Jordi Magriñá

Disabling angina pectoris with normal coronary arteries in patients undergoing long-term hemodialysis

Reports of patients undergoing long-term hemodialysis presenting with angina pectoris have usually shown severe coronary atherosclerosis. We studied a series of nine patients undergoing regular maintenance dialysis referred for incapacitating angina. Of them, four had strictly normal coronary angiograms. The patients with normal angiograms were all females who were significantly younger (p less than 0.05) and had more severe hypertension and higher left ventricular wall stress than patients showing coronary artery lesions. Anemia and increased myocardial oxygen consumption due to high blood pressure may explain the syndrome of angina pectoris in the presence of long-term dialysis in patients with normal coronary arteries. The prevalence of this association cannot be ascertained unless prospective studies are conducted. However, our data suggest that it might not be an uncommon finding.

Feasibility of early discharge after acute Q wave myocardial infarction in patients not receiving thrombolytic treatment

OBJECTIVES The purpose of this study was to analyze the feasibility of early discharge (4 days) after acute myocardial infarction in patients not receiving thrombolytic therapy by first identifying predictors of short-term prognosis and then testing the derived risk profile in an independent cohort of patients. BACKGROUND Previous studies have shown that early discharge after acute myocardial infarction is possible. However, physicians are reluctant to shorten the standard 7- to 10-day hospital stay, presumably because of difficulty in selecting low risk patients. METHODS From January 1985 to November 1986, 358 patients with acute myocardial infarction who did not receive thrombolytic therapy were screened. Those with a Q-wave infarction showing no complications on day 4 were considered candidates for early discharge and were transferred to the ward for a mean of 12 days. During this period, we looked for any event (cardiac or noncardiac) that would have prompted readmission if the patient had been previously discharged. Univariate and multiple regression analysis were performed to identify predictors of these events among 25 baseline variables. The derived risk profile was tested in an independent validation cohort. RESULTS One hundred five (29.3%) of the 358 patients were free of symptoms on day 4, and 29 (27.6%) had at least one cardiac event, including four deaths and one reinfarction. Multivariate analysis selected diabetes, ejection fraction < 40% and age as independent predictors of events. Using the risk profile, 18 (13.2%) of the 136 validation cohort patients were categorized as low risk, and only 1 of them had a major event (progressive angina). Sensitivity for the risk profile was high (91%), but specificity was low (34%). CONCLUSIONS The use of simple clinical variables may allow the safe reduction of hospital stay after infarction in selected patients. However because the proportion of candidates for early discharge is small (12.6%), it seems unlikely that the current policies on length of hospital stay will change in the near future.

Technetium 99m-labeled tetrofosmin and iodine 123-labeled metaiodobenzylguanidine scintigraphy in the assessment of transmyocardial laser revascularization

OBJECTIVE Transmyocardial laser revascularization is a new technique that improves symptoms in patients with refractory angina not amenable to conventional revascularization. The aim of this study was to assess whether transmyocardial laser revascularization produces changes in innervation, perfusion scintigraphy, or both that could explain the benefit to patients. METHODS Sixteen patients (12 men and 4 women; mean age, 60 +/- 8 years) with coronary artery disease were studied. Transmyocardial laser revascularization was performed in 39 myocardial areas supplied by a stenotic vessel. A technetium 99m-labeled tetrofosmin stress-rest tomographic scan and iodine 123-labeled metaiodobenzylguanidine planar scans were performed before and after transmyocardial laser revascularization (3 and 12 months later) to evaluate myocardial perfusion and innervation. Stress and rest perfusion images were quantified on a polar map. Ischemia uptake was also defined as the difference between rest and stress uptake for each area. Innervation planar images were visually analyzed and semiquantified. RESULTS A significant decrease in angina class from baseline was observed at 3, 6, and 12 months after transmyocardial laser revascularization (P <.005). A significant decrease in ischemia uptake was also found between the pre-transmyocardial laser revascularization and the post-transmyocardial laser revascularization studies in treated areas (P <.001). A significant improvement in stress myocardial perfusion at 3 and 12 months after transmyocardial laser revascularization was only found in treated areas that were considered ischemic in the pre-transmyocardial laser revascularization study (P <.05). At 3 months, a significant myocardial innervation worsening was observed in treated areas (P <.001), with partial recovery at 12 months (P <.05). CONCLUSION The transmyocardial laser revascularization mechanism involves both perfusion improvement and denervation, mainly at 3 months, that partially recovered at 12 months.

Impacto de los datos clínicos y concordancia interhospitalaria en la interpretación de la tomogammagrafía miocárdica de perfusión

Introduccion y objetivos Este estudio pretende conocer el impacto de los datos clinicos y la concordancia interhospitalaria en la interpretacion de las imagenes tomograficas y de los mapas polares de la tomogammagrafia miocardica de perfusion. Metodos Se estudian 150 pacientes provenientes de 5 hospitales. Cada uno aporto las imagenes tomograficas y los mapas polares de la tomogammagrafia miocardica de esfuerzo con 99m Tc-tetrofosmina correspondientes a 30 pacientes y sus informes clinicos. Asi, cada centro interpreto un total de 300 imagenes (150 correspondientes a las imagenes tomograficas y 150 a los mapas polares) sin conocimiento de ningun dato del paciente. Resultados Noventa de los 150 pacientes (60%) tenian al menos una estenosis coronaria 3 50%. La sensibilidad y la especificidad del informe clinico fueron del 91 y del 86%, respectivamente. La sensibilidad determinada por decision mayoritaria (tres o mas centros) fue del 82% para las imagenes tomograficas y del 83% para los mapas polares (p = 0,002 y p = 0,03, respectivamente, con respecto al informe clinico). La especificidad fue del 88% para las imagenes tomograficas y del 79% para los mapas polares (p = 0,05 con respecto a las imagenes tomograficas). La concordancia interhospitalaria fue buena tanto para las imagenes tomograficas (kappa: 0,625) como para los mapas polares (kappa: 0,7). Conclusiones La sensibilidad del informe clinico de la tomogammagrafia de perfusion es significativamente superior a la del informe «a ciegas». La especificidad del informe «a ciegas» de los mapas polares tiende a ser inferior a la de las imagenes tomograficas. La concordancia interhospitalaria en la interpretacion de ambos tipos de imagenes es buena.

Bases anatomopatológicas de la disfunción ventricular latente en diabéticos insulinodependientes

Introduccion y objetivos La historia natural dela miocardiopatia diabetica no esta bien definida,debido principalmente a la comun asociacion conenfermedad coronaria e hipertension arterial. Dadoque estas dos entidades son infrecuentes en los pacientesjovenes, estos constituyen un modelo adecuadopara el estudio de la miocardiopatia diabeticaen sus fases incipientes. Pacientes y metodos Se estudiaron 33 pacientesafectados de diabetes mellitus tipo I sin antecedentesde hipertension arterial ni enfermedad coronaria.Su edad media era de 28 ± 8 anos (rango, 18-46anos) y 14 eran varones. Resultados En el ecocardiograma se observo unventriculo izquierdo de tamano normal y sin anomaliasde la motilidad segmentaria, excepto en uncaso. En la ventriculografia isotopica se detectouna fraccion de eyeccion basal del 56,5 ± 6,6% queaumento al 63 ± 7,4% (p Conclusiones La disfuncion ventricular latentees un hallazgo frecuente en los pacientes diabeticosjovenes asintomaticos, y esta no es secundaria aaterosclerosis coronaria ni a enfermedad de pequenovaso. En este grupo de pacientes las anomaliashistologicas son constantes y se manifiestan por fibrosisintersticial, hipertrofia celular, miocitolisis ydepositos lipidicos.

Noninvasive assessment of cardiac risk in type I diabetic patients being evaluated for combined pancreas‐kidney transplantation using dipyridamole‐MIBI perfusion

Abstract This study was performed to determine the value of dipyridamole‐99 mTc‐methoxy‐isobutyl isonitrile perfusion (99mTC‐MIBI) tomographic scintigraphy in the assessment of cardiac risk in patients being evaluated prior to combined pancreas‐kidney transplantation (PKT). We performed perfusion tomographic scintigraphy using single photon emission computed tomography (SPECT) on 77 patients. The tomographic images did not show clinically relevant findings in 65 patients. In the remaining 12 patients, coronary arteriography was performed: 2 showed normal results, 4 showed no stenosis, and 6 showed significant stenosis (≥ 70%). Seventy‐two patients underwent PKT. During the follow‐up (6–48 months), there were seven cardiac events, 4 patients with significant stenosis, and 3 with nonsignificant stenosis upon coronary arteriography, and all had pathological tomographic images. 99mTc‐MIBI tomographic scintigraphy may be useful in identifying patients at low risk of incurring cardiac events after PKT and may, in a large group of patients, obviate the need for routine coronary angiography.

Clinical course and risk stratification of myocardial infarct survivors with three-vessel disease

Prevalence of three-vessel disease was prospectively analyzed in a series of 462 consecutive infarct survivors aged 60 years or less. Eighty-seven percent (403) of the patients were catheterized within one month of the acute event, and were followed for a mean of 43 months (range 21 to 69). Three-vessel disease was present in 96 cases (24%) and these patients form the study population. The primary goals of this study were to determine the prevalence of three-vessel disease and to identify predictors of survival and new coronary events among this subset of infarct survivors. During follow-up, 15 patients died, 17 had a recurrent nonfatal infarction, and 54 developed angina (4-year probability of each cardiac event being 0.20, 0.22, and 0.59, respectively). Coxs stepwise multivariate analysis identified the ejection fraction (EF) as the only predictor of survival (p less than 0.001). No predictors for nonfatal ischemic events were found among the independent variables considered. Patients were stratified in risk categories according to the EF. Four-year probability of survival was 1.0 in participants with EF = greater than 50% (n = 23), 0.77 for those with EF = 21% to 49% (n = 66), and 0.22 in patients with more severe left ventricular dysfunction, EF = less than 20% (n = 7). Probability of occurrence of nonfatal reinfarction or angina was similar in the three risk categories. Thus, our results indicate that a normal ejection fraction is found in 25% of infarct survivors with three-vessel disease, and that this subset of patients has a low incidence of early and intermediate range coronary events.

MEJORIA DE LA PERFUSION MIOCARDICA TRAS REVASCULARIZACION TRANSMIOCARDICA CON LASER

quémica desde 1976. En mayo de 1998 reingresó por un nuevo episodio de angina inestable, en clase funcional IV. Se practicó una prueba de esfuerzo con medicación que fue positiva clínica y eléctricamente a los 6,5 METS, alcanzando el 50% de la frecuencia cardíaca máxima. En la tomografía miocárdica de perfusión con 99mTc-tetrofosmina ( fig. 1, PRE RVTL) se observaron defectos en las regiones anterior (A), septal (S) e inferior (I) tras el esfuerzo (ESF), que mejoraban con el reposo (REP). En un cateterismo cardíaco se detectó una oclusión en el tercio medio de la arteria descendente anterior y una lesión del 70% en la interventricular posterior con vaso distal ateromatoso, que no fueron consideradas aptas para revascularización convencional. Dado de alta, reingresó dos semanas más tarde por nuevo episodio de angina inestable. Se practicó revascularización transmiocárdica con láser (RVTL) de holmio: YAG en las regiones anterior, lateral e inferior, sin complicaciones. A los 3 meses, el pacientes se encuentra en clase funcional II. Una nueva prueba de esfuerzo con medicación fue clínica y eléctricamente negativa, alcanzando 8 METS y el 60% de la frecuencia cardíaca máxima. En la tomogammagrafía (fig. 1, POST RVTL) se observa una mejoría clara de la perfusión en el esfuerzo (ESF) en las caras anterior (A), septal (S) e inferior (I).

Non invasive assessment of cardiac risk in type I diabetic patients being evaluated for combined pancreas-kidney transplantation (PKT) using Dypiridamole-MIBI perfusion tomographic scintigraphy

This study was performed to determine the value of dipyridamole-99m Tc-methoxy-isobutyl isonitrile perfusion (99mTC-MIBI) tomographic scintigraphy in the assessment of cardiac risk in patients being evaluated prior to combined pancreas-kidney transplantation (PKT). We performed perfusion tomographic scintigraphy using single photon emission computed tomography (SPECT) on 77 patients. The tomographic images did not show clinically relevant findings in 65 patients. In the remaining 12 patients, coronary arteriography was performed: 2 showed normal results, 4 showed no stenosis, and 6 showed significant stenosis ( > or = 70%). Seventy-two patients underwent PKT. During the follow-up (6-48 months), there were seven cardiac events, 4 patients with significant stenosis, and 3 with nonsignificant stenosis upon coronary arteriography, and all had pathological tomographic images. 99mTc-MIBI tomographic scintigraphy may be useful in identifying patients at low risk of incurring cardiac events after PKT and may, in a large group of patients, obviate the need for routine coronary angiography.