[Cardiologist training in Chile and contributions from the Chilean Society of Cardiology and Cardiovascular Surgery]. / Formación del cardiólogo en Chile y contribuciones desde la Sociedad Chilena de Cardiología y Cirugía Cardiovascular.

The Chilean Society of Cardiology and Cardiovascular Surgery (SOCHICAR) is a scientific society whose mission is to improve the nation's cardiovascular health. Its primary goals include discussing issues affecting the specialty and engaging in various activities that support its advancement. To achieve these goals, numerous educational initiatives are undertaken for health professionals, including physicians in cardiology training programs. Training specialists in Chile is the responsibility of the universities, which design the curriculum and plan the program according to the graduate profile. SOCHICAR seeks to integrate these new generations of cardiologists, setting up tasks that contribute to their training. It seemed relevant to us to state our position as a Scientific Society in importants aspects related to this process: the graduate profile of the clinical cardiologist, the necessary competencies for their performance nationally, the identification of deficient areas in their training period, and the Society's contributions to this university-dependent process. A total of 15 cardiologists from SOCHICAR, at different stages of professional development, various geographic areas, and areas of performance and functions, were invited to participate in three working groups. This SOCHICAR position statement may be useful and an important source of information to be considered by authorities, accrediting entities, training centers, and the Chilean Society of Cardiology.

Consensus document on anemia and iron deficiency in heart failure: Consejo Interamericano de Falla Cardiaca e Hipertensión Pulmonar (CIFACAH) of the Interamerican Society of Cardiology (IASC).

Heart failure is a pathology that affects 1% of the population and is accompanied by iron deficiency as a comorbidity in 50% of cases. Anemia, meanwhile, is present between 22-37%. This is a consensus document that seeks to synthesize the information available on anemia and iron deficiency and its behavior in patients with HF, which is divided into pathophysiology, classification, clinical scenarios and algorithms (clinical pathways), treatment, and follow-up. This article integrates international recommendations based on evidence and presents a synthesis of management strategies.

La insuficiencia cardíaca (IC) es una patología que afecta al 1% de la población y se encuentra acompañada de deficiencia de hierro como comorbilidad en el 50% de los casos. La anemia, por su parte, está presente en el 22-37% de los casos de IC. Este es un documento de consenso que busca sintetizar la información disponible sobre la anemia y la deficiencia de hierro, y su comportamiento en pacientes con IC, que se divide en fisiopatología, clasificación, escenarios clínicos y algoritmos (rutas de manejo), tratamiento y seguimiento. Este artículo integra las recomendaciones internacionales basadas en la evidencia y se presenta una síntesis de las estrategias de manejo.

Complicaciones cardiovasculares en pacientes COVID-19 hospitalizados en Unidades de Pacientes Críticos en Chile. Registro COVICAR / Cardiovascular complications in COVID-19 patients admitted to intensive care units in Chilean hospitals

BACKGROUND: Patients with a cardiovascular (CV) history may be at greater risk of becoming ill and die due to SARS-CoV-2. AIM: To assess the incidence of CV complications in COVID-19 patients, the type of complication, and their association with CV history. MATERIAL AND METHODS: The clinical course of 1,314 patients with COVID-19 admitted consecutively to critical care units of 10 Chilean hospitals was registered between April and August of 2020. RESULTS: The median age of patients was 59 years and 66% were men. One hundred-four (8%) had a CV history, namely heart failure (HF) in 53 (4.1%), coronary heart disease in 50 (3.8 %), and atrial fibrillation in 36 (2.7 %). There were CV complications in 359 patients (27.3%). The most common were venous thrombosis in 10.7% and arrhythmias in 10.5%, HF in 7.2%, type 2 acute myocardial infarction in 4.2%, arterial thrombosis in 2.0% and acute coronary syndrome (ACS) in 1.6%. When adjusted by age, sex and risk factors, only HF (Odds ratio (OR) = 7.16; 95% confidence intervals (CI), 3.96-12.92) and ACS (OR = 5.44; 95% CI, 1.50-19.82) were significantly associated with CV history. There was no association with arrhythmias, type 2 acute myocardial infarction, arterial or venous thrombosis. CONCLUSIONS: Patients with a history of CV disease are at greater risk of suffering HF and ACS when hospitalized due to COVID-19. Arrhythmias, type 2 AMI, and arterial or venous thrombosis occur with the same frequency in patients with or without CV history, suggesting that these complications depend on inflammatory phenomena related to the infection.

Disección coronaria espontánea en paciente trasplantada de corazón / Spontaneous coronary artery dissection in a heart transplant patient: report of one case

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome that predominantly affects women without cardiovascular risk factors. In transplant patients, spontaneous coronary artery dissection is an extremely rare condition, having been described in only three patients, in whom vascular damage secondary to the use of anticalcineurinics is postulated as a probable mechanism. We report a spontaneous coronary dissection in a female who received a heart transplant at 34 years of age. The diagnosis was made in a follow-up coronary angiography three years after transplantation, supplemented with optical coherence tomography. A percutaneous coronary revascularization of the involved artery was performed, with good immediate results and at one year of follow-up.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology

ABSTRACT Background: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. Aim: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Material and Methods: Review of clinical records of seven patients treated between January 2014 and October 2018. Results: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. Conclusions: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

Antecedentes: El shock cardiogénico (SC) es infrecuente en el laboratorio de cateterismo cardíaco (LCC) entre pacientes que son sometidos a coronariografía. El SC peri-procedimiento es más frecuente en pacientes de alto riesgo y en procedimientos técnicamente complejos. Objetivos: Describir los resultados clínicos de pacientes que fueron conectados a oxigenación con membrana extracorpórea veno-arterial periférica (ECMO-VAp) por SC peri-procedimiento de cardiología intervencional. Material y Métodos: Revisión de fichas clínicas de siete pacientes tratados en nuestro centro desde enero de 2014 a octubre de 2018. Resultados: ECMO-VAp fue utilizado dentro de las primeras 6 horas del procedimiento. Todos los pacientes tenían enfermedad coronaria y uno de ellos tenía además estenosis aórtica severa. Un paciente ingresó al LCC en paro cardíaco. Una intervención coronaria percutánea (ICP) fue realizada en todos los pacientes; 4 se realizaron procedimientos de emergencia y 5 pacientes tuvieron complicaciones de la ICP. A un paciente se le realizó un reemplazo valvular aórtico percutáneo y desarrolló una insuficiencia valvular aórtica aguda severa. Se instaló un balón de contrapulsación en el LCC en 5 pacientes. Seis pacientes tuvieron un paro cardiorrespiratorio. El valor del score de SAVE fue de -4,3 y el lactato basal 55 mg/dL. La duración media del ECMO-VAp fue 5 ± 4 días. La sobrevida al alta y a los 12 meses fue 85,7%. Como complicaciones del sitio de acceso vascular se observaron 1 hematoma y un episodio de sangrado que requirió reparación quirúrgica. Conclusiones: ECMO-VAp debería ser considerado en pacientes con SC peri-procedimiento como un puente a recuperación; su utilización estuvo asociada con mejoría de resultados clínicos en esta serie.

Pacientes elegibles para las nuevas terapias de la insuficiencia cardíaca en un policlínico especializado / Proportion of patients with heart failure in a specialized clinic eligible for novel therapies

Background: Pharmacological treatment improves survival in patients with heart failure with reduced ejection fraction. The use of sacubutril/valsartan and ivabradine has been recently approved and incorporated in the latest guidelines. Aim: To identify candidates eligible for these therapies among patients treated in a heart failure clinic, considering the inclusion criteria for the PARADIGM-HF and SHIFT trials. Material and Methods: Cross-sectional study on 158 patients aged 62 ± 11 years (67% male) with heart failure and reduced ejection fraction, with at least three months of follow-up and without decompensation. The percentage of patients complying for the inclusion criteria for the PARADIGM-HF y SHIFT trials was determined. Results: In 37%, the etiology of heart failure was ischemic, 49% were in functional class I, their ejection fraction was 33 ± 11% and their median Pro-brain natriuretic peptide was 800 pg/mL. Ninety five percent were treated with vasodilators, 97% with beta-blockers and 82% with aldosterone antagonists. Using PARADIGM-HF and SHIFT criteria, 11 patients (7%) were eligible for sacubitril / valsartan and 21 patients (13.3%) for ivabradine. Among the main causes of non-eligibility for sacubitril / valsartan were being functional class I (48.7%) and not achieving a stable dose of enalapril ≥ 20 mg / day or losartan ≥ 100 mg / day (24.7%). In the case of ivabradine, apart from those in functional class I, the absence of sinus rhythm and a heart rate < 70 / min when receiving a maximal tolerated dose of beta-blockers, were present in 22%. Conclusions: A low percentage of our patients were eligible for these therapies. Among the causes that explain these results were clinical stability, a high percentage of patients in functional class I and being in a disease modifying treatment.

Recomendaciones de manejo de pacientes con asistencia circulatoria mecánica de corta duración / Recommendations for the management of patients with short-term mechanical circulatory assistance

There has been a progressive increase in the use of mechanical circulatory support in our country in the last years, mainly in the short-term: as a bridge to cardiac transplant or recovery, which has allowed to rescue patients from a population that concentrates high rates of complications and mortality. This motivated that the Ministry of Health convened a series of experts in the area of heart failure, transplantation and mechanical circulatory support, representatives of different public and private health centers in Chile, with the objective of developing recommendations on the use of short-term mechanical assistance devices, which would serve as a reference for the proper management of these patients. This clinical experts consensus document contains topics related to: definitions and general concepts; indications; contraindications; specific aspects of starting, follow-up and weaning of the devices; process of transfer of patients in circulatory assistance from one center to another and finally criteria of organization, means and competences to be fulfilled by the centers that offer this therapeutic option.

Galectina-3: experiencia en pacientes chilenos con diagnóstico de insuficiencia cardíaca descompensada / Galectin-3 levels in patients hospitalized for decompensated heart failure

Background: Galectin-3 (Gal-3) is a mediator of myocardial fibrosis involved in cardiac remodeling and a potential new prognosis marker in heart failure (HF). Aim: To measure Gal-3 at the moment of discharge in patients hospitalized for HF and its association with different variables. Material and Methods: Patients hospitalized for decompensated HF from four hospitals between August 2014 and March 2015, were included. Demographic, clinical and laboratory variables were recorded at the time of admission. At discharge, a blood sample was withdrawn to measure Gal-3 and brain natriuretic propeptide (Pro-BNP). Patients were separated in two groups, according to the level of Gal-3 (using a cutoff value of 17.8 ng/mL), comparing clinical and laboratory values between groups. Results: We included 52 patients with HF aged 70 ± 17 years (42% females). Functional capacity was III-IV in 46% of patients and the ejection fraction was 34.9 ± 13.4%. Pro-BNP values at discharge were 5,323 ± 8,665 pg/mL. Gal-3 values were 23.8 ± 16.6 ng/mL. Sixty percent of patients had values over 17.8 ng/mL. Those with elevated Gal-3 levels were older (75 ±16 and 62 ± 15 years, respectively, p = 0.025) and were hypertensive in a higher proportion (90.5% and 57.1% respectively, p = 0.021). Conclusions: In patients hospitalized for HF, Gal-3 levels are higher in older and hypertensive subjects.

[Frailty in patients admitted to hospital with acute decompensated heart failure]. / Factores asociados a fragilidad en pacientes hospitalizados con insuficiencia cardiaca descompensada.

BACKGROUND: Frailty is a geriatric syndrome characterized by a progressive impairment in the subjects’ ability to respond to environmental stress. Frailty is more commonly found in heart failure (HF) patients than in general population and it is an independent predictor of rehospitalization, emergency room visits and death. AIM: To estimate the prevalence of frailty in patients with decompensated HF admitted to four hospitals in Santiago, Chile. MATERIAL AND METHODS: Cross-sectional study. Subjects aged 60 or older consecutively admitted for decompensated HF to the study centers between August 2014 and March 2015 were included. Frailty was defined as the presence of three or more of the following criteria: unintended weight loss, muscular weakness, depression symptoms (exhaustion), reduced gait speed and low physical activity. Independent variables were tested for association using simple logistic regression. Variables associated with frailty (p < 0.05) were included in a multiple logistic regression model. RESULTS: Seventy-nine subjects were included. The prevalence of frailty was 50.6%. Frail patients were mostly female (52.6%) and older than non-frail subjects (73.7± 7.9 vs 68.2 ± 7.1; p < 0.003). Independent predictors of frailty were age (Odds raio (OR) 1.10; 95% confidence intervals (CI): 1.03-1.17), quality of life measured with the Minnesota Living with Heart Failure Questionnaire (OR 1.07; IC95%: 1.03-1.11), previous hospitalizations (OR 2.56; 95%CI: 1.02-6.43) and number of medications (OR 4.46; 95%CI: 1.11-17.32). CONCLUSIONS: The prevalence of frailty in patients admitted to the hospital for decompensated heart failure is high. Age, quality of life, hospitalizations and polypharmacy were factors associated with frailty in this group of participants.

Factores asociados a fragilidad en pacientes hospitalizados con insuficiencia cardiaca descompensada / Frailty in patients admitted to hospital with acute decompensated heart failure

Background: Frailty is a geriatric syndrome characterized by a progressive impairment in the subjects’ ability to respond to environmental stress. Frailty is more commonly found in heart failure (HF) patients than in general population and it is an independent predictor of rehospitalization, emergency room visits and death. Aim: To estimate the prevalence of frailty in patients with decompensated HF admitted to four hospitals in Santiago, Chile. Material and Methods: Cross-sectional study. Subjects aged 60 or older consecutively admitted for decompensated HF to the study centers between August 2014 and March 2015 were included. Frailty was defined as the presence of three or more of the following criteria: unintended weight loss, muscular weakness, depression symptoms (exhaustion), reduced gait speed and low physical activity. Independent variables were tested for association using simple logistic regression. Variables associated with frailty (p < 0.05) were included in a multiple logistic regression model. Results: Seventy-nine subjects were included. The prevalence of frailty was 50.6%. Frail patients were mostly female (52.6%) and older than non-frail subjects (73.7± 7.9 vs 68.2 ± 7.1; p < 0.003). Independent predictors of frailty were age (Odds raio (OR) 1.10; 95% confidence intervals (CI): 1.03-1.17), quality of life measured with the Minnesota Living with Heart Failure Questionnaire (OR 1.07; IC95%: 1.03-1.11), previous hospitalizations (OR 2.56; 95%CI: 1.02-6.43) and number of medications (OR 4.46; 95%CI: 1.11-17.32). Conclusions: The prevalence of frailty in patients admitted to the hospital for decompensated heart failure is high. Age, quality of life, hospitalizations and polypharmacy were factors associated with frailty in this group of participants.

Primer puente a trasplante cardiaco exitoso en Chile usando el dispositivo Heart Mate II / First successful bridge to cardiac transplantation in Chile using the Heart Mate II device. Report of one case

Implantable ventricular assist devices are an effective treatment option for end-stage heart failure patients as a bridge to cardiac transplantation, to improve the clinical condition and organ function allowing discharge from the hospital to await for transplantation. The second alternative is to use the device as destination therapy for patients with contraindications for cardiac transplantation, in whom it is maintained indefinitely. We report a 43-year-old patient, with a dilated cardiomyopathy, severe left ventricular dysfunction and advanced heart failure. A ventricular assist device Heart Mate II©, as a bridge to transplantation, was implanted to the patient in the United States. It was explanted for the first time in Chile at the National Thorax Institute. Heart transplantation was performed using the bicaval technique. Induction of immunosuppression was done with basiliximab. Generic immunosuppression was carried out with cyclosporine, mycophenolate mofetil and prednisone. Postoperatively the patient evolved with right femoral vein thrombosis in the femoral cannulation site, phlegmasia alba dolens, rhabdomyolysis, oliguric acute renal failure, which required renal replacement therapy, severe shock, with high requirements of vasoactive drugs and need for mechanical ventilation. He required a reoperation for hemothorax and had an Enterobacter pneumonia. After a period of serious illness, he began a gradual recovery and was discharged from the hospital after 58 days. After two years, he remains in functional class I, with a normal graft function.

Experiencia clínica con 53 trasplantes cardiacos consecutivos / Clinical experience with 53 consecutive heart transplants

Introduction: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. Patients and Methods: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. Results: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). Operative technique: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. Conclusion: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

Incidencia e importancia pronóstica del deterioro de la función renal en pacientes hospitalizados con insuficiencia cardiaca / Deterioration of kidney function as a risk factor for mortality among patients hospitalized for heart failure

Background: Acute deterioration of kidney function among patients admitted to the hospital for cardiac failure is associated with an increased mortality. Aim: To investigate the association between deterioration of kidney function and mortality among patients hospitalized for cardiac failure. Material and Methods: Patients admitted for decompensated cardiac failure to 14 Chilean hospitals between 2002 and 2009 were incorporated to the study. Clinical and laboratory features were registered. Serum creatinine values on admission and discharge were determined. Hospital and long term mortality was determined requesting death certificates to the National Identification Service at the end of follow up, lasting 635 ± 581 days. Results: One thousand sixty four patients were incorporated and 1100, aged 68 ± 13 years (45% females) had information about renal function. Seventy seven percent were hypertensive and 36% were diabetic. Mean ejection fraction was 41 ± 18% and 34% had an ejection fraction over 50%. Mean admission creatinine was 1.7 ± 1.6 mg/dl and 19% had a creatinine over 2 mg/dl. Serum creatinine increased more than 0.5 mg/dl during hospitalization in 9% of general patients and in 11% of diabetics. The increase in creatinine was associated with a higher risk of hospital mortality (odds ratio (OR) 12.9, 95% confidence intervals (CI) 6.7-27.6) and long term mortality (OR 2.1, 95% CI 1.6-3). Conclusions: The deterioration of renal function during hospitalization of patients with heart failure is a risk factor for hospital and long term mortality.

¿Ha habido avances en la insuficiencia cardíaca aguda en los últimos años? / Have there been advances in acute heart failure in recent years?

La Insuficiencia Cardíaca (IC) aguda sigue representando un importante motivo de consulta en los servicios de urgencias y de hospitalización en las unidades críticas, ocasionando elevadas tasas de mortalidad y rehospitalizaciones. Sin embargo, a diferencia de la IC crónica, donde se han producido avances significativos en la terapia médica, la evidencia y los progresos en IC aguda han sido más bien escasos. A pesar de ello existen áreas en las que se han producido logros. Se ha definido con mayor precisión el concepto de IC aguda. Los registros han entregado información relevante y se ha caracterizado de mejor forma la población de pacientes que son hospitalizados por IC. Del análisis de ellos se han propuesto algoritmos de estratificación de riesgo de fácil aplicabilidad. Han surgido conceptos fisiopatológicos nuevos, como el síndrome cardiorenal, la viabilidad miocárdica y la IC con FE preservada. Adicionalmente han aparecido biomarcadores para ayudaren el diagnóstico de IC en los servicios de urgencia y en la estratificación de riesgo de esta población en diferentes escenarios de la hospitalización para predecir mortalidad y rehospitalizaciones. Como se ha señalado, lamentablemente hemos observado pocos avances en el tratamiento farmacológico que se hayan asentado en la práctica clínica. Las principales novedades vienen de los dispositivos. Se han introducido dispositivos de ultrafiltración que podrían constituir una opción alternativa a los diuréticos en casos de congestión refractaria y lo más importante, los dispositivos de asistencia ventricular (DAV) que permiten estabilizar pacientes hacia una recuperación de la función ventricular o estabilizar la función de órganos como un puente al trasplante cardíaco.

The acute cardiac insufficiency (CI) continues to represent an important motive of consultation in the services of urgencies and of hospitalization in the critical units, causing a high rate of mortality and rehospitalization. Nevertheless, unlike the chronic cardiac insufficiency, where significant advances have been produced in the medical therapy, the evidence and the progresses acute CI have been rather scanty. In spite of it areas exist in those who have produced achievements to them. There has been defined by major precision the concept of acute CI. The records have delivered relevant information and there have been characterized of better form the population of patients who are hospitalized by CI. Of the analysis of them they have proposed algorithms of stratification of risk of easy applicability. New pathophysiological concepts have emerged as cardiorenal syndrome, myocardial viability and CI with preserved ejection fraction. Additionally biomarkers have appeared to aid in the diagnosis of cardiac insufficiency in the emergency services and risk stratification of this population in different scenarios to predict mortality and hospital readmissions. Unfortunately, we have been few advances in drug therapy have been established in clinical practice. The principal innovations come from the devices. There have interfered devices of ultrafiltration that might constitute an alternative option to the diuretics in cases of refractory congestion and the most important thing, the ventricular assist devices that patients allow to stabilize towards a recovery of the ventricular function or stabilizing the function of organs as a bridge to the cardiac transplant.

Rabdomiólisis e insuficiencia renal aguda por consumo de cocaína: caso clínico / Rhabdomyolysis and acute renal failure after cocaine overdose: Report of one case

Rhabdomyolysis caused by cocaine abuse is multifactorial, involving tissue ischemia secondary to vasoconstriction and cellular damage caused by the drug. Renal failure may or may be not associated to rhabdomyolysis. We report a 41-year-old male admitted with a severe rhabdomyolysis after a cocaine overdose. In spite of a vigorous hydration and alkalization, he developed acute renal failure. Renal function recovered after several weeks of dialysis.

Influencia de factores socioculturales en la evolución alejada de pacientes con insuficiencia cardíaca / Influence of social and cultural factors in the late course of patients with congestive heart failure

Objetivo: Evaluar el impacto de los factores socioculturales (SC) en Las características del cuidado de la insuficiencia cardiaca (IC) y la evolución post alta en pacientes admitidos con diagnostico de IC descompensada a hospitales del registro ICARO en el periodo 2006-2008.Método: Registro prospectivo de 14 hospitales. Se incorporaron en forma consecutiva pacientes admitidos con el diagnostico de IC descompensada entre enero 2006 y mayo 2008. La mortalidad al fin del seguimiento se determino por la base de datos del Servicio Nacional del Registro Civil e Identificación. Se definió como terapia optima la combinación de en betabloqueador con cualquiera de los siguientes: inhibidores de la enzima convertidora de angiotensina (IECA), antagonistas del receptor de angiotensina Il (ARAlI), hidralazina/isosorbide o espironolactona. Las características de los pacientes se compararon mediante t de Student o chi cuadrado según correspondía. La sobrevida se evaluó mediante Kaplan-Meier.Resultados: Los pacientes de bajo nivel SC son do mayor edad (71 +/- 11 v/s 66 +/-15 años respectivamente, p<0.01). predomina el género femenino (52.2 por ciento v/s 26.1 por ciento, p<0,01), y su previsión fue mayoritariamente FONASA (90 por ciento). La etiología isquémica fue más frecuente en el estrato SC alto (34,5 vs. 16,6 por ciento) y la hipertensiva en el nivel SC bajo (30,3 v/s 16,6 por ciento). La utilización de ARA II fue más frecuente en el nivel SC alto con una tendencia a menor utilización de IECA, el uso de betabloqueadores espironolactona hidralazina e isosorbide amiodarona y anticoagulante fue menor en el estrato SC bajo.

Aim: to evaluate de impact of social and cultural (S-C) factors in the care and course of patients with congestive heart failure (CHF) enrolled in the ICARO study (national registry for patients with head failure). Methods: Patients were enrolled from 2006 through 2008. They were discharged from 14 hospitals participating in the prospectively designed ICARO study. Late mortality was obtained from the national Identification registry. Optimal medical therapy was defined as the use of a betablocker in addition to any of the following ACE inhibitors, ARA II. combination of hydralazine and nitrates, or spironolactone. Statistical analysis included Students t tesl. chi square and Kaplan Meir and Log-rank testing, as appropriate. Results: Patients with a low S-C level were older (71 +/- 11 vs 66 +/- IS years. p<0.01). more frequently females (52.2 percent vs 26.1 percent, p<0.01) and most of them belonged in the FONASA health insurance system (90 percent). Ischemic heart disease was more prevalent in the high S-C level (34.5 vs 16.6 percent) and hypertension in the low S-C level (30.3 vs 16.6 percent). ARA II rather than ACE inhibitors were more commonly used in the high S-C level: A CE inhibitors, betablockers, spironolactone, hydralazine-nitrates, amiodarone and anticoagulatioo were less frequently used in the low S-C level. After discharge a more intensive treatment of heart failure was observed; however, this was less seen in the low S-C level. Patients with decreased left ventricular ejection fraction were similarly treated in both groups. An optimal therapy for CHF was used in 43.7 percent, 43.3 percent and 51.1 percent in S-C levels low, intermediate and high, respectively (NS). Independent predictors for late mortality were age>70 years (HR 2.71 (CI 1.55-3.03), low S-C level (HR 1.57, CII. 17- 2.09), EF<50 percent (HR 1.49, CI 1.04-2.14) and absence of optimal medical therapy at discharge (HR 0.52, CI 0.41-0.66).

Initial experience with bosentan therapy in patients considered ineligible for heart transplantation because of severe pulmonary hypertension.

BACKGROUND: Pre-operative elevated pulmonary vascular resistance (PVR) has been associated with increased right ventricular failure and mortality after heart transplantation. The aim of this study was to assess the efficacy of bosentan, an oral endothelin-receptor antagonist, to reduce PVR in patients considered ineligible for heart transplantation because of severe pulmonary hypertension. METHODS: Seven patients with end-stage congestive heart failure and considered ineligible for heart transplantation because of severe pulmonary hypertension (PVR>2.5 Wood units after nitroprusside infusion) were included in the study. They received bosentan 62.5 mg b.i.d. for four wk and 125 mg b.i.d. thereafter. Right heart catheterization was repeated after six wk of therapy. RESULTS: After six wk of bosentan therapy, there was a significant decrease in PVR (6.0 +/- 2 vs. 3.8 +/- 2 Wood units, before vs. after bosentan; p = 0.02), in PVR during nitroprusside infusion (3.3 +/- 1 vs. 2.1 +/- 1 Wood units, before vs. after bosentan; p = 0.02) and in diastolic pulmonary artery pressure (33 +/- 7 vs. 23 +/- 7 mmHg, before vs. after bosentan; p = 0.04). No significant adverse events were observed. After bosentan therapy, five patients had PVR

Efecto de la implementación de recomendaciones de sedoanalgesia en una UCI general / Effect of the implementation of recommendations about sedoanalgesia in a general ICU

A great part of the patients in an Intensive Care Unit (ICU) need sedo-analgesia (SA), specially in mechanic ventilation (MV). Our unit is a general ICU where a diversity of therapeuticschemes and farmacological presentations have been used, without standard practices. At a first stage we introduced SA recommendations, reinforcing its use. We conducted the present study to evaluate its effect in our clinical practice. Methodology: Indicators of adverse incidents were registered, associated to MV, mortality, permanence in MV,hospitalization in ICU, use of medicines and cost, the results were measured during the 3 months prior to beginning and the 3 months following implementation of the SA recommendations, which ruled the use of the association of midazolam (MZ) (Dormonid (R), Laboratorio Roche (R) and morphine; in cases of the renal insufficiency, hemo-dynamic instability or allergic reaction it was chosen to associate MZ and fentanyl, both associations in continuous infusion and with suspension of morning sedation. The sedation level had to be evaluated with ramsay scale. Neurological patients were excluded. It was considered "strict compliance" when the recommended combination of medicines were utilized, adjusted by sedation scale and with matinal suspension; "partial compliance" when these were utilized without complying with the scale adjustement or the matinal suspension. The results obtained were analyzed utilizing the Primer(R) statistical program. Results: Before the introduction of the recommendations we observed an average MV duration of 5,8 days (Range: 1-82), duration of ICU hospitalization of 9,8 days (Range: 1-101), a mortality of 28 per cent, one case of auto-extubation, with the use of one average dose of MZ of 10±1,8 mg/hr, with a montly use of MZ in the unit of 22,2 g., a montly expense in sedatives, analgesics and relaxants of US$3018. After its introduction we observed an average duration at MV of 4,5 days (Range: 1-41) (NS), duration of hospitalization at ICU of 5,0 days (Range: 1-45) (p=0,001), a mortality of 22 per cent (NS), one case of auto-extubation, with an average dose of MZ of 4,2 g. (p=0,001), a montly expense in sedatives, analgesics and relaxants of US$809 (p=0,0001). Average compliance with the recommendations was 68 per cent (46 per cent partial, 22 per cent strict).