J.I. Pérez Calvo

Síncope: ¿muchos estudios y pocos diagnósticos?

Introduccion El sincope es una patologia frecuente, en ocasiones de dificil diagnostico, de modo que un importante porcentaje queda sin filiar tras realizar pruebas diagnosticas, a veces innecesarias. Metodo Se realiza un analisis retrospectivo de los pacientes ingresados por sincope en un servicio de Medicina Interna del Hospital Clinico Universitario de Zaragoza durante dos anos. Resultados De un total de 2.878 pacientes ingresados en el servicio durante los anos 1999 y 2000, 79 lo fueron por sincope (2,74 %); 45 (57%) hombres y 34 (43%) mujeres, con una edad media de 68,8 anos. Veintisiete pacientes (34%) habian presentado episodios previos de sincope al ingreso. Tras una estancia media de 9,5 dias se llego al diagnostico etiologico en 53 (67%) casos: en 25 pacientes (31,6%) el sincope fue neurologicamente mediado, en 16 (20,25%) fue cardiologico, en 4 (5,06%) neurologico y 8 (10,1%) secundarios a otras causas. A 54 pacientes (68,8%) se les realizo al menos una prueba cardiologica (41 Holter, 32 ecocardiogramas, 6 pruebas de la mesa basculante, 3 maniobras de masaje del seno carotideo, 3 ergometrias, 3 estudios electrofisiologicos, 2 coronariografias y 3 gammagrafias pulmonares de ventilacion/perfusion). A 51 pacientes (64%) se les realizo al menos una prueba neurologica (31 electroencefalogramas [EEG], 42 tomografias axiales computarizadas [TAC], 2 resonancias magneticas nucleares [RMN], 1 doppler transcraneal y 3 electroneuromiogramas). De los registros Holter realizados solo 4 fueron diagnosticos, al igual que 3 de los ecocardiogramas y solo 2 de las TAC realizadas. Ningun EEG fue util para el diagnostico etiologico del sincope. Conclusiones Existe una sobreutilizacion de algunas pruebas diagnosticas (EEG, Holter y TAC cerebral), a pesar de lo cual en un importante porcentaje de casos de sincope no se llega a un diagnostico etiologico (33%). Se propone el uso de algoritmos diagnosticos basados en una minuciosa historia clinica, exploracion fisica y valoracion de ECG que permitirian emitir una hipotesis diagnostica a partir de la cual poder comenzar el estudio con un uso lo mas racional posible de las exploraciones complementarias.

Consenso para la mejora de la atención integral de los pacientes con insuficiencia cardíaca aguda: versión resumida

The purpose of this consensus document was to reach an agreement among experts on the multidisciplinary care of patients with acute heart failure. Starting with a narrative review of the care provided to these patients and a critical analysis of the healthcare procedures, we identified potential shortcomings and improvements and formalised a document on recommendations for optimising the clinical and therapeutic approach for acute heart failure. This document was validated through an in-person group session guided using participatory techniques. The process resulted in a set of 36 recommendations formulated by experts of the Spanish Society of Cardiology, the Spanish Society of Internal Medicine and the Spanish Society of Urgent and Emergency Care. The recommendations are designed to optimise the healthcare challenge presented by the care of patients with acute heart failure in the context of Spains current National Health System.

Estudio de calidad del diagnóstico y seguimiento de los trastornos esqueléticos asociados a la enfermedad de Gaucher tipo 1 en España

Background: bone involvement in type 1 Gaucher’s disease can be devastating and is oftenly silent. Bone MR is generally recomended. The aim of the study was to elucidate whether the size and location of hospitals in Spain implies any difference in management of GD patients. Material and methods: we surveyed the type of facilities in the hospital (namely MRI) as well as for the presence, type, severity and methodology of follow-up of bone involvement associated to GD, according to the category of hospital (local or reference). Results: 31 patients were followed in reference hospitals whereas 16 other were in local hospitals. 70% of cases had some type of bone involvement, 60% had severe bone disease. MRI was the first choice for diagnosis in 65% and for follow-up in 93% of cases. MRI is less indicated among patients from local hospitals. Chitotriosidase is measured in a high, but insufficient, proportion of the followed patients (60%). Conclusions: the Spanish hospital network, either reference or local hospitals, have an adequate infrastructure for the management of GD patients. However, main diagnostic resources are being currently underused.

Implicación de la congestión venosa sistémica en la insuficiencia cardíaca

Systemic venous congestion has gained significant importance in the interpretation of the pathophysiology of acute heart failure, especially in the development of renal function impairment during exacerbations. In this study, we review the concept, clinical characterisation and identification of venous congestion. We update current knowledge on its importance in the pathophysiology of acute heart failure and its involvement in the prognosis. We pay special attention to the relationship between abdominal congestion, the pulmonary interstitium as filtering membrane, inflammatory phenomena and renal function impairment in acute heart failure. Lastly, we review decongestion as a new therapeutic objective and the measures available for its assessment.

Evaluación de la función renal en la insuficiencia cardiaca

Renal function is one of the most consistent prognostic determinants in heart failure. The prognostic information it provides is independent of the ejection fraction and functional status. This article reviews the various renal function assessment measures, with special emphasis on the fact that the patients clinical situation and response to the heart failure treatment should be considered for the correct interpretation of the results. Finally, we review the literature on the performance of tubular damage biomarkers.

Influencia de la edad en la mortalidad de pacientes con insuficiencia cardiaca

OBJECTIVE: Heart failure (HF) is one of the most frequent diagnosis in Internal Medicine Units. High age of patients is an important characteristic in these admissions. Our objective was to evaluate how age interact with mortality, to medium-term, in HF after a decompensated episode. METHOD: Through the patient medical record we obtained data about patients hospitalised in a Internal Medicine Unit, with HF diagnosis, for a year (from September 2000 to August 2001) and their survival at 1st January 2003. 215 patients were reviewed. RESULTS: During follow-up, 60 patients died (27.9% of overall). In elderly patients, we observed a higher number of women and less use of echocardiography and treatment with beta-blockers and warfarin (in patients with atrial fibrillation). In Cox proportional-hazards model, age (OR 1.043 IC 95% 1.002-1.085), days of hospitalization (OR 1.04 IC 95% 1.003-1.078), diabetes mellitus (OR 2.51 IC 95% 1.37-4.60) and do not prescribe warfarin in patients with atrial fibrillation (OR 2.71 IC 95% 1.10-6.60) were independent prognostic factors. CONCLUSIONS: Age was an important prognostic factor in patients with HF. Clinical trials should be done in patients with these characteristics. So, we can know better clinical evolution of HF in this population.

Tratamiento farmacológico de la hipertensión arterial

Indicaciones del tratamiento farmacologico. Hay que tener en cuenta que el objetivo no solo es la reduccion de cifras tensionales, sino el tratamiento integral del riesgo vascular del hipertenso. En general, el objetivo es la reduccion a cifras inferiores a 140/90 mmHg. En el diabetico, el objetivo es alcanzar cifras inferiores a 130/80 mmHg y tambien en casos de nefropatia, en el cual se debe reducir a 125/75 mmHg o menos en caso de proteinuria superior a 1 g/dia. Clases de farmacos y situaciones clinicas. Las distintas clases de antihipertensivos (diureticos, bloqueadores beta y alfa, bloqueadores de los canales del calcio, inhibidores de la enzima convertidora de la angiotensina, antagonistas de receptores de angiotensina II y otros) tienen hoy indicaciones individualizadas para distintas situaciones clinicas, segun los resultados de importantes ensayos clinicos controlados. Control evolutivo y tratamiento asociado. Es preciso el seguimiento del control del hipertenso en tratamiento y tener en cuenta los beneficios demostrados de tratamientos asociados (tratamientos hipolipidemiante, antiagregante y control de glucemia), y en general del riesgo vascular de cada paciente.

Tratamiento de los factores de riesgo vascular y objetivos terapéuticos

Global cardiovascular risk assessment is recommended for every individual patient. Among other risk factors and clinical conditions, management of diabetes, hypertension and smoking will be reviewed here. Goals in diabetes control should be individualized for every patient. Treatment includes diet modification, physical exercise and pharmacological treatment including insulins and oral antidiabetic drugs. When treating hypertension the main benefit depends on the reduction of blood pressure achieved. Both lifestyle modifications and drugs may contribute to reach blood pressure targets. Smoking cessation therapies have shown to reduce quit rates. They are based on behavioral support and pharmacological aids if necessary. First-line smoking cessation therapies help to control smoker physical addiction and are: nicotine replacement therapy (NRT), bupropion and varenicline.

La afectación gastrointestinal de las enfermedades sistémicas y metabólicas

Resumen Hay muchas enfermedades que se presentan con clinica digestiva que no solo condiciona la sintomatologia sino tambien el tratamiento y el pronostico. Recoger todas ellas es dificil, por lo que en esta revision nos centramos en las mas prevalentes o en las que su expresividad clinica es mas caracteristica. Entre ellas se describen la diabetes, con los dos grandes sindromes que ocasiona, la gastroparesia y la diarrea. Tambien se repasan las enfermedades neurologicas, reumatologicas, en especial la clinica y afectacion de las vasculitis y la afectacion digestiva causada por los tumores. Ademas recogemos los efectos secundarios digestivos mas habituales en farmacos de amplio uso.

Hipertensión e hipopotasemia en una mujer de 49 años

Primary aldosteronism resulting from an adrenocortical adenoma is an uncommon but potentially curable form of hypertension. We present the case of a 49-year-old woman that initiated with severe hypertension that was treated with diuretics and ACE inhibitors before being hospitalized. When she came to consult, she had hypokalemia. This persisted in spite of administering potassium supplements and discontinuing the diuretics and ACE