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.

Índice C en médicos de dos centros hospitalarios chilenos según el test de competencia moral de Lind / Assessment of moral competence of physicians

Background: Moral competence (MC) in physicians is fundamental, given the increasing complexity of medicine. The "Moral Competence Test" (MCT © Lind) evaluates this feature and its indicator is the C Index (CI). Aim: To explore moral competence and its associated factors among physicians working in Chile. Material and Methods: The MCT was answered by 236 physicians from two medical centers who voluntarily participated in the study. Besides the test, participants completed an encrypted form giving information about gender, years in practice and post-graduate studies. Results: The average CI value of the participants was 20,9. Post-graduate studies had a significant positive influence on CI. There was a significant decrease in CI, between 16 and 20 years of professional exercise. Gender and the area of post-graduate studies did not have a significant influence. Conclusions: The studied physicians showed a wide range of CI which was positively affected by the postgraduate studies performed. The years of professional practice had a negative influence. Expanding training opportunities during professional practice could have a positive effect on CM as measured by CI.

Factores asociados a fragilidad en pacientes hospitalizados con insuficiencia cardiaca descompensada / Frailty in patients admitted to hospital with acute decompensated heart failure

Background: Frailty is a geriatric syndrome characterized by a progressive impairment in the subjects’ ability to respond to environmental stress. Frailty is more commonly found in heart failure (HF) patients than in general population and it is an independent predictor of rehospitalization, emergency room visits and death. Aim: To estimate the prevalence of frailty in patients with decompensated HF admitted to four hospitals in Santiago, Chile. Material and Methods: Cross-sectional study. Subjects aged 60 or older consecutively admitted for decompensated HF to the study centers between August 2014 and March 2015 were included. Frailty was defined as the presence of three or more of the following criteria: unintended weight loss, muscular weakness, depression symptoms (exhaustion), reduced gait speed and low physical activity. Independent variables were tested for association using simple logistic regression. Variables associated with frailty (p < 0.05) were included in a multiple logistic regression model. Results: Seventy-nine subjects were included. The prevalence of frailty was 50.6%. Frail patients were mostly female (52.6%) and older than non-frail subjects (73.7± 7.9 vs 68.2 ± 7.1; p < 0.003). Independent predictors of frailty were age (Odds raio (OR) 1.10; 95% confidence intervals (CI): 1.03-1.17), quality of life measured with the Minnesota Living with Heart Failure Questionnaire (OR 1.07; IC95%: 1.03-1.11), previous hospitalizations (OR 2.56; 95%CI: 1.02-6.43) and number of medications (OR 4.46; 95%CI: 1.11-17.32). Conclusions: The prevalence of frailty in patients admitted to the hospital for decompensated heart failure is high. Age, quality of life, hospitalizations and polypharmacy were factors associated with frailty in this group of participants.

En el Infarto agudo al miocardio los niveles plasmáticos de microvesículas extracelulares se elevan más precozmente que el aumento de la Troponina-I / Plasma levels of extracellular macrovesicles are elevated earlier than troponin-I in patients with myocardial infarction

Introducción: La Troponina I (TnI) plasmática es el biomarcador "Gold" estándar utilizado en diagnóstico de Infarto Agudo al Miocardio (IAM), indicando necrosis cardíaca. Las microvesículas extracelulares (MVEC), participan en comunicación celular, por lo que estudiar su distribución entregaría información respecto del evento isquémico, antesala del infarto. Objetivo: Estudiar las MVECs plasmáticas en pacientes con Síndrome Coronario Agudo (SCA) y compararlas con los niveles de TnI. Métodos: Plasma de 22 pacientes controles se recolectó 0-2hrs post-ingreso a urgencia. Plasma de 45 pacientes SCA se recolectó 0-2, 6-8 y 10-14hrs post ingreso, junto con la toma de muestra para estudio de TnI. Las MVECs plasmáticas fueron enriquecidas mediante kit comercial. La determinación de la concentración y tamaño MVECs se realizó por NTA (Nanoparticles Tracking Assay) usando el equipo Nanosight. Resultados: La concentración promedio de MVECs 0-2 hrs post ingreso fue 7,2 veces superior en plasma de pacientes con SCA vs controles y la moda del tamaño disminuyó en pacientes con SCA. La TnI no mostró diferencias significativas en 0-2 hrs post ingreso en el grupo estudiado. La concentración de las MVEC disminuyó significativamente después de 10-14 hrs post ingreso, mientras que la concentración promedio TnI se mantuvo invariable demostrando el aumento de MVECs previo al incremento de TnI. Conclusión. El aumento de MVECs previo al incremento de la TnI en pacientes infartados, sugiere que las MVECs aumentan en la fase previa del IAM, como respuesta al daño tisular. Actualmente, estudiamos el contenido molecular de las MVECs, para establecer un método diagnóstico del Síndrome Coronario Agudo basado en MVECs.

Background: Troponin I (TnI) is the gold standard used to establish the diagnosis of myocardial infarction (AMI), indicating the presence of myocardial necrosis. Extracellular micro vesicles are involved in cellular communication. Their distribution may provide information relating to the development of AMI in patients with acute coronary syndromes (ACS) Aim: to study plasma levels of ECMV compared to those of TnI in patients with ACS. Methods: The plasma levels of TnI and ECMV from 22 control patients coming to the emergency units was compared to plasma from 45 patients with ACS. Levels of both parameters were determined 0-2, 6-8 and 10-14 hours post admission. ECMVs were enriched by means of a commercial kit. Concentration and size of ECMV was determined by NTA (Nanoparticles tracking assay) using the Nanosight equipment. Results: Plasma concentration of ECMV was 7.2 times higher than that of TnI 0-2 hrs post admission. The mode of ECMV size was lower in patients with ACS. Concentration of ECMV had decreased significantly 10-14 hrs post admission, whereas the TnI levees remained stable. Conclusion: The increase in ECMV earlier than TnI in AMI suggests that ECMV are elevated in the pre-AMI phase, as a response to early tissue damage. A study of cellular content of ECMV, being carried out, may lead to develop a method for the early diagnosis of AMI in patients with ACS.

Cambios del estado clínico periodontal según consumo sistémico de estatinas / Changes in clinic periodontal status according to systemic statins intake

Objetivos: Describir los cambios del estado clínico periodontal de pacientes según el consumo sistémico de estatinas por indicación del cardiólogo. Material y método Se realizó un estudio descriptivo en el cual se reclutaron pacientes con periodontitis crónica derivados desde cardiología de la Clínica Dávila. Un grupo de ellos iniciaría terapia de estatinas. Se realizaron mediciones clínicas periodontales de profundidad al sondaje (PS), nivel de inserción clínico, índice de sangrado, área de superficie periodontal inflamada, e índice gingival, al inicio (antes de comenzar la terapia de estatinas) y 6 meses después. Los datos fueron analizados utilizando estadística descriptiva. Resultados Diez pacientes participaron del estudio, 5 con indicación de estatinas. El grupo con estatinas en comparación con el grupo sin estatinas presentó una disminución en promedio: de PS (0,4 mm versus 0,13 mm); porcentaje de sitios con PS > 5 mm (4,16 por ciento versus 1,09 por ciento); de nivel de inserción clínico (0,5 mm versus 0,2 mm), índice de sangrado (27,16 por ciento versus 8,8 por ciento) y área de superficie periodontal inflamada (305,68 mm2 versus 121,35). Conclusiones Estos resultados sugieren que pacientes con periodontitis crónica podrían obtener beneficios de la terapia sistémica con estatinas. Se requiere de estudios clínicos con asignación aleatoria y el óptimo tamaño muestral que comprueben el efecto e impacto de las estatinas sobre el estado periodontal.

Objective: To describe changes in periodontal clinical status of patients according to systemic statin use prescribed by a cardiologist. Material and methods A descriptive study was performed on patients with chronic periodontitis referred from the Department of Cardiovascular Diseases of Dávila Clinic. A group of them began statin therapy. Clinical measurements of periodontal probing depth (PD), clinical attachment level, bleeding index, periodontal inflamed surface area, and gingival index, were performed at baseline (before starting statin therapy) and 6 months later. Data were analyzed using descriptive statistics. Results A total of 10 patients participated in the study, and five of them received statin therapy. The statin group compared to the group without statins, showed a mean decrease in: PD (0.4 mm versus 0.13 mm); percentage of PS sites > 5 mm (4.16 percent versus 1.09 percent); clinical attachment level (0.5 mm versus 0.2 mm), bleeding index (27.16 percent versus 8.8 percent), and periodontal inflamed surface area (305.68 versus 121.35 mm2). Conclusions These results suggest that patients with chronic periodontitis may benefit from systemic therapy with statins. Randomized clinical trials with optimal sample size are required to check the effect and impact of statins on the periodontal status.

Estado actual de la terapia con células madre en el tratamiento de las cardiopatías / Stem cells for the treatment of cardiovascular diseases. An update

Available medical therapy is unable to completely prevent or revert the pathological cardiac remodeling secondary to ischemia or other injuries, which is responsible for the development of heart failure. Regenerative medicine through stem cells had an explosive development in the cardiovascular area during the past decade. Stem cells possess the capacity to regenerate, repair or substitute damaged tissue, allowing the reestablishment of its function. Stem cells can also modulate apoptosis, angiogenesis, fibrosis and inflammation, favoring the endogenous regenerative process initiated by the damaged tissue. These capacities have been corroborated in several animal models of cardiovascular diseases with positive results. In humans, therapies with bone marrow mononuclear stem cells, mesenchymal stem cells and cardiac stem cells are safe. Most randomized clinical trials in patients with myocardial infarction or cardiomyopathies of different etiologies have reported benefits on ventricular function, quality of life and even over mortality of treated patients. This article reviews the state of art of stem cell therapy in cardiovascular diseases, focusing on the most common cellular types used in patients with acute myocardial infarction and chronic cardiomyopathies of different etiologies.

Experiencia clínica con 53 trasplantes cardiacos consecutivos / Clinical experience with 53 consecutive heart transplants

Introduction: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. Patients and Methods: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. Results: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). Operative technique: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. Conclusion: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

Puente al trasplante de 4 semanas utilizando el sistema de asistencia ventricular Levitronix Centrimag® en el shock cardiogénico post-infarto al miocardio: Caso clínico / Four-week Levitronix Centrimag® bridge-to-transplant for post myocardial infarction cardiogenic shock: A case report

Cardiogenic shock after myocardial infarction has a high mortality even if early revascularization is achieved. Biventricular assist devices have not been used in Chile in this critical setting. We report a case of a 55 year-old diabetic man who suffered an acute chest pain and ventricular fibrillation. Prompt outside hospital defibrillation/ reanimation restored pulse and allowed emergency room transfer on mechanical ventilation. Electrocardiogram showed an anterior myocardial infarction and early revascularization was achieved by anterior descending artery angioplasty. However, severe cardiogenic shock continued in spite of inotropic and intra aortic balloon pump support. Levitronix Centrimag® biventricular mechanical circulatory support was inserted during reanimation for recurrent ventricular fibrillation and the patient listed for urgent cardiac transplantation upon stabilization. Heart transplantation was performed successfully 28 days later and the patient was discharged after a 21-day recovery period. Twelve months after transplant the patient is in NYHA functional class I with normal biventricular function. Levitronix Centrimag® biventricular mechanical circulatory support could be used successfully as a bridge-to-transplant for myocardial infarction cardiogenic shock.