S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100001 , 04 2001 2001 3 03 03
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100002 Eco intraoperatorio el eslabón entre el cirujano y el cardiólogo Rodríguez Leonardo ,Cleveland Clinic Fundation Cleveland Ohio USA 04 2001 2001 3 4 4
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100003 Utilidad del ecocardiograma transesofágico en el intra y post operatorio de cirugía cardíaca Tibaldi Miguel Lema Luis Coll Marcelo Boccardo Daniel ,F.U.C.C.A.D.I.M. Instituto Modelo de Cardiología Córdoba Córdoba Argentina 04 2001 2001 3 5 20

Objetivos: Analizar la utilidad del Ecocardiograma Transesofágico (ETE) en la asistencia al cirujano y al cardiólogo recuperador para la toma de decisiones. Material y Métodos: Se analizaron retrospectivamente 147 pacientes (p) que requirieron ETE, 110 p (75%) eran hombres con una edad media de 63 años (21-88). Los procedimientos quirúrgicos realizados fueron: By Pass Ao. Co: 70p, reemplazo valvular (RV): 50p, Combinados: 5p, disección aórtica 8p, transplante cardíaco 5p, cierre de CIV: 2 p, aneurismectomía: 2p, extirpación de mixomas: 2p, miectomía: 1p, tromboendarterectomía: 1p y bicavo pulmonar anastomosis: 1p. Se dividió la muestra en 2 grupos: Grupo A: ETE intraoperatorio 104p (70.7%) y Grupo B ETE postoperatorio 43p (29.3%). Las indicaciones fueron: Grupo A: p con dificultad para retirar de circulación extracorpórea (CEC) (A1) 49p, y p para control de procedimiento (pr) (A2) 55p, 24 de los cuales con plástica valvular (plv). Grupo B: p con bajo débito (B1) 25p de los cuales 12 presentaban signos de taponamiento (t). Y p con signos de isquemia perioperatoria 18p. Se utilizó el test X2 para comparar variables categóricas. Resultados: Grupo A1: se detectó alteraciones de la motilidad global o regional en 41p, disfunción protésica en 4p, insuficiencia mitral 1p y obstrucción medio ventricular en 3p. Grupo A2: el ETE indicó 5 RV post plv y 4 RV no programados controlando correctamente el resto de los pr. Grupo B1: de los 12 p con signos de t, el ETE lo confirmó en 6 (50%), y de los restantes p con Bajo Gasto Cardíaco (BGC) detectó t en 3p. Grupo B2: en 15p se detectó trastornos segmentarios de la motilidad requiriendo nueva revascularización. Se consideró como parámetro de utilidad del ETE a los hallazgos que condicionaron un cambio de conducta, presentando una utilidad del 67% en ésta muestra. La mortalidad en el grupo de pacientes en los cuales el ETE produjo un cambio de conducta (98p), obitaron 10 (10%) y en los que no sugirió cambios (39p) obitaron 11 (22%) p=0.04. Conclusión: El ETE intra y post-operatorio constituye una herramienta valiosa para la toma de decisiones quirúrgicas y el manejo post operatorio, mejorando el pronóstico de esta población de pacientes de alto riesgo.

Objetives: To analize how useful is the TEE to assist the surgeon and recover-room cardiologist in decision making. M. and M.: 147 patients who required TEE were analysed. 110 p (75%) were male, with a mean ages of 63 (21-88). The surgical procedures were: coronary artery by pass 70p, valvular replacement (VR) 26p, valvular plastic repair (vpl) 24p, combined procedures 5p, aortic disection 8p, cardiac transplant 5p, closure of ventricular septal defect 2p, aneurysmectomy 2p, myxoma resection 2p, myectomy 1p, thromboendarterectomy 1p and bicavo pulmonary anastomosis 1p. The patients were divided into 2 groups: Group A: intraoperative TEE 1-4p (70.7%) and Group B: postoperative TEE 43p (29.3%). The indications were: Group A p unable to wind them off from extracorporeal circulation (ECC) (A1) 49p, and p who needed procedure control (A2) 55p. Group B: p with low cardiac output syndrome (B1) 25p, 12 of whom presented signs of tamponade and 18p with perioperative ischemia (B2). The chi square test has used to compare categorical variables. Results: Group A1 regional or global wall motion abnormalities (WMA) were detected in 41p, prosthetic dysfuntion in 4p, mitral insuffiency in 1 p and mid ventricular obstruction in 3p. Group A2: 5 valvular replacement were indicated post vpl, 4 replacement were non programmed and the other procedures were correctly controlled. Group B1: out of 12p with signs of tamponade, the TEE confirmed 6 (50%) and detected 3 in p with low cardiac output. Group B2: WMA were seen in 15p, who required re-operation and more complete revascularization. The TEE was considered useful if the findings produced a change in attitude, wich was the case in 67% of the cases. The mortality was less than 10% (10p out of 98p) in the group were there was a change in attitude due to findings of the TEE, while 11p out of 39p died in the group where there was no change due to the TEE findings. (p=0.04). Conc: the intra and post operative TEE is a valuable tool in surgical and post operation decision making, improving the prognosis in this high risk population.

 Ecocardiograma Transesofágico Cirugía Cardíaca Ecocardiograma Intraoperatorio Transesophageal Echocardiogram Cardiac Surgery Intraoperative Echocardiogram Likoff m Reicheck N Sutton M Epicardial mapping of segmental myocardial function:: an echocardiography method applicable in man Circ 1982 66 Matsamuto M Aplication of transesophageal echocardiography to continuos monitoring of left ventricular perfomance Am.J.Cardiol 1980 46 Schulter M Transesophageal cross-sectional echocardiography with a phased array transducer system:: Technique and initial clinical results Br.Heart J 1982 48 Souquet J Hanrath P Zitelli L transesophageal phased array for imaging the heart IEEE Trans Biomed Eng 1982 29 Seward J Biplanar transesophageal echocardiography:: Anatomic correlations, image orientations, and clinical applications Mayo Clinic Proc 1990 65 Freeman W O`hara P Abel M Freeman W Seward J Kandheria B Intraoperative applications of transesophageal echocardiography Transesophageal echocardiography Transesophageal echocardiography 1994 16 Boston Little Brow and Company Kandheria B Oh J Transesophageal echocardiography:: state of the art and future directions Am. J. Cardiol. 1992 69 Beampre P Intraoperative detection of changes on left ventricular segmental viale motion by transesophageal two dimentional echocardiography Am Heart J 1984 10 Branwald E Kloner R The stunned myocardium:: Prolonged post ischemic ventricular dysfunctions Circ 1982 66 Rodriguez L Garcia M Ares M Griffin B Nokatomi S Thomas J Assesment of mitral anular dynamics during diastole by Doppler Tissue imaging:: Comparison match mitral Doppler inflow in subjets without heart disease and in patients with left ventricular hypertrophy Am Heart J 1996 131 Mc Dicken W Sutherland G Moran C Gordon L Color Doppler velocity of the myocardium: Ultrasound in medicine and biology 1992 18 De Jong N Ten Cate F New ultrasound contrast agents and technological innovations ultrasonics 1996 34 Burns P Pomers J Simpsom D Harmonic Imagin:: Principles and preliminary results Clin Radiol 1996 51 ^sl Villanueva F Kaul S Assesment of myocardial perfusion in coronary artery disease using myocardial contrast echocardiography Coron. Art. Dis 1995 6 Villanueva F Camarano G Ismail S Goodman N Skilman J Kaul S Coronary reserve abnormalities in the infarcted myocardium:: Assesment of myocardial viability inmediately versus late after reflow by contrast echocardiography Circulation 1996 94 Hirata N Shimazaki Y Nakano S Sakao K Sakaki S Matsuda H Evaluation of regional myocardial infarction after revascularization by mean of intraoperative myocardial contrast echocardiography J. Thoracic. Cardiovascular Surg. 1994 108 Rin Effect of coronary by pass surgery and valve replacement on the left ventricular function:: Assesment by intraoperative two dimensional echocardiography Am.Heart J 1985 109 Topol E Inmediate improvement of dysfunctional myocardial segments after coronary revascularization:: detection by intraoperative transesophageal echocardiography J.Am.Coll.Cardiol 1984 4 ^s6 Stemart W Currie P Salcedo E Evaluation of mitral leaflet motion by echocardiography and jet direction by Doppler color flow mapping to determine the mechanism of mitral regurgitation J.Am.Coll.Cardiol 1992 20 Stemart W Currie P Salcedo E Intraoperative Doppler color flow mapping for decission making in valve repair for mitral regurgitation: Technique and results in 100 patients Circ 1990 81 Carpentier A Relland J De Loche A Conservative managment of the prolapsed mitral valve Ann. Thorac.Surg 1978 26 Equaras M Intraoperative contrast two dimensional echocardiography:: Evaluation of the presence and severity of aortic and mitral regurgitation during cardiac operations J. Thorac. Cardiovasc. Surg 1985 89 Takamoto S Intraoperative color flow mapping by real time dimensional Doppler echocardiography for evaluation of valvular and congenital heart disease and vascular disease J. Thorac. Cardiovasc. Surg 1985 90 King R Surgery for tricuspid regurgitation late after mitral valve replacement Circ 1984 70 ^s1 Syracuse D Intraoperative intracardiac echocardiography during left ventriculotomy and myectomy for IHSS Circ 1977 56 ^s3 Freeman W Schoff F Oh J.m Evaluation of hipertrophic cardiomiopathy by intraoperative transesophageal echocardiography J. Am.Coll.Cardiol 1993 21 ^sA Laissy J Blanc F Soyes P Thoracic aortic disection.: Diagnosis with transesophageal echocardiography versus M.R. imagin Radiology 1995 194 Sommer T Fehske W Holzknecht N Aortic disection: a comparative study of diagnosis with spiral C.T., multiplanar transesophageal echocardiography and M.R.imagin Radiology 1996 199 Adachi H Omoto R Kjo S Emergency surgical intervention of acute aortic dissection with the rapid diagnosis by transesophageal echocardiography Circ 1991 84 ^sIII Simon P Owen A Havel M Transesophageal echocardiography in the emergency managment of patients with aortic dissection J.Cardiovasc.Surg 1992 103 Mohr-Kahaly S Erbel R Rennollet H Ambulatory follow up of aortic dissection by transesophageal two dimensional and color coded Doppler ehocardiography Circ 1989 80 Balld R Nanda N Gatewood R Usefulness of transesophageal echocardiography in assesment of aortic dissection Circ 1991 84 Hanrich A Miller D Scott W Acute and chronic dissections, determinants of long term outcome for operative survivors Circ 1985 72 ^sII Daniel W Schoeder E Nellessen V Hausmam D Diagnosis of intra and extra cardiac masses by echocardiography. Comparison between the transthoracic and transesophageal approach Circ 1987 76 ^sIV Romeo F Pellicia F Cristofani R Reale A Hipertrophic cardiomyopathy:: Is a left ventricular outflow tract gradient a major prognostic determinant? Eur.Heart.J 1990 11 Ungerleider R Sheik H Philips J Pearce F Routine use intraoperative epicardial echocardiography and Doopler color flow imagind to guide and evaluate repair of congenital heart lesions:: A prospective study J.Thorac.Cardiovasc.Surg 1990 100 Daniel W Schoeder E Nellessen V Diagnosis of intra and extracardiac masses by echocardiography: Comparison between the transthoracic and transesophageal approach Circ 1987 IV Parquer M Perrillo J Echocardiography and nuclar cardiac imaging in the critical care unit JAMA 1985 254 Pearson A Castillo R Labovitz A Safety and utility of transesophageal echocardiography in critically ill patients. Am.Heart J 1994 127 Perez de Prado A García Fernández M Moreno M Torrecillas E San Roman D Delcan J Utilidad de la ecocardiografía transesofágica en las unidades de cuidados cardíacos intensivos generales Rev.Esp.Cardiol 1994 47 Oh J Sinak L Freeman W Seward J Khandheria B Transesophageal echocardiography in patients with shock syndrome Circ 1991 84 ^sII Shama M Novara A Van de Putte P Diebold B Safar M Assart M Diagnostic and therapeutic implication of transesophageal echocardiography in medical ICU patients with unexplained shock, hipoxemia, or suspected endocarditis Intensive Care Med 1996 22 Apridi I Quiones M Zoglibi W Transesophageal echocardiography in critically ill patients:: Feasibility, safety, and impact on management Am.Heart J. 127 Gray R Metloff J Medical management of cardiac surgical patients Medical management of cardiac surgical patients 1990 Baltimore^eMaryland Ed William & Wilbuir Davila Roman V Waggoner A Hopkins W Right ventricular disfunction in low output syndrome after cardiac operation: Assesment by transesophageal echocardiography Ann.Thorac.Surg 1995 60 Reichtert C Visser C Koolen J Wezel H Prognostic value of biventricular function in hipotensive patients after cardiac surgery assesed by transesophageal echocardiography J.CardiothoracicVasc.Anesth 1992 6 Stevenson L Child J Laks H Kern L Incidence and significance of early pericardial effusion after cardiac surgery Am.J.Cardiol 1984 54 Pepi M Barbier P Dona E Arena V Bert M Pericardial effusion after cardiac surgery:: Incidence, site, size, and hemodinamic consequences Br Heart J. 1994 72 Ikaheimo M Huikuri H Tarkka M Pericardial effusion after cardiac surgery:: incidence, relation to type of surgery, antitrombotic therapy, and early coronary by pass graft patency Am.Heart J 1988 116 Chuttami K Tiscker M Paudian N Diagnosis of cardiac tamponade after cardiac surgery:: relative value of clinical, echocardiography, and hemodinamics signs Am.Heart J. 1994 127 Russo A O`Connor W Waxman H Atipical presentations and echocardiographyc findings in patients with cardiac taponade occuring early and late after cardiac surgery Chest 1993 104 Frey M Beiko B Polevky H Herman H Recognition of cardiac taponade in the presence of severe pulmonary hipertension Ann.Inter.Med 1989 111 Simpson I. Smith E Parker D Pericardial hemorhagea causing rigth atrial compression after cardiac surgery: role of transesophageal echocardiography Br.Heart J 1991 65 Kochar G Jacobs L Kother M Right atrial compression in postoperative cardiac patients:: detection by transesophageal echocardiography J.Am.Coll.Cardiol. 1990 16 Beppu S Tanaka N Kumon K Pericardial clot after open heart surgery: Its specific localization on haemodinamic Eur.Heart J 1993 14 Brisblatt W Stein K Wolfe C Acute myocardial dysfunction and recovery:: a common occurence after coronary by pass surgery J.Am.Coll.Cardiol 1990 15 Shively B Watters T Schiller N Benefield D The intraoperative detection of myocardial infarction by transesophageal echocardiography (abstract) J.Am.Coll.Cardiol 1986 7 Chung F Sayone C Transesophageal echocardiography may fail to diagnose perioperative myocardial infarction Can.J.Anesth 1991 38 García Fernández M Tizon G Moreno M Rentabilidad de la ecocardiografía transesofáfica de rutina en la cirugía cardíaca en enfermos no seleccionados: Analisis de 130 casos consecutivos Rev. Arg. Cardiol. 1995 63 ^s6 Ciruzzi M Henquin R Aranda G Bozovich G investigadores del CONAREC III.:: Evolución de los pacientes sometidos a cirugía coronaria. Estudio multicéntrico Rev.Arg.Cardiol. 1996 64 ^s1
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100004 Electrofisiología intervencionista: experiencia inicial en Costa Rica con procedimientos diagnósticos y terapéuticos en arritmias cardíacas Araya Gómez Vivien Gutiérrez Sotelo Oswaldo Cruz Cruz Flory ,CCSS Hospital R.A. Calderón Guardia San José Costa Rica ,Corporación de Electrofisiología de Costa Rica Clínica de Arritmias San José Costa Rica 04 2001 2001 3 22 33

Los estudios electrofisiológicos invasivos con fines diagnósticos se han utilizado desde hace muchos años en la práctica clínica. El uso de estos métodos para el tratamiento definitivo de algunas arritmias cardíacas es más reciente, sin embargo, ya en muchos países se han constituido en una opción terapéutica de uso muy frecuente. El objetivo de este trabajo es presentar la experiencia inicial con la electrofisiología intervencionista en Costa Rica. Entre febrero de 1999 y junio de 2000, se realizaron un total de 48 procedimientos. Los pacientes fueron25 hombres (52%) y 23 mujeres (48%). La edad promedio fue de 50 años (con rango de 16 a 86 años). El tipo de estudio electrofisiológico fue diagnóstico en 14 pacientes (29%) y terapéutico en 34 (71%).Las indicaciones para los de tipo diagnóstico fueron: disfunción sinusal: 1 paciente, estudio de conducción atrioventricular: 2 pacientes, taquicardia supraventricular: 1 paciente, taquicardia ventricular: 10 pacientes.Los estudios terapéuticos correspondieron a: Ablación de taquicardia supraventricular paroxística: 26 pacientes,ablación del nodo AV: 1 paciente y colocación de cardiodesfibrilador implantable: 7 pacientes. Los 26 pacientes con taquicardia supraventricular paroxística, presentaron:14 vías accesorias manifiestas (Síndrome de Wolf-Parkinson-White), 6 reentradas intranodales y 8 vías accesorias con conducción oculta. La ablación del nodo AV se realizó en 1 paciente con fibrilación atrialde alta respuesta ventricular, refractaria a tratamiento farmacológico. Los cardiodesfibriladores se colocaron en pacientes con taquicardia ventricular con síncopey/ó fibrilación ventricular documentadas previamente. En las ablaciones el éxito primario fue de 93% (27/29) y la recurrencia de la arritmia fue de 7% (2/27). El promedio de seguimiento posterior a los procedimientos terapéuticos fuede 8 meses (con un rango de 15 días a 18 meses). Se presentaron complicaciones en 2 pacientes (4%): un derrame pericárdico y una trombosis venosa del miembro inferior derecho; ambas se resolvieron satisfactoriamente. En conclusión, en pacientes con arritmias cardíacas muy sintomáticas o cuando éstas ponen en peligro la vida, existe la posibilidad de un diagnóstico más preciso y un tratamiento definitivo en la mayoría de ellos mediante los estudios electrofisiológicos intervencionistas, que han demostrado ser eficaces y seguros en nuestro medio. Con lo que mejora la calidad y expectativa de vida en muchos de nuestros enfermos.

The diagnostic and therapeutic electrophysiology studies are very useful in the clinical practice.The objective of this work is to present the initial experience with interventional electrophysiology in Costa Rica. Between February 1999 and June 2000, we perform 48 procedures. The patients were 25 men (52%) and 23 women (48%). The average age was 50 years (16 to 86 years). The electrophysiology study (EPS) was diagnosticin 14 patients (29%) and therapeutic in 34 (71%). The diagnostic EPS were: Sinus node disfunction: 1 patient, atrioventricular conduction: 2 patients, supraventricular tachycardia: 1 patient, ventricular tachycardia: 10 patients. The therapeutic EPS were: Radiofrequency catheter ablation (RFCA) for paroxismal supraventricular tachycardia (PSVT): 26 patients, RFCA of AV node: 1 patient andcardioverter-defibrillator (ICD) implant: 7 patients. The 26 patients with PSVT had: 14 accessory pathways with both anterograde and retrograde conduction (Wolf-Parkinson-White Syndrome), 6 AV nodal reentrant tachycardias and 8 accessory pathwayswith only retrograde conduction. The RFCA of AV node was perform in one patient who had atrial fibrillation with high ventricular response, refractory to pharmacology treatment.The ICD were implanted in patients with ventricular tachycardia and syncopeand/or ventricular fibrillation. The RFCA was successful in 93% (27/29) with a recurrence rate of 7% (2/27). The follow-up after this procedures was 8 months (range: 15 days to 18months). The were complications in 2 patients (4%): pericardial effusion in one patient and venous thrombosis of right leg in one patient; both were successful resolute. In conclusion, in this patients with sintomatic cardiac arrhythimas is posible a precise diagnostic and definitive treatment with interventional EPS which are effectives and safes in our country. The quality and expectation of life can increase in many of ours patients.

 Electrofosiología Intervencionista Arritmias Cardíacas Costa Rica Therapeutic Electrophysiology cardiac arrhythimas Costa Rica Araya V Electrofisiología intervensionista:: Procedimientos diagnósticos y terapéuticos en arritmias cardíacas Rev Costarr Cardiol 1999 1 Sunid N Haines D Biophysics and pathology of catheter energy delivery systems Prog CardiovascDis 1995 XXXVII O’Nunain S Ruskin JN Cardiac arrest Lancet 1993 341 Gutiérrez O Estudio electrofisiológico:: Principios básicos y aplicaciones Rev Peru Cardiol 1998 1 Strauss HC Premature atrial stimulation as a key to understanding of sinoatrial conduction in man Circulation 1973 47 Narula OS A new method for measurement of sinoatrial conduction time Circulation 1978 58 Iturralde P Araya-Gómez V Colín L A new ECG algorithm for the localization of accesory pathways using only the polarity of the QRS complex J Electrocardiology 1996 29 Vedel J Frank G Fournial J Gosgogeal Y Block auriculo-ventricular intrahisien definit induit au coure d’ une exploration endoventriculaire droite Arch Mal Coeur 1979 72 Scheinman M Morady F Hess DS González R Catheter induced ablation of the atrio-ventricular junction to control refractory supraventricular arrhythmias JAMA 1982 248 Scheinman MM Morady F Shen E Interventional electrophysiology:: Catheter ablation technique Clin Prog Pacing Electrophysiol 1983 1 Huang SK Bharati S Graham AR Closed-chest catheter dissecation od the atrioventricular junction using radiofrequency energy, a new method of catheter ablation J Am Coll Cardiol 1987 9 Zipes D DiMarco JP Gillette P ACC/AHA Guidelines for clinical electrophysiology and catheter ablation procedures Circulation 1995 92 Iturralde P Colín L Kershenovich S Ablación con radiofrecuencia en el tratamiento de las taquicardias supraventriculares: Experiencia en 500 pacientes consecutivos Arch Inst Cardiol Méx 1995 65 Kay NG Epstein AE Dailey SM Plumb VJ Role of radiofrequency ablation in the management of supraventricular arrhythmias J Cardiovasc Electrophysiol 1993 4 Fuda Y Shoda M Sugiura R A novel cardiac mapping meted for complex tachyarrhythmias using a basket catéter:: local activation vector map PACE 1999 22 Gregoratos G Cheitlin M Conill A ACC/AHA Guidelines for implantation of cardiac pacemakers and antiarrhythmia devices Circulation 1998 97 Moss AJ Hall WJ Cannom DS Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia N Engl J Med 1996 335
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100005 Efectos del Carvedilol en la insuficiencia cardíaca congestiva grado II-IV y establecimiento de la morbimortalidad a 12 meses Pichardo Rafael Valdez Frank Castillo Roberto Díaz A Ernesto González M Angel Corniel Pedro ,Departamento de Investigación del Instituto Dominicano de Cardiología Rep. Dominicana 04 2001 2001 3 35 41

Objetivos: El propósito de este estudio fue establecer la tolerabilidad y la eficacia del carvedilol en pacientes con una clase funcional de la New York Heart Association (NYHA) tipo II, III y IV. Antecedentes. El Carvedilol un beta-antagonista con propiedades de bloqueo alfa adrenérgico y antioxidantes al mismo tiempo, se ha mostrado muy efectivo en mejorar la función ventricular y la supervivencia en pacientes con insuficiencia cardíaca congestiva crónica desde leve a moderada. Métodos: Se estudiaron prospectivamente 27 pacientes con insuficiencia cardíaca congestiva clase II a III ( y algunos IV) con una fracción de eyección < 0.40 % y que tuviesen un diámetro diastólico del VI (DDVI) 55 mm. Los pacientes debían estar estabilizados previamente con digoxina, diuréticos e inhibidores de ECA, comenzándose con una dosis de 3.125 mg b.i.d. y posterior titulación hasta llegar a 25 mg b.i.d. Los pacientes debían completar 9 visitas o 1 año de seguimiento y la dosis mínima aceptada fue de 12.5 mg b.i.d. para considerar a un paciente incluido. Resultados: Del total de 27 pacientes 18 completaron su seguimiento (66.7 %). La tensión arterial no se modificó durante el tratamiento y la frecuencia cardíaca se redujo significativamente de 85 l/min promedio a 70 l/min al final del estudio. La fracción de eyección (FE) se elevó de 0.28 a 0.36 para un aumento de 28.5 % ( P < 0.001 ). De los 18 pacientes, 13 finalizaron en clasificación funcional I incluyendo un paciente tipo IV (72.2 %). Tres pacientes se hospitalizaron (11.1 %) por deterioro, incluyendo un paciente que desarrolló un infarto agudo del miocardio. Dos pacientes fallecieron de muerte súbita en sus casas, lo que representó el 11.1 % del total que comenzaron el estudio. La tolerancia fue excelente y solamente se excluyó un paciente por hipotensión significativa. Conclusiones: Se demuestra que pacientes con dilatación ventricular pero con clasificación funcional basicamente II y III, pueden utilizar carvedilol sin mayores consecuencias, siempre y cuando la dosificación sea adecuada y cuidadosamente titulada comenzando con dosis de 3.125 mg b.i.d.

Objetives: The purpose of this study was established the tolerability and the efficacy of carvedilol in patients with a functional classification of the New York Association (NYHA) type II, III and IV. Background. Carvedilol a nonselective beta-adrenergic blocking drug with alpha-adrenergic blocking and antioxidants properties, has been shown very effective in improving the left ventricular function, clinical outcomes and survival in patients with mild to moderate chronic heart failure. Methods: We studied prospectively 27 patients with congestive heart failure NYHA II, III and some type IV, with a ejection fraction < 0.40 % and left ventricular diastolic diameter 55 mm. The patients should be stabilized with digoxin, diuretics and ACE inhitors, beginning with a dose of 3.125 mg b.i.d. and titrage until arrive to 25 mg b.i.d.. The patients should be complete 9 visits or one year of follow-up and the minimal dose accepted was 12.5 mg b.i.d. in order to consider a patient like included. Results: Of the total 27 patients 18 completed their follow-up (66.7 %). The blood pressure doesn’t modify during the treatment and the heart beat decreased significantly of 85 l/min on the average to 70 l/ min at the end of the study. The ejection fraction (EF) rises from 0.28 to 0.36 for an increase of 28.5 % (P < .001).Of the 18 patients 13 concluded in functional classification type I (72.2 %) including a patient type IV at beginning. Three patients were hospitalized (11.1%) for deterioration including a patient that developped a myocardial infarction. Two patients died of sudden death in their houses and this represented the 11.1 % of the total that the study began. The tolerance was excellent and we excluded only one patient for significant hypotension. Conclusions: We are demostrated that patients with ventricular dilated but functional classification II and III, are able to use carvedilol without consequences provided dosage at minimal dose and the tolerability was excellent.

 carvedilol Insuficiencia cardíaca morbimortalidad Rep. Dominicana carvedilol heart failure morbimortality Rep. Dominicana Consensus recomendations for the management of chronic heart failure Am J Cardiol 1999 83 The effect of digoxin on mortality and morbidity in patients with heart failure N Engl J Med 1997 336 Packer M Carer JR Rodeheffer RJ Effect of milrinone on mortality in severe chronic heart failure N Engl J med 1991 325 Pfeffer M Braunwald G Moye OC Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial inffarction: results of the Survival and Ventricular: Enlargement Trial N Engl J Med 1992 327 Effect of enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure N Engl J Med 1991 325 Waadgstein F Hjalmarson X Varnauskas E Effect of chronic beta adrenergic receptor blockade in congestive cardiomyopathy Br Heart J 1975 37 Cohn JN Levine TB Olivaria MT Plasma norepinephrine as a guide to progression in patients with chronic congstive heart failure N Engl med 1984 311 Packer M Bristow MR Cohn JN Effect of carvedilol on morbidity and mortality in chronic heart failure N Engl J Med 1996 334 Randomized, placebo- controlled trial of carvedilol in patients with congestive heart failure due to ischemic heart disease Lancet 1997 349 Bristow MR Gilbert EM Abraham WT carvedilol produces dose- related improvements in left ventricular ejection fraction and survival in subjects with chronic heart failure Circulation 1996 94 Krun H Sackner- Bernstein JD Goldsmith RG Double- blind, placebo controlled study of the long term efficacy of carvedilol in patients with severe chronic heart failure Circulation 1995 92 Olsen SL Gilbert EM Reglund DG Carvedilol improves left ventricular fraction and syntoms in chronic heart failure, a double- blind randomized study J Am Coll Cardiol 1995 25 Von Mollendorff E Abshagen V Akpan W Clinical pharmacologic investigations with carvedilol, a new beta-blocker with direct vasodilator activity Clin Pharmacol ther 1986 39 Yue TL Cheng HY Lysko PG carvedilol a new vasodilator and beta adrenoceptor antagonist, is an antioxidant and free radical scavenger J Pharmacol Exp ther 1992 263 Sung CP Arleth Al Oblstein EH Carvedilol inhibits vascular smooth muscle cell proliferation J cardiovasc Pharmacol 1993 21 Mortality from congestive heart failure- United States, 1980- 1990 MNWR 1994 43 The cardiac Insufficiency Study 11 (CIBIS -11) : Lancet 1999 353 Effect of metoprolol CR / XL in chronic heart failure :: metoprolol CR/ XL Randomized Intervention Trial in Congestive Heart Failure ( MERIT- HF) Lancet 1999 353 Herlitz J Waagstein F Lindqvist J Swedberg Ic Effect of metoprolol on the prognosis for patients with suspected acute myocardial infarction and indirect sign of congestive heart failure Am J Cardiol 1997 80 Pitt B Zannad F Remme W for The Randomized Aldactone Evaluation Study Investigators: The effect of Espironolactone on morbidity and mortality in patients with severe heart failure N Engl J Med 1999 341 ^s10 Parker M Carvedilol Prospective Randomised Cumulative Survival Trial (COPERNICUS) Carvedilol Prospective Randomised Cumulative Survival Trial (COPERNICUS) American Heart Association Congress Nov 11-15 2000 New Orleans
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100006 Cardiodesfibriladores automáticos implantables: experiencia inicial en Costa Rica Cruz Cruz Flory Araya Gómez Vivien Gutiérrez Sotelo Oswaldo ,Clínica de Arritmias San José Costa Rica 04 2001 2001 3 42 48

Anualmente se reportan alrededor de 350.000 casos de muerte cardíaca súbita (MCS) en Estados Unidos. Menos del 5% sobrevive a la MCS. La taquicardia ventricular (TV) y la fibrilación ventricular (FV) secundarias a cualquier etiología cardíaca suelen ser la causa principal de MCS. Entre la población adulta, la cardiopatía isquémica es la etiología más frecuente, mientras que entre la población pediátrica y adulta jóven es variable su etiología. En los últimos años se han evaluado algunos medicamentos para el manejo de la MCS: antiarrítmicos, y terapias invasivas como la ablación por radiofrecuencia de algunas arritmias y el implante de dispositivos como los cardiodesfibriladores (ICD). En Costa Rica se inició el manejo de la MCS con ICD a partir de abril de 1998. La experiencia nacional comprende de abril de 1998 hasta noviembre del 2000, con un total de ocho pacientes. Todos los pacientes tuvieron una indicación clase I (lineamientos del American Heart Association) para el implante del ICD, corroborado por estudio electrofisiológico (EEF): TV con MCS y TV/FV con MCS. Se presenta la casuística de ocho pacientes, en donde se destaca el período promedio de seguimiento: 15,5 meses (rango de 5 a 31 meses). Durante dicho período, el 75% (6/8) se mantuvo vivo, hubo una mortalidad de 25% (2/8). De los pacientes fallecidos, uno tenía un ICD Guidant bicameral y el otro paciente, un ICD Medtronic bicameral. Las muertes se debieron a falla de bomba e infarto agudo del miocardio (IAM) extenso; ninguno fue por arritmia maligna. Se documentó que en el 37,5% (3/8) de los pacientes tuvo terapias del ICD en forma apropiada: un mismo paciente tuvo varias terapias por FV y TV en forma apropiada y una inapropiada por fibrilación atrial (FA), otro paciente tuvo terapia por TV y un tercer paciente por FV. Los pacientes con MCS pueden ser tratados en forma efectiva y segura con ICD que disminuye el riesgo de muertes por arritmias malignas, no así las muertes cardiácas de otro origen y las muertes no cardiácas, tal y como se ha demostrado en grandes series reportadas en la literatura. El riesgo/beneficio debe de considerarse, ya que el factor económico es una limitante para el desarrollo de estas terapias.

Sudden cardiac death (SCD) strikes 350.000 people per year in the United States. Less than 5% survives SCD. Ventricular tachycardia (VT) or fibrillation (VF) secondary to any cardiac etiology most often causes SCD. In adults, coronary artery disease is the most common etiology. In children and young adults, SCD is caused by other etiologies. Recently, there are using some therapies for treating SCD: drugs, ablative therapy and devices such as implantable cardioverter-defibrillator (ICD). In Costa Rica, we started control SCD with ICD since april, 1998. In our experience, we had eigth cases since that date until november, 2000. All of them had VT/FV with SCD, a class I for the implant of ICD (American Heart Association guidelines). We practiced electrophysiologic study before implant the ICDs. The follow up period was 15,5 months (range 5-31). During follow up, 75% was alive, and 25% death because of heart failure and extensive acute myocardial infarction, none of them because of a malignant arrhythmia. One of these patients had a Medtronic device and the other one has had a Guidant. In 37,5% of cases, there was an appropiate discharge. One patient had more than one ICD discharge treating VT and FV and also one inappropiate discharge ( atrial fibrillation). The other two patients had appropiate discharge of their ICDs. Patients with VT and VF with SCD can be treated efective and safely with an ICD therapy. It is well known that we can not treat other cardiac etiologies of SCD with and ICD. The cost/bennefit must be considered.

 cardiodesfibrilador automático implantable muerte cardíaca súbita taquicardia ventricular fibrilación ventricular implantable cardioverter- defibrillator sudden cardiac death Ventricular tachycardia ventricular fibrillation Roberts W Sudden cardiac death:: Definitions and causes Am J Cardiol 1986 57 Gillum RF Sudden coronary death in the United States Circulation 1989 79 Wellens HJJ Lemerry R Smeets JL Sudden arrhythmic death without overt heart disease Circulation 1992 85 ^sI Cobb LS Weaver WD Fahrenbruch CE Community-based interventions for sudden cardiac death:: Impact, limitations, and changes Circulation 1992 85 ^sI Eisenburg MS Horwood BT Cummnins RO Cardiac arrest and resuscitation:: a tale of 29 cities 1990 19 Annals Emerg Med Cummins RO Ornato JP Thies WH Improving survival fron sudden cardiac death:: The "chain of survival concept: A statement for health professionals from the Advanced Cardiac Life Support Committee and the Emergency Cardiac Care Committee, American Heart Association Circulation 1991 83 Bayés de Luna A Underlying arrthmia of sudden cardiac death Am Heart J 1989 117 Gregoratos G ACC/AHA Guidelines for implantation of cardiac pacemakers and antiarrhythmia devices Circulation 1998 97
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100007 Manejo actual del síndrome coronario agudo: segunda parte, angina inestable-infarto del miocardio no-Q. Obón Arellano Alfonso ,Hospital Cima San José Costa Rica 04 2001 2001 3 49 65 Fuster V Badimon L Badimon J J Chesebro J H The pathogenesis of coronary artery disease and the acute coronary syndromes ( Part I ) N Engl J Med 1992 326 Fuster V Badimon L Badimon J J Chesebro J H The pathogenesis of coronary artery disease and the acute coronary syndromes N Engl J Med 1992 326 Fuster V Badimon L Cohen M Ambrose JA Insights into the pathogenesis of acute ischemic syndromes Circulation 1988 77 Dalager - Pederson S Morre Pederson E Ringgaard S Falk E Coronary Artery Disease:: Plaque Vulnerability,Disruption and Thrombosis Fuster V: The Vulnerable Atherosclerotic Plaque Fuster V: The Vulnerable Atherosclerotic Plaque 1999 American Heart Association Dlavies M J Thhomas A C Plaque fissuring the cause of acute myocardial infarction,sudden ischemic death, and crescendo angina Br Heart J 1985 53 Plutzky J Atherosclerotic Plaque rupture:: emerging insights and opportunities Am J Cardiol 1999 84 Libby P Molecular bases of the Acute Coronary Syndromes Circulation 1995 91 Moreno P R Falk E Palacios JF Neewell JB Fuster V Fallon J Macrophage infiltration in Acute Coronary Syndromes:: implications for plaque rupture Circulation 1994 90 Hamm CW Lorenz RL Bleifeld W Kupper W Biochemical evidence of platelet activation in patients with persistent unstable angina J Am Coll Cardiol 1987 10 Falk E Shah PK Fuster V Coronary Plaque Disruption Circulation 1995 92 DeWood MA Stiffer WF Simpson CS Coronary angiografic findings soon after non Q wave myocardial infarction N Engl J Med 1986 315 Cannon C Curr Probl Cardiol 1999 24 Falk E Unstable Angina with fatal outcome:dynamic coronary thrombosis leading to infarction and/or sudden death Circulation 1985 71 Sullivan E Kearney M Isner J Topol E Losordo D Pathology of unstable angina:: analysis of biopsies obtained by directional coronary atherectomy J Throm Thrombolysis 1994 I Sherman CT Litvack F Grundfest W Lee M Coronary angioscopy in patients with unstable angina pectoris N Engl J Med 1986 315 Mizuno K Satumo K Miyamoto A Arakawa E Angioscopic evaluation of coronary artery thrombi in acute coronary syndromes N Engl J Med 1992 326 Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit lesion in patients presenting with ischemic cardiac pain at rest: Results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) trial Circulation 1993 87 Ambrose JA Hjemda Mosen CE Borrico S Gorlin R Fuster V Angiographic demostration of a common link between unstable angina and non Q wave myocardial infarction Am J Cardiol 1988 61 Fitsgerald DJ Roy L Catella F Fitzgerald GA Platelet activation in unstable coronary disease N Engl J Med 1986 315 Alexopoloulos D Ambrose JA Stump D Borrico S Thrombosis related markers in unstable angina J AmColl Cardiol 1991 17 Oler A Whooley MA Oler J Grady D Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina: A Meta Analysis JAMA 1996 276 A definition of advanced type of atherosclerotic lesions and a histological classification of atherosclerosis:: a report from the Committee on Vascular Lesions of the Council on Atherosclerosis,American Heart Association Circulation 1995 92 Braunwald E Unstable Angina: A classification Circulation 1989 80 Ahmed WH Bittl JA Braunwald E Relation between clinical presentation and angiographic findings in unstable angina pectoris,and comparison with that in stable angina Am J Cardiol 1993 72 Danges G Mehran R Wallenstein S Correlation of angiographic morphology and clinical presentation in unstable angina J Am Coll Cardiol 1997 29 DeServi S Arbustini E Marsica F Correlation of angiographic morphology findings in unstable angina Am J Cardiol 1996 77 Owa M Origasa H Saito M Predictive validity of the Braunwald classification of unstable angina for angiographic finding,short-term prognosis,and treatment selection Angiology 1997 48 Lee T Cook E Weisberg M Sargent RK Acute chest pain in the Emergency Room:: identification and examination of low-risk patients Arch Intern Med 1985 145 Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non Q wave myocardial infarction Circulation 1994 89 Cannon CP McCabe CH Stone P The electrocardiogram predicts one year outcome of patients with unstable angina and non Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study J Am Coll Cardiol 1997 30 Rouan GW Lee T Cook E Brand DA lWeisberg M Goldman L Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms ( a report from the Multicenter Chest Pain Study ) Am J Cardiol 1989 64 Slater DK Hlatky M A Mark DB Harrell FE Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic findings Am J Cardiol 1987 60 Patel DJ Knight CJ Holdright DR Long term prognosis in unstable angina:: the importance of early risk stratification using continuous ST segment monitoring Eur Heart J 1998 19 Gottlieb SO Weisfeldt M L Ouyang P Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina N Engl J Med 1986 314 Roberts R Fromm RE Management of acute coronary sindromes based on risk stratification by biochemical markers: an idea whose time has come Circulation 1998 98 Puleo PR Meyer D Wathen C Use of a rapid assay of subforms of creatine-kinase-MB to diagnose or rule out acute myocardial infarction N Engl J Med 1994 331 Newby LK Gibler WB Ohman WM Biochemical markers in suspected Acute Myocardial Infarction Clin Chem 1995 41 Puleo PR Guadagno PA Roberts R Scheel MV Early diagnosis of acute myocardial infarction based on assay for subforms of creatine kinase-MB Circulation 1990 82 Adams JE Abendschein DR Jaffe AS Biochemical markers of myocardial injury.Is MB creatinine kinase the choice for the 1990 Circulation 1993 88 Antman E Bassand JP Klein W Myocardial Infarction Redefined: A consensus document of the Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of Myocardial Infarction J Am Coll Cardiol 2000 36 de Winter R Risk Stratification with Cardiac Troponin I in Acute Coronary Syndromes J Am Coll Cardiol 2000 36 Hamm CW Ravkilde J Gerhardt W The prognostic value of serum Troponin T in Unstable Angina N Engl J Med 1994 327 Ohman EM Armstrong PW Christenson RH Cardiac Troponin T levels for risk stratification in acute myocardial ischemiaGUSTO II A Investigators N Engl J Med 1996 335 Heeschen C vandenBrand MJ Hamm CW Simoons ML Angiographic findings in patients with refractory unstable angina according to Troponin T status Circulation 1999 100 Hanam CH Braunwald E A Classification of Unstable Angina Revisited Circulation 2000 102 Heeschen C Hamm CW Goldman B Deu A Troponin concentrations for stratification of patients with Acute Coronary Syndromes in relation to therapeutic efficacy of Tirofiban: PRISM Study Investigators. Platelet Receptor Inhibition in Ischemic Syndrome Management Lancet 1999 354 Randomized placebo controlled trial of Abciximab before and during coronary intervention in refractory unstable angina:: the Capture Study Lancet 1997 349 Use of a monoclonal antibody directed against the platelet Glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty N Engl J Med 1994 330 Lindahl B Venge P Wallentin L The FRISC experience with Troponin T.Use as decision tool and comparison with other prognostic markers Eur Heart J 1998 19 ^sN Boersma E Akkerhuis KM Theroux P Califf RM Topol EJ Platelet glycoprotein IIb/IIIa receptor inhibition in non-ST elevation Acute Coronary Syndromes:: early benefit during medical treatment only,with additional protection during percutaneous coronary intervention Circulation 1999 100 Hamm CW Unstable Angina:: the breaktrough Eur Heart J 1999 20 Wallentin L Lagerquist B Husted S Kontwy F Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary artery disease:: the FRISC II invasive randomized trial.Frisc investigators. Fast Revascularization during instability in Coronary Artery Disease Lancet 2000 356 Bertrand ME Smoons ML Fox K Wallentin L Management of Acute Coronary Syndromes:: Acute Coronary Syndromes without persistent ST segment elevation.Recommendations of the Task Force of the European Society of Cardiology Eur Heart J 2000 21 Hamm CW Goldman BU Heeschen C Kreyman G Emergency Room triage of patients with acute chest pain by means of rapid testing for cardiac Troponin T or Troponin I.N Engl J Med 1997 337 Kontos M C Anderson FP Alimard R Ornato JP Ability of Troponin I to predict cardiac events in patients admitted from the emergency department J Am Coll Cardiol 2000 36 Johnson PA Goldman L Sacks D Cardiac Troponin T as a marker for Myocardial Ischemia in patients seen at the Emergency Department for acute chest pain Am Heart J 1999 137 Berck BC Weintraub WS Alexander RW Elevation of C-Reactive protein in "Active coronary artery disease Am J Cardiol 1990 65 Liuzzo G Biasucci LM Gallimorre JR The prognostic value of C-reactive protein in severe angina N Engl J Med 1994 331 Biasucci LM Liuzzo Gk Fantuzzi G Increasing levels of interleukinIL-1Ra and Il-6 during the first 2 days of hospitalization in Unstable Angina are associated with increased risk of in hospital coronary events Circulation 1999 99 Morrow DA Rifai N Antman EM Serum Amyloid A predicts early mortality in acute coronary syndromes:: a TIMI II A substudy J Am Coll Cardiol 2000 35 Braunwald E Mark D Jones R Unstable Angina:: Diagnosis and Management Unstable Angina:: Diagnosis and Management May 19 94 Rockville^eMD Agency for Health Care Policy and Research and the National Heart,Lung,and Blood Institute Braunwald E Joones RH Mark D Diagnosis and managing Unstable Angina Circulation 1994 90 Braunwald E Antman E Beasley JW ACC/AHA guidelines for the management of patients with Unstable Angina and non-ST segment elevation MI:: executive sumary and recommendations: A report of the American Collegue of Cardiology/American Heart Association Task Force on Practice Guideliness J Am Coll Cardiol 2000 36 Gibbons R Chatterje K Daley J ACC/AHA/ACP-ASIM guidelines for the management of patients with Chronic Stable Angina J Am Coll Cardiol 1999 33 Cheitlin MD Hutter A Brindis R ACC/AHA expert consensus document: use of Sildenafil(Viagra) in patients with cardiovascular disease:: American College of Cardiology/American Heart Association J Am Coll Cardiol 1999 33 Yusuf S Wittes J Friedman L Overview of results of randomized clinical trials in heart diseaseII: Unstable Angina, Heart Failure, primary prevention with aspirin,and risk factor modification JAMA 1988 260 Gheorghiade M Schultz L Tilley B Effects of Propanolol in non-Q wave acute Myocardial Infarction in the Beta Blocker Heart Attack Trial Am J Cardiol 1990 66 Gibson R Boden WE Theroux P Strauss H Diltiazem and reinfarction in patients with non -Q wave myocardial infarction.Results of a double-blind,randomized,multicenter trial N Engl J Med 1986 315 The effect of diltiazem on mortality and reinfarction after myocardial infarction N Engl J Med 1988 319 Verapamil in acute myocardial infarction Eur Heart J 1984 5 Yusuf S Sleight P Pogue J Bosch J Davies R Dagenais G Effects of an angiotensin-converting enzime inhibitor,ramipril,on cardiovascular events in high risk patients: The Heart Outcomes prevention Evaluation Study Investigators N Engl J Med 2000 342 ISIS-4:randomized factorial trial assessing early oral captopril,oral monitrate, and intravenous magnesium sulphate in 58050 patients with suspected acute myocardial infarction Lancet 1995 345 Lewis HD Davis JW Archibald D lSteinke W Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina N Engl J Med 1983 309 Cohen M Xiong J Parry G Prospective comparison of unstable angina versus non-Q wave myocardial infarction during anti thrombotic therapy J Am Coll Cardiol 1993 22 Randomized trial of intravenous streptokinase,oral aspirin,both or neither among 17187 cases of suspected acute myocardial infarction:ISIS-2 Lancet 1988 2 A randomized,blinded,trial of Clopidogrel versus Aspirin in patients at Risk of Ischaemic Events (CAPRIE) Lancet 1996 348 Oler A Whooley MA Oler J Meta-Analisis of the benefit of heparin plus aspirin compared with aspirin alone in unstable angina/ non-ST elevation MI JAMA 1996 276 Holdrigh D Patel D Cunningham D Comparison of the effect of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in hospital prognosis in patients with unstable angina J Am Coll Cardiol 1994 24 Hirsh J Fuster V Guide to anticoagulation therapy: Part I: Heparin Circulation 1994 89 Quinn M Fitzgeral D Ticlopidine and Clopidogrel Circulation 1999 100 Cohen M Dermers C Gurfinkel EP A comparison of low molecular weight heparin with unfractionated heparin for ustable coronary artery disease N Engl J Med 1997 100 Antman EM Mcabe CH Gurfinkel EP Enoxaparin prevents death and cardiac ischemic events in unstable angina/non Q wave myocardial infarction:: results of the Thrombolysis in Myocardial Infarction (TIMI)IIB Circulation 1999 100 Antman E M Cohen M Radley D Assessment of the treatment effect of Enoxaparin for Unstable angina/Non Q wave Myocardial Infarction: TIMI-IIB-ESSENCE meta-analysis Circulation 1999 100 Awtry E Loscalzo J Aspirin Circulation 2000 101 Shah P Circulatin Markers of Inflammation for Vascular Risks Prediction Circulation 2000 101 Liuzzo G Biasucci L Gallimore R Enhaced Inflamatory Response in Patients with Preinfarction Unstable Angina J Am Coll Cardiol 1999 34 Lefkovits J Plow EF Topol EJ Platelet glycoprotein II b/IIIa receptores in cardiovascular medicine N Engl J Med 1995 332 Coller B S Blockade of platelet GP IIb/IIIa receptors as an antithrombotic strategy Circulation 1995 92 Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty:: the EPIC Investigation N Engl J Med 1994 330 Platelet Glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization:: the Epilog Investigators N Engl J Med 1997 336 Lincoff AM Califf RM Moliterno DJ Coomplementary clinical benefits of coronary artery stenting and blockade of platelet glycoprotein IIb/IIIa receptors: Evaluation of Platelet IIb/IIIa Inhibition in Stenting Investigators N Engl J Med 1999 341 Inhibition of Platelet Glycoprotein IIb/IIIa with Eptibatide in patients with acute coronary syndromes N Engl J Med 1998 339 A comparison of Aspirin plus Tirofiban with Aspirin plus Heparin for Unstable Angina N Engl J Med 1998 338 Inhibition of the platelet glycoprotein IIb/IIIa receptor with Tirofiban in unstable angina and non-Q wave myocardial infarction N Engl J Med 1998 338 International, randomized, controlled trial of Lamifiban, Heparin or both in unstable angina Circulation 1998 97 Lincoff M Califf R Topol E Platelet Glycoprotein IIb/IIIa receptor blockade in coronary artery disease J Am Coll Cardiol 2000 35 Chew D Moliterno D A critical Appraisal of platelet Glycoprotein IIb/IIIa inhibition J Am Coll Cardiol 2000 36 Scarborough R Kleiman N Phillips D Platelet Glycoprotein IIb/IIIa antagonists.What are the Relevant Issues Concerning their Pharmacology and clinical use ? Circulation 1999 100 Newby LK A randomized comparison of Sibrafiban,an oral glycoprotein (GP)IIb /IIIa receptor antagonist,with and without aspirin versus aspirin after acute coronary syndromes (ACS):: results of the second SYMPHONY Trial J Am Coll Cardiol 200036 Kereiakes DJ Kleiman N Ferguson JJ Pharmacodynamic efficacy, clinical safety and outcomes after prolonged glycoprotein IIb/IIIa, receptor blockade with oral Xemilofiban:: results of a multicenter, placebo, controlled, randomized trial Circulation 1998 98 Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction:: results of the TIMI III B trial.Thrombolysis in Myocardial Ischemia Circulation 1994 89 Guidelines for coronary angiography:: a report of the American College of Cardiology/American Heart Association Task Force on Assessement of Diagnostic and Therapeutic Cardiovascular Procedures J Am Coll Cardiol 1987 10 Ryan TJ Amderson J L Antman E M ACC/AHA guidelines for the management of patients with acute myocardial infarction:: a report of the American College of Cardiology/ American Heart Association task force on practice guidelines(Committee on management of Acute Myocardial Infarction ). J Am Coll Cardiol 1996 28 Boden W E Orourke R A Crawford M H Blaustein AS Deedwania PC Zoble RG Outcomes in patients with acute-non Q wave myocardial infarction randomly assigned to an invasive as compared with a conservative strategy N Engl J Med 1998 338 Invasive compared with non-invasive treatment in unstable coronary artery:: FRISC II prospective randomized multicentre study Lancet 1999 354 Scull GS Martin JS Weaver WD Every NR Early angiography versus conservative treatment in patients with non-ST- elevation acute myocardial infarction J Am Coll Cardiol 2000 35 Randomized placebo- controlled and balloon-angioplasty controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa blockade Lancet 1998 352 Cannon CP Weintraub WS Demopoulos L Aa Robertson DH Gormley GJ Braunwald E Invasive versus Conservative strategies in unstable angina and non Q wave myocardial infarction following treatment with Tirofiban:: rationale and study design of the international TACTIC-TIMI 18 trial Am J Cardiol 1998 82 Welty F Optimal Management of Non-ST Segment Elevation Myocardial Infarction Remains Unclear J Am Coll Cardiol 2000 35 Andrews TC Raby K Barry J Effect of cholesterol reduction on Myocardial Ischemia in patients with coronary artery disease Circulation 1997 95 Aronow H Wolski K Lauer M Marked reduction in mortality with early Lipid-Lowering after ST and non-ST elevation Acute Coronary Syndromes Circulation 2000 102 Hamm C Heeschen C Boehm M Role of Statins in patients with Acute Coronary Syndromes Circulation 2000 102 Walter D Fichtlscherer Sl Britten M Initiation of Statin Therapy Inmeditely after Stent Implantation:: Profund Benefit with Acute Coronary Syndromes Circulation 2000 102 Scwartz G G Oliver M Ezekowitz MD Rationale and design of the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study that evaluates Atorvastatin in Unstable Angina Pectoris and in non-Q-wave acute myocardial infarction J Am Coll Cardiol 1998 82 de Lorgeril M Salen P Martin J Monjaud I Delaye J Mamelle N Mediterranean diet,traditional risk factors and the rate of cardiovascular complications after myocardial infaarction:: Final report of the Lyon Diet Heart Study Circulation 1999 99 Leaf A Dietary Prevention of Coronary Heart Disease The Lyon Heart Study Circulation 1999 99 Sacks FM Pfeller MA Moye L E The effect of pravastatin on coronary events after myocardial infarction in patients with average Cholesterol levels N Engl J Med 1996 335 O'Brien T Simari D Gene therapy for Atherosclerotic Cardiovascular Diseasee:: A time for Optimism and Caution Mayo Clinic Proc 2000 75 O'keefe J Wetzel M Moe R Brosnahan K Lavie K Should and angiotensin -converting enzyme inhibitor be standar therapy for patients with atherosclerotic disease J Am Coll Cardiol 2001 37 Wexler L Blaustein A Lavori P Lehman K Non-Q-wave Myocardial infarction following thrombolytic therapy:: a comparison of outcomes in patients randomized to invasive or conservative post-infarct assessment strategies in the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial J Am Coll Cardiol 200137
S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100008 Electrocardiograma del mes Araya Gómez Vivien , 04 2001 2001 3 67 67
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S1409-414220010001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000100010 Cuestionario de autoevaluación , 04 2001 2001 3 72 74