RESUMEN
BACKGROUND: The functional and prognostic significance of silent ischemia relative to symptomatic ischemia during non-invasive testing remains controversial. DESIGN: The aim of this prospective study was to assess whether the presence of dobutamine-induced silent ischemia was associated with the amount of myocardial ischemic burden and to determine the prognostic significance of painless ischemia in elderly people with stable coronary artery disease. METHODS: A cohort of 289 patients > or =70 years of age with positive dobutamine stress echocardiography result and significant coronary artery disease proven by coronary arteriography, were followed up during a 35 +/- 13 month period for the development of cardiac events. RESULTS: The prevalence of silent ischemia during dobutamine infusion was 63%. Patients with painful ischemia were more likely to have lower peak heart rate (P < 0.01) and showed ST segment depression more frequently during the dobutamine stress test than did patients with painless ischemia (52 versus 31%, P < 0.05). There was no significant difference between the patients with and without angina according to wall motion score index at rest (1.35 +/- 0.29 versus 1.32 +/- 0.37) and at peak stress (1.61 +/- 0.35 versus 1.58 +/- 0.44), stress-rest wall motion index difference (0.27 +/- 0.09 versus 0.25 +/- 0.08), the presence of dyskinesia at peak stress (36 versus 31%), the number of segments with regional > or =2 point change from rest to peak stress (38 versus 29%) and the decrease of left ventricular end systolic volume at peak stress (89 versus 86%). During the follow-up period a total of 269 patients developed 153 (57%) cardiac events: 15 cardiac deaths, 19 non-fatal myocardial infarctions, 119 episodes of unstable angina. No significant difference in cardiac mortality and in total cardiac event rate was observed between patients with or without angina (6 versus 5% and 60 versus 55%, respectively). CONCLUSIONS: Our data demonstrate that the magnitude of myocardial dysfunction assessed by dobutamine stress echocardiography is comparable in elderly patients with or without anginal chest pain. The presence of painful ischemia is not accompanied by an increased risk for subsequent cardiac events in this cohort of patients.
Asunto(s)
Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/fisiopatología , Ecocardiografía de Estrés/efectos adversos , Isquemia Miocárdica/etiología , Isquemia Miocárdica/fisiopatología , Anciano , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Isquemia Miocárdica/diagnóstico por imagen , Dimensión del Dolor , Valor Predictivo de las Pruebas , Pronóstico , Estudios ProspectivosRESUMEN
BACKGROUND: Angiotensin Converting Enzyme inhibitors (ACEi's) confer significant mortality and morbidity benefits in all functional grades of chronic heart failure (CHF). However, physicians' concerns regarding the possible occurrence of first-dose hypotension appear to be a contributing factor to their under-utilisation in both hospital and primary care settings. We investigated whether long-acting and short-acting ACEi's differ in their haemodynamic responses to the first-dose in patients with CHF. METHOD: This was a multicentre, randomised, open, two-parallel-group study of captopril 6.25 mg and perindopril 2 mg. 240 patients with CHF, age 68.9 +/- 8.9 years, of whom 66% were male, NYHA II-IV, with average blood pressure baseline values of 132.2 +/- 16.2/78.5 +/- 10.5 mmHg for systolic and diastolic blood pressure, and left ventricular ejection fraction (LVEF) of 31.3 +/- 7.4% received either captopril (n = 124) or perindopril (n = 116). Blood pressure was continuously monitored during the 8 h following drug intake. Minimum levels and maximum decreases in systolic, diastolic and mean arterial pressures were measured, along with the incidence of hypotensive episodes defined as mean blood pressure (MBP) fall > 20 mmHg, whether symptomatic or not. Subgroups of patients distributed according to age, baseline blood pressure (BP) and LVEF were subsequently analysed. RESULTS: Overall, a statistically significant treatment effect in favour of perindopril was observed. First-dose hypotension was observed more frequently following captopril than perindopril administration, with lower MAP minimal levels (78.0 +/- 8.9 vs. 84.5 +/- 10.1 mmHg, p < 0.0001), greater maximum falls (17.6 +/- 8.3 vs. 12.8 +/- 7.3 mmHg, p < 0.0001) and more frequent hypotensive episodes (42% vs. 15%, p < 0.0001). The incidence of at least one symptomatic episode was also significantly higher with captopril (10 patients vs. one patient, p = 0.029). Subgroup analyses according to age (< or = 70 years or > 70 years) or LVEF (< or = 30% or > 30%) reflected the main result. CONCLUSION: Initiation of treatment with ACE inhibitors is associated with different haemodynamic and clinical tolerances in CHF patients, regardless of their risk for hypotension, with possible clinical implications.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Captopril/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Hipotensión/inducido químicamente , Perindopril/uso terapéutico , Anciano , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Monitoreo Ambulatorio de la Presión Arterial , Captopril/efectos adversos , Relación Dosis-Respuesta a Droga , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Perindopril/efectos adversos , Factores de RiesgoRESUMEN
Cachexia is a strong predictor for mortality in patients with congestive heart failure. To investigate the role of leptin and regulators of apoptosis in cardiac cachexia we compared leptin concentrations and their relation to the TNF system, interleukin 1-beta (IL-1b), and soluble Fas in patients with heart failure with and without cachexia. Patients with cardiac cachexia have increased levels of interleukin-1b compared to non-cachectic heart failure patients [mean(S.E.)=1.11(0.62) vs. 0.02(0.02), P=0.01] and decreased concentrations of leptin [10.79(3.93) vs. 23.24 (8.35), P=0.1]. Leptin levels correlate with TNF-RI in cachectic heart failure patients (r=0.58, P=0.018). The TNF-RI levels were also correlated with Fas, both in all the patients taken together (r=0.5, P=0.006) and in those with cachexia (r=0.52, P=0.036). Our data indicate that more prospective studies are needed to clarify the role of leptin in the pathophysiology of heart failure cachexia.
Asunto(s)
Caquexia/sangre , Insuficiencia Cardíaca/sangre , Leptina/sangre , Anciano , Caquexia/fisiopatología , Ensayo de Inmunoadsorción Enzimática , Insuficiencia Cardíaca/fisiopatología , Humanos , Interleucina-1/sangre , Masculino , Persona de Mediana Edad , Receptores de Leptina , Estadísticas no Paramétricas , Factor de Necrosis Tumoral alfa/metabolismo , Receptor fas/sangreRESUMEN
OBJECTIVES: We sought to prospectively and randomly compare survival with clinical and hemodynamic variables in patients with congestive heart failure (CHF) treated with standard versus high doses of enalapril. BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors produce hemodynamic and symptomatic benefits in patients with CHF, but there is still controversy about the optimal dose in this clinical setting. METHODS: Two hundred and forty-eight patients with advanced CHF (age 56.3+/-12 years) were randomized to receive a maximal tolerated dose of enalapril, up to 20 mg/day in group 1 (mean dose achieved 17.9+/-4.3 mg/day, n = 122) and 60 mg/day in group 2 (mean dose achieved 42+/-19.3 mg/day, n = 126). RESULTS: At enrollment, patients in group 1 were in New York Heart Association (NYHA) functional class 2.6+/-0.7 and had a mean systolic blood pressure (SBP) of 117+/-18 mm Hg, a mean heart rate (HR) of 85+/-16 beats/min and a left ventricular ejection fraction (LVEF) of 20.0+/-9.8%. In group 2, patients were in NYHA class 2.6+/-0.7; their SBP was 118+/-17 mm Hg, HR 83+/-15 beats/min and LVEF 18.8+/-8.1%. There were no significant differences in these characteristics between the two groups of patients at enrollment. After 12 months of follow-up, 22 (18%) of 122 patients in group 1 and 23 (18%) of 126 patients in group 2 had died (p = 0.995, with 80% power of the study to detect a delta difference of 13%). The NYHA class was the same (1.9+/-0.7) in both groups; SBP was 111+/-16 and 111+/-17 mm Hg, HR 77+/-12 and 79+/-13 beats/min and LVEF 31+/-19% and 30+/-12% in groups 1 and 2, respectively. These differences were not statistically significant. The study had a power of 80% to detect (p = 0.05) the following changes: 13% in death rate, 0.25 units in NYHA class, 6 mm Hg in SBP, 5 beats/min in HR and 6% in LVEF. CONCLUSIONS: No significant differences were found in survival and clinical and hemodynamic variables between patients receiving standard and those receiving high doses of enalapril.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Enalapril/administración & dosificación , Insuficiencia Cardíaca/tratamiento farmacológico , Adolescente , Adulto , Anciano , Femenino , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
A transvenous implantable cardioverter defibrillator (ICD) was implanted in a patient with drug refractory ventricular fibrillation who had undergone latissimus dorsi cardiomyoplasty. The skeletal muscle was stimulated by a pulse train generator (cardiostimulator) implanted at the time of cardiomyoplasty. With proper programming of the devices neither adverse ICD-cardiostimulator interactions nor device malfunction were observed. Thus, the combined implantation of a cardiostimulator and an ICD is a feasible and safe therapeutic option.
Asunto(s)
Cardiomioplastia/métodos , Desfibriladores Implantables , Fibrilación Ventricular/terapia , Adulto , Terapia Combinada , Electrocardiografía , Humanos , Masculino , Fibrilación Ventricular/cirugíaRESUMEN
Exercise stress ECG testing is not generally recommended in patients with severe aortic stenosis. Analysis of the utility of exercise testing, both with and without the use of myocardial thallium-201 scintigraphy for the diagnosis of coronary artery disease (CAD), yielded low specificity. A noninvasive, safe, and accurate diagnostic modality to ascertain the presence of CAD is not available to date for patients with severe aortic stenosis. The aim of this study was to assess the safety and diagnostic accuracy of adenosine stress echocardiography (A-Stress-Echo) and of adenosine stress myocardial perfusion scintigraphy (A-SPECT), for the detection of CAD in patients with severe aortic stenosis. The study included 50 patients with severe aortic stenosis (maximal instantaneous aortic valve gradient >80 mmHg, range 81 to 144 mmHg, and aortic valve area <0.75 cm2). All patients were submitted to A-Stress-Echo, after a 6-minute infusion of adenosine (140 microg/kg body weight/min), and then (>3 days later) A-SPECT with the same dosage of adenosine as above. Coronary angiography was performed in all patients. No major complications were observed. The unpleasant symptoms were brief and did not necessitate cessation of the test. Both modalities showed the same sensitivity (85% for A-SPECT and 85% for A-Stress-Echo) angiographically diagnosed CAD while A-Stress-Echo yielded much higher specificity (96.7% vs 76.7%). Concordance of the two methods was found in 40 cases and the specificity for those patients was 100%. A-Stress-Echo and A-SPECT, either separately or in combination, constitute excellent and safe noninvasive diagnostic methods in detecting CAD in patients with severe aortic stenosis.
Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico , Enfermedad Coronaria/diagnóstico , Enfermedad Aguda , Adenosina/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/fisiopatología , Cateterismo Cardíaco , Angiografía Coronaria/estadística & datos numéricos , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/fisiopatología , Ecocardiografía/métodos , Ecocardiografía/estadística & datos numéricos , Prueba de Esfuerzo/métodos , Prueba de Esfuerzo/estadística & datos numéricos , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Sensibilidad y Especificidad , Radioisótopos de Talio , Tomografía Computarizada de Emisión de Fotón Único/métodos , Tomografía Computarizada de Emisión de Fotón Único/estadística & datos numéricosRESUMEN
We assessed coronary flow reserve using transesophageal Doppler echocardiography in patients with coronary artery disease. The study included 33 coronary artery disease patients who were undergoing coronary arteriography. The blood flow velocities of the left anterior descending artery before and after intravenous infusion (0.56 mg/min for 4 min) of dipyridamole were recorded using transesophageal Doppler echocardiography. Fourteen normal healthy individuals, matched for age, served as a control group. The index of coronary flow reserve, i.e. the ratio of dipyridamole to baseline maximum diastolic velocity, was calculated. Maximal coronary flow reserve in coronary artery disease patients was significantly lower than in the control group (1.4+/-0.2 vs. 2.8+/-0.3, P<0.001). The coronary artery disease patients were classified into three groups: Group A included 10 patients with <50% left anterior descending artery stenosis; Group B included seven patients with 50-69% left anterior descending artery stenosis; 16 patients with >70% left anterior descending artery stenosis constituted Group C. The maximum coronary flow reserve was significantly different for A vs. B and A vs. C. (A, 1.77+/-0.18; B, 1.51+/-0.1; C, 1.28+/-0.24). A strong and significant correlation was found between the maximum coronary flow reserve and the degree of proximal left anterior descending artery stenosis (r=0.78, P<0.001). Coronary artery disease patients without left anterior descending artery stenosis on the arteriogram exhibited lower maximum coronary flow reserve compared to the control subjects (1.78+/-0.19 vs. 2.8+/-0.3, P=0.000).
Asunto(s)
Circulación Coronaria/fisiología , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/fisiopatología , Ecocardiografía Transesofágica , Análisis de Varianza , Velocidad del Flujo Sanguíneo/efectos de los fármacos , Estudios de Casos y Controles , Circulación Coronaria/efectos de los fármacos , Dipiridamol , Femenino , Humanos , Masculino , Persona de Mediana Edad , VasodilatadoresRESUMEN
A case report of myocardial bridging of the left anterior descending artery is described. Coronary flow proximal to the myocardial bridge was studied with transesophageal echo Doppler. The patient, a 62-year-old farmer who sustained an anterior myocardial infarction, underwent thrombolysis and was admitted. He subsequently underwent coronary angiography and left ventriculography, which showed a severe myocardial bridge of the midshaft of the left anterior descending artery. The ejection fraction improved from 25 to 48% after thrombolysis, as measured by using echocardiography. Transesophageal Doppler study proximal to the myocardial bridge revealed a relative increase of the diastolic coronary flow velocity (increased acceleration), which reached its peak value in early diastole. Despite the presence of severe myocardial bridging, coronary flow reserve increased substantially two minutes after the infusion of dipyridamole (0.56 mg/kg iv for 4 minutes). Transesophageal Doppler study of coronary blood flow proximal to the myocardial bridge in the left anterior descending artery showed a characteristic waveform that may prove to be indicative of this condition.
Asunto(s)
Circulación Coronaria , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Anomalías de los Vasos Coronarios/fisiopatología , Ecocardiografía Doppler , Ecocardiografía Transesofágica , Dipiridamol , Humanos , Masculino , Persona de Mediana Edad , VasodilatadoresRESUMEN
Evaluation of coronary microvascular function can be obtained through coronary flow reserve measurements. The aim of this study was to evaluate the coronary microvascular function by using transesophageal-Doppler echocardiographic assessment of coronary flow reserve. The study included 32 normotensive patients with type II diabetes mellitus (group A) of short duration (6.1+/-3.8 years) aged 55.4+/-9.4 years and 14 healthy volunteers matched for age, gender and BMI (group B). No patients had clinical evidence of coronary artery disease and all of them produced a negative recent stress ECG test. Excluded from the study were patients with anemia, left ventricular hypertrophy, arrhythmia, congenital, or acquired structural heart disease. All subjects underwent transesophageal-Doppler echocardiography. Satisfactory coronary blood flow velocity recordings could be obtained from the initial segment of the left anterior descending coronary artery in healthy volunteers and in 27 patients at baseline and 2 min after dipyridamole infusion (0.56 mg/kg, for 4 min). In the remaining 5 patients no satisfactory recordings were available. The indexes of coronary flow reserve, i.e. the ratios of dipyridamole over basal maximum and mean diastolic velocities were calculated. Dipyridamole/rest maximal coronary reserve (Table 3) was 1.946+/-0.743, while this ratio for the mean diastolic velocity was 1.969+/-0.805 in group A. The respective values for group B, were 2.811+/-0.345 (P=0.000 vs. group A) and 2.914+/-0.303 (P=0.000 vs. group A). Thus, the increase in coronary flow reserve although present in both groups, it was more impressive in the normal group. Multiple regression logistic analysis of: age, sex, smoking, glucosylated hemoglobin, duration of diabetes and type of therapy, did not show any correlation of these parameters with the above ratios. This study shows that coronary flow reserve, as measured with transesophageal echocardiography-Doppler, is severely impaired in normotensive patients with type II diabetes, with relatively short duration of the disease.
Asunto(s)
Circulación Coronaria , Diabetes Mellitus Tipo 2/diagnóstico por imagen , Ecocardiografía Doppler , Ecocardiografía Transesofágica , Factores de Edad , Velocidad del Flujo Sanguíneo/efectos de los fármacos , Índice de Masa Corporal , Estudios de Casos y Controles , Circulación Coronaria/efectos de los fármacos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/efectos de los fármacos , Vasos Coronarios/fisiopatología , Diabetes Mellitus Tipo 2/dietoterapia , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/fisiopatología , Diástole , Dipiridamol , Electrocardiografía , Prueba de Esfuerzo , Femenino , Hemoglobina Glucada/análisis , Humanos , Modelos Logísticos , Masculino , Microcirculación/efectos de los fármacos , Persona de Mediana Edad , Factores Sexuales , Fumar/fisiopatología , Factores de Tiempo , VasodilatadoresRESUMEN
The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 +/- 8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 +/- 8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 micrograms/kg/minute for five minutes) and the combination of N with D (5-10 micrograms/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients experienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P = NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 +/- 0.22 to 1.71 +/- 0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 +/- 0.31 to 1.30 +/- 0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.
Asunto(s)
Cardiotónicos , Dobutamina , Ecocardiografía , Infarto del Miocardio/diagnóstico por imagen , Miocardio/patología , Nitroglicerina , Vasodilatadores , Adenosina , Supervivencia Celular , Combinación de Medicamentos , Electrocardiografía , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/patología , Sensibilidad y Especificidad , Radioisótopos de Talio , Tomografía Computarizada de Emisión de Fotón ÚnicoAsunto(s)
Cateterismo Cardíaco , Taquicardia Ventricular/terapia , Disfunción Ventricular Izquierda/terapia , Adolescente , Bloqueo de Rama/tratamiento farmacológico , Electrocardiografía , Femenino , Tabiques Cardíacos/fisiopatología , Humanos , Taquicardia Ventricular/diagnóstico , Disfunción Ventricular Izquierda/diagnóstico , Verapamilo/uso terapéuticoRESUMEN
BACKGROUND: The high prevalence of asymptomatic multivessel disease in the elderly and the fact that most of them can not carry out an exercise stress testing renders the application of other stress modalities necessary. The aim of this study is to compare the diagnostic value of dobutamine and adenosine stress echocardiography and their accuracy in determining the extent of coronary artery disease in elderly people. METHODS: Dobutamine and adenosine stress echocardiography were performed in 128 consecutive patients > or = 70 years-of-age with known or suspected coronary artery disease. All patients underwent coronary angiography within 2 weeks of the stress tests. RESULTS: The presence of any echocardiographic abnormality on dobutamine (odds ratio 30.8) and adenosine (odds ratio 18.1) test, the need for cessation of dobutamine test and the ST depression during dobutamine infusion, were independent predictors of significant coronary artery disease. Both tests proved more sensitive for detecting multivessel disease (89% for dobutamine, 74% for adenosine test), than one-vessel disease (74 and 39%, respectively). This difference was statistically significant only for the adenosine echocardiography test (P = 0.008). In patients with localized resting wall motion abnormalities, the accuracy of dobutamine test to predict a remotely diseased vessel (70%), was statistically superior to the accuracy of adenosine test (57%, P = 0.008). Patients with multivessel disease showed delayed resolution of test-induced wall motion abnormalities, during the recovery period after both tests, compared with those who suffered from one-vessel disease. CONCLUSIONS: Dobutamine echocardiography was more sensitive and accurate than adenosine echocardiography in detecting and determining the extent and the severity of coronary artery disease in the elderly. A positive adenosine echocardiography result reflected the presence of advanced coronary artery disease. The two tests, combined with clinical data, could classify the elderly into low- and high-risk subgroups for ischemic heart disease.
Asunto(s)
Adenosina , Cardiotónicos , Enfermedad Coronaria/diagnóstico , Dobutamina , Ecocardiografía , Anciano , Angina Inestable/fisiopatología , Dolor en el Pecho/etiología , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patología , Vasos Coronarios/fisiopatología , Electrocardiografía , Femenino , Hemodinámica , Humanos , Infusiones Intravenosas , Masculino , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
A case of polymorphic ventricular tachycardia torsade de pointes type, appearing in a 70-year-old female following radiofrequency catheter His ablation, is presented. The substrate was slow rate with ventricular bigeminy and QT prolongation which appeared after ablation. The same phenomenon reappeared after permanent VVIR pacemaker implantation with a basal rate of 55 beats/min. One episode of polymorphic ventricular tachycardia deteriorated into ventricular fibrillation, requiring a 360-J DC shock. Raising the pacemaker rate to 80 beats/min abolished the arrhythmias.
Asunto(s)
Fascículo Atrioventricular/cirugía , Ablación por Catéter/efectos adversos , Taquicardia/cirugía , Torsades de Pointes/etiología , Anciano , Electrocardiografía , Femenino , Humanos , Marcapaso Artificial/efectos adversos , Taquicardia/diagnóstico , Taquicardia/fisiopatologíaRESUMEN
The aim of this study was to assess the feasibility, safety, and respective diagnostic accuracy of low-dose dobutamine infusion and rest-redistribution-reinjection thallium 201 single photon emission computed tomography (SPECT) after dipyridamole infusion (Th-DIP), in the prediction of functional improvement of asynergic infarcted zones, after successful revascularization in patients with chronic ischemic heart disease. Thirty-one patients with a previous myocardial infarction and left ventricular dysfunction (mean ejection fraction: 41 +/- 5.8%) were studied. The regional wall motion of the left ventricle was evaluated by basic echocardiography before and 14 +/- 1.7 weeks after successful revascularization (19 by percutaneous transluminal coronary angioplasty and 12 by coronary artery bypass grafting). Dobutamine stress echocardiography (DSE) was performed in all patients with dobutamine infusion of 5 and 10 micrograms/kg/minute over five minutes. Within three days after DSE and prior to revascularization, all patients underwent Th-DIP for myocardial viability assessment. A 16-ventricular-segment model was used for basic, DSE, and Th-DIP images. Viability was assessed by applying the standard criteria for each technique. In the 31 patients, 496 segments were analyzed. By basic echocardiography, 164 (33%) of them were classified as asynergic. The DSE detected viable tissue in 69/496 (14%) segments, whereas Th-DIP identified viability in 95/496 (19%) segments. When the postrevascularization basic echocardiographic study was used as the gold standard in identifying myocardial viability, the sensitivity and specificity for the DSE and Th-DIP were 86.5%, 94.4% and 90.5%, 69%, respectively. No major side effects were observed with both techniques. In conclusion, DSE seems to be an accurate method for identifying viable but asynergic myocardium in patients with chronic ischemic heart disease, whereas Th-DIP overestimates the postrevascularization recovery. Detection of hibernating myocardium can be obtained by these two noninvasive methods. However, DSE seems to be more useful in determining the prospective selection of patients who are going to benefit from revascularization.
Asunto(s)
Cardiotónicos , Dobutamina , Ecocardiografía , Infarto del Miocardio/patología , Radioisótopos de Talio , Tomografía Computarizada de Emisión de Fotón Único/métodos , Función Ventricular Izquierda , Adulto , Supervivencia Celular , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/cirugía , Sensibilidad y EspecificidadRESUMEN
Ten cases of hydatid heart disease were treated over a 15-year period (1980-1995). Cysts were located in the left ventricular wall (four patients), right ventricular wall (one patient), interventricular septum (one patient), interatrial septum (one patient), right atrium (one patient), pericardial cavity (one patient) and in multiple loci (one patient). Apart from two asymptomatic cases, clinical manifestations included chest pain (four patients), anaphylactic shock (one patient), constrictive pericarditis (one patient), congestive heart failure (one patient) and arterial embolism (one patient). Computed tomography was found useful in the detection of hydatid cysts and also in the determination of their morphology. Magnetic resonance was performed in three patients, with satisfactory imaging. Three out of the 10 patients died: rupture of pulmonary echinococcal cyst (one patient), massive pulmonary hydatid embolism (one patient) and rupture of an undiagnosed hydatid cyst of the right atrium during cannulation for cardiopulmonary bypass (one patient). One other patient experienced recurrent systemic embolism and became hemiplegic. Six patients were successfully treated. In five patients, the cysts were excised by open heart surgery, while in one by pericardiectomy. In addition, antiparasitic drugs were successfully used in two patients with long-term satisfactory results. In conclusion, cardiac echinococcosis is associated with an increased risk of potentially lethal complications. Newer techniques of cardiac imaging have helped locate the cysts while surgical removal may offer cure. Some patients responded to specific long-term drug treatment.
Asunto(s)
Equinococosis/epidemiología , Cardiopatías/epidemiología , Adulto , Anciano , Animales , Anticuerpos Antihelmínticos/inmunología , Equinococosis/diagnóstico , Equinococosis/etiología , Equinococosis/terapia , Echinococcus/inmunología , Ecocardiografía , Ensayo de Inmunoadsorción Enzimática , Femenino , Técnica del Anticuerpo Fluorescente Indirecta , Grecia/epidemiología , Corazón/parasitología , Cardiopatías/diagnóstico , Cardiopatías/parasitología , Cardiopatías/terapia , Hemaglutinación , Humanos , Inmunoelectroforesis , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: Our aim was to determine the applicability, safety and prognostic value of adenosine and dobutamine stress echocardiography in patients > or = 70 years old. BACKGROUND: These tests are sometimes mandatory because of difficulties and inaccuracies in interpreting traditional electrocardiographic stress tests. Furthermore, if these tests could be used to avoid coronary arteriography and cardiac catheterization, they would become essential in the care of the elderly, whose numbers are increasing. METHODS: We performed coronary arteriography and dobutamine and adenosine stress echocardiographic tests in 120 patients (72 men) > or = 70 years old who entered the hospital because of chest pain and had known or suspected coronary artery disease. The stress tests were performed on separate days, within 2 weeks of coronary arteriography. Both the arteriograms and the echocardiograms were analyzed by two experts who had no knowledge of the patients' other data or the other interpreter's report. Tests were judged to have positive or negative results, and the patients were followed up for the development of cardiac events. Univariate and multivariate analyses and other statistical modalities were applied for comparisons. RESULTS: Documented coronary artery disease was found in 89 patients. During the 14 +/- 7 of follow-up, cardiac events developed in 50 patients, including 3 (7.9%) of 38 patients with negative dobutamine and 12 (20.7%) of 58 patients with negative adenosine test results. Demonstration of any abnormality on stress echocardiography was an independent factor for cardiac events, both for dobutamine (relative risk 7.3) and for adenosine (relative risk 3.0). Both cessation of dobutamine or adenosine tests and diagnosis of disease in two or more coronary vessels were also independent predictors. ST segment depression > or = 1mm was related to future events only with the dobutamine test. CONCLUSIONS: These echocardiographic stress tests proved safe and well tolerated. They successfully stratified this cohort of elderly patients with coronary artery disease to low or high risk subgroups for subsequent cardiac events.
Asunto(s)
Adenosina , Agonistas Adrenérgicos beta , Enfermedad Coronaria/diagnóstico por imagen , Dobutamina , Ecocardiografía/métodos , Vasodilatadores , Adenosina/efectos adversos , Agonistas Adrenérgicos beta/efectos adversos , Anciano , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/epidemiología , Dobutamina/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Valor Predictivo de las Pruebas , Análisis de Regresión , Factores de Riesgo , Seguridad , Sensibilidad y Especificidad , Factores de Tiempo , Vasodilatadores/efectos adversosRESUMEN
Patients' intrahospital transport is considered as part of the mediconursing care continuum, since patients frequently need diagnostic or therapeutic procedures not performed at the bedside (Waddell 1975, Rutherford & Fisher 1986). Severe complications, such as airway obstruction, artificial airway or intravenous line removal, arterial blood gas and blood pressure changes, and arrhythmias or cardiac arrest, have been described during this transportation, especially in critically ill patients (Taylor et al 1970). Risks can be diminished if the patients are appropriately selected and carefully monitored during transportation (Venkataraman & Orr 1992).