Catéter de Swan Ganz: Opinión de expertos

Actualmente existen dudas sobre la seguridad del uso del catéter de Swan Ganz (CSG). Para definir la opinión de los cardiólogos de nuestro país, el Consejo de Emergencias Cardiovasculares de la Sociedad Argentina de Cardiología (SAC) realizó una reunión para evaluar la opinión de expertos en diferentes escenarios (cirugía no cardíaca, cardíaca, síndromes coronarios e insuficiencia cardíaca), usando el método RAND-UCLA appropiateness. Se envió la evidencia bibliográfica previa a la reunión en la SAC y en la misma los panelistas seleccionaron las variables para conformar las situaciones clínicas que luego fueron enviadas para que individualmente, en una segunda etapa, determinaran si consideraban beneficioso o perjudicial la utilización del catéter con una escala de 1 a 9 (1 significaba que los potenciales perjuicios superaban a los beneficios, 9 que los beneficios eran mayores y 5 que podía considerarse indistintamente beneficioso o perjudicial). Dos expertos analizaron los resultados, describiendo la tasa de acuerdo/desacuerdo. Finalmente, cada indicación se clasificó como “apropiada”, “dudosa” o inapropiada de acuerdo a la mediana definida por los panelistas: 1-3 se clasificó como inapropiado, 4-6 dudoso y 7-9 como indicación apropiada. Observamos gran discrepancia en la opinión sobre la indicación de CSG entre los expertos. Sin embargo, los panelistas estuvieron a favor de su utilización en situaciones que incluían shock y disfunción miocárdica, especialmente cuando se asoció disfunción orgánica. Hubo situaciones en las que los panelistas consideraron inapropiada la indicación del CSG, en pacientes sin disfunción orgánica.(AU)

Investigators have raised doubts as to the safety of the Swan Ganz catheter (SGC). In order to define the point of view of cardiologists in our country, the Argentine Society of Cardiology’s Emergency Council organized a meeting to analyze their views in different settings (non-cardiac surgery, cardiac surgery, acute coronary syndromes and heart failure) using the RAND-UCLA appropriateness method. A detailed review with the scientific evidence was sent to the experts in cardiology prior to the meeting in the SAC auditorium where the panellists selected the clinical variables create the specific situations. These hypothetic situations were resent to the panellists at a second stage for their individual evaluation, rating the benefit-to-harm ratio of the procedure on a scale of 1 to 9 (1 meant that the expected harms greatly outweighed the expected benefits, and 9 that the expected benefits greatly outweighed the expected harms, 5 could mean either that the harms and benefits were roughly equal). Two experts analyzed the results, describing the agreement/disagreement ratio. Finally, each indication was classified as “appropriate,” “uncertain” or “inappropriate” for the procedure in accordance with the panelists’ median score: median scores in the 1-3 range were classified as inappropriate, those in the 4-6 range as uncertain, and those in the 7-9 range as appropriate. We observed high disagreement rates in SGC indications between cardiologists. However, the panelists were in favor of SGC use when situations included shock and myocardial dysfunction, especially in the presence of organic dysfunction. There were some situations when panelists considered SGC not useful, in patients without organ failure.(AU)

Cirugía coronaria sin circulación extracorpórea con puentes arteriales múltiples en pacientes diabéticos: resultados tempranos y alejados / Off-pump Coronary Artery Bypass Surgery with Multiple Arterial Grafts in Diabetic Patients: Short and Long-term Results

Introducción La diabetes mellitus se ha identificado como un fuerte predictor independiente de iniciación y progresión de la enfermedad cardiovascular y se ha reconocido como un factor de riesgo de mortalidad luego de la cirugía coronaria. La cirugía de revascularización miocárdica sin circulación extracorpórea se ha establecido como una alternativa eficaz de revascularización coronaria comparable a la técnica convencional, con resultados que muestran una disminución en la morbilidad del procedimiento y, en pacientes de riesgo alto, una mortalidad posoperatoria menor. Objetivos Comparar los resultados posoperatorios tempranos y alejados de pacientes con y sin diabetes mellitus luego de cirugía de revascularización miocárdica sin circulación extracorpórea con puentes arteriales múltiples y determinar si la hiperglucemia posoperatoria es un predictor independiente de morbimortalidad temprana. Material y métodos Entre enero de 2004 y diciembre de 2008 se efectuó cirugía de revascularización miocárdica sin circulación extracorpórea con puentes arteriales múltiples en 1.002 pacientes en forma consecutiva. La población se dividió en pacientes con diabetes mellitus (n = 234) y sin diabetes mellitus (n = 768). Se efectuó un análisis de las complicaciones posoperatorias y se identificaron predictores independientes de mortalidad hospitalaria. El seguimiento promedio fue de 1.038 ± 517 días y fue completo en el 95,7%. Resultados Los pacientes con diabetes mellitus presentaron mayor incidencia de bajo gasto cardíaco (p = 0,005), fibrilación auricular (p = 0,005) e infección esternal profunda (p = 0,005). Fueron predictores de mortalidad hospitalaria la edad (OR = 1,11), la cirugía no electiva (OR = 5,88) y la glucemia posoperatoria > 200 mg/dl (OR = 6,9). Los pacientes con diabetes mellitus tuvieron menor sobrevida alejada a los 5 años (p = 0,01). Fueron predictores de menor sobrevida alejada la diabetes mellitus (HR = 2,1), la edad (HR = 1,06), la fracción de eyección del ventrículo izquierdo 1,6 mg/dl (HR = 2,46). Conclusiones Los pacientes con diabetes mellitus tuvieron igual mortalidad hospitalaria que los no diabéticos. La presencia de hiperglucemia posoperatoria fue un predictor de mayor mortalidad hospitalaria. La diabetes mellitus y la creatinina > 1,6 mg/dl fueron predictores independientes de menor sobrevida alejada.(AU)

Introduction Diabetes mellitus has been identified as a strong independent predictor of cardiovascular disease onset and progression and acknowledged as a mortality risk factor after coronary artery surgery. Off-pump coronary artery bypass grafting has been established as an efficient alternative for coronary revascularization comparable to the conventional technique, with results evidencing a reduction in procedure morbidity and, in high risk patients, lower postoperative mortality. Objective The aims of this study were to compare short and long-term postoperative results of off-pump coronary artery revascularization surgerywith multiple arterial grafts in patients with or without diabetes mellitus and to determine if postoperative hyperglycemia is an independent predictor of early morbidity and mortality. Methods Off-pump coronary artery revascularization surgery with multiple arterial grafts was consecutively performed on 1002 patients between January 2004 and December 2008. The population was divided in diabetes mellitus (n: 234) and non-diabetes mellitus (n: 768) patients. Post-operative complications were analyzed and independent predictors of in-hospital mortality were identified. The average follow-up period of 1038 ± 517 days was completed by 95.7% of patients. Results Diabetes mellitus patients had lower cardiac output (p = 0.005), atrial fibrillation (p = 0.005) and deep sternal wound infection (p = 0.005). Age (OR = 1.11), non-elective surgery (OR = 5.88) and blood glucose level > 200 mg/dL (OR= 6.9) were significant predictors of in-hospital mortality. Five-year survival was lower in diabetes mellitus patients (p = 0.01). Diabetes mellitus (HR = 2.1), age (HR = 1.06), left ventricular ejection fraction 1.6 mg/dL (HR = 2.46) were significant predictors of decreased long-term survival. Conclusions Diabetes mellitus and non-diabetes mellitus patients had similar in-hospital mortality rates. Postoperative hyperglycemia was a predictor of greater in-hospital mortality. Diabetes mellitus and creatinine > 1.6 mg/dL were independent predictors of decreased long-term survival.(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)

Hiperglucemia en el síndrome coronario agudo: informe científico multidisciplinario / Hyperglycemia in acute coronary syndrome: multidisciplinary scientific report

La hiperglucemia con o sin diabetes preexistente es un hallazgo frecuente en pacientes que cursan un síndrome coronario agudo. Estudios previos han demostrado que la hiperglucemia es altamente prevalente y se asocia a un mayor riesgo de muerte y complicaciones hospitalarias. Los mecanismos fisiopatológicos mediante los cuales la hiperglucemia provoca resultados adversos no son claros, y se desconoce si es un marcador de eventos o su causa. Los efectos perjudiciales de la hiperglucemia en el sistema cardiovascular son múltiples, y el control de los niveles de glucosa con insulina parece mejorar el pronóstico en estos pacientes. Se han desarrollado numerosos protocolos para el control de glucemia que demostraron ser seguros y efectivos. 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 estrategias para el control de la glucemia en pacientes que cursan un síndrome coronario agudo. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia y ofrecer recomendaciones generales de tratamiento en la Unidad Coronaria.(AU)

Hyperglycemia with or without pre-existing diabetes mellitus, occurs frequently in the setting of acute coronary syndrome. Previous studies have demonstrated that hyperglycemia is highly prevalent and is associated with an increased risk of hospital complications and death. The underlying pathophysiology related an adverse clinical outcome to hyperglycemia is unclear, and it is uncertain whether increased serum glucose is simply a marker of adverse outcomes or their cause. Detrimental effects of hyperglycemia on the cardiovascular system are multiple. Glycemia control with insulin would prevent adverse outcomes. Numerous glucose-control protocols have been developed and tested proving to be safe and effective. In an initiative from the Emergency Council of the Argentine Society of Cardiology, local experts analyzed the management of hyperglycemia in acute coronary syndrome. The main objective of the prevent statement is to summarize the current state of knowledge on glycemic control, and to offer general recommendations regarding glucose management in the coronary care unit.(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)

Hiperglucemia en el síndrome coronario agudo: informe científico multidisciplinario / Hyperglycemia in acute coronary syndrome: multidisciplinary scientific report

La hiperglucemia con o sin diabetes preexistente es un hallazgo frecuente en pacientes que cursan un síndrome coronario agudo. Estudios previos han demostrado que la hiperglucemia es altamente prevalente y se asocia a un mayor riesgo de muerte y complicaciones hospitalarias. Los mecanismos fisiopatológicos mediante los cuales la hiperglucemia provoca resultados adversos no son claros, y se desconoce si es un marcador de eventos o su causa. Los efectos perjudiciales de la hiperglucemia en el sistema cardiovascular son múltiples, y el control de los niveles de glucosa con insulina parece mejorar el pronóstico en estos pacientes. Se han desarrollado numerosos protocolos para el control de glucemia que demostraron ser seguros y efectivos. 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 estrategias para el control de la glucemia en pacientes que cursan un síndrome coronario agudo. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia y ofrecer recomendaciones generales de tratamiento en la Unidad Coronaria.(AU)

Hyperglycemia with or without pre-existing diabetes mellitus, occurs frequently in the setting of acute coronary syndrome. Previous studies have demonstrated that hyperglycemia is highly prevalent and is associated with an increased risk of hospital complications and death. The underlying pathophysiology related an adverse clinical outcome to hyperglycemia is unclear, and it is uncertain whether increased serum glucose is simply a marker of adverse outcomes or their cause. Detrimental effects of hyperglycemia on the cardiovascular system are multiple. Glycemia control with insulin would prevent adverse outcomes. Numerous glucose-control protocols have been developed and tested proving to be safe and effective. In an initiative from the Emergency Council of the Argentine Society of Cardiology, local experts analyzed the management of hyperglycemia in acute coronary syndrome. The main objective of the prevent statement is to summarize the current state of knowledge on glycemic control, and to offer general recommendations regarding glucose management in the coronary care unit.(AU)

Actualización en el diagnóstico de la diabetes / [Update on the diagnosis of diabetes].

Diabetes mellitus is a chronic metabolic disease characterized by the presence of hyperglycemia. This condition must be detected early in order to establish a proper treatment and prevent its micro and macro vascular complications. The diagnosis of diabetes mellitus is based on the detection of abnormally high levels of glycemia. This task may appear to be simple but should not be underestimated. Misclassifying an individual as a diabetic can expose him/her not only to emotional damage but also to unnecessary diagnostic tests and potentially harmful treatments. Many different clinical situations such as pregnancy or acute critical illness may hamper the interpretation of laboratory findings. In this article, we present an updated review on the main aspects related to diagnosis of diabetes mellitus.

Actualización en el diagnóstico de la diabetes. / [Update on the diagnosis of diabetes].

Diabetes mellitus is a chronic metabolic disease characterized by the presence of hyperglycemia. This condition must be detected early in order to establish a proper treatment and prevent its micro and macro vascular complications. The diagnosis of diabetes mellitus is based on the detection of abnormally high levels of glycemia. This task may appear to be simple but should not be underestimated. Misclassifying an individual as a diabetic can expose him/her not only to emotional damage but also to unnecessary diagnostic tests and potentially harmful treatments. Many different clinical situations such as pregnancy or acute critical illness may hamper the interpretation of laboratory findings. In this article, we present an updated review on the main aspects related to diagnosis of diabetes mellitus.

Catéter de Swan Ganz. Opinión de expertos. / [Swan Ganz catheter. Experts opinion].

Investigators have raised doubts as to the safety of the Swan Ganz catheter (SGC). In order to define the point of view of cardiologists in our country, the Argentine Society of Cardiologys Emergency Council organized a meeting to analyze their views in different settings (non-cardiac surgery, cardiac surgery, acute coronary syndromes and heart failure) using the RAND-UCLA appropriateness method. A detailed review with the scientific evidence was sent to the experts in cardiology prior to the meeting in the SAC auditorium where the panellists selected the clinical variables create the specific situations. These hypothetic situations were resent to the panellists at a second stage for their individual evaluation, rating the benefit-to-harm ratio of the procedure on a scale of 1 to 9 (1 meant that the expected harms greatly outweighed the expected benefits, and 9 that the expected benefits greatly outweighed the expected harms, 5 could mean either that the harms and benefits were roughly equal). Two experts analyzed the results, describing the agreement/disagreement ratio. Finally, each indication was classified as "appropriate" "uncertain" or "inappropriate" ,for the procedure in accordance with the panelists median score: median scores in the 1-3 range were classified as inappropriate, those in the 4-6 range as uncertain, and those in the 7-9 range as appropriate. We observed high disagreement rates in SGC indications between cardiologists. However, the panelists were in favor of SGC use when situations included shock and myocardial dysfunction, especially in the presence of organic dysfunction. There were some situations when panelists considered SGC not useful, in patients without organ failure.