Recomendaciones de manejo de los anticoagulantes orales directos (DOACs) anti Xa y anti IIa / Recommendations for the practical management of the direct oral anticoagulants anti Xa and anti IIa

Resumen Los anticoagulantes orales directos han surgido como una de las herramientas que ha cambiado el manejo de la enfermedad trombótica en los últimos 15 años. Sus ventajas, desde el punto de vista de la facilidad de uso y menor riesgo de sangrado, especialmente de sangrado cerebral, han posicionado a estos nuevos anticoagulantes como la primera alternativa de tratamiento en las dos indicaciones más frecuentes en que necesitamos estas drogas, la fibrilación auricular y la enfermedad tromboembólica venosa. Sin embargo, no todos los pacientes pueden recibir estos agentes, no todos los anticoagulantes directos tienen las mismas pro piedades y fundamentalmente, no todas las enfermedades con indicación de un anticoagulante pueden tratarse con ellos;con lo cual es necesario que todos los profesionales que están involucrados en el manejo de estos medicamentos estén obligados a conocerlos en profundidad, para poder decidir el mejor tratamiento en cada caso particular. Este documento de posición de expertos de diferentes especialidades de Argentina, presenta lineamientos para el uso correcto de los anticoagulantes directos en base a nueva evidencia y a la experiencia de uso de un amplio grupo de profesionales. La forma de relacionarnos con el tratamiento anticoagulante ha cambiado. Los médicos que trabajamos con ellos también debemos hacerlo.

Abstract Direct oral anticoagulants have emerged as the drugs that have changed the man agement of the antithrombotic treatment in the last 15 years. Their advantages, like a more friendly way of anticoagulation and their lower risk of bleeding, especially in the brain, have positioned these new anticoagu lants as the first drug of choice in the two most frequent indications of anticoagulation, atrial fibrillation, and the venous thromboembolic disease. However, not all the patients can receive these agents, not all the direct oral anticoagulants have the same characteristics, and most importantly, not all the diseases with an indication of an anticoagulant drug can be treated with them. Therefore, it is mandatory that all the faculties involved in the management of these drugs must know them in depth, to decide the best treatment for the patient. This position paper, from a group of experts in anticoagulation in Argentina, can help the general practitioner in the daily use of direct oral anticoagulants based on the new evidence and the experience of a wide group of professionals. The way we relate to the anticoagulant treatment has changed in the last years. The doctors who work with them must also do so.

[MANAGEMENT RECOMMENDATIONS FOR DIRECT ORAL ANTICOAGULANTS (DOACs) ANTI Xa AND ANTI IIa]. / RECOMENDACIONES DE MANEJO DE LOS ANTICOAGULANTES ORALES DIRECTOS (DOACS) ANTI Xa Y ANTI IIa.

Direct oral anticoagulants have emerged as the drugs that have changed the management of the antithrombotic treatment in the last 15 years. Their advantages, like a more friendly way of anticoagulation and their lower risk of bleeding, especially in the brain, have positioned these new anticoagulants as the first drug of choice in the two most frequent indications of anticoagulation, atrial fibrillation, and the venous thromboembolic disease. However, not all the patients can receive these agents, not all the direct oral anticoagulants have the same characteristics, and most importantly, not all the diseases with an indication of an anticoagulant drug can be treated with them. Therefore, it is mandatory that all the faculties involved in the management of these drugs must know them in depth, to decide the best treatment for the patient. This position paper, from a group of experts in anticoagulation in Argentina, can help the general practitioner in the daily use of direct oral anticoagulants based on the new evidence and the experience of a wide group of professionals. The way we relate to the anticoagulant treatment has changed in the last years. The doctors who work with them must also do so.

Los anticoagulantes orales directos han surgido como una de las herramientas que ha cambiado el manejo de la enfermedad trombótica en los últimos 15 años. Sus ventajas, desde el punto de vista de la facilidad de uso y menor riesgo de sangrado, especialmente de sangrado cerebral, han posicionado a estos nuevos anticoagulantes como la primera alternativa de tratamiento en las dos indicaciones más frecuentes en que necesitamos estas drogas, la fibrilación auricular y la enfermedad tromboembólica venosa. Sin embargo, no todos los pacientes pueden recibir estos agentes, no todos los anticoagulantes directos tienen las mismas propiedades y fundamentalmente, no todas las enfermedades con indicación de un anticoagulante pueden tratarse con ellos;con lo cual es necesario que todos los profesionales que están involucrados en el manejo de estos medicamentos estén obligados a conocerlos en profundidad, para poder decidir el mejor tratamiento en cada caso particular. Este documento de posición de expertos de diferentes especialidades de Argentina, presenta lineamientos para el uso correcto de los anticoagulantes directos en base a nueva evidencia y a la experiencia de uso de un amplio grupo de profesionales. La forma de relacionarnos con el tratamiento anticoagulante ha cambiado. Los médicos que trabajamos con ellos también debemos hacerlo.

Single spot albumin to creatinine ratio: A simple marker of long-term prognosis in non-ST segment elevation acute coronary syndromes.

BACKGROUND: Microalbuminuria is a known risk factor for cardiovascular morbidity and mortality suggesting that it should be a marker of endothelial dysfunction. Albumin to creatinine ratio (ACR) is an available and rapid test for microalbuminuria determination, with a high correlation with the 24-h urine collection method. There is no prospective study that evaluates the prognostic value of ACR in patients with non ST-segment elevation acute coronary syndromes (NSTE-ACS). The purpose of our study was to detect the long-term prognostic value of ACR in patients with NSTE-ACS. METHODS: Albumin to creatinine ratio was estimated in 700 patients with NSTE-ACS at admission. Median follow-up time was 18 months. The best cutoff point of ACR for death or acute myocardial infarction was 20 mg/g. Twenty-two percent of patients had elevated ACR. RESULTS: By multivariable Cox regression analysis, ACR was an independent predictor of the clinical endpoint: odds ratio 5.8 (95% confidence interval [CI] 2-16), log-rank 2 p < 0.0001 in a model including age > 65 years, female gender, diabetes mellitus, creatinine clearance, glucose levels at admission, elevated cardiac markers (troponin T/CK-MB) and ST segment depression. The addition of ACR significantly improved GRACE score C-statistics from 0.69 (95% CI 0.59-0.83) to 0.77 (95% CI 0.65-0.88), SE 0.04, 2 p = 0.03, with a good calibration with both models. CONCLUSIONS: Albumin to creatinine ratio is an independent and accessible predictor of long-term adverse outcomes in NSTE-ACS, providing additional value for risk stratification.

Liver Transplantation without Perioperative Transfusions Single-Center Experience Showing Better Early Outcome and Shorter Hospital Stay.

Background. Significant amounts of red blood cells (RBCs) transfusions are associated with poor outcome after liver transplantation (LT). We report our series of LT without perioperative RBC (P-RBC) transfusions to evaluate its influence on early and long-term outcomes following LT. Methods. A consecutive series of LT between 2006 and 2011 was analyzed. P-RBC transfusion was defined as one or more RBC units administrated during or ≤48 hours after LT. We divided the cohort in "No-Transfusion" and "Yes-Transfusion." Preoperative status, graft quality, and intra- and postoperative variables were compared to assess P-RBC transfusion risk factors and postoperative outcome. Results. LT was performed in 127 patients ("No-Transfusion" = 39 versus "Yes-Transfusion" = 88). While median MELD was significantly higher in Yes-Transfusion (11 versus 21; P = 0.0001) group, platelet count, prothrombin time, and hemoglobin were significantly lower. On multivariate analysis, the unique independent risk factor associated with P-RBC transfusions was preoperative hemoglobin (P < 0.001). Incidence of postoperative bacterial infections (10 versus 27%; P = 0.03), median ICU (2 versus 3 days; P = 0.03), and hospital stay (7.5 versus 9 days; P = 0.01) were negatively influenced by P-RBC transfusions. However, 30-day mortality (10 versus 15%) and one- (86 versus 70%) and 3-year (77 versus 66%) survival were equivalent in both groups. Conclusions. Recipient MELD score was not a predictive factor for P-RBC transfusion. Patients requiring P-RBC transfusions had worse postoperative outcome. Therefore, maximum efforts must be focused on improving hemoglobin levels during waiting list time to prevent using P-RBC in LT recipients.

Previous prescription of ß-blockers is associated with reduced mortality among patients hospitalized in intensive care units for sepsis.

OBJECTIVES: Results from basic science and narrative reviews suggest a potential role of ß-blockers in patients with sepsis. Although the hypothesis is physiologically appealing, it could be seen as clinically counterintuitive. We sought to assess whether patients previously prescribed chronic ß-blocker therapy had a different mortality rate than those who did not receive treatment. SETTING: Record linkage of administrative databases of Italian patients hospitalized for sepsis during years 2003-2008 were identified and followed up for all-cause mortality at 28 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 9,465 patients aged≥40 yrs who were hospitalized in critical care units for sepsis. Of these, 1,061 patients were on chronic prescription with ß-blockers and 8404 were not previously treated. Despite a higher risk profile, patients previously prescribed with ß-blockers had lower mortality at 28 days (188/1061 [17.7%]) than those previously untreated (1857/8404 [22.1%]) (odds ratio 0.78; 95% confidence interval 0.66-0.93; p=.005 for unadjusted analysis, and odds ratio 0.81; 95% confidence interval 0.68-0.97; p=.025 for adjusted analyses). Sensitivity and pair-matched results confirm the primary findings. CONCLUSIONS: As far as we are aware, this pharmacoepidemiologic assessment is the largest to examine the potential association of previous ß-blocker prescription and mortality in patients with sepsis. Chronic prescription of ß-blockers may confer a survival advantage to patients who subsequently develop sepsis with organ dysfunction and who are admitted to an intensive care unit. Prospective randomized clinical trials should formally test this hypothesis.

Statins but not aspirin reduce thrombotic risk assessed by thrombin generation in diabetic patients without cardiovascular events: the RATIONAL trial.

BACKGROUND: The systematic use of aspirin and statins in patients with diabetes and no previous cardiovascular events is controversial. We sought to assess the effects of aspirin and statins on the thrombotic risk assessed by thrombin generation (TG) among patients with type II diabetes mellitus and no previous cardiovascular events. METHODOLOGY/PRINCIPAL FINDINGS: Prospective, randomized, open, blinded to events evaluation, controlled, 2×2 factorial clinical trial including 30 patients randomly allocated to aspirin 100 mg/d, atorvastatin 40 mg/d, both or none. Outcome measurements included changes in TG levels after treatment (8 to 10 weeks), assessed by a calibrated automated thrombogram. At baseline all groups had similar clinical and biochemical profiles, including TG levels. There was no interaction between aspirin and atorvastatin. Atorvastatin significantly reduced TG measured as peak TG with saline (85.09±55.34 nmol vs 153.26±75.55 nmol for atorvastatin and control groups, respectively; p = 0.018). On the other hand, aspirin had no effect on TG (121.51±81.83 nmol vs 116.85±67.66 nmol, for aspirin and control groups, respectively; p = 0.716). The effects of treatments on measurements of TG using other agonists were consistent. CONCLUSIONS/SIGNIFICANCE: While waiting for data from ongoing large clinical randomized trials to definitively outline the role of aspirin in primary prevention, our study shows that among diabetic patients without previous vascular events, statins but not aspirin reduce thrombotic risk assessed by TG. TRIAL REGISTRATION: ClinicalTrials.gov NCT00793754.

Control de la glucemia en el postoperatorio de cirugía cardíaca: Informe del Consejo de Emergencias de la Sociedad Argentina de Cardiología / Blood glucose control during cardiac surgery: Report of the Emergency Council of the Argentine Society of Cardiology

La hiperglucemia en el postoperatorio de cirugía cardIaca es un hallazgo frecuente asociado a peor evolución, que afecta tanto a diabéticos como no diabéticos. A pesar de las múltiples publicaciones disponibles, aún no existe un abordaje universalmente aceptado a este problema. En una iniciativa originada en el Consejo de Emergencias de la Sociedad Argentina de Cardiología, se convocó a expertos de nuestro medio con el propósito de debatir cómo debe ser el manejo de la glucemia en el paciente crítico cardiovascular. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia en el postoperatorio de cirugía cardíaca.(AU)

Hyperglycemia after cardiac surgery is a common finding associated with the worse outcomes affecting both diabetic and non diabetic patients. Despite the large number of publications available, there is no universally accepted approach to this problem. In an initiative of the Emergency Council of the Argentine Society of Cardiology, local experts gathered to discuss the management of hyperglycemia after adult cardiac surgery. The main objective of the present paper is to summarize the current state of knowledge regarding glycemic control in postoperative cardiac surgery.(AU)

Control de la glucemia en el postoperatorio de cirugía cardíaca: Informe del Consejo de Emergencias de la Sociedad Argentina de Cardiología / Blood glucose control during cardiac surgery: Report of the Emergency Council of the Argentine Society of Cardiology

La hiperglucemia en el postoperatorio de cirugía cardIaca es un hallazgo frecuente asociado a peor evolución, que afecta tanto a diabéticos como no diabéticos. A pesar de las múltiples publicaciones disponibles, aún no existe un abordaje universalmente aceptado a este problema. En una iniciativa originada en el Consejo de Emergencias de la Sociedad Argentina de Cardiología, se convocó a expertos de nuestro medio con el propósito de debatir cómo debe ser el manejo de la glucemia en el paciente crítico cardiovascular. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia en el postoperatorio de cirugía cardíaca.(AU)

Hyperglycemia after cardiac surgery is a common finding associated with the worse outcomes affecting both diabetic and non diabetic patients. Despite the large number of publications available, there is no universally accepted approach to this problem. In an initiative of the Emergency Council of the Argentine Society of Cardiology, local experts gathered to discuss the management of hyperglycemia after adult cardiac surgery. The main objective of the present paper is to summarize the current state of knowledge regarding glycemic control in postoperative cardiac surgery.(AU)

Control de la glucemia en el postoperatorio de cirugía cardíaca: Informe del Consejo de Emergencias de la Sociedad Argentina de Cardiología / Blood glucose control during cardiac surgery: Report of the Emergency Council of the Argentine Society of Cardiology

La hiperglucemia en el postoperatorio de cirugía cardÍaca es un hallazgo frecuente asociado a peor evolución, que afecta tanto a diabéticos como no diabéticos. A pesar de las múltiples publicaciones disponibles, aún no existe un abordaje universalmente aceptado a este problema. En una iniciativa originada en el Consejo de Emergencias de la Sociedad Argentina de Cardiología, se convocó a expertos de nuestro medio con el propósito de debatir cómo debe ser el manejo de la glucemia en el paciente crítico cardiovascular. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia en el postoperatorio de cirugía cardíaca.

Hyperglycemia after cardiac surgery is a common finding associated with the worse outcomes affecting both diabetic and non diabetic patients. Despite the large number of publications available, there is no universally accepted approach to this problem. In an initiative of the Emergency Council of the Argentine Society of Cardiology, local experts gathered to discuss the management of hyperglycemia after adult cardiac surgery. The main objective of the present paper is to summarize the current state of knowledge regarding glycemic control in postoperative cardiac surgery.

[Blood glucose control during cardiac surgery. Report of the Emergency Council of the Argentine Society of Cardiology]. / Control de la glucemia en el postoperatorio de cirugía cardíaca. Informe del Consejo de Emergencias de la Sociedad Argentina de Cardiología.

Hyperglycemia after cardiac surgery is a common finding associated with the worse outcomes affecting both diabetic and non diabetic patients. Despite the large number of publications available, there is no universally accepted approach to this problem. In an initiative of the Emergency Council of the Argentine Society of Cardiology, local experts gathered to discuss the management of hyperglycemia after adult cardiac surgery. The main objective of the present paper is to summarize the current state of knowledge regarding glycemic control in postoperative cardiac surgery.

Clinical trials using vasodilators in pulmonary arterial hypertension: where do we go from here?

BACKGROUND: The impact of treatment with vasodilators on the survival of patients with pulmonary arterial hypertension (PAH) remains uncertain. Despite several clinical trials have been carried out in the last 15 years, their primary objective was not to assess mortality but the changes on surrogate end points. METHODS AND RESULTS: We reviewed the results of all clinical trials with vasodilators in PAH and the main results of different metaanalysis. Clinical trials and systematic reviews confirm that vasodilator therapies in patients with PAH who are non-vasoreactive produce a consistent, statistically significant but a marginal effect on exercise capacity assessed by the six-minute walk test. The weighted mean difference (95% CI) achieved with epoprostenol (EPO) or other prostacyclin analogues (PCA), endothelin receptor antagonists (ETRA) and phosphodiesterase-type-5 inhibitors (PDE5-I) was 35.4 m (17.3-53.5), 46.1 m (38.1-54.2) and 33.8 m (24.8-42.7), respectively. When considering the cumulative effects within each drug family, no class of drug produced a statistically significant reduction in all cause mortality. The relative risk rates (95% CI) conferred by EPO or PCA, ETRA and PDE5-I were 0.66 (0.36-1.21), 0.48 (0.19-1.23) and 0.65 (0.16-2.67), respectively. INTERPRETATION: Further trials utilizing similar classes of drugs, and following similar trial designs are unlikely to yield different results or offer any more clinical benefits. Given that PAH is a fatal disease this raises concerns about whether they are ethical to conduct or not. Future trials will need to utilize clinical endpoints rather than the ones that are easy to administer and will need to include longer durations of study and other strategies to test the durability of effect.

[NT-Pro-BNP levels performance before and after reversion to sinus rhythm in patients with preserved ventricular function]. / Descenso de los niveles de propéptido natriurético de tipo B-N terminal luego de la reversión de pacientes con fibrilación auricular y función ventricular conservada.

Our objective was to evaluate changes of N-terminal pro-BNP (NT-Pro-BNP) levels at baseline and after restoration to sinus rhythm in hemodynamic stable patients with lone atrial fibrillation (LAF) with preserved left ventricular function. NT-Pro-BNP levels were obtained before and after cardioversion in thirty hemodynamic stable patients with LAF and preserved left ventricular function. At baseline levels of NT-Pro BNP levels were significatively higher than a normal control group. NT-Pro-BNP levels decreased significantly following cardioversion from 529 (157-1763) to 318 (98-870) pg/ml, p < 0.0001. Decreasing of N-terminal pro-BNP concentrations was observed after any mode of cardioversion: electrical or pharmacologic, 345 (153-1151) pg/ml to 169 (86-407) pg/ml, p: 0.02 and from 1624 (541-4010) pg/ml to 856 (532-1160) pg/ml, p < 0.001, respectively. N-terminal pro-BNP decreasing was observed mainly in patients with length of LAF longer than 8 hours: 1289 (338-2103) to 410 (169-905) pg/ml, p < 0.001 but no difference was detected when such length was less than 8 hours: 274 (137-2300) to 286 (82-1440), p = NS. Our study showed that baseline levels of NT-pro-BNP decreased shortly after reversion of patients with LAF to sinus rhythm. This performance occurs predominantly in patients with LAF length of at least eight hours.

Descenso de los niveles de propéptido natriurético de tipo B-N terminal luego de la reversión de pacientes con fibrilación auricular y función ventricular conservada / NT-Pro-BNP levels performance before and after reversion to sinus rhythm in patients with preserved ventricular function

El objetivo fue comparar los niveles de Pro Péptido Natriurético tipo B-N terminal (Pro-BNP-NT) basales y post reversión en pacientes con fibrilación auricular solitaria (FAS) de comienzo reciente y con función ventricular izquierda conservada. Se determinaron niveles del Pro BNP NT antes y después de su reversión en treinta pacientes con FAS de comienzo reciente y fracción de eyección de ventrículo izquierdo ≥ 50%. Basalmente, los niveles de Pro BNP NT fueron significativamente más elevados respecto a un grupo control sano: 529 pg/ml (157-1763) versus 31.5 pg/ml (24-76), p < 0.0001. Las concentraciones de Pro BNP NT descendieron significativamente luego de la cardioversión de 529 (157-1763) a 318 (98-870) pg/ml, p < 0.001. Los descensos se objetivaron tanto luego de la cardioversión eléctrica como de la obtenida por vía farmacológica, 345 (153-1151) pg/ml a 169 (86-407) pg/ml, p: 0.02 y de 1624 (541-4010) pg/ml a 856 (532-1160) pg/ml, p < 0.001, respectivamente. Este fenómeno se observó fundamentalmente en aquellos con una FAS con duración mayor a 8 horas: 1289 (338-2103) a 410 (169-905) pg/ml, p < 0.001. No se observó correlación entre los cambios de la frecuencia cardíaca y del Pro BNP NT pre y post cardioversión a ritmo sinusal. Se observaron descensos significativos de Pro BNP NT basalmente y post reversión (tanto farmacológica como eléctrica) en pacientes con FA de reciente aparición y función ventricular conservada. Estos descensos fueron más ostensibles a partir de las 8 horas de duración de la arritmia.

Our objective was to evaluate changes of N-terminal pro-BNP (NT-Pro-BNP) levels at baseline and after restoration to sinus rhythm in hemodynamic stable patients with lone atrial fibrillation (LAF) with preserved left ventricular function. NT-Pro-BNP levels were obtained before and after cardioversion in thirty hemodynamic stable patients with LAF and preserved left ventricular function. At baseline levels of NT-Pro BNP levels were significatively higher than a normal control group. NTPro-BNP levels decreased significantly following cardioversion from 529 (157-1763) to 318 (98-870) pg/ml, p < 0.0001. Decreasing of N-terminal pro-BNP concentrations was observed after any mode of cardioversion: electrical or pharmacologic, 345 (153-1151) pg/ml to 169 (86-407) pg/ml, p: 0.02 and from 1624 (541-4010) pg/ml to 856 (532-1160) pg/ml, p < 0.001, respectively. N-terminal pro-BNP decreasing was observed mainly in patients with length of LAF longer than 8 hours: 1289 (338-2103) to 410 (169-905) pg/ml, p < 0.001 but no difference was detected when such length was less than 8 hours: 274 (137-2300) to 286 (82-1440), p = NS. Our study showed that baseline levels of NT-pro-BNP decreased shortly after reversion of patients with LAF to sinus rhythm. This performance occurs predominantly in patients with LAF length of at least eight hours.

Takotsubo Cardiomyopathy: A Cardiac Syndrome Mimicking Acute Myocardial Infarction in a Liver Transplant Recipient.

Takotsubo cardiomyopathy (TTC) is a rare clinical syndrome defined as a profound but reversible left ventricular dysfunction in the absence of coronary artery disease. We describe the clinical features and management of TC manifesting in the postoperative period in a patient undergoing liver transplantation. Two days after surgery, the patient developed clinical features of acute myocardial infarction. Ecochardiography revealed hypokinesis of the left ventricle. Coronary angiography revealed normal arteries without any stenosis or obstruction. The patient required vasopressor and inotropic support. The placement of intra-aortic balloon pump had a beneficial effect on the management of heart failure. The patient had a complete recovery of cardiac function 40 days after surgery. TC is a possible occurrence after liver transplant. Awareness of this condition is essential as early diagnosis and prompt management can save the patient's life.

[Liver transplantation during pregnancy in a patient with acute liver failure]. / Trasplante hepático durante el embarazo en una paciente con insuficiencia hepática aguda grave.

Liver transplantation is the best therapeutic approach in patients with acute liver failure. This clinical presentation during pregnancy is an unusual and dramatic event. We report the case of a 18 year-old woman with cryptogenic acute liver failure who underwent successful orthotopic liver transplantation at 20 weeks of pregnancy. Both outcomes were analyzed. Fetal death was observed within 48 hours after liver transplant. After six months of follow-up, the patient is doing well. This case illustrates the challenge of treating acute liver failure during pregnancy and demonstrates that liver transplantation is a feasible therapeutic option for treatment of patient with this condition.

Rescue policy for discarded liver grafts: a single-centre experience of transplanting livers 'that nobody wants'.

BACKGROUND: There is a worldwide need to expand the donor liver pool. We report a consecutive series of elective candidates for liver transplantation (LT) who received 'livers that nobody wants' (LNWs) in Argentina. METHODS: Between 2006 and 2009, outcomes for patients who received LNWs were analysed and compared with outcomes for a control group. To be defined as an LNW, an organ is required to fulfil two criteria. Firstly, each liver must be officially offered and refused more than 30 times; secondly, the liver must be refused by at least 50% of the LT programmes in our country before our programme can accept it. Principal endpoints were primary graft non-function (PNF), mortality, and graft and patient survival. RESULTS: We transplanted 26 LNWs that had been discarded by a median of 12 centres. A total of 2666 reasons for refusal had been registered. These included poor donor status (n= 1980), followed by LT centre (n= 398) or recipient (n= 288) conditions. Incidences of PNF (3.8% vs. 4.0%), in-hospital mortality (3.8% vs. 8.0%), 1-year patient (84% vs. 84%) and graft (84% vs. 80%) survival were equal in the LNW and control groups. CONCLUSIONS: Transplantable livers are unnecessarily discarded by the transplant community. External and internal supervision of the activity of each LT programme is urgently needed to guarantee high standards of excellence.

Registro multicéntrico de disección aórtica aguda: Estudio RADAR. Resultados preliminares / Multicenter Registry of Acute Aortic Dissection: The RADAR Study. Preliminary Results

Introducción El síndrome aórtico agudo (SAA) representa aún hoy una de las más serias afecciones cardiovasculares debido a su alta morbilidad y mortalidad, por lo que el diagnóstico precoz es de vital importancia. Objetivos El Registro de la Sociedad Argentina de Cardiología de Disecciones AóRticas Agudas (RADAR) tiene por objetivo analizar las modalidades de presentación, el diagnóstico, el tratamiento y la mortalidad del SAA a través de un registro continuo de esta enfermedad poco prevaleciente. Material y métodos Desde febrero de 2007 hasta abril de 2009, 12 centros enrolaron 95 pacientes consecutivos admitidos con diagnóstico de SAA, de los que se obtuvieron las características clínicas basales, los estudios complementarios, el tipo de tratamiento y la evolución clínica. Resultados El 68% fueron hombres, la edad media fue de 58,8 ± 13,9 años, el 78% fueron disecciones aórticas de tipo A y el 22% de tipo B. El 84% de los pacientes eran hipertensos, el 28% tabaquistas y el 24% dislipidémicos. El dolor precordial o dorsal estuvo presente en el 85,1%. La mediana global del intervalo síntomas - inicio de la intervención fue de 18 horas (12-72). El 89% de las disecciones de tipo A y el 15% de las de tipo B recibieron tratamiento quirúrgico. Los betabloqueantes se utilizaron en el 64,7% de los casos, el nitroprusiato de sodio en el 47,4%, el ácido acetilsalicílico en el 15,8%, los anticoagulantes en el 3,2% y los trombolíticos en el 3,2%. La mortalidad global fue del 32,6%. La mortalidad en las disecciones de tipo A fue del 37,8% (31% en los operados versus 87,5% en los no operados; p = 0,01). La mortalidad de las disecciones de tipo B fue del 14% en los operados y del 12% en los no operados (p = ns). Se observó un patrón de variación horaria circadiana con respecto al horario del inicio de los síntomas, con un pico en las horas matinales. El análisis de regresión logística mostró que las variables independientes asociadas con la mortalidad hospitalaria fueron la edad mayor de 70 años y el ingreso con hipotensión arterial o shock. Conclusiones A pesar de los avances técnicos, la mortalidad global de los SAA sigue siendo elevada. Su detección requiere un alto nivel de sospecha por parte del médico para un diagnóstico y un tratamiento tempranos. Esta modalidad de registro continuo y multicéntrico permite una aproximación más real a la problemática de esta grave enfermedad en nuestro medio, a fin de optimizar su enfoque diagnóstico y terapéutico.

Background Acute aortic syndrome (AAS) still represents one of the most severe cardiovascular conditions due to its high mortality and morbidity; for this reason, it is extremely important to perform an early diagnosis of the disease. Objectives The Registro de la Sociedad Argentina de Cardiología de Disecciones AóRticas Agudas (RADAR registry) was designed to analyze the modalities of clinical presentation, diagnosis, treatment and mortality of AAS through a continuous registry of this not very prevalent disease. Material and Methods From February 2007 to April 2009, 95 patients consecutively admitted to 12 centers with a diagnosis of AAS were enrolled; basal clinical characteristics, complementary studies, type of treatment and clinical outcomes were obtained. Results Most patients were men (68%), mean age was 58.8±13.9 years, 78% were type A aortic dissections and 22% were type B. Eighty four percent of patients had hypertension, 28% were current smokers and 24% had dyslipemia. Chest pain or dorsal pain was present in 85.1% of cases. Global median time interval from onset of symptoms to intervention was 18 hours (12-72). Surgery was performed in 89% of type A and in 15% of type B dissections. Beta blockers were used in 64.7% of cases, sodium nitroprusside in 47.4%, aspirin in 15.8%, oral anticoagulant agents in 3.2% and thrombolytic drugs in 3.2%. Global mortality was 32.6%. Mortality rate of type A dissection was 37.8% (31% in patients undergoing surgery versus 87.5% in absence of surgical treatment; p=0.01). Dissection type B had mortality rates of 14% versus 12%, respectively (p=ns). A pattern of circadian variation regarding onset of symptoms was observed, with a peak in the morning hours. Logistic regression analysis showed that the independent variables associated with in-hospital mortality were age >70 years and the presence of hypotension or shock at admission. Conclusions Mortality from AAS is still high despite technical progress. Physicians should be alert to detect this condition in order to perform early diagnosis and treatment. This type of continuous and multicenter registry allows a more real approach to the problem related to this severe disease in our environment in order to optimize diagnostic and therapeutic strategies.

Anemia and chronic heart failure: from pathophysiologic mechanisms to clinical trial designs.

In patients with heart failure, anemia is highly prevalent and associated with impaired outcomes. These clinical observations necessitate the realization of pharmacologic interventions to mitigate the effects of anemia and a number of available agents are being tested in large, randomized clinical trials. However, from the pathophysiologic point of view, anemia is multifactorial and difficult to attribute to a single mechanism. Moreover, classic indicators for the identification of etiology and pathways have been found to be less accurate than expected. For these reasons future clinical trials must be designed to be able to elucidate the complexity of mechanisms and the implications for treatment strategies.