Jaume Candell-Riera

Prevalence, Morphologic Types, and Evolution of Cardiac Valvular Disease in Systemic Lupus Erythematosus

We performed echocardiography prospectively 4.9 +/- 0.7 years apart (mean +/- SD), in 74 patients with systemic lupus erythematosus. On the basis of the first study, the patients were distributed in four groups according to the type of valvular involvement: 7 patients had vegetations (Libman-Sacks endocarditis; group 1); 6 patients had rigid and thickened valves with stenosis, regurgitation, or both (group 2); 5 patients had miscellaneous forms of valvular involvement without valvular dysfunction (group 3), as did the 60 controls; and 56 patients had no valvular disease (group 4). The overall prevalence of clinically important valvular disease (groups 1 and 2) was 18 percent. Patients in group 1 were younger than those in group 2 (33.5 +/- 16.7 vs. 47.8 +/- 17.6 years; P less than 0.05), had a shorter mean duration of lupus (4.8 +/- 2.2 vs. 10.7 +/- 6.4 years; P less than 0.001), and had received a smaller cumulative dose of steroids (21.5 +/- 13.1 vs. 79.5 +/- 63.4 g of methylprednisolone or its equivalent; P less than 0.05). During the five-year follow-up, one patient in group 1 and five in group 2 required valve surgery, no patient in group 3 had valvular dysfunction, and five patients in group 4 had mild valvular lesions. We conclude that clinically important valvular involvement in systemic lupus is relatively frequent and sometimes requires surgery. Echocardiography can identify a subset of lesions (valvular thickening and dysfunction), other than verrucous (Libman-Sacks) endocarditis, that are prone to hemodynamic deterioration.

Transient cardiac constriction: an unrecognized pattern of evolution in effusive acute idiopathic pericarditis

In 16 of 177 patients with effusive acute idiopathic pericarditis (10 men, 6 women, mean age 38 years), features of cardiac constriction were detected (by physical examination in 6 patients and by noninvasive recordings in all) between 5 and 30 days after an echocardiogram had shown pericardial effusion, at a time when signs of activity had abated and effusion was already minimal or had altogether disappeared. Cardiac catheterization was performed in 5 patients, showing either overt (3 patients) or occult (2 patients) cardiac constriction. Two patients had clinical signs of cardiac failure. After a mean of 2.7 months, the features of constriction had spontaneously disappeared in all patients in the clinical examination and noninvasive recordings, and remained so in subsequent control studies (mean follow-up 31 months). Repeat cardiac catheterization in the 5 patients in whom it had been previously performed showed normal features both in the basal state and after fluid overload. The results of the present study show that some patients may go through a transient phase of cardiac constriction at the end of the effusive period of acute idiopathic pericarditis. Features of constriction are, in most cases, subtle and can go unrecognized if not specifically sought. However, they may have clinical relevance in some patients. These findings provide insight into the resolution phase of effusive acute idiopathic pericarditis, and an unnecessary pericardiectomy may be avoided.

Simultaneous dipyridamole/maximal subjective exercise with 99mTc-MIBI SPECT: improved diagnostic yield in coronary artery disease.

OBJECTIVES We attempted to demonstrate that simultaneous dipyridamole administration and maximal subjective exercise in patients who are unable to achieve a good exercise level can improve the diagnostic efficacy of technetium-99m methoxy isobutyl isonitrile (99mTc-MIBI) myocardial single-photon emission computed tomography (SPECT). BACKGROUND The results of myocardial perfusion scintigraphy are unsatisfactory if the level of exercise achieved by the patient is insufficient. The use of dipyridamole with maximal subjective stress testing has been shown to improve the quality of the thallium-201 myocardial perfusion images, but there are no studies demonstrating that this combination improves the diagnostic accuracy of myocardial perfusion SPECT. METHODS Two hundred thirty-one consecutive patients, without a previous myocardial infarction, were classified into three groups: group 1, 91 patients with an adequate exercise test; group 2, 68 patients with an inadequate exercise test; group 3, 72 patients with an inadequate exercise test who then received intravenous dipyridamole (0.56 mg/kg body weight over 4 min) simultaneously with exercise. RESULTS Results for sensitivity (89%) and negative predictive value (83%) in group 3 were significantly better than those in group 2 (71% [p = 0.03] and 56% [p = 0.002], respectively) and not significantly different from those in group 1. The polar maps of 20 patients studied with an without dipyridamole at the same exercise level revealed a significantly greater extent of ischemia in each territory and in a global assessment (19 + 20% vs. 8 + 11%, p < 0.0001) when dipyridamole was administered during physical exercise. CONCLUSIONS Intravenous dipyridamole administration during exercise testing is advisable in all patients who are unable to achieve an adequate exercise level. This approach permits physicians to avoid missing ergometric information while optimizing myocardial SPECT results.

Nuclear magnetic resonance‐based metabolomics predicts exercise‐induced ischemia in patients with suspected coronary artery disease

The purpose of this study was to develop a 1H‐nuclear magnetic resonance metabolomic approach capable of predicting the occurrence of exercise‐induced ischemia in patients with suspected coronary artery disease and to identify the metabolite patterns that contribute most importantly to the prediction. In 31 patients with suspected effort angina and without previous myocardial infarction, serum was obtained just prior to a stress single‐photon emission computed tomography. Serum NMR spectra were acquired with pulse‐and‐acquire and T2‐edited sequences. The region between 0.50 and 4.25 ppm was used for analysis. Twenty‐two patients had reversible myocardial perfusion defects and nine did not. Both groups had similar age and clinical profile, except for more smokers and diabetics in the ischemia group, and attained a similar peak heart rate. The best separation was achieved with long T2‐edited spectra, 84% of patients being correctly classified based on the partial least square discriminant analysis. The main contributors to discrimination were lactate, glucose, as well as methyl and methylene moieties of lipids and long‐chain amino acids. Metabolomic analysis of serum can predict exercise‐inducible ischemia in patients with suspected coronary artery disease. This capability could be useful in screening and risk stratification of patients with coronary risk factors. Magn Reson Med 60:27–32, 2008.

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.

Cardiac hemochromatosis: beneficial effects of iron removal therapy: an echocardiographic study

The echocardiographic (echo) features of idiopathic hemochromatosis (IH) were studied in 22 patients. Results were compared with a control group of 22 patients without heart disease. Statistically significant increases in left ventricular (LV) mass, end-diastolic and end-systolic diameters of the left ventricle and in left atrial dimension were observed in patients with IH; significant changes of systolic function indexes (decrease in fractional shortening and ejection fraction and increase in distance of the E point to the septum) were seen as well. These echo abnormalities were mainly seen in patients with abnormal electrocardiograms. In 11 patients with IH, iron removal therapy was carried out by means of periodic phlebotomies. In patients with impaired LV function at the beginning of therapy, comparison between measurements of the initial echo and posttreatment echo showed significant improvement in LV diameters, fractional shortening, ejection fraction, distance from the E point to the septum, LV mass and left atrial dimension.

Strategies for prognostic assessment of uncomplicated first myocardial infarction : 5-year follow-up study

OBJECTIVES Our aim was to use noninvasive studies early after infarction to assess medium-term prognosis in patients with a first uncomplicated myocardial infarction. BACKGROUND Although the use of early postinfarction assessment to gauge short-term prognosis in myocardial infarction is well established, there have been few comprehensive evaluations of noninvasive methods for assessing medium- and long-term prognosis. METHODS We prospectively studied 115 consecutive patients < 65 years old with a first acute uncomplicated myocardial infarction to evaluate the prognostic role of predischarge cardiac studies. These included submaximal exercise testing, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, ambulatory electrocardiographic (Holter) monitoring and cardiac catheterization. All patients without complications were followed up > or = 5 years. RESULTS During the follow-up period, 78 patients (68%) developed complications, which were severe in 37 (32%). Exercise thallium-201 scintigraphy yielded the highest percentage (77%) for correctly classified patients. It also had the highest predictive value for complications (97%) and severe complications (92%) when it was used in association with exercise testing and radionuclide ventriculography. The addition of cardiac catheterization did not improve on the predictive power of noninvasive studies. Four decision trees (exercise testing + echocardiography, exercise testing + radionuclide ventriculography, thallium-201 + echocardiography, thallium-201 + radionuclide ventriculography) allowed stratification of all patients in a high, intermediate or low risk category. The combination of thallium-201 scintigraphy and radionuclide ventriculography yielded the best results (90% predictive value for complications if the outcome of both tests was positive), but there were no significant differences with the other models. CONCLUSIONS Any combination of a test detecting residual ischemia or functional capacity, or both (exercise testing or thallium-201 scintigraphy), and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in useful prognostic information in patients with an uncomplicated first acute myocardial infarction.

Silent myocardial ischemia in patients with symptomatic intracranial atherosclerosis: associated factors.

Background and Purpose— Optimization of coronary risk evaluation in stroke patients has been encouraged. The relationship between symptomatic intracranial atherosclerosis and occult coronary artery disease (CAD) has not been evaluated sufficiently. We aimed to investigate the prevalence of silent myocardial ischemia in patients with symptomatic intracranial atherosclerosis and to identify factors associated with its presence. Methods— From 186 first-ever transient ischemic attack or ischemic stroke patients with intracranial stenoses, 65 fulfilled selection criteria, including angiographic confirmation of a symptomatic atherosclerotic stenosis and absence of known CAD. All patients underwent a maximal-stress myocardial perfusion single-photon emission computed tomography (SPECT). Lipoprotein(a) [Lp(a)], C-reactive protein, and homocysteine (Hcy) levels were determined before SPECT. Results— Stress-rest SPECT detected reversible myocardial perfusion defects in 34 (52%) patients. Vascular risk factors associated with a pathologic SPECT were hypercholesterolemia (P=0.045), presence of >2 risk factors (P=0.004) and high Lp(a) (P=0.023) and Hcy levels (P=0.018). Ninety percent of patients with high Lp(a) and Hcy levels had a positive SPECT. Existence of a stenosed intracranial internal carotid artery (ICA; odds ratio [OR], 7.22, 2.07 to 25.23; P=0.002) and location of the symptomatic stenosis in vertebrobasilar arteries (OR, 4.89, 1.19 to 20.12; P=0.027) were independently associated with silent myocardial ischemia after adjustment by age, sex, and risk factors. Conclusions— More than 50% of the patients with symptomatic intracranial atherosclerosis and not overt CAD show myocardial perfusion defects on stress-rest SPECT. Stenosed intracranial ICA, symptomatic vertebrobasilar stenosis and presence of high Lp(a) and Hcy levels may characterize the patients at a higher risk for occult CAD.

Usefulness of Exercise Test and Myocardial Perfusion–Gated Single Photon Emission Computed Tomography to Improve the Prediction of Major Events

Background—The incremental prognostic value of myocardial perfusion–gated single photon emission computed tomography (MPGS) compared with exercise test has not yet been properly evaluated. Methods and Results—Five thousand six hundred seventy-two consecutive patients with known or suspected coronary disease undergoing exercise MPGS between 1997 and 2007 were included. Three-year predictive models for total death and death from cardiovascular causes or acute myocardial infarction (ie, major cardiovascular events [MCE]) were built using Cox-regression modeling, including only the clinical information. Then the exercise and MPGS information was sequentially added. The added discriminative ability of exercise test information and MPGS was assessed by net reclassification improvement and integrated discrimination improvement. The increase in predictive ability of exercise information for death and MCE was high as assessed by net reclassification improvement (0.199 and 0.263) and integrated discrimination improvement (0.042 and 0.021). The only variable of MPGS associated with total death was ejection fraction (hazard ratio, 0.84; 95% confidence interval, 0.79–0.89; P<0.001). Global stress ischemic score emerged as an additional variable associated with MCE (hazard ratio, 1.07; 95% confidence interval, 1.02–1.12; P=0.007). Adding MPGS information barely improved the prognostic value for total death (net reclassification improvement, 0.017; integrated discrimination improvement, 0.013), but it increased for MCE (net reclassification improvement, 0.122; integrated discrimination improvement, 0.033). Conclusions—Adding MPGS information to exercise information does not improve prediction of total death, although it allows a more accurate prediction of MCE.

Análisis cuantitativo de la función ventricular izquierda como herramienta para la investigación clínica. Fundamentos y metodología

La utilizacion de la fraccion de eyeccion del ventriculo izquierdo como objetivo subrogado en los ensayos clinicos esta avalada por numerosos estudios. Para que el rendimiento de este objetivo sea aceptable, es esencial ser muy rigurosos en la adquisicion de las imagenes y es conveniente utilizar unidades especificamente dedicadas a analizar cuantitativamente parametros de imagen con las diversas tecnicas disponibles. A continuacion se expone la evidencia disponible en relacion con la fraccion de eyeccion y los volumenes del ventriculo izquierdo, la importancia de las unidades de analisis de imagen y las distintas tecnicas disponibles. Finalmente, se comenta sobre las tecnicas de imagen de eleccion segun el contexto clinico.