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AIMS: Our objective was to evaluate, in clinical practice, whether noninvasive assessment of coronary flow velocity reserve in left anterior coronary artery adds diagnostic information to both clinical variables and wall motion abnormalities derived from dobutamine stress echocardiography. METHODS AND RESULTS: We studied 130 patients who were scheduled for coronary angiography after undergoing dobutamine stress echocardiography. The same day, flow in left anterior descending artery was detected by transthoracic Doppler echocardiography. A Doppler signal of left anterior descending artery was detected in 110 patients (85%). We identified significant left anterior descending artery stenosis (>50% diameter stenosis) in 42 patients. Sensitivity and specificity of abnormal coronary flow velocity reserve (<2) to detect left anterior descending artery stenosis were 86% and 57%, respectively. Wall motion abnormalities had a sensitivity and specificity of 52% and 82%. After forcing the clinical and dobutamine stress echo variables into a regression model with three modeling steps, an abnormal coronary flow velocity reserve provided incremental information in predicting significant left anterior descending artery stenosis. CONCLUSION: An abnormal coronary flow velocity reserve by transthoracic Doppler echocardiography adds diagnostic value to both clinical data and variables derived from dobutamine stress echo to detect significant left anterior descending artery stenosis. [ABSTRACT FROM AUTHOR]

Congenital right ventricular muscular diverticula are extremely rare and are usually associated with other congenital cardiac anomalies, (in half of the cases tetralogy of Fallot). They functionally behave like an accessory ventricular chamber which contracts synchronously with the normal ventricles.Less than 30 patients with a right ventricular diverticulum have been reported in literature. An apical right ventricular diverticulum occurs in patients with thoraco-abdominal midline defects or abnormalities of the cardiac position[1]. However, an antero-superior diverticulum is usually associated with other congenital cardiac defects, such as a ventricular septal defect, tetralogy of Fallot, double outlet right ventricle and pulmonary stenosis[2–9].We report an 11-year-old boy with an antero-superior diverticulum of the right ventricle associated with a coarctation of aorta, ductus arteriosus, and atrial and ventricular septum defects. To the best of our knowledge, such an association has not been reported before. [ABSTRACT FROM AUTHOR]

An abstract of the article "Role of nitrates on the measurement of coronary flow velocity reserve by transthoracic echocardiography. Should we administer them as pretreatment?" by R. Florenciano, M. Villegas-Garcia and F. Soria-Arcos is presented.

An abstract of the article "Is noninvasive measurement of coronary flow velocity reserve an aid to dobutamine echocardiography? A case for the use in patients taking a beta-blocker" by R. Florenciano, M. Villegas-Garcia and F. Soria-Arcos is presented.

An abstract of the article "Acute myocardial infarction and coronary flow velocity reserve measured by transthoracic echocardiography. Importance of the cut-off point to predict recovery of systolic function," by R. Florenciano and colleagues is presented.

Background: Echocardiography is essential for the diagnosis and quantification of aortic regurgitation (AR). Velocity-time integral (VTI) of AR flow could be related to AR severity., Objective: This study aims to assess whether VTI is an echocardiographic marker of AR severity., Methods: We included all patients with moderate or severe native AR and sinus rhythm who visited our imaging laboratory from January to October 2016. All individuals underwent a complete echocardiogram with AR VTI measurement. The association between VTI and AR severity was analyzed by logistic regression and multivariate regression models. A p-value<0,05 was considered statistically significant., Results: Among the 62 patients included (68.5±14.9 years old; 64.5%: moderate AR; 35.5%: severe AR), VTI was higher in individuals with moderate AR compared to those with severe AR (2.2±0.5 m vs. 1.9±0.5 m, p=0.01). Patients with severe AR presented greater values of left ventricular end-diastolic diameter (LVEDD) (56.1±7.1 mm vs. 47.3±9.6 mm, p=0.001), left ventricular end-diastolic volume (LVEDV) (171±36.5 mL vs. 106±46.6 mL, p<0.001), effective regurgitant orifice (0.44±0.1 cm2vs. 0.18±0.1 cm2, p=0.002), and regurgitant volume (71.3±25.7 mL vs. 42.5±10.9 mL, p=0.05), as well as lower left ventricular ejection fraction (LVEF) (54.1±11.2% vs. 63.2±13.3%, p=0.012). The VTI proved to be a marker of AR severity, irrespective of LVEDD, LVEDV, and LVEF (odds ratio 0.160, p=0.032) and of heart rate and diastolic blood pressure (DBP) (odds ratio 0.232, p=0.044)., Conclusions: The VTI of AR flow was inversely associated with AR severity regardless of left ventricular diameter and volume, heart rate, DBP, and LVEF. VTI could be a marker of AR severity in patients with native AR and sinus rhythm. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Background: Anticoagulation with vitamin K antagonists continues to be a challenging task given the difficulty of achieving a correct time in therapeutic range (TTR). The SAMeTT 2 R 2 score has been proposed to identify patients that will be good responders. In this study we aimed to analyse clinical and genetic factors involved in a correct level of anticoagulation in patients with atrial fibrillation and thereby potentially improve the diagnostic performance of SAMeTT 2 R 2 score., Methods: We prospectively included 212 consecutive patients with nonvalvular atrial fibrillation under treatment with acenocoumarol for at least 6 months that were attended in a cardiology outpatient clinic and were categorized as adherent to medication. We carried out a multivariate regression analysis to detect the independent predictive factors of good control. In all patients VKORC1 , CYP2C9 ⁎ 2 , CYP2C9 ⁎ 3 , and MIR133A2 genotyping was performed., Results: A total of 128 (60.4%) patients presented TTR <70% (average TTR = 63.2). We identified body mass index (OR 0.94, 95%CI 0.89-0.99, p=0.032) and regular vitamin K intake (OR 0.53, 95%CI 0.28-0.99, p= 0.046) as independent predictors of poor anticoagulation control. The discriminatory power of a clinical-genetic model derived from our cohort was significantly better compared to the SAMeTT 2 R 2 score (C-statistic 0.658 versus 0.524, p<0.001)., Conclusions: In our study the SAMeTT 2 R 2 score revealed a poor ability in the prediction of TTR. Besides SAMeTT 2 R 2 , body mass index and possibly vitamin K intake should be taken into account when deciding the optimal anticoagulation strategy. The information provided by the identified genotypes was marginal.

Background: Blood pressure variability (BPV) has been postulated as a potential predictor of cardiovascular outcomes. No agreement exists as to which measurement method is best for BPV estimation. We attempt to assess the correlation between BPV obtained at the doctor's office, self-measurement at home (SMBP) and ambulatory BP monitoring (ABPM)., Methods: Eight weekly clinic BP measurements, 2 SMBP series, and 1 24-hour ABPM recording were carried out in a sample of treated hypertensive patients. BPV was calculated using the SD, the "coefficient of variation" and the "average real variability." Determinants of short-, mid-, and long-term BPV (within each measurement method) were also calculated. The different BPV determinants were correlated "intramethod" and "intermethod" by linear regression test., Results: For the 104 patients (66.5 ± 7.7 years, 58.7% males), the ABPM BPV (SD, systolic/diastolic: 14.5 ± 3.1/9.8 ± 2.5 mm Hg) was higher than the SMBP (12.2 ± 9.8/7.4 ± 5.8 mm Hg; P < 0.001) and clinic BPV (10 ± 8.9/5.9 ± 4.9 mm Hg; P = 0.001). The main BPV correlation between methods was weak, with a maximum R2 = 0.17 (P < 0.001) between clinic and SMBP systolic BPV. The "intramethod" correlation of BPV yielded a maximum R2 = 0.21 (P < 0.001) between morning diastolic SMBP intershift/intermeans variability. The "intermethod" correlation of short-, mid-, and long-term BPV determinants was weak (maximum R2 = 0.22, P < 0.001, between clinic intraday variability/SMBP morning intershift variability)., Conclusions: The "intramethod" and "intermethod" correlation between BPV determinants was weak or nonexistent, even when comparing determinants reflecting the same type of temporal BPV. Our data suggest that BPV reflects a heterogeneous phenomenon that strongly depends on the estimation method and the time period evaluated., (© American Journal of Hypertension, Ltd 2017. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Introduction and Objectives: Population-based studies in other countries have reported a reduction of standardized rates of hospitalization for heart failure (HF) but data from a well-defined population are lacking in Spain., Methods: All hospitalizations with a principal diagnosis of HF between 2003 and 2013 were obtained from the Minimum Basic Data Set, which includes all hospitals in the Region of Murcia. Health care episodes were identified by the individual health card (27 158 episodes). For each year, we studied the following parameters: crude, age-standardized and sex-standardized hospitalization rates for HF, length of stay, mortality, clinical variables, and the Elixhauser index. Time trends were analyzed using joinpoint regression., Results: Hospitalization rates increased by 76.7%, from 1.28‰ to 2.26‰ (crude) and 1.06‰ to 1.77‰ (standardized); the mean annual percentage of change (APC) was 8.2% until 2007 and was subsequently 1.9% (P < .05). Rates doubled in persons ≥ 75 years, reaching 19.9‰ in those aged 75 to 84 years (APC, 5.4%) and 32.5‰ in those aged ≥ 85 years (APC, 11.7%) but were unchanged in persons aged < 75 years. The hospitalization rate was 36% higher in women than in men but was equal after age-standardization and showed no temporal change. The Elixhauser comorbidity index increased by almost 1 point during the study period and episodes > 6 points increased by 2-fold. Length of stay and mortality were unchanged during the study period., Conclusions: Between 2003 and 2013, there was a sustained increase in standardized rates of hospitalization for HF, which affected persons ≥ 75 years and was associated with a rise in comorbidity. There is a need for strategies focused on this population., (Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To evaluate the contribution of six polymorphisms to the platelet reactivity in patients with acute coronary syndrome (ACS) treated with clopidogrel., Methods: Cross-sectional study of 278 consecutive patients with ACS. Detailed clinical information for each patient was collected and genotypes (CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP2C19*17, CYP3A4*1B, and PON1-Q192R) were evaluated with TaqMan® and KASPar® assays. Platelet reactivity was measured with VerifyNow®., Results: Mean age of patients was 66±11 years and 182 (65.5%) patients presented ACS without ST-segment elevation. A total of 206 (74.1%) patients presented poor response to clopidogrel (PRC). CYP2C19*2 polymorphism (p=0.038) was associated with PRC in the univariate setting. In the multiple logistic regression analysis, the risk factors for PRC were the presence of CYP3A4*1B allele (odds ratio [OR] 4.03; 95% confidence interval [CI] 1.01-16.34), age (OR 1.43; 95% CI 1.03-2.00), and body mass index (OR 4.05; 95% CI 1.21-13.43), whereas elevated hemoglobin was a protective factor. Discrimination of PRC through the model that included the six polymorphisms added modest information to the model based on clinical variables (C statistic difference 3.9%)., Conclusion: CYP3A4*1B allele may be an independent determinant of PRC in patients with ACS, although the variability in response to clopidogrel explained by the six polymorphisms is poor when compared to clinical variables.

Introduction and Objectives: Coronary blood flow measurement using a Doppler guidewire is the most sensitive way of detecting the no-reflow phenomenon following reperfusion of a myocardial infarction (MI). New high-frequency Doppler probes enable coronary blood flow velocity to be measured noninvasively. Our aims were to study the different patterns of left anterior coronary artery blood flow observed by transthoracic Doppler echocardiography, and to describe their association with functional recovery following reperfusion of an anterior MI., Methods: The study included 57 patients with a mean age of 60 years (range 30-85 years). An abnormal coronary blo:d flow pattern was defined as one in which there was a high peak diastolic velocity and a short deceleration time (i.e., < or = 500 ms). We compared the regional contractility, ventricular volumes, and left ventricular ejection fraction (LVEF) measured after 72 hours with those measured 1 month after MI., Results: Overall, 31 patients (54%) had a normal coronary blood flow pattern (Group 1) and 26 (46%), an abnormal pattern (Group 2). After one month, regional contractility improved in Group-1 patients, as did LVEF, from 46.8 (8.6) to 52.6 (8.8)% (P=.002). In these patients, left ventricular volumes were unchanged. In contrast, regional contractility and LVEF remained unchanged in Group-2 patients whereas ventricular volumes increased, from 55.8 (12.9) to 62.9 (16.8) ml/m2 (P=.05), and from 32.2 (9.5) to 37.1 (14.9) ml/m2 (P< .05). Coronary blood flow pattern was the most important independent predictor of left ventricular remodeling, odds ratio =6.14 (95% CI, 1.56-24.17)., Conclusions: Transthoracic Doppler echocardiographic assessment of coronary blood flow following reperfusion of an anterior myocardial infarction can be used to identify patients with microvascular damage who are progressing towards ventricular dilatation without recovery of myocardial function.

The following article reviews some of the most recent data that have come to light in the field of hypertension during the last year, including the long lasting controversy USA/Europe on the definition and treatment of hypertension, the importance of the interrelationship hypertension/sleep apnea syndrome, to conclude by discussing some of the most compelling implications of the main trials that have been published during the last few months.

Introduction and Objectives: Differences between anatomical severity and clinical manifestations are frequent in patients with hypertrophic cardiomyopathy. Our objective was to assess functional capacity in a consecutive group of patients with hypertrophic cardiomyopathy measuring exercise aerobic parameters, as well as clinical and echocardiographic variables., Patients and Method: We studied 98 consecutive patients with hypertrophic cardiomyopathy. All patients underwent both echocardiographic and cardiopulmonary exercise testing. The control group consisted of 22 untrained persons. We studied exercise capacity by analyzing maximal oxygen consumption and aerobic functional capacity, among other variables., Results: Patients with hypertrophic cardiomyopathy attained significantly lower maximal oxygen consumption values than controls (24.1 5.9 vs 36.4 5.9 ml/kg/min; p = 0.0001). Maximal aerobic capacity was significantly different among patients with NYHA functional capacity class I, II or III (78.9 13.5%; 71.9 14.7%; 63.9 15.7%; p = 0.009). However, considerable overlap was found between groups in maximal aerobic capacity. Functional impairment was greater in patients with left ventricular thickness > 20 mm, ejection fraction < 50%, left atrial dimension > 45 mm and pseudonormal or restrictive transmitral flow pattern., Conclusions: Patients with hypertrophic cardiomyopathy show significant functional impairment, which is difficult to detect from their clinical manifestations. Optimal assessment requires cardiopulmonary exercise testing.

Introduction: We evaluated the feasibility of detecting blood flow in the left anterior descending coronary artery and the usefulness of measuring coronary flow reserve to diagnose significant coronary artery disease, both by means of transthoracic Doppler echocardiography using a high-frequency transducer and echo-contrast agent., Patients and Method: We studied 107 patients who were scheduled for coronary arteriography for known or suspected ischemic heart disease. A Doppler signal was recorded by a pulsed wave in the distal left anterior descending artery at baseline and after dipyridamole infusion. An echo-contrast agent was administered to all patients. A coronary flow reserve equal to or higher than 1.7 was considered normal., Results: We recorded Doppler signals in the left anterior descending coronary artery of 83 patients (78%). Significant stenosis of the left anterior descending coronary artery was observed in 24 out of 83 patients (29%). The prevalence of significant stenosis was higher (62 vs 29%; p = 0.006) in patients in which no Doppler signal was detected. The sensitivity, specificity, and accuracy of abnormal coronary flow reserve in detecting significant stenosis of the left anterior descending coronary artery were 87, 74 and 78%, respectively., Conclusions: The measurement of coronary flow reserve by transthoracic Doppler echocardiography using a high-frequency transducer and echo-contrast agent is a feasible, widely available, and accurate method for detecting significant stenosis of the left anterior descending coronary artery.

Since publication of the Spanish Society of Cardiology Clinical Practice Guidelines on High Blood Pressure in January 2000, a new body of scientific evidence has been obtained that needs to be taken into account in clinical practice. A complete clinical evaluation by assessment of the global cardiovascular risk score should be done in patients with hypertension. In this connection, ECG findings and urine albumin excretion are of particular value. Up to now, the results of most important clinical trials indicate that the aim should be to normalize blood pressure, with stricter control in patients at higher risk (diabetes, target organ damage or left ventricular hypertrophy). Antihypertensive therapy should be selected on an individual basis, taking in account that patients with certain associated pathologies will benefit more from particular groups of drugs. Those with diabetes or left ventricular hypertrophy seem to benefit from pharmacological block of the renin-angiotensin system, and patients with heart failure from combined therapy with ACE inhibitors plus beta-blockers.

Introduction: The Influence of diabetes mellitus in the late outcome of coronary stenting remains controversial., Aim: The aim of this study was to determine the late clinical outcome of diabetics in comparison with non diabetics and to establish whether there are subgroups of diabetic patients with a greater need for target lesion revascularization., Methods: Two hundred sixteen consecutive patients (74 diabetics; 95 stents in 90 lesions and 142 non diabetics) who had successfully undergone coronary stenting were included in the study and followed over 17.6 +/- 10 months. The clinical events evaluated were target lesion revascularization, death and acute myocardial infarction. Independent predictive variables of target lesion revascularization were studied in both groups of patients., Results: The diabetic patients presented greater cardiovascular mortality (6.7% vs 1.4%; p=0.02) but the incidence of infarction was similar in the two groups (2.7% vs. 3.5%; p=0.6). The accumulated rate of target lesion revascularization at two years was 18.2% in diabetics vs 13.3% in non diabetics (p=0.09), respectively. The presence of three vessel disease (p=0.014), history of arterial hypertension ([=0.011) and residual stenosis > 0% (p=0.005) were specific predictive factors of target lesion revascularization for diabetic patients and together with vessel diameter < 3mm (p<0.001) subgroups of diabetics were independently selected with a significantly greater incidence of target lesion revascularization than the non diabetic patients., Conclusions: Following coronary stenting, diabetic patients show a greater cardiovascular mortality than non diabetics, but only some subgroups of diabetics (small vessels extensive coronary disease, associated arterial hypertension, residual stenosis) show a significantly greater risk of target lesion revascularization.

High blood pressure is a well-known cardiovascular risk factor that is responsible for an elevated morbidity and mortality. However, although efficacious drugs for treatment and numerous and updated scientific training programs are available, the reality is that only a low percentage of patients are followed up in accordance with the rates which are presently considered normal. The purpose of these guidelines is to provide medical guidance for the prevention, detection and evaluation of hypertension, and to provide the best diagnosis and treatment. The factors involved in cardiovascular complications in the hypertensive patient are multiple. That is why this report places more emphasis in the individual cardiovascular risk stratification as part of the treatment strategy. The information obtained in the most recent studies published confirms the interest in achieving the greatest decrease in rates of blood pressure. This treatment to lower levels is especially useful in the high-risk subgroup. It maintains the necessity of nonpharmacological measures or lifestyle modifications in all patients with high blood pressure who either need or do not need drug therapy. All pharmacological groups may be used, but it is appropriate to choose the specific antihypertensive agent adapted to the clinical and individual situation with the use of low doses of drugs to initiate therapy and the use of appropriate drug combinations.

Background: To analyze the relationship between obesity in its different degrees and the left ventricle morphology., Patients and Methods: M-mode echocardiography was used to estimate the mass, wall thickness and internal dimension of left ventricle in 48 obese women with different degrees of obesity, defined according to the body mass index. 25 women with normal weight were used as controls., Results: The body mass index was correlated with left ventricular mass, as well as with both the wall thickness of the left ventricle and its diastolic internal dimension. The abnormalities in the heart morphology increased according to the obesity degree, ranging from a 59% in the lesser obesity group up to a 100% in the more obese women. The incidence of the left ventricular hypertrophy determined by echocardiography also increased along with the body mass index, ranging from a 29% in the lesser degree of obesity women up to an 82% in the patients with a body mass index > 35 kg/m2., Conclusions: Obesity, even in its lowest degrees, shows frequent alterations in the heart morphology. This is related with a left ventricular mass increase and a higher incidence of the left ventricular hypertrophy. The left ventricular mass increase is due to an increase in the left ventricular walls thickness and also to a dilatation of its cavity.

Naturally occurring or surgically related hormonal deprivation at menopause is associated with cardiovascular and non-cardiovascular complications. Hormonal replacement therapy helps to prevent and treat these complications, not only symptoms associated with menopause (which continue to be their major indication) but also bone and cardiovascular related problems. It is well known that oral contraceptive use is one of the most common reversible causes of secondary hypertension. This is, in part, why the use of hormonal replacement therapy has provoked such suspicion among clinicians who have mainly believed that a similar effect on blood pressure would probably occur with the use of hormonal replacement therapy. However, the results of a variety of clinical studies and surveys do not confirm these suspicions. These beneficial effects have to be weighed against the risk of endometrial hyperplasia, endometrial cancer and breast cancer (among other unwanted effects) that could occur when long-term therapy is implemented. If one considers that the overall risk associated with cardiovascular mortality is more than four times higher than the risk associated with gynecological malignancies, even a modest decrease in the cardiovascular risk could easily outweigh other risks and result in an overall improved risk profile in postmenopausal women.

23 rabbits with Staphylococcus aureus methicillin-sensitive, SAMS, experimentally induced endocarditis (EIE) were studied to compare the efficacy of cloxacillin vs the association cloxacillin-gentamicin. Twelve animals made the control group and 11 the treated ones, 5 with cloxacillin-gentamicin and 6 with cloxacillin. The animals were treated 3 days, then, mortality, blood cultures at 48 and 72 hours and the title of the unit-forming colonies per gram of vegetation (UFC/g) were evaluated. The control group had a mortality of 100% in the first 72 hours, its blood cultures were positive at 48 and 72 hours and the UFC/g was 10,48 o 0.20. There was statistical significance between the control group and both treatment, in mortality, blood culture's positivity and the UFC/g of vegetation. This results confirm the similar efficacy of cloxacillin either alone or in combination in the treatment of SAMSIE and the effectiveness of the experimental model to evaluate antimicrobial treatments.

In order to study the relationship between tensional response of an hypertensive patient to exercise and its cardiac repercussions, we have studied 42 essential hypertensive patients using echocardiography type M and 2D and exercise test. Patients were divided into two groups according to whether they had (GI) or not (GII) left ventricular hypertrophy. LVH was defined calculating left ventricular mass (LVM) or mean wall thickness (MWT). We have found significant correlations between tensional response and LVH, using only MWT as the index of LVH. This correlation was significant not only with maximum systolic arterial pressure but also with systolic arterial pressure in all intermediate charge stages. Evolution time of arterial hypertension significantly correlated with the degree of LVH according to MWT and less significantly with LVM. We conclude that the correlation between tensional response to exercise and cardiac hypertrophy is always higher when considering MWT as the index of LVH since the calculating the mass some other parameters are also present which hinder its significance and that correlation is established not only in the maximum exercise level.

We have studied the effect of atenolol, xipamide, and verapamil in the control of effort tensional response in 54 patients suffering essential hypertension. A first effort test without treatment and a second after a one month treatment randomly assigned were performed in all patients, evaluating the tensional response at 30, 60 and 80 Watts of charge, maximum peak, and after five minutes in recovery. Atenolol significantly reduced (p less than 0.05) systolic arterial pressure and diastolic arterial pressure in every intermediate effort stage, maximum peak and post effort recovery, xipamide, also significantly reduced (p less than 0.05) the systolic hypertensive response at all different levels, however, the diastolic one did not reach any statistic significance. Verapamil at used doses did not modify neither systolic nor diastolic hypertensive response. The beneficial effect of beta-blockers is confirmed although we could not confirm the effect pointed out by other authors regarding calcium antagonists. Tensional control using xipamide was striking although there is some evidence to think that it can have a more important effect in the control than thiazide diuretics or amiloride.

We studied 108 patients who sustained an acute myocardial infarction (AMI) by means of echocardiography, pulsed doppler (PD) and Doppler color flow imaging (CD). We evaluate the presence of mitral regurgitation (MR) and it relationship to the site of the AMI and also to the ventricular function. The incidence of MR was 50.92%, (55/108), it was detected in higher percentage when the AMI was inferior (61.8%) than when anterior (39.6%). The correlation with the ejection fraction (EF) was only significative when the AMI was anterior. The incidence of MR was 57.1% when the EF was below 25%. CD had better diagnostic capabilities independently of the site of the AMI, (48% vs 32.1% when the AMI was anterior and 76.1% vs 52.6% when it was inferior).

We describe a 10 year old girl with ventricular septal defect in whom bidimensional echocardiogram disclosed a membrane in the outflow tract of the left ventricle. Color Doppler found the presence of fixed subaortic stenosis.