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Introduccion y objetivos La deficiencia de testosterona se asocia a un peor pronostico en pacientes con insuficiencia cardiaca. Se desconoce si la testosterona disminuye la apoptosis de cardiomiocitos y si la espironolactona, bloqueador del receptor de aldosterona con actividad progestogenica y antiandrogenica, tiene un efecto diferencial respecto al bloqueo selectivo con eplerenona. Metodos En la linea de cardiomioblastos de rata H9c2, se cuantifico la apoptosis inducida por estres hiperosmotico mediante analisis de viabilidad celular, fragmentacion del ADN y activacion de caspasa 3, 8 y 9. Se estudiaron los efectos de testosterona, en presencia o ausencia de espironolactona y eplerenona. Resultados La exposicion al sorbitol (0,6 M, 3 h) disminuyo la viabilidad celular e incremento la fragmentacion del ADN y la activacion de caspasa 3, 8 y 9. Estos efectos fueron disminuidos significativamente por la testosterona (100 nM) (p Conclusiones La testosterona parece tener un efecto protector contra la apoptosis de celulas cardiacas, que la espironolactona contrarresta, pero no la eplerenona. Estos hallazgos precisan confirmacion en modelos in vivo, pero de estar presentes podrian tener implicaciones clinicas y terapeuticas.

Testosterone deficiency is associated with a poor prognosis in patients with heart failure. It is not clear whether testosterone reduces cardiomyocyte apoptosis or whether the effect of spironolactone, an aldosterone receptor blocker with progestogenic and anti-androgen activity, differs from that of the selective aldosterone blocker eplerenone.Apoptosis induced by hyperosmotic stress in the embryonic rat heart cell line H9c2 was monitored by measuring cell viability, DNA fragmentation and caspase-3, -8 and -9 activation. The effect of testosterone was investigated in the presence or absence of spironolactone and eplerenone.Exposure to sorbitol (0.6 M, 3 h) decreased cell viability and increased DNA fragmentation and caspase-3, -8 and -9 activation. These effects were all significantly reduced by testosterone, 100 nM (P.01). Pretreatment with spironolactone, 10 .M, blocked the effects of testosterone, decreased cell viability (P.01) and increased caspase activation (P.01). In contrast, eplerenone, 10 .M, increased cell viability (P.001) without altering the effect on caspase activation. These actions were not modified by the androgen receptor blocker flutamide. They were mediated by SAPK/JNK and ERK1/2 signaling pathways (P.01).Testosterone appears to have a protective effect against cardiomyocyte apoptosis which is antagonized by spironolactone but not by eplerenone. These effects await confirmation in in vivo models, but their presence could have clinical and therapeutic implications.

Introducción y objetivos: La población de adultos con cardiopatías congénitas es creciente, y de tan reciente aparición que su evolución aún nos es desconocida. Pacientes con cardiopatías congénitas que han podido pasar desapercibidas en la infancia, al ser menos graves, o pacientes con cardiopatías conocidas, pero que no han requerido tratamiento quirúrgico hasta la edad adulta; pacientes con cardiopatías congénitas operadas en la infancia que alcanzan ahora la edad adulta. El objetivo de esta investigación es estudiar la población adulta que requiere intervención quirúrgica de una cardiopatía congénita.Métodos: Análisis de la población adulta con una cardiopatía congénita que ha requerido intervención quirúrgica relacionada con la misma en los últimos diez años en el Servicio Murciano de Salud. Intervención y resultados. Conclusiones: Hasta hace poco únicamente los pacientes con cardiopatías congénitas “muy simples” podían llegar a la vida adulta, por su natural tendencia a la supervivencia. Hoy en día gracias al avance en el manejo tanto médico como quirúrgico, diagnóstico y terapéutico, los adultos con cardiopatías congénitas constituyen un amplio grupo de pacientes tributarios de cirugía cardiovascular.

Introduccion y objetivos La globulina transportadora de hormonas sexuales (SHBG) es una molecula clave en la regulacion del efecto de los esteroides anabolizantes. En la insuficiencia cardiaca cronica se ha descrito un deterioro anabolico, pero se desconoce el valor de la SHBG. Metodos Se incluyeron 104 varones (53 ± 11 anos) con insuficiencia cardiaca (FEVI Resultados A la inclusion, los niveles de SHBG (34,5 [27-50] nmol/l) se correlacionaron con los de NT-proBNP (r = 0,271; p = 0,005), la FEVI (r = −0,263; p = 0,007), el indice de masa corporal (r = −0,199; p = 0,020) y la testosterona total (r = 0,332; p = 0,001). Los niveles de SHBG fueron mayores (48,5 [36-69,5] frente a 33 [25,3-48,7] nmol/l; p = 0,001) en pacientes que fallecieron (n = 16 [15,4%]) y se asociaron a un mayor riesgo de muerte (HR = 1,045; IC del 95%, 1,021-1,069; p Conclusiones Los niveles de SHBG se correlacionan con medidas de severidad de la insuficiencia cardiaca y se asocian a un mayor riesgo de muerte cardiaca. Nuevos estudios deben aclarar si la SHBG tiene un papel en la fisiopatologia de la insuficiencia cardiaca.

INTRODUCTION AND OBJECTIVES: Sex hormone-binding globulin (SHBG) is a key regulator of the actions of anabolic steroids. Chronic heart failure (HF) has been associated with anabolic steroid deficiency, but its relationship with SHBG is not known. METHODS: The study involved 104 men (53+/-11 years) with HF (i.e. left ventricular ejection fraction [LVEF]

Introduction and objectives The duration of the QRS interval measured by ECG is a marker of ventricular dysfunction and indicates a poor prognosis. Its value in patients undergoing coronary revascularization surgery has not been established. Methods The study involved 203 consecutive patients (age, 64[9] years; 74% male) scheduled for elective coronary surgery. The maximum QRS duration measured on a preoperative 12-lead ECG was recorded. Hemodynamic instability was defined as the occurrence of cardiac death, heart failure, or a need for intravenous inotropic drugs or intra-aortic balloon counterpulsation during the postoperative period. Results The occurrence of hemodynamic instability (n=94, 46%) was associated with a longer preoperative QRS duration (97.5[21.14] ms vs 88.5[16.9] ms; P =.001). The QRS duration was also longer in patients who developed heart failure (n=23; 104.3[22.9] ms vs 91.1[18.5] ms; P =.002), needed inotropic drugs (n=77; 96.5[20.5] ms vs 90.1[18.2] ms; P =.007) or developed postoperative atrial fibrillation (n=58; 98.2[23.8] ms vs 90.4[17.0] ms; P =.018). Bundle branch block was associated with a greater need for intra-aortic balloon counterpulsation (29% vs 12%; P =.012) or inotropic drugs (58% vs 35%; P =.014) and a higher incidence of hemodynamic instability (69% vs 42%; P =.006). Multivariate analysis identified the following independent predictors of hemodynamic instability: QRS duration (adjusted odds ratio [OR] per 10 ms=1.49; 95% confidence interval [CI], 1.11-2; P =.007), the lack of an arterial graft (OR=3.6; 95% CI, 1.14-11.6; P =.029) and extracorporeal circulation time (OR per min=1.013; 95% CI, 1.003-1.023; P =.013). Conclusions The intraventricular conduction delay, or QRS duration, was associated with a higher risk of postoperative hemodynamic instability following coronary surgery.

Introduccion y objetivos. La duracion del intervalo QRS en el ECG es un marcador de disfuncion ventricular y peor pronostico. Su valor en pacientes sometidos a cirugia de revascularizacion coronaria no ha sido establecido. Metodos. Estudiamos a 203 pacientes consecutivos (64 ± 9 anos de edad; el 74% varones) programados para cirugia electiva coronaria. Se registro la duracion maxima del intervalo QRS en el ECG de 12 derivaciones preoperatorio. Definimos inestabilidad hemodinamica como la aparicion de muerte cardiaca, insuficiencia cardiaca, uso de farmacos inotropicos intravenosos o balon de contrapulsacion intraaortico durante el postoperatorio. Resultados. La aparicion de inestabilidad hemodinamica (n = 94 [46%]) se asocio a una mayor duracion del intervalo QRS preoperatorio (97,5 ± 21,14 frente a 88,5 ± 16,9 ms; p = 0,001). El QRS fue mayor en quienes aparecio insuficiencia cardiaca (n = 23; 104,3 ± 22,9 frente a 91,1 ± 18,5 ms; p = 0,002), precisaron inotropicos intravenosos (n = 77; 96,5 ± 20,5 frente a 90,1 ± 18,2 ms; p = 0,007) o sufrieron fibrilacion auricular postoperatoria (n = 58; 98,2 ± 23,8 frente a 90,4 ± 17 ms; p = 0,018). El bloqueo de rama se asocio a mayor necesidad de balon de contrapulsacion (el 29 frente al 12%; p = 0,012), inotropicos (el 58 frente al 35%; p = 0,014) y mayor incidencia de inestabilidad hemodinamica (el 69 frente al 42%; p = 0,006). Tras el ajuste multivariable, los predictores de inestabilidad hemodinamica fueron la duracion del QRS (odds ratio [OR] = 1,49; intervalo de confianza [IC] del 95%, 1,11-2; p = 0,007), la ausencia de injerto arterial (OR = 3,6; IC del 95%, 1,14-11,6; p = 0,029) y el tiempo de circulacion extracorporea (OR = 1,013; IC del 95%, 1,003-1,023; p = 0,013), con independencia de otros factores de riesgo. Conclusiones. El retraso de la conduccion intraventricular o duracion del intervalo QRS se asocia a mayor riesgo de inestabilidad hemodinamica durante el post-operatorio de cirugia coronaria.

Introduccion y objetivos La proteina surfactante tipo B (PS-B) es un marcador de dano en la barrera alveolocapilar y podria ser util en la monitorizacion del deterioro pulmonar asociado a la insuficiencia cardiaca cronica (ICC). Metodos Se estudio a 43 pacientes ambulatorios con ICC (edad, 51 ± 10 anos; el 77% varones; fraccion de eyeccion del ventriculo izquierdo [FEVI], 33% ± 11%) a los que se realizo una prueba de esfuerzo cardiopulmonar limitada por disnea. Se obtuvieron muestras de sangre periferica en reposo y en el primer minuto tras el maximo esfuerzo. La presencia y la cantidad de PS-B en suero sanguineo se analizaron mediante analisis Western blot. Resultados En reposo, se detecto PS-B circulante en 35 (82%) pacientes, frente a solo 6 (23%) voluntarios sanos de una muestra control (n = 26; edad, 51 ± 10 anos; el 77% varones), con mayores concentraciones circulantes en pacientes con ICC (mediana [intervalo intercuartilico], 174 [70-283]) frente al grupo control (77 [41-152]; p Conclusiones En pacientes con ICC, la proteina surfactante pulmonar tipo B esta incrementada en la circulacion periferica y se correlaciona con la ineficiencia ventilatoria en el ejercicio expresada como pendiente VE/VCO2.

INTRODUCTION AND OBJECTIVES Surfactant protein B (SP-B) is a marker of damage to the alveolar-capillary barrier that could be useful for monitoring functional impairment in patients with chronic heart failure (HF). METHODS Dyspnea-limited cardiopulmonary exercise testing was carried out in 43 outpatients with chronic HF (age 51+/-10 years, 77% male, left ventricular ejection fraction [LVEF] 33+/-11%). Peripheral blood serum samples were obtained at rest and during the first minute of peak exercise. The presence and concentration of SP-B in the serum samples were determined by Western blot analysis. RESULTS At rest, SP-B was detected in 35 (82%) patients compared with only six (23%) healthy volunteers in a control group (n=26, age 51+/-10 years, 77% male). The median circulating SP-B level was higher in HF patients, at 174 [interquartile range, 70-283] vs. 77 [41-152] (P< .001) in the control group. In HF patients, the presence of circulating SP-B was associated with a lower LVEF (31.4+/-9.6% vs. 41.8+/-15%; P=.01). Multivariate analysis showed that the resting SP-B level correlated with a greater VE/VCO2 slope (beta=1.45; P=.02). The peak-exercise SP-B level correlated almost perfectly with the resting level (r=0.980; P< .001), but there was no significant increase with exercise (P=.164). Nor was there a correlation with any other exercise parameter. CONCLUSIONS In patients with chronic HF, the level of pulmonary surfactant protein B in the peripheral circulation is increased and is correlated with ventilatory inefficiency during exercise, as indicated by the VE/VCO2 slope.

Beta blockers are underprescribed to elderly patients with systolic heart failure (HF). We studied whether the prescription of a beta blocker is associated with a survival benefit in a nonselected population of patients70 years of age hospitalized with acute HF and systolic dysfunction. We studied 272 consecutive patients70 years (median 77.0, interquartile range 73.4 to 81.1) hospitalized with acute HF (left ventricular ejection fraction 34 +/- 8%) during a 2-year period. At discharge, beta-blocker therapy was prescribed in 139 patients (51.1%). A propensity score for the likelihood of receiving beta-blocker therapy was developed and showed a good performance (c-statistic = 0.825 and Hosmer-Lemeshow p = 0.820). After discharge, 120 patients (44.1%) died during the follow-up (median 31 months, interquartile range 12 to 46). Cox regression analysis showed a lower risk of death associated with beta-blocker prescription (p0.001, hazard ratio [HR] 0.450, 95% confidence interval [CI] 0.310 to 0.655), which persisted after risk adjusting for the propensity score (HR 0.521, 95% CI 0.325 to 0.836, p = 0.007). In a propensity-matched cohort of 130 patients, there was a significantly lower mortality in patients receiving beta blockers (log rank 0.009, HR 0.415, 95% CI 0.234 to 0.734, p = 0.003). Risk reduction associated with beta blockade was observed with both high doses (HR 0.472, 95% CI 0.300 to 0.742, p = 0.001) and low doses (HR 0.425, 95% CI 0.254 to 0.711, p = 0.001). In conclusion, beta-blocker prescription at discharge in a nonselected population70 years of age hospitalized with systolic HF is associated with a significantly lower risk of death even at low doses. This benefit remains consistent after adjustment for potential confounders.

Introduction and objectives. To study the usefulness of incremental atrial pacing for evaluating the effect of radiofrequency catheter ablation on slow pathway conduction in patients with atrioventricular (AV) nodal reentrant tachycardia. Methods. A prospective study was carried out in patients either with (ie, AV nodal reentrant tachycardia group) or without (ie, control group) inducible AV nodal reentrant tachycardia who were referred for electrophysiologic study. Incremental atrial pacing involved gradually decreasing the pacing cycle length until the PR interval exceeded the R-R interval (ie, PR>RR) or AV nodal block occurred. The presence of dual anterograde AV nodal physiology was assessed during programmed atrial stimulation using standard criteria. In the AV nodal reentrant tachycardia group, electrophysiologic study was repeated 30 minutes after successful catheter ablation. Results. In the AV nodal reentrant tachycardia group (n=85), 52 patients (61%) exhibited dual AV nodal physiology during programmed atrial stimulation and 66 (78%) had a PR>RR during incremental atrial pacing. In the control group, the corresponding proportions were 10/56 (18%) and 7/56 (12%), respectively. After successful slow pathway catheter ablation (81/85), 37/81 exhibited dual AV nodal physiology during programmed atrial stimulation while 1/81 had a PR>RR during incremental atrial pacing. The positive predictive value of successful slow pathway ablation for the absence of a PR>RR was 98%. Conclusions. Incremental atrial pacing demonstrated that the PR interval exceeded the R-R interval in the majority of patients with inducible AV nodal reentrant tachycardia. This technique could provide a fast and simple way of evaluating the effect of radiofrequency catheter ablation on slow pathway conduction.

Introduccion y objetivos Estudiar la utilidad de la estimulacion auricular progresiva para evaluar el efecto de la ablacion con cateter sobre la conduccion por via lenta en pacientes con taquicardia por reentrada nodal comun. Metodos Estudio prospectivo en pacientes remitidos para estudio electrofisiologico en los que se indujo taquicardia por reentrada nodal comun, empleando como grupo control a los pacientes en los que no se indujo. La estimulacion auricular progresiva se practico mediante la disminucion paulatina del ciclo de estimulacion hasta obtener un intervalo PR > RR o bloqueo auriculoventricular. Durante la estimulacion auricular programada se evaluo la presencia de doble fisiologia nodal siguiendo el criterio estandarizado. En el grupo en que se indujo taquicardia se repitio el estudio electrofisiologico 30 min despues de la ablacion. Resultados En el grupo con taquicardia por reentrada nodal comun (n = 85), 52 pacientes (61%) mostraron criterios de doble via nodal durante la estimulacion auricular programada y 66 (78%) mantenian PR > RR durante la estimulacion auricular progresiva. En el grupo control, la incidencia de estos criterios fue de 10/56 (18%) y 7/56 (12%), respectivamente. Tras la ablacion eficaz de via lenta (81/85), 37 mostraban doble via nodal durante la estimulacion auricular programada y uno tenia PR > RR durante estimulacion auricular progresiva (valor predictivo positivo de la ausencia de PR > RR para ablacion eficaz de via lenta del 98%). Conclusiones La estimulacion auricular progresiva muestra un intervalo PR > RR en la mayoria de los pacientes en los que se induce taquicardia por reentrada nodal comun y puede emplearse como un metodo sencillo y rapido para evaluar el efecto de las aplicaciones de radiofrecuencia sobre la conduccion por via lenta.

El papel de los marcadores de dano miocardico e inflamacion en la cirugia de revascularizacion coronaria (CRC) sin circulacion extracorporea (CEC) no ha sido establecido. Se realizo un estudio prospectivo de 51 pacientes consecutivos que recibieron CRC sin CEC. Se determinaron las concentraciones preoperatorias de troponina T, proteina C reactiva, interleucina-6 y factor de necrosis tumoral alfa. El evento primario fue el combinado de muerte cardiaca o infarto agudo de miocardio (IAM) a los 30 dias. Un total de 7 pacientes (14%) presentaron eventos (3, muerte cardiaca y 6, IAM). En el analisis univariable fueron predictores la insuficiencia renal (el 50 frente al 11%; p = 0,028), la fraccion de eyeccion del ventriculo izquierdo 0,10 ng/dl (el 43 frente al 9%; p = 0,016) y el EuroSCORE (7,6 ± 2,5 frente a 5,2 ± 2,6; p = 0,031). La troponina T > 0,10 ng/dl preoperatoria fue el unico predictor independiente de eventos (p = 0,03). Los marcadores de inflamacion no mostraron diferencias (p > 0,05). La presencia de troponina T preoperatoria > 0,10 ng/dl se asocia con un mayor riesgo de muerte o IAM en pacientes que reciben CRC sin CEC.

In dilated cardiomyopathy, severe functional mitral regurgitation (MR) is associated with a poor prognosis. In 112 consecutive clinically stable patients with non-ischemic dilated cardiomyopathy, echocardiography identified 15 (14%) patients who had severe MR (age, 53+/-12 years; 80% male; left ventricular ejection fraction, 26 +/- 8%). Existing medical treatment with ACE inhibitors and beta-blockers was increased up to the maximum tolerated doses. At 6 months, MR decreased by at least one grade in 13 (87%) patients (P =.001), as did the effective regurgitant orifice area (from 0.41 [0.05] mm2 to 0.20 [0.15] mm2; P.

En la miocardiopatia dilatada, la insuficiencia mitral (IM) funcional grave se asocia con una peor situacion clinica y pronostica. De 112 pacientes consecutivos con miocardiopatia dilatada no isquemica, 15 (14%) presentaban IM grave funcional por ecocardiografia (53 ± 12 anos, 80% varones, FEVI 26 ± 8%). Se optimizo el tratamiento previo hasta dosis maximas toleradas de un inhibidor de la enzima de conversion de la angiotensina (IECA) y un bloqueador beta. A los 6 meses disminuyo el grado de insuficiencia en 13 pacientes (87%) (p = 0,001), el area del orificio regurgitante efectivo (0,41 ± 0,05 frente a 0,20 ± 0,15 mm²; p < 0,001) y del jet (13,6 ± 2,1 frente a 7,4 ± 4,5 cm²; p < 0,001). Estos cambios se correlacionaron con una mayor FEVI (26 ± 8 frente a 35 ± 10%; p = 0,009; r = 0,60, p = 0,01) y un menor volumen telesistolico (168 ± 46 frente 142 ± 72 ml; p = 0,04; r = 0,59, p = 0,02). Se observo una mejoria de la clase NYHA (2,7 ± 0,5 frente a 1,9 ± 0,7; p < 0,001). La IM funcional grave evoluciono hacia la mejoria tras la optimizacion maxima de IECA y bloqueadores beta, lo que parece correlacionar con una mejora de la funcion sistolica.

Introduction and objectives. Measurement of N-terminal pro-B-type natriuretic peptide (NTproBNP) helps in diagnosing heart failure (HF). The test’s usefulness may be greatest in patients with severe dyspnea of uncertain origin. However, NTproBNP has not been evaluated specifically in this setting. Patients and method. This prospective emergency department study included 70 patients with shortness of breath at rest as their chief complaint. In the attending physician’s opinion, both HF and a non-cardiac cause were equally probable. Blinded NTproBNP measurement was carried out in blood samples collected on admission. Patients were monitored and their final diagnoses were based on clinical findings, therapeutic responses, and cardiac and noncardiac tests performed during hospitalization. Results. The NTproBNP level was higher in the 49 patients (70%) with a final diagnosis of HF (P=.006); the area under the ROC curve was 0.72 (0.60-0.82). The optimum diagnostic cut-off value was 900 pg/mL, which had an accuracy of 87%, a sensitivity of 98%, and a negative predictive value of 92%. The NTproBNP level was significantly higher in the 6 patients (9%) who died during hospitalization (P=.009); the area under the ROC curve was 0.87 (0.76-0.93) and the optimum cut-off value for predicting death was 5500 pg/mL, which had an accuracy of 77%, a sensitivity of 100%, and a positive likelihood ratio of 4.2. Conclusions. In patients with severe dyspnea and an uncertain diagnosis of HF, an NTproBNP level 5500 pg/mL identifies patients at an increased risk of death.

Introduccion y objetivos El NTproBNP ayuda a identificar a los pacientes con insuficiencia cardiaca. Su utilidad podria ser maxima en pacientes con disnea severa de origen incierto; sin embargo, esta poblacion no ha sido especificamente evaluada. Pacientes y metodo Estudio prospectivo de 70 pacientes que acudieron a urgencias refiriendo disnea de reposo, cuyo diagnostico clinico inicial fue establecido como dudoso, con probabilidad intermedia de insuficiencia cardiaca. A la llegada a urgencias se extrajeron las muestras analiticas y se determino el valor de NTproBNP de forma ciega. Los pacientes fueron controlados y el diagnostico final se establecio sobre la base de los hallazgos clinicos, la respuesta al tratamiento y las pruebas practicadas durante el curso hospitalario. Resultados El NTproBNP fue mayor en los 49 pacientes (70%) con un diagnostico final de insuficiencia cardiaca (p = 0,006), obteniendo un area bajo la curva ROC de 0,72 (0,60-0,82). El valor de corte diagnostico optimo fue 900 pg/ml, con una precision del 87%, una sensibilidad del 98% y un valor predictivo negativo del 92%. En los 6 pacientes (9%) fallecidos durante la hospitalizacion, el NTproBNP fue significativamente mayor (p = 0,009), con un area bajo la curva ROC de 0,87 (0,76-0,93) y un valor de corte pronostico optimo de 5.500 pg/ml, con una precision del 77%, una sensibilidad del 100% y una razon de probabilidad positiva de 4,2. Conclusiones En una poblacion con disnea severa que acude a urgencias con diagnostico dudoso de insuficiencia cardiaca, un valor de NTproBNP 5.500 pg/ml identifica a los pacientes con un mayor riesgo de muerte hospitalaria.

Introduction and objectives. Differences between anatomical severity and clinical manifestations are frequent in patients with hypertrophic cardiomyopathy. Our objective was to assess functional capacity in a consecutive group of patients with hypertrophic cardiomyopathy measuring exercise aerobic parameters, as well as clinical and echocardiographic variables. Patients and method. We studied 98 consecutive patients with hypertrophic cardiomyopathy. All patients underwent both echocardiographic and cardiopulmonary exercise testing. The control group consisted of 22 untrained persons. We studied exercise capacity by analyzing maximal oxygen consumption and aerobic functional capacity, among other variables. Results. Patients with hypertrophic cardiomyopathy attained significantly lower maximal oxygen consumption values than controls (24.1 ± 5.9 vs 36.4 ± 5.9 ml/kg/min; p = 0.0001). Maximal aerobic capacity was significantly different among patients with NYHA functional capacity class I, II or III (78.9 ± 13.5%; 71.9 ± 14.7%; 63.9 ± 15.7%; p = 0.009). However, considerable overlap was found between groups in maximal aerobic capacity. Functional impairment was greater in patients with left ventricular thickness > 20 mm, ejection fraction 45 mm and pseudonormal or restrictive transmitral flow pattern. Conclusions. Patients with hypertrophic cardiomyopathy show significant functional impairment, which is difficult to detect from their clinical manifestations. Optimal assessment requires cardiopulmonary exercise testing.

The extent of implementation in daily clinical practice of the new definition of myocardial infarction is unknown. The purpose of the present study was to describe the use of the new definition in patients discharged from a cardiology department. We analyzed the clinical records of 277 patients admitted because of acute coronary syndromes and discharged from the cardiology department between 1 March 2001 and 31 August 2001. The final clinical diagnosis based on the presence of classical or only new diagnostic criteria was studied. 127 patients (46%) satisfied the new definition (61% classical criteria and 39% only new criteria). Only 98 (77%) of the patients with myocardial infarction according to the new definition were discharged with this diagnosis (96% of the group that satisfied classical criteria and 48% of the group that satisfied only new criteria). The diagnosis of myocardial infarction is still based predominantly on classical criteria; the new criteria have been only partially implemented.

En la insuficiencia cardiaca, el beneficio de la combinacion ARAII e inhibidores de la enzima conversiva de la angiotensina (IECA) ha sido estudiado solo con dosis submaximas del IECA. Incluimos a 20 pacientes (FEVI 24 ± 7%, NYHA II-III), sin cambios clinicos ni terapeuticos en los 3 meses previos, que recibian dosis maximas del IECA, y asociamos 50 mg/dia de losartan. A los 6 meses, la presion arterial sistolica descendio (115 ± 8 frente a 106 ± 9 mmHg; p = 0,001), la FEVI aumento (24,4 ± 7 frente a 34,1 ± 7%; p 2max (20,8 ± 5,2 frente a 21,8 ± 5,0 ml/kg/min; p = 0,120). Las concentraciones de noradrenalina en reposo y en el momento de maximo esfuerzo, asi como del peptido natriuretico cerebral y de la renina, fueron similares. Con dosis maximas del IECA, la adicion del ARAII fue segura, asociandose a una mejora de la funcion ventricular y la clase funcional, pero sin cambios en el estado neurohormonal.

Presentamos el caso de un paciente de 61 anos con antecedentes de un episodio de muerte subita reanimada y frecuentes episodios sincopales. En el ECG se observo el patron tipico del sindrome de Brugada y un intervalo QTc de 425 ms. La estimulacion ventricular programada indujo, de forma reproducible, taquicardia ventricular polimorfica sincopal autolimitada. Con el diagnostico de sindrome de Brugada se indico un desfibrilador automatico implantable. Dos dias despues del implante el paciente presento dos episodios de taquicardia ventricular polimorfica convertidos por el dispositivo. El ECG realizado en ese momento demostro un intervalo QTc prolongado (500 ms), ademas del patron tipico de Brugada. Se inicio tratamiento con atenolol y en los siguientes 36 meses el paciente ha permanecido asintomatico, sin nuevos episodios arritmicos. Se trata, pues, de un paciente con sindrome de Brugada que tambien cumple criterios clinicos y electrocardiograficos de sindrome de QT largo. Esto puede sugerir un vinculo genetico entre ambos sindromes.

Introduccion y objetivos La induccion de arritmias ventriculares por estimulacion ventricular antibradicardia apropiada en pacientes portadores de desfibrilador automatico implantable es un tipo de proarritmia raramente descrito. El objetivo del estudio es evaluar la incidencia, caracteristicas y manejo de este tipo de episodios. Metodos Revisamos de manera retrospectiva los registros de seguimiento de 180 pacientes portadores de desfibrilador automatico implantable con capacidad de almacenamiento de electrogramas. Se analizaron los episodios de arritmia ventricular inducidos por marcapasos, definidos como aquellos que empiezan inmediatamente despues de un estimulo apropiado de marcapasos, en un paciente con ritmo propio habitual. Se evaluaron el numero de episodios por paciente, el tipo de arritmia inducida, el modo de inicio, la terapia administrada y la efectividad de las medidas adoptadas para corregir el problema. Resultados Se detectaron episodios de arritmia ventricular inducidos por estimulacion en 9 pacientes (5%). Siete de ellos recibieron terapia, que fue efectiva en todos los casos. El numero de episodios por paciente oscilo entre uno y 95 (138 taquicardias ventriculares y 20 taquicardias ventriculares polimorficas/fibrilaciones ventriculares) y se iniciaron por estimulacion ventricular tras una pausa postextrasistolica o durante fibrilacion auricular. Los cambios en la frecuencia de estimulacion resolvieron el problema en 3 de 6 pacientes y la disminucion del voltaje de estimulacion en 3 de 3 casos. En 4 pacientes se anulo la funcion de marcapasos. Conclusiones La induccion de arritmias ventriculares por terapia antibradicardia apropiada es relativamente frecuente en pacientes portadores de desfibrilador automatico implantable. Se puede corregir cambiando la frecuencia y/o la energia de estimulacion, aunque en algun caso puede ser necesario anular la funcion de marcapasos.

Introduccion Distintas variables han sido identificadas como predictoras de reestenosis angiografica intra-stent, pero poco se conoce sobre predictores de reestenosis clinica, un aspecto mas funcional de la reestenosis coronaria. Objetivo Conocer de forma practica si los predictores descritos de reestenosis angiografica predicen y en que grado la reestenosis clinica. Pacientes y metodos Doscientos dieciseis pacientes consecutivos (271 stents en 256 lesiones) con exito del procedimiento al alta hospitalaria fueron seguidos durante 17,6 ± 10 meses mediante revisiones periodicas. Reestenosis clinica del stent se definio como la presencia de sintomas o signos de isquemia junto a una reestenosis angiografica ≥ 50%. Resultados Treinta y tres lesiones (13%), revascularizadas con 34 stents, presentaron reestenosis clinica: 29 casos asociados a angina inestable, tres a infarto agudo de miocardio y uno a la muerte del paciente. El analisis multivariado identifico como predictores independientes el diametro del vaso menor de 3 mm (p 0%) tras el implante (p = 0,02; OR 2,5). Estas tres variables explicaron el 73% de reestenosis clinica y en presencia de alguna de ellas la reestenosis fue del 22%, frente al 4% en su ausencia. El implante en la arteria descendente anterior, de localizacion ostial, en pacientes diabeticos y el numero o longitud total de stents por lesion, no demostraron una asociacion independiente significativa como predictores de reestenosis clinica. Conclusion La mayoria de reestenosis clinica tras el implante de stents intracoronarios puede ser predicha por el caracter reestenotico de la lesion, el diametro del vaso

Introduccion Los resultados publicados por los estudiosStress/Benestent fueron obtenidos en poblacionesseleccionadas y bajo condiciones tecnicas que no reflejanla practica actual con stents intracoronarios. Objetivos Revaluar los resultados clinicos a largo plazodel implante de stents intracoronarios en la practicaactual y comparar los resultados en lesiones con y sin criteriosStress/Benestent. Metodos Doscientos dieciseis pacientes consecutivos,con exito en el implante de 279 stents en 256 lesiones ysin eventos clinicos intrahospitalarios, fueron seguidos durante16,7 ± 10,4 meses. Se implantaron siete tipos destents, expandidos a altas presiones (15,6 ± 2,2 atm), y seadministraron aspirina y ticlopidina asociadas durante cuatrosemanas postimplante. Resultados La incidencia acumulada de revascularizacionde la lesion diana fue del 9,7% a 6 meses, del 13,5% a12 meses y del 15,1% a 18, 24 y 36 meses, y de cualquierevento (revascularizacion de la lesion diana, infarto de miocardioy muerte) fue del 11,3% a 6 meses, del 13,9% a 12meses, del 19,3% a dos anos y del 21,1% a tres anos. Laslesiones no Stress/Benestent fueron 193 (75%), presentandomayores tasas acumuladas de revascularizacion de lalesion diana (17,9 frente a 7,5%; p = 0,015) y eventos clinicoscombinados (22,4 frente a 10%; p = 0,025), que las lesionesStress/Benestent. Conclusion El implante de stents en lesiones coronariasno Stress/Benestent se asocia a un peor pronosticoclinico a largo plazo. Sin embargo, los resultados clinicosa largo plazo obtenidos en una poblacion no seleccionaday en la practica actual son similares a los obtenidos enlos estudios Stress/Benestent, probablemente debido alas mejoras tecnicas alcanzadas.

Objetivo Determinar los resultados clinicos de la revascularizacion con stents intracoronarios en vasos menores de 3 mm. Pacientes y metodos El tamano del vaso se evaluo como menor o mayor o igual de 3 mm en el momento del procedimiento y fue medido en el diametro maximo. Estudiamos a un total de 234 pacientes consecutivos (300 stents en 279 lesiones), con un seguimiento clinico de 17,6 ± 10 meses, comprendiendo 84 stents implantados en 79 lesiones localizadas en vasos pequenos ( Resultados La tasa de exito del implante, sin eventos clinicos hospitalarios, fue del 93,7% en los vasos 3 3 mm (p = NS). La trombosis subaguda del stent ocurrio en tres vasos 3 3 mm (el 3,8 frente al 0%; p = 0,006). A los dos anos, la supervivencia libre de revascularizacion de la lesion diana fue inferior en vasos pequenos (el 73,6 frente al 90,3%; p 3 3 mm (p Conclusion El implante de stents en coronarias

UNLABELLED This study was designed to examine the "true sensitivity" of a specific head-up tilt (HUT) testing protocol using clinical findings. The HUT protocol used 45 minutes at 60 degrees for the baseline portion and intermittent boluses of 2, 4, and 6 micrograms of isoproterenol in the second phase. Eighty-eight patients (40 men and 48 women; mean age of 33.8 +/- 16 years) with recurrent syncope and high pretest likelihood of neurally mediated syncope were included. The following were considerated as high pretest likelihood criteria: (1) at least two syncopal episodes; (2) no structural heart disease and normal baseline ECG; (3) age < 65 years; (4) a typical history of neurally mediated syncope, triggering factors plus premonitory signs; and (5) short duration of symptoms and fast recovery without neurological sequelae. Fifty-four patients (61%) had a positive tilt test (34/88 baseline [39%] and 20/50 with isoproterenol [40%]). The shorter time interval between the last syncopal episode and baseline HUT test was the only predictor for a positive response (P < 0.003). Conversely, this time interval was not predictor of positive responses during isoproterenol-tilt testing. IN CONCLUSION (1) we claim a "sensitivity" for this combined protocol of 61%; and (2) our results indicate that patients with syncope of unknown origin must be tilted nearest as possible to the last syncope to increase the positive responses of HUT test.

Introduccion y objetivos Recientemente se hademostrado que la adenosina es un modulador endogenode las aferencias cardiacas excitatorias, asicomo un posible inductor de respuestas vasovagalesdurante el test de basculacion. El isoproterenolha sido el farmaco utilizado habitualmente para incrementarel numero de respuestas positivas de dichaprueba. El proposito del presente trabajo fueevaluar el posible papel del adenosin trifosfato enla induccion de sincope mediante test de basculacionen pacientes predispuestos, asi como estudiarsu efectividad conjunta y separadamente con la delisoproterenol. Metodos Con este objetivo estudiamos a 30 pacientescon sincope de origen desconocido (16 mujeresy 14 varones, de edad media 37,1 ±} 18 anos),ausencia de cardiopatia y test de basculacion negativo.Una vez concluida la prueba basal los pacientesfueron sometidos a un segundo test de basculaciontras ser aleatorizados a recibir adenosintri fosfato (bolos i.v. de 3, 6 y 9 mg cada 5 min) oisoproterenol (bolos i.v. de 2, 4 y 6 μg cada 5 min).Tras 15 min de reposo se procedia a una tercerabasculacion recibiendo el regimen opuesto. En11 sujetos control, sin antecedentes de sincope, serealizo una basculacion a 60o con adenosin trifosfato(a las mismas dosis/5 min) para evaluar sus efectoshemodinamicos en individuos sanos. Resultados Siete pacientes (23,3%) positivizaronel test de basculacion tras la administracion deATP y nueve (30%) tras la administracion de isoproterenol.Unicamente dos pacientes (6,6%) tuvieronun test positivo con ambos farmacos. De lossujetos del grupo control, solo uno (9%) tuvo unarespuesta positiva durante la prueba. Conclusiones Los resultados del presente estudioindican que el adenosin trifosfato puede ser unfarmaco util en la induccion de respuestas vasovagalesen pacientes con sincope de origen desconocidoy test de basculacion basal negativo.

Introduccion y objetivos El pronostico y el manejoterapeutico de los pacientes con sincope yasistolia prolongada durante el test de basculaciones poco conocido. El proposito del presente trabajofue estudiar la evolucion clinica de un grupo de pacientescon sincope de origen desconocido, ausenciade cardiopatia estructural y test de basculacioncardioinhibidor severo. Metodos Con tal objetivo seguimos prospectivamentea un grupo de 12 pacientes (6 mujeres y 6varones, con una edad media de 31 ± 20 anos) consincope recurrente, ausencia de cardiopatia y testde basculacion positivo con asistolia igual o superiora 3 segundos. Todos los pacientes fueron sometidosa dos nuevos tests, uno con medidas higienico-dieteticas (sal y liquidos) y otro con tratamientomedico (25 mg/12 h de metoprolol). Siguiendoel resultado de estos, 5 pacientes fuerondados de alta con medidas dieteticas y 5 con metoprolol.Dos pacientes que presentaron repetidamenterespuesta cardioinhibidora severa fuerontratados con marcapasos bicameral definitivo. Resultados Tras un seguimiento medio de 34 ±20 meses todos los pacientes continuaban vivos,siendo muy bajo el numero de recurrencias (2 sincopesy 2 presincopes). No se observo relacion entrela presentacion de recurrencias y el tratamientoaplicado. Conclusiones Concluimos que la asistolia prolongadacomo respuesta al test de basculacion enpacientes con sincope recurrente de origen desconocidoy ausencia de cardiopatia no confiere malpronostico, pudiendose considerar benigna su evolucionclinica a corto y medio plazo.

Introduccion y objetivos La ergometria precozes el procedimiento mas utilizado para estratificarel riesgo postinfarto y detectar enfermedad multivaso,hecho asociado a una menor supervivencia alargo plazo. No existen datos al respecto en el grupode pacientes jovenes. El objetivo del estudio esevaluar la sensibilidad, especificidad y valor predictivode la prueba de esfuerzo precoz para detectarenfermedad multivaso en pacientes jovenespostinfarto. Metodos A pacientes de hasta 40 anos, supervivientesa un infarto agudo de miocardio (IAM) seles realizaron prueba de esfuerzo y coronariografiapreviamente al alta, valorando la sensibilidad, especificidad,valor predictivo positivo y negativo dela prueba de esfuerzo. Resultados Se incluyeron 100 pacientes consecutivos,de los que se realizo ergometria a 83 y coronariografiaa 96. En los 83 sujetos con ambaspruebas, 27 presentaron enfermedad multivaso, delos que 15 tuvieron ergometrias positivas, 6 positivasde alto riesgo y 12 normales. En los 56 individuossin enfermedad multivaso, en 41 hubo un testnormal y anormal en los 15 restantes, lo que arrojauna sensibilidad del 56%, una especificidad del73%, un valor predictivo positivo del 50% y un valorpredictivo negativo del 77% en la deteccion deenfermedad multivaso. El valor predictivo positivoaumento hasta el 80% en casos de ergometria positivacon criterios de alto riesgo. Conclusiones Es necesario en este grupo de pacientesel uso de tecnicas complementarias con laprueba de esfuerzo como la ecografia de estres,isotopos o coronariografia, por el bajo poder predictivode aquella para descartar la enfermedadmultivaso.

Introduccion y objetivos Tras el proceso de isquemia-reperfusion de la cirugia cardiaca extracorporea aparecen, entre otros fenomenos, arritmias de reperfusion cuyo mecanismo no esta totalmente definido, pero que puede estar relacionado con la genesis de radicales libres en los inicios de la reperfusion que, teoricamente, podria prevenirse con farmacos antioxidantes, entre los que ha sido estudiado con buenos resultados, in vitro y en animales in vivo, el captopril. Nuestro objetivo es valorar la influencia del pretratamiento con captopril sobre la prevencion de arritmias de reperfusion en pacientes operados con cirugia de sustitucion valvular. Metodos Estudiamos a 30 pacientes aleatorizados a 2 grupos iguales; uno tratado con captopril (CPT) desde 24 h antes de la operacion y otro control (CON) sin tratamiento. Los criterios de exclusion fueron: fraccion de eyeccion menor de 40%, evidencia angiografica de lesiones coronarias, infarto de miocardio previo o infarto de miocardio peroperatorio. La dosis de captopril fue de 12,5 mg orales cada 8 h, desde 24 h antes. Por Holter, analizamos las arritmias ventriculares (extrasistoles, salvas, taquicardia y fibrilacion) en la primera hora de reperfusion, valorandose tambien la necesidad de desfibrilacion electrica para recuperar el ritmo basal y el numero de choques necesitados. Estos hechos fueron correlacionados con parametros analiticos de seno coronario (creatinfosfocinasa, actividad de la enzima convertidora de angiotensina y adenosin monofosfato ciclico), antes del clampaje aortico y despues del recalentamiento cardiaco. Resultados No observamos diferencias significativas en el numero de arritmias ventriculares registradas en la primera hora de reperfusion en ambos grupos. El 60% de casos del grupo CTP tuvieron desfibrilacion espontanea, hecho que solo ocurrio en el 40% de los no tratados, aunque sin alcanzar significacion; en los que necesitaron choques electricos, el numero de estos fue menor (p Conclusiones Estos datos indican que el pretratamiento con captopril, antes de la cirugia cardiaca, no tiene accion significativa en la prevencion de arritmias ventriculares durante la reperfusion, aunque se observa mayor posibilidad de desfibrilacion espontanea y menor numero de choques electricos necesarios para la desfibrilacion en los casos pretratados con captopril.

Resumen La practica comun consiste en a˜nadir tratamiento antiagregante a la terapia anti-coagulante, en los pacientes con fibrilacion auricular (FA) y patologia vascular establecida. Sinembargo, la necesidad de combinar ambas estrategias es un tema controvertido actualmente.© 2012 Instituto Nacional de Cardiologia Ignacio Chavez. Publicado por Masson Doyma MexicoS.A. Todos los derechos reservados. KEYWORDS Atrial fibrillation;Aspirin;Oral anticoagulation;Vascular disease;Spain Should we add antiplatelet therapy to oral anticoagulation in patients with atrialfibrillation and vascular disease? Review of available evidence Abstract Current recommendation is to add antiplatelet drug to oral anticoagulation inpatients with atrial fibrillation (AF) and vascular disease. However, it is debatable to join bothantithrombotic drugs in stable vascular disease.© 2012 Instituto Nacional de Cardiologia Ignacio Chavez. Published by Masson Doyma MexicoS.A. All rights reserved. ∗ Autor para correspondencia: Servicio de Cardiologia, HospitalUniversitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena s/n.C.P. 30120, Murcia, Espana.˜

Current recommendation is to add antiplatelet drug to oral anticoagulation in patients with atrial fibrillation (AF) and vascular disease. However, it is debatable to join both antithrombotic drugs in stable vascular disease.

Seventy-five patients 36 to 68 years of age were studied after undergoing successful single-vessel percutaneous transluminal coronary angioplasty (PTCA). In all cases exercise tests (ETs) were made prior to the procedure and 2 to 4 days and 6 months thereafter. Angiographic controls were performed on patients with positive ET. Both early and late ET carried out after dilatation lasted significantly longer. Patients were able to tolerate greater work loads and their heart rates and arterial blood pressures also were higher. The ETs conducted prior to PTCA were positive in 62 patients. After dilatation, the early test was positive in 18 and the late test, in 10. Angiographic controls revealed restenosis in 75 percent of patients with single-vessel disease and positive ET. Thus, the results of ETs in patients with single-vessel disease tend to become negative after successful PTCA. Early and late positive ETs are associated with restenosis, while negative ETs indicate a good prognosis.

La tetralogia de Fallot con atresia pulmonar constituye una situacion especial en la que se permite la supervivencia hasta la edad adulta. En estos casos se desarrollan complicaciones, como la hemoptisis, que comprometen la vida del paciente y tienen dificil tratamiento. Cuando la causa del sangrado es la rotura de cortocircuitos arteriovenosos, frecuentes en las malformaciones vasculares multiples que se originan en esta cardiopatia, la embolizacion selectiva de estas malformaciones puede ser una opcion eficaz de tratamiento.

To study the usefulness of incremental atrial pacing for evaluating the effect of radiofrequency catheter ablation on slow pathway conduction in patients with atrioventricular (AV) nodal reentrant tachycardia.A prospective study was carried out in patients either with (i.e., AV nodal reentrant tachycardia group) or without (i.e., control group) inducible AV nodal reentrant tachycardia who were referred for electrophysiologic study. Incremental atrial pacing involved gradually decreasing the pacing cycle length until the PR interval exceeded the R-R interval (i.e., PRRR) or AV nodal block occurred. The presence of dual anterograde AV nodal physiology was assessed during programmed atrial stimulation using standard criteria. In the AV nodal reentrant tachycardia group, electrophysiologic study was repeated 30 minutes after successful catheter ablation.In the AV nodal reentrant tachycardia group (n=85), 52 patients (61%) exhibited dual AV nodal physiology during programmed atrial stimulation and 66 (78%) had a PRRR during incremental atrial pacing. In the control group, the corresponding proportions were 10/56 (18%) and 7/56 (12%), respectively. After successful slow pathway catheter ablation (81/85), 37/81 exhibited dual AV nodal physiology during programmed atrial stimulation while 1/81 had a PRRR during incremental atrial pacing. The positive predictive value of successful slow pathway ablation for the absence of a PRRR was 98%.Incremental atrial pacing demonstrated that the PR interval exceeded the R-R interval in the majority of patients with inducible AV nodal reentrant tachycardia. This technique could provide a fast and simple way of evaluating the effect of radiofrequency catheter ablation on slow pathway conduction.

The value of biomarkers of myocardial damage or inflammation in off-pump coronary artery bypass (OPCAB) surgery has not yet been established. In a prospective study of 51 consecutive patients scheduled for elective OPCAB surgery, preoperative levels of troponin T, C-reactive protein, interleukin-6 and tumor necrosis factor-alpha were determined. The primary endpoint was the combination of cardiac death or acute myocardial infarction (AMI) within 30 days. Seven patients (14%) presented with an adverse event: three cardiac deaths and six AMIs. Univariate analysis identified the following adverse event predictors: renal failure (50% vs 11%, P=.028), left ventricular ejection fraction 0.10 ng/dL (43% vs 9%, P=.016), and EuroSCORE rating (7.6 [2.5] VS. 5.2 [2.6], P=.031). A preoperative troponin-T level0.10 ng/dL (P=.03) was the only independent adverse event predictor. No significant differences were found with biomarkers of inflammation (P.05). The presence of a preoperative troponin-T level0.10 ng/dL is associated with a higher risk of cardiac death or AMI in patients undergoing OPCAB surgery.

In dilated cardiomyopathy, severe functional mitral regurgitation (MR) is associated with a poor prognosis. In 112 consecutive clinically stable patients with non-ischemic dilated cardiomyopathy, echocardiography identified 15 (14%) patients who had severe MR (age, 53+/-12 years; 80% male; left ventricular ejection fraction, 26 +/- 8%). Existing medical treatment with ACE inhibitors and beta-blockers was increased up to the maximum tolerated doses. At 6 months, MR decreased by at least one grade in 13 (87%) patients (P =.001), as did the effective regurgitant orifice area (from 0.41 [0.05] mm2 to 0.20 [0.15] mm2; P.

Measurement of N-terminal pro-B-type natriuretic peptide (NTproBNP) helps in diagnosing heart failure (HF). The test's usefulness may be greatest in patients with severe dyspnea of uncertain origin. However, NTproBNP has not been evaluated specifically in this setting.This prospective emergency department study included 70 patients with shortness of breath at rest as their chief complaint. In the attending physician's opinion, both HF and a non-cardiac cause were equally probable. Blinded NTproBNP measurement was carried out in blood samples collected on admission. Patients were monitored and their final diagnoses were based on clinical findings, therapeutic responses, and cardiac and noncardiac tests performed during hospitalization.The NTproBNP level was higher in the 49 patients (70%) with a final diagnosis of HF (P = .006); the area under the ROC curve was 0.72 (0.60-0.82). The optimum diagnostic cut-off value was 900 pg/mL, which had an accuracy of 87%, a sensitivity of 98%, and a negative predictive value of 92%. The NTproBNP level was significantly higher in the 6 patients (9%) who died during hospitalization (P = .009); the area under the ROC curve was 0.87 (0.76-0.93) and the optimum cut-off value for predicting death was 5500 pg/mL, which had an accuracy of 77%, a sensitivity of 100%, and a positive likelihood ratio of 4.2.In patients with severe dyspnea and an uncertain diagnosis of HF, an NTproBNP level900 pg/mL helps exclude the presence of HF, whereas a NTproBNP level5500 pg/mL identifies patients at an increased risk of death.

Differences between anatomical severity and clinical manifestations are frequent in patients with hypertrophic cardiomyopathy. Our objective was to assess functional capacity in a consecutive group of patients with hypertrophic cardiomyopathy measuring exercise aerobic parameters, as well as clinical and echocardiographic variables.We studied 98 consecutive patients with hypertrophic cardiomyopathy. All patients underwent both echocardiographic and cardiopulmonary exercise testing. The control group consisted of 22 untrained persons. We studied exercise capacity by analyzing maximal oxygen consumption and aerobic functional capacity, among other variables.Patients with hypertrophic cardiomyopathy attained significantly lower maximal oxygen consumption values than controls (24.1 5.9 vs 36.4 5.9 ml/kg/min; p = 0.0001). Maximal aerobic capacity was significantly different among patients with NYHA functional capacity class I, II or III (78.9 13.5%; 71.9 14.7%; 63.9 15.7%; p = 0.009). However, considerable overlap was found between groups in maximal aerobic capacity. Functional impairment was greater in patients with left ventricular thickness20 mm, ejection fraction50%, left atrial dimension45 mm and pseudonormal or restrictive transmitral flow pattern.Patients with hypertrophic cardiomyopathy show significant functional impairment, which is difficult to detect from their clinical manifestations. Optimal assessment requires cardiopulmonary exercise testing.

The extent of implementation in daily clinical practice of the new definition of myocardial infarction is unknown. The purpose of the present study was to describe the use of the new definition in patients discharged from a cardiology department. We analyzed the clinical records of 277 patients admitted because of acute coronary syndromes and discharged from the cardiology department between 1 March 2001 and 31 August 2001. The final clinical diagnosis based on the presence of classical or only new diagnostic criteria was studied. 127 patients (46%) satisfied the new definition (61% classical criteria and 39% only new criteria). Only 98 (77%) of the patients with myocardial infarction according to the new definition were discharged with this diagnosis (96% of the group that satisfied classical criteria and 48% of the group that satisfied only new criteria). The diagnosis of myocardial infarction is still based predominantly on classical criteria; the new criteria have been only partially implemented.

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

In heart failure, the benefits of adding angiotensin-receptor blockade to ACE inhibitors have been studied only with submaximal doses of ACE inhibitors. We included 20 patients (LVEF 24 7%, NYHA II-III), with no clinical or therapeutic variations in the previous three months, who were receiving maximal doses of ACE inhibitors. We added losartan 50 mg once a day. At six months, SBP decreased (115 8 vs. 106 9 mmHg; p = 0.001), LVEF increased (24.4 7 vs. 34.1 7%; p0.001), ventricular end-diastolic volumes decreased (220 58 vs 190 46 ml; p = 0.007), and SPAP decreased (43 8 vs. 35 7 mmHg; p0.001). Seven patients improved one degree on the NYHA scale (p = 0.004), but VO2max did not change (20.8 5.2 vs. 21.8 5.0 ml/kg/min, p = 0.120). Plasma levels of norepinephrine, at rest and maximal exercise, brain natriuretic peptide, and renin were similar. After maximum ACE inhibitor doses, the addition of losartan is safe and associated with an improvement in ventricular function and NYHA functional class, but with no change in neurohormonal status.

Fifteen patients with different degrees of chronic bradyarrhythmias of supraventricular origin were studied with Holter monitoring before and during application of a transdermal patch of scopolamine. No changes were found in the mean or minimal heart rates, standard deviation of the RR interval, or the degree of bradyarrhythmia. It is concluded that transdermal scopolamine is not an adequate treatment of chronic symptomatic bradyarrhythmias.

This study was designed to evaluate the role of endogenous opioids in neurally-mediated syncope. Head-up tilt test was performed on 35 patients with syncope of unknown origin. Plasma beta-endorphin was measured (1) at baseline, (2) at the end of tilt test or at time of syncope, (3) 15 min before isoproterenol-test, (4) at the end of the isoproterenol-test or at time of syncope. Subjects with a positive tilt testing showed a larger rise in plasma beta-endorphin concentrations at time of syncope (baseline 13.7+/-8.0 vs. syncope 41.4+/-26.4 pmol l(-1); P