Antonio Salvador Sanz

Valor del nivel de NTproBNP en población adulta extrahospitalaria

Introduction. The diagnosis of chronic heart failure (CHF) is based on demonstrating the cardiac origin of clinical manifestations. Echocardiography is the method of choice for the detection of left ventricular systolic dysfunction (LVSD). Brain natriuretic peptide (BNP) rises during LVSD. Objectives. To analyze the plasma concentration of Nterminal brain natriuretic propeptide (NTproBNP) in a general adult population in relation to different spontaneous circumstances and to study its capacity for identifying patients with LVSD. Methods. A cardiological examination was made and plasma NTproBNP levels were measured in a randomized group of 203 people (49-81 years old) from the Community of Valencia. Results. The average NTproBNP concentration was 52.2 ± 98.2 pmol/l. NTproBNP levels varied with age, gender and functional stage (NYHA). The highest NTproBNP values were observed in people who had previously suffered from acute pulmonary edema or who had an ejection fraction (EF) of less than 40%. There was also a significant elevation in patients with nocturnal dyspnea, orthopnea, atrial fibrillation, EF  50%, angina, and ankle edema. The best concentration of NTproBNP for differentiating EF  50% was 37.7 pmol/l, with 92% sensitivity and 68% specificity. Conclusions. The elevation of NTproBNP concentration indicates the cardiac origin of clinical manifestations and serves to select patients for echocardiographic examination. Low NTproBNP concentrations help to rule out LVSD.

Valor pronóstico de la troponina T en pacientes hospitalizados con angina o infarto sin elevación del segmento ST

Introduction and objectives. Cardiac troponins are highly specific and sensitive for detecting minimal myocardial damage. The aim of our study was to determine the prognostic value of troponinT levels in patients hospitalized for suspected angina or myocardial infarction without STsegment elevation. Patients and method. We recorded the frequency of death, acute myocardial infarction, heart failure, or need for coronary revascularization in the three months after the onset of symptoms in 346 consecutive patients admitted for suspected acute coronary syndrome, excluding those who developed myocardial infarction with persistent ST-segment elevation. Results. Serum troponin T levels were ≥ 0.1 ng/ml in 133 patients (troponin T positive group) and lower in 213 patients (troponin T negative group). The relative risk (RR) and 95 percent confidence intervals (95% CI) of individual and grouped events for the troponin T positive group were 3.2 (95% CI, 1.4-7.3; p = 0.006) for death; 2.8 (95% CI, 1.435.51; p = 0.003) for death or myocardial infarction; and 2.8 (95% CI, 1.6-5.0; p < 0.001) for death, myocardial infarction or heart failure. Diabetes mellitus and troponin T levels ≥ 0.1 ng/ml had independent prognostic value after adjusting for age, sex, and electrocardiographic changes; with RR 2.5 (95% CI, 1.01-5.9) for death, myocardial infarction or heart failure. Conclusions. The prognosis of patients hospitalized for chest pain who do not immediately develop transmural necrosis depends on serum troponin T levels at hospital admission. Troponin T levels ≥ 0.1 ng/ml almost triple the risk of major events in the three months after the acute episode. The prognostic value of troponin T is independent of age, sex, presence of diabetes mellitus, and electrocardiographic changes.

Autonomic nervous system dysfunction in advanced systolic heart failure

BACKGROUND An alteration of the autonomic nervous system has been described in heart failure (HF). The aim of this study was to assess, compare and relate the impairment of both arms of the autonomic nervous systems, the sympathetic and parasympathetic (SNS and PNS) in a same group of patients. METHODS We analyzed 23 patients with advanced HF (NYHA III-IV/IV and IV/IV) and EF<35% who were on the waiting list for heart transplantation. We assessed the SNS by determining cardiac uptake of (123)I metaiodobenzylguanidine, and analyzed the heart mediastinum rate (HMR) and the myocardial washout rate (WR). The PNS was assessed by 24-hour Holter ECG recording and subsequent analyses of heart rate turbulence (HRT) in which turbulence onset (TO) and turbulence slope (TS) were determined. RESULTS In the study of the SNS, HMR values were 1.32 ± 0.12, and WR 0.36 ± 0.1. Higher creatinine levels were associated with a lower WR (r=-0.604; p=0.02). In the study of the SNP, TO was higher the lower the LVEF (r=-0.410; p=0.052), and age was associated with a lower TS (r=-0.4; p=0.059). In the study of the relationships between the SNS and PNS, HMR was correlated in a nearly significant manner with TO (r=-0.399; p=0.059) and WR with TS (r=-0.447; p=0.033). CONCLUSIONS In stable patients with advanced HF (NYHA III-IV and IV/IV), a significant and parallel impairment occurs in both arms of the autonomic nervous system. This could have prognostic implications and would help to prioritize patients on the waiting list for heart transplantation.

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

Dosis repetidas de daclizumab para retrasar la instauración del inhibidor de la calcineurina en pacientes con trasplante cardiaco y disfunción renal postoperatoria

Daclizumab is an interleukin-2 receptor antagonist which is used for induction therapy in heart transplant patients. It has few side effects and is associated with a low infection rate. Postoperative renal failure after heart transplantation is common and potentially fatal. The administration of calcineurin inhibitors in the postoperative period can aggravate the situation. We report the cases of six patients who underwent heart transplantation and developed acute renal failure in the immediate postoperative period. All were administered daclizumab weekly to avoid the introduction of calcineurin inhibitors and to facilitate recovery of renal function. Calcineurin inhibitors were introduced only once renal function had improved. Renal function recovered in all cases and there was a low complication rate. The administration of repeated doses of daclizumab to patients who experience acute postoperative renal failure after heart transplantation may provide an alternative therapeutic approach that enables calcineurin inhibitors to be avoided and, consequently, renal function to recover.

Reversal of Protein-Losing Enteropathy After Heart Transplantation in Young Patients

Protein-losing enteropathy is a rare but life-threatening complication that occurs in some patients who develop intestinal lymphangiectasis secondary to increased systemic venous pressure. Although different forms of treatment have been tried, with varying results, the majority were reported to be unsuccessful. The aim of this study was to demonstrate that heart transplantation may be an appropriate therapeutic option for patients who do not respond to medical treatment. At our center, we performed heart transplantations in 3 patients with this condition. The mean follow-up period was 11(2) months. No patient died and the enteropathy regressed in all 3.