Dysautonomia Evaluation by Holter in Chagas Heart Disease

Abstract Background Sudden cardiac death is the main lethal mechanism associated with Chagas cardiomyopathy. Studies suggest that dysautonomia may represent a relevant, intense, independent, and early phenomenon in the natural history of the disease, even when ventricular systolic function is preserved, and may also be the mechanism that triggers malignant ventricular arrhythmias. Objective To evaluate the degree of dysautonomia and its possible association with ventricular arrhythmias in patients with Chagas cardiomyopathy, according to different categories of mortality risk, as defined by the score proposed by Rassi, used as a surrogate outcome for death. Methods A cross-sectional study involving 43 patients with Chagas cardiomyopathy stratified into risk categories based on the Rassi score, with 23 being classified as low risk and 20 as intermediate-to-high risk. Heart rate variability (HRV) was assessed using Holter monitoring for long-term recordings of 24 hours (time domain) and for short-term recordings of 5 minutes (frequency domain) at rest and after autonomic tests: deep breathing and Valsalva maneuver. The HRV variables were compared between the groups using the Student's t-test and α=0.05. Results Comparison of the results between the risk stratification groups showed no differences in HRV indexes, either in the time or frequency domain. However, results showed a significant increase in the number of arrhythmias as a function of increased risk (p=0.02). Conclusion There was no association between the degree of dysautonomia, evaluated by Holter monitoring, and the categories of mortality risk, despite a direct association between the rate of arrhythmias and the higher risk group.

Heart rate turbulence assessed through ergometry after myocardial infarction: a feasibility study

ABSTRACT BACKGROUND: Coronary artery disease is an important cause of morbidity and mortality. The impact of ventricular arrhythmias with impaired cardiac vagal activity is one of the most recently studied prognostic factors. However, there are no studies evaluating the phenomenon of heart rate turbulence (HRT) during physical exertion. OBJECTIVE: To study the behavior of HRT during exercise testing, among individuals after myocardial infarction. DESIGN AND SETTING: Feasibility study conducted in a university hospital among individuals 4-6 weeks after myocardial infarction. METHODS: All subjects underwent 24-hour Holter monitoring and ergometric stress testing. We considered that abnormal HRT was present if the turbulence onset was ≥ 0% or turbulence slope was ≤ 2.5 mm/relative risk interval. RESULTS: All 32 subjects were asymptomatic. Their median age was 58 years (interquartile range 12.8) and 70% were male. Abnormal HRT was associated with ventricular dysfunction in this population. We found no differences regarding the behavior of HRT, in relation to age, gender, smoking, systemic arterial hypertension, diabetes mellitus or dyslipidemia. Ergometric stress testing detected premature ventricular beats (PVB) in approximately 44% of the examinations, and these occurred both during the active phase of effort and in the recovery period. The low occurrence of several isolated PVB in beta-blocked subjects made it difficult to perform statistical analysis to correlate HRT between ergometric and Holter testing. CONCLUSION: The data obtained in this study do not support performing HRT through ergometric stress testing among patients who remain on beta-blockers post-myocardial infarction, for the purpose of assessing cardiac vagal activity.

Registro prospectivo de pacientes que presentan paro cardiorrespiratorio extrahospitalario en Santiago, Chile / A registry of out-of-hospital cardiac arrest in Chile

BACKGROUND: The rate of survival to hospital discharge is less than 10% for out-of-hospital cardiac arrest (OHCA). AIM: To develop and implement a Chilean prospective, standardized cardiac arrest registry following the Utstein criteria. MATERIAL AND METHODS: We conducted a prospective registry for patients presenting at an urban, academic, high complexity emergency department (ED) after having an OHCA. The facility serves approximately 10% of the national population. Data were registered and analyzed following the Utstein criteria for reporting OHCA. RESULTS: For three years, 289 patients aged 59 ± 19 years (63% men) were included. Fifty seven percent of patients were taken to a health care facility for the first medical assessment by relatives or witnesses and 34% was assisted and transferred by prehospital personnel. In the subgroup of non-traumatic OHCA, 28% (n = 54) received bystander cardiopulmonary resuscitation (CPR). The registered cardiac rhythms were asystole (61%), pulseless electrical activity (PEA) (25%) and ventricular tachycardia (VT) or ventricular fibrillation (VF) (11%). The overall survival rate to discharge from the hospital was 10%, while survival with mRankin score 0-1 was 5%. The median hospitalization length of stay was 18 days among those who survived, compared with five days for the group of patients that died during the hospital stay. CONCLUSIONS: OHCA is an important cause of death in Chile. The development of a national registry that follows the International Liaison Committee on Resuscitation guidelines is the first step to assess the profile of OHCA in the region. It will provide crucial information to identify prognostic factors and variables that can help develop standards of care and set up the basis to optimize cardiac arrest management within our country and region.

The status of knowledge of sudden cardiac death prevention among general practitioners / 中华全科医师杂志

Objective:To survey the knowledge levels of sudden cardiac death (SCD) prevention among general practitioners (GPs) in Henan province.Methods:From October to November 2019, a questionnaire survey on the knowledge of SCD prevention and treatment was conducted among GP residents participating in the standardized training and assistant GPs taking final examination after training in Henan province. The questionnaire included three dimensions of SCD knowledge: prevention, early diagnosis and first aid. The factors influencing the knowledge levels on SCD prevention were analyzed.Results:A total of 546 questionnaires were distributed and 519 responders (95.1%) completed the questionnaire, including 176 GP residencies and 343 assistant GPs. The age of the respondents was 22-44 (27.91±2.84) years, 234 (45.1%) were males and 285 were females. The overall correct rate of SCD prevention and treatment was (61.46±12.39) %, and the correct rates of prevention, early diagnosis and first aid knowledge were (65.22±17.88)%, (56.58±20.20)% and (62.57±14.60)%, respectively. The overall correct rate and the correct rates of SCD prevention and treatment knowledge among GP residents were higher than those among assistant GPs ( t=10.55, 9.20, 8.62, 3.42, P<0.001); the overall correct rates and the correct rates of SCD first aid knowledge of female GPs were higher than those of males ( t=2.26, 2.13, P=0.025, 0.033); the overall correct rate and the correct rates of each dimensions in age group ≥28 years were higher than those in age group <28 years ( t=4.21, 3.37, 3.20, 2.00, P<0.05). The multivariate logistic regression analysis showed that compared to GP residents,the assistant GPs was the factor influencing the lower levels of the overall knowledge ( OR=0.24, 95 %CI:0.16-0.38, P<0.001), knowledge of prevention ( OR=0.19, 95 %CI:0.10-0.32, P<0.001) and knowledge of early diagnosis ( OR=0.35, 95 %CI: 0.23-0.52, P<0.001);compared to male responders,the females had significantly higher pass rate in SCD first aid knowledge ( OR=1.56, 95 %CI:1.07-2.28, P=0.020). Conclusions:The SCD knowledge levels of the prevention, early diagnosis, and emergency treatment are less satisfactory among GPs in Henan province; it is necessity for targeted training on the weak points of SCD knowledge for GPs.

Cost-Effectiveness Analysis of Implantable Cardioverter Defibrillator Therapy for Primary Prevention Patients with Additional Risk Factors in Brazil

Abstract Background: Implantable cardiac defibrillators (ICDs) therapy for primary prevention (PP) of sudden cardiac arrest (SCA) is well-established but underutilized globally. The Improve SCA study has identified a cohort of patients called 1.5 primary prevention (1.5PP), based on PP patients with the presence of documented risk factors: non-sustained ventricular tachycardia, frequent premature ventricular contractions, left ventricular ejection fraction < 25%, and pre-syncope or syncope. Objective: This study evaluated the cost-effectiveness of ICD therapy compared to no ICD among 1.5PP patients in the Brazilian public healthcare system. Methods: Modified inputs to a published Markov model were applied to compare costs and outcomes of ICD therapy to no ICD therapy from the Brazilian payer's perspective. Mortality and utility estimates were obtained from the IMPROVE SCA trial. Additional effectiveness inputs were sourced from the literature. Cost inputs were obtained from the Brazilian Unified Health System and the Ministry of Health. Costs were discounted at 4.7%; quality-adjusted life years (QALYs) were discounted at 1.45%. This study applied a willingness-to-pay (WTP) value of three times Brazil's gross domestic product (GDP) in 2017, R$105,723 (Brazilian Real). Results: The total discounted lifetime costs for ICD therapy were R$100,920 compared to R$43,866 for no ICD therapy. Total discounted QALYs for ICD therapy and no ICD therapy were 9.85 and 7.15, respectively. The incremental cost effectiveness ratio was R$21,156 per QALY and less than the R$105,723 WTP threshold. Results from sensitivity analyses were consistent with base case results. Conclusions: ICD therapy compared to no ICD therapy is cost-effective in the 1.5PP population in Brazil. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

Muerte súbita por fibrilación ventricular en deportista: una presentación inusual del Síndrome de Brugada. Caso Clínico / Sudden cardiac death during exercise due to Brugada syndrome. report of one case

We report a 20-year-old male athlete who while running, presented a sudden death due to ventricular fibrillation. He was successfully rescued by cardiopulmonary resuscitation maneuvers and an automatic external defibrillator. Without evidence of structural heart disease, Brugada syndrome was diagnosed as the cause, after which a subcutaneous implantable cardioverter defibrillator was indicated. We discuss the subject of sudden cardiac death in athletes and its unusual relationship with exercise in this channelopathy.

Attitude and knowledge of medical students toward donation after circulatory death

SUMMARY OBJECTIVE: A survey among medical students in a Brazilian public university was performed to investigate the acceptance of organ donation in Brazil, particularly donation after circulatory death (DCD). METHODS: A questionnaire including 26 objectives and Likert scale questions was validated and sent to all medical students of our institution. The answers were analyzed considering the whole set of individuals as well as by dividing the medical students into two groups: less graduated students and more graduated students. RESULTS: From 1050 students, 103 spontaneous answers (9.8%) were retrieved after 3 weeks. A total of 89.3% agreed totally with deceased donor organ donation and 8.7% agreed partially. However, only 50.5% of the students agreed totally and 31.1% agreed partially to living donation. Students revealed that 82.6% know the concept of brain death. On the other hand, 71.8% of them declared not knowing the concept of planned withdrawal of life-sustaining therapy, mainly cardiorespiratory support. A total of 85.4% of students agreed totally with donation after brain death and 11.7% agreed partially. However, when questioned about donation in awaiting circulatory death after a planned withdrawal of life-sustaining therapy, only 18.4% agreed totally and 32% agreed partially. Both groups of less and more graduated students showed similar results. CONCLUSIONS: Our study found a clear lack of information and consequently in acceptance of DCD. Education in the field of end-of-life management may improve not only the acceptance of DCD donation but also the whole understanding of planned withdrawal of life-sustaining therapy.

Coronary arteritis as a cause of sudden cardiac death in a young girl

A case of probable coronary arteritis in a young girl who died suddenly and unexpectedly is presented. The histologic presentation of the disorder is discussed, especially the differential diagnosis of arteritis of the coronary arteries with an emphasis on tuberculosis (TB). TB myocarditis with or without concomitant lung involvement is rare, and tubercular coronary arteritis without underlying pulmonary Koch's disease is all the rarer. We herein describe a case where the cause of death was ascertained on post-mortem examination.

SWOT analysis on the involvement of general practitioners in prevention and control system of sudden cardiac death / 中华全科医师杂志

Sudden cardiac death (SCD) is one of the most common causes of death for patients with cardiovascular diseases. General practitioners are the providers of primary medical and health service, it its worthwhile to discuss their role positioning in the prevention and control system of SCD. In this study, SWOT analysis was used to explore the strength, weakness, opportunity and threats of the involvement of general practitioners in SCD prevention and control system, to clarify the roles of general practitioners and to provide suggestions for the improvement and development of SCD prevention and control system in China.

Screening of ARVC desmosomal protein gene mutation in Yunnan unexplained sudden death area of a key county, Yunnan / 中华地方病学杂志

Objective:To explore the relationship between arrhythmogenic right ventricular cardiomyopathy (ARVC) desmosomal protein gene mutations and Yunnan unexplained sudden death (hereinafter referred to as Yunnan sudden death) by detecting 5 common ARVC desmosomal protein gene mutations of Yunnan sudden death cases and their relatives in Heqing County, Yunnan Province.Methods:In January 2021, the autopsy heart cavity blood was collected from Yunnan sudden death cases in 8 villages in Heqing County, and peripheral venous blood samples of relatives of the cases were collected. Blood samples' DNA was extracted, after PCR amplification, 97 exons of 5 desmosomal protein genes [desmoplakin (DSP), desmoglein-2 (DSG2), plakophilin-2 (PKP2), junction plakoglobin (JUP) and desmocollin-2 (DSC2)] were sequenced by Sanger method to analyze gene mutations.Results:Three blood samples of Yunnan sudden death cases and 36 blood samples of relatives were collected. A total of 26 gene mutation sites were detected in 39 blood samples, with a total mutation rate of 26.80% (26/97). There were 13, 5, 3, 3 and 2 mutation sites in DSP, DSG2, PKP2, JUP and DSC2 genes, respectively. Among them, 19 were reported mutations and 7 were new mutations: DSP gene exon 3 c.372G>A, exon 15 c.2090A>G, exon 17 c.2371C>A, exon 24-I c.8458T>G; DSG2 gene exon 8 c.861C>T; PKP2 gene exon 3 c.892C>A, exon 8 c.1725G>T. Three Yunnan sudden death cases and 36 relatives were all carriers of compound gene mutation, and the same person carried 3 - 9 gene mutation sites at the same time.Conclusion:Mutations of ARVC desmosomal protein genes DSP, DSG2, PKP2, JUP and DSC2 exist in Yunnan sudden death cases and their relatives, which may be the genetic background factors of some Yunnan sudden death.

Discordância entre Diretrizes Internacionais sobre Critérios de Prevenção Primária de Morte Súbita na Cardiomiopatia Hipertrófica / Discrepancy between International Guidelines on the Criteria for Primary Prevention of Sudden Cardiac Death in Hypertrophic Cardiomyopathy

Resumo Fundamento A estratificação de risco para morte súbita (MS) na cardiomiopatia hipertrófica (CMH) baseia-se em algoritmos distintos propostos pela diretriz norte-americana, ACCF/AHA 2011 e europeia, ESC 2014. Objetivo Analisar o modelo ESC 2014 na determinação do risco de MS e indicação de cardiodesfibrilador implantável (CDI) em prevenção primária na CMH por meio de confrontação com a normativa norte-americana. Métodos Foi avaliada uma coorte de pacientes com CMH, calculado o escore ESC HCM-Risk-SCD e analisada a concordância dos critérios de indicação de CDI entre as duas diretrizes pelo coeficiente de Kappa. O nível de significância adotado nas análises estatísticas foi de 5%. Resultados Em 90 pacientes consecutivos, seguidos por 6±3 anos, o escore calculado foi de 3,2±2,5%. Os preditores que mais contribuíram para o cálculo nas faixas de baixo (1,88% [1,42-2,67]), médio (5,17% [4,89-5,70]) e alto risco (7,82% [7,06-9,19]) foram espessura parietal máxima do ventrículo esquerdo (1,60% [1,25-2,02] ; 3,20% [3,18-3,36] ; 4,46% [4,07-5,09]), diâmetro do átrio esquerdo (0,97% [0,83-1,21]; 1,86% [1,67-2,40]; 2,48% [2,21-3,51]) e idade (-0,91% [0,8-1,13]; -1,90% [1,12-2,03]; -2,34% [1,49-2,73]). O modelo europeu reduziu as recomendações de CDI em 32 (36%) pacientes. Entre os 43 (48%) em classe IIa pela ACCF/AHA , 8 (18%) migraram para IIb e 24 (56%) para III. Baixa concordância foi identificada entre as duas sistematizações, Kappa = 0,355, p = 0,0001. Dos 8 (9%) pacientes com MS ou choque apropriado, 4 (50%) atingiram indicação IIa pela ACCF/AHA , mas nenhum pela ESC . Conclusão Baixa concordância foi identificada entre as diretrizes analisadas. O novo modelo reduziu as indicações de CDI, notadamente em classe IIa, mas deixou desprotegida a totalidade de pacientes com MS ou choque apropriado. (Arq Bras Cardiol. 2020; 115(2):197-204)

Abstract Background Risk stratification for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is based on different algorithms proposed by the 2011 ACCF/AHA and 2014 ESC guidelines. Objective To analyze the 2014 ESC model for SCD risk stratification and primary prevention ICD (implantable cardioverter defibrillator) in HCM in comparison to the North American guideline. Methods An HCM cohort was evaluated and the ESC HCM-Risk SCD score was calculated. Agreement of ICD recommendations criteria between the two guidelines was analyzed with Kappa coefficient. P<0.05 was adopted for the statistical analysis. Results In 90 consecutive patients followed for 6±3 years, the mean calculated ESC risk score was 3.2±2.5%. The risk predictors that have mainly contributed to the score calculation in the low (1.88% [1.42-2.67]), intermediate (5.17% [4.89-5.70]) and high-risk (7.82% [7.06-9.19]) categories were: maximal left ventricular wall thickness (1.60% [1.25-2.02]; 3.20% [3.18-3.36]; 4.46% [4.07-5.09]), left atrial diameter (0.97% [0.83-1.21]; 1.86% [1.67-2.40]; 2.48% [2.21-3.51]) and age (-0.91% [0.8-1.13]; -1.90% [1.12-2.03]; -2.34% [1.49-2.73]). The European model decreased the ICD recommendations in 32 (36%) patients. Among the 43 (48%) individuals with class IIa recommendation under the 2011 ACCF/AHA guideline, 8 (18%) were downgraded to class IIb and 24 (56%) to class III. Low agreement was found between the two systems: Kappa=0.355 and p=0.0001. In 8 (9%) patients with SCD or appropriate shock, 4 (50%) met class IIa indication with the 2011 ACCF/AHA guideline, but none achieved this class of recommendation with the 2014 ESC model. Conclusion Low agreement was found between the two strategies. The novel ESC model decreased the ICD recommendations, especially in those with class IIa recommendation, but left unprotected all patients with SCD or appropriate shock. (Arq Bras Cardiol. 2020; 115(2):197-204)

Supervivencia a 30 días y 1 año de pacientes con muerte súbita con posterior colocación de dispositivo cardíaco implantable en un hospital de alta complejidad / Patients with sudden cardiac death receiving an implantable cardiac device: survival at 30 days and one year

Background: The use of implantable cardiac devices in patients with sudden cardiac arrest has contributed to their survival. Aim: To determine the survival rate at 30 days and one year after hospital discharge of patients who had a cardiac arrest with subsequent placement of an implantable cardiac device. Material and Methods: Twenty-three patients older than 18 years who presented sudden extra-institutional or intra-institutional death with subsequent implantation of an implantable cardiac device and whose survival was recorded at 30 days and one year, were included. A univariate analysis was performed. Results: Eighteen patients had an extra institutional cardiac arrest. All patients were discharged alive. We could not ascertain the health status of one patient at follow-up. Twenty-one patients had a Cerebral Performance Category (CPC) of 1 at discharge. One patient died of a stroke within 30 days and one patient died due to an arrhythmic electrical storm one year later. Twenty patients survived at least one year after hospital discharge. Conclusions: Survival at 30 days and one year, was high in patients with sudden death or cardiac arrest who required intracardiac devices.

Muerte súbita en el ámbito prehospitalario en época de COVID-19 / Sudden death in the prehospital setting in times of COVID-19

RESUMEN Una de cada cinco muertes de adultos en países desarrollados se debe a causas cardiovasculares; la mitad de esas muertes se produce de forma súbita y un gran porcentaje en el ámbito extrahospitalario. Múltiples estudios demostraron que el acceso de la población general al aprendizaje de maniobras de reanimación cardiopulmonar sencillas y pragmáticas y la presencia de desfibrilador externo automático se traducen en un gran aumento de sobrevida sin secuelas en casos de muerte súbita cardíaca extrahospitalaria. Hoy en día existe una situación especial representada por la pandemia por COVID -19, que deja bajo un interrogante todo lo aprendido hasta la fecha y nos enfrenta a dos situaciones sumamente complejas. Por un lado, la afectación cardiovascular y el aumento consecuente de arritmias ventriculares malignas que genera esta infección, tanto en pacientes sanos como en sujetos con patologías preexistentes, han puesto de manifiesto un aumento en la incidencia de episodios de muerte súbita extrahospitalaria. Por otro lado, se vuelve necesario reevaluar todo el accionar puesto en marcha cuando un paciente presenta un episodio de muerte súbita cardíaca extrahospitalaria, ya que ahora se agrega la posibilidad de transmisión de esta enfermedad de alta contagiosidad durante las maniobras de reanimación. Volver a encontrar un equilibrio riesgo-beneficio que permita aumentar la sobrevida del paciente con el mínimo riesgo posible para la persona que realiza la reanimación es el verdadero desafío hoy en día.

ABSTRACT One in five adult deaths in developed countries is due to cardiovascular causes; half of these deaths occur suddenly and a large percentage in the out-of-hospital setting. Multiple studies demonstrated that the access of the general population to learning simple and pragmatic cardiopulmonary resuscitation maneuvers and the presence of automatic external defibrillator translates into a large increase in survival without sequelae in victims of sudden out-of-hospital sudden cardiac death. Today there is a situation represented by the pandemic by COVID -19, which questions what we have learned to date and makes us face two extremely complex situations. On the one hand, the cardiovascular involvement and the consequent increase in malignant ventricular arrhythmias generated by this infection, both in patients with previous pathologies or not, has shown an increase in the incidence of episodes of sudden out-of-hospital death. On the other hand, it forces us to rethink all the actions put into place at the moment that a patient presents with an episode of sudden out-of-hospital sudden cardiac death since now the possibility of transmission of this highly contagious disease is added during resuscitation maneuvers. Refinding a risk-benefit balance that allows increasing the patient's survival with the least possible risk for the person who is resuscitating is the real challenge we are facing today.

Giant cell myocarditis causing sudden death in a patient with sarcoidosis

Giant cell myocarditis (GCM) is a rare and rapidly fatal cardiovascular condition most often seen in young adults. It is characterized microscopically by myocardial necrosis with multinucleated giant cells in the absence of well-defined granulomas. This disorder has typically been attributed to manifest as heart failure, but in some individuals, GCM may present as sudden cardiac death. Herein, we present a fatal case of GCM in a 36-year-old male with a history of autoimmune disorders. The decedent presented to the emergency room due to vomiting and was treated for nausea due to suspected dehydration. He was discharged that night and found dead on his bathroom floor the following day. Postmortem examination revealed psoriasis and granulomatous lesions in the lungs consistent with sarcoidosis, further supporting circumstantial evidence existing between GCM and autoimmune disorders. Additionally, this case provides an opportunity to distinguish GCM from the distinct clinical entity of cardiac sarcoidosis (CS), especially in the setting of systemic sarcoidosis. We hope to raise awareness of this rare disease process and its potential to cause sudden cardiac death so that it may be considered in a differential diagnosis as immunosuppression and early cardiac transplantation largely determine the prognosis.

Cost-utility analysis of an implantable cardioverterdefibrillator for the treatment of patients with ischemic or non-ischemic New York Heart Association class II or III heart failure in Colombia / Análisis de costo-utilidad del desfibrilador cardioversor implantable para el tratamiento de pacientes colombianos con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association

Abstract Introduction: The use of an implantable cardioverter-defibrillator reduces the probability of sudden cardiac death in patients with heart failure. Objective: To determine the cost-utility relationship of an implantable cardioverterdefibrillator compared to optimal pharmacological therapy for patients with ischemic or nonischemic New York Heart Association class II or III (NYHA II-III) heart failure in Colombia. Materials and methods: We developed a Markov model including costs, effectiveness, and quality of life from the perspective of the Colombian health system. For the baseline case, we adopted a time horizon of 10 years and discount rates of 3% for costs and 3.5% for benefits. The transition probabilities were obtained from a systematic review of the literature. The outcome used was the quality-adjusted life years. We calculated the costs by consulting with the manufacturers of the device offered in the Colombian market and using national-level pricing manuals. We conducted probabilistic and deterministic sensitivity analyses. Results: In the base case, the incremental cost-effectiveness ratio for the implantable cardioverter-defibrillator was USD$ 13,187 per quality-adjusted life year gained. For a willingness-to-pay equivalent to three times the gross domestic product per capita as a reference (USD$ 19,139 in 2017), the device would be a cost-effective strategy for the Colombian health system. However, the result may change according to the time horizon, the probability of death, and the price of the device. Conclusions: The use of an implantable cardioverter-defibrillator for preventing sudden cardiac death in patients with heart failure would be a cost-effective strategy for Colombia. The results should be examined considering the uncertainty

Resumen Introducción. El uso del desfibrilador cardioversor implantable reduce la probabilidad de muerte súbita en pacientes con insuficiencia cardíaca. Objetivo. Determinar la relación de costo-utilidad de un desfibrilador cardioversor implantable comparado con la terapia farmacológica óptima para pacientes con insuficiencia cardíaca isquémica o no isquémica de clase II o III según la New York Heart Association (NYHA II-III) en Colombia. Materiales y métodos. Se desarrolló un modelo de Markov que incluyó los costos, la efectividad y la calidad de vida desde la perspectiva del sistema de salud colombiano. Para el caso de base, se adoptó un horizonte temporal de 10 años y una tasa de descuento de 3 % para los costos y de una 3,5 % para los beneficios. Las probabilidades de transición se obtuvieron de una revisión sistemática de la literatura. Los años de vida ajustados por calidad se usaron como resultado de salud. Para estimar los costos unitarios se usaron manuales tarifarios nacionales y, para los costos del dispositivo, se consultó a los fabricantes que lo comercializan en el mercado colombiano. Se hicieron análisis de sensibilidad probabilísticos y determinísticos. Resultados. En el caso base el costo adicional por año de vida ajustado por calidad ganado con el desfibrilador cardioversor implantable fue de USD$ 13,187. Usando un umbral de tres veces el producto interno bruto per cápita como referencia (USD$ 19.139 en 2017), el dispositivo sería costo-efectivo para el sistema de salud colombiano. Sin embargo, este resultado depende del horizonte temporal, de la probabilidad de muerte y del precio del dispositivo. Conclusiones. El uso de un desfibrilador cardioversor implantable sería una estrategia costo-efectiva para Colombia, aunque los resultados deben examinarse teniendo en cuenta la incertidumbre.

Sudden Cardiac Death in Sports: Why Its Prevalence is So Different by Gender?

Sports competition can be a trigger to fatal arrhythmias in predisposed individuals, leading to sudden cardiac death. Athletes have 2.8 fold more risk of sudden cardiac death than non-athletes. However, female athletes seem to have some cardiac protection, dying suddenly much less than men during sports. Although the mechanisms for this protection have not been well established until now, hormonal, genetic and molecular factors may play a role in it. The so-called "fair sex" might harbour the key for sudden cardiac death prevention