Chronic exposure to high altitude and the presence of coronary ectasia in patients with ST elevation myocardial infarction.

Objective: To evaluate the association between chronic exposure to high altitude and the presence of coronary ectasia (CE) in patients with ST-segment elevation myocardial infarction (STEMI) treated in a highly specialized cardiovascular reference hospital in Peru. Materials and methods: Retrospective matched case-control study. The cases were patients with CE and controls without CE. The relationship between CE and chronic exposure to high altitude was evaluated considering intervening variables such as arterial hypertension, diabetes mellitus, dyslipidemia, smoking, and hematocrit values. Patients with chronic inflammatory pathologies, chronic obstructive pulmonary disease, and previous revascularization were excluded. Multivariate logistic regression was applied to obtain the OR value and their respective confidence intervals. Results: Eighteen cases and 18 controls were studied, most of them were men with an average age of 65 years. Thirty-six percent of the population came from high altitude; in this group 76.9% had coronary ectasia of the infarct-related artery. The mean hematocrit value was slightly higher in the high-altitude native (46 ± 7% versus 42 ± 5%, p=0.094). Multivariate conditional logistic regression did not find a significant relationship between exposure to high altitude and the risk of presenting CE (OR:6.03, IC95%: 0.30-118, p=0.236). Conclusions: In patients with STEMI, we found no association between chronic exposure to high altitude and coronary ectasia.

Objetivo: Evaluar la asociación entre la exposición crónica a gran altura y la presencia de ectasia coronaria (EC) en pacientes con infarto de miocardio con elevación del segmento ST (IAMCEST) tratados en un hospital de referencia de alta especialidad cardiovascular en Perú. Materiales y métodos: Estudio retrospectivo de casos y controles emparejados. Los casos fueron pacientes con EC y los controles sin EC. Se evaluó la relación entre EC y exposición crónica a la altura, teniendo en cuenta variables intervinientes como hipertensión arterial, diabetes mellitus, dislipidemia, tabaquismo y valores de hematocrito. Se excluyeron los pacientes con patologías inflamatorias crónicas, enfermedad pulmonar obstructiva crónica y revascularización previa. Se aplicó una regresión logística multivariable para obtener el valor OR y sus respectivos intervalos de confianza. Resultados: Se estudiaron 18 casos y 18 controles, la mayoría hombres con una edad media de 65 años. El 36% de la población procedía de zonas de gran altitud, de ellos, el 76,9% presentaba ectasia coronaria en la arteria responsable del infarto. El valor medio de hematocrito era ligeramente superior en los nativos de altitud (46 ± 7% frente a 42 ± 5%, p=0,094). La regresión logística condicional multivariable no encontró una relación significativa entre la exposición a gran altitud y el riesgo de presentar EC (OR:6,03, IC95%: 0,30-118, p=0,236). Conclusiones: En pacientes con IAMCEST no encontramos asociación entre la exposición crónica a gran altitud y la presencia de ectasia coronaria.

[Proposal for initial management of uncomplicated ST elevation myocardial infarction in centers without percutaneous coronary intervention capacity in Peru]. / Propuesta de manejo inicial del infarto de miocardio con elevación del segmento ST no complicado en centros sin capacidad de intervención coronaria percutánea en el Perú.

ST-segment elevation myocardial infarction (STEMI) is a clinical entity whose adequate treatment will depend on its prompt recognition, accurate diagnosis, and management in reperfusion networks. The first contact with these patients is generally done in centers without reperfusion capacity, attended by non-cardiologist doctors, and in centers far from hospitals with greater resolution capacity, something that is well known in our country. This manuscript proposes a strategy for the diagnosis and treatment of STEMI in centers without percutaneous coronary intervention capacity of the public health system in Peru, emphasizing not losing sight of electrocardiographic patterns compatible with coronary artery occlusion, adequate fibrinolysis and management of its complications, the treatment of infarction in special populations and highlighting the importance of the pharmacoinvasive strategy as the main form of reperfusion treatment in our country.

Late myocardial reperfusion in ST-elevation myocardial infarction: protocol for a systematic review and meta-analysis.

INTRODUCTION: ST-segment elevation myocardial infarction (STEMI) is the most severe clinical form of acute myocardial infarction, for which the current treatment consists of effective and timely myocardial reperfusion (within 12 hours of symptom onset). However, between 10% and 15% of patients with STEMI arrive at hospital facilities 12 hours after the onset of symptoms (late presentation). Therefore, the objective of the present study will be to determine if late revascularisation (12-72 hours after the onset of symptoms) affects the indicators of cardiovascular mortality, reinfarction, recurrent infarction, hospitalisation for heart failure and post infarction angina compared with no late revascularisation in patients with STEMI. METHODS AND ANALYSIS: A systematic literature search of PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus and Global Health will be conducted. Publications in English, Portuguese or Spanish that report the clinical results of primary percutaneous revascularisation (primary PCI) in adult patients with STEMI 12-72 hours after the onset of symptoms will be included. Studies with participants with a diagnosis other than STEMI or patients with STEMI of >12 hours complicated by heart failure, cardiogenic shock or ventricular arrhythmias, and studies of combined interventions (pharmacoinvasive strategy) were excluded. Two independent authors will identify the relevant publications, and discrepancies will be adjudicated by a third author. Data extraction will be performed by two independent authors and verified by a third author. Risk of bias of studies will be assessed using the Cochrane 'risk of bias' tool (RoB 2) or Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. If appropriate, a meta-analysis will be performed in order to examine the effect of late revascularisation in clinical outcomes of interest. ETHICS AND DISCUSSION: This study will use published data only, thus, ethical approval will not be required. The results will be disseminated through peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021283429.

Study Protocol for the Peruvian Registry of Advanced Heart Failure (REPICAV).

Background: Heart failure (HF) is a global problem with a high mortality rate, and advanced HF (AHF) represents the stage with the highest morbidity and mortality. We have no local data on this population and its treatment. The aim of this study will be to determine the epidemiological, clinical, therapeutic, and annual survival characteristics of patients diagnosed with AHF treated in hospitals with HF units in the city of Lima, Peru. Methods and Analysis: An observational, prospective, multicenter study will be conducted with evaluation at baseline and follow-up at 1, 3, 6, and 12 months after study entry. Patients over 18 years of age with AHF seen in referral health facilities in metropolitan Lima will be included. The cumulative mortality during follow-up will be estimated by the Kaplan-Meier method, and Cox regression models will calculate hazard ratios (HRs) and 95% confidence intervals (CI). Likewise, risk ratio (RR) and 95% CI will be estimated using generalized linear models with binomial family and log link function. This study was approved by the Ethics and Research Committee of the National Cardiovascular Institute (Instituto Nacional Cardiovascular "Carlos Alberto Peschiera Carrillo"-INCOR [in Spanish]; Approval report 46/2021-CEI). Discussion: In Peru, there are no scientific data on the epidemiology of AHF in the population. This means that physicians are not adequately trained in the characteristics of the Peruvian population to identify patients who could be candidates for advanced therapies and to recognize the optimal time to refer these patients to more complex HF units. This study will be the first to examine the clinical-epidemiological characteristics of AHF in Peru with a follow-up of 1 year after the event and will provide relevant information on these observable characteristics for the management of high-complexity patients.

Outcomes in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention or pharmacoinvasive strategy in a Latin American country.

OBJECTIVE: The primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). The pharmacoinvasive strategy (PIs) is a reasonable alternative when prompt PPCI is not possible, especially in resource-limited regions. We aimed to compare PPCI versus PIs outcomes in Peru. METHODS: This was a retrospective cohort study based on the second Peruvian Registry of STEMI (PERSTEMI II). We compared the characteristics, in-hospital outcomes and 30-day mortality of patients undergoing PPCI during the first 12 h and those receiving a PIs. A propensity score-matched analysis was conducted to compare the effects of each treatment strategy on clinical outcomes. RESULTS: PIs patients were younger than PPCI patients, had a shorter first medical contact time, first medical contact to reperfusion time, and total ischemic time until reperfusion. Successful PCI was more frequent in the PIs group (84.4% vs. 71.1%, p = 0.035). There were no differences between PIs and PPCI in terms of total in-hospital mortality (5.2% vs. 6.6%, p = 0.703), cardiovascular mortality (4.2% vs. 5.3%, p = 0.735), cardiogenic shock (8.3% vs. 13.2%, p = 0.326), heart failure (19.8% vs. 30.3%, p = 0.112), or major bleeding (0% vs. 2.6%, p = 0.194). In the propensity score-matched analysis, the rates of cardiovascular mortality, postinfarction heart failure and successful reperfusion were similar. CONCLUSIONS: In this real-world study, no differences were found in the in-hospital outcomes between patients with STEMI who received PIs or PPCI.

Association between Altitude and the Framingham Risk Score: A Cross-Sectional Study in the Peruvian Adult Population.

To determine the association between altitude and the Framingham risk score in the Peruvian population, we performed a cross-sectional analytical study of data collected by the 2017-2018 Food and Nutrition Surveillance by Life Stages survey. The outcome of this study was the Framingham 10-year cardiovascular disease event risk prediction, which is composed of six modifiable and non-modifiable coronary risk factors. A generalized linear model (GLM) of the gamma family and log link function was used to report the crude and adjusted ß coefficients. Several sensitivity analyses were performed to assess the association of interest. Data from a total of 833 surveyed participants were included. After adjusting for educational level, poverty level, alcohol consumption, physical activity level, the presence of any limitation, obesity, and area of residence, it was observed that altitude ≥ 2500 m above sea level (ß = -0.42 [95% CI: -0.69 to -0.16]) was negatively and significantly associated with a decrease in the Framingham 10-year risk score. High altitude was significantly and negatively associated with Framingham 10-year risk scores. Our results will allow prevention strategies considering modifiable risk factors to avoid the development of cardiovascular diseases, especially in people living at low altitudes.

[Clinical variables associated with no-reflow after percutaneous coronary intervention in ST-segment elevation myocardial infarction: Secondary analysis of the PERSTEMI I and II study]. / Variables clínicas asociadas a no reflujo tras la intervención coronaria percutánea en el infarto de miocardio con elevación del segmento ST: análisis secundario del estudio PERSTEMI I y II.

Objective: To determine the clinical factors associated to no-reflow after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) in Peru. Materials and methods: Case - control retrospective study, derived from the PERSTEMI (Peruvian Registry of ST-elevation myocardial infarction) I and II study. Cases (group 1) were those patients who presented no-reflow after PCI, defined by a TIMI flow < 3, and controls (group 2) were those with a TIMI 3 flow after the intervention. Clinical and angiographic variables were compared between both groups, and a multivariate analysis was performed looking for associated factors to no-reflow. Results: We included 75 cases and 304 controls. The incidence of no-reflow was 19.8%. There was a higher frequency of no-reflow in patients with primary PCI compared to the pharmacoinvasive strategy, in patients with one-vessel disease and in those with TIMI 0 before PCI. In-hospital mortality and heart failure were higher in patients with no-reflow (21.3% vs. 2.9% and 45.3% vs. 16.5, respectively; p<0.001). After the multivariate analysis, the ischemia time > 12 hours, Killip Kimball (KK) > I, TIMI 0 before PCI, and one-vessel disease were the factors significantly associated with no-reflow after PCI. Conclusions: The ischemia time greater than 12 hours, the highest KK score, the presence of an occluded culprit artery (TIMI 0) before PCI and an one-vessel disease, were factors independently associated to no-reflow in patients with STEMI in Peru.

[One-year survival among patients with ST-elevation myocardial infarction in Peru]. / Sobrevida al año en pacientes con infarto de miocardio con elevación del segmento ST en el Perú.

Objectives: To determine one-year survival and factors associated with mortality in patients with ST-segment elevation myocardial infarction in Peru. Methods: An analysis was made of the cohort of patients included in the PERSTEMI-II registry during the year 2020, in whom survival at one year after the event and its risk factors were evaluated using Kaplan-Meier survival analysis and Cox regression. Results: Of 374 patients in the PERSTEMI-II study, 366 (97.9%) completed follow-up up to one year after the event with a survival rate of 85%. Successful reperfusion was related to better survival at 1 year (hazard ratio [HR]=0.30, 95% CI: 0.14-0.62, p=0.001). Age (HR=1.04, 95% CI: 1.01-1.07, p=0.003), chronic kidney disease (HR=2.15, 95% CI: 1.04-4.39, p=0.037) and cardiogenic shock (HR=6.67, 95% CI: 3.72-11.97, p<0.001) were factors of higher mortality at 1-year follow-up. Conclusion: The PERSTEMI-II registry is the first Peruvian registry that provides data on survival after ST-segment elevation myocardial infarction, which is 85% at one year. Successful reperfusion improves survival at one-year post infarction.

Study protocol of the PEruvian Registry of ST-segment Elevation Myocardial Infarction II (PERSTEMI-II) study.

BACKGROUND: Myocardial infarction (MI) is the most prevalent cardiovascular disease globally and is considered a public health problem. In Peru, MI is the second leading cause of death at the national level, with a mortality rate that exceeds 10% in the hospital setting. The study aims to determine the clinical and epidemiological characteristics of ST-segment elevation myocardial infarction (STEMI) in tertiary care facilities belonging to the Peruvian public health system. METHODS AND ANALYSIS: This will be a prospective, observational, multicenter study, with baseline and two follow-up assessments: at admission to the health service, and 30 days and 12 months after admission. This multicenter study will be conducted in 27 hospitals located in the main cities of Peru. The patients included in the study will be over 18 years of age, of either sex, and will have been admitted to the health facility with a diagnosis of acute coronary syndrome with ST-segment elevation. The Kaplan-Meier method will be used to estimate the cumulative in-hospital mortality of patients at 30 days and 12 months of follow-up, and the log-rank test will be used to evaluate the differences between the survival curves between reperfused and non-reperfused patients. Subsequently, to evaluate the risk factors for successful reperfusion and cardiovascular adverse events, generalized linear models of the binomial family with log link function will be used to estimate the bivariate and multivariate relative risk (RR) with their respective 95% confidence intervals. This project was approved by the Ethics and Research Committee of the National Cardiovascular Institute (Instituto Nacional Cardiovascular "Carlos Alberto Peschiera Carrillo"-INCOR [in Spanish]; Approval report 21/2019-CEI). DISCUSSION: Among the strengths, the observational design will allow the inclusion of a large sample of patients, which will significantly contribute to the knowledge base on STEMI in Peru. It should be noted that this study is the first to examine the clinical-epidemiological characteristics of STEMI in high-resolution hospital centers in Peru with follow-up one year after the event, providing knowledge of these observable characteristics in daily clinical routine. Likewise, the multicenter nature of the study will increase the external validity of the findings. In terms of limitations, the observational design of the study can only describe associations and not causality. Furthermore, since data from medical records will be used, there could be imprecision in the data.

Regional differences in presentation characteristics, use of treatments and outcome of patients with cardiogenic shock: Results from multicenter, international registry.

BACKGROUND: Concurrent evidence about cardiogenic shock (CS) characteristics, treatment and outcome does not represent a global spectrum of patients and is therefore limited. The aim of this study was to investigate these regional differences. METHODS: To investigate regional differences in presentation characteristics, treatments and outcomes of patients treated with all types of cardiogenic shock (CS) in a single calendar year on a multi-national level. Consecutive patients from 19 tertiary care hospitals in 13 countries with CS who were treated between January 1, 2018 and December 31, 2018 were enrolled in this study. RESULTS: In total, 699 cardiogenic shock patients were included in this study. Of these patients, 440 patients (63%) were treated in European hospitals and 259 (37%) were treated in Non-European hospitals. Female patients (P<0.01) and patients with a previous myocardial infarction (P=0.02) were more likely to present at Non-European hospitals; whereas older patients (P=0.01) and patients with cardiogenic shock due to acute heart failure (P<0.01) were more likely to present at European hospitals. Vasopressor use was more likely in Non-European hospitals (P=0.04), whereas use of mechanical circulatory support (MCS) was more likely in European hospitals (P<0.01). Despite adjustment for relevant confounders, 30-day in-hospital mortality risk was comparably high in CS patients treated in European vs. Non-European hospitals (hazard ratio 1.08, 95% CI 0.84-1.39, P=0.56). CONCLUSION: Despite marked heterogeneity in characteristics and treatment of CS patients, including fewer use of MCS but more frequent use of vasopressors in Non-European hospitals, 30-day in-hospital mortality did not differ between regions.

Undiagnosed hypertension in Peru: analysis of associated factors and socioeconomic inequalities, 2019.

OBJECTIVE: To determine the factors associated and measure the socioeconomic inequalities in people with undiagnosed hypertension in Peru. MATERIALS AND METHODS: An observational, cross-sectional, analytical study was performed using data from the 2019 Demographic and Family Health Survey (ENDES, acronym in Spanish) database. The dependent variable was the presence of undiagnosed hypertension (mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥90 mmHg in the two blood pressure measurements and with no prior diagnosis of hypertension by a health care professional). Adjusted prevalence ratios were estimated to determine the factors associated with undiagnosed hypertension. The socioeconomic inequality in undiagnosed hypertension was estimated using concentration curves and the Erreygers concentration index. RESULTS: 67.2% of 3697 persons with hypertension had not been diagnosed. Non-diagnosis of hypertension was more prevalent in men who were residents of the Coast and in inhabitants residing at more than 3000 m above sea level. Being 50 years of age or older, having health insurance, being obese and having diabetes mellitus were associated with a lower prevalence of undiagnosed hypertension. Inequality of the non-diagnosis of hypertension was found to be concentrated in the poorest population. CONCLUSIONS: At least one out of every two adult Peruvians with hypertension have not been diagnosed with this condition. Socioeconomic inequality was found, as well as socio-demographic and health-related factors associated with undiagnosed hypertension. Our findings identify some population subgroups in which interventions for screening and treatment of hypertension should be prioritized in order to reduce both inequalities and complications of hypertension among the most vulnerable.

[Treatment of acute myocardial infarction in Peru and its relationship with in-hospital adverse events: results from the second peruvian registry of ST-segment elevation myocardial infarction (PERSTEMI-II).] / Tratamiento del infarto agudo de miocardio en el Perú y su relación con eventos adversos intrahospitalarios: resultados del segundo registro peruano de infarto de miocardio con elevación del segmento ST (PERSTEMI-II).

Background: ST-segment elevation myocardial infarction (STEMI), is an important cause of morbidity and mortality worldwide, and myocardial reperfusion, when adequate, reduces the complications of this entity. The aim of the study was to describe the clinical and treatment characteristics of STEMI in Peru and the relationship of successful reperfusion with in-hospital adverse events. Materials and methods: Prospective, multicenter cohort of STEMI patients attended during 2020 in public hospitals in Peru. We evaluated the clinical, therapeutic characteristics and in-hospital adverse events, also the relationship between successful reperfusion and adverse events. Results: A total of 374 patients were included, 69.5% in Lima and Callao. Fibrinolysis was used in 37% of cases (pharmacoinvasive 26% and fibrinolysis alone 11%), primary angioplasty with < 12 hours of evolution in 20%, late angioplasty in 9% and 34% did not access adequate reperfusion therapies, mainly due to late presentation. Ischemia time was longer in patients with primary angioplasty compared to fibrinolysis (median 7.7 hours (RIQ 5-10) and 4 hours (RIQ 2.3-5.5) respectively). Mortality was 8.5%, the incidence of post-infarction heart failure was 27.8% and of cardiogenic shock 11.5%. Successful reperfusion was associated with lower cardiovascular mortality (RR:0.28; 95%CI: 0.12-0.66, p=0.003) and lower incidence of heart failure during hospitalization (RR: 0.61; 95%CI: 0.43-0.85, p=0.004). Conclusions: Fibrinolysis continues to be the most frequent reperfusion therapy in public hospitals in Peru. Shorter ischemia-to-reperfusion time was associated with reperfusion success, and in turn with fewer in-hospital adverse events.

[Current Features and Mortality Risk Factors in Cardiogenic Shock due to Myocardial Infarction in a Latin-American hospital]. / Características actuales y factores de riesgo de mortalidad en choque cardiogénico por infarto de miocardio en un hospital latinoamericano.

Objective: To know the clinical characteristics and determine the related factors to higher in-hospital mortality in patients with cardiogenic shock (CS) due to myocardial infarction in a Peruvian reference hospital. Materials and methods: . We conducted a prospective single-center cohort study, to evaluate the clinical characteristics, treatment, and complications of patients with CS due to myocardial infarction from March 2019 to August 2020 at the Instituto Nacional Cardiovascular INCOR. Factors related to higher in-hospital mortality and during follow-up were evaluated. Also, the IABP shock II score was applied to stratify the cohort. Results: Forty patients were included in the study, 75% of cases were due to left ventricular dysfunction, most of the men and with a median age of 75 (69-82) years. Fifty percent of cases presented CS after admission to the emergency room. Patients stratified by the IABP shock II score as low, intermediate, and high risk, had in-hospital mortality of 37.5%, 71.4%, and 91.6% respectively. In a hospital, mortality was 70%, higher in women, in those over 75 years old, and in those who developed CS during their hospitalization. Serum lactate > 4 mmol/L in univariate analysis was associated with higher mortality risk (HR: 2.8; IC:1.6-3.6, p=0.009). Survival to the end of the study was 12.8%. Conclusions: CS due to myocardial infarction is a clinical entity with high mortality in spite of revascularization and the available treatment in our reality. The highest mortality predictor was the serum lactate at admission > 4 mmol/L. The IABP shock II score showed to be an accurate parameter to stratify the death risk in our population.