Desarrollo histórico de la protección miocárdica: el gran salto adelante de la cirugía cardiovascular / Historical development of myocardial protection: the big jump ahead of cardiovascular surgery

La cirugía a "corazón abierto" con circulación extracorpórea se apronta a cumplir 70 años. Desde un comienzo se hizo necesario buscar la forma de tener un campo operatorio quieto y exangüe, sin riesgo de embolia aérea, lo que llevó al desarrollo de la primera "cardioplegía" por Melrose, a fines de los años 1950's. Sin embargo, esta cayó en descrédito rápidamente y fue abandonada en años 1960's. Se necesitó que transcurrieran casi 15 años para el retorno de la cardioplegía, ahora como forma de proteger al corazón de la isquemia. Durante este periodo se volvió a la fibrilación ventricular a la perfusión coronaria, al paro isquémico y a la hipotermia tópica. Sin embargo, algunos investigadores mantuvieron su interés en la cardioplegía, facilitando el retorno clínico de esta con Hearse en 1976, con la solución cardioplégica cristaloide del Hospital St. Thomas, la que se asentó como el principal método de protección miocárdica, hasta la irrupción de Buckberg con su cardioplegía sanguínea en multidosis, la que se convirtió, a comienzo de los años 1990's, en el procedimiento preferido para proteger al corazón durante el periodo de isquemia requerido para operar en él, infundida ahora no solo por vía anterógrada, sino que también por vía retrógrada. Esto, hasta Pedro Del Nido y su vuelta a la dosis única, solo por vía anterógrada.

Open heart surgery with extracorporeal circulation is approaching its 70th anniversary. From the beginning it was necessary to find a way to have a still and bloodless operative field, without the risk of air embolism, which led to the development of the first "cardioplegía" by Melrose, at the end of the 1950's. However, it quickly fell into disrepute and was abandoned in the 1960's. It took almost 15 years for cardioplegía to return, now as a way of protecting the heart from ischemia. During this period, ventricular fibrillation, coronary perfusion, ischemic arrest and topical hypothermia returned. However, some investigators maintained their interest in cardioplegía, facilitating the clinical return of cardioplegía with Hearse in 1976, with the crystalloid cardioplegic solution of St. Thomas's Hospital. This became the main method of myocardial protection until the irruption of Buckberg with his multidose blood cardioplegía, which became, at the beginning of the 90's, the preferred method to protect the heart during the ischemic period required to operate on it, now infused not only by anterograde route but also by retrograde route. This, until Pedro Del Nido and his return to the single dose, only via the antegrade route.

Adherencia a tratamiento de prevención secundaria post síndrome coronario agudo, en pacientes adultos ingresados al Hospital Hernán Henríquez Aravena / Adherence to secondary prevention after acute coronary syndromes: experience in a Chilean general hospital

Antecedentes: En prevención secundaria cardiovascular, el control de los factores de riesgo es deficiente y la falta de adherencia terapéutica parece ser uno de los factores causales. El cumplimiento terapéutico se asocia a un 20% de disminución del riesgo de enfermedad cardiovascular y un 38% de disminución de mortalidad por cualquier causa. Sin embargo, la adherencia a los fármacos preventivos ronda el 50% al año después del alta hospitalaria, lo que multiplica por 3 el riesgo de mortalidad. Objetivos: Describir la adherencia a mediano plazo a tratamiento de prevención secundaria post síndrome coronario agudo de los pacientes adultos ingresados al Hospital Hernán Henríquez Aravena durante el año 2018. Determinar las características clínicas y sociodemográficas de la población y explorar las posibles causas asociadas a la falta de adherencia terapéutica en este grupo de pacientes. Métodos y Resultados: Se evaluaron 396 pacientes con síndrome coronario agudo en el Hospital Hernán Henríquez Aravena de Temuco durante el año 2018. La adherencia a terapia farmacológica se evaluó mediante el cuestionario de Morisky-Green de ocho ítems, aplicado vía telefónica. Se evaluó la asociación de variables clínicas y sociodemográficas con el nivel de adherencia mediante regresión ordinal y análisis de correspondencias. Resultados: Un 41.9% de los pacientes mantuvieron adherencia a la terapia a 2 años de seguimiento. Variables sociodemográficas como el bajo nivel educacional, la ruralidad, y la presencia de 1 o 2 apellidos mapuche se asociaron con baja adherencia a terapia farmacológica. Conclusión: La adherencia a medidas de prevención secundaria después del tratamiento por un síndrome coronario aguda es baja. Los principales factores relacionados a la falta de adherencia fueron el bajo nivel educacional y la ruralidad.

Background: a lack of therapeutic adherence to secondary prevention measures after acute coronary events leads to a poor control of risk factors. Adherence to treatment is associated with a reduction of 20% in the risk of cardiovascular disease and 38% reduction in all-cause mortality long term. However, adherence to drug therapy is about 50% a year after hospital discharge, which leads to an approximately three fold increase in mortality. Objectives: to describe the medium-term adherence to secondary prevention treatment following an acute coronary syndrome in adult patients admitted to a general hospital during 2018. In addition, to relate clinical and sociodemographic characteristics related to poor adherence and also to explore possible causes associated with the lack of therapeutic adherence in this group of patients. Methods: 396 patients treated for an acute coronary syndrome were followed after being discharged from the Hernán Henríquez Aravena Hospital in Temuco (Chile) during 2018. Adherence to pharmacological therapy was evaluated using the eight-item Morisky-Green questionnaire applied via phone call. The association of clinical and sociodemographic variables with the level of adherence was evaluated using ordinal regression and correspondence analysis. Results: Only 41.9% of patients maintained adherence to therapy at 2 years of follow-up. Low educational level, rurality, and the presence of 1 or 2 mapuche surnames were associated to poor adherence to drug therapy.

Recomendaciones en la prevención secundaria de cardiopatía isquémica en la mujer / Secondary prevention of ischemic heart disease in women

Resumen: La enfermedad cardiovascular en la mujer es la principal causa de muerte en Chile. La mujer con cardiopatía isquémica coronaria representa un riesgo de mortalidad dos veces mayor que el del hombre. Desgraciadamente, las mujeres han sido subrepresentadas en la mayoría de los estudios clínicos randomizados en prevención secundaria, y más aún, son pocos los que presentan análisis específicos de género en cuanto a la terapia y los puntos finales duros. Así, la evidencia que existe ha sido dirigida especialmente a hombres. Para reducir esta brecha, presentamos una revisión de la información en las distintas terapias en prevención secundaria de cardiopatía isquémica, destacando los resultados de trabajos en que se hizo análisis género-específico.

Abstract: Cardiovascular disease is the main cause of death in Chilean women. Ischemic heart disease mortality rate in women is two times that of in men. Unfortunately, there have been less enrollment of women in clinical cardiovascular trials and a lack of gender-specific analysis of clinical trial data. Therefore, the evidence for secondary preventive recommendations have been focused on men. To bridge this gap, in this review we address the data for secondary preventive therapies for ischemic heart disease in women assessing the available gender-specific data.

Control de la hipertensión arterial y la prevención secundaria reduce la cardiopatía isquémica. Objetivo alcanzable / Arterial hypertension control and secondary prevention reduce ischemic hearth disease. An aim with in reach

RESUMEN El control de la hipertensión arterial resulta la medida más efectiva para lograr disminuir la mortalidad total. Una propuesta de actualidad para alcanzar ese propósito es la implementación de regímenes de tratamiento estandarizados, asociados a la prevención secundaria de la cardiopatía isquémica. En este sentido es importante el acceso del paciente a los medicamentos, el trabajo en equipo y la vigilancia del control de la presión arterial y del progreso de los pacientes que reciben el tratamiento, para ello el monitoreo y la evaluación son elementos fundamentales.

ABSTRACT The arterial hypertension control is the most effective measure to reach the decrease of the total mortality. A current proposal to reach this goal is the implementation of standardized treatment regimes, associated to the secondary prevention of the ischemic heart disease. In this sense it is important the access of the patient to the medicines, the team work and the surveillance of the arterial pressure control and the progress of the patients receiving treatment, for what monitoring and assessment are main elements.

Diabetes mellitus tipo 2 y cardiopatía isquémica: fisiopatología, regulación génica y futuras opciones terapéuticas / Type II diabetes and ischemic heart disease: pathophysiology, gen regulation and future therapeutic options

Resumen: En los últimos años, la diabetes mellitus tipo 2 (DM2) ha evolucionado en forma epidémica, experimentando un rápido crecimiento y afectando a millones de individuos a nivel mundial. La cardiopatía isquémica es la principal causa de mortalidad en los pacientes diabéticos, quienes poseen un mayor riesgo cardiovascular respecto a los no diabéticos. La DM2 y la cardiopatía isquémica se caracterizan por ser prevenibles, sin embargo, existen diversos factores de riesgo comunes que contribuyen a su desarrollo. Los mecanismos que explican la ateroesclerosis acelerada y el incremento de riesgo de enfermedades cardiovasculares en los pacientes diabéticos tipo 2 incluyen a la hiperglicemia, dislipidemia y la inflamación del endotelio vascular. La diabetes es resultado de una interacción compleja entre la genética y el medio ambiente. Recientemente se han descrito varios genes implicados en el desarrollo de la diabetes y cardiopatía isquémica y que podrían significar nuevas opciones terapéuticas. En este artículo se revisa la relación entre ambas patologías, los mecanismos moleculares y el descubrimiento de factores de riesgo genéticos comunes y su implicancia en el desarrollo de nuevos blancos terapéuticos.

Abstracts: In recent years, type 2 diabetes mellitus has evolved as a rapidly increasing epidemic and affects millions of people worldwide. Ischemic heart disease (IHD) is the main cause of death among diabetic patients, who have a higher cardiovascular risk than non-diabetics. Both, DM2 and IHD are characterized by being preventable, however there are several common risk factors that contribute to their development. The mechanisms that explain accelerated atherosclerosis and increased risk of cardiovascular diseases in patients with type 2 diabetes mellitus include damage by hyperglycemia, dyslipidemia and inflammation on vascular endothelium. Diabetes is the result of a complex interaction between genetics and the environment, recently, several genes have been identified that appear to be involved in diabetes and ischemic heart disease that could explain its relationship and serve as new therapeutic possibilities. In this article, we review the relationship between diabetes and ischemic heart disease, the molecular mechanisms and the discovery of genetic risk factors common to both diseases and their implication in the development of new therapeutic targets.

Attenuation of atherogenic apo B-48-dependent hyperlipidemia and high density lipoprotein remodeling induced by vitamin C and E combination and their beneficial effect on lethal ischemic heart disease in mice

BACKGROUND AND AIMS: Atherosclerotic cardiovascular disease is highly prevalent and its underlying pathogenesis involves dyslipidemia including pro-atherogenic high density lipoprotein (HDL) remodeling. Vitamins C and E have been proposed as atheroprotective agents for cardiovascular disease management. However, their effects and benefits on high density lipoprotein function and remodeling are unknown. In this study, we evaluated the role of vitamin C and E on non HDL lipoproteins as well as HDL function and remodeling, along with their effects on inflammation/ oxidation biomarkers and atherosclerosis in atherogenic diet-fed SR-B1 KO/ApoER61h/h mice. METHODS AND RESULTS: Mice were pre-treated for 5 weeks before and during atherogenic diet feeding with vitamin C and E added to water and diet, respectively. Compared to a control group, combined vitamin C and E administration reduced serum total cholesterol and triglyceride levels by decreasing apo B-48-containing lipoproteins, remodeled HDL particles by reducing phospholipid as well as increasing PON1 and apo D content, and diminished PLTP activity and levels. Vitamin supplementation improved HDL antioxidant function and lowered serum TNF-α levels. Vitamin C and E combination attenuated atherogenesis and increased lifespan in atherogenic diet-fed SR-B1 KO/ApoER61h/h mice. CONCLUSIONS: Vitamin C and E administration showed significant lipid metabolism regulating effects, including HDL remodeling and decreased levels of apoB-containing lipoproteins, in mice. In addition, this vitamin supplementation generated a cardioprotective effect in a murine model of severe and lethal atherosclerotic ischemic heart disease.

CIRBP protects H9C2 cells against myocardial ischemia through inhibition of NF-kappaB pathway

Myocardial ischemia is a major cause of death and remains a disease with extremely deficient clinical therapies and a major problem worldwide. Cold inducible RNA-binding protein (CIRBP) is reported to be involved in multiple pathological processes, including myocardial ischemia. However, the molecular mechanisms of myocardial ischemia remain elusive. Here, we first overexpressed CIRBP by transfection of pc-CIRBP (pcDNA3.1 containing coding sequenced for CIRBP) and silenced CIRBP by transfection of small interfering RNA targeting CIRBP (siCIRBP). pcDNA3.1 and the negative control of siCIRBP (siNC) were transfected into H9C2 cells to act as controls. We then constructed a cell model of myocardial ischemia through culturing cells in serum-free medium with hypoxia in H9C2 cells. Subsequently, AlamarBlue assay, flow cytometry and western blot analysis were used, respectively, to assess cell viability, reactive oxygen species (ROS) level and apoptosis, and expression levels of IκBα, p65 and Bcl-3. We demonstrated that CIRBP overexpression promoted cell proliferation (P<0.001), inhibited cell apoptosis (P<0.05), reduced ROS level (P<0.001), down-regulated phosphorylated levels of IκBα and p65 (P<0.01 or P<0.001), and up-regulated expression of Bcl-3 (P<0.001) in H9C2 cells with myocardial ischemia. The influence of CIRBP knockdown yielded opposite results. Our study revealed that CIRBP could protect H9C2 cells against myocardial ischemia through inhibition of NF-κB pathway.

Effects of Nitrate Intake on Myocardial Ischemia-Reperfusion Injury in Diabetic Rats / Efeitos do Consumo de Nitrato na Lesão de Isquemia-Reperfusão Miocárdica em Ratos Diabéticos

Abstract Background: Coronary artery disease is 2-3 times more common in diabetic individuals. Dietary nitrate/nitrite has beneficial effects in both diabetes and cardiovascular disease. It also has protective effects against myocardial ischemia-reperfusion (IR) injury in healthy animals. However, the effects of nitrate on myocardial IR injury in diabetic rats have not yet been investigated. Objective: We examined the effects of dietary nitrate on myocardial IR injury in streptozotocin-nicotinamide-induced diabetic rats. Method: Rats were divided into four groups (n=7 in each group): control, control+nitrate, diabetes, and diabetes+nitrate. Type 2 diabetes was induced by injection of streptozotocin and nicotinamide. Nitrate (sodium nitrate) was added to drinking water (100 mg/L) for 2 months. The hearts were perfused in a Langendorff apparatus at 2 months and assessed before (baseline) and after myocardial IR for the following parameters: left ventricular developed pressure (LVDP), minimum and maximum rates of pressure change in the left ventricle (±dP/dt), endothelial nitric oxide (NO) synthase (eNOS) and inducible NO synthase (iNOS) mRNA expression, and levels of malondialdehyde (MDA) and NO metabolites (NOx). Results: Recovery of LVDP and ±dP/dt was lower in diabetic rats versus controls, but almost normalized after nitrate intake. Diabetic rats had lower eNOS and higher iNOS expression both at baseline and after IR, and dietary nitrate restored these parameters to normal values after IR. Compared with controls, heart NOx level was lower in diabetic rats at baseline but was higher after IR. Diabetic rats had higher MDA levels both at baseline and after IR, which along with heart NOx levels decreased following nitrate intake. Conclusion: Dietary nitrate in diabetic rats provides cardioprotection against IR injury by regulating eNOS and iNOS expression and inhibiting lipid peroxidation in the heart.

Resumo Fundamentos: A doença arterial coronariana é duas a três vezes mais comum em indivíduos diabéticos. O nitrato/nitrito dietético tem efeitos benéficos tanto para o diabetes quanto para a doença cardiovascular, assim como efeitos protetores contra a lesão de isquemia-reperfusão (IR) miocárdica em animais saudáveis. Porém, os efeitos do nitrato na lesão de IR miocárdica em ratos diabéticos ainda não foram investigados. Objetivos: Foram examinados os efeitos sobre a lesão de IR miocárdica da adição de nitrato à dieta de ratos com diabetes mellitus tipo 2 induzido por estreptozotocina-nicotinamida. Métodos: Os ratos foram divididos em quatro grupos (n = 7 em cada grupo): controle, controle+nitrato, diabetes e diabetes+nitrato. O diabetes foi induzido nos animais por injeção de estreptozotocina e nicotinamida. Nitrato (nitrato de sódio) foi adicionado à água de beber (100 mg/L) por 2 meses. Os corações foram perfundidos em sistema de Langendorff aos 2 meses e avaliados antes (basal) e após IR miocárdica em relação aos seguintes parâmetros: pressão desenvolvida no ventrículo esquerdo (PDVE), taxas máximas de variação positiva e negativa da pressão ventricular esquerda (±dP/dt), expressão do RNAm da óxido nítrico (NO) sintase (NOS) endotelial (eNOS) e da NOS induzível (iNOS), além de níveis de malondialdeído (MDA) e metabólitos do óxido nítrico (NOx). Resultados: A recuperação da PDVE e ±dP/dt foi inferior nos ratos diabéticos versus controles, mas quase normalizou após ingestão de nitrato. Ratos diabéticos apresentaram expressão diminuída de eNOS e aumentada de iNOS tanto no estado basal quanto após IR, e o consumo dietético de nitrato restaurou estes valores para o estado normal após a IR. O nível de NOx cardíaco foi menor nos ratos diabéticos em comparação aos controles no momento basal, mas foi superior após a IR. Ratos diabéticos apresentaram níveis mais elevados de MDA tanto no estado basal quanto após IR que, juntamente com os níveis cardíacos de NOx, reduziram após consumo dietético do nitrato. Conclusões: O consumo dietético de nitrato por ratos diabéticos ofereceu cardioproteção contra a lesão de IR através da regulação da expressão de eNOS e iNOS e inibição da peroxidação lipídica no coração.

Riesgo cardiovascular en pacientes de un consultorio médico del policlínico Ana Betancourt / Cardiovascular risk found in patients from a doctor's office in Ana Betancourt polyclinics

Introducción: la capacidad predictiva del riesgo coronario es superior a la que se establece por la consideración aislada de los factores de riesgo cardiovasculares. Objetivo: determinar la magnitud del riesgo coronario y las prioridades de prevención cardiovascular en pacientes pertenecientes al consultorio médico de la familia No.5, del policlínico Ana Betancourt, en el municipio Playa. Métodos: investigación descriptiva, de corte transversal realizada entre 2009-2010. El universo de estudio estuvo constituido por las 856 personas mayores de 20 años perteneciente a dicho consultorio. Después de aplicados los criterios de selección, la muestra quedó conformada por 242 pacientes. Se utilizaron los criterios de las Tablas de Predicción del Riesgo Coronario de Framingham, que permiten estimar dicho riesgo a diez años, en las personas con factores de riesgo cardiovascular que aún no han tenido enfermedad coronaria establecida y que requieren intervenciones de cambio de su estilo de vida. Resultados: predominaron los pacientes en la categoría de riesgo coronario moderado, 97 (40,1 porciento), seguido por los de alto riesgo, 82 (33, 8 porciento) y finalmente, los de bajo riesgo, 63 (26 porciento). Ninguno de los pacientes estudiados estaba exento de riesgo coronario. Conclusiones: es muy probable, que más de la mitad de la muestra sufra un episodio coronario, mortal o no, durante los próximos diez años. Es urgente aplicar una estrategia de intervención comunitaria, basada en la modificación de los factores de riesgo asociados al estilo de vida, que permita disminuir la actual expresión del riesgo coronario en la población estudiada

Introduction: the predictive capacity of the coronary risk is greater than the prediction set by the individual consideration of the cardiovascular risk factors. Objective: to determine the coronary risk and the cardiovascular prevention priorities in patients from the family doctor's office no.5 in Ana Betancourt polyclinics located in Playa municipality. Methods: a cross-sectional descriptive study was conducted in the 2009-2010 period. The universe of study was made up of 856 people aged over 20 years in this doctor's office. After applying the criteria of selection, 242 patients formed the final sample. The criteria of Framingham's coronary risk prediction tables, which allow estimating the risk covering 10 years in those people who present cardiovascular risk factors but not coronary disease and require health interventions to change their lifestyles, were applied. Results: the patients included in the moderate coronary risk category (97 for 40.1 percent), followed by high risk patients (82 for 33.8 percent) and finally, the low risk (63 for 26 percent) predominated. None of the patients were exempted from the coronary risk. Conclusions: it is more likely that over half of the sample would have some coronary event, either deadly or not, in the forthcoming ten years. Therefore, it is urgent to apply a community-based intervention strategy, based on the change of lifestyle-associated risk factors, capable of reducing the current manifestation of the coronary risk in the studied population

"Non Working Beating Heart": novo método de proteção miocárdica no transplante cardíaco / Non Working Beating Heart: a new strategy of myocardial protection during heart transplant

INTRODUÇÃO E OBJETIVO: Trata-se do implante em posição ortotópica bicaval bipulmonar do coração doado batendo em normotermia. Este estudo busca diminuir o tempo isquêmico e criar condições de ir se adaptando ao organismo hospedeiro. MÉTODOS: Já em CEC, a primeira anastomose a ser feita é a da aorta, reperfundindo as artérias coronárias e recuperando os batimentos. As restantes são realizadas com o coração batendo em ritmo sinusal, sendo a da artéria pulmonar a última. Esta metodologia foi aplicada em 10 pacientes receptores, sendo oito do sexo masculino, com idades entre 16 e 69 (média de 32,7 anos), PSAo 90-100 (média de 96 mmHg), PSAP 25-65 (média de 46,1 mmHg), RVP 0,9-5,0 (média de 3,17 Wood), GTP 4-13 (média de 7,9 mmHg). Entre os 10 doadores, sete eram do sexo masculino, com idade entre 15 e 48 (média 27,7 anos), peso entre 65 e 114 kg (média de 83,1 kg). As causas do coma encefálico foram: TCE (cinco), AVCH (quarto) e tumor cerebral (um). RESULTADOS: O tempo isquêmico variou de 58 a 90 minutos (média 67,6 minutos), sendo que oito doadores estavam em hospitais da região metropolitana de São Paulo e dois em cidades distantes. Todos os enxertos, após completadas as anastomoses, retomaram o fluxo e o débito, mantendo bons parâmetros, com baixa dosagem de inotrópico e mantiveram estas condições no pós-operatório imediato. Não ocorreram óbitos e todos os pacientes obtiveram alta hospitalar. A evolução tardia variou de 20 dias a 10 meses, tendo ocorrido um óbito ao 4º mês pós-transplante, por sepse. CONCLUSÕES: Esta metodologia, além de reduzir o tempo isquêmico, permite ao órgão doado recuperar e manter seus batimentos sem pré nem pós-carga durante o implante, o que enseja proporcionar recuperação fisiológica, ultraestrutural, imunológica, inflamatória e mecânica do enxerto, com resultados consistentes precoces e tardios.

BACKGROUND AND OBJECTIVE: We attempt to reduce the ischemic time during implantation of the donor heart in the bicaval bipulmonary orthotopic position using normothermic beating heart and thus, facilitate the transplanted heart adaptation to the recipient. This study presents a small experience about a new strategy of myocardial protection during heart transplant. METHODS: In cardiopulmonary bypass, the aorta anastomosis was done first, allowing the coronary arteries to receive blood flow and the recovering of the beats. The rest of the anastomosis is performed on a beating heart in sinus rhythm. The pulmonary anastomosis is the last to be done. This methodology was applied in 10 subjects: eight males, age 16-69 (mean 32.7 years), SPAo 90-100 mmHg (mean 96 mmHg), SPAP 25-65 mmHg (mean 46.1 mmHg), PVR 0.9 to 5.0 Wood (mean 3.17 Wood), GTP 4-13 mmHg (mean 7.9 mmHg), and eight male donors, age 15-48 years (mean 27.7 years), weight 65-114 kg (mean 83.1 kg). Causes of brain coma: encephalic trauma in five hemorrhagic stroke in four, and brain tumor in one. RESULTS: The ischemic time ranged from 58-90 minutes (mean 67.6 minutes) and 8 donors were in hospitals of Sao Paulo and two in distant cities. All grafts assumed the cardiac output requiring low-dose inotropic therapy and maintained these conditions in the postoperative period. There were no deaths and all were discharged. The late evolution goes from 20 days to 10 months with one death occurred after 4 months due to sepsis. CONCLUSION: This method, besides reducing the ischemic time of the procedure, allows the donated organ to regain and maintain their beats without pre or after load during implantation entailing the physiological recovery of the graft.

Infarto perioperatorio en cirugía no-cardíaca y dexmedetomidina / Perioperative myocardical infaction in non-cardiac surgery and dexmedetomidine

La patología cardiovascular es la primera causa de muerte en Chile y en el mundo. Desde el punto de vista quirúrgico, anestesiólogos y cirujanos enfrentan más frecuentemente pacientes mayores con patología cardiovascular. La incidencia de isquemia miocárdica en pacientes de alto riesgo, sometidos a cirugía no-cardíaca, es cercana al 40 por ciento durante el perioperatorio. La incidencia de infarto miocárdico y muerte en cirugía no-cardíaca, oscila entre 1 y 5 por ciento. Existe una estrecha relación entre los eventos isquémicos perioperatorios y el aumento de la morbimortalidad cardiovascular. Por este motivo, se han desarrollado medidas terapéuticas orientadas a disminuir la incidencia de isquemia perioperatoria y aminorar el daño asociado a ella. La adecuada identificación de pacientes de riesgo, la optimización del tratamiento médico de patologías asociadas y el uso de fármacos cardioprotectores durante el perioperatorio, han mostrado disminuir la incidencia de complicaciones cardíacas. Dexmedetomidina es un agonista beta2-adrenérgico de uso frecuente en anestesia. La evidencia sugiere que posee propiedades cardioprotectoras que podrían beneficiar a pacientes quirúrgicos de alto riesgo cardiovascular. La cardioprotección conferida por dexmedetomidina estaría mediada por la modulación del sistema nervioso autónomo. La disminución de la frecuencia cardíaca y de la presión arterial observada durante su uso, evitarían el desbalance entre aporte y demanda de oxígeno miocárdico y atenuarían el estrés sobre placas ateromatosas inestables. Hasta este momento se desconoce si dexmedetomidina produce precondicionamiento cardíaco y si activa vías transduccionales asociadas a cardioprotección. Frente a la actual realidad epidemiológica en Chile y el mundo, es importante estudiar y definir, cuales son los fármacos de uso frecuente en anestesia con capacidad cardloprotectora y los mecanismos Involucrados en esta protección. Sería Interesante lograr...

Cardiovascular disease is the leading cause of death In Chile and worldwide. Anesthesiologists and surgeons often face more elderly surgical patients with cardiovascular disease. The incidence of myocardial Ischemia in patents at high risk, undergoing non-cardiac surgery is about 40 percent during the perioperative period. The incidence of myocardial Infarction and death in non-cardiac surgery is between 1 and 5 percent. There is a close relationship between perioperative Ischemic events and increased cardiovascular morbidity and mortality Therefore, therapeutic approaches have been developed to reduce the Incidence of perioperative Ischemia and lessen the damage associated with it. The proper Identification of patients at risk, optimizing the medical treatment of associated diseases and the use of cardioprotective drugs during the perioperative period have shown to decrease the Incidence of cardiac complications. The beta2-adrenergic agonist dexmedetomidine is commonly used in anesthesia. The evidence suggests that possesses cardioprotective properties that could benefit surgical patients at high cardiovascular risk. The cardioprotection conferred by dexmedetomidine would be mediated by modulation of the autonomic nervous system. The decrease in heart rate and blood pressure observed during its use could avoid the Imbalance between supply and myocardial oxygen demand and lessen the stress on unstable athermanous plaques. So far it is unknown whether dexmedetomidine produces cardiac preconditioning by activating cardioprotective-signaling pathways. Faced with the current worldwide epidemiologic situation, It would be Important to study the cardioprotective capacity of drugs frequently used in anesthesia and the mechanisms Involved In that protection. It would be interesting to achieve that definition regarding the perioperative use of dexmedetomidine.

Predicción de eventos coronarios a nueve años mediante el score de Framingham en Uruguay / Prediction of coronary events nine years using the Framingham score in Uruguay

Fundamento: el score de Framingham permite estimar el riesgo de cardiopatía isquémica a diez años a partir de la edad, sexo, niveles de colesterol, presión arterial, y presencia o no de diabetes y tabaquismo. El presente estudio tiene como finalidad evaluar la capacidad predictiva de ese score en nuestro país. Metodología: entre 1995 y 1998 se seleccionó al azar una muestra de asociados con características similares a las de los participantes del estudio de Framingham. Se calculó su riesgo cardiovascular mediante el score y se pesquisó el desarrollo de cardiopatía isquémica hasta 2007. Se analizó la capacidad de discriminación del score mediante el cálculo del área bajo la curva ROC y su calibración mediante la prueba de Hosmer-Lemeshow. Resultados: entre los 1.110 participantes, el riesgo cardiovascular promedio estimado fue 12,4% en hombres y 6,3% en mujeres. La incidencia de cardiopatía isquémica a los nueve años fue 12,1% en hombres y 3,3% en mujeres. La discriminación del score fue 0,76 (IC 95% 0,69 a 0,83) en hombres y 0,63 (IC 95% 0,56 a 0,78) en mujeres y su calibración fue 6,82; p=0,56 en los hombres y 5,09; p=0,64 en las mujeres. Conclusiones: el score de riesgo de Framingham es adecuado para discriminar el riesgo de cardiopatía isquémica en los hombres, pero no en las mujeres de nuestro país. La calibración del mismo, ajustándolo de acuerdo a la prevalencia de factores de riesgo y la incidencia de eventos observada de nuestro medio, podría mejorar su capacidad de predicción.

Background: Framingham risk score allows to estimate the 10 years risk of ischemic heart disease taking into account age, gender, cholesterol and blood pressure levels, and diabetes and smoking presence or not. This study was performed to evaluate the predictive capacity of that score in our country. Methods: between 1995 and 1998 an associate’s random sample with similar characteristics to Framingham study participants was selected. Its cardiovascular risk was estimated with the Framingham score and the development of coronary heart disease was investigated until 2007. The scores discrimination capacity was analyzed with the area under the ROC curve and its calibration with the Hosmer-Lemeshow test. Results: among 1.110 participants, average cardiovascular risk was estimated in 12,4% for men and 6,3% for women. At 9 years, coronary heart disease occurs in 12,1% of men and 3,3% in women. The score discrimination was 0,76 (95% CI 0,69 to 0,83) in men and 0,63 (95% CI 0,56 to 0,78) in women, and its calibration was 6.82, p=0.56 in men and 5,09, p=0,64 in women. Conclusions: the Framingham risk score is adequate to discriminate the risk of coronary heart disease risk among men, but it is not adequate to do it in the women of our country. Its calibration taking into account local prevalence of risk factors and events incidence could improve its predictive capacity.

Cardiopatia isquêmica crônica / Chronic coronary artery disease

A principal causa de insuficiência coronariana é a doença aterosclerótica coronária. As apresentações clínicas da insuficiência coronariana crônica são angina pectoris, isquemia silenciosa e o equivalente isquêmico, sendo a angina do peito a principal manifestação e a isquemia silenciosa a mais frequente apresentação. A presença de isquemia miocárdica é importante fator prognóstico dos pacientes com insuficiência coronariana. A história clínica é fundamental na avaliação do paciente. Associada à presença dos fatores de risco, permite estimar a probabilidade de doença coronária. Caracterizado o diagnóstico de angina estável, procede-se a estratificação de sua severidade e risco, habitualmente utilizando exames complementares, como eletrocardiograma, teste ergométrico e exames de imagem. A estratificação de risco é fundamental por sua implicação terapêutica. Pacientes estratificados como de baixo risco podem ser seguidos clinicamente sem a necessidade de abordagem invasiva. Nos casos de maior risco ou com angina refratária podem ser indicados procedimentos de revascularização do miocárdio (cirúrgico ou por cateter), conforme o achado da anatomia coronária e função ventricular.

Avaliação da prescrição de exercícios pela cintilografia miocárdica na reabilitação de coronariopatas / Evaluation of prescription of exercise, for rehabilitation of coronary artery disease patients by myocardial scintigraphy

FUNDAMENTO: Recomenda-se que a intensidade dos exercícios na reabilitação de coronariopatas não deva produzir isquemia miocárdica. OBJETIVO: Comparar a capacidade da cintilografia tomográfica do miocárdio com a do eletrocardiograma na detecção de isquemia durante sessão de reabilitação. MÉTODOS: Vinte e seis pacientes coronariopatas, em programa de reabilitação e com cintilografia prévia com hipocaptação transitória, receberam nova injeção de MIBI-Tc-99m durante uma sessão de treinamento, quando também foram monitorizados pela eletrocardiografia dinâmica. As cintilografias de repouso, após teste ergométrico em esteira e após sessão de reabilitação, foram analisadas de forma semiquantitativa utilizando-se um escore, de 0 a 4, classificando cada um dos segmentos escolhidos (0 = normal; 1 = hipocaptação discreta; 2 = moderada; 3 = intensa; 4 = ausência da captação). RESULTADOS: As médias dos somatórios dos escores encontrados foram: repouso = 12,9; após teste em esteira = 19,3; após sessão de reabilitação = 15,1. Houve diferenças estatisticamente significativas entre elas. Uma análise individual mostrou que em 14 casos (53,8 por cento) foi identificado algum grau de hipocaptação durante a reabilitação, e em 12 (46,6 por cento), não. Monitorização com sistema Holter não revelou, em nenhum caso, depressão do segmento ST, igual ou maior do que 1 mm. CONCLUSÃO: Exercícios prescritos em doentes coronariopatas, conforme recomendações da literatura, podem desencadear isquemia miocárdica, avaliada pela cintilografia, durante sessão de reabilitação.

BACKGROUND: It is advisable that the intensity of the exercises for rehabilitation of patients with coronary artery disease does not cause myocardial ischemia. OBJECTIVE: Compare the capacity of myocardial tomographic scintigraphy with the electrocardiogram capacity in ischemia detection during rehabilitation session. METHODS: Twenty six patients with coronary artery disease, undergoing the rehabilitation program and with previous scintigraphy, with transient hypo-uptake have been administered a new injection of MIBI-Tc-99m during a training session when they were also monitored with dynamic electrocardiography. The rest scintigraphies, after ergometric treadmill test and rehabilitation session, were assessed in a semi-quantitative way using scores from 0 to 4 to classify each one of the chosen segments (0 = normal; 1 = discrete hypo-uptake; 2 = moderate; 3 = intense; 4 = lack of uptake). RESULTS: The means of the total scores found were: at rest = 12.9; after treadmill test = 19.3; after rehabilitation session = 15.1. There were statistically significant differences among them. An individual assessment showed that in 14 cases (53.8 percent) hypo-uptake to some degree was identified during rehabilitation and in 12 cases (46.6 percent) it was not. Monitoring with the Holter system didn't show in any of the cases a ST segment depression equal or greater than 1mm. CONCLUSION: The exercises prescribed for patients with coronary artery disease, according to recommendations found in the literature, may trigger myocardial ischemia, assessed by scintigraphy during a rehabilitation session.

Las enfermedades crónicas no transmisibles en México: sinopsis epidemiológica y prevención integral / Chronic non-communicable diseases in Mexico: epidemiologic synopsis and integral prevention

El gobierno federal desarrolla acciones para reducir la mortalidad por las "enfermedades crónicas no transmisibles" (ECNT). Una de ellas es la creación de unidades médicas de especialidad (Uneme) diseñadas para el tratamiento especializado de las ECNT (sobrepeso, obesidad, riesgo cardiovascular y diabetes). La intervención se basa en la participación de un grupo multidisciplinario entrenado ex profeso, la educación del paciente sobre su salud, la incorporación de la familia al tratamiento y la resolución de las condiciones que limitan la observancia de las recomendaciones. El tratamiento está indicado con base en protocolos estandarizados. La eficacia de la intervención se evalúa en forma sistemática mediante indicadores cuantitativos predefinidos. Se espera que las Uneme resulten en ahorros para el sistema de salud. En suma, este último desarrolla mejores medidas de control para las ECNT. La evaluación del desempeño de las Uneme generará información para planear acciones preventivas futuras.

The federal government has implemented several strategies to reduce mortality caused by chronic non-communicable diseases (CNTD). One example is the development of medical units specialized in the care of CNTD (i.e. overweight, obesity, cardiovascular risk and diabetes), named UNEMES (from its Spanish initials). These units -consisting of an ad-hoc, trained, multi-disciplinary team- will provide patient education, help in the resolution of obstacles limiting treatment adherence, and involve the family in patient care. Treatment will be provided using standardized protocols. The efficacy of the intervention will be regularly measured using pre-specified outcomes. We expect that these UNEMES will result in significant savings. In summary, our health care system is developing better treatment strategies for CNTD. Evaluating the performance of the UNEMES will generate valuable information for the design of future preventive actions.

Cardiodefibrilador automático implantable: incidencia, causas y predictors de mortalidad. Valor de los registros prospectivos / Implantable automatic cardiodefibrillator: incidence causes and predictors of mortality. Value of the prospective records

The implantable automatic cardiodefibrilator (IACD) has proved to be an effective tool in the prevention of both primary and secondary sudden death. Even so, the mortality of patients receiving an IACD still remains elevated. Recent data, obtained from the secondary analysis of different studies, suggest that the discharges of the deice, between other clinical variables, both electrocardiiographic and ultrasonographic could be associated to a higher mortality, maybe due to a contribution to the progression of the cardiac insufficiency. The aims of this report were to evaluate the incidence of mortality, causes of death and the time since the implantation till the death, to analyze appropriate an inappropriate shocks and other variaables as potential predictors of mortality in patients with IACD. The results obtained in this study are detailed in the article

Riesgo cardiovascular total en los trabajadores del Hotel Meliá Cohíba / Total cardiovascular risk in workers of Meliá Cohíba Hotel

La cardiopatía isquémica es una de las primeras causas de muerte internacionalmente, y para valorar el riesgo cuantitativo de padecerla, se han creado tablas de riesgo, y una de las más empleadas ha sido la tabla de riesgo cardiovascular de Framingham. En Cuba son escasos los estudios sobre valoración de riesgo cardiovascular total. Determinar el nivel de riesgo cardiovascular total en una población de trabajadores. Se realizó un estudio piloto descriptivo en 301 trabajadores del Hotel Meliá Cohíba. Las variables utilizadas: hipertensión arterial y las correspondientes a la tabla de riesgo de Framingham (demográficas, hábitos de fumar, presión arterial sistólica, diabetes, colesterol total, colesterol HDL e hipertrofia ventricular izquierda). Se calculó el riesgo cardiovascular total de cada trabajador. Se utilizaron como medidas de resumen, las frecuencias relativas en por ciento, calculadas mediante el programa SPSS, versión 13,0 y el calificador de riesgo para obtener el puntaje en cada individuo. Los resultados se expusieron en tablas para su análisis y discusión. El riesgo de padecer una enfermedad cardiovascular en los próximos 10 años fue mayor en hombres, y aumentó proporcionalmente con la edad. El riesgo cardiovascular fue considerado bajo en el 80,4 por ciento del total, menor en mujeres. La dislipidemia fue el factor de riesgo cardiovascular más frecuente en esta población, seguida del hábito de fumar (43,2) y la hipertensión arterial (15 por ciento). El bajo nivel de riesgo cardiovascular global en esta población pudiera estar determinado por la edad de la población estudiada. Los factores de riesgo más prevalentes en los casos estudiados fueron la dislipidemia, el hábito de fumar y la HTA.

Ischemic heart disease is one of the first causes of death in the world. To assess the quantitative risk of suffering from it, risk tables have been created and Framingham's cardiovascular risk table has been one of the most used so far. In Cuba, a few studies on the assessment of total cardiovascular risk have been conducted. To determine the total cardiovascular risk level in a population of workers. A pilot descriptive study was carried out among 301 workers of Meliá Cohiba Hotel. The variables used were arterial hypertension and the corresponding to Framingham's risk tables (demographic, smoking habit, systolic arterial pressure, diabetes, total cholesterol, HDL cholesterol and left ventricular hypertrophy). The total cardiovascular risk of each worker was calculated. The relative frequencies in percent, calculated by the SPSS program, version 13.0, and the risk qualifier to obtain the score in every individual, were used as outcome measures. The results were showed in tables for their analysis and discussion. The risk for suffering from a cardiovascular disease in the next 10 years was higher in males, and it increased proportionally with age. Cardiovascular risk was considered low in 80.4 per cent of the total, and it was lower in females. Dyslipidemia was the most common cardiovascular risk in this population, followed by smoking habit (43.2) and arterial hypertension (15 per cent). The low level of global cardiovascular risk could be determined by the age of the studied population. The prevailing risk factors in the analysed cases were dyslipidemia, smoking habit and arterial hypertension.

A Multicenter, Randomized, Open-Label, Therapeutic, and Exploratory Trial to Evaluate the Tolerability and Efficacy of Platelet Glycoprotein IIb/IIIa Receptor Blocker (Clotinab(TM)) in High-Risk Patients with Percutaneous Coronary Intervention

PURPOSE: This study was designed as a multicenter, randomized, open-label study to evaluate the efficacy and tolerability of Clotinab(TM). We expected to obtain same results as with ReoPro(R) in improving ischemic cardiac complications in high-risk patients who were about to undergo percutaneous coronary intervention (PCI). PATIENTS AND METHODS: Patients of 19-80 years of age with acute coronary syndrome (ACS) who were about to undergo PCI were enrolled. After screening and confirmation of eligibility, patients were randomly assigned to different groups. Clotinab(TM) was given to 84 patients (58.7+/-10.6 years, M:F=68:16)and ReoPro(R)(59.0+/-10.5 years, M:F=30:10) was given to 40 patients before PCI. The primary efficacy endpoint was the onset of major adverse cardiac event (MACE) within 30 days from day 1. The tolerability endpoints were assessed based on bleeding, thrombocytopenia, change in Hb/Hct, human antichimetric antibody development, and adverse events. RESULTS: The number of Clotinab(TM) patients experiencing MACE was 0 out of 76 per protocol (PP) patients. The MACE rate was 0%, and its 95% exact CI was [0.00-4.74%]. A major bleeding event developed in 3 patients in the ReoPro(R) group. The probability of MACE onset in Clotinab(TM) was estimated to be less than 5%. There was no clinically significant result in tolerability variables. CONCLUSION: Clotinab(TM) is an effective and safe medicine in preventing ischemic cardiac complications for high-risk patients who will receive PCI.