Search

Background: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. Methods: ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. Results: Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85–1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63–0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08–1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. Conclusions: There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04894877.

Resumen La insuficiencia cardiaca es una enfermedad que precisa un tratamiento multidisciplinario, dadas la diversidad de causas y entornos clinicos implicados que las tratan y las diferentes estrategias terapeuticas que precisan la participacion indispensable de diversas disciplinas. La presencia en los servicios de cardiologia de unidades de insuficiencia cardiaca centradas en el tratamiento de los pacientes con esta afeccion y unidades de rehabilitacion cardiaca que, entre sus indicaciones para la reduccion de la morbimortalidad, tambien estan implicadas en la atencion de esos mismos pacientes puede causar dificultades de coordinacion y perdida de una atencion integral centrada en el paciente. Por estos motivos, en el presente documento se plantea una estrategia de coordinacion entre las diferentes unidades implicadas en el tratamiento de los pacientes dentro de los servicios de cardiologia y la continuidad asistencial con atencion primaria, tanto tras haber conseguido la estabilidad como la interrelacion para una coordinacion posterior mas efectiva.

BACKGROUND: Center-based cardiac rehabilitation (CBCR) improves health outcomes but has some limitations. We designed and validated a telerehabilitation system to overcome these barriers. METHODS: We included 67 low-risk acute coronary syndrome patients in a randomized controlled trial allocated 1:1 to a 10-month cardiac telerehabilitation (CTR) program or an 8-week CBCR program. Patients underwent ergospirometry, blood tests, anthropometric measurements, IPAQ, PREDIMED, HADS, and EQ-5D questionnaires at baseline and 10 months. Data collectors were blinded to the treatment groups. RESULTS: The intention-to-treat analysis included 31 patients in the CTR group and 28 patients in the CBCR group. The primary outcome showed increased physical activity according to the IPAQ survey in the CTR group compared to the CBCR group (median increase 1726 METS-min/week vs. 636, p = .045). Mean VO2max increased 1.62 ml/(kg min) (95% confidence interval [CI]: 0.56-2.69, p < .004) from baseline in the CTR group, and 0.60 mL/(kg min) (p = .40) in the CBCR group. Mean apoB/apoA-I ratio decreased 0.13 (95% CI: -0.03 to 0.24, p = .017) in the CTR group, with no significant change in the CBCR group (p = .092). The median non-HDL cholesterol increased by 7.3 mg/dl (IQR: -2.4 to 18.6, p = .021) in the CBCR group, but the increase was not significant in the CTR group (p = .080). Adherence to a Mediterranean diet, psychological distress, and quality of life showed greater improvement in the CTR group than in the CBCR group. Return-to-work time was reduced with the telerehabilitation strategy. CONCLUSION: This system allows minimal in-hospital training and prolonged follow-up. This strategy showed better results than CBCR.

Background: In the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, all-cause mortality was similar in patients with stable ischemic heart disease (SIHD) randomized to invasive (INV) and conservative (CON) management strategies. This analysis details specific causes of cardiovascular (CV) and non-CV mortality by treatment group. Methods: In ISCHEMIA, 289 deaths occurred after a median follow-up of 3.2 years; 145 (5.6%) in INV and 144 (5.6%) in CON (HR 1.05, CI 0.83-1.32). Deaths were adjudicated by an independent Clinical Events Committee as CV, non-CV with or without a CV contributor or undetermined. The protocol defined CV death as deaths from CV causes, non-CV causes with CV contributor, and cause undetermined; non-CV death was defined as death from non-CV causes without a CV contributor. Multivariable analyses were used to identify factors associated with cause-specific death. Results: CV death was similar between groups [INV 92 (3.6%), CON 111 (4.3%); HR 0.87 (CI 0.66, 1.15)], but INV had more non-CV death [INV 53 (2.0%), CON 33 (1.3%); HR 1.63 (CI 1.06, 2.52)]; fewer undetermined deaths [INV 12 (0.5%) and CON 26 (1.0%); HR 0.48 (0.24, 0.95)] and more malignancy deaths [INV 41 (1.6%), CON 20 (0.8%); HR 2.11 (1.24, 3.61)]. In multivariable analysis, risk factors associated with CV death were age [HR 1.42 (CI 1.19-1.70) per 10-year increase], diabetes [HR 1.39 (CI 1.03-1.87)], history of heart failure [HR 1.96 (CI 1.33-2.91)], and eGFR [HR 1.18 (CI 1.11-1.26) per 5-ml/min decrease below 80ml/min]. Factors associated with non-CV death were age [HR 2.31 (CI 1.75-3.03) per 10-year increase] and randomization to INV [HR 1.76 (CI 1.13-2.75)]. Conclusions: In ISCHEMIA, all-cause mortality was similar for the INV and CON strategies. Excess non-CV deaths in INV with a higher number of deaths from malignancy but a higher number of undetermined deaths in CON requires further evaluation.

Recent studies show that microvascular injury consists of microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH). In patients with reperfused ST-segment elevation myocardial infarction (STEMI) quantitative assessment of IMH with T2* cardiovascular magnetic resonance imaging (CMR) appears to be useful in evaluation of microvascular damage. The current study aimed to investigate feasibility of this approach and to correlate IMH with clinical and CMR parameters. A single center observational cohort study was performed in reperfused STEMI patients with CMR examination 7 days (IQR: 5 to 8 days) after percutaneous coronary intervention. Infarct size (IS) and MVO were evaluated in short-axis late gadolinium enhancement sequences and IMH with whole LV volume T2* mapping sequences. Of the 94 patients, MVO was identified in 52% of patients and the median size of MVO was 3% of LV mass (IQR: 1.5 to 5.4%). IMH was present in 28% of patients and the median size of IMH was 1.1% of LV mass (IQR: 0.5 to 2.9%). IMH extent was independently associated with anterior myocardial infarction (p = 0.022) and thrombectomy (p = 0.049). IMH was correlated with MVO (R = 0.62, p

Intramyocardial hemorrhage (IMH) is considered a marker of tissue damage severity in patients with reperfused ST-segment elevation myocardial infarction (STEMI) and has been associated with a poor prognosis despite successful revascularization of the culprit artery . We aim to study the impact of cardiovascular risk factors and treatment strategies on the presence of IMH studied with T2* -w cardiovascular magnetic resonance (CMR) in this clinical setting METHODS A prospective observational study including patients with repefused STEMI who underwent an MRI during the first week post-revascularization were conducted . The presence of IMH was analyzed in ECG triggered T2 * w sequences as presence of hipointensity area . Clinical data including cardiovascular risk factors and treatment strategies at cath lab were studied. RESULTS 94 patients with reperfused STEMI were included. Demographic data are shown at the the table. No significant association was observed between the presence of IMH and the different treatment strategies used. All data were introduced in a multivariate model including presence of thrombus, total ischemia time and culprit coronary artery. The analysis showed previous infarction as an independent risk factor (OR: 6 p = 0.03, CI: 1.1-29) while history of hypertension (OR: 0.9, p = 0.04, CI: 0.1- 0.9) and systolic blood pressure showed independent protective effect (OR: 0.3 p = 0.02 IC: 0.9-0.99.) CONCLUSIONS. 1. Previous infarction was shown to be an independent risk factor for IMH . 2. Arterial hypertension and systolic blood pressure showed a protective effect. Age (years) 62 ±13 Male sex 72 (77) Diabetes mellitus 32 (34) Hypertension 53 (56) Hyperlipidaemia 52 (55) Current or prior smoking 55 (58) Time to reperfusion 203 (142-300) Infarct-related artery LAD 38 (41) RCA 49 (52) Cx 7 (7) Infarct size (% LV mass) 18 ± 11 MO (% LV mass) 3.15 (1.44-5.48) Abstract P824 Figure. Intramyocardial hemorraghe T2* sequences

The prognostic impact of coronary revascularization in patients with stable angina is limited being reserved nowadays for patients with symptoms or severe ischemia in imaging tests. We propose to study the usefulness of stress CMR to assess the utility of coronary revascularization in patients with stable angina. Methods A retrospective cohort study was conducted including consecutive patients with inducible ischemia in dypiridamol stress CMR. Patients with acute coronary syndrome or severe valvular disease were excluded. The decision to revascularize after MRI was made by the responsible medical team following the guidelines of clinical practice. The presence of cardiovascular events (death, admission or need for new revascularization) was analyzed during follow-up. The stress cardiac MR imaging protocol included a baseline functional study (b-SSFP sequences) and after administration of 0.84 mg / kg IV dipyridamole, perfusion sequences (b-SSFP) obtained during the administration of IV gadolinium contrast and F-GRE viability sequences. Clinical data such as the severity of coronary involvement, the type of coronary revascularization and if it was complete as well as data derived from the baseline functional study of ventricular volumes, segmental contractility score, transmurality and extension of necrosis, extension of hypoperfusion and also number of segments with severe ischemia considering as such those segments with transmural hypoperfusion or stress-induced systolic dysfunction. Results We included 424 patients of mean age of 65+ 10 years, 182 (43%) of them had known coronary artery disease and 93 (20%) of them had pevious percutaneous revascularization. Thirty-five (8%) had left main disease and 176 (41%) multivessel disease. Twenty five patients had normal stroke volume (SV) and depressed left ventricle ejection fraction (LVEF) and 60p had normal LVEF and low SV . One hundred and seven patients of the total group were revascularized (2.5% surgically). Coronary revascularization showed a significant increase in survival only if it was complete (p Conclusions 1. SV is the most powerful predictor of events in patients with stable angina and ischemia in CRM dypiridamol stress test. 2. Patients with an SVi Abstract P359 Figure. Survival curves regarding SV

Resumen Fundamento y objetivo El amino-terminal pro-brain natriuretic peptide (NT-proBNP, ‘fragmento N terminal del peptino natriuretico tipo B’) y el filtrado glomerular renal (eFGR) estan relacionados con el pronostico a corto plazo en la insuficiencia cardiaca (IC). Este estudio evalua el poder predictivo de los valores NT-proBNP sericos y urinarios, asi como del eFGR en pacientes con IC en un seguimiento a 60 meses. Pacientes y metodo Se estudiaron 93 pacientes diagnosticados de IC (66 varones, edad: 65±12 anos). El episodio primario fue muerte cardiovascular y el episodio combinado fue mortalidad o ingreso de origen cardiaco. Resultados Solamente los valores sericos de NT-proBNP tuvieron un area bajo la curva significativa para la presencia de mortalidad cardiaca y episodios combinados: 0,70 (p=0,004) y 0,67 (p=0,019), respectivamente. El NT-proBNP urinario y el eFGR no obtuvieron areas bajo la curva significativas. Los pacientes con altos valores de NT-proBNP en suero tuvieron una peor supervivencia (44 [IC del 95%: 38–50] versus 56 [IC del 95%: 53–59] meses; p=0,0006) y pronostico para episodios (33 [IC del 95%: 28–38] versus 42 [IC del 95%: 28–38] meses; p=0,027). Al englobar la concentracion del peptido y la disfuncion renal, los pacientes con NT-proBNP serico alto y bajo eFGR tuvieron la peor supervivencia (42 [IC del 95%: 33–52] meses; p=0,010). Por ultimo, solo los valores de NT-proBNP sericos mayores de 933 pg/ml y de 550 pg/ml predicen muerte cardiovascular (hazard ratio=2,81; p=0,033) y episodios (hazard ratio=1,79; p=0,049), respectivamente. Conclusiones: Los valores de NT-proBNP sericos fueron un factor predictivo de mortalidad y episodios cardiovasculares a 60 meses, superior a los valores urinarios de NT-proBNP y eFGR, en pacientes diagnosticados de insuficiencia cardiaca con disfuncion renal moderada.

El objetivo fue evaluar el poder predictivo para diagnosticar hipertrofia del ventriculo izquierdo (HVI) de la concentracion urinaria del fragmento N-terminal del propeptido natriuretico tipo B (NT-proBNP) en 160 pacientes asintomaticos diagnosticados de hipertension esencial (HT). Las concentraciones urinarias de NT-proBNP/creatinina estuvieron incrementadas en pacientes con HVI al compararlos con no hipertroficos (p

The aim was to evaluate the usefulness of urinary N-terminal fragment of B-type natriuretic peptide (NT-proBNP) measurement for predicting the presence of left ventricular hypertrophy (LVH) in 160 asymptomatic patients with essential hypertension. The urinary NT-proBNP/creatinine ratio was higher in patients with LVH than in either those without LVH (P.0001) or control subjects (P.0001). Multivariate linear regression analysis identified age (P=.034), left ventricular mass index (P=.026) and serum NT-proBNP level (P=.001) as predictors of the urinary peptide level. The area under the curve for the NT-proBNP/creatinine ratio was 0.71+/-0.04 (P.0001) for identifying LVH. Logistic regression analysis showed that the NT-proBNP: creatinine ratio was a predictor of LVH (odds ratio=4.074; P=.009). In conclusion, the urinary NT-proBNP concentration is a new marker that could be useful for identifying LVH in subjects with essential hypertension.

Introduccion y objetivos La concentracion plasmatica de N-terminal propeptido natriuretico cerebral (NTproBNP) es un marcador sensible de disfuncion ventricular. Se ha demostrado el valor diagnostico y pronostico de sus concentraciones urinarias. Nuestro objetivo es determinar la relacion entre parametros consolidados de la funcion ventricular y concentraciones urinarias de NTproBNP. Metodos Hemos estudiado 74 pacientes diagnosticados de insuficiencia cardiaca (54 varones, edad 66 ± 12 anos). Se les realizo un estudio eco-Doppler y se determinaron el desplazamiento del plano auriculoventricular (DPAV) (mm), la fraccion de eyeccion (FE), la velocidad de propagacion del flujo mitral (Vp) (cm/s) y la relacion E/A. Se midieron las concentraciones plasmaticas y urinarias de NT-proBNP y las de aldosterona (pg/ml). Resultados Para toda la poblacion, los valores plasmaticos de NT-proBNP fueron 948 ± 961 pg/ml, los urinarios 88,7 ± 17,8 pg/ml y los de aldosterona 165 ± 145 pg/ml. Correlacionamos las concentraciones urinarias de NT-proBNP con el DPAV (r = −0,5; p Conclusiones El NT-proBNP en la orina se correlaciona con parametros de funcion del ventriculo izquierdo.Este estudio da soporte al papel del NT-proBNP urinario como marcador bioquimico de la funcion ventricular en pacientes con insuficiencia cardiaca.

Aims The objective of the present study was to evaluate the effect of multipoint pacing (MPP) on acute haemodynamics, cardiac contractility, and left ventricle (LV) dyssynchrony, in comparison with conventional cardiac resynchronization therapy (CRT). Methods and results An open-label, non-randomized, single-centre, prospective study was designed. Twenty-seven consecutive patients were included. Evaluation of pacing configurations was performed in a random order. Transthoracic echocardiography was used to obtain haemodynamic and dyssynchrony parameters. Left ventricular ejection fraction (LVEF) was significantly superior in MPP compared with baseline (38.4 ± 1.8% vs. 26.1 ± 2.2%; P < 0.001), and in conventional pacing configuration compared with baseline (33.2 ± 1.8% vs. 26.1 ± 2.2%; P = 0.007). Cardiac index (CI) was increased by 21.8 ± 5.4% and 34.7 ± 5.1% in conventional and MPP configurations, respectively ( P = 0.19). Percentage of acute responders (CI increase ≥10%) was 62.9 and 85.2% in conventional and MPP, respectively ( P < 0.001). LV dyssynchrony was defined by radial strain rate parameters. Baseline anteroseptal-to-posterior wall time delay was 168 ± 21 ms. It was reduced until 70.4 ± 29 ms in conventional and −6.6 ± 11 ms in MPP (conventional vs. baseline P = 0.04; MPP vs. conventional P = 0.05). Standard deviation of the time-to-peak radial strain of the 6 LV basal segments was 101 ± 9.7, 80.3 ± 9.2, and 66 ± 8.03 ms in baseline, conventional, and MPP configurations, respectively (MPP vs. basal P = 0.012). Finally, we observed a positive correlation ( r = 0.69) between reduction in dyssynchrony and CI increase ( P < 0.0001). Conclusion MPP showed a further reduction in LV dyssynchrony compared with conventional biventricular pacing. Moreover, MPP resulted in an additional improvement in LVEF and in CI, and this was translated into a higher number of acute responders to CRT.

Introduccion y objetivos La insuficiencia cardiaca esta asociada con un incremento en la produccion de radicales libres, llegandose al estado de estres oxidativo. Se conocen diversos marcadores de estres oxidativo, como la 8-hidroxi-2’-desoxiguanosina, marcador del dano oxidativo en el ADN, y la peroxidacion lipidica que permite cuantificar el dano en las estructuras ricas en lipidos. El proposito de este estudio es comparar los valores de 8-hidroxi-2’-desoxiguanosina y de peroxidacion lipidica en pacientes con insuficiencia cardiaca y sujetos sanos, y evaluar la influencia de la etiologia. Metodos Estudiamos a 78 pacientes (57 varones, edad 64 ± 14 anos) diagnosticados de insuficiencia cardiaca y a 12 controles. Los pacientes completaron un cuestionario y fueron clasificados de acuerdo con la New York Heart Association. Se les realizo un estudio eco-Doppler y extraccion de sangre. Medimos las concentraciones de 8-hidroxi- 2’-desoxiguanosina y de peroxidacion lipidica. Resultados Al comparar los valores de 8-hidroxi-2’-desoxiguanosina y peroxidacion lipidica entre pacientes y controles obtuvimos diferencias significativas (0,34 ± 0,54 frente a 0,04 ± 0,07 ng/ml, p Conclusiones Los valores de 8-hidroxi-2’-desoxiguanosina y peroxidacion lipidica se encuentran aumentados en los pacientes con insuficiencia cardiaca al compararlos con los controles. El incremento mas importante lo encontramos en pacientes con miocardiopatia hipertensiva.

Introduccion y objetivos Las concentraciones elevadas de big endotelina 1 (big ET-1) se relacionan con la gravedad y el pronostico de los pacientes con insuficiencia cardiaca (IC), mientras que N-terminal proBNP (NTproBNP) es un marcador de remodelado ventricular. El objetivo de nuestro estudio fue relacionar los valores de big ET-1 con NT-proBNP y con la funcion miocardica. Pacientes y metodo Estudiamos a 103 pacientes (75 varones; 63 ± 13 anos) diagnosticados de IC. Cada participante completo un cuestionario y fue sometido a un estudio eco-Doppler para la medicion de la fraccion de eyeccion (FE), la velocidad de propagacion del flujo mitral (Vp) y el desplazamiento del plano auriculoventricular (DPAV). Se realizo una extraccion de sangre para determinar los valores de big ET-1, aldosterona y NT-proBNP. Resultados Para toda la poblacion, el valor de big ET-1 fue de 1,03 ± 0,75 fmol/ml, el de NT-proBNP de 619 (307-1.328) pg/ml, el de aldosterona de 168 ± 102 pg/ml, la FE de 37 ± 10, la Vp de 37 ± 11 cm/s y el DPAV de 8,0 ± 1,7 mm. La big ET-1 se correlaciono positivamente con el NT-proBNP (r = 0,50; p Conclusiones Los valores plasmaticos de big ET-1 muestran una correlacion positiva con los de NT-proBNP y una correlacion inversa con la FE, la Vp y el DPAV. Estos hallazgos ayudan a esclarecer las relaciones entre la funcion ventricular y la activacion neurohormonal en la insuficiencia cardiaca y facilitan la busqueda de nuevas intervenciones terapeuticas.

It has been published that hypertension (HT) must be taken into account when using NT-proBNP, but left ventricular (LV) hypertrophy without HT could be a cause of NT-proBNP elevation. In a population study we compared NT-proBNP in subjects with hypertrophy, with and without diagnosis of HT.We studied 215 subjects from a random sample of 432 people who had declared to suffer from dyspnea. These 432 subjects were referred to their hospital where blood samples were taken, an echo-Doppler study was performed and a specific questionnaire was completed. We got a positive answer from 215, and 52 (24%) have LV hypertrophy.When we compared NT-proBNP in non-hypertrophic population, 148 +/- 286 pg/ml, with NT-proBNP in LV hypertrophic population, 202 +/- 209 pg/ml, we found P0.001. In the hypertrophic group, when we compared NT-proBNP (199 +/- 201 pg/ml) in normotensive subjects (LV mass index 170 +/- 70 g/m2, Vp 50 +/- 18 cm/s, LVEF 62 +/- 8) with NT-proBNP (205 +/- 220 pg/ml) in subjects with diagnosis of HT (LV mass index 169 +/- 37 g/m2, Vp 55 +/- 20 cm/s, LVEF 64 +/- 10), we found NS.This population study shows that NT-proBNP is elevated in patients with LV hypertrophy with or without HT. In LV hypertrophy the presence of HT does not influence the peptide levels significantly.

Introduction. The diagnosis of chronic heart failure (CHF) is based on demonstrating the cardiac origin of clinical manifestations. Echocardiography is the method of choice for the detection of left ventricular systolic dysfunction (LVSD). Brain natriuretic peptide (BNP) rises during LVSD. Objectives. To analyze the plasma concentration of Nterminal brain natriuretic propeptide (NTproBNP) in a general adult population in relation to different spontaneous circumstances and to study its capacity for identifying patients with LVSD. Methods. A cardiological examination was made and plasma NTproBNP levels were measured in a randomized group of 203 people (49-81 years old) from the Community of Valencia. Results. The average NTproBNP concentration was 52.2 ± 98.2 pmol/l. NTproBNP levels varied with age, gender and functional stage (NYHA). The highest NTproBNP values were observed in people who had previously suffered from acute pulmonary edema or who had an ejection fraction (EF) of less than 40%. There was also a significant elevation in patients with nocturnal dyspnea, orthopnea, atrial fibrillation, EF  50%, angina, and ankle edema. The best concentration of NTproBNP for differentiating EF  50% was 37.7 pmol/l, with 92% sensitivity and 68% specificity. Conclusions. The elevation of NTproBNP concentration indicates the cardiac origin of clinical manifestations and serves to select patients for echocardiographic examination. Low NTproBNP concentrations help to rule out LVSD.

Introduction and objectives. NT-proBNP is useful in the diagnosis of heart failure and ventricular dysfunction. Left atrioventricular plane displacement (AVPD) is a consolidated index of ventricular function. Our objective was to carry out a multicenter population-based study to establish the relationship between plasma NT-proBNP levels with AVPD values. Patients and method. We studied 215 subjects (age 66 ± 9 years; 57.7% women) chosen from a random sample of 432 people from the Community of Valencia, who previously reported suffering from some degree of dyspnea. Doppler echocardiography was done, AVPD was calculated and plasma NT-proBNP concentrations were determined. All studies were completed in 194 patients. Results. For the whole population NT-proBNP was 88 (02,586) pg/ml and AVPD was 11.9 ± 1.6 mm. NT-proBNP concentration correlated well with AVPD (r = 0.44; p < 0.00001), and higher peptide levels were obtained in AVPD quartiles that indicated less displacement (p < 0.05). When NT-proBNP values were grouped according to their association with AVPD lower or higher than the 50th percentile AVPD, the difference was significant at p < 0.01. When AVPD values lower and higher than 10 mm were compared, NT-proBNP values were higher in persons with AVPD lower than 10 mm (p < 0.05). Conclusions. This population study found higher NTproBNP concentrations in subjects with lower AVPD, and illustrates the potential diagnostic usefulness of NTproBNP in clinical practice.

To determine the clinical value of several parameters derived by application of the proximal isovelocity surface area method in the assessment of mitral regurgitation (MR), 28 consecutive patients with angiographic diagnosis of MR underwent color Doppler echocardiography within 48 h of cardiac catheterization. Aliasing velocities ( V N ) were baseline-shifted to 25 cm/s and the maximal radius ( R ) was measured from the first aliasing boundary to the tips of the mitral valve. By continuity, the regurgitant orifice area ( ROA ) and regurgitant stroke volume ( RSV PISA ) were obtained. We have related them to the angiographic grade, and with determination of the regurgitant stroke volume ( RSV DE ) and the regurgitant fraction ( RF ), we calculated the volume of the transmitral flow according to Fisher's method. Results: RSV DE correlated well with RSV PISA ( r =0.98). A clear relation existed between the isovelocity radius and the RSV DE and RF ( r =0.95 and 0.88, respectively). A radius of 8 mm or more was identified well with an RSV DE of 40 cm 3 or more (sensitivity: 100%, specificity: 95%) and an RF of 35% or more (sensitivity: 88%, specificity: 94%). The ROA was closely related to the RSV DE and RF , with r =0.92 and 0.88, respectively. An ROA of 20 mm 2 or more identified well patients with RSV DE values of 40 cm 3 or more and RF values of 35% or more. The radius, RSV PISA and ROA were closely related to the angiographic grade of MR ( r =0.91, 0.83 and 0.92, respectively). A radius of 7 mm or more identified patients with grade III or IV of regurgitation (sensitivity: 82%, specificity: 94%), while an ROA of 15 mm 2 or more discriminated well significant regurgitation (sensitivity: 91%, specificity: 94%). Conclusions: Parameters derived by application of the proximal isovelocity surface area method provide quantitative information that can be helpful in predicting the severity of mitral regurgitation noninvasively.

Percutaneous mitral valvuloplasty has become the technique of choice for mitral stenosis with favorable anatomic features. However, mitral regurgitation is an important complication of this technique that has not reduced with Inoue technique. This study reports the clinical and echocardiographic follow-up (28 +/- 20 months) of 20 patients who developed severe mitral regurgitation after percutaneous mitral valvuloplasty with Inoue technique. The patients were divided into two groups on the basis of the need for mitral valve replacement during follow-up. We analyzed variables before and after percutaneous mitral valvuloplasty using univariate analysis. Multivariate analysis was performed to identify variables as independent predictors of the need for mitral valve replacement. Ten patients needed mitral valve replacement during follow-up. Multivariate analysis showed that suboptimal result of percutaneous mitral valvuloplasty (MVA < 1.5 cm2) was the only independent predictor of the need of mitral valve replacement. We concluded that the need for MVR in patients who develop severe mitral regurgitation after percutaneous mitral valvuloplasty was related to suboptimal result of procedure.

Background Brain naturietic peptide (BNP) elevations have been reported in heart transplant patients both at baseline and during rejection. An association between BNP levels and certain echocardiographic and hemodynamic abnormalities has also been found in nontransplanted heart disease patients. We sought to determine whether BNP values were correlated with echocardiographic and hemodynamic parameters among a large cohort of heart transplant patients. Materials and methods We studied 71 consecutive heart transplant patients, excluding combined grafts, retransplants, and pediatric cases. We performed 488 BNP determinations during catheterization and within 48 hours of echocardiography. Hemodynamic parameters included mean pulmonary artery pressure, right ventricular systolic and diastolic pressures. Doppler echocardiography parameters were wall thickness, ventricular mass, left and right ventricular end-diastolic and end-systolic diameters, isovolumic relaxation time, and mitral flow deceleration time. Results We observed significant correlations between BNP values and left ventricular size, ventricular mass, and a restrictive filling pattern. BNP levels were also significantly correlated with right ventricular size, mean pulmonary artery pressure, and right ventricular diastolic and end-diastolic pressures. Conclusions In heart transplant patients, BNP levels positively correlated with ventricular diameters and a restrictive filling pattern. An increase in right ventricle and pulmonary artery pressures was associated with elevated BNP values.

The amino-terminal pro-brain natriuretic peptide (NT-proBNP) and estimated glomerular filtration rate (eGFR) values are related to short prognosis in patients with heart failure (HF). This study evaluates the prognostic power of serum and urinary NT-proBNP levels, and eGFR values, in HF patients during a 60-month follow-up.We studied 93 HF outpatients (66 males, age 65+/-12). Primary endpoint was defined as cardiovascular mortality and secondary endpoint as cardiovascular mortality or admissions.Only serum NT-proBNP levels had a significant area under the curve for the prognosis of 60-month mortality and combined events, 0.70 (p=0.004) and 0.67 (p=0.019), respectively. Urinary NT-proBNP and eGFR did not have statistical significant areas under the curve. Patients with high serum NT-proBNP had the highest risk of cardiovascular death [44 (IC 95% 38-50) vs. 56 (IC 95% 53-59) months, p=0.0006] and combined events [33 (IC 95% 28-38) vs. 42 (IC 95% 28-38) months; p=0.027]. After the integration of serum NT-proBNP and renal function, patients with high peptide levels and low eGFR had the worst survival [42 (IC 95% 33-52) months; p=0.010]. Finally, only serum NT-proBNP concentration above 933 pg/mL was a predictor of poor survival (hazard ratio=2.81, p=0.033) and NT-proBNP above 550 pg/mL for combined events (hazard ratio=1.79, p=0.049).Serum NT-proBNP levels were superior to urine NT-proBNP and eGFR values for predicting 60-month cardiovascular death and combined events in HF patients.

El absceso periprotesico secundario a endocarditis infecciosa constituye una grave complicacion del reemplazo valvular aortico, con una alta mortalidad a pesar del tratamiento combinado medico-quirurgico, en especial en las endocarditis «precoces». La ecocardiografia transtoracica, y en especial la transesofagica, constituye el procedimiento de eleccion para el diagnostico no invasivo de la vegetacion y de las complicaciones locales. Presentamos el caso de una mujer de 43 anos con un absceso periprotesico aortico y extension a ambas auriculas, provocado por el Staphylococcus epidermidis y que presento un comportamiento muy agresivo y fulminante.

Several studies have analyzed big endothelin-1 as a marker of mortality in patients with severe heart failure (HF). However, it has not proven prognostic value in patients with moderately symptomatic functional class. Our objective was to evaluate, in a 24 months follow-up, the prognostic power of big endothelin-1 in patients with HF and moderately deteriorated functional class.Big endothelin-1 levels were measured in a cohort of 90 outpatients (age 64 (13), 70% males) diagnosed with HF. Patients were functionally classified (NYHA).For the whole population, big endothelin-1 was 0.86 (0.61-1.20)fmol/ml. We evaluated its predictive value in detecting cardiovascular mortality, obtaining an AUC of 0.68 (0.08) (P=.02), and a cut-off value of 0.98 fmol/ml (sensitivity 69%, specificity 75%). When a logistic regression analysis was performed, big endothelin-1 was also an independent predictor of mortality (OR=5.851, P=.009).Big endothelin-1 predicts cardiovascular mortality in patients diagnosed of HF and moderately symptomatic functional class.

The plasma N-terminal probrain natriuretic peptide (NT-proBNP) level is a sensitive marker of ventricular dysfunction. The diagnostic and prognostic value of urinary NT-proBNP measurement has been demonstrated. The objective of this study was to determine the relationship between established parameters of ventricular function and the urinary NT-proBNP level.The study involved 74 patients with heart failure (54 male, age 66 [12] years). A Doppler echocardiographic study was performed to measure atrioventricular plane displacement (AVPD), ejection fraction, mitral flow propagation velocity, and E/A. Urinary and plasma NT-proBNP levels, and the plasma aldosterone level were measured.In the whole group, the plasma NT-proBNP level was 948 (961) pg/mL, the urinary NT-proBNP level was 88.7 (17.8) pg/mL, and the aldosterone level, 165 (145) pg/mL. There were correlations between urinary NT-proBNP level and AVPD (r=-0.5; P.0001), ejection fraction (r=-0.3; P.01), and mitral flow propagation velocity (r=-0.24; P.05). On dividing AVPD and ejection fraction measurements into quartiles, respectively, the urinary NT-proBNP levels for these quartiles were Q1: 103 (28) pg/mL, Q2: 89 (9) pg/mL, Q3: 86 (9) pg/mL, and Q4: 78 (9) pg/mL (P.0001) and Q1: 101 (26) pg/mL, Q2: 85 (12) pg/mL, Q3: 83 (10) pg/mL, and Q4: 85 (11) pg/mL (P.05), respectively. Multiple linear regression analysis showed that the plasma NT-proBNP level was an independent predictor of the urinary NT-proBNP level (P.0001). When the plasma NT-proBNP level was excluded, AVPD and ejection fraction appeared as alternative independent predictors (P.05).There is a correlation between the urinary NT-proBNP level and left ventricular function parameters. This study supports the use of the urinary NT-proBNP level as a biochemical marker of ventricular function in heart failure patients.

N-terminal pro-brain natriuretic peptide (NT-proBNP) is useful in the diagnosis of heart failure (HF). LV two-dimensional cavity area from end-diastole (LVEDA) and end-systole (LVESA), and LV fractional area change (LVFAC) reflect changes in LV morphology and function without using geometric assumptions. In a multicenter study, we correlated LVEDA, LVESA and LVFAC with NT-proBNP, comparing patients with dilated and ischemic cardiomyopathy.We studied 106 HF patients. In the dilated group, NT-proBNP correlated with LVEDAI (r=0.6), LVESAI (r=0.7) and LVFAC (r=-0.6), all significant at p0.001. In patients with ischemic cardiomyopathy we found LVESAI (r=0.3, p0.05) and LVFAC (r=-0.4, p0.01). After adjustment for age and BMI, LVFAC and LVESAI were associated in a multiple linear regression analysis with peptide levels (adjusted r(2)=0.5, p0.001).In this study we found a good correlation of NT-proBNP with LV cavity areas and LVFAC. Multiple regression analysis showed that when adjusted for age and BMI, LVFAC and LVESAI are independent predictors of NT-proBNP levels in both dilated and ischemic etiologies. Patients with dilated cardiomyopathy showed better results than those with ischemic cardiomyopathy. We think LV areas are a useful and reproducible parameter, do not need geometric assumptions and reflect NT-proBNP plasma levels.

Elevated plasma concentrations of big endothelin-1 (big ET-1) are related with severity and prognosis in patients with heart failure, and N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of ventricular remodeling. The purpose of this study was to investigate the relationship between plasma levels of big ET-1 and NT-proBNP, and between the former and ventricular function.We studied 103 patients with heart failure (75 men, mean age 63 [13] years). Each participant completed a questionnaire and underwent Doppler echocardiographic study to measure ejection fraction (EF), mitral flow propagation velocity (Vp) and atrioventricular plane displacement (AVPD). Blood samples were also taken to determine plasma levels of big ET-1, aldosterone and NT-proBNP.For the whole population big ET-1 concentration was 1.03 [0.75] fmol/m, NT-proBNP 619 (307-1328) pg/mL, aldosterone 168 [102] pg/mL, EF 37 [10], Vp 37 [11] cm/s, and AVPD 8.0 [1.7] mm. Plasma big ET-1 correlated positively with plasma NT-proBNP (r=0.50, P.0001). However, a negative correlation was found between big ET-1 and EF (r=-0.30, P.01), Vp, (r=-0.30, P.01) and AVPD (r=-0.21, P.05). When ET-1 levels were divided into quartiles and the corresponding NT-proBNP, EF, Vp and AVPD values were compared, we found significant differences (ANOVA P.0001, P.01, P.05 and P.05, respectively).Plasma levels of big ET-1 correlated positively with NT-proBNP levels and inversely with EF, Vp and AVPD. These findings help clarify the relationships between ventricular function and the neurohormonal activation involved in heart failure, and may aid the search for therapeutic interventions.

N-terminal pro-brain natriuretic peptide (NT-proBNP) is useful in the diagnosis of heart failure. We compared NT-proBNP levels in patients with and without a diagnosis of arterial hypertension.Participants were recruited from a random sample of 999 inhabitants from the Community of Valencia (eastern Spain). Of these patients, 432 said they suffered from dyspnea and were referred to their hospital (10 hospitals involved), where blood samples were taken, an echo-Doppler study was performed, and the patients completed a questionnaire. Of the 432 participants with dyspnea, 215 gave informed consent for their inclusion in the study, and 202 completed the study. Hypertension was diagnosed in 72 participants and 130 were normotensive.For the whole population, NT-proBNP, expressed as the median and range, was 88 (0-2586) pg/mL. When we compared hypertensive with normotensive participants, we found higher NT-proBNP levels in the former group: median 123, range 0-2184 pg/mL, versus median 77, range 0-2586 pg/mL (P.01). When we excluded subjects with systolic left ventricular dysfunction, we found higher levels in participants with hypertension: 119 (0-2184 pg/mL) vs 72 (0-997 pg/mL) (P.01). When we also excluded subjects with diastolic dysfunction, we found (median 85, range 0-430 pg/mL) and (median 66, range 0-997 pg/mL), respectively (p = NS).In a population study of subjects with dyspnea, hypertensive patients have higher NT-proBNP levels than subjects with normal blood pressure. This difference disappeared when patients with diastolic dysfunction were excluded from the analysis. Hypertension can thus be a confounding factor that potentially decreases the specificity of NT-proBNP levels for the diagnosis of heart failure. These findings should be taken into account when conducting clinical and epidemiological studies in which patients with both heart failure and hypertension are included.

NT-proBNP is useful in the diagnosis of heart failure and ventricular dysfunction. Left atrioventricular plane displacement (AVPD) is a consolidated index of ventricular function. Our objective was to carry out a multicenter population-based study to establish the relationship between plasma NT-proBNP levels with AVPD values.We studied 215 subjects (age 66 9 years; 57.7% women) chosen from a random sample of 432 people from the Community of Valencia, who previously reported suffering from some degree of dyspnea. Doppler echocardiography was done, AVPD was calculated and plasma NT-proBNP concentrations were determined. All studies were completed in 194 patients.For the whole population NT-proBNP was 88 (0-2,586) pg/ml and AVPD was 11.9 1.6 mm. NT-proBNP concentration correlated well with AVPD (r = 0.44; p0.00001), and higher peptide levels were obtained in AVPD quartiles that indicated less displacement (p0.05). When NT-proBNP values were grouped according to their association with AVPD lower or higher than the 50th percentile AVPD, the difference was significant at p0.01. When AVPD values lower and higher than 10 mm were compared, NT-proBNP values were higher in persons with AVPD lower than 10 mm (p0.05).This population study found higher NT-proBNP concentrations in subjects with lower AVPD, and illustrates the potential diagnostic usefulness of NT-proBNP in clinical practice.

The diagnosis of chronic heart failure (CHF) is based on demonstrating the cardiac origin of clinical manifestations. Echocardiography is the method of choice for the detection of left ventricular systolic dysfunction (LVSD). Brain natriuretic peptide (BNP) rises during LVSD.To analyze the plasma concentration of N-terminal brain natriuretic propeptide (NTproBNP) in a general adult population in relation to different spontaneous circumstances and to study its capacity for identifying patients with LVSD.Methods. A cardiological examination was made and plasma NTproBNP levels were measured in a randomized group of 203 people (49-81 years old) from the Community of Valencia.The average NTproBNP concentration was 52.2 98.2 pmol/l. NTproBNP levels varied with age, gender and functional stage (NYHA). The highest NTproBNP values were observed in people who had previously suffered from acute pulmonary edema or who had an ejection fraction (EF) of less than 40%. There was also a significant elevation in patients with nocturnal dyspnea, orthopnea, atrial fibrillation, EFor = 50%, angina, and ankle edema. The best concentration of NTproBNP for differentiating EFor = 50% was 37.7 pmol/l, with 92% sensitivity and 68% specificity.The elevation of NTproBNP concentration indicates the cardiac origin of clinical manifestations and serves to select patients for echocardiographic examination. Low NTproBNP concentrations help to rule out LVSD.

Background and purpose: Right ventricular dysfunction (RVD) has been described as an independent factor for morbidity and/ or mortality in various nosological entities. However, there are no data on its true

Aim. To undertake an evolutionary analysis of echocardiographic examinations carried out during follow-up of cardiac transplant patients. Materials and methods. The study included 193 consecutive patients transplanted between August 1998 and December 2004. We excluded pediatric, cardiopulmonary, and repeat transplants. Four echocardiographic examinations were analyzed per patient (first, second, third quarter and the last study carried out; average time from transplant: 1115 ± 681 days). The total number of examinations was 772. The evaluated variables were thickness of walls and diameters of the cavities, systolic and diastolic functions, pericardial effusion, and number of rejections. Results. The isovolumetric relaxation time showed reduced values during early echocardiography with subsequent increases during evolution (first echocardiogram: 92 ± 16 vs final echocardiogram 101 ± 16 ms; P

596 What association predominates for N-terminal pro-brain natriuretic peptide plasma levels, fiber stretching or hypertrophy M. Rivera1, V. Mora2, J. Valencia3, A. Jordan4, R. Talens1, J.L. Bosca5, G. Grau6, V. Bertomeu7, V. Miro8, S. Marti9 1Hospital La Fe, Research Unit, Valencia, Spain; 2Hospital Peset, Cardiologia, Valencia, Spain; 3Hospital General, Cardiologia, Alicante, Spain; 4Hospital Elche, Cardiologia, Elche, Spain; 5Hospital General, Cardiologia, Valencia, Spain; 6Hospital Alcoy, Cardiologia, Alcoy, Spain; 7Hospital S Juan, Cardiologia, Alicante, Spain; 8Hospital La Fe, Cardiologia, Valencia, Spain; 9Hospital Elda, Cardiology, Elda, Spain