Estudio de caso: revascularización de paciente con enfoque en el proceso de atención de enfermería / Case study: Patient revascularization with focus on the nursing care process

Introducción: la cardiopatía isquémica fue la primera causa de muerte en México en el año 2020. Su prevalencia aumenta con la edad y es superior en los hombres que en las mujeres; se presenta mayormente en forma de infarto en edades entre 45 y 94 años. Objetivo: describir el caso de un paciente sometido a revascularización aorto-coronaria por cardiopatía isquémica con enfoque del proceso de atención de enfermería (PAE). Metodología: estudio de caso observacional y descriptivo con aplicación del PAE en el perioperatorio de un hombre de 50 años con cardiopatía isquémica crónica, enfermedad multivascular e hipertensión sistémica controlada de 6 años desde que inició, en un hospital público de tercer nivel en Mérida, Yucatán, México. Resultados: se demostró que si se aplica el PAE hay menor riesgo de shock hipovolémico ocasionado por sangrado activo y disminución de riesgo de infección del sitio de herida quirúrgica, evidenciado por el procedimiento quirúrgico extenso. Conclusiones: la metodología del PAE como método científico facilita innovaciones dentro de los cuidados enfermeros, además de las diferentes alternativas en las acciones a seguir para el tratamiento del paciente quirúrgico cardiovascular. También proporciona un método informativo para la atención de cuidados, desarrolla una autonomía para la enfermería y fomenta la consideración como profesional de salud.

Introduction: Ischemic heart disease was the leading cause of death in Mexico in 2020. Its prevalence increases with age and it is higher in men than in women; it is presented mostly as a heart attack between the ages of 45 and 94 years. Objective: To describe the case of a patient undergoing aorto-coronary revascularization for ischemic heart disease with a nursing care process (NCP) approach. Methodology: Observational and descriptive case study with application of NCP in the perioperative period of a 50-year-old man with chronic ischemic heart disease, multivessel disease and controlled systemic hypertension of 6 years since its onset, in a third level public hospital in Merida, Yucatan, Mexico. Results: It was demonstrated that by applying NCP there is a lower risk of hypovolemic shock caused by active bleeding and decreased risk of surgical wound site infection, evidenced by the extensive surgical procedure. Conclusions: The NCP methodology as a scientific method facilitates innovations within nursing care, in addition to the different alternatives in the actions to follow for the treatment of the cardiovascular surgical patient. It also provides an informative method for care, develops autonomy for nursing and promotes consideration as a health professional.

Cardiopatía isquémica. Consideraciones para la atención odontológica / Ischemic heart disease. Considerations for dental treatment

La cardiopatía isquémica es un padecimiento que se caracteriza por la falta de oxígeno del músculo cardiaco y es la principal causa de infarto de miocardio. Existen múltiples factores que predisponen al desarrollo de ésta como la obesidad, la hiperlipidemia, el sedenta- rismo, tabaquismo, diabetes e hipertensión. Dadas las características que configuran la fisiopatología de la cardiopatía isquémica, existen diversas consideraciones que deben ser tomadas en cuenta toda vez que el estomatólogo brinde atención a un paciente con este padecimiento. El objetivo del presente artículo es conocer todo lo relacionado con la fisiopatología de la cardiopatía isquémica, sus manifestaciones clínicas, su tratamiento médico y lo más importante, las consideraciones que deben tomarse en el consultorio dental cuando se atienda a un paciente que padezca esta condición (AU)

Ischemic heart disease is a condition characterized by a lack of oxygen in the heart muscle and is the main cause of myocardial infarction. There are multiple factors that predispose to the development of this, such as obesity, hiyperlipidemia, sedentary lifestyle, smoking, diabetes and hypertension. Given the characteristics that make up the pathophysiology of ischemic heart disease, there are various considerations that must be taken into account whenever the stomatologist provides care to a patient with this condition. The objective of this article is to know everything related to the pathophysiology of ischemic heart disease, its clinical manifestation, its medical treatment and most importantly, the considerations that must be taken in the dental office when caring for a patient with this condition (AU)

Instrumentos para la investigación de la muerte súbita cardiovascular / Tools for the study of sudden cardiovascular death

Introducción: La mitad de las muertes cardiovasculares son debidas a una de las manifestaciones de mayor impacto y significación dentro de la enfermedad isquémica del corazón: la muerte súbita cardiovascular. Objetivo: Describir el Algoritmo Diagnóstico y el Modelo de Recolección del Dato Primario utilizados como instrumentos para la investigación de la muerte súbita cardiovascular en Cuba. Métodos: Se presenta un Algoritmo Diagnóstico con la metodología para el estudio de los casos de muerte súbita cardiovascular y un Modelo de Recolección del Dato Primario con las principales variables sociodemográficas, clínicas y anatomo-patológicas. Resultados: El Grupo de Investigación en Muerte Súbita ha desarrollado, en un periodo de 25 años (1995-2020), investigaciones científicas con la aplicación del Algoritmo Diagnóstico y el empleo del Modelo de Recolección del Dato Primario. De las 33 718 muertes naturales estudiadas mediante estos instrumentos, se han documentado 2252 decesos súbitos, lo que representa el 6,6 por ciento de la mortalidad global registrada. Conclusiones: Se hace necesario por los colectivos de investigación disponer de instrumentos que permitan ejecutar estudios poblacionales sobre la muerte súbita cardiovascular, considerando que el 90 por ciento de los eventos anualmente sobreviene en este grupo(AU)

Introduction: Half of all cardiovascular deaths are due to sudden cardiovascular death, one of the manifestations with the greatest impact and significance in the realm of ischemic heart disease. Objective: Describe the Diagnostic Algorithm and the Primary Data Collection Model used as tools to study sudden cardiovascular death in Cuba. Methods: A presentation is made of a Diagnostic Algorithm for the study of sudden cardiovascular death cases accompanied by the corresponding methodology, and a Primary Data Collection Model with the main sociodemographic, clinical and anatomopathological variables. Results: The Sudden Death Research Team has used the Diagnostic Algorithm and Primary Data Collection Model herein presented as a scientific research tool for a period of 25 years (1995-2020). Of the 33 718 deaths by natural causes studied with these tools, 2 252 have been sudden, representing 6.6 percent of the overall mortality recorded. Conclusions: Research teams should have access to tools for the conduct of population studies about sudden cardiovascular death, considering that 90 percent of the events recorded annually occur in this risk group(AU)

Lesão Miocárdica após Cirurgia Não Cardíaca - Estado da Arte / Myocardial Injury after Non-cardiac Surgery - State of the Art

Resumo Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.

Abstract Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.

Aspecto da artéria coronária circunflexa retroaórtica por ecocardiografia transesofágica / Retroaortic circumflex coronary artery appearance by transesophageal echocardiography

O sinal RAC (retroaortic anomalous coronary ou artéria coronária anômala retroaórtica) é um achado desconhecido, descrito ao ecocardiograma transtorácico como uma estrutura tubular ecogênica, localizada na face atrial do sulco atrioventricular. Apresentamos um caso onde o sinal RAC se apresenta na ecocardiografia transesofágica (ETE). O conhecimento do sinal RAC e a avaliação com ETE aumentam a sensibilidade e a especificidade e conferem a oportunidade de avaliar características anatômicas de alto risco, importantes na avaliação do risco de morte súbita.(AU)

Etapas del climaterio y enfermedad cardiovascular en mujeres diabéticas de edad mediana / Stages of Climacteric and Cardiovascular Disease among Middle-Aged Diabetic Women

RESUMEN Introducción: La diabetes mellitus tipo 2 es considerada una situación de alto riesgo cardiovascular. En la mujer con diabetes se añade el riesgo que representa el déficit estrogénico posmenopáusico. Objetivo: Determinar la frecuencia de enfermedad cardiovascular en las etapas del climaterio. Métodos: Se realizó un estudio transversal y descriptivo con 611 mujeres con diabetes mellitus tipo 2 en edad mediana (40-59 años), que ingresaron consecutivamente en el Centro de Atención al Diabético de Bayamo, Granma, desde el año 2010 al 2017. Se excluyeron los casos con menopausia artificial. Se empleó la prueba de chi cuadrado para comprobar la relación que pudiera existir entre las variables cualitativas, mientras que para comparar los valores promedio de las variables cuantitativas entre los grupos se utilizó t de Student. Resultados: La frecuencia de hipertensión arterial, hipercolesterolemia y síndrome metabólico fue claramente superior en las mujeres posmenopáusicas que en las premenopáusicas (p = 0,0257; p = 0,0391 y p = 0,0591, respectivamente). Las enfermedades cardiovasculares aumentaron significativamente con la menopausia y con el tiempo de ocurrencia de este evento (p = 0,0014). La relación fue más notoria en el caso de la cardiopatía isquémica y la enfermedad arterial periférica (p = 0,0521 y p = 0,0011, respectivamente). Conclusiones: En las mujeres con diabetes mellitus tipo 2 la enfermedad cardiovascular aumenta significativamente con el avance de la peri a la posmenopausia tardía, fundamentalmente la cardiopatía isquémica y la enfermedad arterial periférica(AU)

ABSTRACT Introduction: Type 2 diabetes mellitus is considered a situation of high cardiovascular risk. Among diabetic women, the risk for postmenopausal estrogen deficiency is added. Objective: To determine the frequency of cardiovascular disease in climacteric stages. Methods: A cross-sectional and descriptive study was carried out with 611 middle-aged (40-59 years old) women with type 2 diabetes mellitus and who were admitted consecutively to the Diabetic Care Center in Bayamo city, Granma, from 2010 to 2017. The cases with artificial menopause were not included in the study. The chi-square test was used to verify the relationship that might exist between qualitative variables, while Student's t test was used to compare the average values of the quantitative variables between the groups. Results: The frequency of arterial hypertension, hypercholesterolemia and metabolic syndrome was clearly higher among postmenopausal women than among premenopausal women (p = 0.0257, p = 0.0391, and p = 0.0591, respectively). Cardiovascular disease increased significantly with menopause and with the time of occurrence of this event (p = 0.0014). The relationship was more noticeable in the case of ischemic heart disease and peripheral arterial disease (p = 0.0521 and p = 0.0011, respectively). Conclusions: In women with type 2 diabetes mellitus, cardiovascular disease increases significantly with the progression from the perimenopausal stage to the late postmenopausal stage, mainly ischemic heart disease and peripheral arterial disease(AU)

Prevalencia de la enfermedad renal oculta en adultos mayores con diabetes mellitus tipo 2 / Prevalence of the Hidden Renal Disease in elder people with diabetes mellitus type 2

RESUMEN Introducción: la Organización Mundial de la Salud, estima que la enfermedad renal crónica estará incluida dentro de las principales causas de discapacidad para el 2020. La prevalencia en países desarrollados es aproximadamente de 500 a 1400 pacientes por millón de habitantes y la incidencia anual se encuentra alrededor de 350 pacientes por millón de población. Objetivo: determinar la prevalencia de la enfermedad renal oculta e identificar algunos factores de riesgos predisponentes en adultos mayores con diabetes mellitus tipo 2 pertenecientes al Policlínico Universitario "Jimmy Hirzel", Bayamo, Granma, en el período comprendido entre junio 2016 - junio 2017. Materiales y métodos: se realizó estudio observacional descriptivo, de corte transversal en el que se incluyeron 180 gerontes con diabetes mellitus tipo 2. Resultados: se estableció el diagnóstico de enfermedad renal oculta en 167 individuos de 180 sujetos estudiados, el grupo de 70 - 79 años de edad fue el más afectado por la nefropatía crónica, mientras que el sexo femenino y la raza blanca fueron los de mayor prevalencia. Los principales factores de riesgo predisponentes de enfermedad renal oculta fueron: cardiopatía isquémica crónica, dislipemias e hipertensión arterial. Conclusiones: existe una alta morbilidad de enfermedad renal oculta en los senescentes estudiados.

ABSTRACT Introduction: the World Health Organization (WHO) estimates that chronic hidden renal disease (ERC) will be included within the principal causes of disability by 2020. The prevalence in developed countries is around 500 to 1400 patients per million inhabitants, and the yearly incidence is around 350 patients per million people. Objective: to determine the prevalence of the hidden renal disease and to identify some predisposing risk factors in elder people with type II diabetes mellitus belonging to the University Policlinic "Jimmy Hirzel", Bayamo, Gramma, in the period between June 2016 and June 2017. Material and methods: an observational descriptive, cross-sectional study was carried out in 180 elder people with type 2 diabetes mellitus. Results: the chronic hidden renal disease was diagnosed in 167 individuals from the 180 studied subjects; the 70-79 years-old-group was the most affected one by chronic renal disease, while the female sex and white race showed the highest prevalence. The main risk factors predisposing to chronic hidden renal disease were: chronic ischemic heart disease, dyslipidemia and arterial hypertension. Conclusions: there is a high morbidity due to hidden renal disease in the studied senescent people.

Fine particulate matter and ischemic heart diseases inrelation to sex. An ecological time series study

ABSTRACT BACKGROUND: Exposure to some air pollutants is associated with cardiovascular diseases. The objective of this study was to quantify the effect of exposure to fine particulate matter in hospitalizations due to ischemic heart disease and the costs to the healthcare system. DESIGN AND SETTING: Time-series ecological study conducted in Taubaté, Brazil. METHODS: Data on hospitalizations due to ischemic heart diseases (ICD I-20 to I-24) in the municipality of Taubaté (SP), Brazil, among adults of both sexes aged 40 years and over, from August 2011 to July 2012, were obtained from DATASUS. Fine particulate matter (PM2.5) concentrations were estimated from a mathematical model. Poisson regression was used in statistical analyses to estimate the relative risks of exposure to PM2.5 for both sexes and after stratification according to sex. The excess of hospitalizations and consequent excess expenditure for the healthcare system were calculated. RESULTS: There were 1040 admissions, among which 382 had ischemic heart diseases (257 males). Themean PM2.5 concentration was 13.2 µg/m3 (SD = 5.6). Significant effects from exposure were noted 4and 5 days after exposure (lag 4 and lag 5) for both sexes and for male sex; for female sex, the effect was 2 days after exposure (lag 2). There were 59 excess hospitalizations for an increase in PM2.5 concentration of 5 µg/m3 and excess expenditure of US$ 150,000 for the National Health System. CONCLUSIONS: An excess of hospital admissions due to ischemic heart disease, with excess expenditure, was identified consequent to PM2.5 exposure.

Diabetes mellitus tipo 2 y cardiopatía isquémica: fisiopatología, regulación génica y futuras opciones terapéuticas / Type II diabetes and ischemic heart disease: pathophysiology, gen regulation and future therapeutic options

Resumen: En los últimos años, la diabetes mellitus tipo 2 (DM2) ha evolucionado en forma epidémica, experimentando un rápido crecimiento y afectando a millones de individuos a nivel mundial. La cardiopatía isquémica es la principal causa de mortalidad en los pacientes diabéticos, quienes poseen un mayor riesgo cardiovascular respecto a los no diabéticos. La DM2 y la cardiopatía isquémica se caracterizan por ser prevenibles, sin embargo, existen diversos factores de riesgo comunes que contribuyen a su desarrollo. Los mecanismos que explican la ateroesclerosis acelerada y el incremento de riesgo de enfermedades cardiovasculares en los pacientes diabéticos tipo 2 incluyen a la hiperglicemia, dislipidemia y la inflamación del endotelio vascular. La diabetes es resultado de una interacción compleja entre la genética y el medio ambiente. Recientemente se han descrito varios genes implicados en el desarrollo de la diabetes y cardiopatía isquémica y que podrían significar nuevas opciones terapéuticas. En este artículo se revisa la relación entre ambas patologías, los mecanismos moleculares y el descubrimiento de factores de riesgo genéticos comunes y su implicancia en el desarrollo de nuevos blancos terapéuticos.

Abstracts: In recent years, type 2 diabetes mellitus has evolved as a rapidly increasing epidemic and affects millions of people worldwide. Ischemic heart disease (IHD) is the main cause of death among diabetic patients, who have a higher cardiovascular risk than non-diabetics. Both, DM2 and IHD are characterized by being preventable, however there are several common risk factors that contribute to their development. The mechanisms that explain accelerated atherosclerosis and increased risk of cardiovascular diseases in patients with type 2 diabetes mellitus include damage by hyperglycemia, dyslipidemia and inflammation on vascular endothelium. Diabetes is the result of a complex interaction between genetics and the environment, recently, several genes have been identified that appear to be involved in diabetes and ischemic heart disease that could explain its relationship and serve as new therapeutic possibilities. In this article, we review the relationship between diabetes and ischemic heart disease, the molecular mechanisms and the discovery of genetic risk factors common to both diseases and their implication in the development of new therapeutic targets.

Preditores da doença arterial coronariana obstrutiva em edema agudo de pulmão de origem não definida / Preditors of coronary obstructive disease in acute pulmonary edema of unclear origin

Background: Cardiogenic Acute Pulmonary Edema (APE) is considered one of the main medical emergencies, and it is the extreme manifestation of acute heart failure. The main etiology of heart failure is ischemic heart disease. To date, the definition of ischemic etiology in acute pulmonary edema was based on criteria such as: clinical history of ischemic heart disease, noninvasive examinations and, in other patients, coronary angiography. Classified as such, ischemic heart disease has been shown to be its main etiology. The high prevalence between these two diseases was evaluated, but not by the exclusive angiographic criterion, the gold standard of this pathology and the reason of this study. Objective: To evaluate the predictors of obstructive coronary artery disease in patients with acute pulmonary edema of unclear origin. Method: Patients admitted to a cardiovascular disease referral emergency unit were recruited to undergo coronary angiography if the acute pulmonary edema etiology was not adequately elucidated. Obstructive coronary disease was considered if at least one epicardial vessel had 70% of occlusion. Results: Obstructive coronary disease was classified by coronary angiography in 149 consecutively evaluated patients, and coronary artery obstruction was the outcome variable of the predictor model. Among the variables related to coronary disease, the predictor variables were the history of coronary artery disease (p < 0.001) and myocardium segmental deficit at the echocardiogram (p < 0.02). Conclusion: The antecedent of coronary disease and the myocardium segmental deficit at the echocardiogram were able to discriminate patients with acute pulmonary edema associated with obstructive coronary disease. Troponin values classified by two cardiologists as secondary to an acute non-ST-segment elevation myocardial infarction, and chest pain preceding the clinical picture were not able to discriminate patients with or without coronary obstruction and thus, the diagnosis of obstructive coronary disease should not be pursued based on the troponin value and/or chest pain preceding the clinical picture

Fundamento: O Edema Agudo de Pulmão cardiogênico é considerado uma das maiores emergências médicas, é a manifestação extrema da insuficiência cardíaca aguda. A principal etiologia da insuficiência cardíaca é a cardiopatia isquêmica. Até o momento, a definição da etiologia isquêmica no edema agudo de pulmão foi baseada em critérios como: história clínica de doença cardíaca isquêmica, exames não invasivos e, em outros pacientes, na cinecoronariografia. Desta forma classificada, a doença isquêmica do coração demonstrou ser sua principal etiologia. A alta prevalência entre estas duas doenças foi avaliada, mas não pelo critério angiográfico exclusivo, o padrão-ouro desta patologia, a razão deste estudo. Objetivo: Avaliar os preditores da doença arterial coronária obstrutiva nos portadores de Edema Agudo de Pulmão de origem claramente não definida. Método: Pacientes admitidos em um pronto-socorro de referência no tratamento das doenças cardiovasculares foram recrutados a realizar a coronariografia se a etiologia do edema agudo de pulmão não era devidamente esclarecida. A doença coronária obstrutiva foi considerada se ao menos um vaso epicádico tivesse oclusão = 70%. Resultados: A doença coronária obstrutiva foi classificada pela cinecoronariografia em 149 pacientes consecutivamente avaliados, a obstrução da artéria coronária foi a variável desfecho do modelo preditor. Dentre as variáveis relacionadas a doença coronária, as variáveis preditoras foram a história de doença da artéria coronária (p < 0,001) e o déficit segmentar do miocárdio ao ecocardiograma (p < 0,02). Conclusão: O antecedente de doença coronariana e o déficit segmentar do miocárdio ao ecocardiograma foram capazes de discriminar pacientes com edema agudo de pulmão associado a doença coronária obstrutiva. Valores da troponina classificados por dois cardiologistas como secundário a um infarto agudo do miocárdio sem elevação do segmento ST a e a dor torácica antecedendo o quadro não foram capazes de discriminar doentes com ou sem obstrução coronária, logo, o diagnóstico de doença coronária obstrutiva não deve ser perseguido baseado no valor da troponina e ou dor torácica antecedendo o quadro

Burden of ischemic heart disease mortality attributable to physical inactivity in Brazil

ABSTRACT OBJECTIVE To analyze if the burden of ischemic heart disease mortality trend attributed to physical inactivity in Brazil differs from the global estimates. METHODS Databases from the Global Burden of Disease Study for Brazil, Brazilian states, and global information were used. We estimated the summary exposure value for physical inactivity, the total number of deaths, and the age-standardized death rates for ischemic heart disease attributed to physical inactivity in the years 1990 and 2015, and the population-attributable fraction. Data were presented according to sex. RESULTS The Brazilian population was found to have a risk of exposure to physical inactivity varying between 70.4% for men and 75.7% for women in the year of 1990. This risk of exposure was similar in 2015. In men, the mortality rate from ischemic heart disease attributed to physical inactivity decreased in 2015 by approximately 24% around the world and 45% in Brazil. For women, this decrease was in 31% around the world and 45% in Brazil. The states of Southern and Southeastern Brazil presented lower mortality rates due to ischemic heart disease attributed to physical inactivity. If physical inactivity were eliminated in Brazil, mortality from ischemic heart disease would be reduced by 15.8% for men and 15.2% for women. CONCLUSIONS Over 25 years, the risk of exposure to physical inactivity in Brazil did not change and was high compared to global estimates. The decrease in ischemic heart disease mortality results from the improvement of health services in Brazil and the control of other risk factors. Approximately 15% of deaths from ischemic heart disease in Brazil could be avoided if people met the recommendations for physical activity.

Cambios electrocardiográficos asociados a hipopotasemia: alteraciones del segmento ST imitando isquemia miocárdica de múltiples territorios / Electrocardiographic changes associated with hypokalemia: ST-segment abnormalities mimicking ischemia of multiple territories

Resumen: Se presenta el caso de un paciente de sexo femenino de 42 años sin antecedentes clínicos de relevancia, con hipopotasemia severa y cambios electrocardiográficos imitando isquemia miocárdica con enfermedad corona-ria de múltiples vasos.

Abstracts: A 42-year-old woman with no previous medical history developed severe hypokalemia. The ECG changes suggested multivessel coronary artery disease with ischemia in several territories.

Blood transfusion and increased perioperative risk in coronary artery bypass grafts

Abstract Objective: To correlate blood transfusions and clinical outcomes during hospitalization in coronary artery bypass grafting surgery (CABG). Methods: Transfusion, clinical and hematological data were collected for 1,378 patients undergoing isolated or combined CABG between January 2011 and December 2012. The effect of blood transfusions was evaluated through multivariate analysis to predict three co-primary outcomes: composite ischemic events, composite infectious complications and hospital mortality. Because higher risk patients receive more transfusions, the hospital mortality outcome was also tested on a stratum of low-risk patients to isolate the effect of preoperative risk on the results. Results: The transfusion rate was 63.9%. The use of blood products was associated with a higher incidence of the three coprimary outcomes: composite infectious complications (OR 2.67, 95% CI 1.70 to 4.19; P<0.001), composite ischemic events (OR 2.42, 95% CI 1.70 to 3.46; P<0.001) and hospital mortality (OR 3.07, 95% CI 1.53 to 6.13; P<0.001). When only patients with logistic EuroSCORE ≤ 2% were evaluated, i.e., low-risk individuals, the mortality rate and the incidence of ischemic events and infectious complications composites remained higher among the transfused patients [6% vs. 0.4% (P<0.001), 11.7% vs. 24,3% (P<0.001) and 6.5% vs. 12.7% (P=0.002), respectively]. Conclusion: The use of blood components in patients undergoing CABG was associated with ischemic events, infectious complications and hospital mortality, even in low-risk patients.

High Prevalence and Clinical Implication of Myocardial Bridging in Patients with Early Repolarization

PURPOSE: Recent evidence suggests that early repolarization (ER) is related with myocardial ischemia. Compression of coronary artery by a myocardial bridging (MB) can be associated with clinical manifestations of myocardial ischemia. This study aimed to evaluate the associations of MB in patients with ER. MATERIALS AND METHODS: In consecutive patients (n=1303, age, 61±12 years) who had undergone coronary angiography, we assessed the prevalence and prognostic implication of MB in those with ER (n=142) and those without ER (n=1161). RESULTS: MB was observed in 54 (38%) and 196 (17%) patients in ER and no-ER groups (p<0.001). In multivariate analysis, MB was independently associated with ER (odd ratio: 2.9, 95% confidence interval: 1.98–4.24, p<0.001). Notched type ER was more frequently observed in MB involving the mid portion of left anterior descending coronary artery (LAD) (69.8% vs. 30.2%, p=0.03). Cardiac event was observed in nine (6.3%) and 22 (1.9%) subjects with and without ER, respectively. MB was more frequently observed in sudden death patients with ER (2 out of 9, 22%) than in those without ER (0 out of 22). CONCLUSION: MB was independently associated with ER in patients without out structural heart disease who underwent coronary angiography. Notched type ER was closely related with MB involving the mid portion of the LAD. Among patients who had experienced cardiac events, a higher prevalence of MB was observed in patients with ER than those without ER. Further prospective studies on the prognosis of MB in ER patients are required.

Factors associated with subendocardial ischemia risk in patients on hemodialysis / Fatores associados ao risco de isquemia subendocárdica em pacientes em hemodiálise

Abstract Introduction: Bone metabolism disorder (BMD) and vascular dysfunction contribute to excess cardiovascular mortality observed in hemodialysis patients. Vascular dysfunction, a new marker of atherosclerosis, can play a role in this risk. Even though associated with higher mortality in the general population, such vascular evaluation in patients on hemodialysis has not been extensively studied. Methods: In this cross-sectional study, hemodialysis patients were submitted to flow-mediated dilation, subendocardial viability ratio (SEVR) and ejection duration index assessment, in order to estimate the impact of BMD markers on vascular dysfunction. Results: A matched cohort of patients with (n = 16) and without (n = 11) severe secondary hyperparathyroidism (SHPT) was studied. Additionally, time spent under severe SHPT was also evaluated. Patients with severe SHPT had lower SEVR and higher ejection duration index, indicating higher cardiovascular risk. Lower SEVR was also associated to diastolic blood pressure (r = 0.435, p = 0.049), serum 25-Vitamin-D levels (r = 0.479, p = 0.028) and to more time spent under severe secondary hyperparathyroidism (SHPT), defined as time from PTH > 500pg/ml until parathyroidectomy surgery or end of the study (r = -0.642, p = 0.027). In stepwise multiple regression analysis between SEVR and independent variables, lower SEVR was independently associated to lower serum 25-Vitamin-D levels (p = 0.005), female sex (p = 0.012) and more time spent under severe SHPT (p = 0.001) in a model adjusted for age, serum cholesterol, and blood pressure (adjusted r² = 0.545, p = 0.001). Conclusion: Subendocardial perfusion was lower in patients with BMD, reflecting higher cardiovascular risk in this population. Whether early parathyroidectomy in the course of kidney disease could modify such results still deserves further investigation.

Resumo Introdução: Distúrbios do metabolismo ósseo (DMO) e alterações da função vascular contribuem para a elevada mortalidade de pacientes em hemodiálise. A disfunção vascular, um novo marcador de aterosclerose, pode contribuir para este risco. Apesar de associada a aumento de mortalidade na população geral, a avaliação de tal disfunção ainda não foi realizada de modo amplo em pacientes em hemodiálise. Métodos: Neste estudo transversal, pacientes em hemodiálise foram submetidos à avaliação da vasodilatação mediada por fluxo, razão de viabilidade subendocárdica (RVSE) e índice de duração de ejeção, como estimativas de avaliação dos marcadores de DMO sobre disfunção vascular. Resultados: Uma coorte pareada com (n = 16) e sem (n = 11) hiperparatireoidismo secundário (HPTS) grave foi estudada. Adicionalmente, o tempo transcorrido do diagnóstico de HPTS grave também foi avaliado. Pacientes com HPTS grave apresentaram menores valores de RVSE e maiores valores de índice de duração de ejeção, apontando maior risco cardiovascular. Baixa RVSE também foi associada à pressão arterial diastólica (r = 0,435, p = 0,049), níveis séricos de 25-Vitamina D (r = 0,479, p = 0,028) e maior tempo transcorrido desde diagnóstico de HPTS grave, definido como tempo em que o paciente permaneceu com valores de paratormônio superiores a 500 pg/ml até realização de cirurgia de paratireoidectomia ou término do estudo (r = -0,642, p = 0,027). Em regressão logística stepwise entre RVSE e variáveis independentes, menor RVSE foi independentemente associado a menores valores de 25-Vitamina D (p = 0,005), sexo feminino (p = 0,012) e maior tempo transcorrido desde diagnóstico de HPTS grave (p = 0,001) em um modelo ajustado para idade, colesterol sérico e pressão arterial (r2 ajustado = 0,545, p = 0,001). Conclusão: A perfusão subendocárdica foi menor em pacientes com DMO, refletindo o maior risco cardiovascular nesta população. Investigações adicionais são necessárias para definir se a paratireoidectomia precoce no curso da doença renal crônica poderia interferir neste risco.

Sevoflurane preconditioning during myocardial ischemia-reperfusion reduces infarct size and preserves autonomic control of circulation in rats

ABSTRACT PURPOSE: To investigate the myocardial ischemia-reperfusion with sevoflurane anesthetic preconditioning (APC) would present beneficial effects on autonomic and cardiac function indexes after the acute phase of a myocardial ischemia-reperfusion. METHODS: Twenty Wistar rats were allocated in three groups: control (CON, n=10), myocardial infarction with sevoflurane (SEV, n=5) and infarcted without sevoflurane (INF, n=5). Myocardial ischemia (60 min) and reperfusion were performed by temporary coronary occlusion. Twenty-one days later, the systolic and diastolic function were evaluated by echocardiography; spectral analysis of the systolic arterial pressure (SAPV) and heart rate variability (HRV) were assessed. After the recording period, the infarct size (IS) was evaluated. RESULTS: The INF group presented greater cardiac dysfunction and increased sympathetic modulation of the SAPV, as well as decreased alpha index and worse vagal modulation of the HRV. The SEV group exhibited attenuation of the systolic and diastolic dysfunction and preserved vagal modulation (square root of the mean squared differences of successive R-R intervals and high frequency) of HRV, as well as a smaller IS. CONCLUSION: Sevoflurane preconditioning better preserved the cardiac function and autonomic modulation of the heart in post-acute myocardial infarction period.

Identification of coronary heart disease in asymptomatic individuals with diabetes mellitus: to screen or not to screen / Identificación de enfermedad cardiaca coronaria en individuos asintomáticos con diabetes mellitus: Tamizar o no tamizar

Coronary heart disease (CHD) is highly prevalent in patients with diabetes mellitus (DM), and remains the single most common cause of death among this population. Regrettably, a significant percentage of diabetics fail to perceive the classic symptoms associated with myocardial ischemia. Among asymptomatic diabetics, the prevalence of abnormal cardiac testing appears to be high, raging between 10% and 62%, and mortality is significantly higher in those with abnormal scans. Hence, the potential use of screening for CHD detection among asymptomatic DM individuals is appealing and has been recommended in certain circumstances. However, it was not until recently, that this question was addressed in clinical trials. Two studies randomized a total of 2,023 asymptomatic diabetics to screening or not using cardiac imaging with a mean follow up of 4.4 ±1.4 yrs. In combination, both trials showed lower than expected annual event rates, and failed to reduce major cardiovascular events in the screened group compared to the standard of care alone. The results of these trials do not currently support the use of screening tools for CHD detection in asymptomatic DM individuals. However, these studies have important limitations, and potential explanations for their negative results that are discussed in this manuscript.

La enfermedad de la arterias coronarias (EAC) es muy prevalente en pacientes con diabetes mellitus (DM), y continúa siendo la principal causa de muerte en estos pacientes. Desafortunadamente, muchos diabéticos pueden carecer de síntomas de alerta en la presencia de isquemia miocárdica, por lo cual el diagnóstico de EAC puede ocurrir de manera tardía. Estudios observacionales han sugerido que la prevalencia de isquemia miocárdica puede ser alta en diabéticos asintomáticos (10 al 62% según la serie) y la mortalidad es mayor en esos pacientes. Por esto, el uso de pruebas para detección de EAC en el paciente diabético asintomático parece atractivo y es recomendado en ciertas circunstancias. Sin embargo, no fue si no hasta hace poco que dos estudios investigaron el verdadero rol de estas pruebas de manera randomizada. En conjunto, 2,023 pacientes diabéticos asintomáticos fueron aleatorizados a recibir o no una prueba para detección de EAC y fueron seguidos en promedio por 4.4 ±1.4 años. Al final de seguimiento, ambos estudios mostraron menos eventos cardiovasculares de los esperados, y el uso de pruebas para detección de EAC no redujo la tasa de eventos cardiovasculares comparado al no uso de estas pruebas. Los resultados de estos ensayos clínicos no soportan actualmente el uso de estas pruebas en el paciente diabético asintomático. Sin embargo, estos estudios tienen limitaciones importantes, y posibles hipótesis para explicar los resultados que son discutidas en el artículo.