Almudena Castro

Infarto agudo de miocardio en el seno de hemoglobinuria paroxística nocturna

Se presenta el caso de un paciente varon de 62 anos de edad diabetico y fumador que, como otros antecedentes de interes, seguia estudio en otro centro hospitalario por presentar anemia, trombopenia y hematuria de varios meses de evolucion. Ingreso en la unidad coronaria en el contexto de un infarto agudo de miocardio transmural extenso que se trato con activador tisular del plasminogeno. A las pocas horas presento «orinas hematuricas», disminucion de las cifras de hemoglobina y plaquetas, asi como insuficiencia renal aguda. Se realizo estudio hematologico que confirmo el diagnostico de hemoglobinuria paroxistica nocturna. El paciente evoluciono de forma desfavorable pese a tratamiento medico intensivo y en su evolucion preciso hemodialisis. Finalmente presento un taponamiento cardiaco y fallecio. Se comenta el papel que tiene la enfermedad hematologica en el infarto agudo de miocardio asi como el tratamiento y la evolucion del sindrome coronario en el contexto de la enfermedad.

Tratamiento hormonal sustitutivo en la prevención de la cardiopatía isquémica en la mujer. Argumentos en contra

El tratamiento hormonal sustitutivo es una de las cuestiones mas dificiles a las que se enfrentan las mujeres y sus medicos. Los estudios epidemiologicos demuestran de manera consistente que las mujeres que toman tratamiento hormonal sustitutivo tienen un riesgo de padecer enfermedad coronaria sustancialmente inferior. Los datos observacionales se sustentan en hallazgos que demuestran que el tratamiento hormonal sustitutivo mejora varios factores de riesgo coronario, en especial los cambios en el perfil lipidico. Sin embargo, no se ha demostrado de forma absoluta que las hormonas ayuden a la prevencion de la enfermedad cardiovascular. En mujeres sin enfermedad coronaria, el beneficio del tratamiento hormonal sustitutivo no esta claro. Lo que si han demostrado estudios clinicos recientes es que no se debe recomendar este tratamiento a mujeres con enfermedad coronaria establecida con el objetivo de obtener un beneficio cardiovascular. Palabras clave

Drugs That Improve Cardiovascular Prognosis in Diabetes and Are Not Yet Used by Cardiologists

Type 2 diabetes mellitus (T2DM) is currently one of the most prevalent health problems worldwide. According to estimated data, 246 million people have T2DM globally, and this figure may double by 2025. If we concentrate on the population with cardiovascular (CV) disease, the registries give figures close to 35% of patients with established CV disease who also have T2DM. Recently, a multidisciplinary team of cardiologists, endocrinologists, and nephrologists published the monograph ‘‘Diabetes tipo 2 en prevención secundaria. Recomendaciones de tratamiento’’ (in English, Type 2 diabetes in secondary prevention. Treatment recommendations). This document contains an extensive review of the CV safety of antidiabetic (AD) drugs and points out that a reduction in CV events and even in CV mortality has been demonstrated for 2 groups of these drugs: sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. It is remarkable that these results have not had an impact in the world of cardiology, despite, as already mentioned, approximately 35% of the patients we treat in secondary prevention (2P) having T2DM and their mortality risk being at least 3 times higher than that patients in 2P without T2DM. Moreover, around 40% of patients with heart failure (HF) have T2DM, which confers a significantly increased risk of hospitalization for HF, CV mortality, and all-cause mortality. This so far lukewarm reaction from cardiologists must be stepped up given that T2DM confers a worse prognosis for our patients and we now have therapeutic tools to improve this situation. The reality is that, until recently, only multifactorial control, particularly of low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP), was demonstrated to reduce CV morbidity and mortality in patients with T2DM and high CV risk. The paradigm shift in the treatment of patients with T2DM in 2P began in September 2015. For the first time, an AD, empagliflozin, was shown in a randomized clinical trial to reduce CV mortality and allcause mortality, reduce major CV events, hospitalization due to HF, and slow progression of and even reverse kidney disease. The most surprising finding was that these benefits were independent of the glycated hemoglobin concentration (HbA1c) achieved by patients during the study. Six months later, another study was published reporting that liraglutide treatment significantly reduced CV mortality and major vascular events in the same population of patients with T2DM in 2P, and again that these benefits were independent of the HbA1c levels reached. Semaglutide, months later, and canagliflozin, in 2017, also showed a reduction in the composite outcome of death, nonfatal myocardial infarction and nonfatal stroke, this benefit being unrelated to HbA1c levels. 11,12 This is the paradigm shift: the reduction in CV complications and mortality in patients with T2DM and CV disease goes beyond glycemic control and appears to be more closely related to the specific benefit provided by these drugs on the heart, hemodynamic status, nephroprotection, and reversal of atherosclerosis. The glucocentric approach for patients with T2DM has been sidelined and the multifactorial approach is gaining ground, particularly the evidence on the CV benefit provided by these 4 drugs: empagliflozin, liraglutide, semaglutide, and canagliflozin. The consequence of this transition in the approach to diabetes goes beyond the points mentioned here. From now on, there will be an unavoidable obligation to be aware of the drugs that can reduce these patients’ CV risk–more drastically than the other drugs currently used in 2P with less evidence of benefit–and not deny patients this treatment. It is necessary, therefore, to raise awareness among the different specialists about the need to incorporate these drugs into the therapeutic arsenal of 2P rather than simply considering them AD drugs. Even more importantly, we must embrace the idea that between us all we need to take control and ensure these patients are treated holistically, with cardiologists, endocrinologists, nephrologists and internists working hand-in-hand and, most importantly, with the involvement of the family doctor to achieve the continuity of care that is so necessary for this patient population. The mechanism of action by which these drugs produce a CV benefit is yet to be elucidated. A period of tremendous research Rev Esp Cardiol. 2018;71(12):999–1000

Small airway dysfunction in smokers with stable ischemic heart disease

Background A higher prevalence of airflow limitation (AL) has been described in patients with ischemic heart disease (IHD). Although small airway dysfunction (SAD) is an early feature of AL, there is little information about its occurrence in IHD patients. Our objective was to describe the prevalence of SAD in IHD patients, while comparing patient-related outcomes and future health risk among IHD patients with AL, SAD and normal lung function. Methods In 118 consecutive smoking patients with stable IHD, comorbidities, utilization of healthcare resources, current treatment, blood biochemistry and health status were recorded. SAD was evaluated by impulse oscillometry, and pre- and post-bronchodilator spirometry was performed. Results The prevalence of AL and SAD were 20.3 (95% CI, 13.1–27.6%) and 26.3% (95% CI, 18.3–34.2%), respectively. Compared to the normal lung function group, patients with SAD and without AL had lower spirometric values, poorer quality of life and higher levels of C-reactive protein (CRP), as well as increased cardiovascular risk and more vascular age. In patients with normal spirometry, the presence of SAD was independently associated with pack-years, HDL-cholesterol and CRP levels. Conclusion In patients with IHD, the presence of SAD is common and that it is associated with reduced health status and increased future cardiac risk.

Fiebre después de un infarto agudo de miocardio

Paciente de mediana edad que ingreso en nuestro hospital con el diagnostico de infarto agudo de miocardio (IAM) anteroseptal de 3 h de evolucion. Era fumador de 1 cajetilla de cigarrillos al dia e hipercolesterolemico sin tratamiento farmacologico. No referia otros antecedentes personales de interes. En el electrocardiograma (ECG) se observo una lesion subepicardica anteroseptal. Las demas pruebas complementarias fueron normales. Se realizo fibrinolisis con estreptocinasa. La CPK maxima fue de 5.320 U/l. La evolucion fue satisfactoria hasta el sexto dia postIAM cuando empezo con fiebre de 39 °C. El paciente permanecio asintomatico y la exploracion fisica fue normal. En la analitica destacaba una caida de la cifra IMAGENES EN CARDIOLOGIA