Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19.

The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Evaluation of Perioperative High-Sensitive Cardiac Troponin I as a Predictive Biomarker of Major Adverse Cardiovascular Events After Noncardiac Surgery.

BACKGROUND: Various studies suggest that perioperative concentrations of high-sensitivity troponins are incremental and predictive factors of a major adverse cardiac event (MACE) and all-cause mortality. OBJECTIVE: The objective of the study was to evaluate the predictive value of high-sensitivity cardiac troponin I (hs-cTnI) in the development of MACE and all-cause mortality, within 30-days and 1-year follow-up after noncardiac surgery. METHODS: In this prospective cohort study, we included men ≥ 45 years and women ≥ 55 years with ≥ 2 cardiovascular risk factors and undergoing intermediate or high-risk noncardiac surgery. Demographic and clinical information was collected from clinical charts. We measured baseline hs-cTnI 24 h before surgery, and its post-operative concentration 24 h after surgery. RESULTS: In the entire sample, 8 patients (8.6%) developed MACE at 30-days follow-up (4 deaths), 12 (12.9%) within the 1st year (7 deaths), and 17 (18.2%) after complete post-surgical follow-up (10 deaths). We observed higher baseline and post-operative concentrations in patients who presented MACE (12 pg/ml vs. 3.5 pg/ml; p = 0.001 and 18.3 pg/ml vs. 5.45 pg/ml; p = 0.009, respectively). The hazard ratios (HRs) calculated by Cox regression analysis between the hs-cTnI baseline concentration and the post-operative development of MACE at 30-days and 1-year were 5.70 (95% confidence interval [CI], 1.10-29.40) with hs-cTnI > 6.2 pg/ml and 12.86 (95% CI, 1.42-116.34) with hs-cTnI > 3.3 pg/ml, respectively. The estimated post-operative HR death risk at 1-year was 14.43 (95% CI, 1.37-151.61) with hs-cTnI > 4.5 pg/ml. CONCLUSIONS: Pre-operative hs-cTnI was an independent predictive risk factor for MACE at 30-days and 1-year after noncardiac surgery and for all-cause mortality at 1-year after noncardiac surgery.

EVALUATION OF PERIOPERATIVE HIGH-SENSITIVE CARDIAC TROPONIN I AS A PREDICTIVE BIOMARKER OF MAJOR ADVERSE CARDIOVASCULAR EVENTS AFTER NONCARDIAC SURGERY.

BACKGROUND: Various studies suggest that perioperative concentrations of high-sensitivity troponins are incremental and predictive factors of a major adverse cardiac event (MACE) and all-cause mortality. OBJECTIVE: The objective of the study was to evaluate the predictive value of high-sensitivity cardiac troponin I (hs-cTnI) in the development of MACE and all-cause mortality, within 30-days and 1-year follow-up after noncardiac surgery. METHODS: In this prospective cohort study, we included men ≥ 45 years and women ≥ 55 years with ≥ 2 cardiovascular risk factors and undergoing intermediate or high-risk noncardiac surgery. Demographic and clinical information was collected from clinical charts. We measured baseline hs-cTnI 24 h before surgery, and its post-operative concentration 24 h after surgery. RESULTS: In the entire sample, 8 patients (8.6%) developed MACE at 30-days follow-up (4 deaths), 12 (12.9%) within the 1st year (7 deaths), and 17 (18.2%) after complete post-surgical follow-up (10 deaths). We observed higher baseline and post-operative concentrations in patients who presented MACE (12 pg/ml vs. 3.5 pg/ml; p = 0.001 and 18.3 pg/ml vs. 5.45 pg/ml; p = 0.009, respectively). The hazard ratios (HRs) calculated by Cox regression analysis between the hs-cTnI baseline concentration and the post-operative development of MACE at 30-days and 1-year were 5.70 (95% confidence interval [CI], 1.10-29.40) with hs-cTnI > 6.2 pg/ml and 12.86 (95% CI, 1.42-116.34) with hs-cTnI > 3.3 pg/ml, respectively. The estimated post-operative HR death risk at 1-year was 14.43 (95% CI, 1.37-151.61) with hs-cTnI > 4.5 pg/ml. CONCLUSIONS: Pre-operative hs-cTnI was an independent predictive risk factor for MACE at 30-days and 1-year after noncardiac surgery and for all-cause mortality at 1-year after noncardiac surgery.

Evaluation of perioperative high-sensitive cardiac troponin i as a predictive biomarker of major adverse cardiovascular events after noncardiac surgery

ABSTRACT Background: Various studies suggest that perioperative concentrations of high-sensitivity troponins are incremental and predictive factors of a major adverse cardiac event (MACE) and all-cause mortality. Objective: The objective of the study was to evaluate the predictive value of high-sensitivity cardiac troponin I (hs-cTnI) in the development of MACE and all-cause mortality, within 30-days and 1-year follow-up after noncardiac surgery. Methods: In this prospective cohort study, we included men ≥ 45 years and women ≥ 55 years with ≥ 2 cardiovascular risk factors and undergoing intermediate or high-risk noncardiac surgery. Demographic and clinical information was collected from clinical charts. We measured baseline hs-cTnI 24 h before surgery, and its post-operative concentration 24 h after surgery. Results: In the entire sample, 8 patients (8.6%) developed MACE at 30-days follow-up (4 deaths), 12 (12.9%) within the 1st year (7 deaths), and 17 (18.2%) after complete post-surgical follow-up (10 deaths). We observed higher baseline and post-operative concentrations in patients who presented MACE (12 pg/ml vs. 3.5 pg/ml; p = 0.001 and 18.3 pg/ml vs. 5.45 pg/ml; p = 0.009, respectively). The hazard ratios (HRs) calculated by Cox regression analysis between the hs-cTnI baseline concentration and the post-operative development of MACE at 30-days and 1-year were 5.70 (95% confidence interval [CI], 1.10-29.40) with hs-cTnI > 6.2 pg/ml and 12.86 (95% CI, 1.42-116.34) with hs-cTnI > 3.3 pg/ml, respectively. The estimated post-operative HR death risk at 1-year was 14.43 (95% CI, 1.37-151.61) with hs-cTnI > 4.5 pg/ml. Conclusions: Pre-operative hs-cTnI was an independent predictive risk factor for MACE at 30-days and 1-year after noncardiac surgery and for all-cause mortality at 1-year after noncardiac surgery.

Extractos de los documentos de posicionamientos y recomendaciones mexicanas en enfermedades cardiovasculares y COVID-19 / Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19

Resumen Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Abstract The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

Cirugía cardiaca en pacientes con lupus eritematoso sistémico: características clínicas y desenlaces / Cardiac surgery in systemic lupus erythematosus patients: Clinical characteristics and outcomes

Objetivos: Estudiar las características clínicas y desenlaces de los pacientes con lupus eritematoso sistémico (LES) intervenidos de cirugía cardiaca. Métodos: Se realizó un estudio retrospectivo de 30 pacientes con LES y cirugía cardiaca en un solo centro. Se registraron comorbilidades, características demográficas, clínicas, serológicas, riesgo cardiovascular, tratamiento, tipo de cirugía, complicaciones postoperatorias, mortalidad e histología. Resultados: La duración de LES al momento de la cirugía fue de 2 años. El procedimiento más frecuente fue recambio valvular (53%), seguido de ventana pericárdica (37%). Al menos una complicación postoperatoria se presentó en el 63% (principalmente infecciones). Un pinzamiento aórtico≥76 min se asoció con al menos una complicación (OR 6,4; IC 95% 1,1-35,4, p=0,03). La mortalidad temprana ocurrió en 5 pacientes (17%) y tardía en 3 (10%); siendo las causas principales sepsis e insuficiencia cardiaca. La actividad de la enfermedad se asoció a la realización de ventana pericárdica (OR 12,6; IC 95% 1,9-79; p=0,007), presencia de linfopenia≤1.200 (OR 10,1; IC 95% 1,05-97; p=0,04), edad≤30 años (OR 7,7; IC 95% 1,2-46,3; p=0,02) y NYHA clase III (OR 7,0; IC 95% 1,1-42, p=0,03). El desarrollo de infección postoperatoria se asoció con estancia hospitalaria≥2 semanas (OR 54,9; IC 95% 5,0-602,1; p=0,001), estancia en UCI≥10 días (OR 20; IC 95% 1,6-171,7, p=0,01), duración de ventilación mecánica ≥ 5 días (OR 16,9, IC 95% 1,5-171,7, p = 0,01) y PSAP≥50mmHg (OR 7,8; IC 95% 1,4-41,2; p=0,01). Conclusiones: La cirugía cardiaca en LES se asocia a alta morbimortalidad

Objectives: To study the clinical characteristics and outcomes in systemic lupus erythematosus (SLE) patients who underwent cardiac surgery. Methods: Retrospective analysis of 30 SLE patients who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical and serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed. Results: Disease duration at surgery was 2 years. Valve replacement was the procedure most frequently performed (53%), followed by pericardial window (37%). At least one postoperative complication developed in 63% (mainly infections). An aortic cross-clamp time≥76minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=.03). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Disease activity was associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=.007); lymphopenia≤1.200 (OR 10.1, 95% CI 1.05-97, p=.04); age≤30 years (OR 7.7, 95% CI 1.2-46.3, p=.02); and New York Heart Association class III (OR 7.0, 95% CI 1.1-42, p=.03). Postoperative infection was associated with length of hospital stay≥2 weeks (OR 54.9, 95% CI 5.0-602.1, p=.001); intensive care unit stay≥10 days (OR 20, 95% CI 1.6-171.7, p=.01); duration of mechanical ventilation≥5 days (OR 16.9, 95% CI 1.5-171.7, p=.01); and pulmonary artery systolic pressure≥50mmHg (OR 7.8, 95% CI 1.4-41.2, p=.01). Conclusions: Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors

Cardiac surgery in systemic lupus erythematosus patients: Clinical characteristics and outcomes. / Cirugía cardiaca en pacientes con lupus eritematoso sistémico: características clínicas y desenlaces.

OBJECTIVES: To study the clinical characteristics and outcomes in systemic lupus erythematosus (SLE) patients who underwent cardiac surgery. METHODS: Retrospective analysis of 30 SLE patients who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical and serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed. RESULTS: Disease duration at surgery was 2 years. Valve replacement was the procedure most frequently performed (53%), followed by pericardial window (37%). At least one postoperative complication developed in 63% (mainly infections). An aortic cross-clamp time≥76minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=.03). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Disease activity was associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=.007); lymphopenia≤1.200 (OR 10.1, 95% CI 1.05-97, p=.04); age≤30 years (OR 7.7, 95% CI 1.2-46.3, p=.02); and New York Heart Association class III (OR 7.0, 95% CI 1.1-42, p=.03). Postoperative infection was associated with length of hospital stay≥2 weeks (OR 54.9, 95% CI 5.0-602.1, p=.001); intensive care unit stay≥10 days (OR 20, 95% CI 1.6-171.7, p=.01); duration of mechanical ventilation≥5 days (OR 16.9, 95% CI 1.5-171.7, p=.01); and pulmonary artery systolic pressure≥50mmHg (OR 7.8, 95% CI 1.4-41.2, p=.01). CONCLUSIONS: Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors.

Eversion Subclavian Endarterectomy and Transposition for Coronary-Subclavian Steal Syndrome in a Patient with Refractory Angina Pectoris.

Late onset of angina pectoris associated with subclavian artery (SA) atherosclerotic occlusive disease is a rare and recognized cause of myocardial ischemia when the lesion is proximal to a left internal mammary artery (LIMA) to coronary bypass. The symptoms typically exacerbate by increasing the flow demand in the extremity; this phenomenon is known as late coronary-subclavian steal syndrome. We describe the case of a 66-year-old woman who underwent coronary artery bypass grafting from the LIMA to the left anterior descending coronary artery in 2000. Years later, she experienced refractory angina pectoris associated to an occlusive lesion in the proximal left SA. SA endarterectomy with eversion technique and subclavian-carotid transposition restored the antegrade flow with resolution of the symptomatology.

[Differential behaviour of blood pressure in patients with neurocardiogenic syncope during the initial stage of the tilt table test]. / Comportamiento diferencial de la tensión arterial de pacientes con síncope neuro-cardiogénico en la fase inicial de la prueba de inclinación.

UNLABELLED: Neurocardiogenic syncope (NCS) is diagnosed by means of a head-up tilt table tests (HUTT). This is a prolonged test although early outcome predictors are known. METHODS: We conducted a study among patients engaged in a syncope study protocol. We performed HUTT in all of them and compared the basal arterial pressure with the arterial pressure at the end of a the 70 degrees tilting. RESULTS: We performed 185 HUTT studies. Systolic blood pressure (BP) raised 0.9% among patients with a negative test, whereas patients with a positive HUTT showed a 2.3% decrease (p = 0.2) in the same measurement. Diastolic BP increased 34% among negative HUTT patients and 14.9% among patients with positive test (p = 0.02). We calculated a relative risk of 1.45 for positive test when the combination of systolic BD decrease and dyastolic increase was present, according to the percentage of change (IC95%: 1.1 to 7.8). CONCLUSIONS: The combination of systolic BP reduction and diastolic BP elevation at the end of the 70 degrees tilting is associated with an increased risk of having a positive HUTT. These changes might be related to differential sympathetic stimulation.

A 57 year old man with chronic renal failure and cardiac tamponade who developed ischemic hepatitis.

Ischemic hepatitis is an infrequent entity, usually associated with low cardiac out put. We present a case of a 57 year-old man with chronic renal failure and cardiac tamponade who developed elevation of serum alanine transferase level of 5,054 U/L, aspartate transferase level of 8,747 U/L and lactate dehydrogenasa level of 15,220 U/L. The patient developed hepatic encephalopathy and hypoglycemia. Liver Doppler ultrasound was normal. He was seronegative for HBV and HCV, drugs list was scrutinized for the names of known hepatotoxins. Ischemic hepatitis was diagnosed. The hypoglycemia and encephalopathy were solved and the patient was discharged with normal transaminase levels. Ischemic hepatitis is typically preceded by hypotension, hypoxemia, or both. As one would expect, the most common cause of sustained systemic hypotension is cardiovascular disease. Liver biopsy is usually not necessary. The best treatment is support measures and correct the underlying condition.

Comportamiento diferencial de la tensión arterial de pacientes con síncope neuro-cardiogénico en la fase inicial de la prueba de inclinación / Differential behaviour of blood pressure in patients with neurocardiogenic syncope during the initial stage of the tilt table test

Neurocardiogenic syncope (NCS) is diagnosed by means of a head-up tilt table tests (HUTT). This is a prolonged test although early outcome predictors are known. METHODS: We conducted a study among patients engaged in a syncope study protocol. We performed HUTT in all of them and compared the basal arterial pressure with the arterial pressure at the end of a the 70 degrees tilting. RESULTS: We performed 185 HUTT studies. Systolic blood pressure (BP) raised 0.9% among patients with a negative test, whereas patients with a positive HUTT showed a 2.3% decrease (p = 0.2) in the same measurement. Diastolic BP increased 34% among negative HUTT patients and 14.9% among patients with positive test (p = 0.02). We calculated a relative risk of 1.45 for positive test when the combination of systolic BD decrease and dyastolic increase was present, according to the percentage of change (IC95%: 1.1 to 7.8). CONCLUSIONS: The combination of systolic BP reduction and diastolic BP elevation at the end of the 70 degrees tilting is associated with an increased risk of having a positive HUTT. These changes might be related to differential sympathetic stimulation.