Clinical practice guidelines for diagnostic and treatment of the chronic heart failure.

Chronic heart failure continues to be one of the main causes of impairment in the functioning and quality of life of people who suffer from it, as well as one of the main causes of mortality in our country and around the world. Mexico has a high prevalence of risk factors for developing heart failure, such as high blood pressure, diabetes, and obesity, which makes it essential to have an evidence-based document that provides recommendations to health professionals involved in the diagnosis and treatment of these patients. This document establishes the clinical practice guide (CPG) prepared at the initiative of the Mexican Society of Cardiology (SMC) in collaboration with the Iberic American Agency for the Development and Evaluation of Health Technologies, with the purpose of establishing recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. This document complies with international quality standards, such as those described by the US Institute of Medicine (IOM), the National Institute of Clinical Excellence (NICE), the Intercollegiate Network for Scottish Guideline Development (SIGN) and the Guidelines International Network (G-I-N). The Guideline Development Group was integrated in a multi-collaborative and interdisciplinary manner with the support of methodologists with experience in systematic literature reviews and the development of CPG. A modified Delphi panel methodology was developed and conducted to achieve an adequate level of consensus in each of the recommendations contained in this CPG. We hope that this document contributes to better clinical decision making and becomes a reference point for clinicians who manage patients with chronic heart failure in all their clinical stages and in this way, we improve the quality of clinical care, improve their quality of life and reducing its complications.

La insuficiencia cardiaca crónica sigue siendo unas de las principales causas de afectación en el funcionamiento y en la calidad de vida de las personas que la presentan, así como una de las primeras causas de mortalidad en nuestro país y en todo el mundo. México tiene una alta prevalencia de factores de riesgo para desarrollar insuficiencia cardiaca, tales como hipertensión arterial, diabetes y obesidad, lo que hace imprescindible contar con un documento basado en la evidencia que brinde recomendaciones a los profesionales de la salud involucrados en el diagnóstico y el tratamiento de estos pacientes. Este documento establece la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología (SMC) en colaboración con la Agencia Iberoamericana de Desarrollo y Evaluación de Tecnologías en Salud, con la finalidad de establecer recomendaciones basadas en la mejor evidencia disponible y consensuadas por un grupo interdisciplinario y multicolaborativo de expertos. Cumple con estándares internacionales de calidad, como los descritos por el Institute of Medicine de los Estados Unidos de América (IOM), el National Institute of Clinical Excellence (NICE) del Reino Unido, la Intercollegiate Network for Scottish Guideline Development (SIGN) de Escocia y la Guidelines International Network (G-I-N). El grupo de desarrollo de la guía se integró de manera interdisciplinaria con el apoyo de metodólogos con experiencia en revisiones sistemáticas de la literatura y en el desarrollo de GPC. Se llevó a cabo y se condujo metodología de panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. Esperamos que este documento contribuya para la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos que manejan pacientes con insuficiencia cardiaca crónica en todas sus etapas clínicas, y de esta manera logremos mejorar la calidad en la atención clínica, aumentar la calidad de vida de los pacientes y disminuir las complicaciones de la enfermedad.

Cardiovascular disease risk in the transgender population.

This review summarizes the impact of gender affirming hormone therapy used in the transgendered population and the classic and emerging risk factors on cardiovascular outcomes and surrogate markers of cardiovascular health. There is a growing body of evidence that people who are transgender and gender diverse are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Previously, disparities have been reported in cardiovascular morbidity and mortality across this group as a result of a higher prevalence of non-healthy life style. However, recent research suggests that there are additional factors playing a role in this differences: there is the hypothesis that the excess of cardiovascular morbility and mortality has been driven by psychosocial stressors across the lifespan at multiple levels, as structural violence (e.g., discrimination, lack of affordable housing, lack of access to health care, etc.). Lack of information and research in this population is an important limitation; therefore, a multifaceted approach that integrates best practice into research, health promotion and cardiovascular care for this understudied and growing population is clearly needed.

Este artículo resume la literatura existente hasta este momento sobre el impacto de la terapia hormonal para la asignación de género utilizada en la población transgénero, y de los factores de riesgo tradicionales y emergentes, en los desenlaces cardiovasculares o los marcadores subrogados de enfermedad cardiovascular. Actualmente se reconoce la evidencia creciente de que las personas transgénero o con género diverso son víctimas de disparidades en una gran variedad de factores de riesgo cardiovascular comparadas con sus pares cisgénero. Se ha reportado disparidad en morbilidad y mortalidad como resultado de una alta prevalencia en estilos de vida no saludables. Sin embargo, recientemente se ha incorporado la interpretación de que no solo la disparidad en factores de riesgo cardiovascular es lo que incrementa el riesgo en la salud cardiovascular de la población transgénero. Existe la hipótesis de que el exceso en morbilidad y mortalidad cardiovascular está relacionado con estresores psicosociales a lo largo de la vida de este grupo en múltiples niveles, incluyendo violencia estructurada (p. ej., discriminación, falta de acceso a los servicios de salud, falta de vivienda digna, etc.). La falta de información y de investigación en este grupo son limitantes importantes que requieren un abordaje multifacético para mejorar aspectos como la promoción de la salud y el mejor cuidado cardiovascular.

Riesgo de enfermedad cardiovascular en la población transgénero / Cardiovascular disease risk in the transgender population

Resumen Este artículo resume la literatura existente hasta este momento sobre el impacto de la terapia hormonal para la asignación de género utilizada en la población transgénero, y de los factores de riesgo tradicionales y emergentes, en los desenlaces cardiovasculares o los marcadores subrogados de enfermedad cardiovascular. Actualmente se reconoce la evidencia creciente de que las personas transgénero o con género diverso son víctimas de disparidades en una gran variedad de factores de riesgo cardiovascular comparadas con sus pares cisgénero. Se ha reportado disparidad en morbilidad y mortalidad como resultado de una alta prevalencia en estilos de vida no saludables. Sin embargo, recientemente se ha incorporado la interpretación de que no solo la disparidad en factores de riesgo cardiovascular es lo que incrementa el riesgo en la salud cardiovascular de la población transgénero. Existe la hipótesis de que el exceso en morbilidad y mortalidad cardiovascular está relacionado con estresores psicosociales a lo largo de la vida de este grupo en múltiples niveles, incluyendo violencia estructurada (p. ej., discriminación, falta de acceso a los servicios de salud, falta de vivienda digna, etc.). La falta de información y de investigación en este grupo son limitantes importantes que requieren un abordaje multifacético para mejorar aspectos como la promoción de la salud y el mejor cuidado cardiovascular.

Abstract This review summarizes the impact of gender affirming hormone therapy used in the transgendered population and the classic and emerging risk factors on cardiovascular outcomes and surrogate markers of cardiovascular health. There is a growing body of evidence that people who are transgender and gender diverse are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Previously, disparities have been reported in cardiovascular morbidity and mortality across this group as a result of a higher prevalence of non-healthy life style. However, recent research suggests that there are additional factors playing a role in this differences: there is the hypothesis that the excess of cardiovascular morbility and mortality has been driven by psychosocial stressors across the lifespan at multiple levels, as structural violence (e.g., discrimination, lack of affordable housing, lack of access to health care, etc.). Lack of information and research in this population is an important limitation; therefore, a multifaceted approach that integrates best practice into research, health promotion and cardiovascular care for this understudied and growing population is clearly needed.

Recommendations for the care of patients with diabetes mellitus with risk factors or established cardiovascular disease and SARS-CoV-2mellitus con factores de riesgo o enfermedad cardiovascular establecida y SARS-CoV-2.

A review is carried out to examine the risk of patients suffering from diabetes mellitus in the context of general morbidity and mortality and related to infection by SARS-CoV-2. Likewise, the general recommendations for food and the prevention of comorbidities that most these patients suffer most frequently are also studied. Finally, a review of the pharmacological recommendations on both oral and parenteral treatment in the outpatient, in hospitalization and in critical states infected with SARS-CoV-2 is made.

Se realiza una revisión sobre el riesgo de los pacientes que padecen diabetes mellitus en el contexto de morbimortalidad general y relacionada a infección por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2). Así mismo se repasan las recomendaciones generales, de alimentación y de la prevención de las comorbilidades que más frecuentemente padecen dichos enfermos. Finalmente se hace una revisión de las recomendaciones farmacológicas sobre el tratamiento tanto oral como parenteral en el paciente ambulatorio, en la hospitalización y en estados críticos infectados por el SARS-CoV-2.

Recomendaciones para la atención de pacientes con diabetes mellitus con factores de riesgo o enfermedad cardiovascular establecida y SARS-CoV-2 / Recommendations for the care of patients with diabetes mellitus with risk factors or established cardiovascular disease and SARS-CoV-2

Resumen Se realiza una revisión sobre el riesgo de los pacientes que padecen diabetes mellitus en el contexto de morbimortalidad general y relacionada a infección por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2). Así mismo se repasan las recomendaciones generales, de alimentación y de la prevención de las comorbilidades que más frecuentemente padecen dichos enfermos. Finalmente se hace una revisión de las recomendaciones farmacológicas sobre el tratamiento tanto oral como parenteral en el paciente ambulatorio, en la hospitalización y en estados críticos infectados por el SARS-CoV-2.

Abstract A review is carried out to examine the risk of patients suffering from diabetes mellitus in the context of general morbidity and mortality and related to infection by SARS-CoV-2. Likewise, the general recommendations for food and the prevention of comorbidities that most these patients suffer most frequently are also studied. Finally, a review of the pharmacological recommendations on both oral and parenteral treatment in the outpatient, in hospitalization and in critical states infected with SARS-CoV-2 is made.

Tumor necrosis factor alpha and interleukin 10 promoter polymorphisms in Mexican patients with restenosis after coronary stenting.

To test for an association with risk for restenosis after coronary stent placement, the TNF-alpha and IL-10 polymorphisms were analyzed by 5' exonuclease TaqMan assays in 162 patients who initially underwent coronary stenting. Analysis of basal and procedure coronary angiographies revealed a higher proportion of restenosis in lesions treated with bare metal stents compared with those treated with drug-eluting stents (P < 0.001). Distribution of TNF-alpha genotypes was similar in patients with and without restenosis. The IL-10 polymorphisms showed a moderate protective trend of the -819 TT genotype against restenosis when the lesions were analyzed (P = 0.071, OR = 0.471). Multivariate analysis confirmed a protective role for drug-eluting stents (P < 0.001, OR = 0.199) and the -819 TT genotype (P = 0.037, OR = 0.391). These results suggest the IL-10 -819 TT genotype has a protective role against in-stent restenosis.

No association found between the insertion/deletion of a 287-bp alu repeat sequence within intron 16 of the angiotensin-I-converting enzyme (ACE) gene in Mexican patients and binary restenosis after coronary stenting.

BACKGROUND: It has been suggested that the incidence of coronary restenosis after a percutaneous coronary intervention is much higher in patients with a 287-bp alu repeat sequence within intron 16 of the angiotensin-I-converting enzyme (ACE) gene (deletion allele) than in others, but published studies are conflicting. METHODS: The presence (insertion) or absence (deletion) of a 287-bp alu repeat sequence within intron 16 of the ACE gene (I/D polymorphism) was analyzed by polymerase chain reaction in a group of 168 patients with coronary artery disease who underwent coronary artery stenting. Basal and procedure coronary angiographies were analyzed searching for angiographic predictors of restenosis and follow-up angiography was analyzed looking for binary restenosis. RESULTS: Distribution of angiotensin converting enzyme I/D polymorphisms was similar in patients with and without restenosis. Similar results were observed when the analysis was made considering the type of stent implanted. On the other hand, the whole group of coronary artery disease patients showed increased frequencies of the D allele (p=0.00001, OR=2.17, 95% CI=1.49-3.16) and ID genotype (p=0.0002, OR=2.58, 95%CI=1.49-4.47) when compared to healthy controls. CONCLUSIONS: Genetic variations of the ACE gene could be a genetic factor related to coronary artery disease in the Mexican mixed racial ancestry individuals, but do not support its role as a risk factor for developing restenosis after coronary stenting.

The interleukin 1B-511 polymorphism is associated with the risk of developing restenosis after coronary stenting in Mexican patients.

Inflammation is the primary response to vessel wall injury caused by stent placement in coronary arteries. Cytokines of the interleukin-1 family are central regulators in immunoinflammatory mechanisms. The objective of this study was to test for association between IL-1 family gene polymorphisms and risk for restenosis after coronary stent placement. The IL-1B-511, IL-1F10.3, RN.4T>C, RN.6/1C>T, RN.6/2C>G, and IL-1RN VNTR polymorphisms were analyzed by 5' exonuclease TaqMan genotyping assays and polymerase chain reaction in a group of 165 patients who underwent coronary artery stenting. Basal and procedure coronary angiography were analyzed in search of angiographic predictors of restenosis and follow-up angiography was analyzed in search of binary restenosis. Patients with IL-1B-511 TT genotype had a 1.89-fold increased risk of developing restenosis. The analysis considering the lesions treated demonstrated that the lesions of patients with IL-1B-511 TT genotype had a 3.44-fold increased risk of developing restenosis. When the analysis considered the type of stent, the risk of developing restenosis was increased in lesions of patients with TT genotype (odds ratio = 4.50) who underwent coronary bare-metal stent implantation. Multiple logistic analysis identified IL-1B-511 TT genotype as an independent predictor for restenosis. The results suggest that IL-1B-511 polymorphism could be involved in the risk of developing restenosis after coronary stent placement.

Predictors of mortality and adverse outcome in elderly high-risk patients undergoing percutaneous coronary intervention.

OBJECTIVES: We sought to identify predictors of in-hospital and long-term (> 1 year) mortality and major adverse cardiac events (MACE) in elderly patients referred for percutaneous coronary intervention (PCI). METHODS: Seventy-three patients (> or = 80 years) were included. Clinical and interventional characteristics were collected retrospectively. Primary end points were in-hospital and long-term mortality, and a composite of non-fatal myocardial infarction, target vessel revascularization, urgent coronary artery bypass graft surgery, and death (MACE). RESULTS: Eighty-three percent of the patients had acute coronary syndromes, 43% three-vessel disease, and 42% heart failure. In-hospital mortality and MACE were 16.4% and 19%, respectively. Long-term mortality and MACE were 11.3% and 16.4%, respectively. Univariate characteristics associated with in-hospital mortality and MACE were: Killip Class III-IV, heart failure, cardiogenic shock, TIMI 0-2 flow prior and after intervention, diabetes mellitus, contrast nephropathy, and presence of A-V block or atrial fibrillation (AF). Long term predictors for mortality were the presence of heart failure, cardiogenic shock, diabetes mellitus, TIMI flow 0-2 before and after intervention, and A-V block or AF. CONCLUSION: The identification of the factors previously mentioned may help to predict complications in elderly patients.

Predictors of mortality and adverse outcome in elderly high-risk patients undergoing percutaneous coronary intervention / Predictores de mortalidad y mal pronóstico en pacientes ancianos y de alto riesgo que van a ser sometidos a intervención coronaria percutánea

OBJECTIVES: We sought to identify predictors of in-hospital and long-term (> 1 year) mortality and major adverse cardiac events (MACE) in elderly patients referred for percutaneous coronary intervention (PCI). METHODS: Seventy-three patients (> or = 80 years) were included. Clinical and interventional characteristics were collected retrospectively. Primary end points were in-hospital and long-term mortality, and a composite of non-fatal myocardial infarction, target vessel revascularization, urgent coronary artery bypass graft surgery, and death (MACE). RESULTS: Eighty-three percent of the patients had acute coronary syndromes, 43% three-vessel disease, and 42% heart failure. In-hospital mortality and MACE were 16.4% and 19%, respectively. Long-term mortality and MACE were 11.3% and 16.4%, respectively. Univariate characteristics associated with in-hospital mortality and MACE were: Killip Class III-IV, heart failure, cardiogenic shock, TIMI 0-2 flow prior and after intervention, diabetes mellitus, contrast nephropathy, and presence of A-V block or atrial fibrillation (AF). Long term predictors for mortality were the presence of heart failure, cardiogenic shock, diabetes mellitus, TIMI flow 0-2 before and after intervention, and A-V block or AF. CONCLUSION: The identification of the factors previously mentioned may help to predict complications in elderly patients.