Vicente Valle

Right ventricular infarction: Relationships between ST segment elevation in V4R and hemodynamic, scintigraphic, and echocardiographic findings in patients with acute inferior myocardial infarction

The relationship between ST segment elevation on the right precordial lead V4R and the hemodynamic, echocardiographic, and myocardial scintigrapic signs suggestive of right ventricular (RV) infarction was studied in 42 patients with acute inferior myocardial infarction. Twenty-two patients had ST segment elevation in V4R. Among these patients, a significant correlation was demonstrated between V4R ST segment elevation and the hemodynamic (p less than 0.001), scintigraphic (p less than 0.001), and echographic (p less than 0.02) criteria for acute RV infarction. These results support the validity of this new electrocardiographic sign as a practical means in aiding the clinical detection of RV involvement with acute transmural inferior myocardial infarction.

Time course and rate dependence of Q-T interval changes during noncomplicated acute transmural myocardial infarction in human beings

Abstract The sequential changes and the rate dependence of the Q-T interval were studied in 21 patients 6 hours to 5 days after an anterior (11 cases) or an inferior (10 cases) acute transmural myocardial infarction. The Q-T interval was analyzed at fixed atrial-paced heart rates in leads aVF and V3 recorded at 100 mm/s and at twice the standard amplitude. Values were compared with those of a group of normal subjects matched by age and sex. Severe ventricular arrhythmias, electrolyte or conduction disturbances and pericarditis were excluded in all patients. Sequential changes in the Q-T interval were apparent only in the leads showing the ischemic changes (lead V3 in anterior and lead aVF in inferior myocardial infarction) in 19 of 21 patients. After an initial shortening (first 12 hours), there was a remarkable lengthening of the Q-T interval coinciding with T wave inversion (12 to 24 hours after the myocardial infarction). By the 4th to the 6th day, there was a return to normal values. The lengthening of the Q-T interval was greater in anterior than in inferior myocardial infarction. The rate-dependent shortening of the Q-T interval at increasing rates was more prominent at the beginning of T wave inversion. It is concluded that lengthening of the Q-T interval is common 12 to 24 hours after the onset of an acute myocardial infarction and that prolongation of up to 20 percent over the initial values may occur in cases not complicated by severe ventricular arrhythmias.

Prognostic Implication of Frailty and Depressive Symptoms in an Outpatient Population With Heart Failure

INTRODUCTION AND OBJECTIVES Heart failure patients have high levels of frailty and dependence. Our aim was to determine the impact of frailty and depressive symptoms on the 1-year mortality rate and the rate of hospitalization for heart failure during a follow-up period of 1 year. METHODS All patients underwent geriatric evaluation, and frailty and depressive symptoms were identified. The study included 622 patients (72.5% male; median age, 68 years; 92% in New York Heart Association class II or III; and median ejection fraction, 30%). RESULTS During follow-up, 60 patients (9.5%) died and 101 (16.2%) were hospitalized for heart failure. Overall, 39.9% of patients exhibited frailty, while 25.2% had depressive symptoms. There were significant associations between mortality at 1 year and the presence of frailty (16.9% vs. 4.8%; P< .001) and depressive symptoms (15.3% vs. 7.7%; P=.006). There was also a significant relationship between heart failure hospitalization and the presence of frailty (20.5% vs. 13.3%; P=.01). No relationship was found between heart failure hospitalization and depressive symptoms. Frailty was an independent predictor of mortality but not of hospitalization. CONCLUSIONS Univariate analysis demonstrated significant relationships between frailty and depressive symptoms and mortality at 1 year. In addition, there was a significant relationship between frailty and the need for heart failure hospitalization. However, only frailty showed prognostic value to predict mortality, which was independent of other variables strongly associated to outcome.

Increased Exercise Capacity after Surgically Induced Weight Loss in Morbid Obesity

Objective: To investigate the effects of surgically induced weight loss on exercise capacity in patients with morbid obesity (MO).

Six-Month Outcome in Patients With Myocardial Infarction Initially Admitted to Tertiary and Nontertiary Hospitals

OBJECTIVES The aim of the present study was to ascertain whether the degree of accessibility to coronary angiography and revascularization results in differing usages or outcomes, or both, in the setting of a high coverage national health system. BACKGROUND The selective use of coronary angiography and revascularization procedures in the management of acute myocardial infarction (MI) remains controversial. METHODS A cohort of 1,460 consecutive patients with a first MI admitted to four referral teaching hospitals (one with tertiary facilities) were followed up for 6 months after admission. Only patients initially admitted to each of the study hospitals were retained for analysis in the original hospitals cohort. End points were 6-month mortality and readmission for reinfarction, unstable angina, heart failure or severe ventricular arrhythmia. RESULTS Patients admitted to the tertiary hospital were more likely to undergo coronary angiography (adjusted relative risk 4.22, 95% confidence interval [CI] 3.37 to 5.45) than those admitted to the nontertiary sites (use rate: 22.1% for nontertiary care, 55.5% for tertiary care). Revascularization procedures were performed in 21.2% of patients in the tertiary hospital and in 8.3% in the nontertiary hospitals (p < 0.0001). Median delay for emergency coronary angiography was shorter in the tertiary hospital (within 1 vs. 2 days, p < 0.0001). Six-month mortality or readmission rates were similar (23.7% and 24.7% for tertiary and nontertiary care, respectively). After adjustment for comorbidity and disease severity, the relative risk of death or readmission for the tertiary hospital was 1.03 (95% CI 0.69 to 1.53) times that of the nontertiary hospitals. CONCLUSIONS Selective use of coronary angiography and revascularization procedures may be as effective as less restricted use in the management of acute MI.

Cardioversion of tachycardias by transesophageal atrial pacing

Transesophageal atrial pacing by means of an electrode catheter placed in the esophagus was attempted in 22 patients for treatment of the following tachyarrhythmias: paroxysmal supraventricular tachycardia (8 patients), atrial flutter (6 patients), atrial fibrillation (3 patients), ventricular tachycardia (3 patients) and nonparoxysmal atroventricular (A–V) junctional tachycardia (2 patients). Atrial pacing was definitely achieved in 17 patients, sinus rhythm was restored in 5 of 8 patients with paroxysmal supraventricular tachycardia and in 1 of 2 patients with nonparoxysmal A–V junctional tachycardia. Atrial pacing failed to restore sinus rhythm in all other types of tachyar-rhythmias treated. In 1 patient with ventricular tachycardia, there was no strong diagnostic evidence for the arrhythmia until atrial pacing was performed and ventricular capture beats became evident. The safety of transesophageal atrial pacing and its advantages over other methods of treatment of tachyarrhythmias are discussed. The results of our study suggest that atrial pacing from the esophagus is the method of choice in the treatment of paroxysmal supraventricular tachycardias and perhaps of nonparoxysmal A–V junctional tachycardias in digitalized patients who require rapid suppression of the arrhythmia. There is also evidence that atrial pacing may be helpful in diagnosing some cases of ventricular tachycardia with a suspected ventricular origin.

Sex and age differences in fragility in a heart failure population.

Heart failure (HF) patients have a high degree of fragility and dependence from physical, cognitive and psychological points of view, and are a mainly geriatric population.

Significado pronóstico de los valores de hemoglobina en pacientes con insuficiencia cardíaca

Introduccion y objetivos Evaluar el valor pronostico de las concentraciones de hemoglobina (Hb) en relacion con la mortalidad y con los ingresos hospitalarios por insuficiencia cardiaca (IC) al ano de la primera visita a la Unidad de IC. Pacientes y metodo Conocemos la situacion vital y los ingresos por IC al ano en 337 pacientes admitidos entre agosto de 2001 y marzo de 2003. Las concentraciones de Hb se recogieron en la primera visita. Resultados Fallecieron 28 (8%) pacientes y hubo 158 ingresos por IC en 66 pacientes. Los valores de Hb se asociaron con la mortalidad a 1 ano (pacientes vivos, 13,0 ± 1,7 g/dl; pacientes fallecidos, 11,6 ± 1,7 g/dl; p Conclusiones Los valores de Hb se asocian inversamente con la mortalidad y los ingresos por IC en el primer ano de seguimiento. La prevalencia de anemia en nuestra poblacion con IC es elevada y tiene valor pronostico independiente.

Patient's education by nurse: what we really do achieve?

Aim: To evaluate what is really achieved with nurse education in an outpatient heart failure population. Method: The answers obtained in a nurse questionnaire performed at the first visit to the Unit and at 1 year of follow-up were compared. The questionnaire was addressed to know how compliant patients were and how much they knew about their disease and their treatment. Results: Two hundred and ninety eight patients (219 men and 79 women) were evaluated. Baseline mean age was 65 years (35–86). At first visit only 30% knew and understood the performance of the heart; 56% at 1 year (p < 0.001). Only 28% initially understood the disease; 55% at follow-up (p < 0.001). Awareness of more than 3 worsening signs increased from 66.5% to 86.5% (p < 0.001). Knowledge of the names of all the pills they were receiving increased from 33% to 44% (p < 0.001), of the action of these pills from 24% to 44% (p < 0.001), and of how to use nitroglycerine among patients with ischemic heart disease from 87% to 96% (p < 0.001). Initially 63% monitored their weight only at the medical visit and 21% monitored it at least once a week; at 1 year these percentages were 16% and 39% respectively (p < 0.001). At baseline 45% checked blood pressure only at the medical visit and 28.5% checked it at least once a week; at 1 year these percentages were 12% and 43% (p < 0.001). Whereas no significant differences were found in sodium restricted diet compliance, exercise performance increased slightly although statistically significantly (p = 0.01). The great majority of patients never or only very rarely smoked or drunk alcoholic beverages, both at first visit and at 1 year, although both habits increased slightly during follow-up. No significant differences in treatment compliance (92% vs. 88% were taking all the medications prescribed) were found. Conclusion: Nurse-guided education has changed self-care behaviour of patients with heart failure in several important aspects, as weight and blood monitoring, and has increased their knowledge and understanding of the disease and treatment. However, these improvements have not been reflected in a better compliance of treatment and sodium restricted diet. Such aspects need more and more work to obtain better results.

Nurse evaluation of patients in a new multidisciplinary Heart Failure Unit in Spain.

Aim: To know how compliant patients are, how much they know about their disease and treatment, and how their level of self-care is. Methods: We performed a short nurse questionnaire during the first visit to a new Heart Failure Unit. Results: Three hundred and twenty-four patients have been evaluated, with a mean age of 65.4 years. Ninety-eight patients (30%) knew and understood the performance of the heart and 85 (29%) understood the disease. Two-hundred and nineteen (67%) knew more than three signs of worsening symptoms. One-hundred and five (32%) knew all the names of the medication they were taking and 74 (23%) knew the action of these medications. Two-hundred and ninety-four (91%) said they were taking all the medication prescribed and 229 (71%) carried on always their written prescription. Sixty-two percent of patients controlled weight only at the medical visit and only 14% controlled weight more than once a week. Fifty-nine (18%) controlled blood pressure more than once a week, while 45% controlled it only at the medical visit. Only 33% of patients were said always to follow sodium restricted diet. The great majority (93%) never smoked and only very rarely took alcohol (83%). While only 18 (6%) performed some kind of physical exercise, the majority (83%) did walking and daily living activities. The 85% of patients with ischemic heart disease knew how to use sublingual nitro-glycerine. When subgroups were analysed, we found significant differences by age, gender and previous specialist management. Younger patients, men and patients referred from the Cardiology outpatient clinic showed a higher level of knowledge and understanding of several aspects of disease and treatment, and performed more physical activities, compared to older patients, women and patients referred from other departments. On the contrary, older patients showed better adherence with sodium restriction, and, as women, better smoking and drinking habits. Conclusion: There is a lot of work to do in nurse-guided education of patients with heart failure, although treatment compliance, use of nitro-glycerine and abstinence of smoking and alcohol intake seem to be quite assumed by the majority of our patients. Significant differences in knowledge and behaviour were evident between younger and older patients, between men and women, and relating to previous specialist management. In spite of that, we found no differences in treatment compliance.