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Introduction and objectives: Coronary lesions with stent overlapping are associated with higher neointimal proliferation that leads to more restenosis. Furthermore, the tapering of coronary arteries is a major challenge when treating long coronary lesions. This study attempted to assess the safety and clinical level of performance of long nontapered sirolimus-eluting coronary stent systems (> 36 mm) to treat long and diffused de novo coronary lesions in real-world scenarios. Methods: This was a prospective, non-randomized, multicentre study that included 696 consecutive patients treated with the long nontapered BioMime sirolimus-eluting coronary stent system in long and diffused de novo coronary lesions. The safety endpoint was major adverse cardiovascular events defined as a composite of cardiac death, myocardial infarction, clinically driven target lesion revascularization, stent thrombosis, and major bleeding at the 12-month follow-up. Results: Of a total of 696 patients, 38.79% were diabetic. The mean age of all the patients was 64.6 ± 14 years, and 80% were males. The indication for revascularization was acute coronary syndrome in 63.1%. A total of 899 lesions were identified out of which 742 were successfully treated with long BioMime stents (37 mm, 40 mm, 44 mm, and 48 mm). The cumulative incidence of major adverse cardiovascular events was 8.1% at the 12-month follow-up including cardiac death (2.09%), myocardial infarction (1.34%), and total stent thrombosis (0.5%). Conclusions: This study confirms the safety and good performance of long nontapered BioMime coronary stents to treat de novo coronary stenosis. Therefore, it can be considered a safe and effective treatment for long and diffused de novo coronary lesions in the routine clinical practice.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a very contagious virus, has led to the coronavirus disease 2019 (COVID-19) pandemic. The clinical manifestations of this virus in humans vary widely, from asymptomatic to severe, with diverse symptomatology and even death. The substantial transmission from asymptomatic people has facilitated the widespread transmission of SARS-CoV-2, hampering public health initiatives to identify and isolate infected people during the pre-symptomatic contagious period. COVID-19 is associated with cardiac complications that can progress from mild to life-threatening. The aim of this article is to analyse the present knowledge of COVID-19 and cardiac involvement, the development of arrhythmia risk and its treatment.

Resumen La fibrilacion auricular es la arritmia cardiaca mas frecuente en la practica clinica diaria. Ademas de las alteraciones hemodinamicas que ocasiona —consecuencia de la perdida de la contraccion auricular y la frecuencia cardiaca habitualmente elevada, que pueden causar la aparicion de insuficiencia cardiaca—, el principal riesgo de la fibrilacion auricular es que la estasis circulatoria en la auricula cause una embolia arterial. Se sabe que la fibrilacion auricular se asocia a un marcado aumento del riesgo de accidentes tromboembolicos arteriales, asociados a elevadas mortalidad y morbilidad y alto riesgo de recurrencia. Esta demostrado que el tratamiento antitrombotico con anticoagulantes orales se asocia a un drastico descenso del riesgo de accidentes tromboembolicos. Sin embargo, los anticoagulantes orales incrementan significativamente el riesgo de hemorragias mayores, de las que es especialmente devastadora la hemorragia intracraneal. Por lo tanto, al iniciar el tratamiento anticoagulante de un paciente con fibrilacion auricular, resulta imprescindible valorar adecuadamente el beneficio/riesgo del tratamiento segun sus caracteristicas clinicas. Multiples estudios han mostrado una serie de variables que determinan los riesgos emboligeno y de sangrado asociados al tratamiento anticoagulante, y con base en ellas se han desarrollado diversos sistemas de estratificacion para calcular el riesgo de embolia secundaria a la fibrilacion auricular y el riesgo de hemorragia relacionado con el tratamiento antitrombotico. En la practica clinica diaria, la aplicacion de estas escalas de riesgo es de gran ayuda para elegir la mejor alternativa terapeutica para un paciente concreto.

Resumen La fibrilacion auricular es una arritmia que se caracteriza por la contraccion de las fibras auriculares de modo caotico e impredecible. Esta disincronia origina la perdida funcional de contractilidad. Por ello, se favorece la coagulacion intraauricular y, consecuentemente, se aumenta la probabilidad de sufrir un ictus por tromboembolia. Es bien conocido que esta arritmia aumenta la mortalidad y la morbilidad. Por lo tanto, su prevencion y manejo son de gran importancia tanto para los pacientes como para el sistema sanitario. Este articulo analiza los datos epidemiologicos de la fibrilacion auricular en Espana.

Impaired interatrial conduction or interatrial block is well documented but is not described as an individual electrocardiographic (ECG) pattern in most of ECG books, although the term atrial abnormalities to encompass both concepts, left atrial enlargement (LAE) and interatrial block, has been coined. In fact, LAE and interatrial block are often associated, similarly to what happens with ventricular enlargement and ventricular block. The interatrial blocks, that is, the presence of delay of conduction between the right and left atria, are the most frequent atrial blocks. These may be of first degree (P-wave duration > 120 milliseconds), third degree (longer P wave with biphasic [+/-] morphology in inferior leads), and second degree when these patterns appear transiently in the same ECG recording (atrial aberrancy). There are evidences that these electrocardiographic P-wave patterns are due to a block because they may (a) appear transiently, (b) be without associated atrial enlargement, and (c) may be reproduced experimentally. The presence of interatrial blocks may be seen in the absence of atrial enlargement but often are present in case of LAE. The most important clinical implications of interatrial block are the following: (a) the first degree interatrial blocks are very common, and their relation with atrial fibrillation and an increased risk for global and cardiovascular mortality has been demonstrated; (b) the third degree interatrial blocks are less frequent but are strong markers of LAE and paroxysmal supraventricular tachyarrhythmias. Their presence has been considered a true arrhythmological syndrome. (C) 2012 Elsevier Inc. All rights reserved.

Eur J Clin Invest 2011; 41 (12): 1268–1274 Abstract Background Age is one the factors associated with poor prognosis in acute coronary syndromes (ACS) and elderly patients are a high-risk collective with few parameters for mid-term cardiovascular stratification. We aimed to assess the predictive value of ankle–brachial index (ABI) in patients (> 75 years) for 1-year mortality after an ACS. Materials and methods Prospective, observational and multicentre study of ACS patients in whom ABI was assessed during hospitalization. Results A total of 1·054 patients were included, mean age 66·6 (11·7) years from whom 26·6% were > 75 years. Elderly patients showed more history of cardiovascular disease and higher prevalence of all risk factors, except current smoking. Angiography and revascularization were performed less frequently in the elderly. Patients > 75 years showed higher presence of three vessel coronary disease and received fewer guideline-recommended treatments. Patients who died through the follow-up, mean time 387·9 ± 7·2 days, had lower ABI (0·73 ± 0·24 vs. 0·92 ± 0·22; P 75 years (HR: 2·30; IC 95% 1·26–4·18; P 0·90 and young patients with ABI

Introduccion: Los farmacos antitromboticos reducen los eventos cardiacos mayores en pacientes con sindrome coronario agudo, pero aumentan el riesgo de sangrado.

Introduccion y objetivos La presencia de enfermedad arterial periferica se asocia con un peor pronostico cardiovascular en el paciente coronario; sin embargo, la mayor parte de ellos estan asintomaticos e infradiagnosticados. El indice tobillo-brazo (ITB) es un metodo sencillo para el diagnostico de esta entidad. El objetivo del presente estudio es determinar el papel de un ITB patologico en la identificacion de enfermedad coronaria multivaso en pacientes con sindrome coronario agudo (SCA). Metodos Se analizaron todos los pacientes con SCA del registro multicentrico PAMISCA (94 centros participantes) a los que se les habia realizado un cateterismo durante su ingreso. Se considero enfermedad coronaria multivaso la afectacion de dos o mas vasos mayores epicardicos y/o enfermedad de tronco coronario izquierdo. Se considero patologico un ITB > 1,4 o ≤ 0,9. Resultados Se incluyeron 1.031 pacientes, con una edad media de 67,7 anos. De ellos, 542 pacientes presentaron afectacion multivaso (52,6%). Respecto a los pacientes sin afectacion multivaso, este grupo presentaba una mayor edad (66,6 frente a 62,6; p Conclusiones En el paciente con SCA, un ITB patologico se asocia de manera independiente con la probabilidad de padecer enfermedad coronaria multivaso.

Introduction and objectives.The presence of peripheral arterial disease in patients with coronary artery disease is associated with a poor cardiovascular outcome. However, the majority of affected patients are asymptomatic and the condition is underdiagnosed. The ankle-brachial index (ABI) provides a simple method of diagnosis. The aim of this study was to assess the usefulness of an abnormal ABI for identifying multivessel coronary artery disease in patients with acute coronary syndrome (ACS). Methods. We analyzed data on all ACS patients included in the PAMISCA multicenter study (with 94 participating hospitals) who underwent catheterization during admission. Patients were diagnosed with multivessel coronary disease if two or more major epicardial vessels or the left main coronary artery, or both, were affected. An ABI ≤0.9 or >1.4 was considered abnormal. Results. The study included 1031 patients with a mean age of 67.7 years. Of these, 542 had multivessel disease (52.6%). Compared with those without multivessel disease, these patients were older (66.6 years vs 62.6 years; P

Observational studies report poor prognosis of patients after acute coronary syndrome (ACS) in the presence of previous peripheral arterial disease (PAD), but data on subclinical PAD are scarce. This study was designed to assess the predictive value of clinical and subclinical PAD in the follow-up of patients after an ACS. We included 1,054 patients hospitalized for an ACS who survived the acute phase. Patients were divided into 3 groups: clinical PAD (previously diagnosed PAD or intermittent claudication), subclinical PAD (defined as ankle-brachial indexor=0.9 or1.4), and no PAD. Clinical PAD was present in 150 patients (14.2%) and 298 cases of subclinical PAD were detected (28.3%). Patients with PAD (clinical and subclinical PAD) were significantly older and had a higher prevalence of hypertension and diabetes mellitus than those without PAD. During the 1-year follow-up, 59 patients died (5.6%). Previous PAD (hazard ratio 4.38, 95% confidence interval 1.96 to 9.82, p0.001) and subclinical PAD (hazard ratio 2.35, 95% confidence interval 1.05 to 5.23, p0.05) were associated with increased cardiovascular mortality. Moreover, patients with clinical PAD had higher rates of major cardiovascular events (myocardial infarction, angina, and heart failure) than patients with subclinical PAD or without PAD. In conclusion, beyond clinical PAD, measurement of ankle-brachial index after ACS provides substantial information on intermediate-term prognosis.

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year.

Debido a la elevada prevalencia de la enfermedad arterial periferica (EAP), que con frecuencia es asintomatica, y sus graves repercusiones pronosticas, se recomienda la criba diagnostica de los pacientes con alto riesgo de sufrirla: a) pacientes de edad > 70 anos; b) pacientes de 50-69 anos con historia de tabaquismo o diabetes mellitus; c) pacientes de 40-49 anos con diabetes mellitus y al menos otro factor de riesgo de arteriosclerosis; d) sintomas compatibles con claudicacion al esfuerzo o dolor isquemico en reposo; e) pulsos anormales en las extremidades inferiores; f) enfermedad arteriosclerosa en otros territorios, o g) pacientes con un score de Framingham entre el 10 y el 20%. Tanto la anamnesis como la exploracion fisica tienen un valor para el diagnostico de la enfermedad limitado porque, aunque son muy especificos, su sensibilidad es muy baja. Existen multiples pruebas diagnosticas para valorar la presencia y la severidad de la enfermedad vascular periferica, entre las que cabe destacar el indice tobillo-brazo, las determinaciones de la presion segmentarias, los estudios de ecografia-Doppler y la angiografia mediante resonancia megnetica, tomografia computarizada o de sustraccion digital. En la actualidad se considera que el indice tobillo-brazo es el metodo no invasivo que presenta mejor rendimiento diagnostico, ya que se trata de una prueba incruenta, facil de realizar a la cabecera del paciente y con una elevada sensibilidad (superior al 90%).

ObjectiveA significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes.MethodsThe PAMISCA register is a prospective, multicenter study involving patients ≥40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event.Results1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03–1.06; p

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1-9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover.

La Seccion de Cardiopatia Isquemica y Unidades de la Sociedad Espanola ha considerado necesario el desarrollo de este documento sobre la necesidad, la estructura y la organizacion de las unidades coronarias de cuidados intermedios (UCCI). Los registros de sindrome coronario agudo (SCA) realizados en Espana indican que una proporcion importante de pacientes recibe una atencion suboptima, en parte debido a una organizacion inadecuada de los recursos asistenciales o a la falta de estos. Las UCCI surgen de la necesidad de corregir estos aspectos y gestionar con eficiencia unos recursos escasos y costosos. Sus objetivos son: a) proporcionar a cada paciente el grado de cuidados que requiere; b) optimizar los recursos estructurales, tecnicos y humanos, y c) facilitar el continuo asistencial y el gradiente de cuidados. Las UCCI se deben constituir en una parte esencial del servicio de cardiologia destinada a la atencion de enfermos cardiologicos que requieren monitorizacion, cuidados y capacidad de respuesta medica superiores a los disponibles en una planta de hospitalizacion convencional de cardiologia, pero cuyo riesgo no justifica la utilizacion de los recursos tecnicos y humanos de una unidad coronaria. Este documento describe la infraestructura (equipamiento, dotacion de personal y organizacion) que se precisa para cumplir los objetivos descritos anteriormente y contiene recomendaciones sobre las indicaciones de ingreso en estas unidades intermedias. Estas incluyen a determinados pacientes con: a) SCA sin elevacion del segmento ST de riesgo intermedio o alto pero estables hemodinamicamente, y b) infarto agudo de miocardio con elevacion del segmento ST no de alto riesgo, o bien, de alto riesgo, pero estabilizado despues de una fase inicial complicada en la unidad coronaria. Tambien se contempla el ingreso de algunos pacientes despues de determinados procedimientos invasivos y de algunas formas de cardiopatias agudas no coronarias.

The Spanish Working Group on Coronary Artery Disease of Spanish Society of Cardiology has considered to be necessary the development of this document on the need, structure and organization of Intermediate Cardiac Care Units (ICCU). Acute coronary syndrome registries show that an important percentage of patients receive a suboptimal care, due to an inadequate management of health resources or absence of them. Intermediate cardiac care units arise to solve these challenges and to manage in an efficient way these expensive and limited resources. Their aims are: a) to provide each patient the level of care required; b) to optimize the structural, technical and human resources, and c) to make easier continuous care and care gradient. As a result, ICCU should be established as an essential part of the cardiology department aim to cardiac patients requiring monitoring and medical care superior to those available in a regular cardiac ward but whose risk does not justify the technical and human costs of a Coronary Unit. This document describes the structure (equipment, human resources, management) required to reach the goals previously reported and includes recommendations about indications of admission in a ICCU. These indications include: a) patients with NSTE-ACS with intermediate or high risk but hemodynamically stable, and b) low risk STEAMI or high risk STEAMI stabilized after an initial admission at the Coronary Unit. The admission of some patients undergoing invasive procedures or suffering non-coronary acute cardiac diseases, is also considered.

La enfermedad cardiovascular es la principal causa de morbilidad y mortalidad en los pacientes con diabetes mellitus. Se ha demostrado que los pacientes diabeticos presentan una mayor incidencia de enfermedad coronaria multivaso, con mayor frecuencia de lesiones complejas, pobres lechos distales y una progresion de la enfermedad mas rapida que la poblacion general no diabetica. La revascularizacion coronaria percutanea (ICP) ha demostrado su utilidad en los pacientes diabeticos. Sin embargo, aunque los resultados angiograficos iniciales son buenos, hay una mayor incidencia de reestenosis, un riesgo mas elevado de complicaciones y una menor supervivencia a largo plazo. Los stents farmacoactivos han reducido notablemente el riesgo de reestenosis y complicaciones tardias. En espera de los resultados de los estudios actualmente en marcha, en los pacientes diabeticos con enfermedad multivaso, la cirugia de derivacion aortocoronaria sigue siendo el tratamiento de primera eleccion. Sin embargo, hay que destacar que, desde un punto de vista practico, a la hora de indicar cirugia de derivacion aortocoronaria o ICP deberemos basarnos en las caracteristicas particulares del paciente (p. ej., comorbilidad asociada) y en la experiencia del propio centro, ya que hay notables diferencias en funcion de la experiencia del equipo quirurgico y de cardiologia intervencionista. Por ultimo, es muy importante destacar que, en los pacientes diabeticos en los que se realiza revascularizacion coronaria, con independencia del metodo utilizado, es de trascendental importancia establecer un tratamiento medico energico que incluya modificaciones en el estilo de vida (tabaquismo, sindrome metabolico, etc.), ntiagregacion plaquetaria, tratamiento con estatinas en las dosis adecuadas (objetivo terapeutico con un valor de colesterol unido a lipoproteinas de baja densidad

Fundamento y objetivo Los objetivos del presente estudio han sido analizar el pronostico en pacientes recuperados de una muerte subita cardiaca extrahospitalaria que ingresaron en la unidad de cuidados intensivos coronarios, asi como identificar los factores asociados a la morbimortalidad. Pacientes y metodo Analizamos a 63 pacientes consecutivos (47 varones), con una edad media (desviacion estandar) de 61 (12) anos, que ingresaron entre noviembre de 1999 y enero de 2004 recuperados de una muerte subita cardiaca y permanecieron en la unidad de cuidados intensivos coronarios. Se examino la relacion de las caracteristicas clinicas y lectrocardiograficas con la mortalidad y las secuelas neurologicas. Resultados Sobrevivieron 35 pacientes (55,5%), mientras que 28 (44,5%) fallecieron transcurridos una media de 28 (4) dias desde el ingreso, la mayoria en el hospital. El sustrato anatomico principal fue la cardiopatia isquemica (80,9%). En los pacientes que fallecieron, comparados con los que sobrevivieron, las variables que se asociaron a un peor pronostico fueron la diabetes mellitus (un 68,4 frente al 17,1%; p Conclusiones La supervivencia en pacientes recuperados de una muerte subita cardiaca extrahospitalaria es alta, aunque la mortalidad todavia sigue siendo elevada. Las complicaciones neurologicas son la principal causa de mortalidad. El pronostico viene determinado por la presencia de factores relacionados con la enfermedad subyacente, el tiempo en iniciar las maniobras de recuperacion y la lesion cerebral postanoxica.

Background Vasospastic angina usually responds well to medical treatment. Hypothesis The present study describes our experience in patients who received a coronary stent because of recurrent variant angina refractory to medical treatment and evaluates stent implantation as an alternative treatment. Materials and methods Between March 1998 and February 2005, recurrent variant angina was diagnosed in 22 patients admitted to our coronary care unit. Of these, five patients (22.7%), were refractory to pharmacologic treatment. Coronary angiography and coronary stents were indicated. Clinical follow-up was 29 ± 6 months. Results Stenting was performed during diagnostic coronary angiography in two patients. In the other three patients, the stent was implanted 24–48 h later. We observed coronary spasm recurrences proximal or distal to the stent in four patients—two during the stent implantation procedure and the other two in the coronary care unit within 48 h post angioplasty. Three patients where treated with additional stenting and the fourth patient improved with pharmacologic treatment. During follow-up three patients remained asymptomatic. The fourth patient had diffuse in-stent restenosis in the third month, and the fifth patient showed a de novo lesion in the treated segment 2 years later. Conclusions Stent implantation in patients with recurrent variant angina refractory to medical treatment may be an alternative treatment in carefully selected, clinically unstable patients. Spasm recurrences may occur in other segments of the treated artery, probably due to the diffuse nature of the disease. Immediate and continued surveillance is recommended because of the risk of adverse clinical events. Copyright © 2006 Wiley Periodicals, Inc. Wiley Periodicals, Inc.

New biological markers of myocardial injury have improved the management of patients with acute coronary syndromes. Among these markers, the most relevant are the cardiac troponins (troponin I and troponin T) because of their cardiospecificity, and myoglobin because of its combination of diagnostic sensitivity and usefulness for an early diagnosis. The serial analysis and combined use of both markers fulfill all diagnostic and prognostic requirements, and are helpful in indicating therapeutic strategies for acute coronary syndromes. However, these markers also have limitations, and their concentrations should always be interpreted in the light of the patient's clinical status.

Introduction -There is scant information about the effects of thrombolysis in the evolution of right bundle-branch block (RBBB) in the setting of acute anterior myocardial infarction.The aim of this study has been to analyse these effects and its impact on prognosis. Methods -We studied 54 patients who presented a RBBB related to an acute anterior myocardial infarction. We defined two groups: those who received thrombolytic treatment and those who did not.We analysed the evolution of RBBB (transience, moment of onset, moment of disappearance) and its relationship with in-hospital mortality. Twenty-one patients (39%) received thrombolytic treatment (group T) and 33 patients (61%) (group NT) did not. Results - The incidence of late appearance (> 6 h) of RBBB was less frequent in group T compared with group NT (10% vs. 33%, p = 0.04). The incidence of transient block was similar in the two groups (57% vs. 45%, p ns). However, early disappearance of RBBB (in < 6 hours) was more common in group T than in group NT (33% vs. 9%, p = 0.04). Mortality was higher in patients with RBBB present at 24 h after admission) than in those with RBBB resolved in less than 24 hours (in group NT, 55% vs. 8%, p = 0.02 and in group T 50% vs. 0%, p = 0.02, respectively). Conclusions -Thrombolysis seems to influence the moment of onset and disappearance of RBBB by promoting its early disappearance and avoiding its late appearance. Disappearance of RBBB is associated with a better prognosis.

Atrial fibrillation (AF) is an arrhythmia characterized by chaotic electrical activity in the atria, which causes asynchrony of atrial fibers excitation and contraction. Thus, the organized contractile capacity of the atrium for filling the ventricles is lost which diminishes the ventricular ejection, as well as, auricular blood stasis and turbulent flow favors thrombosis and consequent thromboembolism may develop. Therefore, this arrhythmia has an important clinical impact. This chapter summarizes the several unmet needs in AF, which still constitute a challenge for patients, physicians and health care managers because its medical, social and economic impact probably will worsen over the next decades. Therefore, research and future knowledge of AF will play a major role for modern societies.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice. It is not a benign disease because is associated to a significant increase in mortality and morbidity. Thus, being AF a potentially dangerous arrhythmia, it seems logical to use antiarrhythmic strategies to avoid, or at least control, this rhythm disturbance [1, 2].

SummaryThe evidence of elevated levels of several biochemical markers of prothrombotic state in patients with unstable angina suggests that thrombus formation and lysis play a pivotal role in acute coronary syndromes. The clinical syndrome of unstable angina encompasses a variety of clinical presentations of transient episodes of myocardial ischemia. This study was designed to assess plasmin generation in different settings of unstable angina. Evidence of plasmin generation in patients with unstable angina was measured by circulating plasmin-α2 antiplas-min complexes (PAP). A second objective was to identify whether PAP levels had a prognostic value to predict outcome. Eighty-five patients admitted to the coronary care unit for unstable angina were classified into three groups. Group A included 26 patients with postinfarction angina; group B comprised 26 patients with new onset angina; and group C included 33 patients with crescendo angina. Mean PAP levels were higher in the three groups compared to healthy controls. A significant correlation was found between levels of PAP and D-dimer, particularly in postinfarction angina (r = 0.6; p Abbreviations and acronyms: CABG: coronary artery bypass graft; CCU: coronary care unit; ECG: electrocardiogram; IABP: intraaortic balloon pump; MI: myocardial infarction; PAP: plasmin-α2 antiplasmin complexes; PTCA: percutaneous transluminal coronary angioplasty

This study was designed to determine the value of automatic corrected QT-interval measurement in Holter tapes in patients after myocardial infarction as a marker of life-threatening ventricular arrhythmias. We compared the corrected QT interval, automatically measured in 24-hour Holter recordings, in two groups of patients after myocardial infarction: group I was composed of 14 patients admitted consecutively to our hospital for documented sustained ventricular tachycardia or out-of-hospital cardiac arrest. Group II consisted of 28 patients with previous myocardial infarction with characteristics similar to those of group I, but without malignant ventricular arrhythmias in the follow-up. The global mean 24-hour corrected QT interval was longer in group I (425 +/- 20 msec) than in those patients after myocardial infarction without arrhythmias (group II) (405 +/- 17 msec; p0.01). Furthermore, a significant proportion of patients of group I (seven of 14) exhibited more peaks of corrected QT longer than 500 msec compared with patients of group II (two of 28; p0.005). A circadian rhythm of corrected QT peaks was observed in group I, having a significantly higher incidence from 11 PM to 11 AM (p0.05). We conclude that automatic corrected QT-interval measurement on Holter electrocardiogram is now available and feasible. Our results suggest that this is a marker for risk assessment of life-threatening ventricular arrhythmias. Large-scale trials are needed to confirm these results and to determine the predictive value of this technique for risk stratification.

The following images belong to a 86-year-old woman with severe aortic stenosis in whom a transcatheter aortic valve replacement (TAVR) was performed ([Figure 1][1], [Online Videos 1][2], [2][3], and [3][4]). Pre-procedural angiography revealed an anomalous origin of the left circumflex coronary

Left ventricular hypertrophy (LVH) is the adaptative mechanism of the heart to systolic overload of the left ventricle. Nevertheless, LVH plays a role in some complications, such as cardiac arrhythmias. Patients with LVH are more likely to develop ventricular arrhythmias than the hypertensive population without LVH. Further, the relation between left ventricular mass and ventricular arrhythmias is graded and continuous. The arrhythmias described in hypertensive patients with LVH are usually isolated premature ventricular contractions. The presence of electrocardiographic criteria of LVH represents a risk of higher incidence of sudden death, especially in men. The risk is even greater in the presence of ventricular arrhythmias. The presence of late potentials has been recently characterized as more related to ventricular arrhythmias than LVH. Antihypertensive drugs that can reduce LVH also have a beneficial effect on cardiovascular morbility and mortality.

Spontaneous coronary artery dissection is an unusual cause of acute coronary syndrome. We describe a series of cases that with an early diagnosis and aggressive treatment, which includes percutaneous angioplasty with stent implantation and cardiac surgery, had a good outcome. The objective was to study the demographic characteristics, clinical settings, treatments, and inhospital course of patients with spontaneous coronary artery dissection. We studied a retrospective case series in 3 coronary care units in third-level university hospitals. The spontaneous coronary artery dissection diagnosis was made by coronary angiography. Seven cases of spontaneous coronary artery dissections were recorded. They were 5 women and 2 men. The age range was 28 to 64 years. Two of them took oral contraceptives and one case occurred in the postpartum period. An acute anterior wall myocardial infarction was the most frequent clinical presentation, occurring in 4 of the 7 cases. In fact, the left anterior descending artery was involved in 6 cases. An urgent coronary angiogram was performed in all cases. Definitive treatment included percutaneous angioplasty and stent implantation in 3 cases, coronary artery bypass surgery in 2 case, and cardiac transplantation in another case. One patient was treated medically. None of the patients died in the hospital. Spontaneous coronary artery dissection remains an unusual cause of acute coronary syndrome. It should be included in the differential diagnosis of acute myocardial infarction, especially when it affects young, healthy females. An early clinical suspicion and diagnosis with urgent coronary angiography and aggressive treatment that includes percutaneous angioplasty with stent implantation and cardiac surgery could improve the prognosis of these patients.

Age is one the factors associated with poor prognosis in acute coronary syndromes (ACS) and elderly patients are a high-risk collective with few parameters for mid-term cardiovascular stratification. We aimed to assess the predictive value of ankle-brachial index (ABI) in patients (75 years) for 1-year mortality after an ACS.Prospective, observational and multicentre study of ACS patients in whom ABI was assessed during hospitalization.A total of 1·054 patients were included, mean age 66·6 (11·7) years from whom 26·6% were75 years. Elderly patients showed more history of cardiovascular disease and higher prevalence of all risk factors, except current smoking. Angiography and revascularization were performed less frequently in the elderly. Patients75 years showed higher presence of three vessel coronary disease and received fewer guideline-recommended treatments. Patients who died through the follow-up, mean time 387·9 ± 7·2 days, had lower ABI (0·73 ± 0·24 vs. 0·92 ± 0·22; P0·01), also in the elderly patients (0·73 ± 0·24 vs. 0·86 ± 0·23; P0·01). Cox regression analysis identified age75 years (HR: 2·30; IC 95% 1·26-4·18; P0·01) and ABI0·90 (HR: 3·58; IC 95% 1·80-7·15; P0·01) as risk factors for to 1-year mortality. Mortality was similar in elderly patients with ABI0·90 and young patients with ABI0·90; the worst prognosis was observed in elderly patients with ABI0·90 (HR: 10·01; 95% CI 3·74-27·15).Elderly patients represent a relevant collective of patients with ACS and are treated less optimally. ABI predicts 1-year mortality after an ACS in elderly patients.

The impact of target organ damage (TOD) clustering in hypertensive patients with established cardiovascular disease has not been clearly defined. Multicentre, observational and prospective study of 1054 consecutive patients with acute coronary syndromes (ACSs). The objective was describing the impact of TOD on first-year mortality. Ankle-brachial index (ABI), left ventricular hypertrophy and renal dysfunction were assessed during hospital stay. Hypertensive patients accounted for 80% of the cohort and had slightly higher mean age, higher prevalence of risk factors, previous cardiovascular disease and TOD. During follow-up, mean time 387.9 (7.2) days and median 382 (364.0-430.0) days, mortality rate tended to be higher in hypertensive patients (6.1 versus 3.5%; P = 0.16). Cox regression survival analysis identified pathological ABI as the only TOD independently associated with mortality. When assessed globally, the presence of at least one TOD predicted mortality only in patients with hypertension and differences in mortality rate appeared very early in the follow-up. A linear increase in mortality rate was observed with the clustering of TOD: 2.0%, if no TOD was present, 7.6% in one TOD, 11.1% in two TODs and 20.0%, if three TODs were present. An increased risk in the combined end point of ischaemic events was observed in hypertensive patients without TOD (odds ratio (OR): 3.18; 95% confidence interval (CI): 1.31-7.70; P = 0.01) and was still higher in patients with hypertension and TOD (OR: 4.61; 95% CI: 1.90-11.80; P < 0.01). TOD predicts mortality and ischaemic events of hypertensive patients after ACS. Journal of Human Hypertension (2011) 25, 600-607; doi:10.1038/jhh.2010.109; published online 16 December 2010

To estimate the costs to manage selected types of bleeding complications in patients with acute coronary syndrome (ACS) treated with antithrombotics, including antiplatelet, and fibrinolytic therapies: decrease in haemoglobin3 g/dL, puncture site, and bleeding requiring transfusion of blood products.Retrospective chart reviews of ACS patients experiencing decrease in Hb, puncture site, or bleeding requiring transfusion were conducted in hospitals in France, Germany, Italy, Spain and Sweden to determine the total length of stay (LOS), stay post-bleeding, procedures to identify the extent of bleeding, number and types of transfusion products, patient demographics, reason for hospital admission and disposition upon discharge. Country-specific costs were applied to estimate the average cost per patient by type of bleeding event.Records of 158 ACS patients with the bleeding complications were examined (26.9% decrease in Hb, 35.5% puncture site, and 37.8% transfusion). The average LOS was 10.6 days for decreasing Hb, 7.7 days for puncture site bleeding, and 11.3 days for patients receiving transfusions due to these bleeding events. The average costs per patient ranged between €3,986 and €10,252. The LOS ranged widely both within and across countries.The study has a small sample size and costs are confounded by co-morbidities.The estimated costs for decreasing Hb, puncture site bleeding and bleeding resulting in transfusions provide a tool for researchers to conduct economic analyses of bleeding events associated with therapies for ACS.

The relationship between silent myocardial ischemia and sudden death depends on the severity and duration of the ischemia. Severe, transmural and persistent ischemia, as occurs in myocardial infarction, can trigger sudden death. When the ischemia is severe and transmural but not long-standing (e.g., Prinzmetal angina), ventricular arrhythmias appear frequently, but they are rarely malignant. In cases of subendocardial ischemia, there is no definitive proof of this relationship.

Peripheral arterial disease (PAD) is associated with an increased risk of cardiovascular morbidity and mortality. Nevertheless, many patients are asymptomatic, and this condition frequently remains underdiagnosed. An ankle-brachial index (ABI) of less than 0.9 is a noninvasive and simple marker in the diagnosis of PAD and is also predictive of target organ damage in hypertension. The prognostic value of such measurements in hypertensive patients with acute coronary syndrome (ACS) is unknown.The Prevalence of Peripheral Arterial Disease in Patients with Acute Coronary Syndrome registry is a multicentre, observational and prospective study that aims to describe the prevalence of and prognosis for PAD, diagnosed by ABI in hypertensive patients with ACS.One thousand one hundred and one hypertensive patients with ACS and at least 40 years of age were prospectively studied. Mean age of the population was 67.4 (11.4) years, and 67.7% were men. The prevalence of ABI less than 0.9 was 42.6% (469 patients). This subgroup was significantly older, had a higher prevalence of diabetes, previous coronary heart disease or stroke, left ventricular hypertrophy and more severe coronary lesions. Hospital mortality was higher in hypertensive patients with ABI less than 0.9 (2.3 vs. 0.2%; P0.01). An ABI less than 0.9 was associated with an increased risk of heart failure after ACS (odds ratio, 1.4; P=0.04), higher hospital mortality (odds ratio, 13.0; P=0.03) and the composite endpoint of mortality, heart failure and angina (odds ratio, 1.4; P=0.03).Asymptomatic PAD is highly prevalent in hypertensive patients with ACS. An ABI less than 0.9 identifies a subset of patients with more extensive target organ damage and higher risk of hospital cardiovascular complications after an ACS.

In the course of the last year, a number of important clinical trials on cardiovascular disease, principally in hypertensive and diabetic patients, have published their results. The findings, some of which were unexpected, have enabled us, in certain instances, to confirm what already we knew about controlling these risk factors, but they have also led to active discussion about well-established topics, such as: To what extent should blood pressure and glycemia levels be reduced in patients with cardiovascular disease? In addition, up-to-date information has become available about treating hypertension with new drugs or new combinations of existing drugs. This article contains a review of all these topics and also summarizes the findings of some observational studies carried out by the working group on hypertension of the Spanish Society of Cardiology that have been reported in the last year.

The best therapeutic approach to the therapy of potentially malignant ventricular arrhythmias is still unknown, particularly in view of the increased mortality with flecainide and encainide shown in the CAST study. Various ongoing studies, particularly with amiodarone, will show whether better results can be obtained with other agents. Flecainide and encainide do, however, have a restricted place when other agents cannot be used. Low-dose amiodarone with low-dose flecainide may be worth trying.

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1-9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover.

El diagnostico clinico de los tumores cardiacos es, a menudo, dificil. Presentamos el caso de un paciente de 17 anos en el que se diagnostico un tumor del ventriculo izquierdo a partir del estudio de un sincope. El estudio anatomopatologico confirmo el diagnostico de mixoma. Clinical diagnosis of cardiac tumours is often difficult. We present the case of a 17 year-old boy inwhom a left ventricular tumour was discovered duringon diagnostic work-up for a syncope. The tumourwas removed and histology confirmed thediagnosis of myxoma.