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The predictive value of insulin resistance in patients hospitalized with heart failure is unknown. To evaluate prognostic value of insulin resistance (defined by a HOMA IR ≥ 2.5) for the combined event of death and readmission at 90 and 365 days post discharge and to determine if there are differences according to ejection fraction. Prospective study of 156 p hospitalized for acute heart failure without diabetes. A total of 83 years, 48% female, EF ≤ 45% 48%. Of 28% presented HOMA ≥2.5. HOMA IR ≥2.5 was associated with combined event (OR 2.4; 95% CI 1.9-5.1; P: 0.02) at 90 days. A multivariate analysis demonstrated its independent predictive value (OR 2.5, 95% CI 1.1-5.8; P: 0.03). At 1 year follow-up HOMA IR did not predict events. The predictive value of HOMA-IR was not associated with ventricular function. HOMA IR index was a predictor of a combined event at 90 days in our population. It is a simple determination that could contribute to identify higher risk patients during this vulnerable post-discharge phase. These data must be validated in larger studies.

Decompensated heart failure (DHF) is an important cause of in-hospital death in the coronary care unit. Estimating this risk becomes a clinical challenge. The shock index (IShock) and its variances have proven to be useful in predicting mortality in other pathologies and are easily obtained at admission. Evaluate the predictive capacity of IShock and its variants for in-hospital mortality in patients with DHF. Retrospective study of patients (p) prospectively and consecutively included in the ARGEN IC national registry. IShock, was calculated using the formula: HR/TAS, IShockM was calculated using HR/TAM, and IShock adjusted for age was calculated using the formula IShock x age. These indices were analyzed using the ROC curve and the Youden index to find the value that predicted in-hospital mortality with the greatest sensitivity and specificity. The prognostic value of the indices for in-hospital mortality was analyzed. Univariate and multivariate analyses were performed. Patients with cardiogenic shock were excluded from the analysis. Eight hundred seventy-nine patients. Age 74 years (IQR 25-75 64-83). 60% male. 74% hypertensive, 33% diabetic and 42% had ejection fraction40%. In-hospital mortality was 6.6%. According to Youden 's test, the best value for predicting IShock mortality was 0.9, for IShockM of 1.26 with and for the adjusted IShock of 50.4. The last two showed an independent predictive value in different multivariate models. The IShockM and the IShock x age, taken at the patient´s admission for decompensated heart failure, are very easily obtained at no additional cost providing useful information on hospital major outcomes.

espanolLos hombres con CHA2DS2-Vasc ≥ 1 o las mujeres con CHA2DS2-Vasc ≥ 2 y fibrilacion/aleteo auricular tienenindicacion de tratamiento antitrombotico al alta.Objetivos: Analizar la prevalencia del uso de anticoagulantes en esta poblacion; hallar predictores del uso de nuevos anticoagulantesorales; y analizar la persistencia al ano del tratamiento con nuevos anticoagulantes orales.Resultados: Pacientes consecutivos: 484. Los criterios de exclusion fueron la muerte intrahospitalaria (n: 12) y CHA2DS2-Vascde 0 en ambos generos y de 1 en mujeres (67 pacientes). Los pacientes analizados fueron 405. Edad mediana: 76 anos, generofemenino: 46%, HTA: 76%, diabetes: 25%, accidente cerebrovascular previo: 10%, antecedentes de fibrilacion/aleteo auricular:30%. Estrategia de control de ritmo: 66%. Fueron anticoagulados al alta 293 pacientes (72%). Entre los pacientes anticoagulados,los nuevos anticoagulantes orales fueron los mas utilizados: 63,5%, especialmente en los menos anosos (74 versus 79,5anos, p: 0,001), con menos antecedentes de accidente cerebrovascular (5,8% versus 18%, p EnglishMen with CHA2DS2-Vasc score ≥1 or women with CHA2DS2-Vasc score ≥2 and atrial fibrillation/flutter have highindication of antithrombotic treatment.Objective: The aim of this study was to analyze the prevalence of anticoagulant therapy in this population, to find predictorsfor the use of new oral anticoagulants and to analyze the one-year adherence to treatment.Methods: A total of 484 consecutive patients were included in the study. Exclusion criteria were in-hospital mortality (n=12) andCHA2DS2-Vasc score of 0 in both genders and 1 in women (n=67). Finally, 405 patients were analyzed with median age of 76years, 46% women, 76% hypertensive, 25% diabetic, 10% with previous stroke and 30% with history of atrial fibrillation/flutter.Results: A rhythm control strategy was used in 66% of cases and 293 patients were anticoagulated at discharge (72%). Amonganticoagulated patients, 63.5% received new oral anticoagulants, especially those who were younger (74 vs. 79.5 years, p=0.001),with lower history of stroke (5.8% vs.18%, p

ObjectivesThe aim of this study was to develop consensus among Argentine cardiologists on a care bundle to reduce readmissions of patients with heart failure (HF).SettingHospitals and cardiology clinics in Argentina that provide in-hospital care for patients with HF.ParticipantsTwenty-four cardiology experts participated in the two online rounds and 18 (75%) of them participated in the third-round meeting.MethodsThis study used a mixed-method design; it was conducted between August 2019 and January 2020. The development of a care bundle (a set of evidence-based interventions applied to improve clinical outcomes) involved three phases: (1) a literature review to define the list of interventions to be evaluated; (2) a modified Delphi panel to select interventions for the bundle and (3) definition of the HF care bundle. Also, the process included three rounds of scoring.ResultsTwenty-six interventions were evaluated. The interventions in the final bundle covered four categories: medication, continuum of care, lifestyle habits, predischarge tests. These were: medication: beta-blockers, angiotensin receptor neprilysin inhibitors or ACE-inhibitors, furosemide and antimineralocorticoids; continuum of care: follow-up appointment, daily weight monitoring; lifestyle habits: smoking cessation counselling and low-sodium diet; predischarge tests: renal function, ionogram, blood pressure control, echocardiogram and determination of decompensating cause.ConclusionFollowing a systematic mixed-method approach, we have developed a care bundle of interventions that could decrease readmission of patients with HF. The application of this bundle could contribute to scale evidence-based interventions.

The aim of this study was to know the problematic posed by a significant range of patients hospitalized for heart failure inprivate urban centers which do not receive patients referred with end-stage disease. Baseline characteristics and outcome of865 consecutive elderly patients hospitalized due to heart failure were analyzed in two of the above-mentioned centers. Meanage was 81 years and 48% were women. Heart failure was of coronary etiology in 25.5% of cases and chagasic in 0.4%, and 78%of patients were hypertensive. Average comorbidities were 3 per patient. Half of the patients had preserved systolic function.Systolic blood pressure on admission was 145 mmHg and ≥ 170 mmHg in 25% of cases. Average hospital stay was 6 days andin-hospital mortality 6.13%. The one-year evolution of these patients is a matter of great concern, with 70% of readmissionsand 40.12% mortality. It should be pointed out that half of the post discharge deaths were not due to heart failure.

RESUMEN: Introducción: La prevención secundaria en pacientes menores de 76 años que han padecido un evento vascular o han sido revascularizados incluye el uso de estatinas en altas dosis. Objetivo: Evaluar la adherencia al año a dicho tratamiento instituido desde el alta de la internación en UCO. Materiales y métodos: Estudio prospectivo de pacientes consecutivos durante el período enero-noviembre de 2015. Seguimiento (mediana) 9 meses. Resultados: Doscientos diez pacientes. El 83% eran hombres. La edad (mediana) alcanzó los 59 años (52-67,5). El 74,5% tuvo alta con atorvastatina a 40 mg/día; un 19%, con rosuvastatina a 20 mg/día; un 2,7%, con atorvastatina a 80 mg/día; y un 3,9%, con rosuvastatina a 40 mg/día. Un 50% de los pacientes continuaron tomando estatinas de alta intensidad, 28% redujeron la dosis y 22% abandonaron el tratamiento. Conclusiones: Solo la mitad de los pacientes con alto riesgo vascular o procedimiento de revascularización reciente mantiene el tratamiento al año. ABSTRACT: Background: Secondary prevention in patients < 76 years with history of a vascular event or previous revascularization includes the use of high intensity-statin therapy. Objective: The aim of this study is to evaluate the 1-year adherence to treatment since patients’ discharge from the coronary care unit. Methods: We conducted a prospective study of consecutive patients between January and November 2015. Median follow-up was 9 months. Results: A total of 210 patients were included; 83% were men and median age was 59 years (52-67.5). Most patients (74.5%) were discharged with atorvastatin 40 mg/day, 19% with rosuvastatin 20 mg/day, 2.7% with atorvastatin 80 mg/day and 3.9% with rosuvastatin 40 mg/day. Half of the patients continued with high-intensity statins, 28% reduced the dose and 22% stopped the treatment. Conclusions: Only half of the patients with high vascular risk or history of recent revascularization continues with the treat-ment after one year.

Diabetes and heart failure are closely interdependent, but its significance in decompensated heart failure (DHF) is not uniformly accepted. Objective: To compare mortality between diabetics and nondiabetics with DHF. Methods and Results: In-hospital and 1-year mortality of 1004 consecutive patients with DHF: 25.6% diabetics; median age was 81, 53% male. Diabetics were younger, more often male, with higher prevalence of ischemic etiology and reduced ejection fraction. Congestion was the most prevalent finding in both groups. In hospital mortality was 6.3% vs 6.6 % in nondiabetics and diabetics respectively and 1-year mortality was 35.77% in nondiabetics and 29.3% in diabetics. There were no significant differences in mortality at univariate and multivariate analyses. We applied a propensity score restricted to 378 patients, 189 (50%) diabetics and 189 (50%) and no significant differences were found. Conclusion: Diabetes had no impact on prognosis in DHF. Advanced age may played a major role in outcomes i thus making less relevant the presence of diabetes.

Background The interaction between chronic medications on admission and the association between serum potassium level and outcome in patients with acute heart failure (AHF) are unknown. Methods Observational intercontinental study of patients admitted with AHF. 15954 patients were included from 12 cohorts in 4 continents. Main outcome was 90-day mortality. Clinical presentation (medication use, hemodynamics, comorbidities), demographic, echocardiographic, and biochemical data on admission were recorded prospectively in each cohort, with prospective adjudication of outcomes. Results Positive and negative linear relationships between 90-day mortality and sK+ above 4.5 mmol/L (hyperkalemia) and below 3.5 mmol/L (hypo-kalemia) were observed. Hazard ratio for death was 1.46 [1.34-1.58] for hyperkalemia and 1.22 [1.06-1.40] for hypokalemia. In a fully adjusted model, only hyperkalemia remained associated with mortality (HR 1.03 [1.02-1.04] for each 0.1 mmol/l change of sK+ above 4.5 mmol/L). Interaction tests revealed that the association between hyperkalemia and outcome was significantly affected by chronic medications. The association between hyperkalemia and mortality was absent for patients treated with beta blockers and in those with preserved renal function. Conclusions In patients with AHF, sK+ > 4.5 mmol/L appears to be associated with 90-day mortality. B-blockers have potentially a protective effect in the setting of hyperkalemia.

To assess, according to age groups, patients' characteristics according to region of origin, the chronic therapeutic management, prognostic utility of clinical variables, and natriuretic peptides. Methods and results The GREAT registry consisted of patients identified as presenting with acute heart failure at the emergency department. Four groups of patients were defined according to age: the young patient group (

Objective To define the relationship between body mass index (BMI) and mortality in heart failure (HF) across the world and identify specific groups in whom BMI may differentially mediate risk. Background Obesity is associated with incident heart failure (HF), but is paradoxically associated with better prognosis during chronic HF. Methods We studied 6,142 patients with acute decompensated HF from 12 prospective observational cohorts followed across 4 continents. Primary outcome was all-cause mortality. Cox proportional hazards models and net reclassification index (NRI) described associations of BMI with all-cause mortality. Results “Normal” weight patients (BMI 18.5-25 kg/m2) were older with more advanced HF and lower cardiometabolic risk. Despite worldwide heterogeneity in clinical features across obesity categories, a higher BMI remained associated with decreased 30-day and 1-year mortality (11% decrease at 30 days; 9% decrease at 1 year per 5 kg/m2; P75; HR=0.82, P=0.006), decreased cardiac function (ejection fraction < 50%; HR=0.85, P

IntroducciónLa insuficiencia cardíaca representa una de las principales causas de internación con una tasa elevada de complicaciones y cuyo enfoque no parece que haya mejorado en los últimos años.ObjetivosConocer el perfil epidemiológico y clínico, analizar las medidas terapéuticas y la evolución durante la internación y a los 3 meses de pacientes admitidos por insuficiencia cardíaca descompensada.Material y métodosRegistro prospectivo, multicéntrico de pacientes internados por insuficiencia cardíaca descompensada en 31 centros de todo el país que aceptaron la invitación a participar del registro. Se analizaron variables vinculadas con la presentación y la evolución hospitalaria y a los 90 días.ResultadosSe incluyeron 736 pacientes, mediana de edad 74 años (64-82), 41% mujeres, 75% hipertensos, 27% diabéticos, 20% infarto previo, 30% fibrilación auricular crónica, 17% insuficiencia renal crónica, 18% EPOC. Sólo el 29% era de etiología isquémico-necrótica. El 47% había tenido internación en el último año por insuficiencia cardíaca. Las causas de descompensación más frecuentes fueron infecciones, suspensión del tratamiento y transgresión alimentaria.Las formas graves de presentación (shock cardiogénico, edema agudo de pulmón, anasarca) representaron el 30%. El 60% de los pacientes se internaron en área crítica. La mediana de permanencia fue de 7 (5-11) días. La mortalidad hospitalaria fue del 8%. A los 90 días, la reinternación fue del 24,5% y la mortalidad posalta fue del 12,8%.ConclusionesEl presente registro confirma que se trata de una población de edad avanzada con una incidencia alta de comorbilidades. Muchas descompensaciones ocurren por factores prevenibles. La tasa de complicaciones es elevada y no se redujo en la última década.REV ARGENT CARDIOL 2009;77:33-39.

RESUMENIntroducciónLas pruebas de evocación de isquemia con imágenes se emplean en la evaluación clínica depacientes internados por un SCASST que presentaron una evolución favorable con tratamientomédico en la etapa hospitalaria. Sin embargo, la importancia pronóstica de latomografía computarizada por emisión de fotón único (SPECT) de bajo riesgo isquémico(BR) en pacientes con síndrome coronario agudo sin elevación del ST (SCASST) manejadosen forma conservadora todavía es incierta, dado que la mayor parte de la información surgedel análisis de pacientes con enfermedad coronaria crónica.Objetivos1) Analizar la evolución del SCASST y la SPECT de BR al alta, 2) comparar los resultadosde la SPECT normal y con defectos de perfusión transitorios (DT), permanentes (DP) ocombinados (DC) y 3) determinar el valor aditivo de la SPECT a las variables de riesgoclásicas.Material y métodosSe incluyeron SCASST ingresados en la UCO con un seguimiento de 12 meses. Definiciones:Riesgo clínico por puntaje (score) TIMI. SPECT de BR (con apremio físico o farmacológico): DT £ 3/17 segmentos, DP £ 3/17 segmentos, DC: DT + DP y normal: sin defectos.Eventos clínicos (EC): muerte/infarto o reinternación por angina.ResultadosSe incluyeron 137 pacientes (edad mediana 59 años), 60% hombres. El puntaje de riesgoTIMI fue bajo en el 54% y moderado en el 46%. EC: 5,8%. Los EC según los defectos deperfusión fueron: normal: 2,1%, DT: 4,5%, DP: 5,9% y DC: 25% (p < 0,02). En el análisismultivariado, que incluyó edad, infarto previo, puntaje TIMI y DT, sólo el DC fue una variableindependiente para EC: OR 7,8 (IC 95% 1,2-49); p = 0,02. El valor predictivo y el likelihoodratio positivos y negativos fueron: 25%, 96%, 5,3 y 0,7, respectivamente.ConclusionesUna SPECT de BR es útil en la evaluación pronóstica del SCASST de riesgo clínico bajo amoderado, ya que identifica a una población con una incidencia baja de EC al año. La presenciade DC individualiza a pacientes con peor evolución, información que es relevantepara la toma de decisiones clínicas apropiadas.REV ARGENT CARDIOL 2009;77:367-372.

AntecedentesLa cirugía de revascularización miocárdica se considera hasta el momento el mejor tratamiento para los pacientes portadores de enfermedad del tronco de la coronaria izquierda (TCI); pese a ello existen pocos datos locales que comuniquen los resultados de esta cirugía.ObjetivosDescribir los resultados inmediatos y a los 5 años de una serie de cirugías coronarias en pacientes con lesiones del TCI.Material y métodosEn el período 2003-2007 se estudiaron 174 cirugías coronarias del TCI realizadas en forma consecutiva en tres servicios quirúrgicos asociados. Se analizaron los resultados quirúrgicos a los 30 días y en el seguimiento hasta 5 años, en los que se tuvieron en cuenta la mortalidad de causa cardiovascular y por otras causas, los eventos cardiovasculares mayores, la necesidad de nueva revascularización y la supervivencia libre de síntomas. Las curvas se compararon con la supervivencia esperada para el mismo grupo de edad y sexo.ResultadosEl 90,8% de los pacientes tuvieron lesiones múltiples. La mortalidad a los 30 días fue del 4,0%, similar a la esperada según el EuroSCORE (6,4%, OR = 0,62, IC 95% 0,21-1,78; p = 0,333), y los eventos cardiovasculares mayores incluyeron 2,9% de infarto y 1,7% de accidente cerebrovascular (ACV). El seguimiento fue de 506 pacientes-años (12 a 60 meses) e involucró al 91% de los pacientes. Al considerar la mortalidad cardiovascular, la supervivencia a los 5 años fue del 83,7%, similar a la esperada en la población general. La supervivencia en el mismo plazo descendió al 77,6% cuando se computaron todas las causas de muerte (p = 0,436). La supervivencia a los 5 años libre de angina y de nueva revascularización fue del 72,2% y del 88,1%, respectivamente.ConclusionesEn este estudio observacional de pacientes operados con lesión del TCI se demostró una mortalidad quirúrgica algo inferior a la calculada con el EuroSCORE y una tasa de ACV e infarto de entre el 1,7% y el 2,9%. El seguimiento a 5 años mostró una supervivencia similar a la esperada en la población general para la misma edad y tasas de supervivencia libre de angina y de nueva revascularización de entre el 72% y el 88%. Por último, el 90% de los TCI se asociaron con lesiones coronarias múltiples, poco proclives al tratamiento con angioplastia. Los resultados analizados en este estudio fueron consistentes con los hallados en la bibliografía internacional.

To assess, according to age groups, patients' characteristics according to region of origin, the chronic therapeutic management, prognostic utility of clinical variables, and natriuretic peptides.The GREAT registry consisted of patients identified as presenting with acute heart failure at the emergency department. Four groups of patients were defined according to age: the young patient group (65 years); 'middle-old' (65-74 years), 'old-old' (75-84 years) and the 'oldest-old' (85-94 years). Follow-up at 1 year was performed via personal contact or national data registries at 1 year. Dataset consisted of 14 758 patients aged up to 95 years, with the 'oldest-old' group being more prevalent in North America and Western Europe. The 30-day mortality rate were, respectively, 8.1%, 8.9%, 10.3%, and 16.3% among the four age groups and 1-year mortality rates were, respectively, 3.1%, 17.1%, 24.7%, and 39.9%. Chronic heart failure treatment was less frequently administered with age (percentage of the 'fully treated' group was 14% in the 'young' compared with 2% in the 'oldest-old' patient group). Reduced left ventricular ejection fraction was present in 70%, 62.3%, 52.5%, and 46.8% among the four age groups, respectively. The prognostic utility of most variables for short- and long-term outcome was attenuated with age, with the exception of natriuretic peptides.This study found a large heterogeneity in age among geographic regions and that the eldest are less likely to be treated in accordance with recommendations of current heart failure guidelines. Natriuretic peptide concentrations retained prognostic value in patients across age strata.

El ECG es el método más simple para el diagnóstico de infarto inferior (IAMinf); sin embargo, su utilidad disminuye para determinar el vaso responsable. Objetivos 1. Analizar la utilidad del desnivel del ST en aVR en la identificación de oclusión de las arterias coronaria derecha (CD) o circunfleja (CX). 2. Evaluar la utilidad agregada a los criterios clásicos. Material y métodos Se incluyeron en el estudio 65 pacientes con IAMinf a quienes se les realizó una cinecoronariografía (CCG) durante la internación. Se analizaron los criterios clásicos, así como el desnivel del ST en aVR: ?ST =?1 mm, ?ST =?1 mm o nivelado (isoST) a 0,08 seg del punto J y se calcularon la sensibilidad (S), la especificidad (E), el valor predictivo positivo (VPP), el valor predictivo negativo (VPN) y el likelihood ratio (LR). Se incluyó la derivación aVR en un análisis multivariado para determinar su valor agregado a los criterios clásicos. Resultados La CD fue responsable de la oclusión en 47 pacientes (72%) y la CX en 18 (28%). Signos clásicos : CD : la relación del ?STD3/D2 =?1 se halló en 52 pacientes (91,5%; p = 0,001) e ?STD1-aVL =?1 mm en 34 (61%; p < 0,05); CX : ?STD2/D3 > 1 en 13 pacientes (50%; p = 0,001) y ?STV5-V6 =?1 mm en 12 (44%; p < 0,001). Derivación aVR : CD : ?ST o isoST en 46 pacientes (81%; p < 0,001); CX : ?ST =?1 mm en 19 (56%; p < 0,001). En el análisis multivariado, el ?ST o isoST en aVR identificó a la CD (OR IC 95% 4,7 (1,1-19,8; p = 0,03), mientras que el ?ST aVR identificó a la CX. Se propone un algoritmo diagnóstico para CD que refleja el valor aditivo de aVR a la presencia de los signos clásicos: ?ST o isoST en aVR (VPP 94%; LR+: 2). Conclusión La derivación aVR es una herramienta útil para la identificación de la arteria responsable en el IAMinf, ya que brinda información diagnóstica adicional a los signos clásicos.

La rabdomiólisis es un síndrome clínico y de laboratorio provocado por la acumulación de sustancias tóxicas por necrosis del músculo esquelético. La causa tradicionalmente descripta ha sido el trauma. Su manifestación clínica puede variar desde la elevación asintomática de la CPK hasta la insuficiencia renal y la muerte. El éxito del tratamiento radica en una rápida sospecha clínica, la hidratación parenteral enérgica y la corrección de las alteraciones electrolíticas. Se presenta el caso de un paciente de 40 años, con un infarto anterior, que fue sometido a múltiples cardioversiones eléctricas por fibrilación ventricular y maniobras de reanimación cardiopulmonar y que presentó rabdomiólisis, con buena evolución posterior.

This study sought to define the relationship between body mass index (BMI) and mortality in heart failure (HF) across the world and to identify specific groups in whom BMI may differentially mediate risk.Obesity is associated with incident HF, but it is paradoxically associated with better prognosis during chronic HF.We studied 6,142 patients with acute decompensated HF from 12 prospective observational cohorts followed-up across 4 continents. Primary outcome was all-cause mortality. Cox proportional hazards models and net reclassification index described associations of BMI with all-cause mortality.Normal-weight patients (BMI 18.5 to 25 kg/m(2)) were older with more advanced HF and lower cardiometabolic risk. Despite worldwide heterogeneity in clinical features across obesity categories, a higher BMI remained associated with decreased 30-day and 1-year mortality (11% decrease at 30 days; 9% decrease at 1 year per 5 kg/m(2); p 0.05), after adjustment for clinical risk. The BMI obtained at index admission provided effective 1-year risk reclassification beyond current markers of clinical risk (net reclassification index 0.119, p 0.001). Notably, the "protective" association of BMI with mortality was confined to persons with older age (75 years; hazard ratio [HR]: 0.82; p = 0.006), decreased cardiac function (ejection fraction 50%; HR: 0.85; p 0.001), no diabetes (HR: 0.86; p 0.001), and de novo HF (HR: 0.89; p = 0.004).A lower BMI is associated with age, disease severity, and a higher risk of death in acute decompensated HF. The "obesity paradox" is confined to older persons, with decreased cardiac function, less cardiometabolic illness, and recent-onset HF, suggesting that aging, HF severity/chronicity, and metabolism may explain the obesity paradox.

Although usage of variable life-adjusted display (VLAD) in medicine was proposed a decade ago, there is only little experience in mortality and morbidity monitoring with this method. The work objective was to study the utility of VLAD for continuous monitoring of cardiac surgery quality indicators.A continuous monitoring of morbidity and mortality with VLADs, was performed in a prospective series of 502 cardiac surgeries. VLAD plots for mortality, reopening for bleeding, deep sternal wound infection, stroke, myocardial infarction and need for postoperative dialysis were done. Mortality was risk-adjusted with Euro-SCORE, while postoperative complications were adjusted with a morbidity risk score. Additionally, internal thoracic artery graft usage in coronary surgery was plotted.VLADs based on risk-adjusted morbidities and mortality could identify several clusters of adverse results, occurring at different periods of time, as well as its temporal relations. In the same way, it could be determined along the series, the net lives saved, the complications avoided and the internal thoracic artery graft usage.Continuous monitoring with VLAD plots would provide on-line control of cardiac surgery outcomes. This method would be, not only useful for mortality supervision, but to check risk-adjusted morbidity and to control other quality indicators, such as internal thoracic artery usage.

We report a very rare case of ascending aortic replacement complicated by acute supravalvular aortic stenosis. A 53-year-old man was referred to our Institution for evaluation of a systolic murmur and congestive heart failure. He had undergone elective ascending aortic replacement one month previously due to acute type A aortic dissection. On admission, transesophageal echocardiography revealed a proximal leak with a pseudoaneurysm compressing the aortic graft and generating a systolic gradient of 84 mmHg. The patient underwent reoperation, the graft was removed and a new Dacron graft was put in place.

Metastatic cardiac myxoid liposarcoma is rare. We present the case of a 56-year-old woman who was admitted for angina and syncope, and in whom a mobile intracardiac mass obstructing the left ventricular outflow tract and protruding into the aortic root during systole was detected by transesophageal echocardiography (TEE). She reported an antecedent of the complete excision of a myxoid liposarcoma of the thigh 12 years before. A surgical resection procedure was performed through an excision of the anterior wall of the left ventricle. The histopathological analysis of the specimens obtained during surgery revealed a low-grade malignancy myxoid liposarcoma, similar to the one resected in the thigh 12 years before. The present case is the first one to report syncope due to left ventricular outflow tract as a cause for admission. TEE was able to visualize the metastatic tumor to the heart, accurately localize its position and allow for prompt surgical treatment that produced relief of the symptoms.

Background We performed this study to develop a new scoring system to stratify different levels of risk in patients admitted to hospital with a diagnosis of unstable angina (UA), which is a complex syndrome that encompasses different outcomes. Many prognostic variables have been described but few efforts have been made to group them in order to enhance their individual predictive power. Methods In a first phase, 473 patients were prospectively analyzed to determine which factors were significantly associated with the in-hospital occurrence of refractory ischemia, acute myocardial infarction (AMI) or death. A risk score ranging from 0 to 10 points was developed using a multivariate analysis. In a second phase, such score was validated in a new sample of 242 patients and it was finally applied to the entire population (n = 715). Results ST-segment deviation on the electrocardiogram, age ≥ 70 years, previous bypass surgery and troponin T ≥ 0.1 ng/mL were found as independent prognostic variables. A clear distinction was shown among categories of low, intermediate and high risk, defined according to the risk score. The incidence of the triple end-point was 6 %, 19.2 % and 44.7 % respectively, and the figures for AMI or death were 2 %, 11.4 % and 27.6 % respectively (p < 0.001). Conclusions This new scoring system is simple and easy to achieve. It allows a very good stratification of risk in patients having a clinical diagnosis of UA. They may be divided in three categories, which could be of help in the decision-making process.