Andrés Enríquez

Assessment of Left Atrial Function in Hypertrophic Cardiomyopathy and Athlete's Heart: A Left Atrial Myocardial Deformation Study

Background: Hypertrophic cardiomyopathy (HCM) is a common cause of sudden death in athletes and differentiating this condition from the nonpathological “athletes heart” remains a challenge. The development of pathological left ventricular hypertrophy (LVH) is associated with left atrial (LA) dilatation and dysfunction. LA strain and strain rate by two‐dimensional (2D) speckle tracking are novel indices of LA function and might contribute to differentiate physiological from pathological LVH among athletes with underdiagnosed HCM. Methods: We evaluated 20 patients with nonobstructive HCM, 20 highly trained athletes and 20 healthy controls matched for age, gender, and body surface area. All patients underwent a transthoracic echocardiogram with evaluation of LA strain: s‐wave (LASs); and strain rate: s‐wave (LASRs) and a‐wave (LASRa). Results: LV mass index, LA volume index, and ejection fraction were comparable between patients with HCM and athletes. Patients with HCM had a significantly lower LASs (19 + 8% vs. 43 + 8%, P < 0.01), LASRs (0.7 + 0.2 s‐1 vs. 1.6 + 0.2 s‐1, P < 0.01), and LASRa (–0.8 + 0.1 s‐1 vs. –1.4 + 0.3 s‐1, P < 0.01) compared to athletes. Among hypertrophic subjects, independent predictors of hypertrophy related to HCM were LASs and E/é ratio. Conclusions: LA myocardial deformation is significantly impaired in patients with HCM compared to athletes and healthy controls. LA strain and strain rate assessed by 2D speckle tracking should be incorporated in the evaluation of trained athletes with LVH and LA dilatation.

Effects of trimetazidine in nonischemic heart failure: a randomized study.

OBJECTIVES Heart failure (HF) is associated with changes in myocardial metabolism that lead to impairment of contractile function. Trimetazidine (TMZ) modulates cardiac energetic efficiency and improves outcomes in ischemic heart disease. We evaluated the effects of TMZ on left ventricular ejection fraction (LVEF), cardiac metabolism, exercise capacity, O2 uptake, and quality of life in patients with nonischemic HF. METHODS AND RESULTS Sixty patients with stable nonischemic HF under optimal medical therapy were included in this randomized double-blind study. Patients were randomized to TMZ (35 mg orally twice a day) or placebo for 6 months. LVEF, 6-minute walk test (6MWT), maximum O2 uptake in cardiopulmonary exercise test, different markers of metabolism, oxidative stress, and endothelial function, and quality of life were assessed at baseline and after TMZ treatment. Left ventricular peak glucose uptake was evaluated with the use of the maximum standardized uptake value (SUV) by 18-fluorodeoxyglucose positron emission tomography ((18)FDG-PET). Etiology was idiopathic in 85% and hypertensive in 15%. Both groups were similar in age, functional class, LVEF, and levels of N-terminal pro-B-type natriuretic peptide at baseline. After 6 months of TMZ treatment, no changes were observed in LVEF (31 ± 10% vs 34 ± 8%; P = .8), 6MWT (443 ± 25 m vs 506 ± 79 m; P = .03), maximum O2 uptake (19.1 ± 5.0 mL kg(-1) min(-1) vs 23.0 ± 7.2 mL kg(-1) min(-1); P = .11), functional class (percentages of patients in functional classes I/II/III/IV 10/3753/0 vs 7/40/50/3; P = .14), or quality of life (32 ± 26 points vs 24 ± 18 points; P = .25) in TMZ versus placebo, respectively. In the subgroup of patients evaluated with (18)FDG-PET, no significant differences were observed in SUV between both groups (7.0 ± 3.6 vs 8.2 ± 3.4 respectively; P = .47). CONCLUSIONS In patients with nonischemic HF, the addition of TMZ to optimal medical treatment does not result in significant changes of LVEF, exercise capacity, O2 uptake, or quality of life.

Four-Limb Acute Ischemia Induced by Ergotamine in an AIDS Patient Treated With Protease Inhibitors

A 32-year-old man infected with HIV presented to the emergency department of our hospital reporting pain, coldness, paresthesias, and cyanosis in both feet and hands. The symptoms had started 3 days before, with lower extremities claudication at 200 m, which progressed to rest pain the day of admission; it was worse on the right foot. He was on chronic antiretroviral therapy with 300 mg QID tenofovir (Viread), 300 mg BID abacavir (Ziagen), and two 200/50 mg BID lopinavir/ritonavir (Kaletra). His CD4 cell count was 245 cells/mm and his HIV viral load was 45 copies/mL. When directly interviewed, the patient remembered that he had taken a single dose of ergotamine (1 mg) for migraine 24 hours before the onset of symptoms. He denied any recent drug intake. On examination, his 4 extremities were cold, cyanotic, and pulseless (Figure 1A). Only femoral pulses were weakly palpable. Plethysmography revealed bilateral multilevel ischemia, with severe proximal disease …

Cambios en el pronóstico a largo plazo de la hipertensión arterial pulmonar

BACKGROUND Pulmonary artery hypertension (PAH) is a progressive disease with high mortality. Major advances had been made in the treatment of this condition during the last decade. AIM To characterize the clinical evolution and mortality of a cohort of Chilean patients. MATERIAL AND METHODS Seventeen patients with PAH diagnosed in the last 10 years in two Chilean hospitals were enrolled. Measurements at diagnosis included hemodynamic variables and 6-minute walk test. The patients were followed clinically for 3 years and the observed mortality was compared with that predicted by the prognostic equation proposed by the historic registry of the National Institutes of Health (NIH). RESULTS The mean age of patients was 45 years and 80% had an idiopathic PAH. The mean median pulmonary artery pressure was 57 ± 15 mmHg, the cardiac index was 2.4 ± 0.7 l/min/m² and the right atrial pressure was 12 ± 8 mmHg. The 6-minute walk distance was 348 ± 98 m. All patients received anticoagulants. Eighty two percent received ambrisentan, 12% received bosentan, 29% received iloprost and 24% sildenafil. At the end of follow-up only 3 patients had died, with an observed survival rate of 88, 82 and 82% at 1, 2 and 3 years, respectively. In contrast, the survival calculated according to the predictive formula of the NIH was 67, 56 and 45%, respectively. Among surviving patients, an improvement in exercise capacity was observed after one year (p < 0.05). CONCLUSIONS The observed survival rate was significantly better than that estimated according to historical data. Furthermore, therapy was associated with an improvement in functional capacity after one year. This prognostic improvement is consistent with data of other contemporary registries published after the NIH Registry.

Acute Necrotizing Eosinophilic Myocarditis Presenting as ST-Elevation Myocardial Infarction: A Case Report

Eosinophilic myocarditis (EM) is a rare disease. The spectrum of clinical presentation is wide and it is often fatal if left untreated. We report a case of eosinophilic myocarditis manifesting as ST-elevation myocardial infarction (STEMI) with cardiogenic shock treated successfully with steroids. This diagnosis should always be considered in patients with an acute coronary syndrome and normal coronary arteries, especially in the presence of a history of allergies, asthma or peripheral eosinophilia.

Relationship between mechanical and metabolic dyssynchrony with left bundle branch block: evaluation by 18-fluorodeoxyglucose positron emission tomography in patients with non-ischemic heart failure.

BACKGROUND Ventricular dyssynchrony is a common finding in patients with heart failure (HF), especially in the presence of conduction delays. The loss of ventricular synchrony leads to progressive impairment of contractile function, which may be explained in part by segmental abnormalities of myocardial metabolism. However, the association of these metabolic disarrangements with parameters of ventricular dyssynchrony and electrocardiography (ECG) findings has not yet been studied. METHODS Our aim was to determine the correlation between the presence of left bundle branch block (LBBB) with left ventricular (LV) mechanical synchrony assessed by multiple-gated acquisition scan (MUGA) and with patterns of 18-fluorodeoxyglucose (18FDG) uptake in patients with non-ischemic heart failure. Twenty-two patients with non-ischemic cardiomyopathy, LV ejection fraction (LVEF) ≤45% and New York Heart Association (NYHA) Functional Class II or III symptoms under standard medical therapy were included, along with 10 healthy controls matched for age and gender. A 12-lead ECG was obtained to measure the length of the QRS. Mechanical LV synchrony was assessed by MUGA using phase analysis. All patients and controls underwent positron emission tomography with 18FDG to determine the distribution of myocardial glucose uptake. The standard deviation of peak (18)FDG uptake was used as an index of metabolic heterogeneity. Students t-test and Pearsons correlation were used for statistical analysis. RESULTS The mean age of the patients with HF was 54 ± 12 years and 72% were male. The length of the QRS was 129 ± 31 milliseconds and LBBB was present in 9 patients. Patients with HF had decreased LV 18FDG uptake compared with controls (7.56 ± 3.36 vs. 11.63 ± 4.55 standard uptake value; p = 0.03). The length of the QRS interval correlated significantly with glucose uptake heterogeneity (r = 0.62; p = 0.002) and mechanical dyssynchrony (r = 0.63; p = 0.006). HF patients with LBBB showed marked glucose uptake heterogeneity compared with HF patients without LBBB (41.4 ± 10 vs 34.7 ± 4.9 ml/100 g/min, respectively; p = 0.01). CONCLUSIONS Patients with non-ischemic heart failure exhibit a global decrease in myocardial glucose uptake. Within this group, subjects who also have LBBB exhibit a marked heterogeneity in segmental glucose uptake, which directly correlates with QRS duration.

Feocromocitoma :presentación como síndrome coronario agudo: Reporte de un caso

The typical symptoms of pheochromocytoma are palpitations, sweating, headaches and hypertension. We report a 70-year-old female admitted to the hospital due to a sudden onset of precordial pain with electrocardiographic changes. After admission the patient evolved with recurrent chest pain accompanied by hypertensive paroxysms and a pheochromocytoma was suspected. Measurement of catecholamines and metanephrines confirmed the diagnosis and an abdominal magnetic resonance localized the tumor. The patient underwent surgery with successful removal of the pheochromocytoma and was discharged in good conditions.

Terapia de resincronización en pacientes con insuficiencia cardiaca: experiencia acumulada de 10 años

BACKGROUND Multiple randomized trials support the clinical benefits of cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and ventricular dyssynchrony. Since the year 2000 this therapy has been increasingly used in Chile. AIM To describe the clinical characteristics and follow-up of HF patients undergoing CRT in a single Chilean university hospital during the last 10 years. PATIENTS AND METHODS All patients undergoing CRT between 2000 and 2010 in our university hospital were included. Clinical and echocardiographic data were extracted from medical records and mortality causes were obtained from the National Identification Service. RESULTS A total of 252 patients underwent CRT during the study period. Seventy five percent were in New York Heart Associatin (NYHA) functional class III and mean ejection fraction was 29 ± 10%. Complete left bundle branch block was present in 55% and 20% had permanent atrial fibrillation (AF). Mean survival was 86% at 1 year and 82% of patients in NYHA class III-IV improved at least one functional class. Survival was poorer in patients with ischemic etiology (hazard ratio (HR) 1.48), functional class IV (HR 2.2), right bundle branch block (RBBB) (HR 3.1) and AF (HR 3.4). No survival differences were observed between patients with and without an implanted cardiodefibrillator. CONCLUSIONS This series show good clinical outcomes, comparable to those reported in randomized trials. Predictors of worse survival included an ischemic etiology, functional class IV, RBBB and AF. Patients with a defibrillator had no better survival, which could be relevant in countries with limited health care resources.

Tormenta eléctrica en síndrome de Brugada tratada exitosamente con infusión de isoproterenol

We report A 22 years old male who experienced several episodes of syncope within a time frame of few hours. In the emergency room, multiple ventricular fibrillation episodes where documented along with a type 1 Brugada ECG pattern. Isoproterenol in continuous infusion was started, which normalized the ECG pattern and avoided the recurrence of arrhythmias. The patient was implanted with an automated defibrillator and discharged 3 days after admission.We report a 22-year-old male who experienced several episodes of syncope within a timeframe of few hours. In the emergency room, multiple ventricular fibrillation episodes where documented along with a type 1 Brugada ECG pattern. Isoproterenol in continuous infusion was started, normalizing the ECG and avoiding further arrhythmia recurrences. The patient was implanted with an automated defibrillator and discharged 3 days after admission.

Strain y Strain rate auricular izquierdo evaluado por speckle tracking está relacionado a PCR ultrasensible en adolescentes obesos

Resumen:Introduccion: La obesidad y el sindrome metabolico estan asocia-dos a un tamano auricular izquierdo (AI) aumenta-do y mayor riesgo cardiovascular. El strain y strain rate longitudinal determinado por speckle tracking son herramientas novedosas en la evaluacion de la funcion AI. Objetivo: evaluar el strain y strain rate AI en ado-lescentes obesos y su relacion con biomarcadores de riesgo cardiovascular. Metodos: se incluyeron adolescentes consecutivos con un z-indice de masa corporal (z-IMC) > 1 en rit-mo sinusal sin otra comorbilidad y un grupo control pareado por edad y sexo. Se registraron las caracteris-ticas clinicas y ecocardiograficas con evaluacion del strain AI: onda s (LASs), onda a (LASa) y strain rate AI: onda s (LASRs), onda a (LASRa) por speckle tracking. Se midio adiponectina y PCR ultrasensible. Se utilizo t-Student, chi-cuadrado y correlacion de Pearson. Resultados: Se incluyeron 15 sujetos por grupo de edad promedio de 13 anos, 47% hombres sin diferen-cia entre ambos grupos. Los pacientes con sobrepeso presentaron significativamente mayores niveles de PCR us respecto del grupo control, 0,5 ± 0,1 mg/L vs 1,4 ± 0,3, p = 0,04 y menores de LASs (44 ± 1,8 vs 32 ± 1,1%;p<0,01), LASa ( -1,7 ± 0,3 vs -0,7 ± 0,3 1/s; p<0,01), LASRs ( 1,7 ± 0,07 vs 1,3 ± 0,03%; p<0,01), LASRa (-1,8 ± 0,1 vs -1,2 ± 0,08 1/s;p<0,01). En el grupo con sobrepeso se encontro una correlacion negativa significativa entre LASs, LASRs y PCR ul-trasensible (R: -0,62; p < 0,01 y R: -0,58: p = 0,02 respectivamente).