutivamente ingresados por infarto de miocardio. Se estudian las caracteristicas basales, la estancia en la unidad coronaria y en el hospital y el estado vital al mes en dos grupos (separados por la estancia en la unidad coronaria de dos dias). Se analiza un subgrupo de pacientes con bajo riesgo de mortalidad al mes y se investiga en ellos las complicaciones que pudo originar el alta precoz de la unidad coronaria. Resultados Fallecieron 73 pacientes en los dos primeros dias; de los supervivientes, en 336 la estancia fue igual o inferior a 2 dias (grupo A) y en 569 fue mayor de 2 dias (grupo B). En el grupo A fue significativamente mas frecuente el antecedente de dislipemia, de clase Killip I al ingreso, de infarto no complicado en la unidad coronaria y el uso de betabloqueantes y menos frecuente, el infarto agudo de miocardio con onda Q, la localizacion anterior y el uso de fibrinoliticos. En el primer mes tras el alta de la unidad coronaria, fallecieron 10 pacientes del grupo A y 18 del grupo B, siendo la tasa de «muerte o reingreso en la UC» a los 30 dias similar en ambos grupos (grupo A = 13% y grupo B = 13%). En un analisis de regresion multiple se observo que la clase Killip en el momento del ingreso y la presencia de complicaciones se relacionaron de forma independiente con la estancia en la unidad coronaria. Se definio un subgrupo de pacientes de bajo riesgo (Killip I al ingreso, sin complicaciones en la unidad coronaria y edad inferior a 71 anos) compuesto por 378 pacientes que no tuvieron mortalidad a los 30 dias y cuya tasa de reingreso al mes fue del 4% (n = 16). Aquellos casos con una estancia igual o inferior a 2 dias reingresaron mas frecuentemente durante la primera semana (grupo A = 9/197 [5%] y grupo B = 1/181 [0,5%]; p = 0,034). Conclusiones En pacientes seleccionados con infarto agudo de miocardio es posible el alta muy precoz de la unidad coronaria con bajo riesgo de muerte. En estos pacientes es previsible una tasa de reingreso en torno al 5% en los dias siguientes al alta.

Introduccion y objetivos La indicacion de coronariografia preoperatoria en pacientes con valvulopatia depende de la prevalencia de enfermedad coronaria en estos pacientes, que varia entre las distintas areas geograficas. El objetivo del estudio fue adecuar los criterios de indicacion de coronariografia preoperatoria a nuestra poblacion de referencia. Metodos Se ha evaluado retrospectivamente la prevalencia de enfermedad coronaria significativa en 511 pacientes consecutivos diagnosticados de una valvulopatia por estudios no invasivos, sometidos a coronariografia preoperatoria entre agosto de 1991 y julio de 1996. Se analizaron en cada paciente, ademas de los datos demograficos, la clinica y los factores de riesgo coronarios. Para adecuar los criterios se considero que la coronariografia preoperatoria se deberia aplicar a los grupos que tuvieran una prevalencia de enfermedad coronaria ≥ 5%. Resultados La edad media fue de 64 ± 10 anos (el 51% varones). Presentaban valvulopatia mitral 135 pacientes, aortica 234 pacientes y mitroaortica 142 pacientes. Referian angina el 30% y factores de riesgo coronario el 52%. La prevalencia de enfermedad coronaria significativa fue del 20,3%. Esta fue significativamente mayor en pacientes con angina (el 35,3% frente al 13,8% en ausencia de angina), y con factores de riesgo (el 28% frente al 12,2% en pacientes sin ellos), sin diferencias significativas entre las valvulopatias. La edad fue tambien significativamente mayor en los pacientes con coronariopatia (69 ± 8 frente a 63 ± 10 anos). El analisis multivariante identifico tres predictores independientes de enfermedad coronaria significativa: 1) edad; 2) angina previa, y 3) presencia de factores de riesgo. La prevalencia de coronariopatia significativa en pacientes sin angina ni factores de riesgo fue inferior al 5% en varones con menos de 60 anos (1 varon: 3,3%) y mujeres con menos de 65 anos (2 mujeres: 3,5%). Conclusiones En nuestra poblacion de referencia y en otras con similar epidemiologia cardiovascular, la coronariografia preoperatoria esta indicada en varones ≥ 60 anos y en mujeres ≥ 65 anos, y en pacientes mas jovenes ante la presencia de angina o factores de riesgo coronarios, independientemente del tipo de valvulopatia.

Assessment of myocardial viability is a field of growing interest. This article summarizes the pathophysiology of myocardial stunning and hibernation; both phenomena are associated with the presence of dysfunctional, viable myocardium. The techniques that are currently available for the assessment of viability, and the clinical situations in which these assessments may be more useful are discussed.

The objective of the present study was to assess the regression of left ventricular hypertrophy (LVH) during antihypertensive treatment, and its relationship with the changes in microalbuminuria.One hundred and sixty-eight previously untreated patients with echocardiographic LVH, 46 (27%) with microalbuminuria, were followed during a median period of 13 months (range 6-23 months) and treated with lifestyle changes and antihypertensive drugs. Twenty-four-hour ambulatory blood pressure monitoring, echocardiography and urinary albumin excretion were assessed at the beginning and at the end of the study period.Left ventricular mass index (LVMI) was reduced from 137 [interquartile interval (IQI), 129-154] to 121 (IQI, 104-137) g/m (P 0.001). Eighty-nine patients (53%) had a reduction in LVMI of at least 17.8 g/m, and an LVH regression rate of 43.8 per 100 patient-years [95% confidence interval (CI) 35.2-53.9]. The main factor related to LVH regression was the reduction in SBP24 h [multivariate odds ratio (ORm) 4.49; 95% CI 1.73-11.63; P = 0.005, highest tertile compared with lower tertiles]. Male sex (ORm 0.39; 95% CI 0.17-0.90; P = 0.04) and baseline glomerular filtration rate less than 90 ml/min per 1.73 m (ORm 0.39; 95% CI 0.17-0.90; P = 0.03) were associated with a lower probability of LVH regression. Patients with microalbuminuria regression (urinary albumin excretion reduction50%) had the same odds of achieving regression of LVH as patients with normoalbuminuria (ORm 1.1; 95% CI 0.38-3.25; P = 0.85). However, those with microalbuminuria at baseline, who did not regress, had less probability of achieving LVH regression than the normoalbuminuric patients (OR 0.26; 95% CI 0.07-0.90; P = 0.03) even when adjusted for age, sex, initial LVMI, GFR, blood pressure and angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) treatment during the follow-up.Patients who do not have a significant reduction in microalbuminuria have less chance of achieving LVH regression, independent of blood pressure reduction.

Cardiovascular disease is the main health problem in developed countries. Prevention is presented as the most effective and efficient primary care intervention, whereas cardiac rehabilitation programs are considered the most effective of secondary prevention interventions; however, these are underused. This literature review examines the effectiveness and the levels of evidence of cardiac rehabilitation programs, their components, their development and role in developed countries, applications in different fields of research and treatment, including their psychological aspects, and their application in heart failure as a paradigm of disease care under this type of intervention. It is completed by a review of the impact of such programs on measures of health-related quality of life, describing the instruments involved in studies in recent scientific literature.

1which provides us with an opportunity to present some interesting additional information not included in the article itself. We agree on the importance of knowing the thromboembolic risk of the population included in the OFRECE study, both for patients with a diagnosis of atrial fibrillation and for the general population. In our study, the mean (standard deviation) CHADS2 and CHAD2DS2-VASc of patients with atrial fibrillation was 2.3 (1.3) and 3.8 (1.6), respectively. In the general population, the mean (standard deviation) CHADS2 and CHAD2DS2-VASc of patients with atrial fibrillation was 0.8 (1) and 1.8 (1.5), respectively. The distribution of both scales is in agreement with that of the Val-FAAP and AFABE studies, 2, 3 although the similarity is greater in the 2 population-based studies (Figure). These data are, we believe, relevant because they show that the level of risk in the population with atrial fibrillation is very similar to that of the populations included in clinical trials with new oral anticoagulants. In addition, an increasing body of evidence suggests that thromboembolic risk, as measured with these scales in the population without a diagnosis of atrial fibrillation, is associated with the onset of events. 4 Figure. Prevalences by thromboembolic risk scales in the OFRECE, AFABE, and Val-FAAP studies.

Coronary artery revascularization is an established therapeutic intervention and is therefore included in all treatment guidelines for patients with coronary artery disease. Although the procedure has been available for more than 40 years, constant technical progress in surgical and percutaneous revascularization continues to bring the benefits of revascularization therapy to new groups of patients. Therefore the indications and limitations of this approach need to be reviewed and updated periodically. The aim of revascularization therapy is to improve the prognosis or symptoms and quality of life in patients with ischemic heart disease. The revascularization process comprises two aspects: 1 ) indication and selection of the revascularization procedure, and 2 ) performance of the procedure. Involvement of the clinical cardiologist in the first step is fundamental. Basing their decisions on clinical, functional and anatomical features, these professionals detect and select patients who would benefit, and also help to select the revascularization technique. In this Update article on revascularization we review, for stable ischemic heart disease and non-ST segment elevation acute coronary syndromes, the following: 1 ) the most relevant aspects to consider when evaluating the need for and the type of revascularization (age, sex, diabetes, renal function, electrocardiographic changes, ventricular function, and quantification of functional relevance of coronary artery disease and viability of the acinetic areas); 2 ) indications for surgical or percutaneous intervention, and the choice of therapeutic strategy according to the latest clinical evidence and guidelines of scientific societies; and 3 ) currently available data on the controversy regarding choice of the revascularization procedure in patients with multivessel disease.