¿Están correctamente anticoagulados nuestros pacientes con fibrilación auricular no valvular? / Are our patients with non-valvular atrial fibrillation receiving appropriate anticoagulation therapy?

Resumen Introducción: La fibrilación auricular es uno de los problemas de salud más importantes en el mundo por su elevada prevalencia, morbilidad y mortalidad, y porque es una causa importante de los ingresos hospitalarios y la principal indicación de la anticoagulación en atención primaria. Objetivo: El objetivo de nuestro estudio era definir el porcentaje de pacientes tratados, en la fibrilación auricular no valvular con anticoagulantes orales y las características clínicas de estos pacientes, calculando los riesgos embolígenos y hemorrágicos en este tipo de pacientes y su adecuación terapéutica. Pacientes y método: Estudio descriptivo, transversal y retrospectivo, pacientes de un centro de salud, de tres cupos de Atención Primaria con diagnóstico de fibrilación auricular no valvular. Variables: datos demográficos, antecedentes personales (hipertensión arterial, diabetes mellitus, dislipidemia, alcoholismo, tabaquismo, cardiopatía isquémica, insuficiencia cardiaca, enfermedad cerebrovascular, insuficiencia renal, arteriopatía periférica y embolia sistémica), cálculo de las escalas CHA2DS2-VASc y HAS-BLED. Resultados: Se encontraron 99 pacientes con fibrilación auricular no valvular de un total de 4.626 pacientes (2,15%). Edad media 77 ± 10 años, 52,5% mujeres y 47,5% hombres. El 33% no toma ningún tratamiento anticoagulante, el 53% toma el acenocumarol y el resto (13%) un Nuevo anticoagulante oral (dabigatran, apixaban o rivaroxaban). El 97% de los pacientes presentan CHA2DS2-VASc ≥ 2 (alto riesgo embolígeno), de los cuales el 30% no está tomando ningún tratamiento anticoagulante. El 80% de los pacientes presentan HAS-BLED ≥ 3 (alto riesgo hemorrágico), de los cuales el 55% toma el acenocumarol, presentando el 25% una razón internacional normalizada fuera de rango terapéutico. Conclusiones: La fibrilación auricular no valvular es una de las principales causas del accidente vascular cerebral en nuestros pacientes. Se demuestra que el tratamiento anticoagulante en aquellos pacientes con alto riesgo embolígeno reduce los eventos cerebrovasculares en un 64% y la mortalidad en un 26%. En nuestro medio la mayoría de los pacientes diagnosticados con fibrilación auricular no valvular presentan ese riesgo, pero tenemos un 33% no anticoagulado y un 25% mal controlado con el acenocumarol (un total del 46% de los pacientes). Todo esto implica que casi el 50% de nuestros pacientes con fibrilación auricular no valvular presenten alto riesgo tromboembólico por falta de tratamiento o ineficacia de este.

Abstract Introduction: Atrial fibrillation is one of the most important health problems in the world due to its high prevalence, morbidity and mortality, and because it is a frequent cause of hospital admission and the main indicator for anticoagulation therapy in primary care. Objective: The motivation of our study was to define the percentage of patients with nonvalvular atrial fibrillation treated with oral anticoagulants and their clinical characteristics, calculating risks for embolisms and bleeding in this type of patients and their appropriate therapeutic approach. Patients and methods: Descriptive, cross-sectional, retrospective study in patients of a primary care centre with three primary care quotas with a diagnosis of non-valvular atrial fibrillation. Variables: demographic data, personal history (arterial hypertension, diabetes mellitus, dyslipidemia, alcohol addiction, smoking habit, ischemic heart disease, heart failure, cerebrovascular disease, kidney failure, peripheral artery disease and systemic embolism), CHA2DS2-VASc and HAS-BLED scores. Results: Out of 4,626 patients, 99 (2.15%) were found to have nonvalvular atrial fibrillation. Average age 77 ± 10 years, 52.5% women and 47.5% men. 33% are not receiving any anticoa- gulation therapy, 53% takes acenocoumarol and the rest (13%) a new oral blood-thinning drug (dabigatran, apixaban or rivaroxaban). 97% of patients present a CHA2DS2-VASc ≥2 risk (high for embolism), of which 30% are not receiving any anticoagulation therapy. 80% of patients present HAS-BLED ≥ 3 risk (high for bleeding), of which 55% is taking acenocoumarol, 25% showing international normalized ratio out of the therapeutic range. Conclusion: Nonvalvular atrial fibrillation is one of the main causes of cerebrovascular accidents in our patients. It is shown that anticoagulation therapy in patients with high risk of embolism reduces cerebrovascular accidents by 64% and mortality by 26%. In our field, most patients diagnoses with nonvalvular atrial fibrillation have this risk, but 33% are not taking anticoagulants and 25% are poorly controlled with acenocoumarol (a total of 46% of patients). All this implies that 50% of our patients with non-valvular atrial fibrillation develop a high risk for thromboembolic events due to lack or inadequacy of the treatment.

Equine leukoencephalomalacia (ELEM) due to fumonisins B1 and B2 in Argentina / Leucoencefalomalacia equina devida a fumonisinas B1 e B2 na Argentina

In August 2007 an outbreak of neurological disease and sudden death in Arabian horses occurred in a farm located in Coronel Rosales County, Buenos Aires Province, Argentina. The animals were on a pasture of native grasses and supplemented ad libitum with corn kernels and wheat bran. Three horses were observed having acute neurologic signs including blindness, four leg ataxia, hyperexcitability, aimless walking and circling, followed by death in two of them. Four other horses were found dead overnight without a history of neurologic signs. The morbidity, mortality and lethality rates were 11.6 percent, 10 percent and 85.7 percent, respectively. Grossly, the brain showed focal areas of hemorrhage, brown-yellow discoloration and softening of the sub-cortical white matter. The microscopic brain lesions consisted of extensive areas of malacia within the white matter of the cerebral hemispheres, brainstem and cerebellum, characterized by rarefaction of the white matter with cavitations filled with proteinaceous edema, multifocal hemorrhages and mild infiltration by neutrophils, and rare eosinophils. Swollen glial cells with abundant eosinophilic cytoplasm, distinct cell borders, intracytoplasmic deeply eosinophilic globules and eccentric, hyperchromatic, occasionally pyknotic nucleus were present throughout the areas of rarefaction hemorrhage, edema and necrosis. The feed supplements contained 12,490µg/kg of fumonisin B1 and 5,251µg/ kg of fumonisin B2. This is the first reported outbreak of ELEM associated with consumption of feed supplements containing high concentrations of fumonisins in Argentina.

Em agosto de 2007, ocorreu um surto de doença neurológica e morte súbita em cavalos árabes em uma propriedade localizada no município de Coronel Rosales, na província de Buenos Aires, Argentina. Os animais estavam em pasto nativo e eram suplementados ad libitum com grãos de milho e farelo de trigo. Três cavalos foram observados com sinais neurológicos agudos, incluindo cegueira, ataxia nas quatro pernas, hiperexcitabilidade, e andar sem rumo e em círculo, seguidos de morte em dois animais. Outros quatro cavalos foram encontrados mortos durante a noite sem histórico de distúrbios neurológicos. A mortalidade, morbidade e letalidade foram de 11,6 por cento, 10 por cento e 85,7 por cento, respectivamente. Macroscopicamente, o cérebro tinha áreas focais de hemorragia, coloração amarelada e amolecimento da substância branca sub-cortical. Microscopicamente, as lesões cerebrais consistiram de extensas áreas de malácia na substância branca dos hemisférios cerebrais, do tronco encefálico e do cerebelo. Estas lesões da substância branca se caracterizaram por rarefação, cavidades contendo fluido proteináceo (edema), hemorragias multifocais e moderado infiltrado por neutrófilos e raros eosinófilos. Células gliais tumefeitas com abundante citoplasma eosinifílico, limites celulares evidentes, globules citoplasmáticos eosinofílicos, e núcleo excéntrico, hipercromático e ocasionalmente picnótico foram observadas nas areas de rarefacção, edema, hemorragias e necrose. Os suplementos alimentares continham 12.490µg/kg de fumonisina B1 e 5.251µg/ kg de fumonisina B2. Este é o primeiro surto reportado na Argentina de leucoencefalomalácia equina associado ao consumo de suplementos alimentares contendo altas concentrações de fumonisinas.