Violence and aggression against nurses during the COVID-19 pandemic in Latin America. From the emerging leaders program of the Interamerican Society of Cardiology (SIAC).

INTRODUCTION: During the Coronavirus (COVID-19) pandemic, healthcare providers have overcome difficult experiences such as workplace violence. Nurses are particularly vulnerable to workplace violence. The objective of this study was to characterize violence and aggression against nurses during the COVID-19 pandemic in Latin America. METHODS: An electronic cross-sectional survey was conducted in 19 Latin American countries to characterize the frequency and type of violent actions against front-line healthcare providers. RESULTS: Of the original 3544 respondents, 16% were nurses (n = 567). The mean age was 39.7 ± 9.0 years and 79.6% (n = 2821) were women. In total, 69.8% (n = 2474) worked in public hospitals and 81.1% (n = 2874) reported working regularly with COVID-19 patients. Overall, about 68.6% (n = 2431) of nurses experienced at least one episode of workplace aggression during the pandemic. Nurses experienced weekly aggressions more frequently than other healthcare providers (45.5% versus 38.1%, p < .007). Nurses showed a trend of lower reporting rates against the acts of aggression suffered (p = .076). In addition, nurses were more likely to experience negative cognitive symptoms after aggressive acts (33.4% versus 27.8%, p = .028). However, nurses reported considering changing their work tasks less frequently compared to other healthcare providers after an assault event (p = .005). CONCLUSION: Workplace violence has been a frequent problem for all healthcare providers during COVID-19 pandemic in Latin America. Nurses were a particularly vulnerable subgroup, with higher rates of aggressions and cognitive symptoms and lower rate of complaints than other healthcare providers who suffered from workplace violence. It is imperative to develop strategies to protect this vulnerable group from aggressions during their tasks.

[Control of arterial hypertension: a pending issueControle da hipertensão arterial: um assunto inacabado]. / El control de la hipertensión arterial, una asignatura pendiente.

Adequate diagnosis, treatment, and control of arterial hypertension (AHT) continues to be a pending issue in the attempt to reduce the incidence of premature mortality and disability due to cardiovascular disease, which is a reality worldwide and in the region of the Americas in particular.Despite having adequate diagnostic algorithms and efficient treatment schemes, the gap between medical knowledge and reality reveals the great difficulty in ensuring that patients follow recommendations. Adherence to treatment is a great challenge and a proper understanding of its dimensions is essential when designing strategies to improve control of AHT.It is clear that part of the solution is having adequate information and disseminating it, but actions that guarantee implementation are no less important. That is why clinical practice guidelines that try to address this problem are welcome. The recent publication of the World Health Organization's guidance on arterial hypertension is a clear example of this type of initiative.Implementation programs are arguably one of the biggest challenges in contemporary medicine. The development of multimodal interventions aimed at improving response capacity at the first level of care and promoting the development of integrated health services networks appears to be the most appropriate way to achieve adequate control of AHT.Scientific societies clearly play an important role in these initiatives by providing support and coordinating interactions among the different actors involved.

O diagnóstico, tratamento e controle adequados da hipertensão arterial sistêmica (HAS) continua sendo uma questão pendente em nossa tentativa de reduzir a incidência de mortalidade cardiovascular prematura e a incapacidade. Essa é a realidade no nível mundial e, particularmente, na região das Américas.Apesar de algoritmos de diagnóstico adequados e esquemas de tratamento eficientes, a lacuna entre o conhecimento médico e a realidade nos mostra como é difícil que nossas recomendações sejam adotadas por nossos pacientes. A adesão representa um grande desafio, e uma compreensão adequada de suas dimensões é essencial ao se projetar estratégias para melhorar o controle da HAS.Claramente, a disponibilidade e a divulgação de informações adequadas é parte da solução, mas não menos importantes são as ações para garantir sua implementação. Portanto, acolhemos de bom grado as diretrizes de prática clínica que visam abordar esta questão. A recente publicação das diretrizes da Organização Mundial da Saúde sobre hipertensão arterial é um claro exemplo de tais iniciativas.Os programas de implementação são indiscutivelmente um dos maiores desafios da medicina contemporânea. O desenvolvimento de intervenções multimodais na atenção primária com o objetivo de melhorar sua resolutividade e promover o desenvolvimento de redes integradas de serviços de saúde parece ser a forma mais apropriada para atingir níveis adequados de controle da HAS.Estamos convencidos do importante papel que nossas sociedades científicas desempenham nestas iniciativas ao prestar apoio, suporte e articulação aos diferentes atores envolvidos.

Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries.

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

Toward a Better Understanding of Cardiovascular Risk in the Transgender and Gender-Diverse Community: A Global Call to Action.

On World Heart Day 2022, the Mexican Society of Cardiology, the Inter-American Society of Cardiology, and the World Heart Federation collaborated on a public call to action regarding the increased risk of adverse cardiovascular health outcomes in transgender and gender diverse (TGD) individuals. The aim of this article is to unpack the numerous factors that contribute to this, such as the social stigma faced by members of the TGD community, their reduced access to clinical care, and the scarcity of research regarding the unique needs of their community, which makes it difficult for clinicians to provide individualized medical care. Decreasing the incidence of adverse cardiovascular events among TGD individuals requires interventions such as educational reform in the medical community, an increase in inclusive research studies, and broader social initiatives intended to reduce the stigma faced by TGD individuals.

Rationale and Design of a Multi-National Study of Physicians' Opinions, Attitudes, and Practices Regarding Influenza Vaccination in Patients with Cardiovascular Diseases: A Mixed Methods Designs. The FLUence Project.

Infections, particularly those involving the respiratory tract, are associated with an increased incidence of cardiovascular events, both de novo and as exacerbations of pre-existing cardiovascular diseases. Influenza vaccination has consistently been shown to reduce the incidence of cardiovascular events. Nonetheless, vaccination rates among adults remain suboptimal, both in the general population and among high-risk individuals. Multiple barriers hinder achieving adequate vaccination rates, with physicians' beliefs and attitudes towards these interventions being crucial. The FLUence project was developed within the framework of the World Heart Federation's Emerging Leaders program, to address this issue. This project has two phases: a global quantitative survey to assess the perceptions, opinions, and attitudes and challenges of physicians worldwide regarding the safety and efficacy of the influenza vaccination use, and a qualitative survey to further investigate the barriers and facilitators of recommending and using this vaccination. The quantitative survey was created and disseminated in five languages (English, Spanish, French, Italian, and Portuguese) to physicians of all specialties who care for adults, with a particular focus on patients with cardiovascular disease. The survey included eight domains with a total of 36 questions with closed options; a Likert scale with five possible answers was used to gauge participants' opinions. To gain deeper insights into the complexities behind the low vaccination rates in adults, the second part of the project comprises a qualitative survey, conducted in the two lower-middle- and upper-middle-income countries: India and Argentina, respectively. These countries were selected because patients with cardiovascular diseases have access to free influenza vaccination in Argentina, whereas patients must pay for the vaccine out of pocket in India. Thus, the FLUence study will provide valuable information to better understand the perceptions and barriers to improving influenza vaccination rates from the perspective of physicians. It is imperative to actively engage all healthcare providers to improve influenza vaccination rates.

World Heart Federation Roadmap for Secondary Prevention of Cardiovascular Disease: 2023 Update.

Background: Secondary prevention lifestyle and pharmacological treatment of atherosclerotic cardiovascular disease (ASCVD) reduce a high proportion of recurrent events and mortality. However, significant gaps exist between guideline recommendations and usual clinical practice. Objectives: Describe the state of the art, the roadblocks, and successful strategies to overcome them in ASCVD secondary prevention management. Methods: A writing group reviewed guidelines and research papers and received inputs from an international committee composed of cardiovascular prevention and health systems experts about the article's structure, content, and draft. Finally, an external expert group reviewed the paper. Results: Smoking cessation, physical activity, diet and weight management, antiplatelets, statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and cardiac rehabilitation reduce events and mortality. Potential roadblocks may occur at the individual, healthcare provider, and health system levels and include lack of access to healthcare and medicines, clinical inertia, lack of primary care infrastructure or built environments that support preventive cardiovascular health behaviours. Possible solutions include improving health literacy, self-management strategies, national policies to improve lifestyle and access to secondary prevention medication (including fix-dose combination therapy), implementing rehabilitation programs, and incorporating digital health interventions. Digital tools are being examined in a range of settings from enhancing self-management, risk factor control, and cardiac rehab. Conclusions: Effective strategies for secondary prevention management exist, but there are barriers to their implementation. WHF roadmaps can facilitate the development of a strategic plan to identify and implement local and national level approaches for improving secondary prevention.

[Self-perception of smoking cessation skills among Cardiology residents in Argentina]. / Autopercepción de las habilidades para la cesación del tabaquismo entre los residentes de cardiología en Argentina.

Objective: To evaluate the self-perception of cardiology residents in Argentina regarding their abilities to help their patients stop smoking, as well as their opinions about their knowledge and skills in this area. Materials and methods: A cross-sectional study was carried out using secondary data from a study carried out in five Latin American countries and Spain, focusing on the information provided by cardiology residents in Argentina. Discrete variables were expressed as median and interquartile range, and categorical variables were expressed as percentages, and were analyzed using the chi-square test or Fisher's exact test, depending on the relative frequency of the expected values. Results: 447 residents participated; 87.5% routinely provided brief advice to quit smoking, and 11.6% used validated questionnaires to assess the degree of addiction. Furthermore, 32.1% stated that they prescribed pharmacological treatment, but 53.1% were only familiar with a single drug. When asked about their self-perception of getting their patients to stop smoking, the median response was 5 (scale from 1 to 10); only 13.7% responded with a score of 8 or more. Conclusions: The present study suggests that cardiology residents in Argentina recognize the importance of carrying out smoking cessation interventions, but a high proportion of them do not feel qualified to do so.

WHF Recommendations for the Use of Echocardiography in Chagas Disease.

Chagas disease (ChD) represents a significant health burden in endemic regions of Latin America and is increasingly being recognized as a global health issue. The cardiac involvement in ChD, known as Chagas cardiomyopathy (ChCM), is the most severe manifestation and a leading cause of heart failure and mortality in affected individuals. Echocardiography, a non-invasive imaging modality, plays a crucial role in the diagnosis, monitoring, and risk stratification of ChCM. This consensus recommendation aims to provide guidance on the appropriate use of echocardiography in ChD. An international panel of experts, including cardiologists, infectious disease specialists, and echocardiography specialists, convened to review the available evidence and provide practical recommendations based on their collective expertise. The consensus addresses key aspects related to echocardiography in ChD, including its role in the initial evaluation, serial monitoring, and risk assessment of patients. It emphasizes the importance of standardized echocardiographic protocols, including the assessment of left ventricular function, chamber dimensions, wall motion abnormalities, valvular involvement, and the presence of ventricular aneurysm. Additionally, the consensus discusses the utility of advanced echocardiographic techniques, such as strain imaging and 3D echocardiography, in assessing myocardial mechanics and ventricular remodeling.

Influenza Vaccination for the Prevention of Cardiovascular Disease in the Americas: Consensus document of the Inter-American Society of Cardiology and the Word Heart Federation.

Background: Cardiovascular mortality is decreasing but remains the leading cause of death world-wide. Respiratory infections such as influenza significantly contribute to morbidity and mortality in patients with cardiovascular disease. Despite of proven benefits, influenza vaccination is not fully implemented, especially in Latin America. Objective: The aim was to develop a regional consensus with recommendations regarding influenza vaccination and cardiovascular disease. Methods: A multidisciplinary team composed by experts in the management and prevention of cardiovascular disease from the Americas, convened by the Inter-American Society of Cardiology (IASC) and the World Heart Federation (WHF), participated in the process and the formulation of statements. The modified RAND/UCLA methodology was used. This document was supported by a grant from the WHF. Results: An extensive literature search was divided into seven questions, and a total of 23 conclusions and 29 recommendations were achieved. There was no disagreement among experts in the conclusions or recommendations. Conclusions: There is a strong correlation between influenza and cardiovascular events. Influenza vaccination is not only safe and a proven strategy to reduce cardiovascular events, but it is also cost saving. We found several barriers for its global implementation and potential strategies to overcome them.

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update.

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

WHF IASC Roadmap on Chagas Disease.

Background: Chagas Disease is a neglected tropical disease caused by the protozoan Trypanosoma cruzi, with some of the most serious manifestations affecting the cardiovascular system. It is a chronic, stigmatizing condition, closely associated with poverty and affecting close to 6 million people globally. Although historically the disease was limited to endemic areas of Latin America recent years have seen an increasing global spread. In addition to the morbidity and mortality associated with the disease, the social and economic burdens on individuals and society are substantial. Often called the 'silent killer', Chagas disease is characterized by a long, asymptomatic phase in affected individuals. Approximately 30% then go on develop chronic Chagas cardiomyopathy and other serious cardiac complications such as stroke, rhythm disturbances and severe heart failure. Methods: In a collaboration of the World Hearth Federation (WHF) and the Inter-American Society of Cardiology (IASC) a writing group consisting of 20 diverse experts on Chagas disease (CD) was convened. The group provided up to date expert knowledge based on their area of expertise. An extensive review of the literature describing obstacles to diagnosis and treatment of CD along with proposed solutions was conducted. A survey was sent to all WHF Members and, using snowball sampling to widen the consultation, to a variety of health care professionals working in the CD global health community. The results were analyzed, open comments were reviewed and consolidated, and the findings were incorporated into this document, thus ensuring a consensus representation. Results: The WHF IASC Roadmap on Chagas Disease offers a comprehensive summary of current knowledge on prevention, diagnosis and management of the disease. In providing an analysis of 'roadblocks' in access to comprehensive care for Chagas disease patients, the document serves as a framework from which strategies for implementation such as national plans can be formulated. Several dimensions are considered in the analysis: healthcare system capabilities, governance, financing, community awareness and advocacy. Conclusion: The WHF IASC Roadmap proposes strategies and evidence-based solutions for healthcare professionals, health authorities and governments to help overcome the barriers to comprehensive care for Chagas disease patients. This roadmap describes an ideal patient care pathway, and explores the roadblocks along the way, offering potential solutions based on available research and examples in practice. It represents a call to action to decision-makers and health care professionals to step up efforts to eradicate Chagas disease.

El control de la hipertensión arterial, una asignatura pendiente / Control of arterial hypertension: a pending issue / Controle da hipertensão arterial: um assunto inacabado

RESUMEN El adecuado diagnóstico, tratamiento y control de la hipertensión arterial (HTA) continúa siendo una asignatura pendiente en nuestro intento de reducir la incidencia de mortalidad cardiovascular prematura y discapacidades, siendo esta una realidad a nivel mundial y particularmente cierta en la región de las Américas. A pesar de contar con adecuados algoritmos diagnósticos y eficientes esquemas de tratamiento, la brecha entre el conocimiento médico y la realidad nos muestra la gran dificultad para que nuestras recomendaciones sean adoptadas por nuestros pacientes. La adherencia representa un gran desafío y la adecuada comprensión de sus dimensiones resulta básico al momento de diseñar estrategias para mejorar el control de la HTA. Es claro que disponer y diseminar información adecuada es una parte de la solución, pero no menos importante son las acciones que garanticen su implementación. Es por lo que damos la bienvenida a guías de práctica clínica que intenten abordar esta problemática. La reciente publicación de guía de la Organización Mundial de la Salud en hipertensión arterial es un claro ejemplo de este tipo de iniciativas. Los programas de implementación posiblemente sean uno de los mayores desafíos de la medicina contemporánea. El desarrollo de intervenciones multimodales en el primer nivel de atención con el objetivo de mejorar su capacidad resolutiva y promover el desarrollo de redes integradas de servicios de salud, impresiona ser el camino mas adecuado para alcanzar niveles adecuados de control de la HTA. Estamos convencidos del importante rol que nuestras sociedades científicas tienen con estas iniciativas dando apoyo, soporte y articulando la interacción con los diferentes actores involucrados.

ABSTRACT Adequate diagnosis, treatment, and control of arterial hypertension (AHT) continues to be a pending issue in the attempt to reduce the incidence of premature mortality and disability due to cardiovascular disease, which is a reality worldwide and in the region of the Americas in particular. Despite having adequate diagnostic algorithms and efficient treatment schemes, the gap between medical knowledge and reality reveals the great difficulty in ensuring that patients follow recommendations. Adherence to treatment is a great challenge and a proper understanding of its dimensions is essential when designing strategies to improve control of AHT. It is clear that part of the solution is having adequate information and disseminating it, but actions that guarantee implementation are no less important. That is why clinical practice guidelines that try to address this problem are welcome. The recent publication of the World Health Organization's guidance on arterial hypertension is a clear example of this type of initiative. Implementation programs are arguably one of the biggest challenges in contemporary medicine. The development of multimodal interventions aimed at improving response capacity at the first level of care and promoting the development of integrated health services networks appears to be the most appropriate way to achieve adequate control of AHT. Scientific societies clearly play an important role in these initiatives by providing support and coordinating interactions among the different actors involved.

RESUMO O diagnóstico, tratamento e controle adequados da hipertensão arterial sistêmica (HAS) continua sendo uma questão pendente em nossa tentativa de reduzir a incidência de mortalidade cardiovascular prematura e a incapacidade. Essa é a realidade no nível mundial e, particularmente, na região das Américas. Apesar de algoritmos de diagnóstico adequados e esquemas de tratamento eficientes, a lacuna entre o conhecimento médico e a realidade nos mostra como é difícil que nossas recomendações sejam adotadas por nossos pacientes. A adesão representa um grande desafio, e uma compreensão adequada de suas dimensões é essencial ao se projetar estratégias para melhorar o controle da HAS. Claramente, a disponibilidade e a divulgação de informações adequadas é parte da solução, mas não menos importantes são as ações para garantir sua implementação. Portanto, acolhemos de bom grado as diretrizes de prática clínica que visam abordar esta questão. A recente publicação das diretrizes da Organização Mundial da Saúde sobre hipertensão arterial é um claro exemplo de tais iniciativas. Os programas de implementação são indiscutivelmente um dos maiores desafios da medicina contemporânea. O desenvolvimento de intervenções multimodais na atenção primária com o objetivo de melhorar sua resolutividade e promover o desenvolvimento de redes integradas de serviços de saúde parece ser a forma mais apropriada para atingir níveis adequados de controle da HAS. Estamos convencidos do importante papel que nossas sociedades científicas desempenham nestas iniciativas ao prestar apoio, suporte e articulação aos diferentes atores envolvidos.

Disfunción de prótesis mitral mecánica: ¿Intervención quirúrgica o tratamiento inmediato con fibrinolíticos? / Mechanical mitral prosthesis dysfunction: Surgical intervention or immediate treatment with fibrinolytics?

Resumen: Existe en la actualidad controversia acerca del mejor tratamiento para los pacientes portadores de trombosis valvular protésica. Muchos factores deben ser tenidos en cuenta al momento de decidir entre la resolución quirúrgica o el tratamiento con fibrinolíticos sistémicos. Las guías americanas recomiendan en plano de igualdad ambas terapéuticas, poniendo énfasis en el análisis de cada caso en particular. Las guías europeas, en cambio, le dan mayor nivel de recomendación a la cirugía, dejando la fibrinólisis para aquellos pacientes con alto riesgo quirúrgico. Se presenta el caso de una paciente de 54 años, portadora de prótesis mitral mecánica implantada hace 15 años, disfuncionante, en clase funcional II de la New York Heart Association, y se discuten las opciones diagnósticas y terapéuticas.

Summary: There is ongoing debate regarding the optimal treatment for patients with prosthetic valve thrombosis. Several issues must be taken into consideration before defining either surgical or fibrinolytic treatment. North American guidelines place both therapeutic modalities under the same recommendation grade with special emphasis on the analysis of each individual case. European guidelines place surgical treatment as the preferred option except in patients with high surgical risk. Thereby, we present the clinical case of a 54 year old female with dysfunctional mechanical mitral prosthesis implanted 15 years ago and functional class II of the New York Heart Association. Diagnostic and therapeutic approaches are discussed.

Insuficiencia mitral crónica asintomática. ¿se justifica la plástica precoz? / Guidelines for the management of Asymptomatic chronic mitral insufficiency

Las indicaciones tradicionales de la cirugía en la insuficiencia mitral (IM) son los síntomas y las indicaciones avanzadas se extienden a los pacientes asintomáticos con disfunción del ventrículo izquierdo (VI), hipertensión pulmonar (HTP) o fibrilación auricular (FA). Recientemente algunos grupos preconizan la plástica precoz aún en pacientes sin síntomas, disfunción del VI, HTP, ni FA, a condición de que la válvula sea reparable y que el riesgo de mortalidad quirúrgica no supere el 1 por ciento...Se concluye que la plástica mitral debería realizarse en los pacientes que no refieren síntomas sólo si existen evidencias objetivas de que se trata de una IM realmente grave asociada a deterioro de la función del VI, HTP o FA.(AU)

Insuficiencia mitral crónica asintomática. ¿se justifica la plástica precoz? / Guidelines for the management of Asymptomatic chronic mitral insufficiency

Las indicaciones tradicionales de la cirugía en la insuficiencia mitral (IM) son los síntomas y las indicaciones avanzadas se extienden a los pacientes asintomáticos con disfunción del ventrículo izquierdo (VI), hipertensión pulmonar (HTP) o fibrilación auricular (FA). Recientemente algunos grupos preconizan la plástica precoz aún en pacientes sin síntomas, disfunción del VI, HTP, ni FA, a condición de que la válvula sea reparable y que el riesgo de mortalidad quirúrgica no supere el 1 por ciento...Se concluye que la plástica mitral debería realizarse en los pacientes que no refieren síntomas sólo si existen evidencias objetivas de que se trata de una IM realmente grave asociada a deterioro de la función del VI, HTP o FA.