The attempt to demolish the science and practice of preventive cardiovascular medicine. Part I. Addendum to the positioning around the diagnosis and treatment of dyslipidemias of ANCAM and the joint group of associated medical societies / El intento de demoler la ciencia y la práctica de la medicina cardiovascular preventiva. Parte I. Addendum al posicionamiento en torno al diagnóstico y tratamiento de las dislipidemias de la ANCAM y del grupo conjunto de sociedades médicas asociadas

Abstract: This manuscript is an addendum to the positioning around the diagnosis and treatment of dyslipidemias of ANCAM and the joint group of associated medical societies, already published. It is the first part of a wider reflection aimed on refute several of the theses and arguments of a group of clinicians and researchers who question the validity of the "cholesterol hypothesis", the usefulness and safety of statins and the most modern inhibitors of proprotein convertase of subtilisin/kexin type 9 (iPCSK9,) and the role of saturated fatty acids consumed in the usual diet in the atherosclerotic risk. This iconoclastic point of view is dangerous insofar as it undermines the scaffolding that supports the primary and secondary prevention of atherosclerosis. In this section of the manuscript, only the cholesterol hypothesis is discussed. The data of comparative zoology are reviewed, and several experimental animal models are analyzed, both supporting the link between cholesterol and the appearance and evolution of atherosclerotic lesions. The methodology and the results of the Study of the 7 Countries are defended and are exposed the numerous epidemiological, pathological, clinical and interventional evidences, which in our opinion give a solid sustenance to the cholesterol hypothesis. Based on this knowledge it is criticized the LDL cholesterol values currently considered adequate. Furthermore, the so-called residual risk is considered, as well as the conflicting evidence about the usefulness of statins in elderly patients.

Resumen: Este manuscrito es un apéndice del posicionamiento en torno al diagnóstico y tratamiento de las dislipidemias de la ANCAM y el grupo de las sociedades médicas asociadas, previamente publicado. Es la primera parte de un trabajo más amplio enfocado a refutar varias de las tesis y argumentos de un grupo de clínicos e investigadores que ponen en duda la validez de la "hipótesis del colesterol", la utilidad y seguridad de las estatinas y los más modernos inhibidores de la proproteína convertasa de la subtilisina/kexina tipo 9 (iPCSK9) y el papel de los ácidos grasos saturados consumidos en la dieta habitual en el riesgo ateroscleroso. Este punto de vista iconoclástico es peligroso porque socava el andamiaje que soporta la prevención primaria y secundaria de la aterosclerosis. En esta primera sección del manuscrito, se discute sólo la hipótesis del colesterol. Se revisan los datos de zoología comparada y se analizan varios modelos animales de experimentación, que apoyan la liga entre el colesterol y la aparición y evolución de las lesiones aterosclerosa. Se defienden la metodología y los resultados del estudio de los 7 países y se exponen las numerosas evidencias epidemiológicas, patológicas, clínicas e intervencionistas, que a nuestro juicio dan un sustento sólido a la hipótesis del colesterol. Se critican también, en base a ese conocimiento, los valores de colesterol LDL actualmente considerados adecuados, a la vez que se discute el llamado riesgo residual y las evidencias conflictivas acerca de la utilidad de las estatinas en pacientes ancianos.

Self-Reported Health and Outcomes in Patients With Stable Coronary Heart Disease.

BACKGROUND: The major determinants and prognostic importance of self-reported health in patients with stable coronary heart disease are uncertain. METHODS AND RESULTS: The STABILITY (Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy) trial randomized 15 828 patients with stable coronary heart disease to treatment with darapladib or placebo. At baseline, 98% of participants completed a questionnaire that included the question, "Overall, how do you feel your general health is now?" Possible responses were excellent, very good, good, average, and poor. Adjudicated major adverse cardiac events, which included cardiovascular death, myocardial infarction, and stroke, were evaluated by Cox regression during 3.7 years of follow-up for participants who reported excellent or very good health (n=2304), good health (n=6863), and average or poor health (n=6361), before and after adjusting for 38 covariates. Self-reported health was most strongly associated with geographic region, depressive symptoms, and low physical activity (P<0.0001 for all). Poor/average compared with very good/excellent self-reported health was independently associated with major adverse cardiac events (hazard ratio [HR]: 2.30 [95% confidence interval (CI), 1.92-2.76]; adjusted HR: 1.83 [95% CI, 1.51-2.22]), cardiovascular mortality (HR: 4.36 [95% CI, 3.09-6.16]; adjusted HR: 2.15 [95% CI, 1.45-3.19]), and myocardial infarction (HR: 1.87 [95% CI, 1.46-2.39]; adjusted HR: 1.68 [95% CI, 1.25-2.27]; P<0.0002 for all). CONCLUSIONS: Self-reported health is strongly associated with geographical region, mood, and physical activity. In a global coronary heart disease population, self-reported health was independently associated with major cardiovascular events and mortality beyond what is measurable by established risk indicators. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00799903.

Practice guidelines for the implementation of a quality program in thromboprophylaxis and treatment management in patients with venous thromboembolic disease.

BACKGROUND: Venous thromboembolic disease is a major cause of morbidity and hospital mortality worldwide. Although exact figures are unknown in Mexico, achieving uniformity of criteria among the specialties involved in the prophylaxis and treatment will offer a clearer picture and contribute to a more rational and interdisciplinary approach in order to improve the quality of care for patients and increase the level of awareness of this entity. DISCUSSION: For the preparation of this document, a total of 11 medical specialists from Mexico City and the interior of the country met along with a highly experienced professional from Chicago, IL, USA with wide experience in the field and knowledge of methodology for the development of a management algorithm for prophylaxis in at-risk patients of venous thromboembolic disease. The expert group met in plenary working sessions, managed uniform criteria and reached consensus agreement by issuing a series of useful recommendations for the care of patients with venous thromboembolism in Mexican hospitals. CONCLUSIONS: In Mexico there is the need to develop and disseminate guidelines on thromboprophylaxis and treatment of venous thromboembolic disease because of the wide disparity of views or simple misinformation, leading to diagnostic and treatment behaviors unique to each institution.

[Risk stratified in the National Registry of Acute Coronary Syndromes at the IMSS]. / Riesgo estratificado de los síndromes coronarios agudos. Resultados del primer Renasca-IMSS.

OBJECTIVE: to identify prognostic factors in the National Registry of Acute Coronary Syndromes. METHODS: patients in medical care units with acute ischemic coronary syndrome (AICS) according to the criteria of the American Heart Association/American College of Cardiology/European Society of Cardiology, considering the GRACE score (GS) were studied. RESULTS: there were 2389 patients, 28.9 % women and 71.1 % men, mean age 63 ± 11.7 years; with AICS with ST-segment elevation (69.11 %) and 30.89 % with AICS without ST elevation. The average of GS was 168. A GS > 150 points in patients with AICS without ST elevation was associated with recurrent ischemia or angina (RR = 1.4, p = 0.05), left ventricular failure (RR = 3.1, p < 0.0001), stroke (RR = 2.9, p = 0.004) and arrhythmias (RR = 2.7, p < 0.0001). The patients with AICS with ST-segment elevation were associated with death (RR = 1.6, p = 0.01), reinfarction (RR = 1.7, p = 0.001), recurrent ischemia (RR = 1.2, p = 0.04), left ventricular failure (RR = 3.4, p < 0.001), stroke (RR = 3.9, p < 0.001) and arrhythmias (RR = 2.3, p < 0.001). Fibrinolytic therapy was used in 40.2 %. There was a negative correlation between GS and fibrinolytic therapy (r -0.04, p = 0.04). CONCLUSIONS: the AICS with ST-segment elevation is more frequent and have a high GS.

Relation of antimyocardium antibodies to mortality in patients with acute myocardial infarction.

BACKGROUND: Antimyocardium antibodies (AMA) have been observed in patients with acute myocardial infarction (AMI). At present it is unknown if these AMA play a role in the pathogenesis of acute or chronic myocardial damage or if they are only produced as a result of tissue destruction, disappearing later without clinical manifestations. However, some studies have shown that patients with AMI and AMA have higher possibilities of presenting heart failure and death. The aim of the present study was to determine if there is an association (odds ratio, OR) between AMA and death in patients with AMI. METHODS: The design was a cross-sectional study. One hundred patients with acute myocardial infarction were recruited consecutively at the Coronary Care Unit of the Hospital de Especialidades at La Raza National Medical Center, IMSS, Mexico City. IgG antimyocardium antibodies were identified using the enzyme-linked immunosorbent assay technique (ELISA). RESULTS: Of the 100 patients studied, 81 were males and 19 females, with an average age of 58 +/- 11 years. Of the population studied, 44% showed AMA. It was observed that patients with positive AMA had an OR for heart failure of 3.40 (CI 95% 0.97-12.5, p = 0.06) and for death of 7.94 (CI 95%, 1.49-56.1, p = 0.003). This variable was analyzed with other confounding variables using logistic regression, and an OR of 11.8 (CI 95% 1.63-86.3, p = 0.001) was obtained. CONCLUSIONS: AMAs were an independent predictive factor for mortality in patients with AMI.

[Antibodies against Chlamydophila in patients with acute myocardial infarction and coronary risk and their association with mortality]. / Anticuerpos contra Chlamydophila en pacientes con infarto agudo del miocardio y riesgo coronario, y su relación con la muerte.

OBJECTIVE: The primary aim of this study was to determine whether antibodies against Chlamydophila pneumoniae in patients with acute myocardial infarction (AMI) and coronary risk factors are associated with death. MATERIAL AND METHODS: A cross-sectional study was conducted among 100 patients hospitalized in the Coronary Unit of Centro Medico La Raza Hospital of the Mexican Institute of Social Security, between 1999 and 2000. Subjects were males and females older than 18 years, diagnosed with AMI and coronary risk. Antibodies against Chlamydophila pneumoniae, Chlamydophila psitacii and Chlamydia trachomatis were measured using an indirect microinmunofluorescence assay. In addition, blood samples from 33 patients from the original group were taken when the patients were discharged from the hospital,and 3 months after their myocardial infarction. Data analysis consisted of geometric means and standard deviations as well as odds ratios with 95% confidence intervals. RESULTS: Seventy percent of patients presented antibodies against Chlamydophila pneumoniae. Antibodies against Chlamydophila psittaci and Chlamydia trachomatis were not identified. No statistically significant association was found between antibodies and death in these patients with coronary risk factors and AMI. In the subgroup of 33 individuals 25 had antibodies against Chlamydophila pneumoniae and in 83% of them antibodies decreased three months after the AMI event. CONCLUSIONS: Even though patients with coronary risk factors and AMI had an increased seropositivity for Chlamydophila pneumoniae it was not significantly associated with death.

Mexican Registry of Acute Coronary Syndromes.

OBJECTIVE: The registry intends to establish the clinical characteristics, identify therapeutic approaches and describe in-hospital outcome of patients with acute coronary syndromes in Mexico. METHODS AND RESULTS: RENASICA II is a prospective registry that included 8,098 patients with final diagnosis of acute coronary syndromes. Three thousand five hundred and forty three patients had unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI) and 4,555 ST elevation myocardial infarction. (STEMI) On admission typical chest pain was identified in 78% and 85% respectively. Non-ST elevation high risk group was identified in 36%. In STEMI group anterior myocardial infarction and Killip class I had a higher occurrence. The use of aspirin, unfractionated heparin, low molecular weight heparin, nitrates, beta blockers and ACE inhibitors for patients with UA/NSTEMI were 90%, 50%, 45%, 58%, 50% and 54% respectively, with corresponding rates of 88%, 54%, 44%, 66%, 51% and 64% for STEMI patients. Coronary angiography, angioplasty and coronary bypass surgery were performed in 62%, 30% and 8% in UA/NSTEMI patients respectively with corresponding rates of 44%, 27% and 4% for the STEMI group. Among patients with STEMI 37% were under fibrinolytic therapy and 15% received primary or facilitated angioplasty. Overall In-hospital mortality was 7%, 4% UA/NSTEMI and 10% STEMI 10%. CONCLUSION: The largest registry ACS in Latin-America provides important and reliable information on the complete spectrum, outcome, quality of care, and identifies areas for further improvement of the quality of our cardiovascular care. RENASICA II broadens our knowledge about how reperfusion and antithrombotic approaches modify the outcome and what needs to be improved in the real practice in Mexico.

Registro Mexicano de Síndromes Coronarios Agudos: RENASICA II Mexican Registry of Acute Coronary Syndromes

Objetivo: El registro pretende establecer en México las características clínicas, identificar abordajes terapéuticos y conocer la evolución hospitalaria en pacientes con síndromes coronarios agudos. Métodos y resultados: RENASICA II es un registro prospectivo que incluye 8,098 pacientes con diagnóstico final de síndrome coronario agudo. Tres mil quinientos cuarenta y tres tuvieron angina inestable o infarto sin elevación del ST (AI/IMNEST) y 4,555 con infarto con elevación del ST (IMEST). A su ingreso al hospital se identificó dolor torácico típico de isquemia en 78% y 85% respectivamente. Se consideró de alto riesgo al 36% de los pacientes con AI/IMNEST. En la mayoría de los pacientes con IMEST la localización fue anterior y se encontraban en clase KK I. En AI/IMNEST se utilizó aspirina en el 90%, heparina no fraccionada 50%, heparina de bajo peso molecular 45%, nitratos 58%, bloqueadores beta 50% e inhibidores de enzima convertidora en el 54%. En IMEST estos medicamentos se utilizaron en el 88%, 54%, 44%, 66%, 51% y 64% respectivamente. En pacientes con AI/IMNEST se realizó angiografía en el 62%, angioplastía coronaria 30% y cirugía de revascularización 8%. En el grupo con IMEST estos procedimientos se realizaron en el 44%, 27% y 4% respectivamente. En IMEST el 37% recibió terapia fibrinolítica y 15% fueron llevados a angioplastía primaria o facilitada. La mortalidad hospitalaria global del 7%, en AI/IMNEST fue del 4% y en IMEST del 10%. Conclusión: El más grande registro de síndromes coronarios agudos en Latinoamérica provee información importante sobre el espectro clínico, evolución hospitalaria, calidad de atención e identifica áreas de oportunidad para mejorar la atención médica. El RENASICA II extiende nuestro conocimiento sobre cómo la reperfusión y el tratamiento antitrombótico modifican la evolución y cuáles procesos necesitamos mejorar en la práctica real en México.

Objective: The registry intends to establish the clinical characteristics, identify therapeutic approaches and describe in-hospital outcome of patients with acute coronary syndromes in Mexico. Methods and results: RENASICA II is a prospective registry that included 8,098 patients with final diagnosis of acute coronary syndromes. Three thousand five hundred and forty three patients had unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI) and 4,555 ST elevation myocardial infarction (STEMI). On admission typical chest pain was identified in 78% and 85% respectively. Non-ST elevation high risk group was identified in 36%. In STEMI group anterior myocardial infarction and Killip class I had higher occurrence. The use of aspirin, unfractionated heparin, low molecular weight heparin, nitrates, beta blockers and ACE inhibitors for patients with UA/NSTEMI were 90%, 50%, 45%, 58%, 50% and 54% respectively, with corresponding rates of 88%, 54%, 44%, 66%, 51% and 64% for STEM I patients. Coronary angiography, angioplasty and coronary bypass surgery were performed in 62%, 30% and 8% in UA/NSTEMI patients respectively with corresponding rates of 44%, 27% and 4% for STEMI group. Among patients with STEMI 37% were under fibrinolytic therapy and 15% received primary or facilitated angioplasty. Overall In-hospital mortality was 7%, 4% for UA/NSTEMI and 10% for STEMI. Conclusion: The largest registry on ACS in Latin-America provides important and reliable information on complete spectrum, outcome, quality of care, and identifies areas for further improvement of such quality. RENASICA II broadens our knowledge about how reperfusion and antithrombotic approaches modify the outcome and what needs to be improved in the real practice in Mexico.

Limitación de la expansión miocárdica con trombolisis tardía, evaluada por ecocardiografía bidimensional / Limitation of myocardial expansion in late thrombolysis. Evaluation by means of bidimensional echocardiography

La expansión miocárdica en el infarto agudo del miocardio se presenta hasta en un 45 por ciento de los pacientes dentro de las primeras 72 horas. Ésta se ha asociado con la formación de aneurismas ventriculares, ruptura miocárdica, insuficiencia cardiaca y muerte temprana. Estudios experimentales en animales con infarto agudo del miocardio (IAM) han utilizado la reperfusión tardía para disminuir la incidencia de expansión teniendo resultados satisfactorios. Se llevó a cabo un estudio prospectivo, longitudinal, abierto y aleatorio en 21 pacientes con IAM de localización anterior para evaluar si la reperfusión tardía (6 a 12 horas), puede disminuir la incidencia de expansión miocárdica, evaluada cuantitativamente con ecocardiografía bidimensional. Se formaron 2 grupos: grupo A (n=12) quienes recibieron trombolisisi con estreptocinasa 1.5 millones IV y aspirina 150 mg al día. Grupo B sólo recibió aspirina 150 mg al día (n=9). Ambos grupos tuvieron las mismas características del IAM y clase funcional de Killip y Kimball (clase I y II). El manejo intrahospitalario fue en forma libre para ambos grupos. La expansión se evaluó mediante ecocardiografía bidimensional utilizando el método propuesto por Jugdutt. En el grupo A, la expanción se presentó en un 25 por ciento de los casos mientras que en el grupo B fue de 66.6 por ciento (p<0.0005). El área de distorsión, el pico de distorsión, el grosor septal y la longitud del segmento asinérgico fueron los parámetros ecocardiográficos más sensibles para identificar la expansión miocárdica. Nuestros resultados son muy semejantes a los obtenidos en los estudios esperimentales. Se concluye que la trombolisis tardía puede se útil para disminuir la incidencia de expansión miocárdica. Por otra parte la ecocardiografía bidimensional es un método útil, rápido y seguro que nos permite identificar la expansión miocárdica

Función renal en el infarto agudo del miocardio / Renal function in acute myocardial infarction

Introducción. El infarto agudo del miocardio frecuentemente se asocia a disfunción renal. Objetivo. Reportar las alteraciones de la función renal en pacientes con infarto agudo del miocardio. Pacientes y métodos. Estudiamos prospectivamente 25 pacientes que ingresaron a una unidad de cuidados coronarios/unidad de cuidados intensivos (UCC/UCI) con infarto agudo del miocardio no complicado. Se hizo seguimiento de la función renal a las 24 y 72 horas de evolución a través de la evaluacion de las fuciones glomerular y tubular. Resultados. La diuresis disminuyó significativamente después de 72 horas; la función glomerular no cambió a las 24 horas pero se deterioró 72 horas más tarde; la función tubular se alteró durante las primeras horas y se normalizó al final del estudio; solo un paciente se complicó con isuficiencia renal aguda. Conclusión. La función renal se alteró transitoriamente durante las primeras 72 horas de evolución del infarto agudo del miocardio. La insuficiencia renal es poco frecuente