Variability of door-to-device times at a rural tertiary care center.

OBJECTIVES: Target door-to-device (DTD) time for ST-elevation myocardial infarction (STEMI) patients has been 90 minutes, with no distinction between urban and rural hospitals. Rural hospitals have longer DTD times for transferred patients attributed to long transportation times from referring hospitals. Longer DTD times have also been reported during after-hours. The aim of the study was to determine whether DTD times at our rural facility were impacted by arrival method, arrival time period, and season. DESIGN: Retrospective chart review. SETTING: Rural tertiary care center in central Wisconsin. METHODS: We studied 412 patients presenting with STEMI after initiation of the Rescue One program for rapid triage and transfer from October 2006 through December 2012. They were subdivided by arrival method, arrival time (ON=Monday-Friday, 8 AM-5 PM; OFF=after-hours, weekends, holidays), and season. Median DTD times and proportions below and above 90 minutes were compared. RESULTS: Median DTD time for all groups, which include both directly admitted and transferred patients, was 85 minutes with 60% of patients achieving DTD times below 90 minutes while 30-day mortality was 5.3%. Median DTD time was 67 minutes for the Emergency Department (ED) (n=164), 95 minutes for Transfers (n=204), 68 minutes for Urgent Care (n=22) and 86 minutes for Field (n=22). ED had the highest proportion of patients achieving goal DTD time (81%) compared to Transfers (42%). Patients arriving by ED during OFF hours had a median DTD time 28 minutes longer than during ON hours with 21% fewer patients achieving goal DTD time, attributed to the time required to call in the catheterization team. Seasonal variability was observed due to differences in pre-hospital ambulance transportation times in the Field group. CONCLUSIONS: Our data confirm that in a rural facility such as ours, ED patients arriving during after-hours and transferred patients have longer DTD times. Methods are being implemented to shorten the time to assemble the catheterization lab team during after-hours. Better performance will be seen once the first medical contact to device (FTD) time goal of 120 minutes for transferred patients is adopted at our institution. Fibrinolytic therapy should be considered at referring institutions where the FTD time is expected to exceed 120 minutes.

Consensus document of the management of type 2 diabetes and heart failure: Consejo Interamericano de Falla Cardíaca e Hipertensión Pulmonar (CIFACAH) and Inter-American Society of Cardiology (IASC).

Heart failure (HF) syndrome is a global public health issue. On the other hand, type 2 diabetes is a risk factor associated with overweight/obesity and a sedentary lifestyle. This consensus aims to compile information available on the relationship between HF and type 2 diabetes and present, in a summarized and practical way, the management recommendations based on scientific evidence. The document includes the description of the epidemiology of HF and type 2 diabetes; pathophysiology of HF and type 2 diabetes; cardiovascular complications of type 2 diabetes; stages of HF; management of type 2 diabetes in patients with HF; and management of HF in patients with type 2 diabetes. Lastly, in the conclusions section, the growing trend of both events and the need to start preventive activities is presented, as well as the favorable role of antidiabetic drugs in the treatment of patients with HF.

El síndrome de insuficiencia cardíaca (IC) es un problema de salud pública global. Por su parte, la diabetes tipo 2 es un factor de riesgo asociado a sobrepeso/obesidad y sedentarismo. El presente consenso busca recopilar la información disponible sobre la relación entre la IC y la diabetes tipo 2, y presentar, de manera práctica y resumida, las recomendaciones de manejo basadas en la evidencia científica. El documento se estructura en la descripción de la epidemiología de la IC y la diabetes tipo 2; la fisiopatología de la IC y la diabetes tipo 2; las complicaciones cardiovasculares de la diabetes tipo 2; los estadios de la IC; el manejo de la diabetes tipo 2 en pacientes con IC; y el manejo de la IC en pacientes con diabetes tipo 2. Por último, en el apartado de conclusiones se presenta una clara tendencia creciente de ambos eventos y se señala la necesidad del inicio de actividades preventivas, así como también el papel favorable de los fármacos antidiabéticos en el tratamiento de los pacientes con IC.

Consensus document on the use of sacubitril/valsartan in patients with heart failure: Consejo Interamericano de Falla Cardiaca e Hipertensión Pulmonar (CIFACAH) of the Inter-American Society of Cardiology (IASC).

Heart failure (HF) is a significant event for public health. It has a prevalence between 1-2%, mortality rate between 7-17%, and hospitalization between 32-44%. This implies a risk to health and quality of life, but also great financial efforts for health systems. Sacubitril/valsartan is a medication recognized for its efficacy, and this consensus seeks to synthesize the available information regarding its use for the benefit of patients. This document consists of a description of the epidemiology of HF, pharmacology of the drug, clinical trials, use of the drug in cases with reduced ejection fraction, mildly reduced ejection fraction and preserved ejection fraction, available literature on HF guidelines, recommendations and conclusions.

La insuficiencia cardiaca (IC) es un evento significativo para la salud pública. Tiene una prevalencia entre el 1 y 2%, tasa de mortalidad entre el 7 y 17% y de hospitalización entre el 32 y 44%. Esto implica un riesgo a la salud y calidad de vida, pero también grandes esfuerzos financieros para los sistemas de salud. El sacubitrilo/valsartán es un medicamento reconocido por su eficacia, y este consenso busca sintetizar la información disponible respecto a su uso en búsqueda del beneficio de los pacientes. El presente documento se compone de una descripción de la epidemiología de la IC, farmacología del medicamento, estudios clínicos sobre este, uso del medicamento en casos con fracción de eyección reducida, fracción de eyección ligeramente reducida y fracción de eyección preservada, literatura disponible en guías de IC, recomendaciones y conclusiones.

Interamerican Society of Cardiology (CIFACAH - ELECTROSIAC)/Latin American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of cardiac resynchronization therapy in heart failure.

Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Los estudios epidemiológicos sugieren que aproximadamente la mitad de los pacientes con insuficiencia cardiaca (IC) tiene fracción de eyección reducida, mientras que la otra mitad, fracción de eyección (FE) normal. Actualmente, las guías internacionales consideran la duración de QRS mayor a 130 ms, en presencia de disfunción ventricular (FE < 35%), como criterio para selección de pacientes a terapia de resincronización cardiaca (TRC). La TRC ayuda a restaurar la sincronía intraventricular y auriculoventricular, mejorando el rendimiento del ventrículo izquierdo (VI), reduciendo la regurgitación mitral funcional e induciendo la remodelación inversa del VI. Esto se evidencia en el aumento del tiempo de llenado del VI y la fracción de eyección del VI, la disminución de los volúmenes telediastólico y telesistólico del VI, y la regurgitación mitral y discinesia septal. Como los mecanismos de la disincronía pueden ser heterogéneos, es posible que ninguna medida prediga con exactitud la respuesta a la TRC. Finalmente, la TRC cardiaca ha demostrado progresivamente ser segura y factible, mejora el estado funcional y la calidad de vida, remodela inversamente el VI, disminuye el número de hospitalizaciones, la mortalidad total en pacientes con IC refractaria, la disfunción ventricular izquierda y los trastornos de conducción intraventricular; es una terapia basada en marcapasos para la IC y gracias a la tecnología actual es posible realizar una supervisión remota y segura de casi todos los tipos de dispositivos cardiacos y obtener alertas útiles en la práctica clínica.

[Interamerican Society of Cardiology (CIFACAH - ELECTROSIAC)/Latin American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of cardiac resynchronization therapy in heart failure]. / Sociedad Interamericana de Cardiología (CIFACAH-ELECTROSIAC)/Sociedad Latinoamericana de Ritmo Cardiaco (LAHRS): revisión multidisciplinaria sobre el uso apropiado de la terapia de resincronización cardiaca en la insuficiencia cardiaca.

Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Los estudios epidemiológicos sugieren que aproximadamente la mitad de los pacientes con insuficiencia cardiaca (IC) tiene fracción de eyección reducida, mientras que la otra mitad, fracción de eyección (FE) normal. Actualmente, las guías internacionales consideran la duración de QRS mayor a 130 ms, en presencia de disfunción ventricular (FE < 35%), como criterio para selección de pacientes a terapia de resincronización cardiaca (TRC). La TRC ayuda a restaurar la sincronía intraventricular y auriculoventricular, mejorando el rendimiento del ventrículo izquierdo (VI), reduciendo la regurgitación mitral funcional e induciendo la remodelación inversa del VI. Esto se evidencia en el aumento del tiempo de llenado del VI y la fracción de eyección del VI, la disminución de los volúmenes telediastólico y telesistólico del VI, y la regurgitación mitral y discinesia septal. Como los mecanismos de la disincronía pueden ser heterogéneos, es posible que ninguna medida prediga con exactitud la respuesta a la TRC. Finalmente, la TRC cardiaca ha demostrado progresivamente ser segura y factible, mejora el estado funcional y la calidad de vida, remodela inversamente el VI, disminuye el número de hospitalizaciones, la mortalidad total en pacientes con IC refractaria, la disfunción ventricular izquierda y los trastornos de conducción intraventricular; es una terapia basada en marcapasos para la IC y gracias a la tecnología actual es posible realizar una supervisión remota y segura de casi todos los tipos de dispositivos cardiacos y obtener alertas útiles en la práctica clínica.

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.

Factors Associated with Return to Work After Heart Transplantation: A Systematic Review of the Literature.

BACKGROUND: Heart transplantation represents one of the last treatment options for advanced heart failure. Little is known about the factors associated with return to work in patients after heart transplantation. The aim of this study was to identify those factors. METHODS: A systematic literature review was conducted in the PubMed, LILACS, SCIELO and ScienceDirect databases using the keywords "trasplante cardiaco", "calidad de vida", "reingreso laboral", "return to work", "heart transplantation" and "occupation related". Quantitative studies with patients over 18 years of age that were published between January 2007 and June 2017 were included. RESULTS: A total of 6 articles were included, none from Latin America. Heart transplantation patients had a mean age of 51 years; approximately 17% were over 65 years of age; 73-84% were males; 7-16.4% were professionals; 70-86.6% were previously employed; and 30-60% returned to work. The following factors were related to return to work: higher education (p = 0.0017), young age (p = 0.003), better scores on the physical and mental domains of the SF-36 questionnaire (p = 0.035), higher six-minute walk test results (median of 560 m), and previous employment with less than 24 months interrupted by the inability to work (p = 0.017). Return to work occurred, on average, 6 to 7.5 months after heart transplantation. CONCLUSIONS: Return to work after heart transplantation is variable, with a tendency to be low, and is lower in patients near to retirement age. Protective factors were related to the social, physical and mental environment.

Treatment of intractable angina pectoris utilizing spinal cord stimulation.

Intractable angina pectoris affects approximately 5% to 15% of patients with ischemic heart disease. Current treatment options for refractory angina can be divided into 3 groups: pharmacological, nonpharmacological noninvasive, and invasive. The newest pharmacological treatment option for intractable angina pectoris is ranolazine. Non-pharmacological, noninvasive treatment options include enhanced external counterpulsation and transcutaneous electrical nerve stimulation. Invasive treatment options include revascularization procedures: coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, and percutaneous laser revascularization. Spinal cord stimulation (SCS) as a palliative intervention for refractory angina has been underutilized in the United States. This case review describes application of SCS in a 43-year-old woman with a 10-year history of symptomatic ischemic heart disease who was unresponsive to all available treatment options for intractable severe chest pain. Following spinal cord stimulator placement, the patient reported no further angina, discontinued nitroglycerine, had improved sleep quality, and resumed full-time employment.

Patent foramen ovale with right to left shunt as a cause of hypoxia.

Patent foramen ovale with right to left shunt as a cause of hypoxia without Eisenmengers physiology or with only moderately pulmonary artery pressures is an uncommon presentation. Initial diagnosis via transesophageal echocardiography requires detection of a shunt with either color Doppler or agitated saline contrast with or without Valsalva maneuver. This rare but diagnosable case presented was simply corrected with placement of a CardioSEAL device. Causes of right to left shunt without elevated pulmonary artery pressures are discussed.

Percutaneous closure of patent foramen ovale: a case series and literature review.

Patent foramen ovale (PFO) is an anatomical variant of the interatrial septum with an overall prevalence of 27% in autopsy studies. PFOs have a potential role in causation of stroke, platypneaorthodeoxia, decompression sickness, right to left shunt and migraine headaches. Data regarding percutaneous closure of PFO in low volume tertiary care centers is lacking. Retrospective review of 14 percutaneous PFO closures done in our facility from March 2005 to August 2006 was performed for efficacy of procedure and safety. All patients received clopidogrel for a period of 3 months, and aspirin and subacute bacterial endocarditis prophylaxis for 6 months. Mean age of the study population was 54 years. Fifty percent (7 of 14) of patients experienced an atrial septal aneurysm and 14% (2 patients) exhibited a hypercoagulable state. The indication for closure in 13 patients was transient ischemic attacks or strokes, while one patient had persistent hypoxia due to a severe right to left shunt at PFO. Patients received either a CardioSEAL or Amplatzer device. Deployment rate was 100%. All patients completed a minimum of 6 months of follow-up, with a mean follow-up time of 14.9 +/- 7.6 months. No immediate or late bleeding complication occurred in any patient. One patient developed paroxysmal atrial fibrillation and one patient developed thrombotic complications at 7 months post-procedure secondary to the progression of her anal carcinoma and subsequently died. Pending the results of the four large randomized trials that are enrolling patients, percutaneous closure of PFO for cryptogenic strokes is an attractive alternative to lifelong anticoagulation with relatively few complications, even in low volume centers. There are many challenges in the management of this subset of patients, the foremost being the selection of a target patient population. Role of PFO in migraines is less clear.

Caracterización de una población pediátrica seguida en una clínica de anticoagulación / Description of a pediatric population followed at an anticoagulation clinic

Resumen Introducción: En la población pediátrica, el 95% de las tromboembolias venosas son secundarias a un factor de riesgo; la presencia de catéter venoso central es el factor de riesgo más importante para el desarrollo de trombosis venosa profunda en esta población. Los estudios en población adulta sobre el uso de anticoagulantes se han extrapolado a la población pediátrica, y por ello es importante tener en cuenta las características diferenciales entre ambas poblaciones. Método: Se realizó un estudio descriptivo en el que se revisaron 2300 registros clínicos de pacientes seguidos por la Clínica de Anticoagulación institucional desde 2011 hasta 2019, buscando identificar pacientes menores de 18 años que hubieran recibido manejo anticoagulante ambulatorio. Resultados: Se encontraron 43 pacientes menores de 18 años, el 60% de sexo femenino, con una edad promedio de 9.8 ± 5.2 años. El antecedente patológico más prevalente fueron las valvulopatías (28%). Las principales indicaciones para recibir manejo anticoagulante incluyeron cardiopatías congénitas (21%), prótesis valvular cardíaca mecánica (21%, 5 aórticas y 4 mitrales) y trombosis venosa profunda (14%). La warfarina se utilizó en el 72% de los pacientes. El 81% de los pacientes recibieron tratamiento anticoagulante extendido. Las principales complicaciones durante el tratamiento anticoagulante fueron sangrado ginecológico y cutáneo, así como trombocitopenia. Conclusiones: Las cardiopatías congénitas y las valvulopatías cardíacas son las principales indicaciones para considerar el manejo anticoagulante en la población pediátrica. La warfarina es el medicamento más utilizado en forma ambulatoria en esta población. La adherencia adecuada y el seguimiento ambulatorio en esta población requieren herramientas adicionales para lograr un excelente tratamiento anticoagulante.

Abstract Introduction: In pediatric patients, 95% of venous thromboembolisms are secondary to a risk factor; the presence of central venous catheter is the most important risk factor for the development of deep vein thrombosis in this population. Studies about anticoagulation treatment in adult patients have been extrapolated to the pediatric population, it is important to consider the differential characteristics between these two populations. Method: A descriptive study was conducted; there were reviewed 2300 clinical records of patients followed by the institutional anticoagulation clinic from 2011 to 2019, looking for underage patients who have received ambulatory anticoagulation treatment management. Results: 43 patients under the age of 18 years old were found. 60% were female and the average age was 9.8 ± 5.2 years. The most prevalent pathological antecedent was valve disease (28%). The main indications for anticoagulant treatment included congenital heart disease (21%), mechanical heart valves (21%, 5 aortic and 4 mitral) and deep vein thrombosis (14%). Warfarin was found in 72% of patients. 81% of patients received extended anticoagulation therapy. The main complications during anticoagulant treatment included gynecological and cutaneous bleeding, as well as thrombocytopenia. Conclusions: Congenital heart disease and heart valve disease are the main indications for considering anticoagulation treatment in the pediatric population. Warfarin is the most formulated anticoagulant in this outpatient population. Adequate adherence and outpatient follow-up in requires additional tools to achieve excellent anticoagulant treatment.

Trombosis venosa abdominal en una población adulta seguida en una clínica de anticoagulación / Abdominal venous thrombosis in an adult population followed in an anticoagulation clinic

Resumen Introducción: La trombosis venosa abdominal es inusual y es una de las formas menos estudiada de la enfermedad tromboembólica venosa. Objetivo: Describir las características epidemiológicas, los factores de riesgo, las complicaciones y el manejo anticoagulante en pacientes con diagnóstico de trombosis venosa abdominal, atendidos en una clínica de anticoagulación en Cali, Colombia. Materiales y método: Estudio descriptivo en el que se identificaron 83 pacientes con diagnóstico de trombosis venosa abdominal, manejados en la clínica de anticoagulación de la Fundación Valle del Lili, entre los años 2011 y 2019. La edad promedio fue de 53.3 ± 17.4 años y el 59% eran de sexo femenino. Fue más frecuente en las venas mesentéricas (19%), seguidas de la vena porta (18%). Los antecedentes incluyen cáncer, hipertensión arterial y estado hipercoagulable/trombofilia. Conclusiones: La trombosis venosa abdominal es una patología poco frecuente. El principal compromiso se presenta en la vena mesentérica. La enoxaparina es el manejo más frecuente. Los pacientes requieren en su mayoría anticoagulación extendida.

Abstract Introduction: Abdominal venous thrombosis is rare condition and is one of the least studied forms of venous thromboembolic disease. Objective: To describe the epidemiological characteristics, risk factors, complications and anticoagulant management in patients with a diagnosis of abdominal venous thrombosis, treated at an anticoagulation clinic in Cali, Colombia. Materials and method: Descriptive study, 83 patients with diagnosis of abdominal venous thrombosis were identified, managed in the anticoagulation clinic of Fundación Valle del Lili, between the years 2011 and 2019. The average age was 53.3 ± 17.4, and 59% female. More frequent in mesenteric veins (19%), followed by portal vein (18%). Personal antecedent includes cancer, high blood pressure, and hypercoagulable/thrombophilia status. Conclusions: Abdominal vein thrombosis is a rare disease. The main compromise occurs at the level of the mesenteric vein. Enoxaparin is the most common management. Most patients require extended anticoagulation.

Registro colombiano de falla cardiaca (RECOLFACA): metodología y datos preliminares / Colombian heart failure registry (RECOLFACA): methodology and preliminary data

Resumen El registro RECOLFACA es la primera aproximación que se realiza en Colombia sobre el perfil clínico y demográfico de los pacientes con falla cardiaca, e incluye instituciones de gran parte del territorio nacional. Esta información es de gran relevancia ya que permitirá caracterizar la población y servir como base para diseñar políticas públicas que ofrezcan una mejor atención en salud a esta población. Este importante proyecto epidemiológico, llevado a cabo por el Capítulo de Falla Cardíaca, Trasplantes e Hipertensión Pulmonar de la Sociedad Colombiana de Cardiología y Cirugía Cardiovascular, es pionero en la evaluación de las enfermedades cardiovasculares en Colombia y, adicionalmente, servirá como modelo para la evaluación de otras enfermedades.

Abstract The RECOLFACA registry is Colombia’s first approach to describing the clinical and demographic profile of patients with heart failure, which includes institutions throughout much of the country. This information is of great importance as it will characterize the population and serve as the basis for designing public policies which will provide better health care to this population. This important epidemiological project, carried out by the Heart Failure, Transplants and Pulmonary Hypertension Chapter of the Sociedad Colombiana de Cardiología y Cirugía Cardiovascular [Colombian Society of Cardiology and Cardiovascular Surgery] is a pioneer in evaluating cardiovascular diseases in Colombia, and will also serve as a model for evaluating other diseases.

Registro colombiano de falla cardiaca (RECOLFACA): resultados / Colombian registry of heart failure (RECOLFACA): results

Resumen Introducción: La falla cardiaca (FC) es un problema de salud pública mundial. En Latinoamérica, la incidencia es de 199/100.000 personas-año y la prevalencia de ≈1%. En Colombia, pocos estudios han descrito el comportamiento sociodemográfico y clínico de los pacientes con FC agudamente descompensada (FCAD) y FC crónica (FCC). Método: Se implementó un registro multicéntrico para identificar características que puedan ayudar en la planeación y desarrollo de estrategias de prevención secundaria y tratamiento de esta población. Resultados: Se incluyeron 2528 pacientes. 57.59% hombres, edad promedio 69 años. La principal comorbilidad fue hipertensión arterial (72.04%). Las principales causas de descompensación de la FC fueron la progresión de la enfermedad (35.00%) y el tratamiento insuficiente (19.09%). La etiología más frecuente fue isquémica (43.99%). Al momento del ingreso, 86.95% de pacientes recibían betabloqueador, 67.25% recibían diuréticos, 55.66% recibían ARM, 42.41% recibían ARA-II, 33.66% recibían IECA y 9.73% recibían ARNI. Conclusiones: Los pacientes con FC en Colombia son similares a los descritos por otros registros de FC en el mundo occidental, destacando el uso de terapias basadas en la evidencia. Se documentó una proporción menor de fibrilación auricular, con mayor frecuencia de disfunción sistólica moderada-grave y un aparente uso subóptimo de dispositivos implantables.

Abstract Introduction: Heart failure (HF) is a public health problem worldwide. In Latin America, incidence is 199 / 100,000 person-year and prevalence is ≈1%. In Colombia, few studies have described the sociodemographic and clinical behavior of patients with acutely decompensated HF (ADHF) and chronic HF (CHF). Method: A multicenter registry was implemented to identify characteristics that can help in the planning and development of secondary prevention and treatment strategies for this population. Results: 2528 patients were included. 57.59% men, average age 69 years. The main comorbidity was arterial hypertension (72.04%). The main causes of HF decompensation were disease progression (35.00%) and insufficient treatment (19.09%). The most frequent etiology was ischemic (43.99%). At the time of admission, 86.95% of patients received beta-blocker, 67.25% received diuretics, 55.66% received MRA, 42.41% received ARB-II, 33.66% received ACEI, and 9.73% received ARNI. Conclusions: Patients with HF in Colombia are similar to those described by other HF registries in the western world, highlighting the use of evidence-based therapies. A lower proportion of atrial fibrillation was documented, with a higher frequency of moderate-severe systolic dysfunction and an apparent suboptimal use of implantable devices.

Tromboprofilaxis, anticoagulación y coagulopatía en tiempos de pandemia: recomendación de la ACATA, ACMI, SCC CCV y ACMV / Thromboprophylaxis, anticoagulation and coagulopathy in times of pandemic: The ACATA, ACMI, SCC CCV and ACMV recommendation

Resumen Introducción La enfermedad por coronavirus 2019 (COVID-19) puede predisponer a tromboembolia venosa o trombosis arterial debido a una respuesta inflamatoria aumentada, hipoxia, inmovilización y coagulación intravascular diseminada; hasta en un 20 a 50% de pacientes hospitalizados con COVID-19 tienen alteraciones hematológicas relacionadas con coagulopatía (dímero D elevado, tiempo de protrombina prolongado, trombocitopenia y/o fibrinógeno bajo). Evaluaciones post mortem evidencian depósitos trombóticos microvasculares típicos, ricos en plaquetas en vasos pequeños de pulmones y otros órganos. Objetivo Brindar una aproximación práctica y actualizada en el manejo del paciente con riesgo elevado o que presentan eventos tromboembólicos en el marco de la actual pandemia por COVID-19. Material y métodos: Se realizó una revisión narrativa que incluyó estudios observacionales descriptivos. Se efectuó una búsqueda de la literatura de evidencia médica en diferentes buscadores como Science Direct y PubMed, usando las palabras claves “thromboprophylaxis”, “anticoagulation”, “thrombosis”, “anticoagulant”, “COVID-19”, “SARS-CoV-2”, “coronavirus”. Posteriormente se escribieron las recomendaciones generales referentes al tema. Conclusiones Existen diferentes formas en las que la pandemia por COVID-19 puede predisponer al desarrollo de enfermedades trombóticas o tromboembólicas, el efecto directo o indirecto de este virus relacionado con la tormenta de citocinas que precipita el inicio del síndrome de respuesta inflamatoria sistémica y predispone al desarrollo de eventos trombóticos; también las intervenciones disponibles pueden tener interacciones farmacológicas con antiagregantes y/o anticoagulantes.

Abstract Introduction Coronavirus 19 infection can predispose to VTE or arterial thrombosis due to a heightened inflammatory response, hypoxia, immobility and DIC. Up to 20-50% of hospitalized patients with COVID-19 have hematological disorders related to coagulopathies (elevated D-dimer, prolonged PT, thrombocytopenia and/or low fibrinogen). Post-mortem examinations show typical platelet-rich microvascular thrombotic deposits in the small vessels of the lungs and other organs. Objective To provide a practical, updated approach to the treatment of patients at high risk for or with ongoing thromboembolic events in the current COVID-19 pandemic setting. Material and methods A narrative review was performed including descriptive observational studies. A search of the medical evidence literature was carried out in different search engines such as ScienceDirect and PubMed, using the following key words: “thromboprophylaxis”, “anticoagulation”, “thrombosis”, “anticoagulant”, “COVID-19”, “SARS-CoV-2”, and “coronavirus”, and general recommendations on the topic were subsequently composed. Conclusions The are various ways in which the COVID-19 pandemic may predispose to the development of thrombotic or thromboembolic diseases. The virus may have a direct or indirect effect related to the cytokine storm which triggers the onset of systemic inflammatory response syndrome and predisposes to the development of thrombotic events. The available interventions may also have pharmacological interactions with antiplatelet drugs and/or anticoagulants.

Factores determinantes en la calidad de vida de pacientes con enfermedad coronaria sometidos a diferentes intervenciones terapéuticas / Determinants in quality of life of patients with coronary artery disease who underwent different therapeutic interventions

Resumen Introducción: La enfermedad coronaria es la principal causa de mortalidad en el mundo. Su tratamiento se asocia con una mejor calidad de vida, la cual puede medirse con el cuestionario de MacNew. Objetivo: Establecer los factores determinantes de calidad de vida en pacientes con enfermedad coronaria. Materiales y métodos: Estudio analítico de corte transversal, en el que se usó el cuestionario de MacNew para valorar la calidad de vida en tres dominios: social, emocional y físico. Se incluyeron 249 pacientes con enfermedad coronaria diagnosticada en los años 2004, 2009 o 2013. Los resultados se estratificaron por el tipo de tratamiento (médico, implantación de stent o cirugía de revascularización miocárdica). Se usó un modelo de regresión beta, como una alternativa al modelo de regresión lineal. Resultados: Los puntajes más bajos se asociaron con hipertensión arterial, diabetes mellitus, dislipidemia y aumento del índice de masa corporal. En el dominio físico el puntaje disminuyó en los pacientes mayores de 60 años. El alto grado de escolaridad se asoció con mayores puntajes en todos los dominios. Conclusiones: Los pacientes con enfermedad coronaria presentaron menor calidad de vida asociada a hipertensión arterial, diabetes mellitus, dislipidemia, aumento del índice de masa corporal o mayor edad y mejor calidad de vida asociada con mayor nivel de escolaridad y afiliación al sistema de salud, indiferente a la intervención terapéutica.

Abstract Introduction: Coronary heart disease is the leading cause of mortality worldwide. Its treatment is associated with a better quality of life; it can be measured with the MacNew questionnaire. This study aims to establish the determin. Objective: To stablish the determinants of quality of life in coronary heart disease patients, in Cali, Colombia. Materials and methods: Analytical cross-sectional study, in which the MacNew questionnaire was applied to assess life quality in three domains: social, emotional and physical. 249 patients with coronary heart disease diagnosed in 2004, 2009 or 2013 were included. The results were stratified by type of treatment (doctor, stent implantation or myocardial revascularization surgery). Beta regression model was used, as an alternative to the linear regression model. Results: The MacNew lower scores were associated with hypertension, diabetes mellitus, dyslipidemia and increased body mass index. In the physical domain, the life quality score decreased in patients older than 60 years. High levels of education were associated with higher quality of life scores in all domains. Conclusions: Coronary heart disease patients presented lower quality of life associated with hypertension, diabetes mellitus, dyslipidemia, increased body mass index or older age and better quality of life associated with higher level of education and affiliation to the health system, regardless of the therapeutic intervention received.

Relación entre mortalidad y tratamiento recibido en pacientes con endocarditis infecciosa / Relationship between mortality and treatment received in patients with infective endocarditis

Resumen Introducción: La endocarditis infecciosa es una enfermedad de baja incidencia y alta morbilidad. Puede tener un curso agudo o subagudo, con complicaciones que están directamente relacionadas con la mortalidad y varían según el agente infeccioso; el más frecuente es Staphylococcus aureus. Dependiendo de la condición clínica se puede elegir una terapia antimicrobiana exclusiva o una terapia combinada (antimicrobiana y cirugía); la elección adecuada impacta en las tasas de sobrevida. Objetivo: Describir las características clínicas, microbiológicas y ecocardiográficas en pacientes con endocarditis infecciosa y analizar la mortalidad según el tratamiento recibido (terapia antimicrobiana o terapia combinada). Método: Estudio de cohorte retrospectivo, realizado en el Hospital Universitario Fundación Valle del Lili, en Cali, Colombia, en el que se incluyeron pacientes hospitalizados mayores de 18 años que cumplían los criterios de Duke modificados para diagnóstico de endocarditis infecciosa. Se evaluaron dos cohortes según hubieran recibido tratamiento antimicrobiano exclusivo o terapia combinada. Los pacientes fueron seguidos hasta el egreso hospitalario. Resultados: De 101 pacientes, 58 recibieron terapia antimicrobiana y 43 terapia combinada. La sobrevida global fue del 77.35%; el grupo de terapia combinada tuvo una hazard ratio ajustada de 0.13 (intervalo de confianza del 95%: 0.036-0.505; p = 0.003). La tasa de mortalidad calculada por 1000 días-persona fue de 25.9 con terapia antimicrobiana y de 4.33 con terapia combinada. Conclusiones: El grupo de terapia combinada tuvo más complicaciones y mayor estancia en la unidad de cuidados intensivos, pero menores tasas de mortalidad que los pacientes con terapia antimicrobiana exclusiva. De acuerdo con las indicaciones actuales de manejo quirúrgico descritas en las guías internacionales, se pueden obtener excelentes resultados en los pacientes más enfermos.

Abstract Introduction: Infective endocarditis is a disease of low incidence but high morbidity. It can have an acute or subacute course, with complications that are directly related to mortality and vary according to the infectious agent; the most common is Staphylococcus aureus. Based on the clinical condition, an exclusive antimicrobial therapy or a combined therapy (antimicrobial and surgery) can be chosen; their proper choice impacts survival rates. Objective: To describe the clinical, microbiological and echocardiographic characteristics in patients with infective endocarditis and to analyze how mortality behaved according to the treatment received (antimicrobial therapy or combined therapy). Method: A retrospective cohort study, carried out at the Fundación Valle del Lili University Hospital, Cali, Colombia, which included hospitalized patients over 18 years of age who met modified Duke criteria for the diagnosis of infective endocarditis. Two cohorts were evaluated according to treatment: exclusive antimicrobial and combined therapy. They were followed until discharge from the hospital. Results: Of 101 patients, 58 received antimicrobial therapy and 43 combined therapy. Overall survival was 77.35%, the combined therapy group had an adjusted hazard ratio of 0.13 (95% confidence interval: 0.036-0.505; p = 0.003). The mortality rate calculated per 1000 person-days was 25.9 in antimicrobial therapy and 4.33 in combination therapy. Conclusions: the combined therapy group had more complications and a longer hospital stay in the ICU, but lower mortality rates than the patients on exclusive antimicrobial therapy. According to the current indications for surgical management described in international guidelines, excellent results can be obtained in sicker patients.

Factores asociados a la mortalidad en el primer año postrasplante cardíaco / Factors associated with mortality in the first year post-cardiac transplantation

Resumen Introducción: en el trasplante cardiaco la sobrevida es del 81 al 85% en el primer año; las infecciones y la falla del injerto son las principales causas de mortalidad. Objetivo: determinar los factores de riesgo asociados a mortalidad al año postrasplante cardiaco en un hospital de alta complejidad del suroccidente colombiano. Métodos: cohorte retrospectiva de pacientes con trasplante de corazón llevado a cabo entre 1996 a 2015. Se obtuvo la información de las características del donante, receptor y procedimiento quirúrgico. Se realizó una regresión de Cox; el evento de interés fue la mortalidad al primer año de seguimiento. En el análisis multivariable se incluyeron variables con p ≤ 0,20 y significancia clínica. Resultados: se incluyeron 158 pacientes, con mediana de edad de 50 años (RIC: 39-57), 76% hombres. La principal etiología de falla cardiaca fue idiopática (45%). La mediana de tiempo de isquemia fue 187 minutos (RIC: 142-300). La mortalidad fue 24%, y se atribuyó principalmente a infecciones (29%). Fueron factores asociados a mortalidad la cardiopatía congénita como etiología de falla cardíaca (p 0,048), antecedente de diabetes mellitus (p 0,001), cirugía cardiaca previa (p 0,023) tiempo de isquemia mayor a 150 minutos (p 0,038) y relación receptor hombre/donante mujer (p 0,022). Conclusiones: los factores asociados a mayor mortalidad en el primer año postrasplante cardiaco fueron: etiología de la falla cardíaca por cardiopatía congénita, antecedente de diabetes mellitus, cirugía cardiaca previa, relación receptor hombre con donante mujer, tiempo de isquemia mayor a 150 minutos.

Abstract Introduction: The survival rate in the first year after heart transplant is between 81% and 85%. The main causes of mortality are infections and failure of the graft. Objective: To determine the risk factors associated with mortality at one year post- cardiac transplant in a high complexity hospital in south-west Colombia. Methods: A retrospective cohort study was performed on patients with a heart transplant carried out between 1996 and 2015. Information was obtained on the characteristics of the donor, recipient, and surgical procedure. A Cox regression was performed, with the event of interest being mortality in the first year of follow-up. In the multivariate analysis, variables were included that had a P≤ .20 and clinical significance. Results: The study included a total of 158 patients, with a median age of 50 years (IQR: 39-57), of whom 76% were males. The most common origin was idiopathic heart failure (45%). The median time of ischaemia was 187 minutes (IQR: 142-300). The mortality was 24% and was mainly due to infections (29%). There were factors associated with the congenital heart failure mortality such as origin of heart failure (P = .048), history of diabetes mellitus (P = .001), previous cardiac surgery (P = .023), ischaemia time greater than 150 minutes (P = .038), and the male recipient / female donor ratio (P = .022). Conclusions: The factors associated with higher mortality in the first year post-cardiac transplant were: origin of heart failure due to congenital heart disease, history of diabetes mellitus, previous cardiac surgery, the male recipient / female donor ratio, and an ischaemia time greater than 150 minutes.

The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations.

End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.