Juan A. Ruipérez

Hyperuricaemia and long-term outcome after hospital discharge in acute heart failure patients

Uric acid (UA) may be involved in chronic heart failure (HF) pathogenesis, entailing a worse outcome. The purpose of this study was to examine the role of hyperuricaemia as a prognostic marker after hospital discharge in acute HF patients.

Ventricular function during liver reperfusion in hepatic transplantation. A transesophageal echocardiographic study.

Postreperfusion syndrome (PRS) is the most dramatic and acute hemodynamic alteration that occurs in OLT. Our aim was to determine heart function by hemodynamic monitoring and transesophageal echocardiography during PRS. We studied 24 nonconsecutive patients allocated to 2 groups: group A (n = 8), patients with PRS, and group B (n = 16), patients without PRS. Usual hemodynamic data were obtained simultaneously with transesophageal echocardiography recording of the left ventricular imaging in 4 different stages: after induction of anesthesia, 5 min before the end of the anhepatic phase, between 2 and 5 min after reperfusion, and 5 min after graft reperfusion. The hemodynamic and echocardiographic findings during reperfusion were (group A vs. group B patients): mean arterial pressure, 50.0 +/- 15.2 vs. 74.7 +/- 13.9 mmHg (P < 0.01); pulmonary capillary wedge pressure, 12.7 +/- 6.1 vs. 13.9 +/- 5.7 mmHg (NS); left ventricular ejection fraction, 79.6 +/- 9.3 vs. 83.4 +/- 9.4% (NS); left ventricular end diastolic volume index, 35.5 +/- 12.7 vs. 54.7 +/- 21.3 ml/m2 (P < 0.05); and stroke volume index, 27.9 +/- 8.9 vs. 45.5 +/- 15.9 ml/m2 (P < 0.01). There was a mild decrease in left ventricular compliance in group A. We found no alteration in left ventricular function that can justify PRS. The hemodynamic changes during PRS seemed to be caused by an insufficient increase in preload after unclamping.

Differential Actions of Eplerenone and Spironolactone on the Protective Effect of Testosterone Against Cardiomyocyte Apoptosis In Vitro

INTRODUCTION AND OBJECTIVES Testosterone deficiency is associated with a poor prognosis in patients with heart failure. It is not clear whether testosterone reduces cardiomyocyte apoptosis or whether the effect of spironolactone, an aldosterone receptor blocker with progestogenic and anti-androgen activity, differs from that of the selective aldosterone blocker eplerenone. METHODS Apoptosis induced by hyperosmotic stress in the embryonic rat heart cell line H9c2 was monitored by measuring cell viability, DNA fragmentation and caspase-3, -8 and -9 activation. The effect of testosterone was investigated in the presence or absence of spironolactone and eplerenone. RESULTS Exposure to sorbitol (0.6 M, 3 h) decreased cell viability and increased DNA fragmentation and caspase-3, -8 and -9 activation. These effects were all significantly reduced by testosterone, 100 nM (P< .01). Pretreatment with spironolactone, 10 .M, blocked the effects of testosterone, decreased cell viability (P< .01) and increased caspase activation (P< .01). In contrast, eplerenone, 10 .M, increased cell viability (P< .001) without altering the effect on caspase activation. These actions were not modified by the androgen receptor blocker flutamide. They were mediated by SAPK/JNK and ERK1/2 signaling pathways (P< .01). CONCLUSIONS Testosterone appears to have a protective effect against cardiomyocyte apoptosis which is antagonized by spironolactone but not by eplerenone. These effects await confirmation in in vivo models, but their presence could have clinical and therapeutic implications.

Head-Up Tilt Test in Patients with High Pretest Likelihood of Neurally Mediated Syncope: An Approximation to the “Real Sensitivity” of this Testing

This study was designed to examine the “true sensitivity” of a specific head‐up tilt (HUT) testing protocol using clinical findings. The HUT protocol used 45 minutes at 60± for the baseline portion and intermittent boluses of 2, 4, and 6 μg of isoproterenol in the second phase. Eighty‐eight patients (40 men and 48 women; mean age of 33.8 ± 16 years) with recurrent syncope and high pretest likelihood of neurally mediated syncope were included. The following were considerated as high pretest likelihood criteria: (1) at least two syncopal episodes; (2) no structural heart disease and normal baseline ECG; (3) age < 65 years; (4) a typical history of neurally mediated syncope, triggering factors plus premonitory signs; and (5) short duration of symptoms and fast recovery without neurological sequelae. Fifty‐four patients (61%) had a positive tilt test (34/88 baseline [39%] and 20/50 with isoproterenol [40%]). The shorter time interval between the last syncopal episode and baseline HUT test was the only predictor for a positive response (P < 0.003). Conversely, this time interval was not predictor of positive responses during isoproterenol‐tilt testing. In conclusion: (1) we claim a “sensitivity” for this combined protocol of 61%; and (2) our results indicate that patients with syncope of unknown origin must be tilted nearest as possible to the last syncope to increase the positive responses of HUT test.

Sex Hormone-Binding Globulin: A New Marker of Disease Severity and Prognosis in Men With Chronic Heart Failure

INTRODUCTION AND OBJECTIVES Sex hormone-binding globulin (SHBG) is a key regulator of the actions of anabolic steroids. Chronic heart failure (HF) has been associated with anabolic steroid deficiency, but its relationship with SHBG is not known. METHODS The study involved 104 men (53+/-11 years) with HF (i.e. left ventricular ejection fraction [LVEF] <40%) attending a specialist clinic on optimum treatment and in a stable condition. At enrolment, the median and interquartile range (IQR) SHBG level was determined, associated hormone levels were measured, and known risk factors were recorded. The study end-point was cardiac death within 3 years. RESULTS At enrolment, the SHBG level (median 34.5 nmol/L, IQR 27-50 nmol/L) was correlated with the N-terminal probrain natriuretic peptide level (r=0.271, P=.005), LVEF (r=-0.263, P=.007), body mass index (r=-0.199, P=.020) and total testosterone level (r=0.332, P=.001). The median SHBG level was higher in the 16 patients (15.4%) who died, at 48.5 nmol/L (IQR 36-69.5 nmol/L) vs. 33 nmol/L (IQR 25.3-48.7 nmol/L; P=.001), and a high level was associated with an increased risk of death (hazard ratio [HR]=1.045, 95% confidence interval [CI] 1.021-1.069; P< .001). The association remained significant after adjustment in Cox multivariate regression modeling, at HR=1.049 (95% CI 1.020-1.079; P=.001). Analysis by SHBG tertiles showed mortality was 30% in the third tertile, 14% in the second, and 4% in the first (log rank 0.007; HR=3.25, 95% CI 1.43-7.34; P=.004). CONCLUSIONS The SHBG level correlated with measures of HF severity and was associated with a higher risk of cardiac death. Further studies are needed to clarify whether SHBG plays a role in HF pathophysiology.

Pulmonary Surfactant Protein B in the Peripheral Circulation and Functional Impairment in Patients With Chronic Heart Failure

INTRODUCTION AND OBJECTIVES Surfactant protein B (SP-B) is a marker of damage to the alveolar-capillary barrier that could be useful for monitoring functional impairment in patients with chronic heart failure (HF). METHODS Dyspnea-limited cardiopulmonary exercise testing was carried out in 43 outpatients with chronic HF (age 51+/-10 years, 77% male, left ventricular ejection fraction [LVEF] 33+/-11%). Peripheral blood serum samples were obtained at rest and during the first minute of peak exercise. The presence and concentration of SP-B in the serum samples were determined by Western blot analysis. RESULTS At rest, SP-B was detected in 35 (82%) patients compared with only six (23%) healthy volunteers in a control group (n=26, age 51+/-10 years, 77% male). The median circulating SP-B level was higher in HF patients, at 174 [interquartile range, 70-283] vs. 77 [41-152] (P< .001) in the control group. In HF patients, the presence of circulating SP-B was associated with a lower LVEF (31.4+/-9.6% vs. 41.8+/-15%; P=.01). Multivariate analysis showed that the resting SP-B level correlated with a greater VE/VCO2 slope (beta=1.45; P=.02). The peak-exercise SP-B level correlated almost perfectly with the resting level (r=0.980; P< .001), but there was no significant increase with exercise (P=.164). Nor was there a correlation with any other exercise parameter. CONCLUSIONS In patients with chronic HF, the level of pulmonary surfactant protein B in the peripheral circulation is increased and is correlated with ventilatory inefficiency during exercise, as indicated by the VE/VCO2 slope.

Tetralogía de Fallot en el adulto complicada con hemoptisis grave. Tratamiento mediante embolización de la arteria tirocervical izquierda

La tetralogia de Fallot con atresia pulmonar constituye una situacion especial en la que se permite la supervivencia hasta la edad adulta. En estos casos se desarrollan complicaciones, como la hemoptisis, que comprometen la vida del paciente y tienen dificil tratamiento. Cuando la causa del sangrado es la rotura de cortocircuitos arteriovenosos, frecuentes en las malformaciones vasculares multiples que se originan en esta cardiopatia, la embolizacion selectiva de estas malformaciones puede ser una opcion eficaz de tratamiento.

Trombosis subaguda con tratamiento antiagregante en una población no seleccionada de stents intracoronarios: incidencia y predictores

Introduccion Tras la implantacion de stents intracoronarios, el tratamiento con ticlopidina y acido acetilsalicilico ha conseguido incidencias de trombosis subaguda del 0% en poblaciones seleccionadas y con ultrasonidos intracoronarios. Objetivo. Evaluar la incidencia y los predictores de trombosis subaguda, en una poblacion no seleccionada, usando solo antiagregacion plaquetaria. Metodos Se estudiaron 285 stents implantados consecutivamente con exito en 268 lesiones de 226 pacientes. Se uso dilatacion a altas presiones, sin ultrasonidos intracoronarios. El protocolo postimplante incluyo ticlopidina y acido acetilsalicilico durante cuatro semanas, sin anticoagulacion. Se considero trombosis subaguda del stent la aparicion, tras las primeras 24 h y durante el primer mes, de muerte, infarto agudo de miocardio u oclusion angiografica del stent con flujo TIMI 0-I. Resultados Se produjeron 4 eventos (1,7%): tres pacientes presentaron infarto agudo de miocardio no fatal extrahospitalario, con trombosis angiografica del stent, y un paciente fallecio por infarto agudo de miocardio hospitalario. En los tres casos de infarto agudo de miocardio no fatal, los pacientes estaba tomando acido acetilsalicilico sin ticlopidina (p Conclusion Tras el implante de stents intracoronarios en una poblacion no seleccionada, la antiagregacion con ticlopidina y acido acetilsalicilico permite alcanzar incidencias de trombosis subaguda cercanas al 1%. La ticlopidina parece tener el papel preventivo fundamental, maxime en situaciones predisponentes, como los vasos pequenos.

Comparison of Late Mortality in Hospitalized Patients >70 Years of Age With Systolic Heart Failure Receiving Beta Blockers Versus Those Not Receiving Beta Blockers

Beta blockers are underprescribed to elderly patients with systolic heart failure (HF). We studied whether the prescription of a beta blocker is associated with a survival benefit in a nonselected population of patients >70 years of age hospitalized with acute HF and systolic dysfunction. We studied 272 consecutive patients >70 years (median 77.0, interquartile range 73.4 to 81.1) hospitalized with acute HF (left ventricular ejection fraction 34 +/- 8%) during a 2-year period. At discharge, beta-blocker therapy was prescribed in 139 patients (51.1%). A propensity score for the likelihood of receiving beta-blocker therapy was developed and showed a good performance (c-statistic = 0.825 and Hosmer-Lemeshow p = 0.820). After discharge, 120 patients (44.1%) died during the follow-up (median 31 months, interquartile range 12 to 46). Cox regression analysis showed a lower risk of death associated with beta-blocker prescription (p <0.001, hazard ratio [HR] 0.450, 95% confidence interval [CI] 0.310 to 0.655), which persisted after risk adjusting for the propensity score (HR 0.521, 95% CI 0.325 to 0.836, p = 0.007). In a propensity-matched cohort of 130 patients, there was a significantly lower mortality in patients receiving beta blockers (log rank 0.009, HR 0.415, 95% CI 0.234 to 0.734, p = 0.003). Risk reduction associated with beta blockade was observed with both high doses (HR 0.472, 95% CI 0.300 to 0.742, p = 0.001) and low doses (HR 0.425, 95% CI 0.254 to 0.711, p = 0.001). In conclusion, beta-blocker prescription at discharge in a nonselected population >70 years of age hospitalized with systolic HF is associated with a significantly lower risk of death even at low doses. This benefit remains consistent after adjustment for potential confounders.

Stents intracoronarios en vasos pequeños: resultados clínicos a corto y largo plazo

Objetivo Determinar los resultados clinicos de la revascularizacion con stents intracoronarios en vasos menores de 3 mm. Pacientes y metodos El tamano del vaso se evaluo como menor o mayor o igual de 3 mm en el momento del procedimiento y fue medido en el diametro maximo. Estudiamos a un total de 234 pacientes consecutivos (300 stents en 279 lesiones), con un seguimiento clinico de 17,6 ± 10 meses, comprendiendo 84 stents implantados en 79 lesiones localizadas en vasos pequenos ( Resultados La tasa de exito del implante, sin eventos clinicos hospitalarios, fue del 93,7% en los vasos Conclusion El implante de stents en coronarias