Paul McNab

Markedly increased Rho-kinase activity in circulating leukocytes in patients with chronic heart failure

BACKGROUND The small guanosine triphosphatase Rho and its target Rho-kinase have significant roles in experimental remodeling and ventricular dysfunction, but no data are available on Rho-kinase activation in patients with heart failure (HF). We hypothesized that, in patients with chronic HF, Rho-kinase in circulating leukocytes is activated and related to left ventricular (LV) remodeling and dysfunction. METHODS Accordingly, Rho-kinase activity, assessed by the levels of phosphorylated to total myosin light chain phosphatase 1 (MYPT1-P/T) in circulating leukocytes, and echocardiographic LV function data were compared between patients with HF New York Heart Association functional class II or III due to systolic dysfunction (n = 17), healthy controls (n = 17), and hypertensive patients without HF (n = 17). RESULTS In the control subjects, mean MYPT1-P/T ratio was 1.2 ± 0.2 (it was similar in the hypertensive patients without HF), whereas in patients with HF, it was significantly increased by >100-fold (P < .001). Both MYPT1-P/T and log MYPT1-P/T ratios were inversely correlated with ejection fraction (r = -0.54, P < .03 and r = -0.86, P < .001, respectively). Furthermore, in patients with HF with LV end-diastolic diameter <60 mm, MYPT1-P/T ratio was 35.8 ± 18.1, whereas it was significantly higher in patients with LV diameter ≥60 mm (P < .05). CONCLUSIONS Rho-Kinase activity is markedly increased in patients with stable chronic HF under optimal medical treatment, and it is associated with pathologic LV remodeling and systolic dysfunction. Mechanisms of Rho-kinase activation in patients with HF, its role in the progression of the disease, and the direct effect of Rho-kinase inhibition need further investigation.

Hipokalemia, hipovolemia y repercusión electrocardiográfica secundarias a ingesta prolongada de furosemida: Caso clínico

<3.5 mEq/l) is a potentially seriousadverse effect of diuretic ingestion. We report a 27 year-old woman admitted with muscleweakness, a serum potassium of 2.0 mEq/1, metabolic alkalosis and EKG abnormalitiessimulating cardiac ischemia, that reverted with potassium chloride administration. Sheadmitted high dose furosemide self-medication for edema. Glomerular filtration rate, tubularsodium reabsortion, potassium secretion, the renin-aldosterone system, total body waterdistribution and capillary permeability, were studied sequentially until 90 days after heradmission. There was hyperactivity of the renin-aldosterone axis, reduction in extracellularand intracellular volumes, normal capillary permeability and high sodium tubularreabsorption, probably explained by a “rebound” salt retention associated with her decreasedextracellular volume (Rev Med Chile 2007; 135: 1456-62).(

Seguimiento alejado de pacientes evaluados en una Unidad de Dolor Torácico

Introduccion: el dolor toracico (DT) constituye un importante motivo de consulta y dilema diagnostico en los servicios de urgencia, en especial por la posible presencia de enfermedad coronaria, existiendo evidencia de diferencias en la presentacion, diagnostico y pronostico alejado entre hombres y mujeres. Objetivo: Evaluar el seguimiento alejado de pacientes que consultan en la Unidad de dolor Toracico (UDT), evaluando diferencias entre ambos generos. Metodos: Evaluacion prospectiva de pacientes que consultaron por dolor toracico en un periodo de 4 anos. Se registraron caracteristicas basales y el diagnostico final de la UDT u hospitalizacion. Seguimiento telefonico de al menos un ano registrandose mortalidad mediante certificacion del Registro Civil. Se utilizo Kaplan-Meier y log Rank test para curvas de sobrevida y regresion logistica multiple para evaluar predictores de mortalidad y evento cardiovascular. Resultados: 1168 pacientes, edad promedio 62 ± 23 anos, 69% hombres se hizo el diagnostico definitivo de enfermedad coronaria (EC) en el 32,2%. Seguimiento promedio 28±20 meses. Las mujeres con EC presentaron una mortalidad de 27,6% versus un 14% (p=0,02) para los hombres. Las variables predictoras fueron: bloqueo completo de rama izquierda en el ECG inicial OR 12,52(1,98-25,8), la presencia de enfermedad coronaria OR 3,98(1,45-13,8), troponina I elevada OR 2,12(1,05-7,89); el genero femenino pierde significancia en el modelo ajustado OR: 1,02(0,88-25,8). Conclusiones: La presencia de edad avanzada, BCRI, presencia de marcadores de dano miocardico y la etiologia coronaria del DT constituyen elementos de mal pronostico en los pacientes que consultan por DT. Las mujeres presentan el doble de mortalidad alejada.

Edad mayor a sesenta años y tabaquismo son predictores de la presencia ecocardiográfica de placa aórtica complicada en pacientes con accidente cerebrovascular isquémico sin cardiopatía

El ACV es la segunda causa es-pecifica de muerte en nuestro pais, siendo el origen cardioembolico responsable del 20% al 40% de los casos. En pacientes sin patologia cardiovascular eviden-te, clinica o por ecocardiografia transtoracica (ETT), la identificacion de la fuente embolica requiere la realiza-cion de ecocardiografia transesofagica (ETE), que puede confirmar la presencia de una placa aortica complicada (PAC) como agente causal de este fenomeno.

Estimación auscultatoria de la presiónsistólica de arteria pulmonar: ¿Es factible?. Correlación con determinación ecocardiográfica

BACKGROUND The clinical assessment of pulmonary artery systolic pressure (PASP) by means of heart auscultation may be comparable to the measures obtained by Doppler echocardiography. AIM To compare PASP estimated by heart auscultation and echocardiography. MATERIAL AND METHODS Thirty consecutive patients aged 70 ± 16 years (68% women) were evaluated prospectively, all of whom had an echocardiogram requested by their attending physician. Echocardiographic evaluation of PASP was made by tricuspid regurgitation velocity plus right a trial pressure estimate. Two trained clinicians, blinded for the clinical history and rest of physical examination, auscultated the patients. PASP was estimated from the auscultatory intensity of the pulmonary component in comparison to the aortic component of the second heart sound and its propagation towards the apex, in accordance to a pre-established algorithm. Correlation between auscultatory and echocardiographic measures of PASP was made by Pearson test. Variability between both methods and among observers was evaluated with Bland-Altman analysis. RESULTS Fifty two per cent of patients were hypertensive and 20% diabetic. Admission diagnoses were heart failure in 50% of cases, exacerbation of chronic obstructive pulmonary disease in 20%, pulmonary thromboembolism in 10% and other clinical entities in 20%. A significant correlation was found between auscultatory and echocardiographic estimation of PASP (r = 0.64, p = 0, 01). Bland-Altman analysis showed a mean difference between both determinations of 7.6 ± 7.6 mmHg. Bland-Altman analysis between both operators showed an average difference of 5.4 ± 8.4 mm Hg. CONCLUSIONS Heart auscultatory evaluation allows a precise and reproducible estimation of PASP and compares favorably with echocardiographic assessment.

“Gigantic” biatrial myxoma with right heart functional impairment

Cardiac myxomas are frequently located in the left or right atria, with multiple locations being rare. We report a 59‐year‐old healthy female with 5 months of cough and exertional dyspnea. A transthoracic echocardiography (TTE) exhibits a 9 × 5 cm nonpedunculated tumor arising from the interatrial septum (IAS) and inhabiting both atria, but was unable to depict the relation with the IAS. Transesophageal echocardiography exposes a single tumor crossing the IAS through an ostium secundum atrial septal defect (ASD) causing right heart functional impairment. Uneventful cardiac surgery allowed complete resection of the lesion and ASD closure. Pathology reported a myxoma.

Big thrombus “sitting” in an atrial septal aneurysm

A 79 year‐old‐man presented three episodes of upper gastrointestinal bleeding and weight loss. Endoscopy revealed bleeding and extrinsic compression at the pyloric region. Computed tomography scan showed a pancreatic tumor, peritoneal carcinomatosis, vascular infiltration, and incidentally found a partially calcified hypodense lesion of 35 mm in the left atrium, suggesting a myxoma or a thrombus. Echocardiography revealed moderate left atrium enlargement, dilated left atrial appendage with spontaneous echo contrast, moderate dilatation and dysfunction of the left ventricle, ejection fraction was 39%, and an atrial septal aneurysm in which a piriform, mass of 35×33×25 mm, was “sitting,” suggesting an organized thrombus.

Reparación de una perforación valvular mitral como secuela de endocarditis, aporte de la ecocardiografía tridimensional

Resumen Reportamos un caso de reparacion de perforacion valvular mitral en un joven de 18 anos que consulta por disnea de esfuerzos y con el an-tecedente remoto de una artritis septica de rodilla tratada. En el examen fisico se encontro un soplo holosistolico 4/6 en el foco mitral. Se realizo un ecocardiograma transtoracico (ETT) que objetivo una insuficiencia mitral severa, con un jet de recorri-do muy excentrico originado desde anterior, sospe-chando una perforacion del velo anterior, sin lograr caracterizarla por dicha tecnica. Se complemento el estudio con un ecocardiograma transesofagico (ETE) en una plataforma EPIQ 7 cv (PHILIPS), que identifico en el cuerpo del segmento 2 del velo an-terior mitral (A2) una posible perforacion. El anali-sis de la valvula mediante ETE tridimensional (3D), confirmo una perforacion circular de bordes netos, de dimensiones maximas 6x6 mm, localizada en el cuerpo de A2. El analisis 3D aporto valiosa informa-cion para programar la reparacion valvular, la cual se efectuo mediante un parche de pericardio autolo-go fresco (sin fijacion en glutaraldehido) y una anu-loplastia con un anillo rigido, con optimo resultado y sin complicaciones.

La disincronía cardíaca se correlaciona con el remodelado ventricular izquierdo postinfarto agudo al miocardio

97, p =0.34). At baseline there were significantcorrelations between IAV and LVEF, and between IAV and LVEDV (r =-0.48, p =0.001 and r =-0.41,p =0.004, respectively). These correlations remained significant after 6 months. There was apositive correlation between IAV and LVEDV changes at six months (r =0.403, p =0.04).

Predictores de síndrome coronario agudo sin supradesnivel del ST y estratificación de riesgo en la unidad de dolor torácico. Experiencia en 1.168 pacientes

BACKGROUND Nearly 10% of patients with an actual acute coronary syndrome (ACS) are discharged with an inadequate diagnosis. AIM To select clinical and laboratory predictors to identify patients with a high likelihood of ACS in the Chest Pain Unit. MATERIAL AND METHODS Prospective evaluation of patients consulting in a Chest Pain Unit of a University Hospital. Initial assessment was standardized and included evaluation of pain characteristics, electrocardiogram and Troponin I. Independent predictors of ACS were identified with a multiple logistic regression. RESULTS In a four years period, 1,168 patients aged 62+/-23 years (69% males), were studied. After initial evaluation, 62% of the patients were admitted to the hospital for further testing and in 71% of them, a definite diagnosis of ACS was made. No events were reported by patients directly discharged from the Chest Pain Unit. Independent predictors associated with a higher likelihood of ACS were an abnormal electrocardiogram at the initial evaluation (Odds ratio (OR) 5.37, 95% confidence intervals (CI) 3.61-7.99), two or more cardiovascular risk factors (OR 2.16, 95% CI 1.21-2.84), cervical irradiation of the pain (OR 1.84, 95% CI 1.25-2.69), age over 65 years (OR 1.73, 95% CI (1.32-2.27) and a Troponin I above the upper normal limit (OR: 5.68, 95% CI 3.72-8.29). CONCLUSIONS Simple clinical findings allow an appropriate identification of patients with a high likelihood of ACS without specialized methods for myocardial ischemia detection.