Asunto(s)

RESUMEN

Clinical manifestation of carotid occlusive disease is largely dependent on the severity of stenosis and the capability of collateral circulation. However, due to the complexity and difficulty in evaluation, cerebral collateral circulation has, so far, remained underappreciated. We report a patient with advanced extracranial arterial disease (including the right subclavian steal, occlusion of the right external carotid artery, and severe stenosis of the left vertebral artery), who underwent transient right internal carotid artery occlusion during carotid intervention. Throughout the occlusion, the flow into the right hemisphere (monitored by transcranial Doppler ultrasound in the right middle cerebral artery) was sufficient despite almost totally dependent on the anterior communicating artery, which highlights its role as the most potent collateral pathway.

RESUMEN

Several randomized studies have suggested that pretreatment with statins may reduce a periprocedural biomarker release in patients who underwent percutaneous coronary intervention (PCI); however, results remain controversial. The purpose of this study was to investigate the effect of a 1-day rosuvastatin therapy on troponin I release in patients who underwent nonemergency PCI. A total of 445 patients with angina pectoris were randomly assigned to therapy with rosuvastatin (20 mg 12 hours before coronary angiography + 20 mg immediately before PCI; rosuvastatin group, 220 patients) or PCI without statin therapy (control group, 225 patients). In patients taking statins (73%), rosuvastatin was added to their long-term statin therapy. The primary end point was the incidence of TnI microleak defined as TnI elevation >1.5× upper limit of normal, and the secondary end point was the incidence of post-PCI TnI elevation >3× upper limit of normal. The incidence of primary and secondary end point in the rosuvastatin versus control group was 13.6% versus 12% (p = 0.61) and 8.2% versus 7.1% (p = 0.67), respectively. Patients with C-reactive protein ≥2.0 mg/L had a decreased release of post-PCI TnI in the rosuvastatin group (0.032 [0.010 to 0.143] µg/L vs 0.056 [0.018 to 0.241] µg/L; p = 0.04). In conclusion, 1-day rosuvastatin therapy (20 mg twice a day) did not influence post-PCI TnI release in patients with angina. However, these results suggest that, in patients with an advanced inflammatory status, rosuvastatin loading therapy might have a cardioprotective effect.

Asunto(s)

RESUMEN

BACKGROUND: The aim of this randomized study was to investigate the effect of seven-day high-dose atorvastatin therapy on the incidence of peri-procedural myocardial infarction (PMI) in patients receiving long-term statin therapy. METHODS: The patients with stable angina receiving statin therapy and referred for percutaneous coronary intervention (PCI) were randomized (ratio 1:1) to a 7-day pre-treatment with atorvastatin of 80 mg daily and subsequent PCI (Atorvastatin group), or immediate PCI (Control group). The incidence of PMI was based on serum concentration of creatine kinase myocardial band (CK-MB) mass and troponin I (TnI), which were measured prior to and between 16 and 24h post PCI. The values were considered as positive if they were elevated ≥ 3 times the upper limit normal. RESULTS: We randomized 202 patients (male 67%, 65.5 ± 9.2 years; 100 vs. 102 pts.). There were no significant differences in the baseline characteristics among the randomized groups. The incidence of PMI, based on post-interventional release of TnI and/or CK-MB mass was 15% in the Atorvastatin group vs. 14% in the Control group (p=0.80). One patient (3%) in Atorvastatin group suffered from MI between randomization and PCI. CONCLUSIONS: These results suggest that 7-day pre-PCI therapy with high-dose atorvastatin did not reduce the occurrence of PMI in patients receiving chronic statin therapy.

Asunto(s)

RESUMEN

INTRODUCTION: Little is known about the prognosis of moderate versus critical carotid stenosis treated by carotid artery stenting (CAS). MATERIAL AND METHODS: This was a retrospective analysis of a single-centre registry including 271 consecutive patients (69 ±9 years, 87% at high risk for surgery), in whom 308 procedures were performed. The study included both symptomatic (≥ 50% carotid artery stenosis) and asymptomatic (≥ 70% carotid artery stenosis) patients. The primary endpoint was the rate of adverse events during follow-up (range 1-48 months), defined as all-cause death or stroke. RESULTS: We treated 115 critical and 193 moderate stenoses and implanted 318 stents (56% with closed cell design). Embolic protection systems were used in 296 cases (96%). The technical success rate was 98.2% in the critical stenoses group and 99% in the moderate group (NS). During follow-up, the incidence of the primary endpoint was 12.9% (13 pts) in the critical stenoses group and 14.7% (25 pts) in the moderate stenoses group (estimated 3-year freedom from death/stroke was 0.844 vs. 0.812; log-rank test p = 0.983). Left ventricular ejection fraction < 40%, significant contralateral carotid artery occlusion or stenosis and renal insufficiency were identified as significant predictors of the primary endpoint (p < 0.03). CONCLUSIONS: Carotid artery stenting with embolic protection systems in patients at high risk for carotid endarterectomy is safe. Patients with initially moderate and critical stenoses have an identical mid-term prognosis with regard to death and stroke.

RESUMEN

Several randomized studies and meta-analyses have suggested that pretreatment with statins may decrease periprocedural myocardial infarction (MI) in patients undergoing percutaneous coronary intervention (PCI). The purpose of this randomized study was to investigate the effect of a 2-day atorvastatin therapy before PCI on long-term clinical outcome. Two hundred statin-naive patients with stable angina pectoris referred for PCI were enrolled and randomized (ratio 1:1) to 2-day pretreatment with atorvastatin 80 mg/day and subsequent PCI (atorvastatin group), or immediate PCI (control group). The registry group comprised 182 consecutive patients on long-term statin therapy referred for immediate PCI during the same period as randomized patients. We compared the first occurrence of MI or death during long-term follow-up. There were no significant differences in most clinical characteristics and early results among the 3 groups. Median follow-up was 45 months (1 to 59). Incidences of death/MI were 11.4%, 12.9%, and 13.8% in the atorvastatin, control, and registry groups, respectively. In the same groups, age-adjusted estimated 4-year freedom from death/MI was 0.78 versus 0.75 versus 0.80, respectively (p=0.882, log-rank test). In multivariate analysis, only age of patients (odds ratio 1.04, 95% confidence interval 1.02 to 1.07, p<0.001) was identified as a significant predictor of death or MI during follow-up. In conclusion, these results suggest that 2-day therapy with high-dose atorvastatin before PCI did not influence occurrence of periprocedural MI or long-term clinical outcomes.

Asunto(s)

RESUMEN

INTRODUCTION: Peri-procedural myocardial infarction (PMI) is a frequent and prognostically important complication of percutaneous coronary intervention (PCI). This study was designed to determine the predictors of PMI in patients pre-treated with statins. MATERIAL AND METHODS: A total of 418 stable angina pectoris patients taking statins and aspirin were included. All the patients underwent PCI. Serum concentrations of creatine kinase (CK-MB mass) and troponin I (TnI) were measured prior to and then within 16 to 24 hours after PCI. The incidence of PMI was assessed using the established criteria (≥ 3 times upper limit of normal). RESULTS: Four hundred and eighteen stable patients (63 ±10 years, 68% males) were treated by PCI. The technical success rate of PCI was 99%. The incidence of PMI based on CK-MB mass or TnI release was 12% (PMI group). There were no significant differences in baseline clinical and procedural characteristics between PMI and non-PMI groups except for the balloon inflation time (40 ±44 s vs. 26 ±27 s; p = 0.02) and the proportion of treated type C lesions (42% vs. 28%; p = 0.03). In multivariate analysis, the independent predictors of PMI were balloon inflation time (OR = 1.01; 95% CI 1.001-1.020; p = 0.02) and pre-procedural level of C-reactive protein (OR = 1.38; 95% CI 1.059-1.808; p = 0.02). CONCLUSIONS: These results suggest that C-reactive protein and balloon ischaemic time are independent predictors of PMI in stable angina patients pre-treated with statins.

RESUMEN

BACKGROUND: Alcohol septal ablation (ASA) is a catheter-based intervention that has been used as an alternative to surgical myectomy in highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: This retrospective study was designed to evaluate the incidence of major complications in the mid-term follow-up of low-dose (1-2.5 ml of ethanol), echo-guided alcohol septal ablation. RESULTS: A total of 101 consecutive patients (56 +/- 15 years) with highly symptomatic HOCM were enrolled. At 6 months, there was a significant decrease in resting outflow gradient accompanied by reduction in basal septal diameter and improvement in symptoms (P < 0.01). Two patients (2%) experienced procedural ventricular tachycardias terminated by electrical cardioversion. A total of 87 patients (86%) underwent an uneventful postprocedural hospital stay. The postprocedural complete heart block occurred in 10 patients (10%), and subsequent permanent pacemaker was implanted in four cases (4%). Sustained ventricular arrhythmias requiring electrical cardioversion occurred in four patients (4%) within postprocedural hospital stay. Subsequently, ICD was not implanted in any of these cases. The patients were repeatedly examined by Holter ECG monitoring, and in the mid-term follow-up (6-50 months), they stayed asymptomatic and without any ventricular arrhythmias. CONCLUSION: This study demonstrates the same early incidence of complete heart block requiring permanent pacemaker implantation (4%) and sustained ventricular arrhythmias following low-dose, echo-guided ASA.

Asunto(s)

RESUMEN

Both randomized and observational studies have suggested that pretreatment with statins may reduce the incidence of periprocedural myocardial infarction (PMI) in patients with stable angina during elective percutaneous coronary intervention (PCI). The purpose of this randomized study (Clinical Trial Registration No. NCT00469326) was to investigate the effect of 2-day atorvastatin therapy on the incidence of PMI in patients with stable angina pectoris undergoing elective PCI. A total of 200 patients with stable angina pectoris who were not taking statins and who had been referred for PCI were enrolled and randomized (ratio 1:1) to a 2-day pretreatment regimen with atorvastatin 80 mg/day and subsequent PCI or immediate PCI. The serum concentration of creatine kinase-MB mass and troponin I were measured before and 16 to 24 hours after PCI. The incidence of PMI was assessed using established criteria. Of the patients, 10% in the atorvastatin group and 12% in the control group had a postprocedural creatine kinase-MB mass elevation > or =3 times the upper limit of normal (p = 0.65). The incidence of PMI as determined by the postinterventional release of troponin I > or =3 times the upper limit of normal was 17% in the atorvastatin group and 16% in the control group (p = 0.85). The median creatine kinase-MB mass peak after PCI was 1.46 ng/ml (interquartile range 0.83 to 2.52) in the atorvastatin group and 1.40 ng/ml (interquartile range 0.90 to 2.54) in the control group (p = 0.70). The median peak troponin I level after PCI was 0.100 ng/ml (0.096 to 0.385) in the atorvastatin group and 0.100 ng/ml (0.60 to 0.262) in the control group (p = 0.54). On multivariate analysis, the only independent predictor of PMI was patient age (odds ratio 1.09, 95% confidence interval 1.025 to 1.159, p = 0.006). In conclusion, in the present study 2-day pre-PCI therapy with atorvastatin did not reduce the occurrence of PMI in patients with stable angina pectoris undergoing elective PCI.

Asunto(s)

RESUMEN

BACKGROUND: Alcohol septal ablation (ASA) decreases the left ventricular (LV) outflow gradient and relieves symptoms in patients with highly symptomatic hypertrophic obstructive cardiomyopathy (HOCM). The aim of this study was to evaluate the early course of hemodynamic, morphologic and clinical changes in younger and elderly patients. METHODS AND RESULTS: Forty-four consecutive patients (age, 24-81 years) underwent the ASA procedure for HOCM. Clinical and echocardiographic data were obtained at baseline and periodically up to 12 months after ASA. There was a significant correlation between septum thickness and age at baseline and in the early post procedural period (p = 0.004 at baseline, p = 0.0033 days postoperative, p = 0.0193 weeks pos operative). The dependence of septal thickness on the duration of follow-up (p < 0.001) was significantly influenced by age (p = 0.026), which retained statistical significance after multivariate adjustment (p = 0.031). A decrease in the gradient of the LV outflow was identified in all age-related groups of patients (p < 0.001). After multivariate adjustment, there was a significant influence of age (p = 0.003) and creatine kinase-MB peak (p = 0.016) on the course of outflow gradient reduction. CONCLUSIONS: ASA is an effective treatment option for patients with HOCM, irrespective of their age. Younger patients are characterized by a thicker basal septum at baseline and a slower hemodynamic improvement within the early post procedural period.

Asunto(s)

RESUMEN

This study evaluates the association between statin therapy in patients treated by percutaneous coronary intervention (PCI) for stable angina pectoris and postinterventional myocardial injury with subsequent long-term clinical outcome. Prospectively collected data on 400 consecutive patients with stable angina pectoris or evidence of inducible myocardial ischemia were analyzed. The incidence of myocardial infarction based on postinterventional release of troponin I>1.5 ng/ml was 12% in the statin pretreated patients and 20% in those not pretreated with statin therapy (P=0.04, odds ratio 1.84, 95% confidence interval 1.06-3.21). Of the patients experiencing a post-PCI troponin elevation>1.5 ng/ml, those pretreated with a statin pre-PCI had a lesser troponin elevation compared with those not receiving a statin pre-PCI (median: 2.9 ng/ml [1.9-11.5] vs 5.0 ng/ml [3.1-8.8]; P<0.001). In the multivariate model, preprocedural statin therapy was identified as the only independent negative predictor of procedure-related myocardial necrosis based on postprocedural troponin elevation. In the 21-month follow-up period, statin pretreated patients were observed to have fewer deaths, revascularizations, or myocardial infarction; however, this difference was not statistically significant. These results suggest that pretreatment with statins in patients undergoing PCI for stable angina pectoris reduces the risk and extent of procedure-related myocardial injury measured by troponin release.

Asunto(s)

RESUMEN

Coronary artery anomalies remain a poorly understood topic in modern cardiology. The most important issue is the origin of the left coronary artery or the left anterior descending artery from the opposite aortic sinus, frequently associated with sudden cardiac death. We report our experience concerning the evaluation of these anomalies. From 15 April 1997 to 1 December 2004, we performed 13.407 coronary angiographies and found eight patients with these anomalies. In seven patients the coronary angiography was sufficient for the ultimate decision. However, in one case was the angiographic signs contradictory and the optimal imaging of the coronary tree was received by the multi-slice spiral computer tomography. We consider the coronary angiography a sufficient method of evaluation in most of the patients with the coronary artery anomalies, but the 'gold standard' is 3-dimensional examination by the multi-slice computer tomography or the magnetic resonance. The computer tomography is the method of the choice to distinguish interarterial, intraseptal and prepulmonary course of the left coronary artery originating from the right aortic sinus.

Asunto(s)

RESUMEN

Low-grade inflammation as detected by increased C-reactive protein (CRP) levels predicts the risk of cardiovascular events. However, there is still controversy over the mid-term predictive value of CRP in patients referred for elective percutaneous coronary revascularization (PCI) for stable angina pectoris. The aim of this study was to assess the relationship between baseline CRP level and mid-term outcome of patients undergoing PCI. Two groups of patients with stable angina pectoris were prospectively studied. Group A consisted of 150 consecutive patients with a CRP level < or = 3 mg/L, and group B consisted of 150 consecutive patients with a CRP level > 3 mg/L undergoing PCI at our institution. Comparing both groups of patients, the analysis confirmed a significant difference between medians of the CRP levels (0.5 versus 8 mg/mL; P < 0.001). A higher level of CRP in group B was associated with a lower presence of male gender (P < 0.05) and history of myocardial infarction (P < 0.05). On the other hand, in group B there was higher occurrence of smoking (P < 0.001), hypertension (P < 0.05), hypertriglyceridemia (P < 0.001), and diabetes mellitus (P < 0.01). The incidence of myocardial infarction based on post-interventional release of TnI > 1.5 ng/mL reached 12% in group A and 14% in group B (P = 0.73). Analyses were repeated with adjustment for significant baseline variables, which did not change our findings. The incidence of adverse cardiovascular events during a six month follow-up was 13% in both groups (NS). Increased CRP serum prior to PCI was not associated with the risk and extent of procedure-related myocardial injury measured by TnI release and does not portend heightened cardiovascular risk at six months after percutaneous revascularization. On the other hand, a CRP level > 3 mg/L was associated with a higher occurrence of cardiovascular risk factors (smoking, hypertension, hypertriglyceridemia, and diabetes mellitus).

Asunto(s)

RESUMEN

This prospective, randomized study evaluates the association between ethanol dose and postprocedural hemodynamic changes in 42 patients treated by alcohol septal ablation for obstructive hypertrophic cardiomyopathy. These results suggest that the early course of hemodynamic changes is not related to the use of a small (1 to 2 ml) or standard (>2 ml) dose of ethanol.

Asunto(s)

RESUMEN

Alcohol septal ablation (PTSMA) improves outflow gradient, left ventricular (LV) diastolic function, and symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). Tei index (TI) is a Doppler parameter reflecting both systolic and diastolic LV function. Midterm changes of TI after PTSMA have not been determined up to now. Twenty-seven consecutive patients (mean age 53 +/- 13 years) with symptomatic HOCM underwent PTSMA procedure. Clinical and echocardiographic data were collected at baseline, 6 and 12 months after PTSMA. TI decreased from 0.67 +/- 0.11 to 0.55 +/- 0.06, isovolumic contractile time (ICT) decreased from 74 +/- 20 to 48 +/- 11 ms, isovolumic relaxation time decreased from 146 +/- 25 to 117 +/- 9 ms, and LV ejection time decreased from 330 +/- 42 to 298 +/- 13 ms. LV remodeling was determined by LV dimension increase from 46 +/- 6 to 48 +/- 6 mm and basal septum thickness reduction from 22 +/- 4 to 15 +/- 3 mm. LV ejection fraction decreased from 78 +/- 7 to 73 +/- 6% and maximal outflow gradient decreased from 69 +/- 44 to 15 +/- 11 mmHg. All changes were statistically significant (P <0.01). Symptomatic improvement was characterized by relief of dyspnea (2.5 +/- 0.7 versus 1.4 +/- 0.6 NYHA class; P <0.01) and angina pectoris (2.6 +/- 0.9 versus 0.7 +/- 0.7 CCS class; P <0.01). PTSMA is an effective method of therapy for HOCM. Shortening of TI suggests the improvement of LV myocardial performance in the midterm follow-up.

Asunto(s)

RESUMEN

Patients with highly symptomatic hypertrophic obstructive cardiomyopathy (HOCM) are considered to be good candidates for percutaneous transluminal septal myocardial ablation (PTSMA). However, there is ongoing discussion regarding the optimal dose of alcohol injected into target septal artery and the impact of infarct sizes on the clinical and hemodynamic outcome. Thirty-four patients with symptomatic HOCM receiving maximum medical therapy were consecutively enrolled. Patients were randomized in a 1:1 ratio into one of the two arms according to dose of injected alcohol during echocardiography-guided PTSMA procedure. Clinical, electrocardiographic, and echocardiographic evaluation were performed 6 months after the procedure in all the patients. Both groups of patients matched in all clinical and echocardiographic data. The dose of alcohol injected was 1.6 +/- 0.4 and 3.4 +/- 0.9 (P < 0.001) with subsequent peak of CK-MB 1.9 and 3.2 microkat/L (P < 0.05) in group A and B, respectively. There was a correlation between amount of injected alcohol and the peak of CK-MB (r = 0.58; P < 0.01), whereas no significant relationship (r = 0.16; P = NS) was documented between the peak of CK-MB and left ventricular outflow gradient at follow-up. At 6-month follow-up, both groups of patients were not significantly different with regard to symptoms or electrocardiographic and echocardiographic findings. In conclusion, this study suggests that the low dose (1- 2 ml) of alcohol injected into target septal branch reduces size of necrosis. Moreover, the low dose is probably as safe and efficacious as usually used doses (2-4 ml).

Asunto(s)

RESUMEN

BACKGROUND AND AIM: Alcohol septal ablation (PTSMA) decreases left ventricular outflow gradient (LVOG) and relieves symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). The time course of early changes of LVOG has not been clearly determined up to now. METHODS: Doppler echocardiography was used to determine the maximal LVOG. Thirty-nine consecutive patients (24 women; age 55+/-14) were examined at baseline, immediately after the procedure, and 3-5 days, 3 weeks and 3 months thereafter. RESULTS: The baseline LVOG decreased immediately after PTSMA from 73+/-49 mmHg to 13+/-16 mmHg (p<0.01). During the hospital stay (postprocedural period) LVOG increased from 13+/-16 to 37+/-35 mmHg (p<0.01). All the patients were discharged 5-10 days after the procedure. At three-week examination LVOG decreased from 37+/-35 to 25+/-12 mmHg (p<0.01). Three-month survival was 97%. One patient died suddenly one month after PTSMA. At three-month examination LVOG decreased from 25+/-12 to 17+/-14 mmHg (NS). All the patients reported an improvement in symptoms at follow-up. CONCLUSIONS: The immediate decrease of LVOG after PTSMA procedure caused by myocardial necrosis and stunning, was followed by a significant LVOG increase during the early postprocedural period and continuous LVOG decrease at the short-term follow-up.

Asunto(s)

RESUMEN

The authors report a case of recurrent left anterior descending artery rupture during coronary interventions in a 70-year-old man. Coronary artery rupture was treated successfully by percutaneous coronary stent-graft implantation. Based on this experience, the authors advise against repeat angioplasty of a coronary artery which has ruptured during a prior intervention. Membrane-covered stents should be the first choice in the treatment of life-threatening coronary artery rupture.

Asunto(s)

RESUMEN

Research on the evolution of life histories addresses the topic of fitness trade-offs between semelparity (reproducing once in a lifetime) and iteroparity (repeated reproductive bouts per lifetime). Bulmer (1994) derived the relationship v+P(A)<1 (P(A) is the adult survival;vb(S) and b(S) are the offspring numbers for iteroparous and semelparous breeding strategies, respectively), under which a resident semelparous population cannot be invaded by an iteroparous mutant when the underlying population dynamics are stable. We took Bulmer's population dynamics, and added noise in juvenile and adult survival and in offspring numbers. Long-term coexistence of the two strategies is possible in much of the parameter region ofv +P(A)<1 when noise occurs simultaneously in all three components, or (more restricted) when it affects juvenile and adult survival or adult survival and offspring numbers. Iteroparity cannot persist when the environmental variability involves juvenile survival and offspring numbers, or when the noise acts on the three components separately.

Asunto(s)

RESUMEN

BACKGROUND: C-reactive protein (CRP) level is a sensitive marker of inflammation and a probable predictor of cardiovascular risk. The aim of this study was to assess the relationship between the presence and the extent of coronary atherosclerosis and CRP level in patients referred for coronary angiography for stable angina pectoris or a pathological exercise test. PATIENTS AND METHODS: A group of 200 patients were prospectively analyzed for the relationship between the presence and extent of coronary atherosclerosis and high-sensitivity CRP. Patients with stable angina pectoris or a pathological exercise test were included. RESULTS: For the whole group the CRP geometric mean was 2.92 mg/l and the median 3.0 mg/l. There was no difference between groups of patients with different extents of coronary lesions (P = 0.320, one-way analysis of variance). In patients without significant coronary disease the CRP geometric mean was 3.1 (2.28-4.21) mg/l with a variation coefficient of 118.4%; in patients with coronary artery disease the geometric mean was 2.83 (2.34-3.43) mg/l with a variation coefficient of 104.0%. The difference in CRP between both groups was not significant (P = 0.601). There was also no significant difference in CRP levels between groups of patients with and without a history of myocardial infarction (2.65 (2.08-3.36) mg/l and 3.18 (2.54-3.98) mg/l, P = 0.266) respectively. There was no correlation between the classification of angina pectoris and the logarithm of CRP level (P = 0.331). This relationship was not confirmed even in the group of patients with significant coronary artery disease (P = 0.693). CONCLUSIONS: CRP level is not related to the extent or the presence of coronary atherosclerosis assessed by coronary angiography, history of myocardial infarction or class of stable angina pectoris in patients referred for coronary angiography for stable angina pectoris or a pathological exercise test.

Asunto(s)