Enrique Galve

Intravenous amiodarone in treatment of recent-onset atrial fibrillation: results of a randomized, controlled study.

OBJECTIVES This study was designed to determine the efficacy of intravenous amiodarone in the management of recent-onset atrial fibrillation. BACKGROUND The optimal approach for acute atrial fibrillation has not been established. Amiodarone is a unique antiarrhythmic agent with activity in both supraventricular and ventricular tachyarrhythmias, but its value for the restoration of sinus rhythm in patients with recent-onset atrial fibrillation has not been demonstrated. METHODS Sample size was calculated to detect a 25% increase in reversion rate with amiodarone with a statistical power of 80%. One hundred consecutive patients with recent-onset (<1 week) atrial fibrillation and not taking antiarrhythmic agents were randomized to receive either intravenous amiodarone, 5 mg/kg body weight in 30 min followed by 1,200 mg over 24 h, or an identical amount of saline. Both groups received intravenous digoxin, 0.5 mg initially, followed by 0.25 mg at 2 h and 0.25 mg every 6 h thereafter, to complete 24 h while the ventricular rate was >100 beats/min. Amiodarone and digoxin blood levels were determined. Both groups were homogeneous regarding underlying heart disease, time from onset to treatment, initial ventricular rate and left atrial size. RESULTS By the end of the 24-h treatment period, 34 patients (68%, 95% confidence interval [CI] 53% to 80%) in the amiodarone group and 30 (60%, 95% CI 45% to 74%) in the control group had returned to sinus rhythm (p = 0.532). Mean times (+/-SD) of conversion were 328 +/- 335 and 332 +/- 359 min, respectively (p =0.957). Among patients who did not convert to sinus rhythm, treatment with amiodarone was associated with a slower ventricular rate (82 +/- 15 beats/min in the amiodarone group vs. 91 +/- 23 beats/min in the control group, p = 0.022). After restoration of sinus rhythm, atrial fibrillation recurred during a 15-day follow-up period in 4 (12%) of 34 patients (95% CI 3% to 27%) in the amiodarone group and in 3 (10%) of 30 (95% CI 2% to 26%) in the control group (p = 0.861). CONCLUSIONS Intravenous amiodarone, at the doses used in this study, produces a modest but not significant benefit in converting acute atrial fibrillation to sinus rhythm.

Worldwide perspective of valve disease

Valvar heart disease is a paradigm of the changing aetiology of human disease. In particular, we have witnessed dramatic changes in the incidence of rheumatic heart disease (fig 1); such changes have been limited mostly to industrialised countries, highlighting the role of factors other than microorganisms in this disease. Interestingly, the frequency of valvar heart disease is still high in industrialised countries, as new types of valve disease become increasingly prevalent (fig 2). The most important of them is degenerative valve disease, which relates directly to the increased lifespan of people living in industrialised countries compared to those in developing countries. On the other hand, aetiologies related to the relative wealth of industrialised countries have also appeared, the most dramatic example being valve disease related to appetite suppressant drugs. Figure 1 Changes in the incidence of rheumatic fever. Rheumatic fever increased during the period of the industrial revolution, possibly because of overcrowding in urban areas. Later on, it reached a steady state as living standards began to improve. Finally, in the postindustrial period, the decline in incidence was associated with an easier access to medical care, widespread use of antibiotics, and reduced overcrowding. At the present time, when the disease is considered to be nearly eradicated, isolated outbreaks continue to occur. Figure 2 Evolution of different types of valve disease in the developed world. Rheumatic valve disease has witnessed an abrupt decline, which has been matched in part by an increase in degenerative valve disease, related to aging. Meanwhile, new types of valve disease have emerged, although they account for a minority of all cases in comparison with the old incidence of rheumatic valve disease or the current incidence of degenerative valve disease. Although rheumatic fever was thought to be nearly eradicated from developed countries, it continues to be a challenge because of its …

Pericardial effusion in the course of myocardial infarction: incidence, natural history, and clinical relevance.

Incidence and significance of pericardial effusion in patients with acute myocardial infarction (AMI) have not been established. To evaluate these issues, we studied prospectively 138 consecutive patients with AMI. An echocardiogram was obtained in each 1, 3, and 10 days and 3 and 6 months after admission. Fifty four patients with unstable angina and 57 without heart disease were studied as controls. Echocardiographic diagnostic criteria of pericardial effusion were established from 33 additional patients undergoing surgery. Pericardial effusion was found in 28% of patients with AMI. Twenty-five percent of patients with AMI had pericardial effusion on the third day, vs 8% of patients with unstable angina (p less than .02) and 5% of patients without heart disease (p less than .01). At 1, 3, and 10 days and 3 and 6 months prevalence of pericardial effusion was 17%, 25%, 21%, 11%, and 8%, respectively. There was no case of tamponade. Pericardial effusion was more common in anterior AMI (p less than .02) and in patients with heart failure (p less than .05) but it was not significantly associated with early pericarditis, peak creatine kinase-MB, the level of anticoagulation, or mortality. Thus, pericardial effusion is a common event in patients with AMI (incidence of 28%), but does not result in specific complications. The reabsorption rate of pericardial effusion is slow and, in our experience, mild or moderate pericardial effusion does not preclude heparin therapy.

Late benefits of dual-chamber pacing in obstructive hypertrophic cardiomyopathy: a 10-year follow-up study

Objective To examine the mid-term and long-term outcomes in patients with obstructive hypertrophic cardiomyopathy (HCM) submitted to pacing. Design Prospective, observational study. Setting Single, non-referral centre. Patients and intervention Fifty patients (62±11 years) with HCM refractory to medical treatment, all in New York Heart Association (NYHA) class III or IV, and with a rest gradient >50 mm Hg underwent a dual-chamber pacemaker implantation. Patients were followed-up for up to 10 years (mean 5.0±2.9, range 0.6–10.1). Results During the first year of follow-up, rest gradients decreased (baseline 86±29 mm Hg; 3 months 55±37; l year 41±26; p=0.0001). NYHA class improved, as well as exercise tolerance (baseline 281±112 m; 3 months 334±106 m; 1 year 348±78 m; p<0.0001). The physical and mental components of the quality of life instrument SF-36 also improved. Left ventricular wall thickness remained unchanged, while ejection fraction decreased (baseline 76±10%; 3 months 74±8%; 1 year 66±13%; p=0.002). During the long-term follow-up, an additional reduction in obstruction was found (final rest gradient 28±24 mm Hg, p<0.02). Those patients who did not improve to NYHA class I or II and continued to have obstruction were given other treatments (six, alcohol ablation; three, surgical myectomy). Conclusions Pacing in HCM results in a significant reduction in obstruction, improvement of symptoms and exercise capacity that is progressive and may be achieved after a long period of time. In this series, only 18% of cases needed a more aggressive treatment to relieve residual obstruction and obtain a satisfactory symptomatic status. In conclusion, these results emphasise the need for new controlled studies of pacing with a longer follow-up.

Factores asociados a la falta de control de la hipertensión arterial en pacientes con y sin enfermedad cardiovascular

INTRODUCTION AND OBJECTIVES Hypertension is one of the most prevalent and poorly controlled risk factors, especially in patients with established cardiovascular disease (CVD). The aim of this study was to describe the rate of blood pressure (BP) control and related risk factors. METHODS Multicenter, cross-sectional and observational registry of patients with hypertension recruited from cardiology and primary care outpatient clinics. Controlled BP defined as <140/90 mmHg. RESULTS 55.4% of the 10 743 patients included had controlled BP and these had a slightly higher mean age. Patients with uncontrolled BP were more frequently male, with a higher prevalence of active smokers, obese patients, and patients with diabetes. The rate of controlled BP was similar in patients with or without CVD. Patients with uncontrolled BP had higher levels of blood glucose, total cholesterol, low density lipoproteins and uric acid. Patients with uncontrolled BP were receiving a slightly higher mean number of antihypertensive drugs compared to patients with controlled BP. Patients with CVD were more frequently receiving a renin-angiotensin-aldosterone axis inhibitor: 83.5% vs. 73.2% (P<.01). Multivariate analysis identified obesity and current smoking as independently associated with uncontrolled BP, both in patients with or without CVD, as well as relevant differences between the two groups on other factors. CONCLUSIONS Regardless of the presence of CVD, 55% of hypertensive patients had controlled BP. Lifestyle and diet, especially smoking and obesity, are independently associated with lack of BP control. Full English text available from: www.revespcardiol.org.

Clinical and neurohumoral consequences of diuretic withdrawal in patients with chronic, stabilized heart failure and systolic dysfunction

Loop diuretics are beneficial in heart failure in the short term because they eliminate fluid retention, but in the long‐term, they could adversely influence prognosis due to activation of neurohumoral mechanisms.

Novedades en hipertensión arterial y diabetes mellitus

Las novedades en hipertension arterial (HTA) y diabetes mellitus (DM) del ano 2009 han estado claramente marcadas por los resultados y debates suscitados por el estudio ONTARGET, la publicacion de los primeros ensayos clinicos realizados con aliskiren y los resultados de los estudios que analizaron el control estricto de la glucemia en pacientes con DM. Los resultados de los estudios ONTARGET, TRANSCEND y ACCOMPLISH han mantenido candente el debate sobre la maxima reduccion de la presion arterial y la terapia de tratamiento combinado optima. Ademas, la publicacion de los estudios AVOID y ALLAY ha supuesto una autentica novedad en el tratamiento de la HTA, aportando evidencia de la seguridad y la eficacia de esta familia terapeutica: los inhibidores directos de la renina. En el ano 2009 se ha suscitado un gran debate por la publicacion de diferentes estudios que han puesto en duda el control estricto de la glucemia en pacientes diabeticos; finalmente, se publico un documento de consenso de las sociedades cientificas al respecto que enfatiza el control estricto de los factores de riesgo y la necesidad de minimizar el riesgo de hipoglucemias con tratamientos intensivos en pacientes con alto riesgo.

Diagnóstico y tratamiento de la hipercolesterolemia familiar en España: documento de consenso

Familial hypercholesterolemia (FH) is a common genetic disorder, clinically manifested since birth, and associated with very high levels of plasma LDL-cholesterol (LDL-c), xanthomas, and premature coronary heart disease. Its early detection and treatment reduces coronary morbidity and mortality. Despite effective treatment being available, FH is under-diagnosed and under-treated. Identification of index cases and cascade screening using LDL-c levels and genetic testing are the most cost-effective strategies for detecting new cases and starting early treatment. Long-term treatment with statins has decreased the vascular risk to the levels of the general population. LDL-c targets are < 130 mg/dL for children and young adults, <100mg/dL for adults, and < 70 mg/dL for adults with known coronary heart disease or diabetes. Most patients do not to reach these goals, and combined treatments with ezetimibe or other drugs may be necessary. When the goals are not achieved with the maximum tolerated drug treatment, a reduction ≥ 50% in LDL-c levels can be acceptable. Lipoprotein apheresis can be useful in homozygous, and in treatment-resistant severe heterozygous, cases. This Consensus Paper gives recommendations on the diagnosis, screening, and treatment of FH in children and adults, and specific advice to specialists and general practitioners with the objective of improving the clinical management of these patients, in order to reduce the high burden of coronary heart disease.

Update in Cardiology: Vascular Risk and Cardiac Rehabilitation

Cardiovascular disease develops in a slow and subclinical manner over decades, only to manifest suddenly and unexpectedly. The role of prevention is crucial, both before and after clinical appearance, and there is ample evidence of the effectiveness and usefulness of the early detection of at-risk individuals and lifestyle modifications or pharmacological approaches. However, these approaches require time, perseverance, and continuous development. The present article reviews the developments in 2013 in epidemiological aspects related to prevention, includes relevant contributions in areas such as diet, weight control methods (obesity is now considered a disease), and physical activity recommendations (with warnings about the risk of strenuous exercise), deals with habit-related psychosocial factors such as smoking, provides an update on emerging issues such as genetics, addresses the links between cardiovascular disease and other pathologies such as kidney disease, summarizes the contributions of new, updated guidelines (3 of which have recently been released on topics of considerable clinical importance: hypertension, diabetes mellitus, and chronic kidney disease), analyzes the pharmacological advances (largely mediocre except for promising lipid-related results), and finishes by outlining developments in the oft-neglected field of cardiac rehabilitation. This article provides a briefing on controversial issues, presents interesting and somewhat surprising developments, updates established knowledge with undoubted application in clinical practice, and sheds light on potential future contributions.

Advances in Arterial Hypertension and Diabetes Mellitus

In 2011, the importance of hypertension and diabetes mellitus as the two main risk factors responsible for the development of cardiovascular disease became clear, as did their significance as major public health issues. Compared with previous years, in which publication of the results of large clinical trials dominated scientific progress, in the last year, the focus has shifted to evidence that novel mechanisms associated with blood pressure, glucose metabolism and diabetes can influence cardiovascular disease. Of particular importance were clinical trials in the area of renal dysfunction, such as the SHARP and ROADMAP trials.