Concordancia en interpretación electrocardiográfica en síndromes coronarios agudos entre especialistas del servicio de urgencias y cardiólogos

Introducción: El ECG es una herramienta básica en el estudio del dolor torácico, no hay evidencia que demuestre si la interpretación electrocardiográfica de los especialistas de medicina interna y emergencias es similar a la de cardiólogos en casos de SCA. El propósito de este estudio es determinar si existe concordancia en interpretación de los hallazgos electrocardiográficos más frecuentes en la fase aguda de los síndromes coronarios. Metodología: Estudio retrospectivo de concordancia diagnóstica electrocardiográfica, realizado en un hospital universitario de cuarto nivel. Se escogieron los hallazgos electrocardiográficos más frecuentes en síndromes coronarios agudos para ser evaluados por 3 diferentes especialidades y se hizo el análisis de concordancia mediante el cálculo estadístico kappa. Resultados: Se analizaron 200 electrocardiogramas aleatorizados, de pacientes con SCA entre noviembre de 2012 a abril de 2013. La edad promedio fue 65,14 años, la mayoría hombres (62,5%), la hipertensión arterial y enfermedad coronaria fueron las comorbilidades más frecuentes. Se encontró un grado de concordancia moderada (k = 0.61 – 0.80, p <0.001) entre cardiólogos vs emergenciólogos y cardiólogos vs internistas, excepto en lesión subendocárdica (k = 0.11 y 0.24 respectivamente), hubo un grado de concordancia débil (k = 0.41 – 0.60, p <0.001) entre emergenciólogos e internistas. El hallazgo en el que hubo grado de concordancia muy bueno (k > 0.81) fue bloqueo de rama izquierda. Conclusión: Existe grado de concordancia moderada en la lectura electrocardiográfica en la mayoría de variables en relación con síndrome coronario agudo entre los especialistas de medicina interna y emergencias al compararlo con cardiólogos.

Prevalencia de anormalidades estructurales cardiacas en pacientes con enfermedad isquémica. Bogotá 2007 – 2009

Introducción: Las enfermedades cardiovasculares son la causa de muerte más frecuente en el mundo desarrollado, la mayoría de éstas se relacionan con alteraciones de las arterias coronarias, sin embargo un subgrupo de pacientes presentan como causa de isquemia cardiaca alteraciones estructurales. Material y métodos: Estudio Descriptivo. Se utilizó la base de datos recolectada en un servicio de hemodinamia de Bogotá durante dos años. Se aplicaron criterios de inclusión y exclusión y se determinaron cuatro grupos etáreos, a todos los pacientes se les practicó cateterismo cardiaco diagnóstico. Las variables analizadas fueron: diagnóstico de referencia, antecedentes y resultados del cateterismo incluyendo presencia de anomalías estructurales como las valvulopatias, el origen anómalo de las coronarias y los puentes miocárdicos. Para el análisis descriptivo se utilizó reporte de prevalencias y para el análisis de asociaciones se utilizaron tablas de contingencia y el estadístico de prueba Chi cuadrado, no se realizó análisis multivariado debido a que no se encontraron asociaciones estadísticamente significativas. Resultados: La edad promedio de los pacientes fue de 62 años (DS= 10,5), la representación del género masculino fue del 61,7%, la prevalencia de angina estable fue del 61,6%, los 3 antecedentes más prevalentes fueron: hipertensión arterial (41,4%), la hiperlipidemia (19,1%) y la Diabetes Mellitus (17,7%). La prevalencia de las alteraciones estructurales en la población de estudio de manera general fue del 12,9%, y su distribución por tipo fue: 1,4% para puentes miocárdicos, 0,7% para origen anómalo de las arterias coronarias y 10,8% de enfermedad valvular. Conclusiones: Se encontró una asociación entre los antecedentes médicos y la presencia de valvulopatias cardiacas. Se evidenció que el género no tiene relación con la presencia de alteraciones cardíacas a pesar de la mayor participación de hombres en la población de estudio. Las limitantes de este estudio se relacionaron con el tamaño de muestra, debido a la baja prevalencia de las anomalías estructurales medidas.

Incidencia de fibrilación auricular en las primeras 72 horas del post operatorio de revascularización miocárdica

Determinar la incidencia de fibrilación auricular en las primeras 72 horas del post operatorio en pacientes llevados a revascularización miocárdica utilizando dos técnicas de anestésia una convencional (AC) con anestésicos inhalados y opioides y otra con dexmedetomidina (AD.). cohorte retrospectivo, en donde se seleccionarán dos grupos de estudio, un grupo de expuestos, pacientes llevados a revascularización miocárdica con utilización técnica anestésica convencional y un grupo de no expuestos pacientes llevados a revascularización miocárdica con uso de dexmedetomidina como técnica de anestesia; A estos grupos se les hizo seguimiento por 72 horas para determinar la presencia de fibrilación auricular y la terapéutica instaurada.

Protección miocárdica con custodiol y trastornos de la osmolalidad

En análisis retrospectivo evaluamos 91 pacientes llevados a cirugía cardiaca entre 2013 y 2014 en la Fundación Cardioinfantil, en quienes se administro Custodiol, analizando los niveles de sodio y osmolalidad plasmática efectiva antes, durante y después del procedimiento quirúrgico. Nosotros evaluamos la relación entre administración de Custodiol y cambios en el sodio y osmolalidad plasmática del paciente llevado a cirugía cardiaca.

Characterisation and regulation of E2F-6 and E2F-6b in the rat heart: a potential target for myocardial regeneration?

The E2F transcription factors are instrumental in regulating cell cycle progression and growth, including that in cardiomyocytes, which exit the cell cycle shortly after birth. E2F-6 has been demonstrated to act as a transcriptional repressor; however, its potential role in normal cardiomyocyte proliferation and hypertrophy has not previously been investigated. Here we report the isolation and characterisation of E2F-6 and E2F-6b in rat cardiomyocytes and consider its potential as a target for myocardial regeneration following injury. At the mRNA level, both rat E2F-6 and the alternatively spliced variant, E2F-6b, were expressed in E18 myocytes and levels were maintained throughout development into adulthood. Interestingly, E2F-6 protein expression was down-regulated during myocyte development suggesting that it is regulated post-transcriptionally in these cells. During myocyte hypertrophy, the mRNA expressions of E2F-6 and E2F-6b were not regulated whereas E2F-6 protein was up-regulated significantly. Indeed, E2F-6 protein expression levels closely parallel the developmental withdrawal of myocytes from the cell cycle and the subsequent reactivation of their cell cycle machinery during hypertrophic growth. Furthermore, depletion of E2F-6, using anti-sense technology, results in death of cultured neonatal myocytes. Taken together, abrogation of E2F-6 expression in neonatal cardiomyocytes leads to a significant decrease in their viability, consistent with the notion that E2F-6 might be required for maintaining normal myocyte growth.

Coxsackievirus B3-associated myocardial pathology and viral load reduced by recombinant soluble human decay-accelerating factor in mice

Coxsackievirus B3 (CVB3) infection can result in myocarditis, which in turn may lead to a protracted immune response and subsequent dilated cardiomyopathy. Human decay-accelerating factor (DAF), a binding receptor for CVB3, was synthesized as a soluble IgG1-Fc fusion protein (DAF-Fc). In vitro, DAF-Fc was able to inhibit complement activity and block infection by CVB3, although blockade of infection varied widely among strains of CVB3. To determine the effects of DAF-Fc in vivo, 40 adolescent A/J mice were infected with a myopathic strain of CVB3 and given DAF-Fc treatment 3 days before infection, during infection, or 3 days after infection; the mice were compared with virus alone and sham-infected animals. Sections of heart, spleen, kidney, pancreas, and liver were stained with hematoxylin and eosin and submitted to in situ hybridization for both positive-strand and negative-strand viral RNA to determine the extent of myocarditis and viral infection, respectively. Salient histopathologic features, including myocardial lesion area, cell death, calcification and inflammatory cell infiltration, pancreatitis, and hepatitis were scored without knowledge of the experimental groups. DAF-Fc treatment of mice either preceding or concurrent with CVB3 infection resulted in a significant decrease in myocardial lesion area and cell death and a reduction in the presence of viral RNA. All DAF-Fc treatment groups had reduced infectious CVB3 recoverable from the heart after infection. DAF-Fc may be a novel therapeutic agent for active myocarditis and acute dilated cardiomyopathy if given early in the infectious period, although more studies are needed to determine its mechanism and efficacy.

Diacylglycerol-induced protection against injury during ischemia and reperfusion can be achieved without activation of protein kinase C in the rat heart: Comparative studies with ischemic preconditioning

The role of protein kinase C (PKC) activation in ischemic preconditioning remains controversial. Since diacylglycerol is the endogenous activator of PKC and as such might be expected cardioprotective, we have investigated whether: (i) the diacylglycerol analog 1,2-dioctanoyl-sn-glycerol (DOG) can protect against injury during ischemia and reperfusion; (ii) any effect is mediated via PKC activation; and (iii) the outcome is influenced by the time of administration. Isolated rat hearts were perfused with buffer at 37°C and paced at 400 bpm. In Study 1, hearts (n=6/group) were subjected to one of the following: (1) 36 min aerobic perfusion (controls); (2) 20 min aerobic perfusion plus ischemic preconditioning (3 min ischemia/3 min reperfusion+5 min ischemia/5 min reperfusion); (3) aerobic perfusion with buffer containing DOG (10 μM) given as a substitute for ischemic preconditioning; (4) aerobic perfusion with DOG (10 μM) during the last 2 min of aerobic perfusion. All hearts then were subjected to 35 min of global ischemia and 40 min reperfusion. A further group (5) were perfused with DOG (10 μM) for the first 2 min of reperfusion. Ischemic preconditioning improved postischemic recovery of LVDP from 24±3% in controls to 71±2% (P<0.05). Recovery of LVDP also was enhanced by DOG when given just before ischemia (54±4%), however, DOG had no effect on the recovery of LVDP when used as a substitute for ischemic preconditioning (22±5%) or when given during reperfusion (29±6%). In Study 2, the first four groups of study were repeated (n=4–5/group) without imposing the periods of ischemia and reperfusion, instead hearts were taken for the measurement of PKC activity (pmol/min/mg protein±SEM). PKC activity after 36 min in groups (1), (2), (3) and (4) was: 332±102, 299±63, 521±144, and 340±113 and the membrane:cytosolic PKC activity ratio was: 5.6±1.5, 5.3±1.8, 6.6±2.7, and 3.9±2.1 (P=NS in each instance). In conclusion, DOG is cardioprotective but under the conditions of the present study is less cardioprotective than ischemic preconditioning, furthermore the protection does not appear to necessitate PKC activation prior to ischemia.

Increased protein SUMOylation following focal cerebral ischemia

Stroke is a major cause of death and disability, which involves excessive glutamate receptor activation leading to excitotoxic cell death. We recently reported that SUMOylation can regulate kainate receptor (KAR) function. Here we investigated changes in protein SUMOylation and levels of KAR and AMPA receptor subunits in two different animal stroke models: a rat model of focal ischemia with reperfusion and a mouse model without reperfusion. In rats, transient middle cerebral artery occlusion (MCAO) resulted in a striatal and cortical infarct. A dramatic increase in SUMOylation by both SUMO-1 and SUMO-2/3 was observed at 6h and 24h in the striatal infarct area and by SUMO-2/3 at 24h in the hippocampus, which was not directly subjected to ischemia. In mice, permanent MCAO resulted in a selective cortical infarct. No changes in SUMOylation occurred at 6h but there was increased SUMO-1 conjugation in the cortical infarct and non-ischemic hippocampus at 24h after MCAO. Interestingly, SUMOylation by SUMO-2/3 occurred only outside the infarct area. In both rat and mouse levels of KARs were only decreased in the infarct regions whereas AMPARs were decreased in the infarct and in other brain areas. These results suggest that posttranslational modification by SUMO and down-regulation of AMPARs and KARs may play important roles in the pathophysiological response to ischemia.

Investigating the mechanisms underlying neuronal death in ischemia using in vitro oxygen-glucose deprivation: potential involvement of protein SUMOylation

It is well established that brain ischemia can cause neuronal death via different signaling cascades. The relative importance and interrelationships between these pathways, however, remain poorly understood. Here is presented an overview of studies using oxygen-glucose deprivation of organotypic hippocampal slice cultures to investigate the molecular mechanisms involved in ischemia. The culturing techniques, setup of the oxygen-glucose deprivation model, and analytical tools are reviewed. The authors focus on SUMOylation, a posttranslational protein modification that has recently been implicated in ischemia from whole animal studies as an example of how these powerful tools can be applied and could be of interest to investigate the molecular pathways underlying ischemic cell death.

Lipoprotein (a) as a predictor of myocardial infarction in middle-aged men

We found that a high Lp(a) level was an independent predictor of the development of coronary heart disease in middle-aged men.

Are transgenic mice the 'alkahest' to understanding myocardial hypertrophy and failure?

Murine transgenesis using cardioselective promoters has become increasingly common in studies of cardiac hypertrophy and heart failure, with expression mediated by pronuclear microinjection being the commonest format. Without wishing to decry their usefulness, in our view, such studies are not necessarily as unambiguous as sometimes portrayed and clarity is not always their consequence. We describe broadly the types of approach undertaken in the heart and point out some of the drawbacks. We provide three arbitrarily-chosen examples where, in spite of a number of often-independent studies, no consensus has yet been achieved. These include glycogen synthase kinase 3, the extracellular signal-regulated kinase pathway and the ryanodine receptor 2. We believe that the transgenic approach should not be viewed in an empyreal light and, depending on the questions asked, we suggest that other experimental systems provide equal (or even more) valuable outcomes.

Conditional transgenic expression of fibroblast growth factor 9 in the adult mouse heart reduces heart failure mortality after myocardial infarction

BACKGROUND: Fibroblast growth factor 9 (FGF9) is secreted from bone marrow cells, which have been shown to improve systolic function after myocardial infarction (MI) in a clinical trial. FGF9 promotes cardiac vascularization during embryonic development but is only weakly expressed in the adult heart. METHODS AND RESULTS: We used a tetracycline-responsive binary transgene system based on the α-myosin heavy chain promoter to test whether conditional expression of FGF9 in the adult myocardium supports adaptation after MI. In sham-operated mice, transgenic FGF9 stimulated left ventricular hypertrophy with microvessel expansion and preserved systolic and diastolic function. After coronary artery ligation, transgenic FGF9 enhanced hypertrophy of the noninfarcted left ventricular myocardium with increased microvessel density, reduced interstitial fibrosis, attenuated fetal gene expression, and improved systolic function. Heart failure mortality after MI was markedly reduced by transgenic FGF9, whereas rupture rates were not affected. Adenoviral FGF9 gene transfer after MI similarly promoted left ventricular hypertrophy with improved systolic function and reduced heart failure mortality. Mechanistically, FGF9 stimulated proliferation and network formation of endothelial cells but induced no direct hypertrophic effects in neonatal or adult rat cardiomyocytes in vitro. FGF9-stimulated endothelial cell supernatants, however, induced cardiomyocyte hypertrophy via paracrine release of bone morphogenetic protein 6. In accord with this observation, expression of bone morphogenetic protein 6 and phosphorylation of its downstream targets SMAD1/5 were increased in the myocardium of FGF9 transgenic mice. CONCLUSIONS: Conditional expression of FGF9 promotes myocardial vascularization and hypertrophy with enhanced systolic function and reduced heart failure mortality after MI. These observations suggest a previously unrecognized therapeutic potential for FGF9 after MI.

Molecular targets underlying SUMO-mediated neuroprotection in brain ischemia

SUMOylation (small ubiquitin-like modifier conjugation) is an important post-translational modification which is becoming increasingly implicated in the altered protein dynamics associated with brain ischemia. The function of SUMOylation in cells undergoing ischemic stress and the identity of small ubiquitin-like modifier (SUMO) targets remain in most cases unknown. However, the emerging consensus is that SUMOylation of certain proteins might be part of an endogenous neuroprotective response. This review brings together the current understanding of the underlying mechanisms and downstream effects of SUMOylation in brain ischemia, including processes such as autophagy, mitophagy and oxidative stress. We focus on recent advances and controversies regarding key central nervous system proteins, including those associated with the nucleus, cytoplasm and plasma membrane, such as glucose transporters (GLUT1, GLUT4), excitatory amino acid transporter 2 glutamate transporters, K+ channels (K2P1, Kv1.5, Kv2.1), GluK2 kainate receptors, mGluR8 glutamate receptors and CB1 cannabinoid receptors, which are reported to be SUMO-modified. A discussion of the roles of these molecular targets for SUMOylation could play following an ischemic event, particularly with respect to their potential neuroprotective impact in brain ischemia, is proposed.