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Introduction and Objectives: Clinical trials have shown that combining beta-blockers and angiotensin-converting enzyme (ACE) inhibitors has an additive effect in reducing mortality in patients with left ventricular dysfunction following acute myocardial infarction. Whether this additive effect also occurs in unselected post-myocardial infarction patients is unknown., Methods: In total, 5397 patients who were discharged from hospital after suffering an acute myocardial infarction were followed for 1 year. The primary endpoint was all-cause mortality. The effects of the medications on 1-year survival were analyzed using a Cox regression model, which included propensity scores for beta-blocker and ACE inhibitor use to take account of any potential imbalance in drug prescription rates., Results: At hospital discharge, 55.9% of patients were receiving beta-blockers and 45.1%, ACE inhibitors. The 1-year mortality rate was 5.5%. Overall, combination of the two medications significantly reduced the 1-year mortality rate (hazard ratio [HR]=0.51; 95% confidence interval [IC], 0.32-0.82); P<.005) to a greater extent than ACE inhibitors alone (HR=0.78; 95% CI, 0.54-1.12; P=.2) or beta-blockers alone (HR=0.67; 95% CI, 0.43-1.05; P=.08). The same trend was also observed in low-risk patients without acute heart failure who had an ejection fraction > or =40%., Conclusions: In unselected post-myocardial infarction patients, combined prescription of beta-blockers and ACE inhibitors had an additive effect on the 1-year survival rate.

Background: We review our experience in patients who required surgical correction of tricuspid valve disease with concomitant disease of the mitral or aortic valve, or both, operated on between 1987 and 1999., Methods: We studied 232 consecutive patients (mean age, 59.8 years) followed for a mean of 6.8 years (range, 2 to 12 years). All patients were investigated by means of Doppler echocardiography, with hemodynamic studies in 135. Median tricuspid insufficiency was 3+. The cause was rheumatic heart disease in 186 patients and degenerative in 46. All patients underwent suture annuloplasty (De Vega or segmental) at the time of mitral or aortic valve surgery. Tricuspid lesions were functional in 128 patients and organic in 104., Results: The hospital and late mortality rates were 8.1% and 23.3%, respectively. These figures were independent of the type of annuloplasty performed. Predictors of hospital mortality were biologic prosthesis, renal insufficiency, time of cardiopulmonary bypass, and use of inotropic drugs. Predictors of late mortality were age older than 60 years, left ventricular ejection fraction less than 0.50, and New York Heart Association functional class IV. At 12 years, the actuarial survival rate was 50.5% +/- 6.1%, and the actuarial curve free from reoperation 75.7% +/- 7.3%. The actuarial curve for freedom from valve-related complication was 39.0% +/- 6.3% at 11 years., Conclusions: Despite the use of modern technologic advances in the diagnosis and treatment of valvular hear disease, tricuspid insufficiency continues to be a poor prognostic factor in patients with concomitant disease of the mitral or aortic valve, or both.

Background: A study was designed to determine significant variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm., Patients and Methods: Data of 106 unselected consecutive patients with ruptured abdominal aortic aneurysm undergoing operation between 1989 and 1998 were identified from a prospective hospital-based registry. A total of 32 variables were analyzed including demographic characteristics, vascular risk factors, coexisting conditions, preoperative findings, intraoperative variables, and postoperative complications. Preoperative and intraoperative variables related to vital status (alive, death) in the univariate analysis were subjected to stepwise linear regression analysis to determine whether a combination of variables would predict death. Of 99 evaluable patients, 48 died (mortality rate 48.5%)., Results: At univariate analysis, age, serum creatinine, hemoglobin, electrocardiographic ischemia, loss of consciousness on admission, preoperative shock, supra-renal rupture, and transfusion requirements were significantly associated with 30-day operative mortality. Postoperative complications except sepsis, mesenteric ischemia, and neurologic events were significantly associated with mortality. Electrocardiographic ischemia, shock, and supra-renal rupture appeared to be independent predictors of mortality in the multivariate analysis. The cumulative effect of 0, 1, and > or = 2 risk factors on mortality was 29%, 39%, and 90%, respectively., Conclusions: Electrocardiographic ischemia, preoperative shock, and supra-renal rupture were predictors of death in patients with ruptured abdominal aortic aneurysm.

Mercury is a neurotoxin that exists in a number of physical and chemical forms, producing different effects in the brain. In the present work, we have studied the effects of intrastriatal administration of different doses (40 microM, 400 microM, and 4 mM) of organic mercury (methyl-mercury, MeHg) on the dopaminergic system of rat striatum, in conscious and freely-moving animals, using microdialysis coupled to Liquid Chromatography. In previous works, we have discussed the effects of chronic and acute administration of MeHg on striatal dopaminergic system assessing changes in both release and metabolism of striatal dopamine (DA). In the present study we report that the intrastriatal administration of different doses of MeHg (40 microM, 400 microM, and 4 mM) produced significant increases (907 +/- 31%, 2324 +/- 156%, and 9032 +/- 70% of basal levels, respectively for the different doses) in DA release from rat striatal tissue associated with significant decreases in extracellular levels of its main metabolites dihydroxyphenylacetic acid (DOPAC) and homovallinic acid (HVA) using the dose of 4 mM MeHg (35 +/- 3% and 48 +/- 1%, respectively), whereas non-significant changes in metabolite levels were observed with the doses of 40 microM and 400 microM MeHg. We explain these effects as a result of stimulated DA release and/or decreased DA intraneuronal degradation.

In the recent years, new possibilities have emerged in the diagnosis and management of acute myocardial infarction with ST segment elevation and its complications. Moreover, a deep transformation has taken place in the health care system organization, particularly in aspects related to care of patients presenting non-traumatic chest pain, both in pre-hospital and hospital areas. All these issues warrant a consensus document in Spain dealing with the role that these important changes should play in the whole management of myocardial infarction patients. This document revises and updates all the main clinical issues of acute myocardial infarction patients from the moment they contact with the health care system outside the hospital until they return home, after staying at the coronary care unit and the general hospitalization ward. All those aspects are considered not only in the uncomplicated myocardial infarction but also in the complicated one. This review also includes a set of recommendations on structural and organisational aspects, mainly referred to the prehospital and emergency levels.

Introduction and Objectives: To assess the anti-ischemic efficacy of nitroglycerin patches (10 mg/day), we studied, by means of serial exercise testing (Bruce protocol), 10 patients with stable effort angina in a randomized, placebo-controlled, cross-over, double-blind essay., Methods: Patients were exercised 1, 4, 12 and 24 hours after a single patch, and 4 and 12 hours after a 48 hours therapy course. Chronic therapy was assessed after both continuous and intermittent (intermission of 12 hours) patch application., Results: After single patch, time to angina and time to 1 mm ST depression were significantly increased with respect to placebo at 1-hour test (83 +/- 27 s and 119 +/- 39 s, respectively), 4-hour test (100 +/- 34 s and 87 +/- 29 s, respectively) and 12-hour test (46 +/- 15 s and 64 +/- 20 s, respectively). No effect was demonstrated at 24-hour test. After continuous treatment no differences with respect to placebo were found at any test. After intermittent treatment time to angina was prolonged (75 +/- 23 s) only at 4-hour test, and time to 1 mm ST depression at 4-hour test (61 +/- 19 s) and 12-hour test (41 +/- 14 s)., Conclusions: Nitroglycerin patches improve parameters of exercise ischemia for a 12 hours period. Tolerance is developed very early and provokes absolute lack of efficacy. Tolerance can be avoided with intermittent patch application. No treatment schedule shows 24 hours efficacy.

The anaesthetic management of a patient with a phaeochromocytoma and cardiomyopathy is described. The control of dysrhythmias was the major problem. Ventricular dysrhythmias were treated with lignocaine, and intravenous amiodarone was used to control the supraventricular rhythm disturbances.