Fibrilación auricular una arritmia y un sindrome / Atrial fibrillation, an arrhythmia and a syndrome

Atrial Fibrillation (AF) is the most common sustained arrhythmia and is highly prevalent in elderly patients. It confers a higher risk for ischemic stroke, heart failure and death. The diagnosis and treatment of AF has been extensively studied and remain under constant revision. This article reviews the recent European guidelines and the advances observed with the introduction of direct oral anticoagulants in the last ten years. This new family of drugs has clear benefits in terms of efficacy and safety compared with traditional vitamin K antagonists. Treatment of most common comorbidities in patients with AF such as advanced age, heart failure, diabetes, renal failure, and others are also analyzed. New therapies for AF will be shortly available.

Bernard Lown y el arte de sanar / Bernard Lown and the art of healing

RESUMEN: Se presenta una semblanza del Dr. Bernard Lown, uno de los más destacados cardiólogos del siglo XX. Muy relevantes fueron sus estudios sobre arritmias ventriculares e isquemia miocárdica, como también la influencia del estrés sobre el umbral de la fibrilación ventricular. Simultáneamente con otros investigadores europeos desarrolló el cardiovertor eléctrico. Se releva particularmente su condición de gran clínico y el trato humano con sus pacientes. Finalmente, se destaca su contribución a evitar una guerra nuclear por lo cual, junto al Dr Chazov, recibió el Premio Nobel de la Paz.

ABSTRACT: This is a biographical note on Bernard Lown MD, recently deceased. He was one of the foremost cardiologist in the XXth century. Relevant were his studies on ventricular arrhythmias and myocardial ischemia, as well the effect of mental stress in lowering the ventricular arrhythmia threshold. Along with European researchs he developed the electric cardiovertor. Special emphasis is placed on his skills as a clinician and is humane approach to patient care. He contributed to international efforts to prevent nuclear war. For this effort he was awarded, along with Dr Chazov, the Nobel Peace Price.

Reperfusión fármaco-invasiva en el manejo del infarto agudo de miocardio en Chile: un llamado a la acción / Pharmaco-invasive reperfusion in acute myocardial infarction in Chile: a call for action

Resumen En Chile, se han logrado avances importantes en el manejo del Infarto Agudo de Miocardio (IAM) con elevación del segmento ST (IAMCEST). Debido a la mejoría en el diagnóstico precoz y tratamiento, particularmente, con el incremento de la Angioplastía Primaria (APP), hoy están dadas las condiciones para seguir progresando por la vía de la combinación de estrategias de reperfusión y la creación de Redes de Manejo del IAM. El siguiente artículo revisa la evidencia que justifica impulsar dicho avance y se esbozan posibles caminos para lograrlo.

Abstract In Chile, important advances have been made in the management of Acute Myocardial Infarction (MI) with ST segment elevation (STEMI). Due to the progress in early diagnosis and treatment, particularly with the increase in Primary Angioplasty (Primary PCI), nowadays there are conditions to improve early management through the combination of reperfusion strategies and the implementation of MI reperfusion networks. The present article reviews the evidence justifying the promotion of this strategy and outlines possible actions to achieve it.

Manejo de hemorragia asociada a anticoagulantes orales directos: estado actual de las estrategias de reversión / Management of bleeding associated with direct oral anticoagulants: update on reversal strategies

Direct oral anticoagulants (DOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban have at least comparable efficacy as vitamin K antagonists along with a better safety profile, reflected by a lower incidence of intracranial hemorrhage. Specific reversal agents have been developed in recent years. Namely, idarucizumab, a specific antidote for dabigatran, is currently approved in most countries. Andexanet, which reverses factor Xa inhibitors, has been recently approved by the FDA, and ciraparantag, a universal antidote targeted to reverse all DOACs, is still under investigation. In this review we provide an update on the pharmacology of DOACs, the risk of hemorrhagic complications associated with their use, the measurement of their anticoagulant effect and the reversal strategies in case of DOAC-associated bleeding.

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

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

Strain auricular izquierdo y biomarcadores cardíacos como predictores de accidente cerebrovascular en pacientes con fibrilación auricular de reciente comienzo / Left atrial strain and biomarkers for stroke in patients with recent onset atrial fibrillation

Introducción: La miopatía y fibrosis auricular representan el sustrato protrombótico y proarrítmico en pacientes con fibrilación auricular (FA). Estudios recientes muestran relación entre el strain auricular izquierdo (SAI), eventos cardiovasculares y recurrencia en pacientes con FA. La asociación entre SAI y bio-marcadores cardíacos como predictores de accidente cerebrovascular silente (ACVs) en pacientes con FA de reciente comienzo (FArc) no ha sido estudiada. Objetivo: Determinar si la asociación entre SAI y biomarcadores cardíacos contribuye a la predicción de ACV en pacientes con FArc. Métodos: Se realizó un estudio prospectivo que permitió reclutar 57 pacientes con FArc (primer episodio de < de 8 semanas de evolución). Obtenido consentimiento informado (CI) se realizó recolección de datos clínicos y muestras de sangre para determinación de Pro-BNP, Dimero-D y GDF-15. Se realizó resonancia nuclear magnética cerebral (RNMc) y ecocardiograma transtorácico (ETT) durante los primeros 3 días de inclusión y en ritmo sinusal. Para la evaluación de SAI se consideró la curva de deflexión positiva durante la sístole ventricular (SAIs), derivada de speckle tracking, considerando el promedio de 5 ciclos. Se utilizó Mann Whitney U test y Spearman Rho para análisis estadístico. Resultados: La edad promedio fue 70±8,2 años y el 70% fueron hombres. El CHA2DS2-VASc score promedio fue 3,1±1 y el promedio de pro-BNP, Di-mero-D y GDF-15 fue 96,1±12,4 pg/ml, 990±140 ng/ ml y 12 ng/ml respectivamente. 15% de los pacientes (n=9) presentaban ACVs en la RNMc al momento del diagnóstico. Se observó, además, que los pacientes con ACV presentaban un SAIs más bajo que los pacientes sin eventos (5,5±1,1% y 14,6±7,3% respectivamente p=0.04). Adicionalmente, se encontró una correlación significativa entre SAIs y pro-BNP, Dimero-D y GDF-15. Conclusiones: En este trabajo se evidenció que el 15% de los pacientes con FArc presenta ACVs al momento del diagnóstico. El SAIs bajo se correlaciona de forma inversa con los biomarcadores de sobrecarga, trombogénesis, fibrosis auricular y presencia de ACV silente. Estos resultados pueden ser utilizados para una mejor estratificación del riesgo de ACV en pacientes con FA.

Introduction: Atrial myopathy and fibrosis constitute a pro-arrhythmic and pro-thromboembolic substrate in patients with atrial fibrillation (AF). Recent studies using left atrial strain (LAS) have shown that LAS contributes to predict AF recurrence in patients with paroxysmal AF. The association between LAS and cardiac biomarkers in predicting silent stroke (SS) in patients with new AF has not been studied. Aim: The association of LAS and cardiac biomarkers contribute to predict SS in patients with new AF. Methods: We have prospectively evaluated 57 consecutive patients with new AF (first episode with less than 8 weeks of evolution). Baseline clinical characteristics and blood samples for determinations of Pro-BNP, D-Dimer and GDF-15 were obtained. Brain magnetic resonance (BMRI) and 2D Echo were performed within 3 days. In sinus rhythm, the positive deflection during ventricular systole of the LAS curve derived from speckle tracking was considered (mean of 5 cycles) (LASS). Mann Whitney U test and Spearman Rho were used for statistical analysis. Results: Mean age was 70±8,2 years, 70% were men. The mean CHA2DS2-VASc score was 3,1±1. Mean pro-BNP, D-Dimer and GDF-15 were 96,1±12,4 pg/ml, 990±140 ng/ml and 12 ng/ml, respectively. Fifteen percent of patients (n=9) had evidence of previous SS in BMRI. Patients with SS had significantly less LASS than patients without events (5,5±1,1% and 14,6±7,3% respectively p=0,04). In addition, a significant correlation between LASs and pro-BNP, D-Dimer and GDF-15 was found. Conclusion: Evidence of SS was found in 15% of patients with new AF. This was associated with LASs impairment, which was inversely correlated with cardiac biomarkers of LV overload, thrombogenesis and LA fibrosis. These findings could be utilized for a better risk stratification of stroke in patients with new AF.

Impacto de un programa de rehabilitación cardiovascular fase II sobre la calidad de vida de los pacientes / Quality of life: impact of a phase II cardiovascular rehabilitation program

Antecedentes: La rehabilitación cardiovascular (RCV) ha demostrado mejorar la capacidad física (CF) y la calidad de vida. La relación de estos aspectos ha sido escasamente reportada en Chile. Objetivos: 1) Determinar el impacto de la RCV fase II sobre la calidad de vida, medida por la encuesta SF36 y, 2) determinar qué factores, relacionados con el paciente, pueden incidir en esta relación. Método: Estudio prospectivo en sujetos que completaron 36 sesiones de un programa de RCV y Prevención Secundaria (PREV2). Se registraron al ingreso y final de la RCV: antecedentes médicos, factores de riesgo cardiovascular (CV), parámetros antropométricos, previsión de salud, CF (determinada por los metros caminados en test de marcha de 6 minutos-TM6) y puntaje en la encuesta SF36. Resultados: 277 sujetos (78% hombres, edad 59 años). Hubo una mejoría significativa en: a) los metros caminados (diferencia final/inicial= 56 metros, p<0.0001), b) puntaje de salud física (68 vs 79; p<0.0001), c) salud emocional (68 vs 78, p<0.0001) del SF36. Los hombres caminaron más metros promedio (p<0.0001). Hubo una asociación significativa entre los deltas del TM6 final-inicial y SF36 final-inicial, sólo para salud física (p<0.01). Por un aumento de 10 metros caminados en el TM6 final se incrementa el puntaje de la SF36 para salud física (Hombres: 0.38/ Mujeres: 1.52). La mejoría en la salud emocional sólo se asoció significativamente con los cambios en la salud física (p<0.0001). Conclusion: Los pacientes que asisten a un programa de RCV mejoran significativamente su capacidad aeróbica, y su percepción de salud física y emocional.

Background: Cardiovascular rehabilitation (CVR) has been shown to improve functional capacity (FC) and quality of life. The relation between these aspects has been scarcely reported in Chile. Objectives: 1) To determine the impact of the CVR phase II program on quality of life as measured by the SF36 survey and 2) to determine which patient related factors can influence this relationship. Method: Prospective study in subjects who completed 36 sessions of an RCV and Secondary Prevention program (PREV2). Medical records, cardiovascular risk factors (CV), anthropometric parameters, health forecast, functional capacity (FC) (determined by meters walked on 6-minute Walking test-TM6) and SF36 scores were recorded at the beginning and end of the CVR. Results: Data on 277 subjects (78% men, age 59 years) was analyzed. There was a significant improvement in: a) walking meters (final / initial difference = 56 meters, p <0.0001), b) physical health score (68 vs 79, p <0.0001), c) emotional health (68 vs 78, p <0.0001) of the SF36. The men walked more meters (p <0.0001). There was a significant association between delta TM6 final-initial and SF36 final-initial only for physical health (p <0.01). For an increase of 10 meters walked in the final TM6, SF36 score for physical health increased 0.38 points in men ad 1.52 in women. Improvement in emotional health was significantly associated only with changes in physical health (p <0.0001). Conclusion: Patients attending a phase II cardiovascular rehabilitation program significantly improve their aerobic capacity, and their perception of physical and emotional health.

Implante percutáneo de válvula aórtica con apoyo de circulación extracorpórea en paciente con insuficiencia aórtica severa / Trans catheter aortic valve implantation with extra corporeal circulation support in a patient with severe aortic insufficiency

An 84-year man with prior coronary artery bypass surgery and endovascular repair of an abdominal aortic aneurysm developed congestive heart failu-re. He had calcific aortic valve disease with severe regurgitation. A #29 Edwards-Sapien aortic valve via trans-apical approach was implanted with the patient connected to extra corporeal circulation. The patient recovered successfully and remained in functional class II 8 months after hospital dis-charge.

Evaluación de la anticoagulación con rivaroxaban, en pacientes con fibrilación auricular no valvular de reciente diagnóstico / Evaluation of oral anticoagulation with rivaroxaban, in patients with new onset non valvular atrial fibrillation

Background: Atrial fibrillation (AF) generates a hypercoagulable state with an increased thrombin generation and raised levels of thrombin-antithrombin complexes, which results in a high risk of stroke and thromboembolism. Aim: To evaluate the anticoagulant effect of rivaroxaban by anti-Xa factor activity and its correlation with thrombin-antithrombin complexes, thrombin generation and prothrombin time in patients newly diagnosed with non-valvular AF. Patients and Methods: Prospective study in patients with indication of anticoagulation. Demographic variables, cardiovascular risk factors, CHA2DS2-VASc and HAS-BLED scores were recorded. Blood samples were taken at baseline, at 3 and 24 hours after the administration of the drug and at 30 days. Rivaroxaban levels, anti-Xa activity, prothrombin time, thrombin generation and plasma levels of thrombin-antithrombin complexes were determined. Results: We studied 20 patients aged 76.3 ± 8.0 years (60% female) with a CHA2DS2-VASc score > 2 points. The anti-Xa factor activity correlated with rivaroxaban plasma levels at 3 hours (r = 0.61, p < 0.01), at 24 hours (r = 0.85, p < 0.01) and at 30 days (r = 0.99, p < 0.01), with prothrombin time at 3 hours (r = -0.86, p = 0.019) and at 30 days (r = -0.63, p = 0.02) and with a sustained decrease in thrombin generation at 30 days of follow-up (r = -0.74, p < 0.01). There was no correlation with thrombin-antithrombin complexes (r = -0.02, p = 0.83). Conclusions: Rivaroxaban consistently inhibited the mild pro-coagulant state found in newly diagnosed non-valvular AF patients through the first 24 hours and this effect was maintained at 30 days. Plasma levels of the drug correlated with anti-Xa factor activity, thrombin generation and prothrombin time

Características, manejo y evolución intrahospitalaria de usuarios de drogas ilícitas con infarto agudo del miocardio / Characteristics, management, and outcomes of illicit drug consumers with acute myocardial infarction

Background: Consumption of illicit drugs (ID) has been associated with an increased risk of acute myocardial infarction (AMI). There is limited national evidence about the impact of substance use over the clinical presentation, management and outcomes of AMI patients. Aim: To describe the prevalence of ID consumption in patients within the Chilean Registry of Myocardial Infarction (GEMI), comparing clinical characteristics, management and outcome according to consumption status. Material and Methods: We reviewed data from the GEMI registry between 2001 and 2013, identifying 18,048 patients with AMI. The sample was stratified according to presence or absence of previous ID consumption, comparing different demographic and clinical variables between groups. Results: Two hundred eighty five patients (1.6%) had history of ID consumption (cocaine in 66%, cannabis in 35% and central nervous system stimulants in 24.0%). Compared with non-users, ID consumers were younger, predominantly male and had a lower prevalence of cardiovascular risk factors, except for tobacco smoking (86.3% and 42.5% respectively, p < 0.01). Among consumers, there was a higher percentage of ST segment elevation (85.2% and 67.8% respectively, p < 0.01) and anterior wall AMI (59.9 and 49.5% respectively, p = 0.01). Additionally, they had a higher rate of primary angioplasty (48.8% and 25.5% respectively, p < 0.01). There was no difference in hospital mortality between groups when stratified by age. Conclusions: A low percentage of patients with AMI had a previous history of ID consumption in our national setting. These patients were younger and had a greater frequency of ST segment elevation AMI, which probably determined a more invasive management.

Efecto del nivel educacional en la sobrevida posterior a un infarto agudo de miocardio: Registro Chileno de Infarto de Miocardio, GEMI 2009-2012 / Effect of educational level on the prognosis of acute myocardial infarction

Background: Socioeconomic status is associated with cardiovascular mortality. Aim: To evaluate the effect of educational level, on the prognosis of patients with acute myocardial infarction in Chile. Material and Methods: Cohort study of 3,636 patients aged 63.1 ± 13.2 years, 27% women, hospitalized in 16 centers participating in the Chilean Myocardial Infarction Registry (GEMI) between 2009 and 2012. Vital status was obtained from the National Mortality Database. Patients were divided, according to educational level, in four groups, namely none (no formal education), basic (< 8 years), secondary (8-12 years) and tertiary (> 12 years). Crude and adjusted (age, sex, cardiovascular risk factors and treatments) hazard ratios (HR) were estimated using Cox regression models. Results: The distribution by educational level was 3.2% none, 31.8% basic, 43.0% secondary and 22.0% tertiary. During a median follow-up period of 22 months (interquartile range 11-37 years), 631 patients died (17.3%), of whom 198 died during hospitalization (5.5%). The 30 day case-fatality rate according to educational level was 3.4% in tertiary, 4.7% in secondary, 11.9% in basic, 19.1% in none (p < 0.0001). Among patients surviving the first 30 days, the case-fatality rate was 4.4%, 8.6%, 14.6% and 27.0%, respectively (p < 0.0001). The increased risk of death for groups with lower education compared with individuals with tertiary education, persisted in the multivariate analysis with a hazard ratio for secondary education 1.58 (95% confidence intervals (CI), 1.18-2.10); for basic education 1.90 (95% CI, 1.41-2.47) and for none 3.50 (95% CI, 2.35-5.21). Conclusions: A lower educational level was associated with a worse prognosis in patients with myocardial infarction, even after controlling for potential confounding factors.

Eficacia y seguridad del tratamiento anticoagulante oral con antagonistas de vitamina k en pacientes con prótesis valvulares cardíacas / Safety and efficacy of anticoagulation with vitamin k antagonists in patients with prosthetic heart valves

Introducción: Los pacientes con válvulas mecánicas cardíacas (VMC) representan una proporción significativa del total de pacientes que requieren anticoagulación. Sin embargo, hay pocos estudios que comparen la efectividad de la anticoagulación con distintos antagonistas de vitamina K (AVK). Objetivo: Comparar la efectividad y seguridad del tratamiento con warfarina y acenocumarol en pacientes con VMC. Métodos: Estudio observacional de pacientes en po-liclínico de anticoagulación UC sometidos a recambio valvular entre los años 2005 y 2013. Se estandarizó las dosis de AVK con software Isaza Hytwin Biostac 2.0. Se evaluaron registros de hemorragia mayor y menor (seguridad) y accidentes vasculares y embolías sistémicas (efectividad). La efectividad se analizó mediante el tiempo en rango terapéutico (TTR) con método de Ro-sendaal. Resultados: Se incluyó 365 pacientes con edad promedio de 64,1 +/- 13,2 años, 53,9 por ciento de sexo femenino. El seguimiento promedio fue de 33,3 +/- 18 meses; La mortalidad registrada fue 2,1 por ciento. El promedio de TTR fue 68 +/- 13,3 por ciento (recambio aórtico TTR 66,1 +/- 12,6 por ciento, recambio mitral TTR 65,8 +/- 13,8 por ciento y recambio mitro-aórtico TTR 61,2 +/- 12 por ciento). Acenocumarol presentó un TTR menor que warfarina (65,1 +/- 13,1 vs. 71,2 +/- 13,6, p = 0,001), sin aumento del riesgo de complicaciones. Conclusión: Aunque warfarina ofrece un mejor perfil de TTR, no existen diferencias significativas en la eficacia o seguridad al compararla con acenocumarol.

Background: Patients with cardiac mechanical valves (MHV) represent a significant proportion of all patients requiring anticoagulation. However, there are few studies comparing safety and efficacy of different vitamin K antagonists (VKA). Aim: To compare the efficacy and safety of warfarin and acenocoumarol in patients with MHV. Methods: Observational study of patients who had a mitral and /or aortic valve replacement between 2005 and 2013, followed at the Catholic University anticoagulation clinics. VKA dose adjustments were performed using the Isaza Hytwin Biostac 2.0 software. Major and minor bleeding (safety) and stroke and systemic embolism (effectiveness) were evaluated. The efficacy was estimated by the time in therapeutic range (TTR) with the Rosendaal method. Results: 365 patients were included with a mean age of 64.1 +/- 13.2 years, 53.9 percent of them were females. Mean follow-up was 33.3 +/- 18 months Overall mortality rate was 2.1 percent, which is similar to that of patients treated with VKA for other reasons. The average TTR was 68 +/- 13.3 percent (66,1 +/- 12,6 percent for aortic valves, 65,8 +/- 13,8 percent for mitral valves and 61,2 +/- 12 percent for aortic and mitral valves). TTR was lower with acenocoumarol compared to warfarin (65.1 +/- 13.1 vs. 71.2 +/- 13.6 , p = 0.001 ), However, the risk of complications was not different between groups. Conclusions: Although warfarin provides a better profile of TTR , there were no significant differences in efficacy or safety when compared with acenocoumarol.

Rehabilitación cardiovascular y ejercicio en prevención secundaria / Exercise and cardiac rehabilitation in secondary cardiovascular prevention

Exercise and cardiac rehabilitation are indications with type I A evidence in most secondary cardiovascular prevention guidelines. Rehabilitation programs not only include exercise but also provide integral care and education about cardiovascular risk factors. However there is a paucity of such programs in Chile. Moreover there is a lack of awareness about the benefits of exercise and there is lack of knowledge about the details of exercise prescription in secondary prevention. Therefore, the divulgation of this knowledge is of utmost importance.

¿Sirven los marcadores de riesgo no tradicionales en la diferenciación del riesgo cardiovascular en adultos jóvenes con exceso de peso? / Carotid intima media thickness and C reactive protein among overweight or obese subjects without metabolic syndrome

Background: Recognizing cardiovascular risk in overweight adults is challenging, as they usually have a low Framingham risk score (FRAM). In these subjects, non-traditional biomarkers could improve risk stratification. Aim: To assess carotid intima media thickness (CIMT) and ultrasensitive C-reactive protein (usCRP) among overweight and obese subjects without metabolic syndrome (MetSyn). Subjects and Methods: In 1558 asymptomatic participants (816 women, 45 ± 11 years) we measured body mass index (BMI), waist circumference, blood pressure, lipid profile, blood glucose, FRAM, usCRP and CIMT. For analytical purposes, we divided the subjects in three groups according to BMI and number of ATPIII-MetSyn risk factors (RF): 1) BMI < 25 and < 3RF, 2) BMI ≥ 25 and < 3RF and 3) BMI ≥ 25 and ≥ 3RF. Results: Participants of group 2 (BMI ≥ 25 and < 3RF) had a low FRAM (8%). Compared with participants of group 1, they had a higher CIMT (0.61 ± 0.1 and 0.57 ± 0.09 mm, respectively, p < 0.01) and usCRP (2.1 ± 2.1 and 1.5 ± 1.9 mg/L respectively, p < 0.01). Conclusions: This study shows that although subjects with overweight/obesity without MetSyn have low cardiovascular risk based on FRAM, they have higher CIMT and usCRP than their normal weight counterparts.

Relación colesterol total a HDL y colesterol no HDL: los mejores indicadores lipídicos de aumento de grosor de la íntima media carotidea / Total/HDL cholesterol ratio and non HDL cholesterol as predictors for increased intima media thickness

Background: LDL, HDL cholesterol and triglycerides, are the most commonly used lipid cardiovascular risk predictor indicators. However population based studies have shown that non-HDL cholesterol and total/HDL cholesterol ratio are better predictors, are easy to measure and do not require fasting. Aim: To determine which lipid indicators are better determinants of subclinical atherosclerosis, measured by intima media thickness (IMT) among subjects without demonstrated atherosclerosis. Material and Methods: Lipid profile, height, weight, blood pressure and bilateral IMT, measured by ultrasound with automatic border recognition software, were assessed in 770 men and 854 women aged 45 ± 11 years, in Santiago de Chile. Results: Mean total cholesterol was 202, HDL 50, LDL 121, triglycerides 157 and non-HDL cholesterol 152 mg/dl. Total/HDL cholesterol ratio was 4.3. MeanIMTwas 0.62 mm. All lipid markers were significantly correlated with IMT. This correlation was higher for non-HDL cholesterol (r = 0.24, p < 0.0001) and total/HDL cholesterol ratio(r = 0.23, p < 0.0001). In both men and women, total/HDL cholesterol ratio was the best predictor of having an IMT over the 75th percentile (odds ratio 1.21, 95% confidence intervals 1.09-1.35, p < 0.01). Conclusions: Total/HDL cholesterol ratio was the best determinant of subclinical atherosclerosis.

Perfil de riesgo cardiovascular en adultos jóvenes asintomáticos con grosor íntima media carotídeo elevado / Cardiovascular risk factors among young subjects with high carotid intima media thickness

Background: Cardiovascular risk factor (RF) assessment is essential to prevent and predict cardiovascular disease. The presence of RF at early ages, are determinant for the presence of atherosclerosis later in life. Aim: To determine the RF profile of young subjects with high carotid intima media thickness (CIMT). Material and Methods: We studied 689 subjects (50 percent women, mean age 36±6 years) from Santiago, Chile. We determined body mass index (BMI), waist circumference, blood pressure, fasting serum lipids, blood glucose and C-reactive protein. CIMT was assessed by ultrasound using an automatic border recognition software. Results: Body mass index, waist circumference, blood pressure and serum lipids were significantly higher among subjects located in the higher CIMT quartile. Also, subjects in the higher quartile of CIMT had a higher prevalence of three or more RF compared with the lower quartile (p = 0.01). Finally, individuals with three or more RF showed three times more risk of being in the higher CIMT quartile, than subjects with no RF (odds ratio = 3.1, p < 0.01). Conclusions: There is a negative influence of cardiovascular RF on CIMT among young subjects.

Resultados Chilenos del registro internacional de factores de riesgo y tratamiento de angina inestable e infarto al miocardio sin supradesnivel del segmento ST: ACCORD (ACute CORonary syndrome Descriptive study) / Chilean results of the international registry of risk factors and treatment of unstable angina and non ST elevation myocardial infarction: ACCORD (ACute CORonary syndrome Descriptive study)

Background: Guidelines for the management of unstable angina (UA) and non ST elevation myocardial infarction (NSTEMI) have been issued, however cu-rrent practices are unknown in Chile. Aitn: To evalúate in a prospective cohort of NSTEMI patients the current practices, treatments and risk factors. Material and Methods: Oneyear prospective International non interventional registry, conducted in Chile between January 2005 and November 2006. Results: Two hundred thirty three Chilean NSTEMI patients were enrolled. Mortality was 5.5 percent at the end ofthe follow-up. Mean age was 61.6 years, and 30.6 percent were female. Most of the patients had at least one risk factor (98 percent): hypertension (84 percent), previous myocardial infarction (33 percent), dyslipidemia (54 percent), diabetes (33 percent), current smoking (30 percent). Main procedures duringthe hospitalization were coronary angiogram (67 percent), angioplasty (33 percent; 88 percent with stent) and coronary bypass surgery (7 percent). Duringprocedures, 31 percent of patients received clopidogrel, and 4.2 percent glycoprotein Ilb/IIIa antagonists. Medical management was selected for 60 percent of patients. In comparison to men, women received less interventional procedures despite havingmore risk factors. Treatments prescribed at discharge were aspirin (97 percent), clopidogrel (49 percent), beta blockers (78 percent), diuretics (21 percent), lipid lowering agents (78 percent), oral hypoglycemic agents (13 percent) and insulin (9 percent). At the end ofthe 1-year follow-up, treatments were aspirin (84 percent), beta blockers (72 percent), diuretics (19 percent), and dual antiplatelet therapy with clopidogrel (16 percent). Conclusions: A high prevalence of múltiple risk factors for cardiovascular disease in Chilean patients with NSTEMI was observed. More aggressive primary and secondary preventive measures are urgently needed. Use of therapies proposed in the guidelines is high, but dual antiplatelet therapy is less than 50 percent at discharge and decreases during the one year-follow-up.