We are the combination of four hospitals: the General Hospital, the Children’s Hospital, the Women’s Hospital and the Traumatology, Rehabilitation and Burns Hospital. We are part of the Vall d’Hebron Barcelona Hospital Campus: a world-leading health park where healthcare plays a crucial role.
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Once in the haemodynamics room, the nurse will apply stickers connecting you to the electrocardiogram to monitor you at all times, and will check the IV line is working correctly to administer medication if required during the procedure. Next, the access site chosen by the haemodynamics specialist (either the groin or wrist) will be disinfected and covered with a sterile dressing. It is very important not to touch anything to maintain sterility and avoid infection, and you should keep completely still while the procedure is carried out.
A member of the unit’s nursing staff will be beside you throughout the procedure, and you may ask them any questions or let them know if you are uncomfortable in any way.
Possible access sites are the radial artery, femoral artery and humeral artery.
Arterial access has to be obtained via a small puncture of the skin so that a catheter that travels to the heart can subsequently be introduced. This is always done under local anaesthetic. Next, the artery is punctured and a small tube inserted which will provide access for the exploratory catheters. You may notice some discomfort or pressure in the puncture area, but it should not be painful.
Once the tube is in position in the chosen artery (usually the radial artery in the wrist), a catheter will be introduced (the narrow blue tube in the above photo) which will travel along the blood vessels until it reaches the heart, where the arteries that irrigate it originate. A radiopaque contrast substance will be injected into the same catheter, which will allow radiological images of the anatomy of your coronary arteries to be viewed on a monitor.
If no angiographic lesions are found: A report will be sent to your cardiologist, who will decide the treatment to be followed.
If angiographic lesions are found: If angiographic lesions are found during catheterization, a decision will be made as to whether they should be treated there and then, or whether discussion with your cardiologist is needed first in order to decide the most beneficial treatment. You will be told of the findings and decisions taken at all times.
Therapeutic catheterization.
When treatment is required for the angiographic lesions found, the specific material used in each case will depend on the type of coronary lesion to treat, the aim being to open it up and restore blood flow through the artery. You may notice some discomfort, and should inform the nurse of this so they can administer the necessary analgaesics to keep you comfortable.
If you have a stent implant, you will have to take specific medication, if this has not already been prescribed. You will be told the type of medication and how to take it in the haemodynamics unit and once you have been transferred for recovery, it will also be recorded in your discharge report so that both you and your cardiologist or GP are aware of it
Once the procedure has finished, a haemostatic compression device is applied to the puncture site. This performs conventional haemostasis by compression, which helps clotting and subsequent healing of the arterial wall. It is a non-invasive technique.
There are several types:
Elastic radial compression: A solid dressing is placed on the puncture site, held in place with elastic bandages which exert consistent pressure on the area. This bandaging should be worn for at least 4 hours and be removed by the Day Hospital or ward nurse, as appropriate. In any case, it should be worn for longer if the puncture site continues to bleed when the compress is removed.
Radial compression with a pneumatic device: This involves a plastic device held in place on the wrist with Velcro. An air chamber inflates, exerting consistent pressure on the insertion point. It should be worn for at least 4 hours and be removed by the Day Hospital or ward nurse, as appropriate. In any case, it should be worn for longer if the puncture site continues to bleed when the compress is removed.
It is normal for the thumb to go numb when using either of these devices. You can move your fingers and raise and lower your arm, but you should not bend your wrist under any circumstances. The wrist must be rested in the days after the catheterization and no sudden movements or lifting of heavy items should be attempted in order to help the radial artery heal completely.
The leg should not be moved until the bandages are removed 4-8 hours after catheterization depending on whether it was simply for diagnosis or if any coronary lesions have been treated. Movement should begin again gradually.
Percutaneous femoral closure device: This device puts a stitch in the femoral artery. You should rest and then begin to move again 4-6 hours after the procedure.
The arterial access tube is removed and firm pressure applied to the artery until bleeding stops, at which point bandage compression should be applied immediately. You should rest for 4-8 hours after the procedure and then start to move again gradually.
Once in the Day Hospital or ward, you may start to drink liquids, unless you are told otherwise by the professionals who looked after you in the haemodynamics unit. You may start to eat solid food two hours after the catheterization.
Once the catheterization has finished, you will be transferred back to the Day Hospital, where you will stay as long as necessary until the compression bandaging is removed and there is no evidence of bleeding or other complications. If everything is in order, the doctor will discharge you and you can go home.
If you have been admitted to hospital, the nurse will remove the compression bandaging after the requisite time, and will check the puncture site. They will also give you instructions on eating and drinking. Your cardiologist will talk to you about the process during your stay in hospital and the best treatment plan for you so that you can be discharged and go home as soon as possible.
Infectious endocarditis involves the presence of a microbial infection in the endocardial surface (internal surface of the heart). It is the most frequent cardiovascular infection and it is very important because of its potential severity and its different forms of presentation.
Infectious endocarditis mainly affects cardiac valves, whether natural or artificial, although sometimes it can occur in other structures of the heart.
It is classified according to the time the infection has been established (days, weeks or months) and according to the bacteria or microorganism (yeast, fungus) that causes it.
The characteristic lesion of infectious endocarditis is endocardial vegetation. It is made up of the completely abnormal presence of an aggregate of platelets, fibrin, bacteria and inflammatory cells that adhere to the internal surface of the heart, usually on the surface of a cardiac valve, and which is susceptible to breaking off, causing an infectious embolism at a distance in another organ (skin, nervous system, limb).
It is considered a serious illness and although in most cases it is cured, it also has significant complications and mortality despite treatment. In many cases, patients must be subjected to surgical intervention in order for it to be definitively cured, eliminating the affected tissue and inserting a new artificial heart valve.
In its most acute form infectious endocarditis can produce high fever, chills, prostration and severally affect the patient's general condition in a short time period (hours-days). In subacute forms it may evolve over weeks or months, with a clinical presentation of tiredness, lack of appetite and low-grade fever. In these cases, infectious skin manifestations may also occur as nodules or characteristic spots, which do not always appear.
In patients with severe cardiac valve involvement, the valves themselves may not function correctly, which may result in symptoms of heart failure such as severe shortness of breath and swelling of the lower limbs
Infectious endocarditis has a global incidence of 2-3 cases per 100,000 population per year, and so it is estimated that in Catalonia around 200 cases are diagnosed every year. Its incidence increases greatly with age, reaching 15-30 cases/per 100,000 population/year in over 65s, or 10 times higher than that of the younger population.
The cause of infectious endocarditis has changed a lot in recent decades. In recent years the most frequent causal bacterium has been streptococcus, especially a species called viridans. There is currently a great variety of causal agents, although staphylococci are the most frequent, followed by streptococci and enterococci. It is, however, advisable to note that any microorganism that circulates through the blood can adhere to a heart valve, especially if it has previous injuries or is an artificial valve.
The diagnosis of endocarditis is based essentially on:
- blood cultures to identify the bacterium that causes the infection and allow the most suitable specific antibiotic treatment to be chosen.
- echocardiogram that allows the endocardial vegetations typical of the disease to be located. It also informs doctors about the function of the valve affected and contributes significantly to assessing the need for surgical treatment in some patients.
- in some cases it is necessary to carry out other explorations (such as CAT or scintigraphy) to rule out the existence of peripheral embolisms, which are very common at the time of diagnosis or during the course of treatment of the disease.
The treatment of infectious endocarditis is antibiotic, but specifically targeting the microorganism that causes it. The doses are high and prolonged over time because the vegetations typical of the disease are not very vascularised and antibiotics must penetrate through diffusion from circulating blood. In patients who do not respond adequately to this antibiotic treatment or who have major valve damage as a consequence of the infection, it is necessary to assess the need for valve replacement surgery.
Blood cultures and echocardiogram, both at the time of diagnosis and to monitor the evolution of the illness.
When an alteration of a person's heart valve is recognised, antibiotic prevention must be administered before any dental or gum treatment is given, following specialised consultation.
Preventive measures must also be taken in the case of endoscopes, especially of the upper gastrointestinal tract (gastroscopy), with the antibiotic and guidelines indicated by the doctor.
This prevention is very important because the presence of bacteria in the blood, as a result of the intervention or exploration, carries a significant risk of infectious endocarditis.
The Inherited Heart Disease Unit is basically devoted to providing care. We have a team of two cardiologists, three interns and two nurses, one full-time and one part-time. This Unit addresses all myocardiopathies in general, and inherited cases in particular.
Myocardiopathies are diseases where the myocardium is weak, dilated or has some other structural problem. Often, the heart is unable to pump or work properly. In the case of inherited myocardiopathies, due to the fact they are often treated as part of uncommon diseases, specialist management is not within the scope of all clinical cardiologists. It requires specific treatment and involves specific technology.
The aim of the electrocardiogram is to determine any damage to the heart and the effects of medication and devices on the circulatory system’s main organ, as well as being very useful in detecting and analysing cardiac arrhythmias, acute episodes of coronary artery disease and myocardial infarction. It can also be used in preoperative examinations, especially in medium- and high-complexity surgery, if there are risk factors such as ischemic heart disease, diabetes, stroke, heart failure or renal dysfunction.
To carry out the test, the healthcare professional connects the wires of the electrocardiogram to the skin of the patient using adhesives or suction cups called "electrodes", which are connected to the ankles, wrists and chest in order to detect electrical impulses from different parts of the body.
During the electrocardiogram, the patient must be lying down, relaxed and silent, with normal breathing and with their arms and legs still. Occasionally, the doctor may ask the patient to hold their breath for a few seconds.
The electrocardiogram records electrical activity from the surface of the heart, thanks to electrodes that are stuck to the body. This record of electrical activity is then copied onto paper that is then interpreted by a professional based on the patient’s symptoms and clinical history.
It is a simple, fast test that causes no discomfort or pain. It poses no risk to patients.
The heart is made up of four cavities, two atria and two ventricles. The atria are separated from each other by an interatrial wall or septum, and the ventricles by an interventricular wall or septum. Between the atrium and the ventricle there is the atrioventricular valve. The veins arrive into the atria and the major arteries leave the ventricles. Between the ventricle and its artery outlet there is the semilunar valve. The heart is divided into the right and left sides.
Non-oxygenated blood arrives at the right atrium via the venae cavae, from the head and arms (upper vena cava) and from the abdomen and legs (lower vena cava). This blood passes to the right ventricle through the tricuspid valve. The right ventricle pumps this blood, through the pulmonary valve, into the lungs through the pulmonary arteries, which is where the blood gets it oxygen.
This oxygenated blood returns to the left atrium via the pulmonary veins. From the left atrium it is directed to the left ventricle through the mitral valve. The left ventricle pumps the blood to the aorta through the aortic valve to distribute it to all the organs and tissues in the body.
The heart is irrigated by the coronary arteries, right and left. These coronary arteries divide into several branches to carry oxygenated blood throughout the heart tissue.
The heart contracts due to an electric stimulus triggered by the conduction system. The cardiac conduction system is made up of a series of cells that have the capacity to create this stimulus and determine heart rate. This stimulus begins in the sinus node, which is found where the superior vena cava enters the right atrium. This stimulus causes the atrium to contract. This stimulus then propagates the ventricle through another structure called the atrioventricular node. This conduction system is capable of increasing the heart rate when necessary, such as for example during exercise, when you have a fever, when you feel emotions, etc., or decreasing the heart rate when you are sleeping. This system is regulated by the action of different hormones or in response to nervous stimuli in the cardiac plexus.
The cardiac cycle has two phases: systole and diastole. In systole, the heart contracts to send blood to the major arteries and during diastole it relaxes to fill with blood to later be ejected.
Acute myocardial infarction (AMI), commonly known as a heart attack, is the necrosis –the degeneration of tissues due to cell death– of a part of the heart, caused by an interruption in blood flow (ischaemia). The most common cause is the obstruction of a coronary artery (the arteries that supply blood to the heart itself) by a blood clot formed by the rupture or erosion of an atherosclerotic plaque. In the absence of atherosclerosis, there are other, less frequent mechanisms that can cause this condition, such as strokes, dissection, and coronary artery spasms. The main factor determining the prognosis and initial course of treatment is whether the obstruction of blood flow to the heart is total and persistent or not. The former case is a medical emergency, since the entire myocardial area irrigated by the obstructed artery will die if the blood flow is not quickly restored. The latter, without total and persistent blockage, constitutes a less severe heart attack and treatment is not as urgent. The clinical presentation, in which the symptoms and initial signs can be characterised, and, most importantly, the electrocardiogram (ECG) results, help distinguish between these two scenarios. AMI is one of the leading causes of death worldwide, since it goes hand-in-hand with a high risk of serious complications, such as malignant arrhythmias, especially in the first few hours following the heart attack. It is also a common cause of long-term disability. Even with the considerable therapeutic advances of the past few decades, it is still a serious condition. A timely diagnosis and treatment initiation is essential in improving the prognosis.
The most common symptom is chest pain, usually described by patients as a kind of pressure in the middle of their chest, which often radiates to the arms, neck, jaw, or back; it starts off as mild pain and progressively increases in intensity. It is sometimes defined as a burning sensation, and it can occur in other parts of the body, such as the stomach area.
Often, it is accompanied by a subjective feeling of weightiness, cold sweats, nausea, and vomiting. Sometimes, especially in the elderly, in women, and in diabetic patients or those with other chronic diseases, the pain is not as obvious or it is accompanied by other symptoms such as shortness of breath, fatigue, or feeling unsteady.
AMI can occur suddenly, as the first sign of ischaemic heart disease, but often, patients have had prior, brief episodes of chest pain, usually upon physical exertion, which should serve as a warning that they may have an unstable coronary injury. Other associated symptoms, such as trouble breathing, fainting, confusion, drowsiness, or extreme weakness usually indicate the presence of serious complications of AMI such as heart failure, arrhythmia, or cardiogenic shock.
Many people, since ischaemic heart disease is the leading cause of death worldwide. According to the WHO, in 2016, it caused close to 10% of deaths overall, surpassing strokes and chronic obstructive pulmonary disease. In Europe, the mortality rates due to ischaemic heart disease and cancer are quite similar. The prevalence of AMI and ischaemic heart disease in general is less in the Mediterranean countries than in the Northern or Eastern European countries.
In Spain, there are some 100,000 cases of AMI per year, a third of which prove to be fatal before the patient reaches the hospital. The prognosis for hospitalised patients has improved greatly in the past few decades; the current hospital mortality rate here is close to 5%.
The prevalence of AMI increases at advanced ages. Although it is commonly believed that AMI is a condition that affects mostly men, its prevalence is similar in both sexes. What happens is that men usually develop this condition starting in their forties, whereas women see an increased incidence of the disease 10-20 years later, almost always after menopause. However, young women can also have an AMI.
Anyone can suffer an AMI, but there are risk factors that are closely associated with a higher risk. The most characteristic of these are those related to any kind of atherosclerosis, such as tobacco use, diabetes, hypertension, and high cholesterol. There are also genetic traits associated with an increased predisposition to the illness.
Lastly, there are factors that can provoke a rupture in the atherosclerotic plaque or a thrombotic response and trigger an AMI, such as:
It is of the utmost importance to identify those patients with complete coronary artery blockage, and who therefore require urgent reperfusion treatment (which restores the blood flow to the blocked arteries), as soon as possible. Every minute counts when it comes to saving myocardial tissue.
In most cases, this identification can be done by assessing the symptoms and analysing the ECG. Therefore, patients with chest pain or other symptoms consistent with an AMI should immediately seek medical attention, and medical staff should perform a clinical evaluation and ECG analysis without delay.
The safest and most effective way to do this is to call 112, as the Spanish Medical Emergency System usually evaluates these patients faster than most accident and emergency departments at health centres and hospitals. In addition, when an AMI requiring immediate catheterisation is detected, the treatment process is initiated at the site where the patient first receives medical attention and they are transferred to a hospital that is equipped for the procedure they need. Moreover, the patient is received directly at the cardiac catheter laboratory, where a team will have already been alerted and will be waiting for them, without losing time having to first go through the emergency department.
In Patients with an ECG that is normal or whose ECG shows ischaemic changes but in whom a complete coronary artery blockage is not suspected, do not require immediate catheterisation and can be evaluated with less urgency at an accident and emergency department. An AMI diagnosis is confirmed by the presence of elevated myocardial necrosis markers in the blood analysis.
From the moment they are diagnosed, AMI patients' heart rate must be continuously monitored to detect and treat serious ventricular arrhythmias, in case they occur. They should be admitted to a cardiovascular intensive care unit or intermediate care unit, depending on their initial risk assessment, and once they are stabilised, they can be transferred to the general ward. The average length of hospital stay due to a non-complicated AMI is 4 to 5 days.
AMI patients require antiplatelet drugs to combat thrombosis and a coronarography is also recommended in all cases. When an acute coronary occlusion is suspected, the coronarography must be performed quickly so than an angioplasty can be carried out to re-open the obstructed artery as soon as possible. Often, a coronary stent, a device that reduces the risk of reobstruction, is simultaneously implanted. If an urgent coronarography cannot be done, for example because the patient is located in an area very far away from a hospital equipped for this procedure, pharmaceuticals can be administered to dissolve the coronary thrombus.
In all other AMI cases, the coronarography and revascularisation are carried out within the first few days of admission. Some patients may require coronary bypass surgery instead of percutaneous revascularisation and stenting, due to the characteristics of their cardiovascular injuries. Apart from this, all patients will receive pharmaceuticals to reduce their cholesterol, and those with severe heart attacks will require specific medications to improve their ventricular dysfunction and prognosis. Participating in cardiovascular rehabilitation programmes after discharge has been shown to improve the prognosis and fosters patient adherence to healthy lifestyle guidelines.
Some patients who experience complications may require implantable electronic devices such as pacemakers or defibrillators, and more severe cases may warrant aggressive interventions such as:
The risk of suffering an AMI can be reduced with preventative health measures, including controlling one's diet. Regular physical exercise and avoiding being overweight are very beneficial to this end. One's diet should be balanced, and following a Mediterranean diet rich in virgin olive oil, vegetables, fruits, legumes, and fish, supplemented with nuts and with a limited intake of red meat and sugar, is the healthiest option. Tobacco consumption should be completely eliminated, and it is wise to avoid heavy exposure to pollution, as well as strenuous activity and high-stress situations.
For patients with cardiovascular risk factors, medications to control cholesterol, hypertension, and diabetes are often recommended, and in very high-risk patients, prophylactic therapy with antiplatelet drugs may be warranted.
Scleroderma is an autoimmune disorder characterised by increased collagen in various body tissues, structural alteration of microcirculation and certain immune abnormalities. The term scleroderma comes from the Greek “skleros”, which means hard, and “derma”, which means skin. This indicates that skin hardening is the most characteristic feature of the condition. As well as the skin, it can also affect the digestive tract, lungs, kidneys and heart. The prognosis varies. There is currently no cure, but the condition can be treated with general measures and treatment of symptoms, depending on the organs affected.
Raynaud syndrome: one of the most characteristic manifestations of the condition (97% of cases), it is the first clinical expression in most patients. It is caused by vasoconstriction of the capillaries. Patients report that with the cold their fingers change colour and turn pale (like wax) first, then turn blue after a while and finally turn reddish. The presence of Raynaud syndrome is not always an indication of scleroderma. In reality, only 5% of people with Raynaud syndrome later develop the condition. Almost half of sufferers may have digital ulcers, as an expression of a severe microcirculatory injury.
The most peculiar manifestation of the disease is the way it affects the skin. It is hard, tight and wrinkle-free (hard to pinch). The extent of the skin condition varies and is related to the prognosis. Two clinical forms are distinguished: limited (distal skin condition to elbows and knees) and diffuse (distal and proximal skin condition to elbows and knees, and torso). The face can be affected equally in both clinical forms. The limited subtype has a better prognosis than the diffuse one. Reduced aperture of the mouth (microstomy) may also be seen. In the skin there are hyperpigmented and coloured areas, telangiectasia (accumulation of small blood vessels) and sometimes subcutaneous calcium deposits can be felt (calcinosis).
Most patients experience joint and muscle pain, and in extreme cases contraction and retraction of the fingers are observed. When the digestive tract is affected, which often happens, the patient complains of a burning sensation and difficulty swallowing, as the oesophagus has lost its ability to move food towards the stomach. Pulmonary disease is the leading cause of death and may occur in the form of fibrosis or pulmonary hypertension; coughing, choking and heart failure are the main manifestations of lung involvement. When the heart is affected, heart rhythm disturbances and in some cases symptoms of angina pectoris are detected, due to the involvement of the small coronary vessels. In a small percentage (about 5%) scleroderma alters the kidney (scleroderma renal crisis) and manifests itself as malignant arterial hypertension and kidney failure.
It should be noted that not all patients with scleroderma present all the manifestations described above. It can also be concluded that there is great, almost individual, variability in the clinical expression of the disease.
Scleroderma is a rare disease with an incidence of 4-18.7/million/year and a prevalence of 31-286/million. It is more common in females, with a variable ratio, depending on the series, ranging from 3:1 to 14:1 (female/male). The age at which it presents is around 30-40 years.
When the above symptomatology is clear, the diagnosis does not offer too much room for doubt. Various complementary tests are helpful in confirming diagnosis and in assessing the degree of involvement of the various organs that may be affected.
“An incurable, but not untreatable condition”. There is currently no treatment for scleroderma that has satisfactory results, but this does not mean that it cannot be treated. Treatment is symptomatic, depending on the organ affected. For Raynaud syndrome: vasodilators, antiplatelets; gastro-oesophageal reflux: proton pump inhibitors; renal crisis: angiotensin converting enzyme inhibitors/dialysis; pulmonary fibrosis: immunosuppressants/lung transplant; pulmonary hypertension: vasodilators/lung transplant. In patients with the diffuse form and less than three years of evolution, immune modulators such as mycophenolate sodium (or mycophenolate mofetil) or methotrexate may be indicated as a basic treatment.
The most common tests to confirm and/or assess the degree of involvement of the various organs are: general analyses and immunological data (specific antinuclear antibodies); capillaroscopy, high-resolution computerised axial tomography scan of the chest, respiratory functional tests, oesophageal manometry and echocardiogram. In the follow-up for these patients, respiratory functional tests and an echocardiogram should be performed annually.
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