An analysis of death trends in Argentina, 1990-2017, with emphasis on the effects of economic crises.

BACKGROUND: Economic crises have heterogeneous effects on population-level mortality between high- and low- or middle-income countries. Argentina - a middle income country- has suffered economic crises repeatedly over the past 30 years and is a model case study for the effects of economic crises on mortality. METHODS: Over 28 years (1990-2017), all death records in Argentina were analysed at the most disaggregated level possible (departments, that is, second-level administrative divisions). Age-and-sex-standardized all-cause mortality, premature death (<75 years) and the probability of death at different ages for both the entire population and each socio-economic quintile were calculated by level of unsatisfied basic needs (UBNs). Standardized rates are reported as biannual average and 95% confidence interval. RESULTS: Considered globally since the beginning of the series and using the 1990-1 biennium as a reference category, the standardized death rate was significantly reduced from biennium 2 (1992-3) to biennium 14 (2016-7), interrupted by two statistically significant increases in mortality, in years 2002-3 and 2016-7. In 2002-3, women had greater increase in mortality than men, and in 2016-7, even more so. The probability of dying before 75 years of age increased significantly in the last biennium, mostly among people between 50 and 74 years in the most deprived quintiles. CONCLUSIONS: Despite significant overall improvement over time, economic crises impose severe increases in mortality, especially among vulnerable groups such as the poor, the elderly, and women.

The rationale and design of the FORomegaARD Trial: A randomized, double-blind, placebo-controlled, independent study to test the efficacy of n-3 PUFA for the maintenance of normal sinus rhythm in patients with previous atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is associated with increased risk of death, thromboembolic complications, and a lowered quality of life. Despite this burden, pharmacologic agents for prevention of AF in patients who achieved normal sinus rhythm are of limited utility, mostly because of serious and frequent side effects. Thus, the availability of safer and more effective drugs may reduce the burden of disease. TRIAL DESIGN: Patients aged > or =21 years with previous symptomatic AF and who have recovered normal sinus rhythm will be randomized to 1 g daily of omega-3-acid ethyl esters or identical placebo. To be included in the trial, patients must have either (a) at least 2 symptomatic episodes of documented AF in the 6 months before randomization, with the last episode occurring in the 14 to 90 days before randomization (paroxysmal AF), or (b) successful electrical or pharmacologic cardioversion for persistent AF. Ethical committees of 71 cardiology centers in 16 provinces of Argentina have qualified and approved the protocol and are expected to enroll 1,400 patients to test the primary end point of efficacy, which is survival free of AF during follow-up. CONCLUSION: The Fish Oil Reserach with omega-3 for Atrial fibrillation Recurrence Delay (FORomegaARD) trial will determine whether pharmacologic supplementation with 1 g of omega-3-acid ethyl esters can reduce AF recurrence in patients with previous AF who have recovered normal sinus rhythm.

Seasonal variation and trends in heart failure morbidity and mortality in a South American community hospital.

Circannual variation in cardiovascular events is well-known. Seasonal variation (SV) in heart failure (HF) has been described in the Northern Hemisphere, but there is scarcity of data in South America. The goals of the present study were to (1) describe the SV of admissions and deaths for HF, and (2) describe trends in HF morbidity and mortality in a community hospital in Argentina from 1992 to 1999. The study sample included 6369 admissions. During this period, the number of HF admissions rose by 188% and the rate HF admissions/all admissions increased from 3.28% to 7.84%. In-hospital mortality decreased from 21% to 13%. HF admissions followed a seasonal pattern with a winter-spring predominance. Male and very old patients were the subgroups with the highest SV. The authors identified clear SV in HF deaths and admissions, which raises a different hypothesis about the rationale of HF admissions and provides information for the organization of care and resource allocation.

Achieving LDL cholesterol, non-HDL cholesterol, and apolipoprotein B target levels in high-risk patients: Measuring Effective Reductions in Cholesterol Using Rosuvastatin therapY (MERCURY) II.

BACKGROUND: National Cholesterol Education Program Adult Treatment Panel III guidelines for patients at a high risk of coronary heart disease set a low-density lipoprotein cholesterol (LDL-C) target of < 100 mg/dL. This target can be difficult to attain with diet and current therapy. METHODS: In a 16-week multinational trial, 1993 high-risk patients were randomized to rosuvastatin 20 mg, atorvastatin 10 mg, atorvastatin 20 mg, simvastatin 20 mg, or simvastatin 40 mg for 8 weeks. Patients either remained on starting treatment or switched to lower or milligram-equivalent doses of rosuvastatin for 8 more weeks. RESULTS: At 16 weeks, more patients achieved their LDL-C target by switching to rosuvastatin 10 mg than staying on atorvastatin 10 mg (66% vs 42%, P < .001) or simvastatin 20 mg (73% vs 32%, P < .001). Changing to rosuvastatin 20 mg brought more patients to their LDL-C target than staying on atorvastatin 20 mg (79% vs 64%, P < .001) or simvastatin 40 mg (84% vs 56%, P < .001). More very high risk patients achieved an LDL-C target of < 70 mg/dL when changed to rosuvastatin from atorvastatin or simvastatin (within-arm comparisons P < .01). More hypertriglyceridemic patients (triglycerides > or = 200 mg/dL) met LDL-C, non-high-density lipoprotein cholesterol (non-HDL-C), and apolipoprotein B targets by changing to rosuvastatin. Switching to rosuvastatin produced greater reductions in LDL-C, total cholesterol, non-HDL-C, apolipoprotein B, and lipid ratios. All treatments were well tolerated, with no differences among treatment groups in skeletal muscle, hepatic, or renal toxicity. CONCLUSION: Rosuvastatin 10 or 20 mg is an effective and safe therapeutic option for high-risk patients to achieve their lipid and apolipoprotein targets.

N-3 polyunsaturated fatty acids to prevent atrial fibrillation: updated systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Previous studies have suggested that n-3 polyunsaturated fatty acids (n-3 PUFAs) have antiarrhythmic effects on atrial fibrillation (AF). We aimed to assess the effects of therapy with n-3 PUFAs on the incidence of recurrent AF and on postoperative AF. METHODS AND RESULTS: Electronic searches were conducted in Web of Science, Medline, Biological Abstracts, Journal Citation Reports, and the Cochrane Central Register of Controlled Trials databases. In addition, data from the recently completed FORωARD and OPERA trials were included. We included randomized controlled trials comparing treatment with n-3 PUFAs versus control to (1) prevent recurrent AF in patients who underwent reversion of AF or (2) prevent incident postoperative AF after cardiac surgery. Of identified studies, 12.9% (16 of 124) were included, providing data on 4677 patients. Eight studies (1990 patients) evaluated n-3 PUFA effects on AF recurrence among patients with reverted AF and 8 trials (2687 patients) on postoperative AF. Pooled risk ratios through random-effects models showed no significant effects on AF recurrence (RR, 0.95; 95% CI, 0.79 to 1.13; I(2), 72%) or on postoperative AF (0.86; 95% CI, 0.71 to 1.04; I(2), 53.1%). A funnel plot suggested publication bias among postoperative trials but not among persistent AF trials. Meta-regression analysis did not find any relationship between doses and effects (P=0.887 and 0.833 for recurrent and postoperative AF, respectively). CONCLUSIONS: Published clinical trials do not support n-3 PUFAs as agents aimed at preventing either postoperative or recurrent AF. CLINICAL TRIAL REGISTRATION: URL: http://www.crd.york.ac.uk/PROSPERO. Unique Identifier: CRD42012002199.

Omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: results of the FORWARD (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation) trial.

OBJECTIVES: The aim of this study was to evaluate the efficacy of polyunsaturated fatty acids (n-3 PUFA) for the prevention of recurrent atrial fibrillation (AF) in patients with normal sinus rhythm. BACKGROUND: Current pharmacological treatments to limit recurrent AF in patients with previous AF have limited efficacy and high rates of adverse events. Results of trials that tested the efficacy of n-3 PUFA provided heterogeneous results. METHODS: This was a prospective, randomized, double-blind, placebo-controlled, multicenter trial involving 586 outpatient participants with confirmed symptomatic paroxysmal AF that required cardioversion (n = 428), at least 2 episodes of AF in the 6 months before randomization (n = 55), or both (103). Patients were randomly allocated to n-3 PUFA (1 g/day) or placebo for 12 months. The primary endpoint was symptomatic recurrence of AF. RESULTS: There were no significant differences between patients allocated to placebo and those who received n-3 PUFA for the main outcome. At 12 months, 56 of 297 participants (18.9%) in the placebo group and 69 of 289 participants (24.0%) in the n-3 PUFA group had a recurrent symptomatic AF (hazard ratio: 1.28, 95% confidence interval: 0.90 to 1.83, p = 0.17). There was no difference between treatment with placebo and n-3 PUFA for any of the other pre-specified endpoints, including the composite of all-cause mortality, nonfatal stroke, nonfatal acute myocardial infarction, systemic embolism, heart failure development, or severe bleeding that occurred in 20 (6.7%) and 16 (5.5%) of patients randomized to placebo or n-3 PUFA, respectively (hazard ratio: 0.86, 95% confidence interval: 0.44 to 1.66, p = 0.65). CONCLUSIONS: Pharmacological supplementation with 1 g of n-3 PUFA for 1 year did not reduce recurrent AF. (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation [FORWARD]; NCT00597220).

Inequidad social, lugar de residencia y muerte prematura por cualquier causa en la Argentina / Social Inequity, Place of Residence and All-Cause Premature Death in Argentina

Introducción: Aunque recientemente se reportó la relación entre la muerte prematura y la condición socioeconómica en la Argentina, no existen análisis sobre el impacto que dicha condición tiene en distintas regiones del país. Objetivo: Describir el impacto que la condición socioeconómica presentó sobre la incidencia de muerte prematura en las distintas provincias de la Argentina durante el período 2000-2010. Material y métodos: Se utilizó un modelo ecológico, que evaluó las tasas estandarizadas de muerte prematura (≤ 74 años) durante el período 2000-2010. Asimismo, se examinó la relación entre la condición socioeconómica medida en deciles de necesidades básicas insatisfechas por departamento geográfico y la muerte prematura. La unidad de análisis fueron los 512 departamentos de la Argentina y las 15 comunas de la ciudad de Buenos Aires. Resultados: La condición socioeconómica estuvo significativamente asociada con la muerte prematura en la Argentina durante el período analizado. En todas las provincias y regiones se observó un gradiente lineal entre la muerte precoz y la condición socioeconómica. Sin embargo, la pendiente de desigualdad entre los componentes de la condición socioeconómica varió significativamente entre los distintos departamentos. Mientras que en toda la Argentina la diferencia absoluta en la tasa estandarizada de muerte prematura entre los componentes extremos de condición socioeconómica fue de 10 muertes (rango: 7,81-12,36) por cada 10.000 personas por año, en la ciudad de Buenos Aires esa diferencia fue de 61 muertes (rango: 53-69). Las comunas del sur de la ciudad de Buenos Aires fueron las zonas con mayor desigualdad social y sanitaria de la Argentina. Conclusiones: Aunque la inequidad social tuvo un impacto significativo en la muerte prematura en todo el período en toda la Argentina, la ciudad de Buenos Aires se mostró como la región más desigual.

Background: Although the relationship between premature death and socioeconomic status has been recently reported in Argentina, there are no analyses on the impact of this condition in different regions of the country. Objective: The aim of this study was to describe the influence of socioeconomic status on the incidence of premature death rate in different provinces of Argentina, from 2000 to 2010. Methods: An ecological model was used to evaluate standardized premature death rates (≤74 years) during the period between 2000 and 2010. In addition, the relationship between socioeconomic status, measured in deciles of unmet basic needs at geo-graphic departmental level and premature death was examined. The units of analysis were the 512 Argentine departments and the 15 communes of the city of Buenos Aires. Results: Socioeconomic status was significantly associated with premature death rate in Argentina during the study period. A linear gradient was observed between premature death and socioeconomic status in all provinces and regions. However, the slope index of inequality varied significantly between departments. While the absolute difference in standardized premature death rate between the extreme components of socioeconomic status was 10 deaths (range: 7.81-12.36) per 10,000 persons pers year in all Argentina, in the city of Buenos Aires this difference was 61 deaths (range: 53-69). The Southern communes of Buenos Aires were the areas with the highest social and health inequalities of Argentina. Conclusions: Although social inequity had a significant impact on premature death rate throughout Argentina during the study period, the city of Buenos Aires was the most unequal region.

Premature Cardiovascular death and socioeconomic status in argentina. On the Opportunities and Challenges of Representing Vulnerable Populations / Muerte cardiovascular prematura y condición socioeconómica en la Argentina. Acerca de las oportunidades y desafíos de representar a poblaciones vulnerables

Background: Premature death is a challenge from the social, medical, sanitary and economic point of view. Many of these deaths are avoidable with the implementation of State policies. Scientific societies may and should participate in the guidance of public policies. However, precise data and an inclusive approach are necessary to accomplish this end. Objective: The aim of this study was to describe the temporal trend of premature all-cause and cardiovascular deaths in Argentina during the period 2000-2010. Methods: An ecological model, evaluating the evolution of specific and standardized rates of premature death (≤74 years) was used. Additionally, the relationship between socioeconomic status (SES) and premature death was examined. The 513 departments of Argentina were the analysis unit. Results: Premature all-cause mortality (median per 10,000 persons/year; p value) declined from 42.65 in 2000 to 38.67 in 2011 (p<0.001). A similar result was obtained for cardiovascular death (from 12.75 in 2000 to 10.09 in 2011; p<0.001). A significant, linear relationship between SES and premature death was verified without threshold in all years. The velocity and relative reduction were significantly different across different SES strata. Conclusions: Although the mortality rate was reduced, the gap between SES and premature deaths widened in Argentina, indicating the need to think on whom and how we should pay closer attention.

Introducción: La muerte prematura constituye un desafío desde el punto de vista social, médico, sanitario y económico. Muchas son evitables con la implementación de políticas de Estado. Las sociedades científicas pueden y deben participar en el asesoramiento de políticas públicas. Sin embargo, para esto son necesarios datos precisos y una mirada inclusiva. Objetivo: Describir la tendencia temporal de muertes prematuras por todas las causas y cardiovasculares en la Argentina en el período 2000-2011. Material y métodos: Se utilizó un modelo ecológico, que evaluó la evolución de las tasas específicas y estandarizadas de muerte prematura (≤74 años). Asimismo, se examinó la relación entre la condición socioeconómica (CSE) y la muerte prematura. La unidad de análisis fueron los 513 departamentos de la Argentina. Resultados: La muerte prematura (mediana cada 10.000 personas/año; valor de p) por todas las causas se redujo significativamente desde el año 2000 (42,65) hasta el 2011 (38,7) (p < 0,001). Lo propio sucedió con la muerte cardiovascular (de 12,75 en el año 2000 a 10,09 en el año 2011; p < 0,001). La muerte prematura tuvo una asociación significativa con la CSE, existiendo un gradiente lineal, sin umbrales en todos los años entre CSE y muerte prematura. La velocidad y la reducción relativa fueron significativamente distintas entre los diversos estratos de CSE. Conclusiones: Aunque la tasa de mortalidad se redujo, la brecha entre la CSE y la muerte prematura se incrementó, lo que obliga a reflexionar sobre en quiénes y cómo debemos depositar la mirada.

Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up.

OBJECTIVES: The purpose of this study was to assess the rate of death and hospitalization for heart failure (HF) 1 and 3 years after a randomized trial of telephone intervention aimed to improve education and compliance in stable patients with HF ended. BACKGROUND: The long-term effects of HF programs are not well known. METHODS: In all, 1,518 patients with HF were randomized into the DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure). After completion of the trial, patients were followed up to 3 years to assess major outcomes. Compliance with diet, weight control, and treatment was evaluated. The effect of the intervention on mortality and HF hospitalizations was assessed using relative risk (RR), relative risk reduction, and Cox proportional hazards model for adjusting by potential confounders. RESULTS: The rate of death or hospitalization for HF was lower in the intervention group (37.2% vs. 42.6%, RR: 0.81, 95% confidence interval [CI]: 0.69 to 0.96; p = 0.013) 1 and 3 years (55.7% vs. 57.5%, RR: 0.88, 95% CI: 0.77 to 1.00; p = 0.05) after the intervention ended. This benefit was mainly caused by a reduction in admission for HF (28.5% vs. 35.1% after 3 years, RR: 0.72, 95% CI: 0.60 to 0.87; p = 0.0004). Patients who showed improvement in 1 or more of 3 key compliance indicators (diet, weight control, and medication) had lower risks of events. CONCLUSIONS: The benefit observed during the intervention period persisted and was sustained 1 and 3 years after the intervention ended. This effect may be explained by the impact of the educational intervention on patients' behavior and habits.

Impact of a standardized titration protocol with carvedilol in heart failure: safety, tolerability, and efficacy-a report from the GESICA registry.

Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA) studied whether a standardized protocol for the initiation and titration of the beta-blocker carvedilol in a multicenter, open-label program would optimize beta-blocker use in heart failure (HF) patients. The program included: (1) the carvedilol initiation and titration period, and (2) long-term follow-up at 6 and 12 months. Of 1299 patients in the registry, 504 were excluded due to current therapy; of the remaining 795 eligible patients, 293 were excluded due to contraindications. Of the included patients with follow-up data (n = 316), 93.3% tolerated carvedilol initiation and 47.7% of the patients reached the target dose of 50 mg/day for a mean dose of 39 mg/day. Rates were comparable in the elderly (n = 83), of which 53% achieved a target dose for a mean dose of 43.08 mg/day. This protocol improved therapy rates and achieved target doses quickly (average of 4 visits). Concomitant medications did not have to be adjusted and there were low withdrawal rates (10%) and hospital admissions (7.2%) for HF. Patients were able to maintain carvedilol therapy at 6 and 12 months. These results indicate that a standardized titration protocol, as used in GESICA, for the initiation and titration of beta-blockers is well tolerated and may improve beta-blocker use in carefully selected heart failure patients.

Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL): study design and preliminary observations.

BACKGROUND: In the last few years different approaches based on comprehensive patient care and close surveillance by multidisciplinary teams have shown promising results in heart failure. However, current evidence mainly derives from small and often nonrandomized studies performed at a single center, with selected populations, using dissimilar and complex strategies. We designed a large randomized study to test the hypothesis that a single program, based on a centralized telephone intervention performed by trained nurses, could reduce morbidity and mortality in chronic heart failure. METHODS: The Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL) is a randomized, controlled, open trial designed to compare frequent telephone follow-up intervention versus control. We enrolled 1518 patients with stable chronic heart failure and optimal treatment from 51 centers in Argentina. DIAL trial intervention strategy is based on frequent telephone follow-up provided by nurses trained in heart failure and performed from a single surveillance center, assuring a homogeneous and high quality intervention. The primary objective is to determine the effect of the intervention as compared with the usual follow-up on the combined endpoint of all-cause mortality or hospitalization for worsening heart failure. The objectives of the intervention are education, counseling, and monitoring to enhance self-control mechanisms, timely medical visits, diet, and drug therapy compliance. Telephone call frequency was determined according to preestablished criteria of clinical status severity assessed at each phone contact. The study ended in August 2002. CONCLUSION: The results of this study may provide information about mortality, hospitalizations, and quality of life contributing to set standards for management programs in the current treatment of chronic heart failure.

Valor pronóstico del índice de masa corporal en pacientes con insuficiencia cardíaca crónica: registro GESICA / Prognostic value of body mass index in patients with chronic heart failure: the GESICA registry

Objetivos: Comparar las características clínicas en pacientes con insuficiencia cardíaca (IC) de acuerdo con el IMC, evaluar si el IMC tiene valor pronóstico, describir el tipo de asociación del IMC con la mortalidad y valorar si presenta un impacto similar en diferentes subgrupos. Material y métodos: A partir de una cohorte de 2331 pacientes ambulatorios con IC, se compararon las características clínicas de acuerdo con el IMC. La asociación entre el IMC y la mortalidad se evaluó a través de análisis univariado y multivariado incluyendo potenciales confundidores (regresión de Cox). Se describió la relación entre el IMC y la mortalidad. Se realizó un subanálisis en obesos mórbidos. Se evaluó el impacto del IMC en subgrupos. Seguimiento promedio: 957 días. Resultados: Población de acuerdo con grupos de IMC: < 20 kg/m² 61 pacientes (2,61 por ciento), 20 a 24,99 kg/m² 668 pacientes (28,65 por ciento), 25 a 29,99 kg/m² 999 pacientes (42,85 por ciento) y 30 kg/m² o más 603 pacientes (25,86 por ciento). A mayor IMC se observó menor severidad de la IC y menor mortalidad. Análisis multivariado: IMC < 20 kg/m²: HR 1,72 ( 1,14 a 2,59; p = 0,009), IMC 25-29,99 kg/m²: HR 0,78 ( 0,64 a 0,95; p = 0,015), IMC = 30 kg/m²: HR 0,79 ( 0,63 a 0,99; p = 0,047). Se observó un impacto menor del IMC bajo (< 24 kg/m²) en pacientes con insuficiencia renal crónica, en tratamiento con betabloqueantes o estatinas. La obesidad mórbida (IMC >35 kg/m²) se asoció con menor mortalidad. Conclusiones: El IMC presenta información pronóstica adicional en la IC. Su valor pronóstico es similar en diferentes subgrupos de pacientes de acuerdo con la función ventricular, el tiempo de evolución o las comorbilidades.

Seguimiento al año luego de finalizada la intervención telefónica en pacientes con insuficiencia cardíaca crónica: estudio DIAL / Follow-up one year after phone intervention in patients with chronic cardiac insufficiency: DIAL Study

Objetivos: Evaluar la incidencia de internación por insuficiencia cardíaca (IC) y/o muerte luego de 6 meses y de un año de finalizada la intervención del estudio DIAL. Material y métodos: A partir del estudio DIAL (n = 1.518) se completó un seguimiento clínico de 1 año luego de finalizada la intervención. Se analizó la incidencia de eventos a los 6 meses y al año. Se realizaron los siguientes análisis: 1) inicio a luego de 6 meses, 2) inicio a luego del año, 3) fin a luego de 6 meses y 4) fin a luego del año. Análisis: log-rank e informe de RR e IC 95 por ciento. Puntos finales: primario (internación por IC y/o muerte), internación por IC, muerte. Resultados: La incidencia del punto final primario (internación por IC y/o muerte) fue menor en el grupo intervención durante todo el seguimiento alejado, tanto a 6 meses (intervención 31,97 por ciento versus control 38,39 por ciento, RR 0,78 (0,65-0,93); p = 0,0049 como al año de finalizado (intervención 37,23 por ciento versus control 42,61 por ciento, RR 0,81 (0,69-0,96); p = 0,013). Este beneficio se debió en especial a una reducción en las internaciones por IC. Considerando los eventos ocurridos una vez finalizada la intervención, los pacientes que habían recibido la intervención presentaron una incidencia menor de eventos, aunque este efecto no fue significativo debido al bajo número de eventos y al tiempo de seguimiento. Luego de 6 meses desde el fin de la intervención, la incidencia del punto final primario en el grupo intervención fue del 7,67 por ciento y en el grupo control del 10,70 por ciento, RR 0,70 (0,46-1,06); p = 0,08. Al año de finalizada, la incidencia fue del 14,64 por ciento en el grupo intervención versus el 16,44 por ciento en el grupo control, RR 0,87 (0,63-1,19); p = 0,38. Conclusiones: El beneficio obtenido mediante la intervención telefónica continúa incrementándose durante los primeros 6 meses luego de finalizada la intervención y se mantiene al año. Este efecto sostenido podría explicarse por el impacto educativo de la intervención sobre hábitos y conductas de los pacientes.

Efecto del tratamiento con estatinas en la insuficiencia cardíaca crónica: registro GESICA / Statin treatment in chronic heart failure: GESICA registry

Objetivo: Analizar las características clínicas y los eventos de pacientes ambulatorios con insuficiencia cardíaca (IC) tratados con estatinas. Material y métodos: A partir de una cohorte de 2331 pacientes ambulatorios con IC, se evaluó el tratamiento con estatinas a la inclusión. Se analizaron las características clínicas de los pacientes tratados y la incidencia de eventos (log rank test), ajustado por confundidores (regresión de Cox). Seguimiento promedio: 957 días. Resultados: Población: edad 63 años, hombres 71,5 por ciento, CF III-IV 52,2 por ciento, deterioro severo de la función VI 49,4 por ciento, cardiopatía isquémica 40,6 por ciento. Uso de estatinas al ingreso: 8,7 por ciento. Estatinas versus no estatinas: hombres 78,4 por ciento versus 70,9 por ciento, p = 0,02; cardiopatía isquémica 72,2 por ciento versus 37,6 por ciento, p < 0,0001; dislipemia: 85,1 por ciento versus 9,4 por ciento, p < 0,0001; EPOC 5,2 por ciento versus 9,8 por ciento, p = 0,03; CF III-IV: 38,7 por ciento versus 53,4 por ciento, p < 0,0001; anemia 5,8 por ciento versus 12,4 por ciento, p = 0,006; disfunción sistólica 87,5 por ciento versus 81,6 por ciento, p = 0,03. Eventos: la mortalidad fue menor en el grupo tratado (16,1 por ciento versus 26,8 por ciento, HR 0,55 IC 95 por ciento [0,38-0,77], p = 0,001). Análisis multivariado: HR = 0,62, IC 95 por ciento [0,43-0,89], p = 0,009. El beneficio se observó en cardiopatía isquémica (HR = 0,61, IC 95 por ciento [0,45-0,82], p = 0,001) y no isquémicos (HR = 0,65, IC 95 por ciento [0,41-1,00], p = 0,05), p de interacción: 0,85. Se observó una tendencia a reducción de internaciones por insuficiencia cardíaca aunque no significativa: 22,4 por ciento versus 25,7 por ciento, p = 0,07. Conclusiones: Las estatinas podrían ser beneficiosas en la insuficiencia cardíaca por diversos mecanismos. Estos resultados y los de otros estudios observacionales generan la hipótesis de que las estatinas podrían reducir la mortalidad en la IC, que requerirá ser evaluada a través de ensayos clínicos aleatorizados.

Predictores de morbimortalidad en pacientes con insuficiencia cardíaca y función sistólica conservada / Predictors of disease progresion and mortality in patients with heart failure and preserved systolic function

Objetivos: El objetivo principal de este estudio es el de analizar las variables asociadas con mortalidad e internaciones por descompensación en pacientes con insuficiencia cardíaca y función sistólica conservada. Por otra parte, construímos y validamos una regla de predicción clínica de mortalidad en esta población. Material y métodos: A partir de 2279 pacientes incluídos en forma consecutiva en el registro GESICA de insuficiencia cardíaca, analizamos 401 individuos con fracción de eyección > 40 por ciento. Este grupo se caracterizó por tener un promedio de edad de 70 años, un 41 por ciento de mujeres, el 57 por ciento se hallaba en CF III/IV y el 24 por ciento tenía cardiopatía isquémica. Durante el seguimiento promedio de 540 días, el 14,4 por ciento de los pacientes se internaron al menos una vez por IC y el 15,2 por ciento fallecieron. Resultados: La única variable independiente asociada con la internación por insuficiencia cardíaca fue el múmero de internaciones en el año previo: HR 1,72 (1,0-2,97), p= 0,05; mayor ó menor 2 internaciones: HR 2,78 (1,15-6,72), p = 0,023. Las variables predictoras independientes de mortalidad fueron: clase funcional, uremia, natremia, enfermedad pulmonar obstructiva crónica, sexo masculino, índice de masa corporal y tensión arterial sistólica < 110 o > 140 mm Hg. El sexo masculino, la enfermedad pulmonar obstructiva crónica y la tensión arterial sistólica elevada predijeron mortalidad sólo en pacientes sin disfunción sistólica. Conclusión: En los pacientes con insuficiencia cardíaca y función sistólica conservada, las variables asociadas con una severidad clínica mayor predicen mayor mortalidad, mientras que las internaciones previas se asocian solamente con nuevas internaciones por insuficiencia cardíaca.