Background The tilt test (TT) is a diagnostic tool used to evaluate autonomic function in patients with syncope. However, as TT has a high rate of false positive results and the duration of the test is long, new strategies are emerging. A device developed in Argentina allowed establishing a non-invasive, reproducible and reliable method to measure pulse wave velocity in the carotid and radial arteries during a conventional TT and to determine its likelihood to predict the result of the test. Objective To assess the usefulness of time delay of the pulse waveform from the onset of the QRS complex in order to predict the result of the tilt test. Material and Methods We conducted an observational study on consecutive patients with syncope referred to the tilt test laboratory. During the test blood pressure, heart rate and carotid and radial pulse waves were recorded simultaneously with a specially designed polygraph. Univariate and multivariate analyses were performed to assess the ability of time delay of the pulse waveform from the onset of the QRS complex to predict the result of the TT. This ability was evaluated with the analysis of ROC curves. Results A total of 43 patients were included; 24 (55.8%) were women. The TT was positive in 18 patients (11 women). Univariate analysis determined that changes in systolic blood pressure (p=0.02) and diastolic blood pressure (p<0.01) measured at 10 minutes, the use of ACEI/ARB (p=0.01) and time delay of the carotid pulse wave (p<0.01) were related to the result of the TT. At multivariate analysis, only time delay of the carotid pulse wave was a significant predictor of the result (p=0.036). The C statistic of the time delay of the carotid pulse wave was 0.88 (95% CI 0.76 to 0.99). Conclusions Measurement of the time delay or the carotid pulse wave at 5 minutes is an independent predictor of the result of the TT, allowing a correct classification in 88% of patients before the development of symptoms.

Introducción El tilt test (TT) es un método diagnóstico de rutina para evaluar la función autonómica de pacientes con síncope. Debido a su tasa elevada de resultados falsos negativos y al tiempo que insume, el desarrollo de nuevas metodologías que puedan facilitar el diagnóstico ha ganado una importancia creciente. Un equipo desarrollado en la Argentina permitió establecer una metodología confiable, reproducible y no invasiva para la medición de la velocidad de onda de pulso carotídeo y radial durante un TT convencional y determinar si tiene el potencial de predecir precozmente el resultado de esta prueba. Objetivo Evaluar la utilidad del retraso en la aparición de la onda de pulso desde el inicio del QRS para predecir el resultado del tilt test. Material y métodos Se realizó un estudio observacional en pacientes consecutivos derivados para el estudio de síncope a través de la realización de un TT. Durante la prueba se registraron simultáneamente la presión arterial y la frecuencia cardíaca y la onda de pulso radial y carotídeo mediante un polígrafo diseñado especialmente. Se evaluó la capacidad del retraso en la aparición de la onda de pulso desde el inicio del QRS para predecir el resultado del TT mediante análisis univariado y multivariado. La capacidad para predecir el resultado de la prueba se evaluó a través del análisis de curvas ROC. Resultados Se incluyeron 43 pacientes, 24 (55,8%) mujeres. El TT fue positivo en 18 pacientes (11 mujeres). En el análisis univariado, el cambio de la presión arterial sistólica (p = 0,02) y diastólica (p < 0,01) a los 10 minutos, el uso de IECA/ARA II (p = 0,01) y el retraso de la onda de pulso carotídeo (p < 0,01) estuvieron relacionados con el resultado del TT. En el análisis multivariado, sólo el retraso del pulso carotídeo fue un predictor significativo del resultado (p = 0,036). El estadístico C del retraso del pulso carotídeo fue de 0,88 (IC 95% 0,76 a 0,99). Conclusiones La medición del retraso de la onda de pulso carotídeo a los 5 minutos predice en forma independiente el resultado del TT, lo que permite clasificar correctamente al 88% de los pacientes antes de que desarrollen síntomas.

FUNDAMENTO: Os recentes estudos MADIT II e SCD-HeFT levaram a uma expansão das indicações do uso profilático de cardiodesfibrilador implantável (CDI) em pacientes com grave disfunção ventricular esquerda. Essa terapia não foi totalmente adotada em nosso sistema de saúde, sobretudo em virtude de seu alto custo. OBJETIVO: Avaliar a taxa de mortalidade global de pacientes da nossa prática diária que têm o mesmo perfil dos participantes do estudo SCD-HeFT, estão recebendo tratamento clínico otimizado e não foram submetidos a implante de CDI, e comparar essa taxa com a do grupo de placebo do estudo SCD-HeFT. MÉTODOS: Foram incluídos neste estudo pacientes com o mesmo perfil dos participantes do estudo SCD-HeFT identificados a partir de prontuários médicos. A taxa de mortalidade global foi avaliada por contato telefônico. A análise estatística foi realizada com o teste t de Student, teste de Mann-Whitney ou teste de qui-quadrado, dependendo do tipo de variável. As taxas cumulativas de mortalidade foram calculadas de acordo com o método de Kaplan-Meier. RESULTADOS: Este estudo englobou 102 pacientes, 74 dos quais do sexo masculino. A mediana da idade foi 64 anos e a média da fração de ejeção, 25%. Não encontramos diferenças entre os nossos pacientes e os pacientes do estudo SCD-HeFT em relação a essas três variáveis. Durante o período de acompanhamento de 19,6 meses, 21 pacientes morreram (20,6%), contra 28,8% do estudo SCD-HeFT. Essa diferença não foi estatisticamente significante (p = 0,08). CONCLUSÃO: Não houve diferença na taxa de mortalidade dos nossos pacientes e dos pacientes do grupo de placebo do estudo SCD-HeFT. Esses resultados indicam que a população do SCD-HeFT é representativa dos nossos pacientes.

BACKGROUND: Recent MADIT II and SCD-HeFT trials have led to an expansion of indications for use of prophylactic Implantable Cardioverter Defibrillator (ICD) in patients with severe left-ventricular impairment. This therapy has not been fully adopted in our health care system, mainly due to its high cost. OBJECTIVE: To assess total mortality of SCD-HeFT-like patients from our daily practice who are under stable, optimal medical treatment and who have not received an ICD; and to compare it to that of the placebo arm of the SCD-HeFT Trial. METHODS: SCD-HeFT-like patients identified from office medical records were included in our study. Total mortality was assessed by telephone contact. Statistical analysis was performed by Student's t-Test, Mann-Whitney Test or chi2 test, depending on the type of variable. Cumulative mortality rates were calculated according to the Kaplan-Meier method. RESULTS: Our study comprised 102 patients (seventy-four of which were men) with a median age of 64 years, and an overall median ejection fraction of 25%. We found no differences between our patients and SCD-HeFT patients across these 3 variables. Over a 19.6-month follow-up period, 21 patients died (20.6%) vs. 28.8% of the SCD-HeFT patients. This difference was not statistically significant (p = 0.08). CONCLUSION: SCD-HeFT-like patients from our practice had no difference in mortality rate than patients enrolled in the placebo arm of the SCD-HeFT trial. These results suggest that the SCD-HeFT population is representative of our patients.

Among sustained arrhythmias, atrial fibrillation is one of the most common causes of patient consultation. Its substrate comprises various mechanisms, including left atrial enlargement. In this report, we present the case of a 33 yearold woman with a history of palpitations, who was admitted to the emergency room due to atrial fibrillation with a rapid ventricular response. In the chest X-ray, the left border of the cardiac silhouette was deformed. Subsequently, both the transesophageal echocardiogram and the magnetic resonance images showed a giant aneurysmal left atrial appendage, probably due to a pericardial defect. Treatment consisted of oral anticoagulation and atenolol, with a favorable patient outcome.

La FA constituye una de las arritmias sostenidas más frecuentes que motivan la consulta. El sustrato comprende diferentes mecanismos, entre los que se encuentra el agrandamiento auricular izquierdo. Presentamos el caso de una mujer de 33 años con antecedentes de palpitaciones, que ingresó en la guardia por FA de alta respuesta ventricular. En la radiografía de tórax se observó una deformación del borde izquierdo de la silueta cardíaca. Posteriormente, el ecocardiograma transesofágico y la resonancia magnética nuclear evidenciaron una megaorejuela aneurismática debida, probablemente, a un defecto pericárdico. La conducta fue anticoagulación oral y tratamiento con atenolol, con evolución favorable.

Glucose Intolerance Increases Left Ventricular Mass Index And Arterial Stiffness In Males with Mild Hypertension The aim of this study was to evaluate if a group of mild hypertensive males with glucose intolerance and central obesity, meeting metabolic syndrome (MS) criteria, presented greater left ventricular mass index and altered arterial compliance compared to a group of mild hypertensive males with central obesity but without glucose intolerance or MS. Fifty six male patients of 51±6 years of age were included and separated into two groups: A)28 with metabolic syndrome (ATP III): fasting blood sugar ≥1.10 g/l and < 1.26 g/ l or oral glucose tolerance test >1.40 g/l and < 2 g/l, waist circumference >102 cm and blood pressure ≥ 130/85 mmHg. B)28 patients without metabolic syndrome: fasting blood sugar < 1.10 g/l and oral glucose tolerance test < 1.40 g/l, and similar waist circumference and blood pressure as those in group A. Two-dimensional echocardiography was used to assess left ventricular mass index. Arterial compliance was measured by augmentation index and pulse wave velocity by Sphygmocor. Conclusion The association of mild hypertension and glucose intolerance leads to greater LVMI and arterial stiffness compared to non glucose intolerant hypertensive males.

Con la finalidad de evaluar si en un grupo de hipertensos de nivel I con intolerancia a la glucosa y obesidad abdominal, por lo cual reúnen criterios para diagnóstico de síndrome metabólico (SM), existe un índice de masa ventricular izquierda mayor y una alteración mayor de la distensibilidad arterial respecto de un grupo de hipertensos de nivel I con obesidad abdominal, no intolerantes a la glucosa y sin SM, en el presente trabajo se incluyeron 56 varones, de 51 ± 6 años, con hipertensión de nivel I, que se dividieron en dos grupos. Grupo A) 28 con SM: glucemia en ayunas >1,10 g/L y < 1,26 g/L o poscarga de glucemia >1,40 g/L y menor de 2,00 g/L, perímetro abdominal > 102 cm y PA ≥ 130 y/u / 85 mm Hg. Grupo B) 28 sin SM: el perímetro abdominal y la presión arterial eran similares al grupo A, pero con glucemias en ayunas < 1,10 g/L y poscarga < 1,40 g/L. Se midió el índice de masa ventricular izquierda (IMVI) por ecocardiografia bidimensional y distensibilidad arterial: velocidad de onda de pulso, onda refleja central (ORC) por Sphygmocor Conclusión La presencia de intolerancia a la glucosa en pacientes con hipertensión de nivel I se asocia con mayor masa ventricular izquierda y rigidez arterial que en los casos con el mismo nivel de hipertensión sin intolerancia a la glucosa.