José Luis Winter

Matrix metalloproteinase-9 activity is associated to oxidative stress in patients with acute coronary syndrome

Abstract In the present work we evaluate the relationship between oxidative stress and matrix metalloproteinases-2 and -9 (MMP-2 and -9) activities in 44 patients with non ST-elevation acute coronary syndrome. We found an early increase in malondialdehyde (MDA) levels (oxidative stress marker) and MMP-9, with decrease of both at day five. A positive correlation was found between fractional changes of MDA and MMP-9, suggesting a common role in the pathophysiology of the acute coronary syndrome.

Effects of trimetazidine in nonischemic heart failure: a randomized study.

OBJECTIVES Heart failure (HF) is associated with changes in myocardial metabolism that lead to impairment of contractile function. Trimetazidine (TMZ) modulates cardiac energetic efficiency and improves outcomes in ischemic heart disease. We evaluated the effects of TMZ on left ventricular ejection fraction (LVEF), cardiac metabolism, exercise capacity, O2 uptake, and quality of life in patients with nonischemic HF. METHODS AND RESULTS Sixty patients with stable nonischemic HF under optimal medical therapy were included in this randomized double-blind study. Patients were randomized to TMZ (35 mg orally twice a day) or placebo for 6 months. LVEF, 6-minute walk test (6MWT), maximum O2 uptake in cardiopulmonary exercise test, different markers of metabolism, oxidative stress, and endothelial function, and quality of life were assessed at baseline and after TMZ treatment. Left ventricular peak glucose uptake was evaluated with the use of the maximum standardized uptake value (SUV) by 18-fluorodeoxyglucose positron emission tomography ((18)FDG-PET). Etiology was idiopathic in 85% and hypertensive in 15%. Both groups were similar in age, functional class, LVEF, and levels of N-terminal pro-B-type natriuretic peptide at baseline. After 6 months of TMZ treatment, no changes were observed in LVEF (31 ± 10% vs 34 ± 8%; P = .8), 6MWT (443 ± 25 m vs 506 ± 79 m; P = .03), maximum O2 uptake (19.1 ± 5.0 mL kg(-1) min(-1) vs 23.0 ± 7.2 mL kg(-1) min(-1); P = .11), functional class (percentages of patients in functional classes I/II/III/IV 10/3753/0 vs 7/40/50/3; P = .14), or quality of life (32 ± 26 points vs 24 ± 18 points; P = .25) in TMZ versus placebo, respectively. In the subgroup of patients evaluated with (18)FDG-PET, no significant differences were observed in SUV between both groups (7.0 ± 3.6 vs 8.2 ± 3.4 respectively; P = .47). CONCLUSIONS In patients with nonischemic HF, the addition of TMZ to optimal medical treatment does not result in significant changes of LVEF, exercise capacity, O2 uptake, or quality of life.

Relationship between mechanical and metabolic dyssynchrony with left bundle branch block: evaluation by 18-fluorodeoxyglucose positron emission tomography in patients with non-ischemic heart failure.

BACKGROUND Ventricular dyssynchrony is a common finding in patients with heart failure (HF), especially in the presence of conduction delays. The loss of ventricular synchrony leads to progressive impairment of contractile function, which may be explained in part by segmental abnormalities of myocardial metabolism. However, the association of these metabolic disarrangements with parameters of ventricular dyssynchrony and electrocardiography (ECG) findings has not yet been studied. METHODS Our aim was to determine the correlation between the presence of left bundle branch block (LBBB) with left ventricular (LV) mechanical synchrony assessed by multiple-gated acquisition scan (MUGA) and with patterns of 18-fluorodeoxyglucose (18FDG) uptake in patients with non-ischemic heart failure. Twenty-two patients with non-ischemic cardiomyopathy, LV ejection fraction (LVEF) ≤45% and New York Heart Association (NYHA) Functional Class II or III symptoms under standard medical therapy were included, along with 10 healthy controls matched for age and gender. A 12-lead ECG was obtained to measure the length of the QRS. Mechanical LV synchrony was assessed by MUGA using phase analysis. All patients and controls underwent positron emission tomography with 18FDG to determine the distribution of myocardial glucose uptake. The standard deviation of peak (18)FDG uptake was used as an index of metabolic heterogeneity. Students t-test and Pearsons correlation were used for statistical analysis. RESULTS The mean age of the patients with HF was 54 ± 12 years and 72% were male. The length of the QRS was 129 ± 31 milliseconds and LBBB was present in 9 patients. Patients with HF had decreased LV 18FDG uptake compared with controls (7.56 ± 3.36 vs. 11.63 ± 4.55 standard uptake value; p = 0.03). The length of the QRS interval correlated significantly with glucose uptake heterogeneity (r = 0.62; p = 0.002) and mechanical dyssynchrony (r = 0.63; p = 0.006). HF patients with LBBB showed marked glucose uptake heterogeneity compared with HF patients without LBBB (41.4 ± 10 vs 34.7 ± 4.9 ml/100 g/min, respectively; p = 0.01). CONCLUSIONS Patients with non-ischemic heart failure exhibit a global decrease in myocardial glucose uptake. Within this group, subjects who also have LBBB exhibit a marked heterogeneity in segmental glucose uptake, which directly correlates with QRS duration.

Angiographic and electrocardiographic parameters of myocardial reperfusion in angioplasty of patients with ST elevation acute myocardial infarction loaded with ticagrelor or clopidogrel (MICAMI—TICLO trial)

INTRODUCTION Ticagrelor has been shown to improve outcomes in patients with ACS. However, the effects of this drug on parameters of microvascular flow in patients presenting with ST-segment elevation myocardial infarction (STEMI) have not been completely evaluated. METHODS Ninety-two patients presenting with STEMI where randomized to a loading dose of clopidogrel (600 mg) or ticagrelor (180 mg) before undergoing primary angioplasty. We assessed angiographic and electrocardiographic parameters of myocardial reperfusion. Blinded operators calculated angiographic corrected TIMI Frame count (cTFC) and myocardial blush grade (MBG) before and after stent implantation. ST segment resolution was also measured in all patients. Primary endpoint was cTFC after PCI. Secondary endpoints were cTFC prior to PCI, TIMI flow grade, MBG and the percentage of ST resolution. RESULTS Of the 92 randomized patients, 70 patients were analyzed. Mean age of patients was 58.8±10 years. Patients presented with a mean ischemic time of 4.4±2.6 hours. There were no significant differences in the time between loading dose and stent deployment (35.2±36.4 in ticagrelor and 42.7±29.5 min in clopidogrel, p=0.36). cTFC before angioplasty was significantly lower in ticagrelor than in clopidogrel (81.1±29.4 vs. 95.1±17.5 frames respectively, p=0.01). After angioplasty there were no differences between ticagrelor and clopidogrel in cTFC (24.6±9.3 vs. 27.0±13.4 frames respectively, p=0.62); MBG grade 3 was present in 76.4 vs. 69.4% of patients, respectively (p=0.41). The percentage of ST resolution did not show any differences between groups (84.8±23.4 in ticagrelor vs. 70.8±33.7 in clopidogrel, p=0.36). CONCLUSION Compared with clopidogrel, ticagrelor loading in patients presenting with STEMI is not associated with an improvement of angiographic and electrocardiographic parameters of myocardial reperfusion after angioplasty.

INFARTO AGUDO AL MIOCARDIO EN PACIENTES MENORES DE 40 AÑOS: CARACTERISTICAS CLÍNICAS, ANGIOGRÁFICAS Y ALTERNATIVAS TERAPÉUTICAS

Analisis retrospectivo de los pacientes que se presentaron con un IAM con SDST y fueron some-tidos a angiografia coronaria durante el periodo entre enero de 2009 y diciembre de 2011. Se identifico a los pacientes menores de 40 anos y se registraron sus carac-teristicas clinicas y angiograficas, las terapias utilizadas y sus resultados a mediano plazo. Estos datos fueron com -parados con los pacientes de 40 o mas anos atendidos durante el mismo periodo.

Determinaciones de niveles de creatina y lípidos mediante espectroscopia por resonancia magnética en miocardio de pacientes con insuficiencia cardiaca no isquémica

Heart failure (HF) is characterized, among other features, by the development of alterations in myocardial energy metabolism, involving a decrease in glucose utilization and increased free fatty acid uptake by cardiomyocytes, associated with decreased deposits of high-energy phosphates (creatine phosphate/ creatine transporter). Magnetic resonance (MR) imaging allows a direct and noninvasive assessment of myocardial metabolites.

Nitroprusiato: una droga confiable para la estimación de la reserva de flujo fraccional coronario

Resumen: La angiografia coronaria permanece como “gold standard” para el diagnostico y toma de decisiones en la enfermedad coronaria. Sin embargo, la significacion de lesiones con estenosis de 50-70% es dificil. La medicion de la reserva de flujo fraccional (FFR) es una herramienta util para dilucidar esta inte-rrogante. Generalmente se usa adenosina (A) en bolo intracoronario para inducir maxima vasodilatacion y hay poca evidencia para drogas alternativas con este ob-jeto. En este estudio evaluamos el uso de nitroprusiato (N) como droga alternativa. Metodos y Resultados: Se efectuo un estudio clinico aleatorizado. A (120 ug IC) y posteriormente N (50 ug IC), o vice-versa, se usaron para evaluar cada lesion. Se evaluaron 60 lesiones en 44 pacientes (24 hombres) de 63.5 ± 9.6 anos, con masa corporal 28.95 ± 3.32 kg/m2. Las lesiones se localizaron en arteria descendente anterior en 46.7%, coronaria derecha en 26.7%, circunfleja en 11.7% y 13.9% en las otras ar-terias. La estenosis coronaria promedio evaluada por angiografia cuantitativa fue 49.5% (95% CI: 46.5 - 52.5%). La presion arterial media (PAM) basal fue similar en ambos grupos (pre - A: 106.5 ± 18.2 mmHg, pre - N: 105.6 ± 18.8 mmHg, NS) o despues de A, pero se observo un descenso transitorio despues de NP (descenso promedio de 12.5 mmHg, 95% CI: 9.2 a15.7 mmHg, 2p < 0.001). Este efecto estaba asociado a la hiperemia prolongada lograda con N. (duracion de hiperemia con N: 39.2 ± 8.7 s., y con A of 15.3 ± 3.2 s. 2p < 0.001). Hubo excelente correlacion entre los resultados de A y de N respecto de FFR (r 0.986). Se observo solo 1 caso de hipotension sintomatica con N. cuatro pacientes con A y 2 con N desarrollaron angina. Ademas, 10 pacientes desarrollaron bloqueo A-V tran-sitorio con A y ninguno con N.

Spontaneous rupture of tricuspid valve papillary muscle in pulmonary hypertension secondary to HIV infection. Report of one case

Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42-year-old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who presented with an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilator therapy. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully controlled with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a life saving and useful approach in this condition.Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42 years old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who developed an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilators. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully managed with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a live saving and useful approach in this condition.

Rotura espontánea de válvula tricúspide en un paciente con hipertensión pulmonar secundaria a VIH

Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42-year-old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who presented with an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilator therapy. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully controlled with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a life saving and useful approach in this condition.Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42 years old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who developed an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilators. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully managed with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a live saving and useful approach in this condition.

CRT-200.47 Primary Angioplasty in Bifurcation Lesions: Comparision of a Complex vs Simple Strategy and Its Impact on Myocardial Reperfusion

It is not uncommon to find bifurcation lesions in a primary angioplasty (AP) in patients coursing an acute myocardial infarction with ST segment elevation (STEMI). Although the literature supports a simple strategy in patients with stable coronary heart disease and bifurcations, there is little