Cost-effectiveness in unstable economies: the case of sacubitril/valsartan in heart failure with reduced ejection fraction in Argentina.

BACKGROUND: Sacubitril/valsartan (an Angiotensin receptor-neprilysin inhibitor-ARNI) is one of the cornerstones in the management of patients with heart failure with reduced ejection fraction (HFrEF) having demonstrated significant reductions in both mortality and hospitalisations as compared with enalapril. It proved to be a cost-effective treatment in many countries with stable economies. In Argentina, a country with chronic financial instability and a fragmented health care system, the estimation of its cost-effectiveness requires to consider local financial data. OBJECTIVES: To estimate the cost-effectiveness of sacubitril/valsartan in HFrEF in Argentina. METHODS: We populated an Excel-based cost-effectiveness model, previously validated, using inputs from the pivotal phase-3 PARADIGM-HF trial and from local sources. As the main problem to consider was the financial instability, we adopted a differential approach to cost discounting based on the opportunity cost of capital. Thus, a discount rate for costs were set at 31.6%, using the BADLAR rate published by the Central Bank of Argentina. Discount for effects were set at 5% as is the current practice. Costs were expressed in Argentinian pesos (ARS). We used the perspective for both the social security and private payers at a 30-year horizon. The primary analysis was the incremental cost-effectiveness ratio (ICER) versus enalapril, the previous standard of care. Alternative scenarios performed included a 5% cost discount rate and 3 a 5-year horizon (as is usually used). RESULTS: In Argentina the cost-per quality adjusted life-year (QALY) gained for sacubitril/valsartan versus enalapril was 391,158 ARS and 376,665 ARS for a social security and a private payer, respectively, at a 30- year horizon. These ICERs were under the cost- effectiveness threshold of 520,405.79 ARS (1 Gross domestic product (GDP) per capita) suggested by Argentinian health technology assessment bodies. Probabilistic sensitivity analysis showed an acceptability of sacubitril/valsartan as a cost-effective alternative of 86.40% and 88.25% for social security and private payers, respectively. CONCLUSION: Sacubitril/valsartan is a cost-effective treatment in HFrEF using local inputs that considered the financial instability. For both payers considered the cost per QALY gained are under the cost-effectiveness threshold considered.

Real-world data meta-analysis: procedural success and clinical outcomes after radiofrequency ablation of atrial fibrillation in South America.

OBJECTIVE: To profile patients' characteristics, in-hospital results, and recurrence rates after radiofrequency ablation of atrial fibrillation (RAAF) in South America. METHODS: We comprehensively searched for single-center studies from South America with ≥10 patients receiving RAAF, published or presented from January 1, 2010, through June 29, 2020, excluding those reports aimed to specific populations such as permanent atrial fibrillation, structural cardiopathies, or re-do procedures. RESULTS: Main pooled estimates from a random-effects meta-analysis that included 3909 patients from 27 cohorts (from 5 countries): a) Patients characteristics: age 57.6 years (95% CI 55.7-59.5), male gender 71.5% (95% CI 67.0-75.6%), hypertension 54.2% (95% CI 45.4-62.8%), paroxysmal atrial fibrillation 79.8% (95% CI 71.3-94.5%), CHADS score 1.2 (95% CI 0.5-1.9), b) Acute procedural success 91.1% (95% CI 82.2-95.8%), c) In-hospital complications: stroke 0.6% (95% CI 0.3-1.2%), cardiac tamponade 2.3% (95% CI 1.4-3.7), hematoma 3.5% (95% CI 2.0-6.1), pseudoaneurysm 1.2% (95% CI 0.6-2.3), arteriovenous fistula 2.5% (95% CI 1.6-4.1). There were no cases of esophageal-atrial fistula nor death. Pooled estimate for arrhythmia recurrence (excluded 3-months blanking period) at 12 months was 19.9% (95% CI 17.0-23.1). CONCLUSION: In-hospital results of RAAF reported for South American centers were worse than published international registries, even when included populations profile was of lower risk, as reflected in younger age and less prevalence of non-paroxysmal AF. Late recurrence rates seemed appropriate. This study provides a real-life framework for the analysis of the performance of this technology in the region.

Temporal Trends in Self-Expandable Transcatheter Aortic Valve Replacement in South America: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study aimed to estimate temporal trends in clinical presentation and short-term outcomes of transcatheter aortic valve replacement (TAVR) with self-expandable prostheses in South America through a systematic review and meta-analysis of observational data. METHODS: We comprehensively searched for articles published in peer-reviewed medical journals and for abstracts presented in medical conferences of the region from September 1, 2008, to June 29, 2020. We included single-center studies on self-expandable TAVR populations with ≥ 10 patients from South America. RESULTS: A total of 28 cohorts from 6 countries pooling 1780 patients were included in a random-effects meta-analysis. Pooled estimates of age changed during time (period 2011-2015, 81.6 years; 95% confidence interval [CI] 80.7-82.4; period 2016-2018, 80.6 years; 95% CI 79.8-81.3; period 2019: 78.5 years; 95% CI 77.0-80.0; P = .0003); no other temporal trends in patient characteristics were ascertained. Temporal trends in short-term mortality pooled estimates were in-hospital mortality (11.8% [95% CI 8.2-16.7] for the period 2011-2015, 6.6% [95% CI 4.5-9.6] for the period 2016-2018, and 4.4% [95% CI 1.9-9.8] for the period 2019 [P = .007]) and 30-day mortality (12.8% [95% CI 7.7-20.4], 9.7% [95% CI 7.0-13.3], and 5.7% [95% CI 2.8-11.3], respectively [P =.044]). These associations between reporting year of the study and lower mortality remained after adjusting by age and surgical risk (multivariate meta-regression). CONCLUSIONS: In studies reported between 2011 and 2019 in South America, we demonstrated a clear time trend toward reduction of short-term mortality after self-expandable TAVR, independently of age and surgical risk of populations. These findings are relevant to the local reassessment of cost-effectiveness of TAVR.

Clinical outcomes after transcatheter aortic valve replacement in South America: A centre-level systematic review and meta-analysis of observational data.

OBJECTIVES: To estimate in-hospital and 30-day outcomes after transcatheter aortic valve replacement (TAVR) in South America through a systematic review and meta-analysis of observational data. METHODS: We comprehensively searched for papers published in peer-reviewed medical journals and for abstracts presented in medical conferences of the region from 1 September 2008, through 29 June 2020, using predefined criteria. We included single-centre studies on TAVR populations with ≥10 patients from South America reporting any in-hospital or 30-day clinical outcome. RESULTS: Fifty-five cohorts from seven countries, pooling 3001 patients, were included in a random-effects meta-analysis. Self-expandable prostheses were the most frequently implanted. Pooled estimate of procedure success by VARC2 criteria was 90.0% (95%CI 81.8%-94.7%; I2 75.0%). The pooled estimate rates of the outcomes were as follow: post-procedure moderate or severe aortic regurgitation, 9.7% (95%CI 6.0%-15.4%; I2 65.4%), in-hospital cardiac tamponade, 4.0% (95%CI 2.5%-6.6%; I2 0%), in-hospital stroke, 4.1% (95%CI 2.9%-5.7%; I2 0%), in-hospital major vascular complication, 7.8% (95%CI 5.2%-11.5%; I2 22.3%), in-hospital permanent pacemaker implantation, 19.4% (95%CI 15.9%-23.4%; I2 53.8%), in-hospital mortality, 8.0% (95%CI 6.7%-9.6%; I2 0%), and 30-day mortality, 9.7% (95%CI 7.9%-11.8%; I2 26.4%). CONCLUSION: As compared with published international registries, the overall results of TAVR in South America seemed underrated. Significant heterogeneity was observed in procedural success, pacemaker requirement, and post-procedure moderate or severe aortic regurgitation. This study provides a real-life framework for the analysis of the performance of this technology in the region, intended to be a starting point for quality improvement.

Clinical Management Strategies in Mild COVID-19 cases in Latin-America: A Decision Model / Estrategias de manejo clínico de casos leves de COVID-19 en América Latina: Modelo de decisión

COVID-19 pandemic is challenging Latin American health systems, which could benefit from information to make appropriate decisions in contexts of constrained health resources.Objective: to evaluate, in adult patients with suspected mild clinical forms of COVID-19, the clinical effectiveness (life expectancy) and resource consumption (days of hospitalization) of different management strategies.Methods: stochastic decision tree comparing the conventional strategy recommended by WHO - PAHO (diagnostic test for COVID-19 and hospitalization of patients testing positive) versus two alternative strategies (immediate addition of a prognostic test with hospitalization according to its result, or follow-up with hospitalization only in case of clinical deterioration).Results: the alternative management strategies showed expected clinical utility similar to the conventional strategy in 80 years-old base cases, and slightly lower in 60 years- and 40 years-old base cases, with lower consumption of hospitalization days. In sensitivity analysis, alternative strategies comparatively improved their expected clinical utility given a lower sensitivity of the diagnostic test or a higher ability of the follow-up to detect clinical worsening.Conclusions: in cases of suspected COVID-19 without pneumonic infiltrate or signs of severity, alternative strategies can be considered to avoid hospitalization for the majority of patients, especially if efficient follow-up modalities can be implemented. This information is valuable for health decision-makers, to carefully weight clinical and epidemiological elements and design locally feasible strategies.

La pandemia COVID-19 desafía los sistemas de salud de Latinoamérica, que podrían beneficiarse de información para tomar decisiones apropiadas, en contextos de escasez de recursos sanitarios.Objetivo: evaluar, en pacientes adultos con sospecha de formas clínicas leves de COVID-19, la efectividad clínica (expectativa de vida) y el consumo de recursos (días de hospitalización) de distintas estrategias de manejo. Métodos: árbol de decisión estocástico, comparando la estrategia convencional recomendada por OMS - OPS (prueba diagnóstica para COVID-19 y hospitalización ante resultado positivo) versus dos estrategias alternativas (agregado inmediato de una prueba pronóstica con hospitalización según ese resultado, y seguimiento con hospitalización sólo ante empeoramiento clínico). Resultados: las estrategias de manejo alternativas mostraron utilidad clínica esperada similar a la estrategia convencional en casos base de 80 años de edad, y ligeramente inferior en casos base de 60 años y 40 años de edad, con menor consumo de días de hospitalización. En el análisis de sensibilidad, las estrategias alternativas mejoraron comparativamente su utilidad clínica esperada si la sensibilidad de la prueba diagnóstica fuera menor o la capacidad del seguimiento para detectar empeoramiento clínico fuera mayor. Conclusiones: ante casos sospechosos de COVID-19 sin infiltrado neumónico ni signos de gravedad, pueden considerarse estrategias que eviten la hospitalización de la mayoría de los pacientes, en especial si pueden implementarse modalidades de seguimiento eficientes. Esta información es valiosa para los decisores en salud, para analizar ponderadamente elementos clínicos y epidemiológicos y diseñar estrategias factibles localmente.

Periprocedural adverse events in cell therapy trials in myocardial infarction and cardiomyopathy: a systematic review.

BACKGROUND: Cell therapy (CTh) is a promising novel therapy for myocardial infarction (MI) and ischemic cardiomyopathy (iCMP). Recognizing adverse events (AE) is important for safety evaluation, harm prevention and may aid in the design of future trials. OBJECTIVE: To define the prevalence of periprocedural AE in CTh trials in MI and iCMP. METHODS: A literature search was conducted using the MEDLINE database from January 1990 to October 2010. Controlled clinical trials that compared CTh with standard treatment in the setting of MI and/or iCMP were selected. AE related to CTh were analyzed. RESULTS: A total of 2,472 patients from 35 trials were included. There were 26 trials including 1,796 patients that used CTh in MI and 9 trials including 676 patients that used CTh in iCMP. Periprocedural arrhythmia monitoring protocols were heterogeneous and follow-up was short in most of the trials. In MI trials, the incidence of periprocedural adverse events (AE) related to intracoronary cell transplantation was 7.5 % (95 % CI 6.04-8.96 %). AE related to granulocyte colony-stimulating factor (GCS-F) used for cell mobilization for peripheral apheresis was 16 % (95 % CI 9.44-22.56 %). During intracoronary transplantation in iCMP, the incidence of periprocedural AE incidence was 2.6 % (95 % CI 0.53-4.67 %). There were no AE reported during transepicardial transplantation and AE were rare during transendocardial transplantation. CONCLUSIONS: The majority of periprocedural AE in CTh trials in MI occurred during intracoronary transplantation and GCS-F administration. In iCMP, periprocedural AE were uncommon. Avoiding intracoronary route for CTh implantation may decrease the burden of periprocedural AE. Standardization of AE definition in CTh trials is needed.

Sex-stratified socio-economic gradients in physical inactivity, obesity, and diabetes: evidence of short-term changes in Argentina.

OBJECTIVES: To evaluate how socio-economic gradients in NCDs and NCD-related risk factors change over time. METHODS: Secondary analysis of cross-sectional data from the 2005 and 2009 Argentine National Risk Factor Surveys (N = 41,392 and N = 34,732) was conducted. We analyzed inequalities in three risk factors (low physical activity, obesity, and diabetes) according to income and educational attainment. The analysis was based on sex-stratified and age-adjusted logistic regression. RESULTS: The overall prevalence of low physical activity, obesity, and diabetes increased from 2005 to 2009. Increases occurred in most of the income and education groups, but females with the lowest socio-economic status generally showed the highest increases. In 2005, differences in physical inactivity among women with different levels of education were not statistically significant. By 2009, women with low education (OR = 1.57, 95 % CI = 1.34-1.84) and medium education (OR = 1.18, 95 % CI = 1.06-1.32) were more likely than women with high education to be physically inactive. CONCLUSION: Inequalities in physical inactivity, obesity, and diabetes have grown in Argentina over a short period of time.

Trabajar mejor para trabajar mejor: ¿Se discute la problemática profesional en el Congreso Argentino de Cardiología? ¿Se ocupa el médico de esta problemática? / Better Work, Working Better: Are Professional-Related Problems Discussed at the Argentine Congress of Cardiology? Are Physicians Concerned with this Problem? / Better Work, Working Better: Are Professional-Related Problems Discussed at the Argentine Congress of Cardiology? Are Physicians Concerned with this Problem?

Introducción Los grandes cambios producidos en las dos últimas décadas en las reglas laborales en salud, los estilos de trabajo, la organización sanitaria, el uso y la importancia de la tecnología y en la consideración social acerca del profesional médico tienen causas complejas y multifactoriales; las mismas presentan elementos comunes como el empeoramiento de la remuneración que perciben los médicos, la disminución absoluta y relativa de los honorarios profesionales y la percepción del médico respecto de su propia profesión y marcan una realidad que exige reconsiderar el lugar del médico en sus nuevos escenarios de trabajo. Objetivos Definimos como "problemática médica" a toda vivencia o situación problemática que experimenta el médico durante el ejercicio de su actividad. Sobre el tema existen abundantes datos y opiniones en los últimos años referidos a la insalubre situación laboral del médico y a la propia percepción negativa sobre su tarea. El objetivo de presente trabajo fue explorar si la problemática médica era tratada en el Congreso Argentino de Cardiología. Material y métodos Estudio observacional, descriptivo, sobre la existencia de temas libres y mesas sobre problemática médica en los últimos tres Congresos Argentinos de Cardiología y su ubicación temática. Algunas de las palabras clave fueron: realidad laboral, trabajo médico, burn out, bioética, ética, condiciones de trabajo y otras. Resultados Hubo en total 2254 temas libres en los tres años, de los cuales 8 (0,35%) trataron sobre elementos de problemática médica. Los temas libres se ubicaron en las categorías "miscelánea", psicosociales, educación médica o salud pública. Hubo 13 mesas, organizadas por el Comité de Bioética, el Área de Investigación de la Sociedad Argentina de Cardiología, CONAREC y la Fundación Cardiológica Argentina. Conclusiones En el período estudiado hubo una proporción muy escasa de mesas y temas libres dirigidos a la problemática médica, estos últimos sin un marco conceptual preestablecido adecuado. Así, la problemática médica no es considerada un objeto de estudio relevante. Es conveniente la discusión e investigación para la búsqueda de planteos y soluciones a múltiples niveles, o no podrá hacerse un diagnóstico y tratamiento del tema, con las eventuales y enormes implicaciones futuras potenciales.

Background The big changes produced during the last two decades have produced a reality that requires physicians to reconsider the role they play in their new working scenario. These changes include regulations in health care working, work styles, health organization, use and importance of technology and how the physician is socially considered. The causes are complex and multifactorial, yet they share common elements as worse payment to physicians, an absolute and relative reduction in professional fees and physicians' perception about their own profession. Objectives A "medical problem" is defined as any problematic experience or situation felt by a physician during his/her practice. In the last years, there are plenty of information and several opinions about this matter, in reference to the working conditions of physicians and to their negative self-perception about medical practice. The goal of the present study was to explore if the Argentine Congress of Cardiology dealt with the medical problem. Material and Methods Observational and descriptive study about open-topic sessions and roundtable sessions dealing with the medical problem -and under which field the medical problem was considered- during the past/latest three Argentine Congresses of Cardiology. The following key words were used: working reality, medical practice, burnout, bioethics, ethics and working conditions, among others. Results Of 2254 open topics presented in the three years, 8 (0.35%) dealt with the medical problem. The open topics were considered under "miscellany", psychosocial, medical education or public health fields. Thirteen roundtable sessions were identified and organized by the Committee on Bioethics, the Research Area of the Argentine Society of Cardiology, the CONAREC and the Argentine Cardiology Foundation. Conclusions We found very few roundtable sessions and opened-topic sessions -and without an adequate preestablished conceptual framework- focused on the medical problem. Thus, the medical problem is not considered an important topic of study. Discussion and investigation are convenient to search for arguments and solutions at multiple levels, otherwise it will not be possible to make a diagnosis and treatment of the topic, with the eventual and important future implications.

Trabajar mejor para trabajar mejor: ¿Se discute la problemática profesional en el Congreso Argentino de Cardiología? ¿Se ocupa el médico de esta problemática? / Better Work, Working Better: Are Professional-Related Problems Discussed at the Argentine Congress of Cardiology? Are Physicians Concerned with this Problem? / Better Work, Working Better: Are Professional-Related Problems Discussed at the Argentine Congress of Cardiology? Are Physicians Concerned with this Problem?

Introducción Los grandes cambios producidos en las dos últimas décadas en las reglas laborales en salud, los estilos de trabajo, la organización sanitaria, el uso y la importancia de la tecnología y en la consideración social acerca del profesional médico tienen causas complejas y multifactoriales; las mismas presentan elementos comunes como el empeoramiento de la remuneración que perciben los médicos, la disminución absoluta y relativa de los honorarios profesionales y la percepción del médico respecto de su propia profesión y marcan una realidad que exige reconsiderar el lugar del médico en sus nuevos escenarios de trabajo. Objetivos Definimos como "problemática médica" a toda vivencia o situación problemática que experimenta el médico durante el ejercicio de su actividad. Sobre el tema existen abundantes datos y opiniones en los últimos años referidos a la insalubre situación laboral del médico y a la propia percepción negativa sobre su tarea. El objetivo de presente trabajo fue explorar si la problemática médica era tratada en el Congreso Argentino de Cardiología. Material y métodos Estudio observacional, descriptivo, sobre la existencia de temas libres y mesas sobre problemática médica en los últimos tres Congresos Argentinos de Cardiología y su ubicación temática. Algunas de las palabras clave fueron: realidad laboral, trabajo médico, burn out, bioética, ética, condiciones de trabajo y otras. Resultados Hubo en total 2254 temas libres en los tres años, de los cuales 8 (0,35%) trataron sobre elementos de problemática médica. Los temas libres se ubicaron en las categorías "miscelánea", psicosociales, educación médica o salud pública. Hubo 13 mesas, organizadas por el Comité de Bioética, el Area de Investigación de la Sociedad Argentina de Cardiología, CONAREC y la Fundación Cardiológica Argentina. Conclusiones En el período estudiado hubo una proporción muy escasa de mesas y temas libres dirigidos a la problemática médica, estos últimos sin un marco conceptual preestablecido adecuado. Así, la problemática médica no es considerada un objeto de estudio relevante. Es conveniente la discusión e investigación para la búsqueda de planteos y soluciones a múltiples niveles, o no podrá hacerse un diagnóstico y tratamiento del tema, con las eventuales y enormes implicaciones futuras potenciales.(AU)

Background The big changes produced during the last two decades have produced a reality that requires physicians to reconsider the role they play in their new working scenario. These changes include regulations in health care working, work styles, health organization, use and importance of technology and how the physician is socially considered. The causes are complex and multifactorial, yet they share common elements as worse payment to physicians, an absolute and relative reduction in professional fees and physicians perception about their own profession. Objectives A "medical problem" is defined as any problematic experience or situation felt by a physician during his/her practice. In the last years, there are plenty of information and several opinions about this matter, in reference to the working conditions of physicians and to their negative self-perception about medical practice. The goal of the present study was to explore if the Argentine Congress of Cardiology dealt with the medical problem. Material and Methods Observational and descriptive study about open-topic sessions and roundtable sessions dealing with the medical problem -and under which field the medical problem was considered- during the past/latest three Argentine Congresses of Cardiology. The following key words were used: working reality, medical practice, burnout, bioethics, ethics and working conditions, among others. Results Of 2254 open topics presented in the three years, 8 (0.35%) dealt with the medical problem. The open topics were considered under "miscellany", psychosocial, medical education or public health fields. Thirteen roundtable sessions were identified and organized by the Committee on Bioethics, the Research Area of the Argentine Society of Cardiology, the CONAREC and the Argentine Cardiology Foundation. Conclusions We found very few roundtable sessions and opened-topic sessions -and without an adequate preestablished conceptual framework- focused on the medical problem. Thus, the medical problem is not considered an important topic of study. Discussion and investigation are convenient to search for arguments and solutions at multiple levels, otherwise it will not be possible to make a diagnosis and treatment of the topic, with the eventual and important future implications.(AU)

Trabajar mejor para trabajar mejor: ¿Se discute la problemática profesional en el Congreso Argentino de Cardiología? ¿Se ocupa el médico de esta problemática? / Better Work, Working Better: Are Professional-Related Problems Discussed at the Argentine Congress of Cardiology? Are Physicians Concerned with this Problem? / Better Work, Working Better: Are Professional-Related Problems Discussed at the Argentine Congress of Cardiology? Are Physicians Concerned with this Problem?

Introducción Los grandes cambios producidos en las dos últimas décadas en las reglas laborales en salud, los estilos de trabajo, la organización sanitaria, el uso y la importancia de la tecnología y en la consideración social acerca del profesional médico tienen causas complejas y multifactoriales; las mismas presentan elementos comunes como el empeoramiento de la remuneración que perciben los médicos, la disminución absoluta y relativa de los honorarios profesionales y la percepción del médico respecto de su propia profesión y marcan una realidad que exige reconsiderar el lugar del médico en sus nuevos escenarios de trabajo. Objetivos Definimos como "problemática médica" a toda vivencia o situación problemática que experimenta el médico durante el ejercicio de su actividad. Sobre el tema existen abundantes datos y opiniones en los últimos años referidos a la insalubre situación laboral del médico y a la propia percepción negativa sobre su tarea. El objetivo de presente trabajo fue explorar si la problemática médica era tratada en el Congreso Argentino de Cardiología. Material y métodos Estudio observacional, descriptivo, sobre la existencia de temas libres y mesas sobre problemática médica en los últimos tres Congresos Argentinos de Cardiología y su ubicación temática. Algunas de las palabras clave fueron: realidad laboral, trabajo médico, burn out, bioética, ética, condiciones de trabajo y otras. Resultados Hubo en total 2254 temas libres en los tres años, de los cuales 8 (0,35%) trataron sobre elementos de problemática médica. Los temas libres se ubicaron en las categorías "miscelánea", psicosociales, educación médica o salud pública. Hubo 13 mesas, organizadas por el Comité de Bioética, el Area de Investigación de la Sociedad Argentina de Cardiología, CONAREC y la Fundación Cardiológica Argentina. Conclusiones En el período estudiado hubo una proporción muy escasa de mesas y temas libres dirigidos a la problemática médica, estos últimos sin un marco conceptual preestablecido adecuado. Así, la problemática médica no es considerada un objeto de estudio relevante. Es conveniente la discusión e investigación para la búsqueda de planteos y soluciones a múltiples niveles, o no podrá hacerse un diagnóstico y tratamiento del tema, con las eventuales y enormes implicaciones futuras potenciales.(AU)

Background The big changes produced during the last two decades have produced a reality that requires physicians to reconsider the role they play in their new working scenario. These changes include regulations in health care working, work styles, health organization, use and importance of technology and how the physician is socially considered. The causes are complex and multifactorial, yet they share common elements as worse payment to physicians, an absolute and relative reduction in professional fees and physicians perception about their own profession. Objectives A "medical problem" is defined as any problematic experience or situation felt by a physician during his/her practice. In the last years, there are plenty of information and several opinions about this matter, in reference to the working conditions of physicians and to their negative self-perception about medical practice. The goal of the present study was to explore if the Argentine Congress of Cardiology dealt with the medical problem. Material and Methods Observational and descriptive study about open-topic sessions and roundtable sessions dealing with the medical problem -and under which field the medical problem was considered- during the past/latest three Argentine Congresses of Cardiology. The following key words were used: working reality, medical practice, burnout, bioethics, ethics and working conditions, among others. Results Of 2254 open topics presented in the three years, 8 (0.35%) dealt with the medical problem. The open topics were considered under "miscellany", psychosocial, medical education or public health fields. Thirteen roundtable sessions were identified and organized by the Committee on Bioethics, the Research Area of the Argentine Society of Cardiology, the CONAREC and the Argentine Cardiology Foundation. Conclusions We found very few roundtable sessions and opened-topic sessions -and without an adequate preestablished conceptual framework- focused on the medical problem. Thus, the medical problem is not considered an important topic of study. Discussion and investigation are convenient to search for arguments and solutions at multiple levels, otherwise it will not be possible to make a diagnosis and treatment of the topic, with the eventual and important future implications.(AU)

Evaluación del riesgo cardiovascular en siete ciudades de Latinoamérica: las principales conclusiones del estudio CARMELA y de los subestudios / Evaluation of Cardiovascular Risk in Seven Cities in Latin America: The Main Conclusions of the CARMELA Study / Assessment of Cardiovascular Risk in Seven Latin American Cities: The Main Conclusions of the CARMELA Study and Substudies

Para evaluar el nivel de riesgo cardiovascular de la población latinoamericana se diseñó un estudio en siete ciudades de la región a fin de realizar un muestreo poblacional homogéneo con metodología única, exámenes de laboratorio y físicos estandarizados y controlados para obtener así datos epidemiológicos confiables. El estudio CARMELA (Cardiovascular Risk Factor Multiple Evaluation in Latin America) evaluó 11.550 sujetos de la población general. Los resultados mostraron que la hipertensión tuvo una prevalencia equiparable a nivel mundial sólo en tres ciudades, en tanto que en el resto fue menor. La hipercolesterolemia fue muy prevalente aun en ciudades de diferente nivel socioeconómico. La diabetes se halló entre el 7% y el 9% en Ciudad de México, Bogotá y Santiago de Chile. El tabaquismo fue muy alto en ambos sexos en Santiago de Chile y en Buenos Aires. La obesidad abdominal y el síndrome metabólico predominaron en las mujeres de bajos recursos. El espesor íntima-media y la prevalencia de placa carotídea tuvieron una amplia variación entre ciudades. Los datos epidemiológicos recabados en el estudio CARMELA completan el panorama del riesgo cardiovascular de nuestra región y muestran que su prevalencia indica la necesidad de contar con políticas de salud racionales.

To assess the cardiovascular risk of the Latin American population, we conducted a homogeneous population-based sampling study in seven cities of the region following controlled and standardized methods, laboratory tests and physical examination and thus obtain reliable epidemiological data. The CARMELA study (Cardiovascular Risk Factor Multiple Evaluation in Latin America) evaluated 11550 subjects from the general population. The prevalence of hypertension mirrored the world average in 3 cities but was lower in the rest. Hypercholesterolemia was highly prevalent even in countries of different socioeconomic levels. The prevalence of diabetes ranged between 7% and 9% in Mexico City, Bogotá and Santiago de Chile. Tobacco use was high in both sexes in Santiago and Buenos Aires. Abdominal obesity and the metabolic syndrome were more prevalent in women of low resources. Intima-media thickness and carotid plaque prevalence varied widely. The epidemiological data obtained in the CARMELA study complete the outlook of the cardiovascular risk in our region and indicate the need of rationale urban health policies.

Educational inequalities in obesity, abdominal obesity, and metabolic syndrome in seven Latin American cities: the CARMELA Study.

AIMS: Earlier reviews have found that the proportion of inverse associations between socioeconomic status and obesity increased according to the level of development of the studied country. Based on this finding, it has been hypothesized that in low- to middle- income countries the burden of obesity shifts to disadvantaged groups as a country develops. METHODS AND RESULTS: CARMELA is a cross-sectional, population-based observational study that sampled 11,550 women and men age 25-64 from seven major Latin American cities. We analyzed by gender the association of educational attainments (as proxy of socioeconomic status) with body mass index, waist circumference and metabolic syndrome. Participating cities were divided by country Human Development Index (HDI). An inverse gradient between socioeconomic status and body mass index in women was uniformly present in High HDI cities (Buenos Aires, Santiago, Mexico) but not in Medium HDI group (Barquisimeto, Bogota, Lima, Quito), where two cities showed an inverse gradient and two cities did not. In men, no clear socioeconomic gradients were found. Findings regarding waist circumference and metabolic syndrome closely mirrored those about body mass index. CONCLUSION: In women but not men, these results give support to the hypothesis of obesity shifting to the poor and extend it to the related concepts of abdominal obesity and metabolic syndrome. Obesity should be considered as a socially-generated disease and an indicator of socioeconomic disadvantage, to be approached by comprehensive strategies that bear in mind this perspective.

Cardiovascular risk awareness, treatment, and control in urban Latin America.

Effective prevention and treatment of cardiovascular diseases require regular screening for risk factors, high awareness of the condition, effective treatment of the identified risk factors, and adherence to the prescribed treatment. The Cardiovascular Risk Factor Multiple Evaluation in Latin America study was a cross-sectional, population-based, observational study of major cardiovascular risk factors-including hypertension, diabetes, and hypercholesterolemia-in 7 Latin American cities. This report presents data on assessment, diagnosis, extent, and effectiveness of treatment, adherence to treatment, and reasons for nonadherence. Data were collected through household questionnaire-based interviews administered to 5383 men and 6167 women, 25-64 years of age, living in the following cities: Barquisimeto, Venezuela; Bogota, Colombia; Buenos Aires, Argentina; Lima, Peru; Mexico City, Mexico; Quito, Ecuador; and Santiago, Chile. Participants also completed a clinic visit for anthromorphometric and laboratory assessments. Rates of prior diagnosis of hypertension and diabetes were high (64% and 78% of affected individuals, respectively) but relatively low for hypercholesterolemia (41%). The majority of affected individuals (hypercholesterolemia 88%, diabetes 67%, and hypertension 53%) were untreated. Among individuals who were receiving pharmacologic treatment, targets for control of hypertension, diabetes, and hypercholesterolemia were achieved by 51%, 16%, and 52%, respectively. Adherence to treatment was observed in 69% of individuals with hypertension, 63% with diabetes, and 66% with hypercholesterolemia. Forgetfulness was the major cause of nonadherence for all 3 conditions. There is a substantial need for increasing patient education, diagnosis, treatment, adherence, and control of cardiovascular risk factors in the 7 Latin American cities.

Dyslipidemia in seven Latin American cities: CARMELA study.

OBJECTIVE: The objective of this study was to describe the prevalence of dyslipidemia in the CARMELA study population. METHODS: CARMELA was a cross-sectional study of cardiovascular risk conducted between September 2003 and August 2005 in adults (aged 25 to 64 years) living in Barquisimeto (n=1,824), Bogotá (n=1,511), Buenos Aires (n=1,412), Lima (n=1,628), Mexico City (n=1,677), Quito (n=1,620), and Santiago (n=1,605). Dyslipidemia was defined as the presence of one or more of the following conditions: triglycerides>/=200 mg/dL, or total cholesterol (TC)>/=240 mg/dL, or HDL cholesterol<40 mg/dL, or LDL cholesterol=not optimal, or currently taking antilipemic agents. RESULTS: Prevalence rates of dyslipidemia in men and women were: 75.5% (CI: 71.9-79.1) and 48.7% (CI: 45.4-51.9) in Barquisimeto; 70% (CI: 66.2-73.8) and 47.7% (CI: 43.9-51.5) in Bogotá; 50.4% (CI: 46.8-54.0) and 24.1% (CI: 21.0-27.2) in Buenos Aires; 73.1% (CI: 69.3-76.8) and 62.8% (CI: 59.2-66.5) in Lima; 62.5% (CI: 58.5-66.5) and 37.5% (CI: 33.5-41.6) in Mexico City; 52.2% (CI: 47.9-56.5) and 38.1% (CI: 34.5-41.7) in Quito; and, 50.8% (CI: 47.1-54.4) and 32.8% (CI: 29.3-36.3) in Santiago. CONCLUSIONS: Dyslipidemia was disturbingly prevalent and varied across cities. The most frequent dyslipidemia was low HDL-C followed by high triglycerides. The high TC/HDL-C ratios and non-HDL-C levels suggest a high risk of cardiovascular disease.

Prevalence of the metabolic syndrome in Latin America and its association with sub-clinical carotid atherosclerosis: the CARMELA cross sectional study.

BACKGROUND: Metabolic syndrome increases cardiovascular risk. Limited information on its prevalence in Latin America is available. The Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study included assessment of metabolic syndrome in 7 urban Latin American populations. METHODS: CARMELA was a cross-sectional, population-based, observational study conducted in Barquisimeto, Venezuela; Bogota, Colombia; Buenos Aires, Argentina; Lima, Peru; Mexico City, Mexico; Quito, Ecuador; and Santiago, Chile. The prevalence of metabolic syndrome, defined according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), and associated carotid atherosclerosis were investigated in 11,502 participants aged 25 to 64 years. RESULTS: Across CARMELA cities, metabolic syndrome was most prevalent in Mexico City (27%) and Barquisimeto (26%), followed by Santiago (21%), Bogota (20%), Lima (18%), Buenos Aires (17%), and Quito (14%). In nondiabetic participants, prevalence was slightly lower but followed a comparable ranking. Overall, 59%, 59%, and 73% of women with high triglycerides, hypertension, or glucose abnormalities, respectively, and 64%, 48% and 71% of men with abdominal obesity, hypertension, or glucose abnormalities, respectively, had the full metabolic syndrome. Prevalence of metabolic syndrome increased with age, markedly so in women. Mean common carotid artery intima-media thickness (CCAIMT) and prevalence of carotid plaque increased steeply with increasing numbers of metabolic syndrome components; mean CCAIMT was higher and plaque more prevalent in participants with metabolic syndrome than without. CONCLUSION: The prevalence of metabolic syndrome and its components by NCEP ATP III criteria was substantial across cities, ranging from 14% to 27%. CARMELA findings, including evidence of the association of metabolic syndrome and carotid atherosclerosis, should inform appropriate clinical and public health interventions.

CARMELA: assessment of cardiovascular risk in seven Latin American cities.

OBJECTIVE: This cross-sectional, population-based observational study using stratified multistage sampling assessed the prevalence of cardiovascular risk factors and carotid plaques and measured carotid intima-media thickness in individuals living in major cities in 7 Latin American countries. PATIENTS AND METHODS: The study comprised individuals (n=11,550) aged 25 to 64 years, living in Barquisimeto, Bogota, Buenos Aires, Lima, Mexico City, Quito, and Santiago. Data on anthropometric parameters, blood pressure, fasting glucose, total and high-density lipoprotein cholesterol, triglycerides, carotid intima-media thickness, carotid plaque, and smoking status were collected through household interviews and clinical, biochemical, and sonographic measurements. RESULTS: The overall prevalence rates (ranges across cities) were as follows: hypertension (> or = 140/90 mm Hg or pharmacologic treatment), 18% (9%-29%); hypercholesterolemia (total cholesterol > or = 240 mg/dL), 14% (6%-20%); diabetes (glycemia > or = 126 mg/dL or self-reported diabetes), 7% (4%-9%); metabolic syndrome, 20% (14%-27%); obesity (body mass index > or = 30 kg/m2), 23% (18%-27%); smoking, 30% (22%-45%); and plaque, 8% (5%-14%). The mean intima-media thickness was 0.65 mm (0.60-0.74 mm). CONCLUSION: The prevalence of hypertension mirrored the world average in 3 cities but was lower in the rest. Hypercholesterolemia was highly prevalent even in countries of different socioeconomic levels. The prevalence of diabetes was similar to that in the developed countries. Tobacco use in women living in Santiago and Buenos Aires was among the world's highest. Intima-media thickness and carotid plaque prevalences varied widely.

Determinación combinada de proteína C reactiva y troponina I en pacientes que concurren a la Unidad de Emergencias con dolor precordial / Prognostic value of C-reactive and troponin I C in patients with chest pain

Introducción y objetivos: Los hallazgos clínicos, electrocardiográficos y los niveles séricos de CK-MB son variables pronósticas en la evaluación de pacientes con dolor precordial. El objetivo de este trabajo fue determinar el valor pronóstico adicional de la troponina I (TnI) y de la proteína C reactiva (PCR) en una población de pacientes con dolor de precordial que consultan al Departamento de Emergencias. Material y métodos: Se realizó el seguimiento de 784 pacientes consecutivos con dolor precordial durante 120 días para evaluar la frecuencia de muerte o IM no fatal. Se obtuvo sangre al ingreso para evaluar los niveles de TnI y PCR. Los investigadores fueron ciegos a estos resultados. Resultados: Del total de pacientes, 394 (50,2 por ciento) fueron dados de alta (dolor no coronario) y 390 (49,8 por ciento) fueron hospitalizados con diagnóstico de angina inestable o infarto. La frecuencia de muerte o infarto a los 120 días fue del 3,8 por ciento; la frecuencia más alta (14,9 por ciento) se observó en el grupo con TnI y PCR elevadas (p = 0,0001). Se identificaron cuatro predictores independientes de muerte o infarto por regresión de Cox: enfermedad coronaria previa (HR 2,97, IC 95 por ciento 1,42- 6,25; p = 0,004); cambios del segmento ST (HR 3,01, IC 95 por ciento 1,31-7,14; p = 0,009); TnI = 0,4 ng/ml (HR 2,85, IC 95 por ciento 1,23-6,66; p = 0,015) y PCR = 5 mg/L (HR 2,42, IC 95 por ciento 1,45-5,26; p = 0,020). La combinación de TnI y PCR fue superior que la estratificación convencional por clínica y ECG, especialmente en el grupo de riesgo intermedio. Conclusiones: En pacientes con dolor torácico, la combinación de TnI y PCR mejora la estratificación de riesgo en comparación con el uso convencional de la clínica y el ECG, especialmente en los pacientes con un nivel de riesgo intermedio.

Seguridad, eficacia y costo de una Unidad de Dolor Torácico para el manejo de pacientes con dolor torácico agudo / Safety, efficacy and cost of a Chest Pain Unit for the triage of patients with acute chest pain

Se incluyeron 216 pacientes con angina probable o probablemente no angina y sin cambios electrocardiográficos en una Unidad de Dolor Torácico que incluía observación clínica, ECG y dosaje de CPK seriados, y prueba evocadora de isquemia, diagnosticándose síndrome isquémico agudo en 39 pacientes (18,1 por ciento), que tuvieron 20,5 por ciento de eventos isquémicos a los 90 días, en comparación con el 0,6 por ciento de eventos en el resto de los pacientes. El tiempo de internación y los costos del protocolo fueron menores que un control histórico de Unidad Coronaria. La Unidad de Dolor Torácico mejora el manejo de estos pacientes en comparación con la Unidad Coronaria

Seguridad, eficacia y costo de una Unidad de Dolor Torácico para el manejo de pacientes con dolor torácico agudo / Safety, efficacy and cost of a Chest Pain Unit for the triage of patients with acute chest pain

Se incluyeron 216 pacientes con angina probable o probablemente no angina y sin cambios electrocardiográficos en una Unidad de Dolor Torácico que incluía observación clínica, ECG y dosaje de CPK seriados, y prueba evocadora de isquemia, diagnosticándose síndrome isquémico agudo en 39 pacientes (18,1 por ciento), que tuvieron 20,5 por ciento de eventos isquémicos a los 90 días, en comparación con el 0,6 por ciento de eventos en el resto de los pacientes. El tiempo de internación y los costos del protocolo fueron menores que un control histórico de Unidad Coronaria. La Unidad de Dolor Torácico mejora el manejo de estos pacientes en comparación con la Unidad Coronaria (AU)