Alicia Maceira

Guías de práctica clínica de la Sociedad Española de Cardiología en pruebas de esfuerzo

La mayor parte de las pruebas de esfuerzo se realizan a pacientes adultos con cardiopatia isquemica en estudio o ya conocida. En los ultimos anos se ha producido la incorporacion de las tecnicas de imagen en este campo, mejorando asi la informacion aportada por la prueba de esfuerzo convencional. Pero cada vez existen mas situaciones que escapan a esta norma general, tanto en sujetos sanos (asintomaticos, atletas, discapacitados, etc.) como en pacientes con cardiopatias diferentes de la isquemica (insuficiencia cardiaca congestiva avanzada, hipertension, trastornos del ritmo, cardiopatias congenitas etc.). Todos estos aspectos justifican un documento de consenso en Espana, necesariamente multidisciplinario. Este documento revisa en profundidad la metodologia de las pruebas de esfuerzo convencionales, sin olvidar las realizadas con determinacion de consumo de oxigeno. El papel de esta exploracion en el manejo de la cardiopatia isquemica, asi como las aplicaciones de las tecnicas de imagen al campo del estres, ocupan un lugar fundamental en esta revision. Por ultimo, se analiza la utilidad de las pruebas de esfuerzo en diversas cardiopatias no isquemicas y en diferentes poblaciones de sujetos sanos.

Fiabilidad de los índices de viabilidad miocárdica por resonancia magnética para predecir la mejoría de la función sistólica en pacientes con un primer infarto reciente y arteria abierta

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

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO ( Indicadores de Calidad en Unidades Asistenciales del Área del Corazón ): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Usefulness of NT-proBNP Level for Diagnosing Left Ventricular Hypertrophy in Hypertensive Patients. A Cardiac Magnetic Resonance Study

The presence of left ventricular hypertrophy (LVH) is associated with an increase in cardiovascular morbidity and mortality in hypertensive patients. We investigated the diagnostic value of the N-terminal probrain natriuretic peptide (NT-proBNP) level for detecting LVH in hypertensive patients with a conserved left ventricular ejection fraction. The study involved 27 consecutive patients. Cardiac magnetic resonance imaging was performed to determine left ventricular mass and the plasma NT-proBNP level was measured. A significant correlation was found between the NT-proBNP level and left ventricular mass (r=0.598; P=.001). Use of a cut-off point of 35 pg/mL enabled the presence of LVH to be identified with a sensitivity of 100% (95% confidence interval [CI], 69%-100%) and a specificity of 70.6% (95% CI, 44.1%-89.6%). The area under the receiver operating characteristic (ROC) curve was 0.867 (95% CI, 0.73-1; P< .05). The plasma NT-proBNP level may be useful for identifying patients with LVH.

Quality markers in cardiology: measures of outcomes and clinical practice--a perspective of the Spanish Society of Cardiology and of Thoracic and Cardiovascular Surgery.

The complexity of the individual patient and organization of medical practice results in important institutional and country quality of care variability.1–17 Attempts to assess the quality of clinical practice have established rating systems that may yield completely different results and rating for the same hospital during the same period of time, adding confusion rather than help to prove their usefulness and, questioning whether existing measures can actually measure quality.18–35 Most important, benchmarking may be associated with progressive improvement both in performance and outcomes,18,26,28,36–38 highlighting the relevance of standardization of quality measures and the responsibility of scientific societies. The Spanish Society of Cardiology (SSC) and the Spanish Society of Thoracic and Cardiovascular Surgery (SSTCS) organized a task force to identify and define two sets of quality metrics in hospital cardiology practice: (i) outcome measures (metrics of the final quality of the practice of cardiology) and (ii) performance measures (metrics of clinical practice which are known to positively influence desirable outcomes). Beyond this objective, Scientific Societies and Health Care Authorities should be responsible for the implementation of programmes to measure quality, ensure the quality of the data, benchmarking, and certification/accreditation of cardiology services. All European Society of Cardiology (ESC)32 and American Heart Association/American College of Cardiology33 guidelines were reviewed and recommendations related to quality standards were included in the document. ### Grading of quality markers Three levels were established both for class recommendation and level of evidence considering (i) clinical and practical …

Resonancia magnética cardiaca en miocardiopatía arritmogénica. Tipos de afección y patrones de realce tardío de gadolinio

INTRODUCTION AND OBJECTIVES Biventricular arrhythmogenic cardiomyopathy and left dominant arrhythmogenic cardiomyopathy forms had recently been included in the spectrum of arrhythmogenic cardiomyopathy. The aim of the study was to describe, using cardiovascular magnetic resonance, the patterns of ventricular involvement as well as late gadolinium enhancement in these conditions. METHODS Medical databases and records from the cardiology units of 3 hospitals were reviewed to obtain data from patients with arrhythmogenic cardiomyopathy. RESULTS Twenty-six consecutive patients were included (40 [16] years, 16 males). Right ventricle involvement was present in 19 patients (73%). Among them, 13 patients (50%) had volumes over the upper limit of normality, 11 (42%) patients had late gadolinium enhancement in right ventricle and 6 patients (23%) had just mild involvement with wall motion abnormalities or microaneurysms. Left ventricle involvement was present in 24 patients (92%), all of them with late gadolinium enhancement. In 15 patients (57%) left ventricular systolic dysfunction was observed, and dilatation in 3 patients (11%). Late gadolinium enhancement was more frequent in the inferior, lateral, and inferolateral walls (65%, 57%, and 61% of patients, respectively) while septum was seldom affected (26% of cases). The pattern of late gadolinium enhancement was mainly subepicardial (46% of patients) or transmural (19%), and was intramyocardial in only 12% of the cases. CONCLUSIONS In this sample, left ventricle involvement is very common. The most frequent finding was left ventricular late gadolinium enhancement, while the least frequent was dilatation. The pattern of late gadolinium enhancement was more frequently subepicardial and located in the inferior and inferolateral walls.

Reliability of Cardiac Magnetic Resonance Imaging Indicators of Myocardial Viability for Predicting the Recovery of Systolic Function After a First Acute Myocardial Infarction With a Patent Culprit Artery

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

Cardiac magnetic resonance imaging in amyloidosis

mm Hg, with no other data of interest. The initial electrocardiogram (ECG) showd LBBB. After administration of sublingual Cafinitrina, chest pain receded and LBBB disappeared in the ECG, with the trace falling to 65 bpm and normal repolarization. A new episode of chest pain followed the same pattern (Figure A and B). Cardiac enzyme levels were normal in repeated testing. Diagnosed with acute coronary syndrome, cardiac catheterization was performed finding normal left ventricle and absence of lesions in both coronary arteries. The patient was discharged at 48 hours with no other incident and prescribed low molecular weight heparin and a calcium antagonist. At 1 year, she continued asymptomatic with normal ECG and had not presented a similar episode. The pathophysiology of painful LBBB is unknown. Although some authors have suggested it is caused by microvascular ischemia, basing themselves on finding of high levels of lactate in the coronary sinus, the most widely accepted view today attributes it to a dysynergy of the contraction with mechanoreceptor stimulation causing chest pain. The interest of this patient lies in our having been able to observe LBBB during episodes of such intense chest pain and accompanied by nausea and vomiting, at rest. The discrete increase in heart rate during pain does not permit us to attribute the conduction disturbance to a frequency-dependent mechanism. Almost all episodes of painful LBBB described previously have been related to increased heart rate during exercise. In our patient, with angina at rest and angiographically normal coronary arteries without other cardiac illness, a hypothesis of microvascular angina seems most plausible after discounting a heart rate dependent mechanism. It is difficult to diagnose acute ischemia in patients with LBBB as many ECG diagnostic criteria are not applicable. Anomalous ventricular depolarization produces secondary alteration in the process of recovery, a phenomenon that appears in the ECG with changes in repolarization in a direction opposite to the principal QRS deflection or “appropriate discordance” between the QRS complex and ST-segment. Elevation of ST-segment in association with positive QRS complex, or ST-segment depression in V1, V2 or V3 leads do not occur in uncomplicated bundle branch block, known as “inappropriate discordance,” which is indicative of acute ischemia. Extreme ST-segment elevation (>5 mm) in V1 and V2 also indicate acute ischemia. Given the high mortality of myocardial infarction electrically hidden by LBBB, the norm should be to perform immediate cardiac catheterization.