Complicaciones cardiovasculares en pacientes COVID-19 hospitalizados en Unidades de Pacientes Críticos en Chile. Registro COVICAR / Cardiovascular complications in COVID-19 patients admitted to intensive care units in Chilean hospitals

BACKGROUND: Patients with a cardiovascular (CV) history may be at greater risk of becoming ill and die due to SARS-CoV-2. AIM: To assess the incidence of CV complications in COVID-19 patients, the type of complication, and their association with CV history. MATERIAL AND METHODS: The clinical course of 1,314 patients with COVID-19 admitted consecutively to critical care units of 10 Chilean hospitals was registered between April and August of 2020. RESULTS: The median age of patients was 59 years and 66% were men. One hundred-four (8%) had a CV history, namely heart failure (HF) in 53 (4.1%), coronary heart disease in 50 (3.8 %), and atrial fibrillation in 36 (2.7 %). There were CV complications in 359 patients (27.3%). The most common were venous thrombosis in 10.7% and arrhythmias in 10.5%, HF in 7.2%, type 2 acute myocardial infarction in 4.2%, arterial thrombosis in 2.0% and acute coronary syndrome (ACS) in 1.6%. When adjusted by age, sex and risk factors, only HF (Odds ratio (OR) = 7.16; 95% confidence intervals (CI), 3.96-12.92) and ACS (OR = 5.44; 95% CI, 1.50-19.82) were significantly associated with CV history. There was no association with arrhythmias, type 2 acute myocardial infarction, arterial or venous thrombosis. CONCLUSIONS: Patients with a history of CV disease are at greater risk of suffering HF and ACS when hospitalized due to COVID-19. Arrhythmias, type 2 AMI, and arterial or venous thrombosis occur with the same frequency in patients with or without CV history, suggesting that these complications depend on inflammatory phenomena related to the infection.

Ejercicio: una herramienta clave en la prevención cardiovascular: Consenso de la Sociedad Chilena de Cardiología y Cirugía Cardiovascular y de la Sociedad Chilena de Kinesiología en Cardiología y Cirugía Cardiovascular / Excercise, a key intervention in Cardiovascular Prevention: Consensus of the Chilean Society of Cardiology and Cardiovascular Surgery and the Chilean Society of Kinesiology in Cardiology and Cardiovascular Surgery

This is a Document from de Chilean Society of Cardiology and Cardiovascular Surgery, along with the Chilean Society of Physical Therapy of Cardiology and Cardiovascular Surgery.

External Validation of Cardiovascular Risk Scores in the Southern Cone of Latin America: Which Predicts Better? / Validación externa de ecuaciones de riesgo cardiovascular en el Cono Sur de Latinoamérica: ¿cuál predice mejor?

ABSTRACT: Background: Inaccurate estimates of demographic cardiovascular risk may lead to an inadequate management of preventive medical interventions such as the use of statins. Objectives: The aim of this study was to evaluate the external validity of cardiovascular risk equations in the general population of the Southern Cone of Latin America. Methods: Equations including variables evaluated in the CESCAS cohort study and that estimate overall cardiovascular mortality (CUORE, Framingham, Globorisk and Pooled Cohort Studies) were assessed. For each equation, an independent analysis was per-formed taking into account the cardiovascular events originally considered. Discrimination of each equation was evaluated through C-statistic and Harrell's C-index. To assess calibration, a graph was built for each equation with the proportion of observed events vs. the proportion of estimated events by risk quintiles and the β slope of the resulting linear regression was calculated. Sensitivity and specificity were determined for the detection of people at high cardiovascular risk. results: The median follow-up time of the cohort at the time of the analysis was 2.2 years, with an interquartile range of 1.9 to 2.8 years. Sixty cardiovascular events were incorporated into the analysis. All C-statistic and Harrell's-C index values were greater than 0.7. The value of the β slope farthest from 1 was that of the Pooled Cohort Studies score. Conclusions: Although the external validation parameters evaluated were similar, CUORE, Globorisk and the Framingham equa-tions showed the best global performance for cardiovascular risk estimation in our population.

RESUMEN: introducción: La estimación inexacta del riesgo cardiovascular poblacional puede llevar a un manejo inadecuado de las intervenciones médicas preventivas, como, por ejemplo, el uso de estatinas. Objetivo: Evaluar la validez externa de ecuaciones de predicción de riesgo cardiovascular en población general del Cono Sur de Latinoamérica. Material y métodos: Se evaluaron ecuaciones que incluyen variables evaluadas en el estudio CESCAS y que predicen tanto morbilidad como mortalidad cardiovascular global (CUORE, Framingham, Globorisk y Pooled Cohort Studies Equations). Para cada ecuación se realizó un análisis independiente en el que se tuvieron en cuenta los eventos cardiovasculares relevados. Se evaluó la discriminación de cada ecuación a través del cálculo del estadístico-C y el índice Harrell C. Para evaluar la calibración se graficó la proporción de riesgos observados vs. estimados por quintilos de riesgo para cada ecuación y se calculó la pendiente β de regresión lineal para las estimaciones. Se calculó sensibilidad y especificidad para la detección de personas con elevado riesgo cardiovascular. resultados: La mediana del tiempo de seguimiento de la cohorte al momento del análisis es de 2,2 años, con un rango intercuartilo de 1,9 a 2,8 años. Se incorporaron a los análisis 60 eventos cardiovasculares. Todos los valores de estadístico-C y del índice de Harrell fueron superiores a 0,7. El valor de la pendiente β más alejado de 1 fue el de Pooled Cohort Studies Euations. Conclusiones: Si bien los parámetros de validación externa evaluados fueron similares, CUORE, Globorisk y el índice de Framing-ham fueron las ecuaciones con mejores indicadores globales de predicción de riesgo cardiovascular.

Smoking and obesity in Chile's Third National Health Survey: light and shade / El tabaquismo y la obesidad en la tercera Encuesta Nacional de Salud de Chile: luces y sombras / Tabagismo e obesidade na Terceira Pesquisa Nacional de Saúde do Chile: luzes e sombras

ABSTRACT The Chilean Ministry of Health recently disclosed the first results of the 2016-2017 National Health Survey (Encuesta Nacional de Salud, ENS). The survey was cross-sectional and used a multistage stratified random sampling strategy resulting in a final sample of 6 233 persons ≥ 15 years old, with national, regional, and urban/rural representativeness. The survey results show consistent reductions in tobacco consumption compared to previous national health surveys (ENS 2003 and ENS 2009-2010), most likely due to stringent tobacco control policies enacted in the last 10 years. However, the results also show that there were alarming increases in obesity in the last 15 years. Stronger regulatory policies may be needed to curb the obesity epidemic that besets Chile, along the lines of what was done with tobacco use. The lesson learned seems to be that pushing for stronger policy measures leads to good results, as seems to be the case for tobacco use, while weak measures may not be sufficient for the scale of the health epidemics Chile is now facing, such as excess weight.

RESUMEN El Ministerio de Salud chileno divulgó recientemente los primeros resultados de la Encuesta Nacional de Salud 2016-2017 (ENS). Se trataba de una encuesta transversal, en la cual se usó una estrategia de muestreo polietápico aleatorio y estratificado, cuyo resultado fue una muestra final de 6 233 personas ≥ 15 años, con representatividad nacional, regional y urbana o rural. Los resultados de la encuesta muestran reducciones constantes en el consumo de tabaco en comparación con encuestas nacionales de salud anteriores (la ENS 2003 y la ENS 2009-2010), muy probablemente debido a las políticas estrictas de control del tabaco sancionadas en los últimos 10 años. Sin embargo, los resultados también indican que la obesidad aumentó de forma alarmante en los últimos 15 años. Es posible que se necesiten políticas regulatorias más firmes para reducir la epidemia de obesidad que se registra en Chile, de manera similar a lo que se hizo con el consumo de tabaco. Pareciera que la enseñanza extraída es que impulsar medidas políticas más firmes conduce a buenos resultados, como parece ser el caso del consumo de tabaco, mientras que las medidas débiles pueden ser insuficientes para la escala de las epidemias en el ámbito de la salud a las que Chile se enfrenta ahora, como el sobrepeso.

RESUMO O Ministério da Saúde do Chile divulgou recentemente as conclusões preliminares da Pesquisa Nacional de Saúde (PNS) 2016-2017. Foi conduzida uma pesquisa de delineamento transversal com uma estratégia de amostragem aleatória estratificada com múltiplos estágios, resultando em uma amostra final de 6.233 indivíduos com 15 anos de idade ou acima de representatividade nacional, regional e urbana/rural. Os resultados de pesquisa demonstram uma redução constante do tabagismo em relação às pesquisas nacionais anteriores (PNS 2003 e PNS 2009-2010), provavelmente decorrente das políticas de controle rigoroso do tabagismo promulgadas na última década. Porém, os resultados também indicam um aumento alarmante da obesidade nos 15 últimos anos. Políticas de regulamentação mais rigorosas devem ser necessárias para conter a epidemia de obesidade que assola o país, na mesma linha do que foi feito com o tabagismo. O ensinamento a ser tirado parece ser o seguinte: a pressão para que sejam adotadas políticas mais duras leva a bons resultados, como no caso do tabagismo, e medidas brandas não são suficientes diante da magnitude das epidemias em saúde enfrentadas atualmente pelo país, como o excesso de peso.

Guías para la monitorización ambulatoria de presión arterial de 24 horas: documento de la Sociedad Chilena de Cardiología y Cirugía Cardiovascular / 24 hour blood pressure monitoring: recommendations from the Chilean Society of Cardiology and Cardiovascular Surgery

Abstracts: 24 hour blood pressure monitoring. Recommendations from the Chilean Society of Cardiology and Cardiovascular Surgery. The recommendations for blood pressure monitoring from the Chilean Society of Cardiology and Cardiovascular Surgery are analyzed. Emphasis is placed on indications for the procedure, according to different classes and causes of hypertension. Implications of different types of hypertension for prognosis and indications for adequate therapy are discussed.

Efectividad y seguridad del tratamiento anticoagulante con acenocumarol en fibrilación auricular no valvular / Effectiveness and safety of oral anticoagulation treatment with acenocoumarol in non-valvular atrial fibrillation

Background: Vitamin K antagonists significantly decrease the incidence of stroke but increase the risk of bleeding. Aim: To assess the effectiveness and risk of bleeding of vitamin K antagonists in non-valvular atrial fibrillation. Material and Methods: Retrospective cohort study of 524 patients, 236 women (45%) and 288 men (55%) with non-valvular atrial fibrillation (NVAF) admitted to the oral anticoagulation treatment (OAT) clinic at four public hospitals, between 2009 and 2012. They were followed until March 2013, measuring the quality of OAT, ischemic and bleeding events. Results: The mean follow-up was 26.1 months, with 1,154.7 person-years of follow-up accrued. The percentage of time in therapeutic range (TTR) was 35.2 ± 18%; this was deemed to represent the quality of OAT. The cumulative incidence of ischemic events, either stroke or systemic embolism, was 2.25/100 person-years, being greater in patients with previous embolism (Risk ratio 5.21, 95% confidence intervals 2.31- 11.73, p < 0.01). The cumulative incidence of major bleeding events-extracranial and intracraneal-was 4.08/100 person-years. The main site of extracranial major bleeding was the gastrointestinal tract (32%). Conclusions: In our clinical practice, the effectiveness of OAT with acenocoumarol in NVAF patients is similar to that published abroad. However, the incidence of bleeding complications is higher. The quality of the OAT measured by the TTR was lower than abroad.

Características basales, manejo de terapias antitrombóticas y pronóstico de pacientes chilenos con FA no valvular. Lecciones del Registro GARFIELD AF en Chile / Features, management and prognosis of Chilean patients with non valvular atrial fibrillation: GARFIELD AF registry

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with high rates of death, ischemic stroke and systemic embolism (SE). There is scarce information about clinical characteristics and use of anti-thrombotic therapies in Chilean patients with non-valvular AF. Aim: To describe the characteristics and 1-year outcomes of patients with recently diagnosed AF recruited in Chile into the prospective global GARFIELD-AF registry. Material and Methods: Between 2011-2016, we prospectively registered information of 971 patients recruited at 15 centers, 85% of them from the public system and 15% from the private sector. Demographics, clinical characteristics and use of antithrombotic therapies were recorded for all patients. Adverse clinical outcomes were analyzed in 711 patients with 1-year follow-up. Results: The mean age was 71.5 years (66-79), 50% were men. Mean CHAD2S2 Vasc and HAS BLED scores for stroke risk were 3.3 (2.0-4.0) and 1.5 (1.0-2.0) respectively. Oral anticoagulants were prescribed in 82% of patients. Seventy percent received Vitamin K antagonists, 10% novel direct anticoagulants or antiplatelet therapy and only 8% did not receive any antithrombotic therapy. Mean time in optimal therapeutic range (an international normalized ratio of 2 to 3), was achieved in only 40.7% (23.0-54.8) of patients receiving Vitamin K antagonists. One year rates of death, stroke/systemic embolism and bleeding were 4.75 (3.36-6.71), 2.40 (1.47-3.92) and 1.64% (0.91-2.97) per 100 person-years. Ischemic stroke occurred in 1.8% and hemorrhagic stroke in 0.8% of patients at 1-year of follow up. Conclusions: Although the use of vitamin K antagonists at baseline was high, the mean time in optimal therapeutic range was low. Mortality and stroke rates are higher than those reported in other contemporary registries.

Dislipidemia aterogénica en Latino América: prevalencia, causas y tratamiento / Atherogenic dislipidemia in Latin America: prevalence, causes and treatment

En las guías clínicas actuales, la dislipidemia aterogénica (DA) es una entidad escasamente atendida. Debido a las frecuentes alteraciones en los lípidos asociados a la DA en Latino América (LA), se organizó un grupo de expertos que se ha denominado Academia Latino Americana para el estudio de los Lípidos (ALALIP) para generar un documento con análisis de su prevalencia y ofrecer recomendaciones prácticas. Se utilizó la metodología Delphi modificada, con revisión comprensiva de la literatura con énfasis en aquellas publicaciones con implicaciones para LA. Subsecuentemente, se desarrollaron preguntas claves para ser discutidas. En LA no existe un estudio global sobre los factores de riesgo que representan a la totalidad de la población. El análisis sistemático de las encuestas nacionales de salud y de los estudios sistemáticos de cohorte muestran consistentemente una alta prevalencia de las anormalidades lipídicas que definen la DA. La concentración baja del colesterol unido a las lipoproteínas de alta densidad (C-HDL) varía entre 34,1% a 53,3% y la de triglicéridos (TG) elevados del 25,5% al 31,2%, con mayor prevalencia entre los hombres. Múltiples causas se han reconocidos, como alta ingesta de alimentos de mayor densidad calórica, contenido de colesterol, grasas trans, sedentarismo y cambios epigenéticos. La DA bien puede ser tratada con los cambios terapéuticos del estilo de vida (CTEV) con incremento en la actividad física, ejercicio regular y dieta baja en carbohidratos y alta en ácidos grasos poliinsaturados, tales como los ácidos grasos omega-3 como intervención primaria. De ser necesario, esta estrategia sera suplementada con terapia farmacológica como la monoterapia con estatinas o la combinación de fibratos/ácidos grasos omega-3. Las anormalidades lipídicas que definen la DA tienen una elevada prevalencia en LA; su interacción con un estilo de vida no saludable, herencia y cambios epigenéticos están ligados a sus posibles causas. La DA es una causa importante de riesgo cardiovascular residual (RCVR) que debe ser diagnosticada y tratada. Es importante y necesario diseñar un estudio global de factores de riesgo en LA para conocer la real prevalencia de la DA.

In the current clinical guidelines, atherogenic dyslipidemia (AD) is a poorly recognized entity. Due to the frequent lipid alterations associated with AD in Latin America (LA), we organized a group of experts named Latin American Academy for the study of Lipids (ALALIP), to generate a document for analyzing its prevalence and to offer practical recommendations. Using the Delphi methodology, we conducted a comprehensive literature review, with emphasis on those publications with implications for LA. Subsequently we developed key questions to be discussed. In LA there is no a global study on risk factors that represent the entire population. The systematic analysis of national health surveys and regional cohort studies showed a consistent high prevalence of the lipid abnormalities that define AD. Low high density lipoprotein cholesterol (HDL-C) ranges from 34.1% to 53.3% and elevated triglycerides (TG) from 25.5% to 31.2%, more prevalent in men. There are multiple causes: high consumption of foods with a high caloric density, cholesterol and trans fats, sedentary lifestyle and epigenetic changes. AD must be well treated with therapeutic changes in lifestyle with increased in physical activities, regular exercise and a diet with a low proportion of carbohydrates y rich in poliunsatured fatty acid, such as omega-3 fatty acid as primary intervention. If needed, this strategie must be supplemented with pharmacological therapies such as monotherapy with statins or a combination of fibrates plus omega-3.fatty acid. Lipid abnormalities that define AD have a high prevalence in LA; the interaction between non-healthy lifestyle, inheritance and epigenetic changes, possibly are its cause. AD is an important cause of cardiovascular residual risk (CVRR), that must be diagnosed and treated. It is important and neccesary to design a global study of risk factors in LA to know the true prevalence of AD.

Association of polymorphisms within the Renin-Angiotensin System with metabolic syndrome in a cohort of Chilean subjects

ABSTRACT Objective Metabolic syndrome (MetS) is associated with hypertension, obesity and dyslipidemia. Thus, genetic variants related with these conditions may modulate its development. We evaluated the effect of polymorphisms in the renin-angiotensin system (RAS) on metabolic syndrome risk in a cohort of Chilean subjects. Subjects and methods A total of 152 subjects, 83 with MetS (51.2 ± 9.6 years) and 69 without MetS (49.5 ± 9.3 years) of both genders were included, according to the ATP III update criteria. The rs4340 Insertion/Deletion (I/D), rs699 (T>C) and rs5186 (A>C) of the ACE, AGT and AGTR1 genes, respectively, were genotyped. Results After adjusting for age and gender, we observed the DD genotype of rs4340 associated with MetS (p = 0.02). Specifically, the DD genotype was associated with MetS risk in women (OR = 4.62, 95%CI, 1.41 – 15.04; p < 0.01). In males, the AA genotype for rs5186 variant was associated with an increased risk for developing MetS when compared with women carrying the same genotype (OR = 3.2; 95%CI, 1.03 – 9.89; p = 0.04). In subjects without MetS, DD genotype was associated with increased waist circumference (p = 0.023) while subjects with MetS carrying the rs5186 TT genotype showed higher levels of HDL-cholesterol (p = 0.031). Conclusion The present study contributes data highlighting the role for RAS polymorphisms in predisposing to metabolic syndrome in Chilean subjects.

Asociación de polimorfismos del gen factor de necrosis tumoral (TNF) con el desarrollo de reestenosis de stent post angioplastía coronaria / Polymorphisms of tumor necrosis factor gen: are they associated to stent restenosis after coronary angioplasty?

Introducción: La intervención coronaria percutánea (PCI en inglés) con implante de stent coronario es uno de los procedimientos más utilizados para la revascularización miocárdica en condiciones agudas o crónicas. Múltiples factores se han relacionado con la restenosis de stent, incluyendo aspectos clínicos, angiográficos, genéticos y epigenéticos. La respuesta inflamatoria en gran parte está determinada genéticamente y probablemente sea el rol más importante en la restenosis. El factor de necrosis tumoral a (TNF-α;) es un mediador clave en la respuesta inflamatoria actuando en sitios de injuria tisular inducida por el daño de las paredes del vaso. Objetivo: Determinar la asociación entre polimorfismos genéticos del TNF y restenosis en pacientes coronarios sometidos a angioplastía. Métodos: Se diseñó un estudio de casos y controles incidentes no pareados, aprobado por el comité de ética institucional. Se incluyeron pacientes con cardiopatía coronaria sometidos a PCI con implante de stent BMS o DES, con un tiempo de control angiográfico mayor de 6 meses. Los casos fueron definidos como aquellos pacientes con estenosis de stent >50% y como controles aquellos con estenosis <50%, con respecto del lumen del vaso de referencia. Se efectuó la genotipificación de los polimorfismos rs361525 (-238G/A) y rs1799964 (-1031 T/C) del gen TNF mediante PCR en tiempo real mediante sondas alelo-específicas. Además, se registraron variables clínicas y demográficas. Resultados: Se incluyó en este estudio de análisis de genotipificación del polimorfismo del gen TNF 82 pacientes como casos, y 102 controles. No hubo diferencias significativas en las siguientes variables clínicas y demográficas: edad (63.7 ± 10.5 vs. 65.4 ± 9.6 años; p=0.24), género masculino (75 vs. 69%, p=0.5), IMC (28.5 ± 3.6 vs. 28 ± 3.8 Kg/m2; p=0.78) y tabaquismo (79 vs. 77%; p=0.7). En contraste, se observó una diferencia significativa en la frecuencia de DM-2 casos y controles (43.2 vs. 26.5%; p=0.03) y %HbA1c entre ambos grupos (6.78 ± 1.5 vs. 6.1 ± 0.8%; p=0.01). Respecto a las variantes genéticas estudiadas, no hubo diferencias significativas en la frecuencia relativa del alelo mutado tanto para el polimorfismo rs361525 (Alelo A, casos: 0.06 vs. controles: 0.08; p=0.37), como para la variante rs1799964 (Alelo C, casos: 0.2 vs. controles: 0.2; p=0.96). Las OR asociadas a dichos alelos fueron 0.68 (I.C. 95%= 0.29 - 1.59) y 0.99 (I.C. 95%= 0.58 - 1.67), respectivamente; confirmando la ausencia de asociación. Conclusión: Nuestros datos sugieren que las variantes genéticas estudiadas no están relacionadas al desarrollo de restenosis en los sujetos estudiados, y probablemente en nuestra población los factores clínicos sean más determinantes para el desarrollo de reestenosis coronaria post angioplastía que los factores genéticos.

Multiple factors have been associated to the development of stent restenosis after coronary angioplasty (PCA). including clinical, angiographic, genetic and epigenetic factors. The inflammatory response is genetically determined and it may be the most important factor. Tumor necrosis factor a (TNFα) is a potent mediator of this response at the endothelial wall. Aim: To determine the association between TNFα; genetic polymorphisms and stent restenosis. Methods: A case-control study was performed in patients submitted to PTCA with stent implantation(-bare metal or drug eluting stent) at least 6 months prior to the study. Cases were defined by the presence of >50% intra stent stenosis. PCR was used for type classification of polymorphisms rs361525 (-238G/A) y rs1799964 (-1031 T/C) of the TNFα; gene. Results: 82 cases and 102 controls were included. No differences were observed in clinical and demographic variables: age (63.7 ± 10.5 vs. 65.4 ± 9.6 years, p=0.24, for cases and controls, respectively), male gender (75 vs. 69%, p=0.5), BMI (28.5 ± 3.6 vs. 28 ± 3.8 Kg/m2, p=0.78) and active smoking (79 vs. 77%, p=0.7). In contrast, Diabetes was more frequent in cases than in controls (43.2 vs. 26.5%, p=0.03). There was no difference in the relative frequency of mutations of the rs361525 polymorphism (Allele A, 0.06 vs 0.08, p=0.37 for cases and controls, respectively) nor for variant rs1799964 (0.2 in both cases and controls). Non significant associations were confirmed by Odd ratios with 0 included in the 95% confidence interval. Conclusion: No association of genetic polymorphisms of TNFa and stent restenosis was found, which suggests that clinical factors my be more important for the development of post PTCA stent restenosis.

Bajos niveles de colesterol HDL es un predictor de mortalidad y de fibrilación auricular postoperatoria posterior a la cirugía de revascularización miocárdica / Low HDL level is a predictor of post operative atrial fibrillation and mortality after coronary artery bypass surgery

Introducción: Se ha demostrado que bajos niveles de colesterol HDL (C-HDL) se asocian a una mayor incidencia de fibrilación auricular y de mortalidad global y cardiovascular. En un estudio observacional previo en nuestro centro, encontramos que un bajo nivel de C-HDL se asoció a mayor riesgo de fibrilación auricular postoperatoria (FAPO) en pacientes sometidos a cirugía de revascularización miocárdica (CRM). Objetivo: Evaluar si el bajo nivel de C-HDL se asocia a mayor incidencia de FAPO y mortalidad en un seguimiento a un año en un estudio controlado. Método: Se realizó un estudio observacional prospectivo que incluyó a 100 pacientes consecutivos sometidos a CRM por enfermedad coronaria estable sin antecedentes de FA y que ingresaron a la UCI Cardio-quirúrgica en ritmo sinusal. Se definió FAPO como FA con duración mayor a 5 minutos o 5 episodios de FA mayores a 30 segundos de duración en los primeros 5 días post operatorios. Se consideró bajo nivel de C-HDL a un valor < 30mg/dL. Los pacientes se siguieron por un año. Se utilizó un análisis univariado y multivaria-do para identificar factores predisponentes de FAPO y mortalidad. Resultados: 31 pacientes presentaron FAPO. El análisis multivariado mostró un incremento de FAPO con C-HDL <30mg/dL (OR 5.01, IC95% 1.3-18.8, p=0,017) y con albúmina <3,5 gr/dL (OR 6.42, IC95% 1.58-26.0, p=0,009). En un seguimiento de 14.1±1.7 meses. La mortalidad global fue 6% y un C-HDL <30mg/dL resultó ser un predictor independiente (HR 11.1, IC95% 1.1-38.4, p=0,039). Conclusión: En nuestra serie un C-HDL menor a 30mg/dL es un predictor independiente de FAPO y mortalidad posterior a la CRM.

Background: Low C-HDL level has been associated to an increased incidence of atrial fibrillation (AF) and cardiovascular mortality. Previously, we have observed that low C-HDL had the same type of association with post operative AF (POAF) and mortality following surgery for coronary artery disease. Aim: to evaluate whether a low C-HDL level is a predictor of POAF and mortality following revascularization surgery in a controlled study. Method: A prospective observational study included 100 consecutive patients undergoing revascularization surgery for stable coronary artery disease (CAD) in sinus rhythm and no prior AF. POAF was defined as AF sustained for more than 5 min or the occurrence of 5 or more episodes of AF extending for more than 5 seconds during the first 5 post operative days. A value <30 mg/dl was considered low C-HDL. Patients were followed for one year. Uni and multivariate analysis were used to identify predictors of POAF and mortality. Results: 31 patients developed POAF. A significant (p=0.017) OR of 5.01 (95% CI 1.3 - 18.8) between low C-HDL and POAF was shown. A similar association linked low serum albumin level to POAF (OR 6.4, C.I. 1.6 - 26). After 14.1 ± 1.7 months of follow-up global mortality was 6%. Low C-HDL turned out to be a significant predictor of mortality (H.R. 11.1, C.I. 1.1 - 38.4, p=0.04). Conclusion: Low C-HDL is an independent predictor of POAF and mortality after coronary artery revascularization surgery.

Evolución del riesgo cardiovascular y sus factores en Temuco entre 1989 y 2011-12 / Cardiovascular risk factors among males in 1989 and 2011-12 in a southern Chilean city

Background: A successful cardiovascular prevention program should induce a reduction of risk factors along time. Aim: To assess changes in cardiovascular risk factors among males aged between 35 and 65 years living in Southern Chile. Material and Methods: The results of two cross sectional household surveys, with a probability sampling stratified by socioeconomic status, were analyzed. Two hundred males were evaluated in 1989 and 800 in 2011-12, paired by age for selection. Results: In the second survey, a mean weight increase of 4.5 kg was recorded. Body mass index increased from 27.1 to 28.6 kg/m² (p < 0.01), especially in men younger than 45 years old. No changes in smoking prevalence were observed. The prevalence of hypertension and hypertensive patients in treatment increased from 32.7 to 38.1% and from 17 to 33%, respectively. The number of treated hypertensive patients with a well-controlled blood pressure did not change significantly. In 1989 and 2011-12, mean total cholesterol values were 192 and 201 mg/dl respectively (p < 0.01). The figures for mean non-HDL cholesterol were 152 and 160 mg/dl (p = 0.03). The frequency of people with total cholesterol over 240 mg/dl or using statins increased from 15 to 25% (p < 0.01). The estimated 10 years risk of myocardial infarction and coronary death using Framingham tables was 9,0 in both periods (p = 0.95). Conclusions: In a 22 years period an increase in the prevalence of obesity and elevated total cholesterol was observed. There was a higher proportion of individuals treated for hypertension and dyslipidemia, but without reduction in the estimated cardiovascular risk.

Consenso latino-americano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólica / Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome

O presente documento foi preparado por um grupo de especialistas, membros das Sociedades de Cardiologia, Endocrinologia, Medicina Interna, Nefrologia e Diabetes dos países da América Latina, para que sirva de diretriz para médicos que cuidam de pacientes com diabetes, hipertensão e fatores de risco concomitantes ou complicações de ambas as condições. Embora o conceito de síndrome metabólica seja atualmente muito discutido, a alta prevalência na América Latina do conjunto de alterações metabólicas que a compõem sugere que a síndrome metabólica é uma entidade nosográfica útil no contexto da medicina latino-americana. Devido a isso, no presente documento presta-se especial atenção a essa síndrome com a finalidade de alertar aos médicos sobre uma população particularmente de alto risco, que, por ser subestimada, não é tratada de forma adequada para os fatores de risco que constituem a síndrome metabólica. As recomendações deste documento são o resultado de apresentações e debates que ocorreram durante um encontro de dois dias em Bucaramanga (Colômbia), em outubro de 2012. Todos os participantes aprovaram as decisões finais. Os autores reconhecem que a publicação e difusão das diretrizes não serão suficientes para alcançar as mudanças recomendadas tanto em estratégias diagnósticas como terapêuticas, por isso programaram intervenções que permitirão identificar as barreiras do conhecimento, as atitudes e comportamento, o que permitirá tanto aos médicos como aos pacientes uma adequada adesão às recomendações sugeridas nestas diretrizes. Arq Bras Endocrinol Metab. 2014;58(3):205-25.

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is a useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high-risk population, usually underestimated and undertreated. These recommendations result from presentations and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming knowledge, attitude and behavioural barriers, preventing both physicians and patients from effectively adhering to guideline recommendations. Arq Bras Endocrinol Metab. 2014;58(3):205-25.

Prevención secundaria post infarto agudo de miocardio en hospitales públicos: implementación y resultados de las garantías GES / Universal health coverage and accomplishment of secondary prevention goals among patients with acute myocardial infarction

Background: In 2005, acute myocardial infarction (AMI) was included in a universal health plan (GES) to reduce inequity in care and optimize its diagnosis and treatment. Aim: To evaluate the effect of GES in risk factor control and therapeutic management among patients with AMI. Material and Methods: A survey was conducted in 2008-2009 in six public hospitals. Patients were identified from a hospital based registry of AMI and evaluated one year later with laboratory tests and an interview. Results: The registry enrolled 534 patients with ST and non ST segment elevation myocardial infarction. Of these, 416 patients aged 63 ± 12 years (25% women) were evaluated one year later. Eighty three percent were evaluated by a cardiologist and 37% by a general practitioner. Twenty two percent were evaluated by a nurse and 22% by a nutritionist. At the moment of the interview, 9% smoked, 78% were overweight or obese, 24% performed moderate or vigorous physical activity ≥ 150 min/week, 60% had systolic pressure > 130 mmHg and 63% a diastolic pressure > 80 mmHg. In 30%, LDL cholesterol was > 100 mg/dl and in 43%, triglycerides were > 150 mm/dl. Twenty two percent were diabetic and among them, 52% had a glycosilated hemoglobin > 7%. Forty five percent of non-diabetic patients had a fasting glucose > 100 mg/dl. Ninety three percent were in treatment with aspirin, 86% with statins, 66% with b-blockers, and 73% with angiotensin converting enzyme inhibitors or angiotensin receptor blockers and 20% with clopidogrel. Conclusions: Despite the high proportion of patients in treatment with evidence-based therapy, many do not achieve the targets for risk factor control with the new health care model.

Incidencia e importancia pronóstica del deterioro de la función renal en pacientes hospitalizados con insuficiencia cardiaca / Deterioration of kidney function as a risk factor for mortality among patients hospitalized for heart failure

Background: Acute deterioration of kidney function among patients admitted to the hospital for cardiac failure is associated with an increased mortality. Aim: To investigate the association between deterioration of kidney function and mortality among patients hospitalized for cardiac failure. Material and Methods: Patients admitted for decompensated cardiac failure to 14 Chilean hospitals between 2002 and 2009 were incorporated to the study. Clinical and laboratory features were registered. Serum creatinine values on admission and discharge were determined. Hospital and long term mortality was determined requesting death certificates to the National Identification Service at the end of follow up, lasting 635 ± 581 days. Results: One thousand sixty four patients were incorporated and 1100, aged 68 ± 13 years (45% females) had information about renal function. Seventy seven percent were hypertensive and 36% were diabetic. Mean ejection fraction was 41 ± 18% and 34% had an ejection fraction over 50%. Mean admission creatinine was 1.7 ± 1.6 mg/dl and 19% had a creatinine over 2 mg/dl. Serum creatinine increased more than 0.5 mg/dl during hospitalization in 9% of general patients and in 11% of diabetics. The increase in creatinine was associated with a higher risk of hospital mortality (odds ratio (OR) 12.9, 95% confidence intervals (CI) 6.7-27.6) and long term mortality (OR 2.1, 95% CI 1.6-3). Conclusions: The deterioration of renal function during hospitalization of patients with heart failure is a risk factor for hospital and long term mortality.

Consenso latinoamericano de hipertensión en pacientes con diabetes tipo 2 y síndrome metabólico / Latin american consensus of hypertension in patients with type 2 diabetes and metabolic syndrome

Resumen El presente documento ha sido preparado por un grupo de expertos, miembros de las sociedades de cardiología, endocrinología, medicina interna, nefrología y diabetes de los países de América Latina, para que sirvan de guía a los médicos que cuidan a pacientes con diabetes, hipertensión y enfermedades concomitantes o complicaciones de ambas condiciones. Aunque el concepto de síndrome metabólico actualmente es discutido, la alta prevalencia en América Latina del conjunto de alteraciones metabólicas que lo conforman sugiere que el síndrome metabólico es una entidad nosográfica común en el contexto de la medicina latinoamericana. Por lo tanto, en el presente documento se presta especial atención a este síndrome con el fin de alertar a los médicos de una particular población de alto riesgo, en la que por lo general es subestimada y no se tratan en forma optima los factores de riego que constituyen el síndrome metabólico. Las presentes recomendaciones son el resultado de las presentaciones y los debates en los paneles de discusión durante una reunión de dos días celebrada en Bucaramanga en octubre de 2012. Todos los participantes han aprobado las conclusiones finales. Los autores reconocen que la publicación y difusión de las guías no serán suficientes para alcanzar los cambios recomendados tanto en las estrategias diagnósticas como terapéuticas, por lo que se ha programado intervenciones que permitan identificar las barreras del conocimiento, de las actitudes y de comportamiento, lo que permitirá tanto a los médicos como a los pacientes una adecuada adherencia a las recomendaciones de las guías. (Acta MedColomb 2013; 38: 154-172).

Abstract The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American Countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high- risk population, usually underestimated and undertreated. These recommendations results from presentation and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming both physicians and patients from effectively adhering to guideline recommendations. (Acta Med Colomb 2013; 38: 154-172)).

Consenso latinoamericano de hipertensión en pacientes con diabetes tipo 2 y síndrome metabólico / Latin american consensus on hypertension in patients with diabetes type 2 and metabolic syndrome

El presente documento ha sido preparado por un grupo de expertos, miembros de las sociedades de cardiología, endocrinología, medicina interna, nefrología y diabetes de los países de América Latina, para que sirvan de guía a los médicos que cuidan a pacientes con diabetes, hipertensión y enfermedades concomitantes o complicaciones de ambas condiciones. Aunque el concepto de síndrome metabólico actualmente es discutido, la alta prevalencia en América Latina del conjunto de alteraciones metabólicas que lo conforman sugiere que el síndrome metabólico es una entidad nosografías útil en el contexto de la medicina latinoamericana. Por lo tanto, en el presente documento se presta especial atención a este síndrome con el fin de alertar a los médicos de una particular población de alto riesgo, en la que por lo general se subestimada y no se trata en forma óptima los factores de riego que constituyen el síndrome metabólico. Las presentes recomendaciones son el resultado de las presentaciones y los debates en los paneles de discusión durante una reunión de 2 días celebrada en Bucaramanga en octubre de 2012. Todos los participantes han aprobado las conclusiones finales. Los autores reconocen que la publicación y difusión de las guías no serán suficientes para alcanzar los cambios recomendados tanto en las estrategias diagnósticas como terapéuticas, por lo que se ha programado intervenciones que permitan identificar las barreras del conocimiento, de las actitudes y de comportamiento, lo que permitirá tanto a los médicos como a los pacientes una adecuada adherencia a las recomendaciones de las guías(AU)

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American Countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high- risk population, usually underestimated and undertreated. These recommendations results from presentation and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming both physicians and patients from effectively adhering to guideline recommendations(AU)

Consenso latinommericano de hipertensión en pacentes con diabetes tipo 2 y sínndrome metabólico / Latin american consensus on hypertension in patients with type 2diabetes and meetabolic syndrome / Consenso latinoamericano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólico

El presente documento ha sido preparado por un grupo de expertos, miembros de las sociedades de cardiología, endocrinología, medicina interna, nefrología y diabetes de los países de América Latina, para que sirva de guía a los médicos que cuidan a pacientes con diabetes, hipertensión y enfermedades concomitantes o complicaciones de ambas condiciones. Aunque el concepto de síndrome metabólico actualmente es discutido, la alta prevalencia en América Latina del conjunto de alteraciones metabólicas que lo conforman sugiere que el síndrome metabólico es una entidad nosografías útil en el contexto de la medicina latinoamericana. Por lo tanto, en el presente documento se presta especial atención a este síndrome con el fin de alertar a los médicos de una particular población de alto riesgo, en la que por lo general se subestimada y no se trata en forma optima los factores de riego que constituyen el síndrome metabólico. Las presentes recomendaciones son el resultado de las presentaciones y los debates en los paneles de discusión durante una reunión de 2 días celebrada en Bucaramanga en octubre de 2012. Todos los participantes han aprobado las conclusiones finales. Los autores reconocen que la publicación y difusión de las guías no serán suficientes para alcanzar los cambios recomendados, tanto en las estrategias diagnósticas como terapéuticas, por lo que se ha programado intervenciones que permitan identificar las barreras del conocimiento, de las actitudes y de comportamiento, lo que permitirá tanto a los médicos como a los pacientes una adecuada adherencia a las recomendaciones de las guías.

The present document has been prepared by a group of experts, members of cardiology, endocrinology, internal medicine, nephrology and diabetes societies of Latin American Countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of metabolic syndrome is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that metabolic syndrome is useful nosography entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particular high- risk population, usually underestimated and undertreated. These recommendations results from presentation and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming both physicians and patients from effectively adhering to guideline recommendations.

O presente documento tem sido preparado por um grupo de expertos, membros das sociedades de cardiologia, endocrinologia, medicina interna, nefrologiae diabetes dospaíses da América Latina, para que sirva de guia aos médicos que tomam conta de pacientes com diabetes, hipertensãoe enfermidades concomitantes ou complicaçõesdas duas condições. Porémoconceito de síndrome metabólico atualmente é discutido, a alta prevalênciana América Latina do conjunto de alterações metabólicas que o conformam,sugereque o síndrome metabólico é uma entidade nosográfica útil no contexto da medicina latino americana. Pelo tanto, no presente documento se presta especial atenção a este síndrome comofim de alertar aos médicos de una particular população de alto risco,a qual pelo geralé subestimada e não se trata em forma ótimaosfatores de risco que constituemo síndrome metabólico. As presentes recomendações sãoo resultado das apresentaçõeseos debates nos painéis de discussão durante una reunião de 2 dias celebrada em Bucaramanga em outubro de 2012. Todosos participantes têm aprovado as conclusões finais. Os autores reconhecem que a publicaçãoe difusão dos guias no serão suficientes para alcançar os câmbios recomendados tanto nas estratégiasdiagnósticas quanto terapêuticas, pelo que se têm programadointervenções que permitam identificar as barreiras do conhecimento, das atitudes e de comportamento, o que permitirá tanto aos médicos quanto aos pacientes una adequada aderênciaàs recomendações dos guias.

Effect of five single nucleotide polymorphisms of ABCG5 and ABCG8 genes on eLipid-lowering response / Efecto de cinco polimorfismos de los genes ABCG5 y ABCG8 sobre la respuesta hipolipemiante a ezetimiba

In this study we evaluated the possible association between five single nucleotide polymorphisms in ABCG5 (rs6720173) and ABCG8 (rs11887534, rs4148211, rs4148217 and rs6544718) genes and ezetimibe response in Chilean hypercholesterolemic subjects. A total of 60 non-related hypercholesterolemic subjects, aged 18 to 65 years old were included in this study. These subjects were treated with ezetimibe (10mg/day) during one month. The ABCG5 and ABCG8 genotypes were assessed by PCR-RFLP. The genotype distribution of the ABCG5/ABCG8 polymorphisms was in Hardy-Weinberg equilibrium. Our results showed that the investigated polymorphisms were not associated with the response to ezetimibe. Nevertheless, the T allele of rs6544718 polymorphism was related to higher baseline levels of LDL-cholesterol (p<0.001). In addition, the G allele for the rs4148211 polymorphism was associated with greater baseline concentrations of triglycerides (P=0.019). This allele was also associated with lower concentrations of HDL-cholesterol (P=0.027), after ezetimibe treatment. Our results suggest that the studied polymorphisms do not affect the therapeutic response to ezetimibe in the evaluated subjects.

En este estudio se evaluó la posible asociación entre cinco polimorfismos de nucleótido único en los genes ABCG5 (rs6720173) y ABCG8 (rs11887534, rs4148211, rs4148217 y rs6544718) y la respuesta a ezetimiba en pacientes hipercolesterolémicos chilenos. Un total de 60 individuos hipercolesterolemicos, no relacionados, con edades entre 18 y 65 años fueron incluidos. Estos sujetos fueron tratados con ezetimiba (10mg/día) durante un mes. Los genotipos de ABCG5 y ABCG8 fueron evaluados por PCR-RFLP. La distribución de genotipos de los polimorfismos de ABCG5/ABCG8 se encontraba en equilibrio de Hardy-Weinberg. Nuestros resultados mostraron que los polimorfismos estudiados no se asociaron con la respuesta a la ezetimiba. Sin embargo, el alelo T del polimorfismo rs6544718 fue relacionado con niveles basales elevados de LDL-colesterol (p <0,001). Además, el alelo G para el polimorfismo rs4148211 se asoció con una mayor concentración basal de triglicéridos (p = 0,019). Este alelo también se asoció con concentraciones más bajas de HDL-colesterol (p = 0,027), después del tratamiento con ezetimiba. Nuestros resultados sugieren que los polimorfismos estudiados no afectan a la respuesta terapéutica a la ezetimiba en los sujetos evaluados.

¿Está comprobado que la reducción de la ingesta de sal reduce la morbimortalidad por riesgo cardiovascular? / Is there evidence showing that salt intake reduction reduces cardiovascular morbidity and mortality risk?

Una revisión sistemática reciente de la colaboración Cochrane sobre el efecto de la reducción de sal en la dieta, concluyó que “aún no hay poder estadístico suficiente para excluir efectos clínicamente importantes de la dieta baja en sal en mortalidad o morbilidad cardiovascular en población normotensa o hipertensa”. Esta conclusión ha generado un debate importante porque la estimación que existe de que la reducción del consumo de sal prevendría los accidentes vasculares cerebrales en 24 por ciento y la enfermedad coronaria en 18 por ciento, ha llevado a las autoridades de salud de varios países a instaurar políticas públicas de reducción del consumo de sal. La revisión de estudios ecológicos y ensayos clínicos permite concluir que la reducción del consumo de sodio disminuye la presión arterial, y estudios metodológicamente sólidos de cohortes demuestran que el riesgo de eventos cardiovasculares disminuye progresivamente mientras más baja es la presión arterial. La combinación de estos dos resultados permite suponer que existiría un beneficio para las poblaciones al reducir la ingesta de sal aunque efectivamente no existan estudios que demuestren que en poblaciones con alto consumo de sal hay una reducción de eventos cardiovasculares al reducir la ingesta de sal.

A recent systematic review of Cochrane collaboration about the effect of reducing dietary salt concluded that “there is still insufficient power to exclude clinically important effects of reduced dietary salt on mortality or cardiovascular morbidity in normotensive or hypertensive populations”. This conclusion has generated an important debate, because the estimation that salt reduction can prevent 24 percent of strokes and 18 percent of myocardial infarctions has decided the health authorities of several nations to implement salt consumption reduction programs. The review of ecological studies and clinical trials allow to conclude that a reduction in salt consumption reduces blood pressure and methodological well conducted cohort studies has shown that cardiovascular events risk decreases progressively with lower levels of blood pressure. Combining this two finding we can assume that population should benefice from a decrease on salt consumption although there are no studies that shown a reduction in cardiovascular events in population with high sodium intake when dietary salt is reduced.