Irene Marín

Use of Irbesartan to Maintain Sinus Rhythm in Patients With Long-Lasting Persistent Atrial Fibrillation A Prospective and Randomized Study

Background—Data from studies of angiotensin-converting enzyme inhibitors provide evidence that the renin-angiotensin-aldosterone system plays a role as a mediator of atrial remodeling in atrial fibrillation. The present study has evaluated the effect of treatment with the angiotensin I type 1 receptor blocker irbesartan on maintaining sinus rhythm after conversion from persistent atrial fibrillation. Methods and Results—To be included in the present study, patients must have had an episode of persistent atrial fibrillation for >7 days. The patients were then randomized and scheduled for electrical cardioversion. Two groups of patients were compared: Group I was treated with amiodarone, and group II was treated with amiodarone plus irbesartan. The primary end point was the length of time to a first recurrence of atrial fibrillation. From a total of 186 patients assessed in the study, 154 were analyzed with the use of intention-to-treat analysis. Seventy-five patients were randomly allocated to group I and 79 to group II. After 2 months of follow-up in the intention-to-treat analysis, the group treated with irbesartan had fewer patients with recurrent atrial fibrillation (Kaplan-Meier analysis, 84.79% versus 63.16%, P =0.008). The Kaplan-Meier analysis of time to first recurrence during the follow-up period (median time, 254 days [range, 60 to 710]) also showed that patients treated with irbesartan had a greater probability of remaining free of atrial fibrillation (79.52% versus 55.91%, P =0.007). Conclusions—Patients treated with amiodarone plus irbesartan had a lower rate of recurrence of atrial fibrillation than did patients treated with amiodarone alone.

Use of Irbesartan to Maintain Sinus Rhythm in Patients With Long-Lasting Persistent Atrial Fibrillation

Background— Data from studies of angiotensin-converting enzyme inhibitors provide evidence that the renin-angiotensin-aldosterone system plays a role as a mediator of atrial remodeling in atrial fibrillation. The present study has evaluated the effect of treatment with the angiotensin I type 1 receptor blocker irbesartan on maintaining sinus rhythm after conversion from persistent atrial fibrillation. Methods and Results— To be included in the present study, patients must have had an episode of persistent atrial fibrillation for >7 days. The patients were then randomized and scheduled for electrical cardioversion. Two groups of patients were compared: Group I was treated with amiodarone, and group II was treated with amiodarone plus irbesartan. The primary end point was the length of time to a first recurrence of atrial fibrillation. From a total of 186 patients assessed in the study, 154 were analyzed with the use of intention-to-treat analysis. Seventy-five patients were randomly allocated to group I an...

The role of angiotensin receptor blockers and/or angiotensin converting enzyme inhibitors in the prevention of atrial fibrillation in patients with cardiovascular diseases: meta-analysis of randomized controlled clinical trials

The inhibition of the renin‐angiotensin system has demonstrated both experimental and clinical effects in preventing atrial fibrillation. However, there is still uncertainty about the role of these drugs in clinical practice. The objective of this review has been to assess the effects of angiotensin II type‐1 receptor blockers (ARBs) and/or angiotensin converting enzyme inhibitors (ACEIs) for preventing atrial fibrillation. We searched the Cochrane controlled Trials Register (Cochrane Library Issue 4, 2002), MEDLINE (January 1980 to November 2003), EMBASE (January 1980 to November 2003) and reference list of articles. We also contacted manufacturers and researchers in the field. Selection criteria: We conducted a meta–analysis of all randomized controlled clinical trials that compared ARBs and/or ACEIs with either placebo or conventional therapy in patients with either hypertension, heart failure, ischemic heart disease, or diabetes mellitus. The pooled outcome was the development of new onset atrial fibrillation. Two reviewers independently assessed trial quality and extracted data. In some cases, the study authors were contacted for additional information. Seven trials involving a total of 24,849 patients were included (11,328 randomized to active therapy and 13,521 to control). There was a significant statistical difference in the pooled development of atrial fibrillation between the treatment and control group. (OR, 0.57; 95% CI, 0.39 to 0.82); test for overall effect z = 2.98 P = 0.003). Treatment with ACEIs/ARBs markedly reduces the risk of development or recurrence of atrial fibrillation.

Resincronización cardíaca en la insuficiencia cardíaca: bases, métodos, indicaciones y resultados

98 La insuficiencia cardíaca es una de las enfermedades más prevalentes en los países desarrollados. El pronóstico de los pacientes con insuficiencia cardíaca avanzada es todavía malo, a pesar de que en las últimas décadas se han investigado nuevas terapias para mejorar la calidad de vida y la supervivencia de estos enfermos. Por otra parte, hasta el 30% de los pacientes con insuficiencia cardíaca avanzada presenta alteraciones de la conducción intraventricular, lo que condiciona una asincronía en la contractilidad normal del ventrículo que deteriorará la función cardíaca. Mediante la terapia de estimulación cardíaca con resincronización se puede conseguir una mayor sincronía en la contractilidad ventricular. Numerosos estudios han demostrado el beneficio que produce la terapia de estimulación biventricular en la mejora de los parámetros hemodinámicos, la calidad de vida, el test de los 6 min y la clase funcional en pacientes con insuficiencia cardíaca, disfunción sistólica ventricular y retraso de la conducción intraventricular. Algunos estudios han demostrado una mayor supervivencia en los pacientes tratados con resincronización y desfibrilador. Todavía quedan bastantes interrogantes por resolver sobre los efectos de la terapia de resincronización cardíaca, el lugar de estimulación y el tipo de dispositivo a implantar (desfibrilador o marcapasos).

Usefulness of Brain Natriuretic Peptide to Evaluate Patients With Heart Failure Treated With Cardiac Resynchronization

INTRODUCTION AND OBJECTIVES The aim of the present study was to document the evolution of the blood levels of brain natriuretic peptide (BNP) in patients with heart failure and their correlation with the clinical course after implantation of a biventricular pacemaker. PATIENTS AND METHOD Twenty-eight patients with heart failure associated to left bundle branch block and left ventricular systolic dysfunction were included in the study. In each patient we performed laboratory tests, chest X-ray, electrocardiogram and echocardiogram, and measured blood levels of BNP. RESULTS During follow-up (10 [6] months) functional capacity improved, decreasing from 3.3 (0.6) to 2.10 (0.4) (P=.03). The rate of hospitalizations for heart failure decreased from an average of 1.8 (0.7) (6 months before the procedure) to 0.8 (0.3) (6 months after the procedure; P=.04). The basal value of BNP decreased from 193 (98) pg/mL to 52 (14) at the end of the follow-up in the responder group (22 patients) and increased from 564 (380) to 650 (80) pg/mL in the nonresponder group (6 patients). Patients who responded showed significant clinical improvement and decreasing levels of BNP, which reached a plateau an average of 6 months after implantation. Multivariate logistic regression analysis identified lower levels of BNP, idiopathic dilated cardiomyopathy, and functional class as independent predictors of response to therapy. Age, QRS width and left ventricular ejection fraction were not predictors of response. CONCLUSIONS Brain natriuretic peptide concentrations allowed us to monitor, in an objective manner, the clinical course of patients with biventricular resynchronization therapy.

El fenotipo «hipertrigliceridemia-cintura abdominal aumentada» es un factor de riesgo de aterosclerosis subclinica en pacientes con infeccion por el virus de la inmunodeficiencia humana

BACKGROUND AND OBJECTIVE To study the association between hypertriglyceridemic waist phenotype and the presence of subclinical atherosclerosis in human immunodeficiency virus (HIV) infected patients. PATIENTS AND METHODS Cross sectional study. Hypertriglyceridemic waist phenotype was considered if the waist was ≥90cm and triglycerides ≥2.0mmol/l (178mg/dl) in men and ≥85cm and ≥1.5mmol/L (133mg/dl) in women, respectively. We used the intima-media thickness (IMT) to detect carotid subclinical atherosclerosis. RESULTS We analyzed 152 patients, of whom 128 (84.2%) were receiving antiretroviral therapy, 40.7% were receiving protease inhibitors and 38.1% were treated with non-nucleoside reverse transcriptase inhibitors. The prevalence of hypertriglyceridemic waist phenotype was 23.6% (95% confidence interval [CI] 16.8-30.3%). Patients with hypertriglyceridemic waist phenotype had higher cardiovascular risk according to the Framingham score (11.09 [7.6] vs 3.88 [4], P=0.001) and lipodystrophy (33.3 vs. 13.7%, P=0.032) and metabolic syndrome (69.4 vs. 1.9%, P<0.001) were more frequent. The IMT was elevated in 21 (13.8%) patients. Hypertriglyceridemic waist phenotype (odds ratio [OR] 4.66 [95%CI 1.05-20.6; P = 0.043]) and metabolic syndrome (OR 3.74 [95%CI 1.25-11.23; P = 0.018]) were independently associated with higher IMT. CONCLUSIONS The hypertriglyceridemic waist phenotype is a risk factor for subclinical atherosclerosis in HIV infected patients and it is useful to detect patients with lipodystrophy, metabolic syndrome and high cardiovascular risk.

Improvement of endothelial function after switching previously treated HIV-infected patients to an NRTI-sparing bitherapy with maraviroc.

Nucleoside reverse transcriptase inhibitor (NRTI) is associated with endothelial dysfunction and proinflammatory effects. Maraviroc (MVC) is an antagonist of CCR5 receptor. CCR5 is the receptor of RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted), a mediator of chronic inflammation and endothelial function. Our aim was to evaluate the maintenance of viral suppression and improvement of endothelial function in virologically suppressed HIV‐infected patients switched to an NRTI‐sparing combined antiretroviral therapy (cART) with MVC.

The CD4:CD8 ratio is associated with IMT progression in HIV-infected patients on antiretroviral treatment

Inversion of the CD4:CD8 ratio (<1) has been identified as a hallmark of immunosenescence and an independent predictor of mortality in the general population. We aimed to assess the association between the CD4:CD8 ratio and intima‐media thickness (IMT) progression in treated HIV‐infected patients as a marker of early atherosclerosis.

High Prevalence of Subclinical Atherosclerotic Disease in Spanish HIV-Infected Patients with Low Cardiovascular Risk

Dear Editor: Patients with HIV infection have an increased mortality, largely attributable to cardiovascular disease (CVD). In addition to traditional and not traditional cardiovascular risk factors, HIV infection and antiretroviral therapy (ART) have also been implicated in the premature development of atherosclerosis and coronary heart disease. There is the need to stratify the risk of coronary events in HIV patients. Framingham risk score is an extensively studied index to predict cardiovascular risk in the general population. It includes current smoking status, gender, age, cholesterol concentrations and blood pressure, and estimates the risk of coronary events by stratifying individuals into three risk categories: low ( < 10% risk of an event in 10 years), intermediate (10– 20%), and high ( > 20%). Framingham risk score could underestimate prediction in HIV-infected patients because there are many aspects that contribute to it. A inflammatory reaction associated with HIV infection may play a role in the atherosclerotic process. In addition, ART is associated with metabolic abnormalities that increase cardiovascular risk. Endothelial dysfunction and increased intima medial thickness (IMT) are considered an early event in the development of atherosclerosis. In general population have shown to correlate with coronary atherosclerosis, and have been directly associated with an increased risk of myocardial infarction and stroke in older adults without a history of CVD. We aimed to investigate whether Framingham risk score predict subclinical atherosclerotic disease (SAD) in HIV infected patients with low cardiovascular risk. We also studied the prevalence of SAD, the association of SAD with cardiovascular risk factors and HIV-related factors, and its relationship with plasma levels of several proatherosclerotic biomarkers. The study was conducted at the HIV outpatient clinic of the University Hospital Reina Sofia of Murcia, Spain. Consecutive healthy HIV-infected adults visiting from January 2009 to June 2009 were invited to participate. The investigation was approved by the Ethics Committee for Clinical Research and the patients’ informed consent was obtained. Details were taken for age, HIV transmission category, stage of HIV infection according to Center for Disease Control and Prevention (CDC) criteria, duration of ART, current antiretroviral medication, coinfection with hepatitis B or C virus, cardiovascular risk factors and pharmacologic treatment of dyslipidemia, diabetes, or hypertension. Blood samples were collected after an 8-h overnight fast for measurement of glycemia, total cholesterol, high-density lipoprotein (HDL) cholesterol, direct low-density lipoprotein (LDL) cholesterol, triglycerides, creatinine, insulinemia, CD4 + T-cell count, and HIV plasma viral load. An additional sample was processed by centrifugation. Plasma aliquots obtained were stored at 80 C. All frozen samples were subsequently defrosted and plasma levels of several proatherosclerotic biomarkers were simultaneously measured. More precisely, we determined levels of vascular cell adhesion molecule (VCAM), secretory phospholipase A2 (SPLA2), thiobarbituric acid reactive species (TBARS), superoxide dismutases (SOD), resistin, adiponectin, high-sensitivity Creactive protein (hsCRP), and antioxidant capacity. Plasma concentrations of sVCAM-1, SPLA-2, adiponectin, and hsCRP were measured using commercially available enzyme-linked immunosorbent assay (ELISA) kits. TBARS, SOD, and antioxidant capacity were measured using colorimetric assay. The 10-year risk of developing myocardial infarction or coronary death was calculated for each patient with the Framingham equation. To determine SAD we measured endothelial function and common and bulb carotid intima media thickness (c-IMT). SAD was considered if common c-IMT >0.8 mm or bulb cIMT >1 mm or flow-mediated dilatation (FMD) <5%. Endothelial function was evaluated measuring FMD. Patients were required to fast and not use any tobaccocontaining products for 8 h before the study. Patients were placed in a supine position and a blood pressure cuff was placed on the widest part of the proximal right forearm, approximately 1 cm distal to the antecubital fossa. Using a high-resolution ( ‡ 7 MHz) linear array vascular ultrasound transducer (Philips iE33, Philips, Andover, MA), the brachial artery was located above the elbow and scanned in longitudinal sections. Baseline vessel diameter was determined with the mean of three measures. The forearm cuff was inflated to 240 mm Hg for 5 min to induce reactive hyperemia. FMD

Multiple Pulmonary Nodules and Amiodarone. KL-6 as a New Diagnostic Tool

Pulmonary toxicity is an infrequent but serious adverse event in patients treated with amiodarone. The main problem at present is that we lack the necessary tools to detect this event or predict which patients will develop pulmonary toxicity. Serum Krebs von den Lungen-6 (KL-6) has been previously recognized as a marker for the activity of diffuse interstitial lung disease. We describe a patient with pulmonary toxicity due to amiodarone with increased blood levels of this new marker, and discuss the clinical usefulness of this new diagnostic tool.