José Luis Moya

Endothelial dysfunction, intima-media thickness and coronary reserve in relation to risk factors and Framingham score in patients without clinical atherosclerosis.

Background Endothelial dysfunction, decreased coronary flow reserve (CFR) and increased intima–media thickness (IMT) are related to atherosclerosis and can be assessed non-invasively by echography. Objectives In order to describe the relationship between these parameters and with cardiovascular risk, this study investigated them simultaneously in patients without clinical atherosclerosis. Methods A total of 106 subjects were studied, 91 with and 15 without cardiovascular risk factors. Cardiovascular disease was excluded in all cases. Doppler ultrasound was used to analyse endothelium-dependent vascular dilation in the brachial artery, IMT in the common carotid artery and CFR in the left anterior artery. Results Patients with cardiovascular risk factors had impaired flow-mediated dilation (FMD; 3.7 ± 3.2 versus 11.6 ± 4.4%, P = 0.000); greater IMT (0.89 ± 0.3 versus 0.56 ± 0.14 mm, P = 0.000) and lower CFR (2.7 ± 0.9 versus 4 ± 1.2, P = 0.000). Correlation was found between IMT and FMD r = −0.240, (P = 0.013), IMT and CFR, r = −0.384 (P = 0.000), and between FMD and CFR of r = 0.289 (P = 0.007). All patients with IMT greater than 1 mm showed depressed FMD, most of them with low values of CFR, but patients with reduced FMD or CFR did not necessarily show increased IMT. There was a significant correlation between the three parameters and the Framingham risk score. Multiple linear regression analysis showed that IMT was the only factor related to the Framingham score. Conclusion In patients without clinical atherosclerotic disease, cardiovascular risk factors are associated with impaired FMD, CFR and increased IMT. Even though a correlation between these changes was found, they showed different dependence on cardiovascular risk factors and with global risk, IMT being the best correlated with the Framingham score.

Trends in neurological complications of endocarditis

Neurological complications (NCs) are a major cause of morbidity and mortality in patients with infectious endocarditis (IE). The frequency of these complications has been found to remain constant since the preantibiotic era despite profound epidemiological changes and therapeutic advances. We have reviewed retrospectively all the cases of IE attended at a single institution between 1985 and 2003, aiming to study the clinical characteristics of the NCs, and to analyse possible temporal trends in their frequency. Among 550 patients with IE, 71 (13%) suffered NCs. NCs presented more frequently in native (NVE) and prosthetic (PVE) valve endocarditis (17% and 20%, respectively) than in endocarditis associated with drug addiction (IDU-NVE) or pacemeker (6% and 9%, respectively). Cerebrovascular disorders were the most frequent NCs (60% of the patients had ischemic events and 21% had haemorrhages). Meningitis and cerebral abscess occurred in 16% and 3% of patients with NCs, respectively, and diffuse encephalopathy in 13%. Staphylococus aureus infection was the only factor associated with NCs, but only in NVE. During the study period there was a trend for increasing frequency of NCs in IE patients, probably associated to several factors: a decrease in IDUNVE, an increase in more aggressive nosocomial acquired NVE, and an increase in NVE caused by S. aureus. Mortality among patients with NCs (34%) was significantly higher than in IE patients without them (11%). During the study period mortality increased in patients with NVE and NCs.

Asociación de la disfunción endotelial y el grosor mediointimal carotídeo con los factores de riesgo coronario en pacientes sin evidencia clínica de aterosclerosis

Introduccion y objetivos La disfuncion endotelial y el aumento del grosor mediointimal carotideo son fenomenos tempranos en el desarrollo de la aterosclerosis, que pueden estudiarse de forma incruenta por ecocardiografia. Se pretende analizar la funcion endotelial, el grosor mediointimal carotideo y la correlacion entre ambos parametros con los factores de riesgo coronario en pacientes sin evidencia clinica de aterosclerosis. Pacientes y metodo Se incluyeron 52 sujetos, 13 sin ningun factor de riesgo coronario y 39 con al menos un factor de riesgo coronario. Se les realizo una medicion ecocardiografica de la vasodilatacion dependiente del endotelio en la arteria braquial y del grosor mediointimal en la carotida comun. Resultados En comparacion con los sujetos sin factores de riesgo coronario, los pacientes con factores de riesgo presentaron una disminucion de la vasodilatacion dependiente del endotelio: 11,98 ± 4,61% frente a 2,77 ± 2,57%, (p Conclusiones En pacientes sin evidencia clinica o complicaciones ateroscleroticas pero con factores de riesgo coronario, la funcion endotelial es peor y el grosor mediointimal carotideo es mayor que en pacientes sin ellos. Ademas, existe una asociacion lineal negativa entre la vasodilatacion dependiente del endotelio y el grosor mediointimal.

Diagnosis and grading of intrapulmonary vascular dilatation in cirrhotic patients with contrast transesophageal echocardiography

BACKGROUND/AIMS The use of transesophageal contrast echocardiography (TOCE) in the diagnosis of intrapulmonary vascular dilatation (IVD) and hepatopulmonary syndrome (HPS) needs to be studied. We tested the specificity of TOCE using traditional criteria and the value of a new method based on TOCE, a grading scale and a selected contrast. METHODS 1) Several solutions were tested and two were selected: 20% mannitol and 0.9% saline. 2) 71 cirrhotic patients and 20 controls were studied. Left atrium opacification with contrast was classified into 6 degrees by TOCE. Mild and significant IVD were considered in relation to results in controls. Patients were studied with saline and mannitol-TOCE. Results were compared to transthoracic contrast echocardiography (TTCE), to gas exchange abnormalities and to Child class. RESULTS The reproducibility of TOCE grading was excellent, (Kappa >0.9). IVD detection using TTCE, mannitol-TOCE and saline-TOCE was 29.5%, 55% (25% mild and 30% significant), and 45% (38% mild and 7% significant), respectively. The best agreement with TTCE (reference method) was obtained with mannitol-TOCE, using significant IVD as the cut point. By this criterion, 18% reached the criteria of HPS using TTCE and 22% using mannitol-TOCE. Patients with IVD by TTCE had non-significant changes in gas exchange determinations. Patients with significant IVD by saline TOCE had lower mean PaO2 levels (67.3+/-14 vs. 79.5+/-11 mm Hg, p<0.05) than patients without IVD. Patients with significant IVD by mannitol TOCE had higher mean AaPO2 (29.3+/-14 vs. 19.7+/-9 mm Hg; p<0.005) and lower mean PaCO2 levels (30.1+/-4.4 vs. 33.4+/-4.8 mm Hg; p<0.05) than patients without IVD. Severity of IVD by TOCE correlated to Child class (r = 0.43; p<0.001). CONCLUSIONS The presence of contrast in the left atrium cannot be a criterion of IVD when TOCE is used. Our semi-quantitative scale has proved to be feasible and reproducible, presenting a good agreement with TTCE, and has shown better correlation with gas exchange abnormalities and Child class. Saline TOCE appears to be more specific in the detection of hypoxemic patients with IVD, but mannitol TOCE adds sensitivity.

Regression of left ventricular hypertrophy by a candesartan-based regimen in clinical practice. The VIPE study.

The VIPE study was a prospective, non-comparative, open-label clinical evaluation of 97 hypertensive patients (69.1% female; 68.9±9.5 years; mean blood pressure (BP) 160±12/90±9 mmHg) with echocardiographic evidence of left ventricular hypertrophy (LVH). Patients were treated for six months with a candesartan-based regimen (8 mg/16 mg + HCTZ 12.5 mg + additional drugs to lower BP < 140/90 mmHg). After six months, systolic/diastolic BP was decreased by 19.3±8/9.4±5 mmHg (p<0.001 for both), and left ventricular mass index (LVMI) decreased 17.01 g/m2 (95%CI: -13.2 to -20.99; p<0.001). During treatment with the candesartan-based regimen all echocardiographic parameters related to LVMI were significantly reduced and 28% achieved a target LVMI [< 134 g/m2 (men) and < 110 g/m2 (women) ]. No significant changes were observed in ejection fraction, shortening fraction or LV diastolic function. Univariate analysis showed that both age (p=0.03) and diabetes (p=0.029) were predictive of LVH regression. Thus, a candesartan-based regimen for six months significantly reduced echocardiographic LVH in hypertensive patients in general practice. The drug was very well tolerated and no serious adverse events were reported.

Extracción de electrodos de marcapasos y desfibrilador mediante técnicas percutáneas

Introduccion y objetivos La necesidad de retirar los electrodos endocavitarios del marcapasos o el desfibrilador es cada vez mas frecuente, aunque no esta exenta de riesgos y complejidad. Revisamos nuestra experiencia en la retirada de electrodos por via percutanea desde abril de 1989 hasta junio de 2006. Metodos Se retiraron 314 electrodos en 187 pacientes, implantados durante un periodo medio de 69,16 meses (intervalo, 0,11-234,6 meses; mediana 60,25 meses). En total, 115 fueron auriculares, 196 ventriculares y 3 de seno coronario, encontrandose 78 de ellos abandonados en el lecho vascular. Resultados Las indicaciones fueron: infeccion (26,1%), disfuncion (22,9%), decubito (25%), endocarditis (20,7%) y bacteriemia (2,7%). El 58,8% de los pacientes fue remitido desde otros servicios. El 96,8% de los electrodos se retiro completamente. Se utilizo la traccion simple en el 23,4% de los pacientes y tecnicas de contratraccion (con y sin radiofrecuencia) en el 60,7%. En caso de que hubiera electrodos abandonados, se utilizo una pinza de biopsia (4,3%) combinada con sistemas de contratraccion o lazos femorales (10,1%). Se necesito una esternotomia media en 3 pacientes de los 10 en los que quedaron restos de electrodos. El porcentaje de complicaciones fue del 4,6% (un 2,5% de complicaciones mayores). Estas se relacionaron con la edad menor de 60 anos (odds ratio [OR] = 5,38; intervalo de confianza [IC] del 95%, 1,07- 27,23), la presencia de endocarditis (OR = 4,97; IC del 95%, 1,04-23,70) y la implantacion por el lado derecho (OR = 17,09; IC del 95%, 2,15-135,70). Conclusiones La retirada de electrodos endocavitarios con los modernos sistemas de extraccion soluciona el problema en la mayoria de los casos. Debido a la posibilidad, aunque baja, de complicaciones durante la retirada, se aconseja realizar el procedimiento en centros especializados con capacidad quirurgica.

Cierre de ductus en adultos mediante dispositivo de Rashkind: resultados comparativos

Introduccion. El cierre del conducto arterioso persistente mediante dispositivo de Rashkind es una alternativa a su correccion quirurgica en ninos y, sin embargo, existe escasa informacion sobre su utilidad en adultos. Metodo. Entre 1990 y 1996 se sometieron al cierre ductal 127 pacientes estudiando el resultado retrospectivamente. Segun la edad se clasificaron en 105 pacientes menores de 14 anos (ninos) y 22 pacientes mayores de 14 anos (adultos). El cierre se analizo mediante aortograma inmediato y ecocardiograma-Doppler color a las 24 h y a los 6 y 12 meses. Resultados. De los adultos, 19 se encontraban asintomaticos (86%) y en 13 (59%) los ductus eran silentes. Encontramos cocientes QP/QS similares (1,61 ± 0,47 en adultos frente a 1,49 ± 0,51 en ninos), pero presiones pulmonares mayores en ninos (12,50 ± 2,97 frente a 16,84 ± 5,88 mmHg; p = 0,003). En adultos, la anatomia ductal favorable (tipos A y B de Krichenko) fue mas frecuente (el 91 frente al 73%; p = 0,06) y el diametro ductal significativamente mayor (3,03 ± 1,50 frente a 2,41 ± 0,96 mm; p = 0,009). En dicho grupo se usaron mas frecuentemente dispositivos de 17 mm (el 91 frente al 61% p = 0,02). No se produjeron complicaciones (embolizacion, endarteritis, hemolisis o estenosis de ramas pulmonares) en adultos frente a un 4,72% por embolizacion en ninos. Se logro el cierre mas frecuentemente en adultos principalmente en los primeros controles: el 55 frente al 34% (p = 0,09), y el 82 frente al 69%, el 91 frente al 77% y el 95 frente al 83% (p > 0,10). El analisis multivariante identifico a la edad superior a 14 anos como predictor independiente de cierre. Conclusion. Nuestra experiencia sugiere que el cierre ductal con dispositivo de Rashkind en adultos es seguro y tanto o mas eficaz que en ninos a pesar de tratarse generalmente de ductus asintomaticos y silentes.

Prognostic value of transthoracic echocardiography in hemodynamically stable patients with acute symptomatic pulmonary embolism

OBJECTIVE To determine the prognostic value of transthoracic echocardiography in hemodynamically stable patients diagnosed with acute symptomatic pulmonary embolism. PATIENTS AND METHODS Hemodynamically stable outpatients diagnosed with acute symptomatic pulmonary embolism at a tertiary university hospital were prospectively included in the study. All patients underwent transthoracic echocardiography within 48 hours of diagnosis. The primary endpoint was all-cause mortality at 1 month. RESULTS Right ventricular dysfunction was documented by echocardiography in 86 of the 214 patients (40%) in our series. In the first month of follow-up, 7 patients died--4 with positive echocardiographic findings and 3 with negative findings (odds ratio, 2.0; 95% confidence interval, 0.4-9.3; P=.41). For the primary endpoint, the negative predictive value of transthoracic echocardiography was 98%, the positive predictive value was 5%, and the negative likelihood ratio was 0.7. The negative predictive value was 100% and the positive predictive value was 3% when we analyzed death due to pulmonary embolism only. CONCLUSIONS In our setting, transthoracic echocardiography is not useful for prognostic stratification of hemodynamically stable patients with pulmonary embolism.

Noninvasive Assessment of the Effect of Atorvastatin on Coronary Microvasculature and Endothelial Function in Patients With Dyslipidemia

INTRODUCTION AND OBJECTIVES The effect of statins has been monitored mainly in peripheral arteries. It is now possible to study coronary microcirculation by analyzing coronary reserve with transthoracic echocardiography. The aim of this study was to use this noninvasive technique to evaluate the effect of atorvastatin on peripheral endothelial function and on the coronary microvasculature in patients with dyslipidemia. PATIENTS AND METHOD We included 21 patients with dyslipidemia but no clinical antecedents of atherosclerosis. Mean (SD) age was 64.9 (11) years, and women made up 61.9% of the group. All patients were treated with 20 mg atorvastatin during 3 months. Lipid profile, carotid intima-media thickness, endothelium-dependent vasodilation and coronary flow reserve were determined at baseline and at the end of treatment. All studies were performed with echocardiographic techniques. RESULTS Together with improvements in the lipid profile, we found a 43% increase in endothelium-dependent vasodilation (4.3 [4.4] to 6.2 [3.8]; P=.07) and a 25% increase in coronary flow reserve (2.5 [0.6] vs 3.1 [0.8]; P=.002). The increase in endothelium-dependent vasodilatation correlated with age (r=-0.60; P=.004), intima-media thickness (r=-0.47; P=.029), low-density lipoprotein level before treatment (r=-0.43; P=.05), and baseline endothelium-dependent vasodilatation (r=-0.63; P=.002). The increase in coronary flow reserve correlated with low-density lipoprotein level after treatment (r=-0.51; P=.04). CONCLUSIONS Short-term treatment with atorvastatin improved the lipid profile, coronary microvascular function and endothelium-dependent vasodilation in the peripheral circulation. The noninvasive assessment of coronary reserve is feasible with transthoracic echocardiography.

Consenso sobre la terapia de Resincronización Cardíaca

Dentro del arsenal terapeutico de la insuficiencia cardiaca, la resincronizacion cardiaca cada vez esta adquiriendo un papel mas importante como coadyuvante del tratamiento medico. Se ha demostrado ampliamente que en los pacientes con insuficiencia cardiaca avanzada y bloqueo de rama izquierda, la estimulacion biventricular produce una mejoria hemodinamica y clinica, asi como un remodelado inverso del ventriculo izquierdo. Algunos estudios sugieren tambien una disminucion de la mortalidad. Sin embargo, es una terapia costosa y compleja que no esta libre de complicaciones y con un porcentaje de pacientes que no mejoran. Por ello, para su correcta aplicacion es necesaria una colaboracion multidisciplinaria. El Grupo de Trabajo de Resincronizacion Cardiaca de la Sociedad Espanola de Cardiologia ha redactado el presente documento de consenso con especial interes por exponer las indicaciones de esta terapia, asi como la correcta seleccion de los dispositivos y su adecuada tecnica de implante y seguimiento.