Ángel M. Alonso Gómez

Comentarios a la guía de práctica clínica de la ESC para el manejo del infarto agudo de miocardio en pacientes con elevación del segmento ST

The European Society of Cardiology (ESC) guidelines are endorsed by the Spanish Society of Cardiology (SEC) and translated into Spanish for their publication in the Revista Española de Cardiología. Under the policy introduced in 2011, each new guideline is accompanied by an article that formulates comments in accordance with the objectives and methodology recommended in the article that established the Guidelines Committee of the SEC.1 In the present article, we discuss the new European guidelines for ST-segment elevation acute myocardial infarction (STEMI).2 The Guidelines Committee established a work group composed of members proposed by the Ischemic Heart Disease, Hemodynamics, Clinical Cardiology, Heart Failure, and Geriatric Cardiology work groups. As a general comment, we consider that the present guidelines introduce highly interesting developments and that the topics are dealt with clearly and in detail. However, we should also point out that it contains 157 recommendations, 69 (44%) of which are accompanied by level C evidence (expert consensus), predominantly in the sections on in-hospital management, heart failure, and complications, fields in which there thus remains ample room for individualization and progress in clinical research. In applying them, we should not forget that the guidelines themselves remind us that the level A and B recommendations are based on clinical trials, and that even these results are open to interpretation. The different therapeutic options could be influenced by the available resources. Thus, it will be increasingly necessary to perform cost-efficiency studies that aid us in choosing among the different strategies. For the purpose of making the article more readable and to highlight the most relevant or novel aspects, as well as those that are not made clear or are not addressed, we have summarized them in Tables 1 and 2, respectively.

Comentarios a la guía de práctica clínica de la ESC para el manejo del síndrome coronario agudo en pacientes sin elevación persistente del segmento ST. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

doi: 10.1016/j.rec.2011.12.004 The new guidelines for the management of acute coronary syndrome in patients without persistent ST-elevation (NSTE-ACS),1 prepared in 2011 by the European Society of Cardiology (ESC), have been accepted by the Spanish Society of Cardiology (SEC) and translated to Spanish for publication in their entirety in the Revista Española de Cardiología2. As a support tool for the implementation of these guidelines, and in accordance with the new SEC policy for clinical practice guidelines,3 this editorial discusses the innovations and new recommendations in these guidelines and evaluates some aspects considered to be controversial, so as to facilitate the implementation of the new guidelines in our field.

Comentarios a la guía de práctica clínica de la ESC sobre prevención de la enfermedad cardiovascular (versión 2012). Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

As proposed by the SEC clinical practice guidelines committee, the Hypertension and Preventive Cardiology and Rehabilitation sections selected a group of CVD prevention experts to review the ESC guidelines published in 2012 and translated in REVISTA ESPAÑOLA DE CARDIOLOGÍA. Their objective was to discuss the contents and appropriacy of the guidelines, analyze the method and highlight issues considered innovative, positive or questionable, as well as any left with no comment. The guidelines were divided into 5 parts and each was independently commented on by 2 experts. Based on their opinions, a document was prepared and, in turn, reviewed and approved by a group of experts designated by the SEC sections involved. All the experts have declared their conflicts of interest, which are stated in detail at the end of this article.

Comentarios a la guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de las enfermedades arteriales periféricas. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

doi: 10.1016/j.rec.2011.12.003 The European Society of Cardiology (ESC) has released its first guidelines for the diagnosis and treatment of peripheral artery disease (PAD)1,2, excluding aortic disease. This editorial provides comments on this guideline, based on the recently established criteria of the Spanish Society of Cardiology (SEC).3 Atherosclerosis is a pathological process that affects the entire vascular system, although it predominantly manifests in specific organs. The risk factors for this condition are common, and the primary and secondary prevention measures are useful for the various vascular areas. This requires that we not only diagnose and treat the primary disease, but also explore the rest of the vascular system. This, then, is an important guideline for cardiologists, since it addresses the need to understand and analyze coronary patients using a global approach that goes beyond the cardiac disease.

Miocarditis de células gigantes simulando un infarto de miocardio apical

Se presenta el caso de un varon de 57 anos con miocarditis de celulas gigantes que comenzo como una taquicardia ventricular polimorfa sostenida, en un contexto interpretado como infarto de miocardio apical antiguo, con posterior evolucion hacia la insuficiencia cardiaca refractaria, necesitando finalmente de trasplante ortotopico urgente. Se comentan las caracteristicas de esta forma de miocarditis infrecuente y de mal pronostico y el resultado de las exploraciones complementarias que llevaron a un diagnostico incorrecto en este paciente.

Comentarios a la guía de práctica clínica de la ESC para el tratamiento de las enfermedades cardiovasculares durante el embarazo. Una visión crítica desde la cardiología española

doi: 10.1016/j.rec.2011.12.002 Along the lines of the new philosophy regarding clinical practice guidelines established by the Executive Committee of the Sociedad Española de Cardiología (SEC: Spanish Society of Cardiology), described and explained in an article recently published in Revista Española de Cardiología (REC),1 a document has been drafted to provide the framework for the discussion of the most important and novel aspects of the guidelines for the treatment of cardiovascular diseases during pregnancy, issued by the European Society of Cardiology (ESC) and endorsed by other European scientific societies.2 In the Spanish cardiology setting, the clinical practice recommendations concerning the subject of heart disease and pregnancy were set forth in the document “Guías de práctica clínica de la Sociedad Española de Cardiología en la gestante con cardiopatía” (Practice Guidelines of the Spanish Society of Cardiology for the Management of Cardiac Disease in Pregnancy), published in 2000,3 and the Sociedad Española de Ginecología y Obstetricia (Spanish Society of Gynecology and Obstetrics) designed a protocol for heart diseases and pregnancy (available at www.prosego.com). More recently, valuable contributions have appeared in our scientific literature,4,5 but there has been a need for an update of guidelines encompassing the body of knowledge that has been consolidated over the past decade. METHODS

II. Papel de la ecocardiografía Doppler en el manejo de la cardiopatía isquémica crónica

La ecocardiografia Doppler permite identificaranomalias regionales y globales de la contractilidaddel ventriculo izquierdo de una forma rapida,sencilla e incruenta, por lo que se puede considerarel metodo de mayor aplicabilidad para este fin dentrode las tecnicas de imagen. En este documentose ha revisado el papel de la ecocardiografia Doppleren el manejo de la cardiopatia isquemica, tantopara el estudio de la funcion global y regional ensituacion basal, como en las aplicaciones derivadasde su uso durante una sobrecarga. Se analizan lastecnicas habituales de ecocardiografia de estrespara el diagnostico de la enfermedad coronaria, asicomo su utilidad en el estudio de la viabilidad miocardica,estableciendo una serie de recomendacionespara el uso de la tecnica en la practica clinica.

Valor del Doppler de esfuerzo para el diagnóstico de la estenosis mitral severa

Introduccion En la estenosis mitral, el ejercicioproduce un aumento en el gasto y la frecuencia cardiacos,lo que condiciona el incremento en el gradientetransmitral. Sin embargo, no esta establecidoen la estenosis mitral severa el nivel quealcanzan los gradientes al esfuerzo y si el incrementodel gradiente con el esfuerzo es diferente alde las estenosis no severas. Objetivos Evaluar la respuesta al esfuerzo, enpacientes con estenosis mitral severa, de los gradientesen valores absolutos y el incremento conrespecto a los valores basales. Metodos A 48 pacientes con estenosis mitral(edad media: 48,8 ± 11 anos) se les realizaron 50Doppler de esfuerzo sobre cicloergometro en decubito(dos estadios con incrementos de 25 watioscada 3 minutos), obteniendose el gradiente pico ymedio mitral por Doppler continuo ciego. Catorceindividuos con protesis de Bjork mitral normofuncionante,de edad media 50 ± 6 anos, realizarontambien el protocolo. Resultados Se definio un perfil hemodinamicode severidad con los datos de 18 pacientes cuyaarea mitral basal era menor de 1,2 cm2 (grupo I),comparandolos con los datos de los 32 estudios conestenosis mitral de area mayor de 1,1 cm2 (grupoII) y los pacientes con protesis mitral (grupo III).El gradiente medio mitral (mmHg) en el grupo Ifue mayor que en el grupo II en situacion basal (9,3± 3,2 frente a 6,6 ± 2,7; p Conclusiones El Doppler de esfuerzo permite definirun perfil hemodinamico diferente en los pacientescon estenosis mitral severa, y puede utilzarsezarsecomo indicador aislado de severidad en la estenosismitral.

Comments on the ESC guidelines on the management of valvular heart disease (version 2012). A report of the Task Force of the Clinical Practice Guidelines Committee of the Spanish Society of Cardiology.

A task force was formed consisting of experts from different fields. Members of the task force were proposed by the SEC Clinical Cardiology, Cardiac Catheterization, and Cardiac Imaging sections and by the SECTCV (Spanish Society of Thoracic and Cardiovascular Surgery). The Task Force was coordinated by 2 representatives of the CGPC. The guidelines were divided into blocks and sent to members of the Task Force, who analyzed the most novel and important aspects in terms of clinical practice. They also gave their opinion on the methodology used, possible areas of conflict, and limitations with regard to other guidelines. In addition, they were asked to describe the implications for actual practice in the Spanish setting. The information received was used to produce a first draft of the document, which the original committee evaluated before referring it to a second group of 11 reviewers also proposed by sections of the SEC and the SECTCV. All authors and reviewers were asked to disclose any conflicts of interest, details of which are provided at the end of the article.

Miocardiopatía hipertrófica apical con obstrucción medioventricular y necrosis apical

517 Paciente de 83 anos que ingreso por cuadro de reagudizacion infecciosa de limitacion cronica al flujo aereo (LCFA), complicado con insuficiencia respiratoria aguda severa que preciso ventilacion mecanica. Durante su ingreso se observo curva de elevacion enzimatica de fraccion MB de la creatincinasa junto con cambios en la polaridad de la onda T, que se hizo difusamente negativa. Al realizarse un posterior estudio ecocardiografico se objetivo acinesia apical localizada, con un gradiante medioventricular en el Doppler color cuya causa no se podia definir con exactitud. Con la inyeccion de contraste ecografico se pudo aclarar que existia una obstruccion medioventricular por hipertrofia parietal, y se establecio el diagnostico de miocardiopatia hipertrofica apical con obstruccion medioventricular y necrosis apical. El estudio con resonancia magnetica corroboro dicho diagnostico. IM A G E N E S E N CA R D I O L O G I A