Amador López-Granados

Insuficiencia cardiaca con función sistólica conservada. Diferencias pronósticas según la etiología

Introduccion y objetivos La insuficiencia cardiaca con funcion sistolica conservada (ICFSC) parece tener un pronostico similar al de la insuficiencia cardiaca con funcion sistolica disminuida. Sin embargo, no se conoce si la ICFSC es una entidad pronostica homogenea o si su morbimortalidad varia segun su etiologia. Metodos Se ha evaluado a una serie de 95 pacientes diagnosticados consecutivamente de ICFSC, con fraccion de eyeccion mayor del 45%, y hemos comparado los grupos de etiologia isquemica (nxa0=xa025; 26%) y no isquemica (nxa0=xa070; 74%). Resultados La edad media fue de 73xa0±xa06 anos, el 60% eran mujeres y la fraccion de eyeccion era del 61xa0±xa07%, con cifras similares en ambos grupos. Tras un seguimiento de 53xa0±xa08 meses (limites, 4-69; mediana, 46), el grupo isquemico presento mayor mortalidad (17,88 frente a 2,37 muertes/100 pacientes/ano; pxa0 Conclusiones La ICFSC no es una entidad homogenea desde el punto de vista pronostico. La morbimortalidad es mas elevada en los casos de etiologia isquemica, y sus mecanismos son tambien distintos.

Anticoagulación oral en la fibrilación auricular no valvular: ¿son efectivas y seguras las recomendaciones científicas en la práctica clínica diaria?

INTRODUCTION AND OBJECTIVES: To study the efficacy and safety of an oral anticoagulation protocol for the treatment of nonvalvular atrial fibrillation, based on scientific associations recommendations, in unselected patients seen in daily clinical practice. METHODS: The study included all consecutive patients with permanent nonvalvular atrial fibrillation who attended two outpatient cardiology clinics between February 1, 2000 and February 1, 2002. They were treated according to an anticoagulation protocol based on Spanish Society of Cardiology and American College of Cardiology/American Heart Association/European Society of Cardiology guidelines. Patients were followed up prospectively for major events, such as death, stroke, transient ischemic attack, peripheral embolism and severe hemorrhage, which were recorded by treatment group. RESULTS: A total of 624 patients were included in the study. Those receiving anticoagulation therapy (n=425; 68%) more frequently had hypertension, diabetes and previous embolism as well as a greater number of cardioembolic risk factors (P< .001). Overall, 93% of non-anticoagulated patients received platelet aggregation inhibitors (92% received aspirin). After a median follow-up of 21 months, the probability of an embolic event was lower in anticoagulated patients (0.81% vs 14.04%; P< .001), as was all-cause mortality (3.27% vs 6.42%; P=.003). However, there was no significant difference in the probability of severe bleeding (2.75% vs 2.93%; P=.96). Results were unchanged after adjustment for age, sex, and previous embolic events. CONCLUSIONS: Oral anticoagulation therapy for nonvalvular atrial fibrillation implemented according to scientific associations recommendations is effective and safe in daily clinical practice.

Severe Mitral Regurgitation in Libman-Sacks Endocarditis. Conservative Surgery

Libman-Sacks endocarditis is a classic but rarely symptomatic manifestation of systemic lupus erythematosus, and valvular surgery is needed in a few cases. We present a patient with systemic lupus erythematosus and Libman-Sacks endocarditis that progressed rapidly to severe mitral regurgitation that needed surgery; surgical valve repair was decided upon. The literature on this topic is reviewed.

Regurgitación mitral severa en endocarditis de Libman-Sacks. Cirugía reparadora

Libman-Sacks endocarditis is a classic but rarely symptomatic manifestation of systemic lupus erythematosus, and valvular surgery is needed in a few cases. We present a patient with systemic lupus erythematosus and Libman-Sacks endocarditis that progressed rapidly to severe mitral regurgitation that needed surgery; surgical valve repair was decided upon. The literature on this topic is reviewed.

Should Angiotensin-Converting Enzyme Inhibitors Be Continued Over the Long Term in Patients Whose Left Ventricular Ejection Fraction Normalizes After an Episode of Acute Myocarditis?

It is well established that long-term administration of angiotensin-converting enzyme (ACE) inhibitors has a favorable effect in patients with chronic heart failure and dilated cardiomyopathy. However, less information is available on patients whose left ventricular ejection fraction normalizes after an episode of systolic dysfunction secondary to acute myocarditis. We followed 35 patients who were diagnosed at our center between 1987 and 1995 with acute myocarditis and an ejection fraction<45%. All were taking ACE inhibitors. After 34 (23) months of follow-up, the left ventricular ejection fraction was >50% in all 35 patients. Treatment with ACE inhibitors was discontinued in 15 of the 35 patients, while the other 20 continued ACE inhibitor therapy. After 3 years of follow-up, no death had occurred, but the incidence of new episodes of heart failure with a left ventricular ejection fraction<45% was higher in patients who stopped taking ACE inhibitors (33% vs 5%, P=.064), and their ejection fraction was lower (47 [12%] vs 57 [11%], P=.002). These results suggest that ACE inhibitors should be continued over the long term in these patients.

Se deben mantener los inhibidores de la enzima de conversión de la angiotensina a largo plazo en pacientes que normalizan la fracción de eyección tras un episodio de miocarditis aguda

El efecto favorable de la administracion de los inhibidores de la enzima de conversion de la angiotensina (IECA) a largo plazo en pacientes con insuficiencia cardiaca cronica y fraccion de eyeccion deprimida esta bien establecido, ero no hay tanta evidencia en pacientes con disfuncion sistolica secundaria a miocarditis aguda que normalizan la contraccion ventricular. Hemos seguido a 35 pacientes con miocarditis aguda y fraccion de eyeccion 50% en los 35 casos. De esos 35, en 15 se suspendieron los IECA, mientras que 20 continuaron tomandolos. A los 3 anos de seguimiento no hubo ninguna muerte, pero los pacientes en los que se suspendieron los IECA tuvieron una mayor incidencia de nuevos episodios de insuficiencia cardiaca con fraccion de eyeccion

Heart Failure With Preserved Ejection Fraction. Effect of Etiology on Prognosis

INTRODUCTION AND OBJECTIVESnHeart failure with preserved systolic function accounts for almost 40% of heart failure cases. Prognosis is similar to that in patients with a low left ventricular ejection fraction (LVEF). However, it is not clear whether the etiology of heart failure with preserved systolic function has an effect on prognosis.nnnMETHODSnWe assessed 95 consecutive patients admitted to our hospital with heart failure and a LVEF>45%. Twenty-five (26%) had an ischemic etiology and 70 (74%), a non-ischemic etiology.nnnRESULTnThe patients mean age was 73 (6) years, 60% were female, and their mean LVEF was 61 (7)%. These characteristics were similar in the two etiological groups. After a mean follow-up period of 53 (8) months (4-69 months; median 46 months), mortality was higher in ischemic patients (17.88 vs 2.37/100 patient-years; P<.0001), as was the rate of cardiovascular admissions (24.58 vs 4.14/100 patient-years; P<.0001). The rates of mortality due to heart failure and sudden death were also higher in ischemic patients, at 7.82 vs 0.59/100 patient-years, and 7.82 vs 0.30/100 patient-years, respectively (P<.0001). The higher overall admission rate found in the ischemic group was due to higher rates of admission for heart failure (14.53 vs 0.89/100 patient-years; P<.0001) and acute coronary syndrome (8.94 vs 1.78/100 patient-years; P=.003).nnnCONCLUSIONSnIn terms of prognosis, heart failure with preserved systolic function is not a homogeneous disease entity. Morbidity and mortality rates are higher in patients with an ischemic etiology. Moreover, different mechanisms are involved.

Severe right heart failure due to the combination of Ebstein's anomaly and pericardial constriction.

We present the case of a 52-year-old male, smoker who drinks approximately 60 g of alcohol daily and is under observation for atrial fibrillation and an Ebstein anomaly that was causing massive tricuspid regurgitation (TR) and right heart failure (RHF), treated with diuretics. He was admitted due to a notable clinical worsening with severe ascites. A chest radiograph showed the presence of a left pleural effusion (Figure 1A) and the lateral view demonstrated a sharp line of pericardial calcification, indicating pericardial constriction (Figure 1B, arrow). The pleural effusion proved to be transudative. Following multiple recurrences, a permanent intrapleural catheter was placed to drain the effusions as needed. Analysis of the ascitic fluid indicated that portal hypertension had caused the ascites. Although RHF could have caused it, we first had to ensure that it was not due to cirrhosis. The liver examination using ultrasound and fibroscan was inconclusive, and the laboratory tests (hemoglobin, platelets, creatinine, proteins, coagulation study, transaminases, and bilirubin) came back normal. Lastly, a transjugular liver biopsy showed that it was cirrhosis. The etiological study found no other causes in addition to those proposed a priori (alcohol and congestion), and the clinical, histopathological, and laboratory data indicated that congestion was the primary cause. The echocardiogram still indicated a diagnosis of Ebstein anomaly, and underlined its functional repercussions, the massive TR, and consequent right heart overload, which hindered the evaluation of echocardiographic signs of pericardial constriction. The multislice computerized tomography provided an anatomical definition of the Ebstein anomalies, and revealed extensive calcification of the right pericardium (Figure 2). During the heart catheterization, coronary disease was ruled out LETTERS TO THE EDITOR