Jesús M. de la Hera

Anomalías congénitas de las arterias coronarias del adulto descritas en 31 años de estudios coronariográficos en el Principado de Asturias: principales características angiográficas y clínicas

Objective. The aim of this study was to determine the incidence of adult congenital anomalies of the coronary arteries over 31 years of angiographic studies, describing their angiographic and clinical characteristics. The results have been compared with the main series published. Methods. The diagnostic angiographic reports done in the Principado de Asturias from 1968 to 1999 are reviewed. In those in which a congenital anomaly was diagnosed, the clinical report and the angiography were studied. The initial course of the anomaly was defined following angiographic criteria. Results. Thirteen thousand five hundred reports were reviewed describing 75 patients with 75 anomalies (0.5%) incluiding: anomalous origin of the left circumflex coronary artery (n = 24), coronary artery fistulae (n = 21), both coronary arteries arising from the left coronary sinus (n = 15), single coronary arteries (n = 6), both coronary arteries arising from the right coronary sinus (n = 2), separated origin of anterior descending and left circumflex coronary arteries (n = 3), anterior descending artery arising from the right coronary sinus (n = 2), and others (n = 1). Angiographic studies were done because of: angina (59%), dysnea (25%), atypical chest pain (7%), syncope (3%), dizziness (3%) and palpitations (3%). The initial course was retroaortic in all the circumflex arteries, interarterial in the right coronaries, anterior in the anterior descending arteries and retroaortic, septal and combined, in the left coronaries. Conclusions. Adult congenital anomalies of the coronary arteries are not very common and are usually casual findings of diagnostic angiographic studies. Left circumflex coronary artery anomalies are the most frequently diagnosed.

Prevalence and outcome of newly detected diabetes in patients who undergo percutaneous coronary intervention

AIMS The beneficial effect of specific measures in patients with newly detected diabetes during percutaneous coronary intervention (PCI) has been poorly studied. Here, we determined the prevalence of newly detected diabetes in a cohort of patients who underwent PCI and analysed their clinical outcome. METHODS AND RESULTS A prospective study included patients without previous diagnosis of diabetes that were referred for PCI between November 2005 and May 2006. Major cardiac events were registered after admission and during 12 months of follow-up, and oral glucose tolerance was tested at 15 days after hospital discharge. Six hundred and sixty-two consecutive patients were referred to our hospital for PCI. The distribution of the glycometabolic state of the entire population was (95% CI): known diabetes 28.8% (25.2-32.6), newly detected diabetes 16.2% (13.1-19.8), impaired glucose tolerance 24.5% (20.8-28.5), impaired fasting glucose 1% (0.4-2.4), and normal glucose regulation 29.5% (25.5-33.7). In a multivariable analysis, the presence of newly detected diabetes was not an independent predictor of cardiac events after 1 year of follow-up. CONCLUSION The prevalence of diabetes in patients who underwent PCI was very high (45%), 35% of which was patients with newly detected diabetes. In our series newly detected diabetes was not an independent predictor of outcome at 12 months. Nevertheless, this finding requires independent confirmation in other series to draw general conclusions on the whole spectrum of percutaneous interventions.

Real Incidence of Diabetes Mellitus in a Coronary Disease Population

The high prevalence of unknown diabetes mellitus (DM) in patients with coronary disease and that the oral glucose tolerance test (OGTT) is the best diagnostic method in this context are well known. However, data about the incidence of DM in this population have not been well described. In the present study, we sought to determine the actual incidence of new-onset DM in patients with coronary disease using the OGTT. Our secondary objective was to validate a predictive model. We studied a series of 338 patients with coronary disease without known DM using the OGTT. After the OGTT, the patients were reclassified as normoglycemic, prediabetic, and unknown DM, according to the American Diabetes Association 2010 criteria. After 3 years of follow-up, the patients without DM were again reassessed using the OGTT. We then built a predictive model using the multivariate logistic regression method and validated it using the leave-one-out method. The final sample was 191 patients. The mean follow-up was 3.13 years. The overall incidence of DM was 43.6 cases/1,000 person-years (95% confidence interval [CI] 26.8 to 60.4). The incidence was significantly different between the initially normoglycemic patients (11.5%, 95% CI 2.3% to 31.8%) and the prediabetic patients (70.5%, 95% CI 42.7% to 98.3%; p <0.001). A risk model that included the glucose level 2 hours after challenge, glycosylated hemoglobin and triglyceride levels, and presence of noncoronary vascular disease showed good predictive capacity for incident DM (area under the curve 0.882, 95% CI 0.819 to 0.946; p <0.0001). In conclusion, the real incidence of new DM is very high in the coronary population, especially in those with prediabetes. It is necessary to use the OGTT for diagnosis, but we can optimize its indication using a risk model.

Rendimiento de la glucohemoglobina y un modelo de riesgo para la deteccion de diabetes desconocida en pacientes coronarios

INTRODUCTION AND OBJECTIVES Traditionally, the oral glucose tolerance test has been useful to diagnose unknown diabetes. Recently, the American Diabetes Association committee has accepted glycated hemoglobin ≥ 6.5% as a criterion for unknown diabetes. The aim was to determine the benefit of glycated hemoglobin for diagnosing unknown diabetes and also create a predictive model that adjusts the indication for oral glucose tolerance test in coronary patients. METHODS We examined the glycemic profile of 338 coronary patients without previous diagnosis of diabetes, applying 2010 American Diabetes Association criteria. A unknown diabetes risk predictive model was developed using logistic regression analysis, and then validated in another cohort. RESULTS Using the glycated hemoglobin criteria and/or fasting plasma glucose, unknown diabetes was diagnosed in 26 patients. The remaining patients were classified according to oral glucose tolerance test as follows: unknown diabetes 53 (17%), prediabetes 144 (46.2%), and normoglycemic 115 (36.8%). The diagnostic method for unknown diabetes was fasting plasma glucose in 25.3%, glycated hemoglobin in 7.6%, and oral glucose tolerance test in 67.1%. A risk model including fasting plasma glucose, glycated hemoglobin, left ventricular ejection fraction, age, and noncoronary vascular disease was shown to effectively predict unknown diabetes after oral glucose tolerance test: area under the ROC curve 0.8 (95% confidence interval: 0.74-0.87). When the oral glucose tolerance test is restricted to patients with a risk score >6 (31% of our sample) we properly identify 83% of unknown diabetes cases (sensitivity: 75%, specificity: 73%, positive predictive value: 40%, negative predictive value: 93%). The model was adequately validated in another cohort of 115 patients (area under the ROC curve 0.84 [95% confidence interval: 0.74-0.95]). CONCLUSIONS In coronary patients, glycated hemoglobin alone failed to detect many cases of unknown diabetes. However, its inclusion in a risk prediction model leads to optimizing the usefulness of oral glucose tolerance test.

KCNQ1 gene variants in the risk for type 2 diabetes and impaired renal function in the Spanish Renastur cohort

Several common KCNQ1 gene polymorphisms have been associated with the risk of type 2 diabetes (T2DM) and diabetic nephropathy. This effect is explained by the role of the kcnq1 protein as a potassium channel that in the pancreatic beta-cells drives an electrical signal that facilitates glucose-stimulated insulin secretion. The KCNQ1 gene is also expressed in the kidney, and could thus be implicated in the risk of developing impaired renal function. To test this hypothesis, we genotyped six common KCNQ1 gene variants (three single nucleotide polymorphisms, rs2237892, rs2237895, and rs231362, and three intronic indels) in 681 healthy elderly individuals (>65 years old) from the Spanish Renastur cohort. None of the six variants was associated with T2DM (180 diabetics vs. 581 non-diabetics). The intron 12 insertion allele was associated with a reduced estimated glomerular filtration rate (eGFR<60, n = 90 vs. eGFR≥60, n = 591; II vs ID + DD genotypes, p = 0.031, OR = 2.06, 95%CI = 1.12-4.14). We also performed a next generation sequencing search of variants in the coding regions of the KCNQ1 gene in 100 individuals with the extreme eGFR values. We found two rare amino acid changes (p.K393N and p.P408A) and the 393 Asn variant was found only among diabetics (n = 4; p = 0.05). The two rare alleles were present in the two eGFR groups. Our results suggest that a common KCNQ1 intron 12 indel polymorphism is a risk factor for impaired renal function independent of T2DM. If this association is confirmed by others, further research to determine the mechanism that drives this association would be warranted.

Grado de conocimiento de la profilaxis de endocarditis infecciosa entre los dentistas españoles

The association between heart disease and the development of infectious endocarditis (IE) has been known since the beginning of the last century. In 1909, Horder discovered the association between dental hygiene and IE. For many years, the practice of dental antibiotic prophylaxis has been recommended in most patients with prostheses, valvular heart disease, or congenital heart disease. As the incidence and mortality of IE have not changed during this period, the role of such measures has become a matter of debate. Thus, clinical guidelines have restricted the indications to high-risk procedures and high-risk patients. The aim of this study was to determine the degree of knowledge of IE prophylaxis among Spanish dentists. Between September 2011 and October 2011, we conducted a telephone survey of 2 oral health professionals from each of the 52 Spanish provinces. The sample was randomly selected from the Yellow Pages listing. Table 1 shows the list of questions. We interviewed 104 dental specialists: 50 (48.5%) dental physicians, 50 (48.5%) odontologists, and 4 (3%) maxillofacial surgeons. Their work experience was 19.1 (8.8) years. One hundred (97%) of the respondents considered IE to be fatal. Nevertheless, only 8 respondents thought that mortality could exceed 50%; 94 respondents (91.3%) recognized that IE prophylaxis was important or very important and routinely provided it in their clinical practice according to their own criteria. In total, 84.6% considered that cardiologists were accessible or reasonably accessible, but only 12% routinely consulted one to make a decision. A total of 54% stated that patients who needed prophylaxis did not attend their clinic with a recommendation for prophylaxis. Table 2 shows the cardiac conditions requiring antibiotic prophylaxis according to the respondents. In total, 93% stated they were unaware of the guidelines on the prevention of IE. In addition, 54 (56.1%) thought that the message from the cardiology community is vague and changeable. Only 27 dentists (25.9%) completely agreed with the restrictions included in the updated guidelines. Several studies on native-valve IE and prosthetic-valve IE have demonstrated a change in the epidemiology of this disease. This entity affects an older population and is associated with the increased use of invasive techniques; a decrease in the cases of streptococcal infection and an increase among patients with a structurally normal heart has been observed. In addition, several studies have shown that daily activities such as chewing gum or tooth brushing can cause transient bacteremia. Based on the foregoing, the guidelines on the prevention of IE have increasingly restricted the indications for prophylaxis. Since more than 90% of the respondents were unaware of these consensus guidelines, prophylaxis is probably being applied unnecessarily to patients with heart disease (more than 60% of respondents), patients with any type of mitral valve prolapse (65%) and patients with heart failure (40%). Proper indication in cases such as prosthetic valves or congenital heart disease remained high (75%), although it was slightly lower than in similar studies, where proper indication reached 80%. The sources of information used by these professionals were journals or dentistry bulletins. Most dentists thought that the message from the cardiology community is changeable and vague. Given that more than 80% stated that cardiologists are accessible or reasonably accessible, and that most considered the role of prophylaxis to be very important, we may be facing a serious communication problem between cardiologists and professionals in this field, since we are not obtaining the intended effect. There may also be a medicolegal reason for this situation. In Spain, dentistry is one of the liberal professions, and although it seems clear when prophylaxis should be indicated and in whom, there is a broad spectrum of patients, including specific groups Rev Esp Cardiol. 2012;65(12):1134–1142

Contrast echocardiography and clinical safety

The use of contrast media provides a greater diagnostic yield for echocardiographic techniques.1 In combination with the possibility of performing myocardial perfusion studies, its use can be generalized in stress echocardiography. It therefore leads us to question the safety they afford concerning adverse reactions, an issue that has recently led to the temporary withdrawal from the market of one of these products used in echocardiography. We present the case of a 42 year old man with a history of an acute anterior myocardial infarction 4 months previously, and single vessel coronary disease (100% middle anterior descending), with a normal ejection fraction and apical akinesia. He was referred to the echocardiograph laboratory for measurement of apical myocardial viability by means of stress echocardiography with dobutamine, prior to attempting revascularization. When the patient was clinically and hemodynamically stable, the study was started according to the usual protocol; contrast material was not considered necessary at this point. On reaching a dobutamine infusion dose of 10 μg/kg/min, a heart rate of 105 bpm, and a blood pressure of 140/70 mm Hg, a bolus dose of 1.5 mL of Sonovue® was given, maintaining a mechanical index of 0.3. The patient immediately developed sudden sweating, rubefaction and bradycardia, followed by severe hypotension and cardiorespiratory arrest. Advanced cardiopulmonary Letters to Editor

Time-dependent responses to provocative testing with flecainide in the diagnosis of Brugada syndrome

BACKGROUND Time-dependent variability of electrocardiogram (ECG) in patients with Brugada syndrome could affect the interpretation of provocative testing. OBJECTIVE The aim of this study was to characterize ECG changes during and after flecainide infusion. METHODS We studied 59 consecutive patients. The ECG was continuously analyzed during the first 30 minutes of provocative testing, and a single ECG was recorded 60 minutes later. We analyzed CYP2D6 and CYP3A5 variants affecting flecainide metabolism and performed blinded measurements at lead II. RESULTS At baseline, ECG patterns were classified as follows: type II in 31 patients (53%), type III in 15 (25%), and normal ECG in 13 (22%). Because of induction of type I ECG, the percentage of responders progressively increased with longer recording time periods (6.8% in 10 minutes vs 11.9% in 20-30 minutes vs 18.6% in 90 minutes; P < .01). Four patients displayed a late response, which was evidenced 90 minutes after the initiation of provocative testing. QRS width differentially increased between responders and nonresponders (P < .01), with a maximum QRS width of 110 ms during the first 30 minutes being effective for identifying possible late responders (sensitivity 100%; specificity 85.6%; positive predictive value 88%; negative predictive value 100%). The incidence of CYP2D6 variants was lower in late responders than in early or delayed responders (0% vs 75% vs 100%; P = .04), while a homogeneous distribution of CYP3A5*3/*3 was observed in our population. CONCLUSION Response to flecainide exhibits time-dependent variability of ECG patterns and intervals. Longer periods of ECG recording increase the recognition probability of type I ECG.

Diabetes and Screening for Coronary Heart Disease: Where Should We Focus our Efforts?

Jesus Maria de la Hera*, Jose Manuel Garcia-Ruiz y Elias Delgado Unidad de Imagen Cardiaca, Area del Corazon, Hospital Universitario Central de Asturias, Oviedo, Asturias, Espana Unidad de Cuidados Cardiologicos Agudos, Area del Corazon, Hospital Universitario Central de Asturias, Oviedo, Asturias, Espana c Servicio de Endocrinologia, Hospital Universitario Central de Asturias, Facultad de Medicina, Universidad de Oviedo, Oviedo, Asturias, Espana

Eficacia diagnóstica de la tomogammagrafía miocárdica en la detección de reestenosis coronaria postangioplastia

Introduccion y objetivos Analizar la eficacia de la tomogammagrafia miocardica de esfuerzo con compuestos tecneciados para el diagnostico de re estenosisen pacientes con angioplastia previa. Pacientes y metodos Se ha analizado retrospectivamente a 71 pacientes con angioplastia previa(16 mujeres, edad media: 60 anos, 35 con enfermedad multivaso y 78 angioplastias en total) y comprobacioncoronariografica. A todos se les habiapracticado, por motivos asistenciales, una tomogammagrafiamiocardica de esfuerzo con 99mTc (53con MIBI y 18 con tetrofosmina) entre 1 mes y 4anos despues de la angioplastia. A 16 pacientes se les administro dipiridamol intravenoso simultaneo con el ejercicio puesto que este fue insuficiente. Resultados La sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y valor global de la tomogammagrafia fueron significativamentesuperiores a los de la prueba de esfuerzo (80% frente al 63%; p = 0,05; 83% frente al 37%;p = 0,001; 91% frente al 69%; p = 0,007; 64% frenteal 31%; p = 0,009, y 81% frente al 55%; p = 0,0006 respectivamente). Al comparar los resultados de los pacientes con enfermedad multivaso respecto a los de un solo vaso observamos que fue en estos donde la eficacia diagnostica de la tomogammagrafia fue significativamente superior a la de la ergometria. Conclusiones La tomogammagrafia miocardicade esfuerzo con compuestos tecneciados es una exploracioncon una elevada eficacia para el diagnosticode la reestenosis postangioplastia, sobre todo en los pacientes con enfermedad de un solo vaso.