Chronic hyperkalemia, diagnosis and management. Colombian consensus.

OBJECTIVE: Generate recommendations for the diagnosis, management, and follow-up of chronic hyperkalemia. METHOD: This consensus was made by nephrologists and cardiologists following the GRADE methodology. RESULTS: Chronic hyperkalemia can be defined as a biochemical condition with or without clinical manifestations characterized by a recurrent elevation of serum potassium levels that may require pharmacological and or non-pharmacological intervention. It can be classified as mild (K+ 5.0 to < 5.5 mEq/L), moderate (K+ 5.5 to 6.0 mEq/L) or severe (K+ > 6.0 mEq/L). Its incidence and prevalence have yet to be determined. Risk factors: chronic kidney disease, chronic heart failure, diabetes mellitus, age ≥ 65 years, hypertension, and drugs that inhibit the renin angiotensin aldosterone system (RAASi), among others. There is no consensus for the management of chronic hyperkalemia. The suggested pattern for patients is to identify and eliminate or control risk factors, provide advice on potassium intake and, for whom it is indicated, optimize RAASi therapy, administer oral potassium binders and correct metabolic acidosis. CONCLUSIONS: The recommendation is to pay attention to the diagnosis, management, and follow-up of chronic hyperkalemia, especially in patients with risk factors.

OBJETIVO: Generar recomendaciones para el diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica. MÉTODO: Este consenso fue realizado por nefrólogos y cardiólogos siguiendo la metodología GRADE. RESULTADOS: La hiperkalemia crónica puede definirse como una condición bioquímica, con o sin manifestaciones clínicas, caracterizada por una elevación recurrente de las concentraciones séricas de potasio que puede requerir una intervención farmacológica, no farmacológica o ambas. Puede clasificarse en leve (K+ 5,0 a < 5,5 mEq/l), moderada (K+ 5,5 a 6,0 mEq/l) o grave (K+ > 6,0 mEq/l). Su incidencia y prevalencia no han sido claramente determinadas. Se consideran factores de riesgo la enfermedad renal crónica, la insuficiencia cardiaca crónica, la diabetes mellitus, la edad ≥ 65 años, la hipertensión arterial y el tratamiento con inhibidores del sistema renina-angiotensina-aldosterona (iSRAA), entre otros. No hay consenso sobre el manejo de la hiperkalemia crónica. Se sugiere identificar y eliminar o controlar los factores de riesgo, brindar asesoramiento sobre la ingesta de potasio y, para quien esté indicado, optimizar la terapia con iSRAA, administrar aglutinantes orales del potasio y corregir la acidosis metabólica. CONCLUSIONES: Se recomienda prestar atención al diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica, en especial en los pacientes con factores de riesgo.

Addressing Barriers for Women with Advanced Heart Failure.

PURPOSE OF REVIEW: Describe disparities in diagnosis and management between men and women with advanced heart failure (HF). Our goal is to identify barriers and suggest solutions. RECENT FINDINGS: Women with advanced HF are less likely to undergo diagnostic testing and procedures (i.e., revascularization, implantable cardioverter defibrillators, cardiac resynchronization therapy, mechanical circulatory support, and orthotopic heart transplantation). Disparities related to gender create less favorable outcomes for women with advanced HF. The issues arise from access to care, paucity of knowledge, enrollment in clinical trials, and eligibility for advanced therapies. In this review, we propose a call to action to level the playing field in order to improve survival in women with advanced HF.

Multidisciplinary Heart Failure Care Program: An Experience From Colombia.

The prevalence of Heart Failure is growing alarmingly; its treatment consumes health resources and affects the quality of life of patients. To describe the changes in NYHA functional Class, ejection fraction, hospitalizations, and mortality after 8 years of follow up in a multidisciplinary heart failure program in Colombia as a model for lower and middle income countries. An observational study was performed with the retrospective analysis of the information. 1757 patients were included, The NYHA functional class at the beginning of the program was: NYHA I 23.5%, NYHA II 50.3%, NYHA class Improvement was observed at the end of the follow-up with an increase in the percentage of patients in Functional Class NYHA I and II. The reduction in hospitalizations were 35% less (mean: 0.68 ± 0.95, P < 0.0001), a reduction in the length of stay in the hospital was 13.2% (before: 4.46 ± 7.16, after 3.87 ± 8.1 days, P < 0.001). The total mortality after eight years of follow-up was 6.6 % (n = 116). Multidisciplinary follow-up in Heart Failure (HF) programs improves Functional Class and EF, decreases hospital admissions as well as hospitalization and the length of stay. This is a very simple and successful model of care for this disease that can be implemented for countries of lower- and middle-income countries.

Hiperkalemia crónica, diagnóstico y manejo. Consenso colombiano / Chronic hyperkalemia, diagnosis and management. Colombian consensus

Resumen Objetivo: Generar recomendaciones para el diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica. Método: Este consenso fue realizado por nefrólogos y cardiólogos siguiendo la metodología GRADE. Resultados: La hiperkalemia crónica puede definirse como una condición bioquímica, con o sin manifestaciones clínicas, caracterizada por una elevación recurrente de las concentraciones séricas de potasio que puede requerir una intervención farmacológica, no farmacológica o ambas. Puede clasificarse en leve (K+ 5,0 a < 5,5 mEq/l), moderada (K+ 5,5 a 6,0 mEq/l) o grave (K+ > 6,0 mEq/l). Su incidencia y prevalencia no han sido claramente determinadas. Se consideran factores de riesgo la enfermedad renal crónica, la insuficiencia cardiaca crónica, la diabetes mellitus, la edad ≥ 65 años, la hipertensión arterial y el tratamiento con inhibidores del sistema renina-angiotensina-aldosterona (iSRAA), entre otros. No hay consenso sobre el manejo de la hiperkalemia crónica. Se sugiere identificar y eliminar o controlar los factores de riesgo, brindar asesoramiento sobre la ingesta de potasio y, para quien esté indicado, optimizar la terapia con iSRAA, administrar aglutinantes orales del potasio y corregir la acidosis metabólica. Conclusiones: Se recomienda prestar atención al diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica, en especial en los pacientes con factores de riesgo.

Abstract Objective: Generate recommendations for the diagnosis, management, and follow-up of chronic hyperkalemia. Method: This consensus was made by nephrologists and cardiologists following the GRADE methodology. Results: Chronic hyperkalemia can be defined as a biochemical condition with or without clinical manifestations characterized by a recurrent elevation of serum potassium levels that may require pharmacological and or non-pharmacological intervention. It can be classified as mild (K+ 5.0 to < 5.5 mEq/L), moderate (K+ 5.5 to 6.0 mEq/L) or severe (K+ > 6.0 mEq/L). Its incidence and prevalence have yet to be determined. Risk factors: chronic kidney disease, chronic heart failure, diabetes mellitus, age ≥ 65 years, hypertension, and drugs that inhibit the renin angiotensin aldosterone system (RAASi), among others. There is no consensus for the management of chronic hyperkalemia. The suggested pattern for patients is to identify and eliminate or control risk factors, provide advice on potassium intake and, for whom it is indicated, optimize RAASi therapy, administer oral potassium binders and correct metabolic acidosis. Conclusions: The recommendation is to pay attention to the diagnosis, management, and follow-up of chronic hyperkalemia, especially in patients with risk factors.

Fibrosis endomiocárdica: una revisión actualizada a propósito de unos casos en un programa de falla cardiaca / Endomyocardial fibrosis: an updated review, about some cases in a heart failure program

Resumen Introducción La fibrosis endomiocárdica es una enfermedad cardiovascular olvidada, principal causa de cardiomiopatía restrictiva. Se estima que en el mundo hay 10-12 millones de personas con la enfermedad. La mayoría se restringen a zonas de África, Asia y, en Latinoamérica, en Brasil y Colombia. La etiología y la fisiopatología son poco comprendidas. Para su diagnóstico se deben tener en cuenta los datos del paciente, el cuadro clínico y los hallazgos ecocardiográficos. Presentamos los casos confirmados en un centro de referencia cardiovascular. Descripción de los casos: Se han documentado tres casos, de los cuales dos son mujeres. Todos debutaron con un cuadro insidioso de disnea con esfuerzo. Los hallazgos ecocardiográficos fueron disfunción diastólica con patrón restrictivo, insuficiencia moderada de válvulas auriculoventriculares e hipertensión pulmonar; en dos casos se encontraron imágenes anormales endocárdicas en el ventrículo izquierdo y se realizó biopsia endomiocárdica para confirmar el diagnóstico. Ninguno mejoró la clase funcional ni la frecuencia de hospitalizaciones. Conclusiones La fibrosis endomiocárdica debe considerarse en todo paciente con falla cardiaca con un patrón restrictivo asociado y con poca respuesta al manejo farmacológico convencional. Los pacientes presentados tenían hallazgos típicos de la enfermedad, con la particularidad de ser de edades mayores.

Abstract Introduction Endomyocardial fibrosis is one of the neglected cardiovascular disease, the main cause of restrictive cardiomyopathy. There are an estimated 10-12 million people with the disease worldwide. Most are restricted to areas of Africa, Asia and in Latin America in Brazil and Colombia. The etiology and pathophysiology are poorly understood. For its diagnosis, the patient's data, the clinical picture and the echocardiographic findings must be taken into account. We present the confirmed cases in a cardiovascular referral center. Description of the cases Three cases have been documented of which two are women. All debuted with insidious dyspnea on exertion. The echocardiographic findings were diastolic dysfunction with a restrictive pattern, moderate atrioventricular valve insufficiency, and pulmonary hypertension. In two cases, endocardial abnormal images were found in the left ventricle and an endomyocardial biopsy was performed to confirm the diagnosis. None improved functional class or frequency of hospitalizations. Conclusions Endomyocardial fibrosis should be considered in a patient with heart failure with an associated restrictive pattern, and with little response to conventional pharmacological management. The patients presented had typical findings of the disease with the particularity of being older.

A propósito de la cardiopatía periparto: una etiología olvidada / Regarding peripartum heart disease: a forgotten etiology

Resumen Objetivo: Identificar la epidemiología clínica y los procesos diagnósticos y terapéuticos de las mujeres con miocardiopatía periparto en un centro de referencia cardiovascular. Método: Se realizó un estudio observacional descriptivo retrospectivo con pacientes de sexo femenino de entre 15 y 50 años con diagnóstico de cardiopatía periparto durante los últimos 10 años en una institución especializada de la ciudad de Medellín. Resultados: Hubo 17 mujeres con diagnóstico de cardiopatía periparto, con una edad media de 31 años (± 6.7). El número promedio de embarazos fue de 1.0, con un 52.9%. Las condiciones más frecuentes durante la gestación fueron obesidad y preeclampsia, con un 23.5% para ambas; se halló diabetes gestacional en una paciente (5.9%) y dos presentaron hemorragia del primer trimestre (11.8%). El 41.2% de las mujeres tuvieron parto vértice espontáneo. Ninguna mujer tuvo antecedentes cardiovasculares. Los síntomas presentados al momento del diagnóstico fueron deterioro de la clase funcional (100%), edema en miembros inferiores (52.9%), ortopnea (76.4%) y disnea paroxística nocturna (88.2%). La terapia farmacológica iniciada incluyó diuréticos (58.8%), inhibidores de la enzima convertidora de angiotensina (IECA) (64.7%), betabloqueadores (82.4%), bromocriptina (5.8%), ivabradina (23.5%) y antagonistas de la aldosterona (64.7%). Conclusiones: Este registro señala la similitud en nuestro medio de esta enfermedad, respecto a la epidemiología, la presentación y el manejo, con el resto del mundo. Muestra que el tratamiento farmacológico para falla cardiaca con la combinación de betabloqueadores, IECA y diuréticos sigue siendo el pilar fundamental en el tratamiento; además, destaca que la miocardiopatía periparto aún es una afección grave, con alta morbilidad y que permanece en insuficiencia cardiaca después del diagnóstico y con un riesgo importante de mortalidad.

Abstract Objective: To identify the epidemiology and the diagnostic and therapeutic processes of women with peripartum cardiomyopathy on a cardiovascular reference center. Method: A retrospective descriptive observational study was conducted with female patients between 15 and 50 years of age with a diagnosis of peripartum cardiomyopathy during the last 10 years. Results: 17 women with a diagnosis of peripartum cardiomyopathy where included, with a mean age of 31 (± 6,7) years at the time of diagnosis. The average number of previous pregnancies was 1.0 in 52.9% of the population. Obesity and preeclampsia were present in 23.5% and 18.8%, respectively. Diabetes was found in one patient (5.9%) and two had hemorrhage of the first trimester (11.8%). 41.2% of the women had a spontaneous vertex delivery. The symptoms presented at the time of diagnosis were deterioration of their functional class in 100.0%, edema in the lower limbs in 52.9%, orthopnea in 76.4% and paroxysmal nocturnal dyspnea in 88.2%. Conclusions: Our data show that peripartum cardiomyopathy occurs with a mode of presentation similar to the rest of the world, pharmacological treatment for heart failure with the combination of beta blockers, ACE inhibitors/ARBs, and diuretics continue to be the fundamental pillar in the treatment of peripartum cardiomyopathy; It is also important to note that peripartum cardiomyopathy remains a serious condition with a high rate of critically ill patients who remain in heart failure after diagnosis with a significant risk of mortality.

Chagas Disease: Chronic Chagas Cardiomyopathy.

Chagas disease (CD) is a tropical vector-borne infection caused by the protozoan parasite Trypanosoma cruzi (T. cruzi), also known as American Trypanosomiasis. It is considered endemic in all South and Central America and in this past decades its becoming a burden particularly in the United States and Europe due to human migration. The vast majority of patients during the acute phase are asymptomatic, while chronic symptomatic phase appears years later, with around 30% progressing toward detectable organ damage affecting mainly the cardiovascular and digestive systems. Chagas cardiomyopathy is the leading cause of nonischemic cardiomyopathy (NICM) in Latin America and affects around 30% of infected patients. The foremost characteristics are a diffuse myocarditis with focal fibrosis, mainly located in the apex and basal segments of the posterior and inferior wall, leading to a highly arrhythmogenic disease. Treatment can be etiologic during the parasitic infection, without and established efficacy during the advanced chronic symptomatic phase. Chronic Chagas cardiomyopathy treatment consists in guided medical therapy for non-ischemic cardiomyopathy, but more studies are imperative to improve clinical outcomes, some of them already in progress, and hopefully soon refine treatment and recommendations.

Arterial lactate levels and their prognostic value in patients undergoing pulmonary thromboendarterectomy.

Objective: Evaluate the change of lactate levels and its prognostic role in the postoperative period of patients undergoing pulmonary thromboendarterectomy. Methods: Retrospective study between 2001 and 2019. Patients older than 18 years and who underwent pulmonary thromboendarterectomy were included. The U Mann Whitney test was performed to evaluate the change between lactate levels, and Cox regression analysis to evaluate the relationship with mortality. Areas under the curve were constructed for lactate levels. Results: Seventy-three patients were operated on during the study period. Median age was 51 years, 55% female. The median lactate on days 1 was 4.65 mml/L and on day 2 it was 1.62 mml/L with a change of 2.87 mml/L. No differences were found between the levels measured on day 1 and 2 between the people who died and those who did not on day 30. In the multivariate regression of COX, no relationship with mortality was found. The area under the curve shows regular performance on both day 1 and day 2 in predicting mortality outcomes. Conclusions: The behavior of the lactate in patients undergoing pulmonary thromboendarterectomy shows a rapid change during the first hours after the procedure. No role was found as a predictor of mortality neither in-hospital nor in follow-up.

Objetivo: Evaluar el cambio de los niveles de lactato y su rol pronóstico en el posoperatorio de pacientes sometidos a tromboendarterectomía pulmonar. Métodos: Estudio retrospectivo entre 2001 y 2019. Se incluyeron pacientes mayores de 18 años que fueron sometidos a tromboendarterectomía pulmonar. Para evaluar el cambio entre los niveles de lactato se realizó la prueba de U Mann Whitney. Para evaluar la relación con la mortalidad se realizó un análisis multivariado de Cox. Se construyeron áreas bajo la curva para los niveles de lactato. Resultados: . Setenta y tres pacientes fueron operados durante el período de estudio. La mediana de edad fue de 51 años, 55% mujeres. La mediana de lactato en el día 1 fue de 4,65 mmL/L y en el día 2 fue de 1,62 mmL/L con un cambio de 2,87 mmL/L. No se encontraron diferencias entre los niveles medidos el día 1 y 2 entre las personas que murieron y las que no al día 30 hospitalario. En la regresión multivariada de COX no se encontró relación con la mortalidad. El área bajo la curva muestra un desempeño regular tanto en el día 1 como en el día 2 para predecir el resultado de la mortalidad en especial intrahospitalaria. Conclusiones: El comportamiento del lactato en pacientes sometidos a tromboendarterectomía pulmonar muestra un cambio rápido durante las primeras horas posteriores al procedimiento. No se encontró que sea un predictor de mortalidad ni hospitalaria ni durante el seguimiento.

Impacto de COVID-19 en la enfermedad cardiovascular / Impact of COVID-19 on cardiovascular disease

Resumen La enfermedad por coronavirus-2019 (COVID-19) es una enfermedad infecciosa cuya sintomatología inicial, en la mayoría de las ocasiones, se manifiesta con compromiso del tracto respiratorio. El virus que causa dicha enfermedad se denomina síndrome respiratorio agudo severo por coronavirus 2 (SARS-CoV2). Si bien la manifestación grave más frecuente de la infección parece ser la neumonía, se han documentado diversas implicaciones cardiovasculares. Las personas que cursan con dicha infección y que tienen una enfermedad cardiovascular preexistente tienen un riesgo mayor de cuadros graves y mortalidad. Existen asociaciones directas o indirectas de la infección con injuria miocárdica, arritmias, enfermedad tromboembólica venosa y miocarditis. Los tratamientos en investigación pueden tener efectos adversos en el sistema eléctrico del corazón; además, algunos medicamentos de uso crónico (como los inhibidores del sistema renina angiotensina aldosterona) se les ha otorgado un polémico papel en la virulencia del microorganismo. La alta demanda en atención en salud que requieren los pacientes infectados por SARS-CoV 2 puede comprometer la asistencia de pacientes cardiovasculares sin dicha infección y dejar en riesgo de exposición al personal sanitario. Se presenta una revisión sobre los aspectos más llamativos donde estas dos condiciones interaccionan.

Abstract Coronavirus-2019 disease (COVID-19) is an infectious disease which initial symptoms, in most cases, manifest with respiratory tract compromise. The virus that causes said disease is called severe acute respiratory syndrome by coronavirus 2 (SARS-CoV 2), although the most frequent serious manifestation of the infection appears to be pneumonia, various implications have been documented from the cardiovascular point of view. People who have this infection and a pre-existing cardiovascular disease have an increased risk of severe symptoms and mortality. There are direct or indirect associations of the infection with myocardial injury, arrhythmias, venous thromboembolic disease and myocarditis. Investigational treatments may have adverse effects on the heart's electrical system. In addition, some medications of chronic use (such as renin angiotensin aldosterone systeminhibitors), have been given a controversial role in the virulence of the organism. The high demand in health care required by patients infected with SARS-CoV 2 can compromise the care of cardiovascular patients without said infection, in addition to leaving healthcare personal at risk of exposure. Therefore, a review is presented on the most striking aspects where these two conditions interact.

Aneurisma de arteria pulmonar: un hallazgo incidental / Pulmonary artery aneurysm: an incidental finding

Resumen Los aneurismas de la arteria pulmonar son entidades infrecuentes y su tratamiento es tema de discusión. Desde el punto de vista etiológico pueden ser congénitos o adquiridos. Los primeros, generalmente se asocian a malformaciones cardiacas que producen hipertensión pulmonar, siendo el ductus arterioso la más frecuente. Otras anomalías incluyen defectos auriculares o ventriculares. Las causas adquiridas pueden ser idiopáticas o estar asociadas a infecciones (tuberculosis, sífilis), traumatismos o colagenopatías. Presentamos el caso de una mujer de 62 años, quien consultó por un cuadro clínico en el que se destacaba su sintomatología neurológica e infecciosa, con posterior progresión a un choque séptico y en quien los hallazgos de las imágenes mostraron un aneurisma gigante de la arteria pulmonar siendo este un hallazgo incidental y sin relación a la sintomatología de la paciente.

Abstract Aneurysms of the pulmonary artery are rare entities and their treatment is a matter of discussion. From the etiological point of view, they can be congenital or acquired. Those in the first group are generally associated with cardiac malformations that generate pulmonary hypertension, with the ductus arteriosus being the most frequent. Other abnormalities include atrial or ventricular defects. The acquired causes may be idiopathic or associated with infections (tuberculosis, syphilis), trauma, or collagen disease. We present the case of a 62-year-old woman, which consulted for a clinical condition where neurological and infectious symptoms stood out, with subsequent progression to a state of septic shock, and in whom the imaging finding showed a giant pulmonary artery aneurysm. this being an incidental finding and unrelated to the patient's symptoms.

Unexpected or Nonsuspected?: A Rare Cause of Recovered Left Ventricular Ejection Fraction After ECMO.

Acute heart failure represents a challenge, especially in infrequent etiologies. We present the clinical case of a young woman diagnosed with acute heart failure and cardiogenic shock. Pheocromocytoma was identified as a reversible etiology. The surgical treatment led to a complete recovery of cardiac function. (Level of Difficulty: Beginner.).

[Heart Failure With Preserved Ejection Fraction: A Problem Of Contemporary Cardiology]. / Falla Cardíaca con Fracción de Eyección Preservada: Un Problema de la Cardiología Contemporánea.

Heart failure with preserved ejection fraction (HFpEF) is a frequent and overlooked medical condition that represents a great challenge for diagnosis and treatment. Current data shows a temporal trend towards a higher prevalence of HFpEF, even above heart failure with reduced ejection fraction (HFrEF). The pathophysiology of HFpEF is heterogeneous and involves several factors such as genetics, lifestyle, and cardiac and non-cardiac comorbidities. These factors result in remodeling, maladaptation and cardiac stiffness, that later on cause dyspnea, exercise intolerance, and fatigue. Although the mortality outcome of HFpEF is as high as HFrEF, no specific therapy has demonstrated overall benefit in these patients; which is why future therapies will bet on an individualized approach according to the patients phenotype.

Síndrome De Sturge-Weber: Reporte De Un Caso Y Revisión De La Literatura / Sturge-Weber Syndrome: A Case Report And Literature Review

Resumen El Síndrome de Sturge-Weber es un trastorno poco común del desarrollo neuroectodérmico, caracterizado por un angioma facial tipo nevus flammeus y una angiomatosis leptomeníngea, con frecuencia ipsilateral al nevus. Este síndrome predispone a calcificaciones, atrofia cerebral y convulsiones refractarias. Propósito: En este artículo se realiza una revisión de la literatura sobre el Síndrome de Sturge-Weber y se reporta el caso de un paciente de 18 meses de edad diagnosticado con esta patología que ingresa a urgencias por presentar cuadro febril de tres días y comienzo de convulsiones tónico clónicas localizadas en hemicuerpo derecho refractarias al tratamiento convencional; en esta revisión se resalta la importancia del diagnóstico y manejo oportuno al igual que un adecuado seguimiento. Desarrollo: se realizaron búsquedas en las bases de datos PubMed, Science Direct y Scielo, confirmando que aún se desconocen algunos aspectos de esta patología, sin embargo, con el descubrimiento de la mutación somática de GNAQ hay un amplio campo para próximas investigaciones. Hallazgos y conclusiones: Es importante en el ejercicio médico no pasar de alto las lesiones angiomatosas que posean una ubicación trigeminal en los recién nacidos, con el fin de establecer un diagnóstico oportuno e intentar conseguir un mejor desarrollo a futuro.

Abstract Sturge-Weber Syndrome is a rare developmental neuroectodermical disorder. It is characterized by a facial port-wine stain and a leptomeningeal angiomata, frequently localized ipsilateral to the facial port-wine stain. This syndrome predisposes either to brain atrophy, calcifications and refractory seizures. In this paper a Sturge-Weber Syndrome literature review was made and a 18 month aged child case with this diagnosis is reported. He was admitted to the emergency department of a local hospital with a history of three days of fever and tonic-clonic seizures localized on the right side and refractory to conventional treatment. This review highlights the importance of an early diagnosis and an appropriate follow up. To carry out this review a search in PubMed, Science Direct and Scielo databases was done, confirming that there are some issues about this disorder that are still unknown. However, with the GNAQ somatic mutation discovery, there is an open field for new researches. It is very important in medical practice not to understimate a facial port-wine stain over trigeminal territory in newborns in order to make an early diagnosis and try to achieve a better future neurodevelopment.

Trombólisis intraparo en tromboembolia pulmonar masiva / Thrombolysis during cardiopulmonary resuscitation in massive pulmonary embolism

Resumen La tromboembolia pulmonar forma parte de la enfermedad tromboembólica venosa, junto con la trombosis venosa profunda. Es una patología de alta morbimortalidad, principalmente si no se diagnostica y/o trata de manera oportuna. El diagnóstico es difícil debido a su presentación clínica variable y poco específica. En el contexto de tromboembolia pulmonar de alto riesgo, que se presenta como una condición que amenaza la vida y requiere intervención inmediata para impactar el pronóstico del paciente, la trombólisis constituye una alternativa en quienes cursen con inestabilidad hemodinámica o incluso parada cardiaca, que no tengan contraindicaciones para su realización. Se presenta el caso de un hombre de 54 años quien consultó al servicio de urgencias tras presentar síncope y posteriormente dolor torácico, precedido por 15 días de dolor y edema en pantorrilla. Sufrió deterioro y evolucionó a parada cardiopulmonar. Se diagnosticó tromboembolia pulmonar de alto riesgo mediante ecocardiograma; se iniciaron maniobras de reanimación y, de manera paralela, se administró trombolítico. Posteriormente, respondió de manera satisfactoria a la terapia.

Abstract Pulmonary thromboembolism (PE) is part of venous thromboembolic disease, along with deep venous thrombosis (DVT). It has a high morbidity and mortality, particularly if it is not diagnosed and / or treated in a timely manner. The diagnosis is difficult due to its variable and unspecific clinical presentation. In the context of high-risk PE, which presents as a life-threatening condition and requires immediate intervention to have an impact on the prognosis of patients, thrombolysis is an alternative in those with haemodynamic instability or even cardiac arrest, if they have no contraindications for performing this. The case is presented of a 54 year old man who consulted in the emergency department after presenting with syncope followed by chest pain, preceded by 15 days of pain and oedema in the calf. The patient deteriorated rapidly, evolving to cardiopulmonary arrest. A high-risk PE was diagnosed by echocardiography, resuscitation manoeuvres were initiated, and thrombolytic therapy given in parallel. Subsequently the patient had a satisfactory outcome with the therapy.

The Hypertensive Myocardium: From Microscopic Lesions to Clinical Complications and Outcomes.

The chronic hemodynamic load imposed by hypertension on the left ventricle leads to lesions in the myocardium that result in structural remodeling, which provides support for alterations in cardiac function, perfusion, and electrical activity that adversely influence the clinical evolution of hypertensive heart disease. Management must include detecting, reducing, and reversing left ventricular hypertrophy, as well as the detection and repair of microscopic lesions responsible for myocardial remodeling. Reducing the burden associated with hypertensive heart disease can be targeted using personalized treatment. The noninvasive, biomarker-mediated identification of subsets of patients with hypertensive heart disease is essential to provide personalized treatment.

Factores demográficos, técnicos y características asociados a bacteremia en pacientes con catéter venoso central en unidad de cuidado intensivos del Hospital Universitario San Vicente Fundación (HUSVF), 2009-2011 / Demographic factors, technical and associated features bacteremia in patients with central venous catheter in intensive care unit HUSVF, 2009-2011

Resumen Objetivo: Determinar los factores demográficos, técnicos y características del catéter en el desarrollo de bacteriemia en pacientes mayores de 15 años con catéter venoso central que estuvieron hospitalizados en las unidades de cuidados intensivos del Hospital Universitario San Vicente Fundación de Medellín (Colombia) entre 2009 y 2011, con el fin de generar información que contribuya a implementar estrategias de prevención. Método: Estudio observacional analítico transversal con análisis de casos y controles en las unidades de cuidados intensivos, utilizando una base de datos del Hospital Universitario San Vicente Fundación recolectada desde 2009 a 2011. Fueron definidos como casos los pacientes con diagnóstico de bacteriemia asociada a catéter venoso central, y como controles, pacientes con catéter venoso central sin bacteriemia. Un total de 66 pacientes fueron analizados (22 casos y 44 controles), con una relación 1:2. Se buscó asociación o relación entre las variables con prueba Chi cuadrado (x²) de Pearson, Fisher o Correlación de Yates, según el número de casillas observadas y esperadas, y prueba de Mann- Whitney para comparación de medianas. Resultados: Se encontró en el análisis multivariado una asociación significativa con la indicación de administración de medicamentos y monitoreo hemodinámico (OR= 12,14; IC 95= 1,03-110,237 ) concomitante y administración de nutrición parenteral (OR=4,5;IC95%= 0,586-34,873). Conclusiones: Las variables asociadas a la bacteriemia por catéter venoso central fueron: la administración de medicamentos más el monitoreo hemodinámico concomitante y la administración de NPT.

Abstract Objective: to determine demographic, technical and characteristics of the catheter in the development of bacteremia in patients over 15 years with central venous catheter were hospitalized in the intensive care unit of the Hospital Universitario San Vicente Fundación Medellín between 2009 and 2011, in order to generate information that contributes to implement prevention strategies. Method: cross-sectional observational study case-control analysis in intensive care units, using a database of the Hospital Universitario San Vicente Fundación collected from 2009-2011. Cases were defined as patients with a diagnosis of bacteremia associated with central venous catheter as controls patients with central venous catheter without bacteremia. A total of 66 patients were analyzed (22 cases and 44 controls), with a 1:2 ratio. We sought association or relationship between variables with chi-square test of Pearson x2, Fisher or Yates correlation, as the number of observed and expected cell, and Mann-Whitney test for comparison of medians. Results: It was found in the multivariate analysis a significant association with the indication of drug administration and hemodynamic monitoring (OR = 12.14, 95 = 1.03 to 110.237) and concomitant administration of parenteral nutrition (OR = 4.5; 95 % CI = 0.586 to 34.873). Conclusions: The variables associated with central venous catheter bacteremia were: the administration of medications and concomitant hemodynamic monitoring TPN.

Correlation of angiographic late loss with neointimal proliferation in stents evaluated by OCT and histology in porcine coronary arteries.

OBJECTIVES: We aimed to evaluate the correlation of angiographic late loss (LL) with the degree of in-stent neointimal proliferation assessed by optical coherence tomography (OCT) and histology. BACKGROUND: Angiographic LL is the most common endpoint used in clinical trials for the evaluation of the efficacy of drug-eluting stents (DES). However, there are few data in regards to the accuracy of angiographic LL in the evaluation of DES displaying lower degrees of neointimal proliferation. METHODS: A total of 49 stents (36 DES and 13 bare-metal stents) were deployed in coronary arteries of 23 domestic swine and followed up for 28 or 90 days, thus obtaining different degrees of neointimal proliferation. Each stent was divided into 8 to 9 segments along the longitudinal axis to match corresponding histological cross sections. Angiographic LL was calculated at each segment throughout the entire length of the stent and compared with in-stent neointimal thickness (NT) obtained by OCT and histology. RESULTS: A total of 382 angiographic segments were suitable for matched comparison with both OCT and histological findings. The mean LL at follow-up was 0.60 ± 0.57 mm (range: -0.46 to 2.3 mm) for all segments. Approximately 13.9% of stent segments had a LL between -0.5 and 0 mm, and 22.5% had a LL greater than 1.0 mm. The correlation between OCT and histology for the evaluation of NT was adequate regardless the level of angiographic LL. In addition, overall correlations between angiographic LL and NT by OCT or histology were adequate (R = 0.77 and 0.63, respectively). However, angiographic LL showed a poor correlation with NT by OCT or histology at a value <0.55 mm (R = 0.38 and 0.15, respectively). CONCLUSIONS: Angiographic LL below a threshold value of 0.55 mm correlates poorly with NT obtained by OCT and histology. These results suggest a cautious interpretation is needed to evaluate angiographic endpoints in DES trials in which LL values below this threshold are reported.

Caracterización clínica y de conglomerados de clases latentes de la migraña familiar en el aislado genético de Antioquia / Clinical and latent class cluster characteristics of familiar migraine in the antioquian genetic isolate

INTRODUCCIÓN: la migraña es una entidad de alta prevalencia cuya etiología parece tener un gran componente genético. OBJETIVOS: determinar las características clínicas y la de conglomerados de clases latentes (CCL) en las familias colombianas de la región de Antioquia con un caso índice con cefalea crónica. MATERIAL Y MÉTODOS: se estudiaron 550 individuos (374 mujeres y 176 hombres) de 121 familias colombianas de la región de Antioquia. A todos se les hizo una pregunta de rastreo para seleccionar a los miembros con posible migraña. A los sospechosos se les hizo una entrevista con los criterios de la International Headache Society (IHS) y un examen neurológico para establecer el diagnóstico y su clasificación en migraña con aura (MCA) y migraña sin aura (MSA). Los criterios de la IHS fueron usados para hacer un análisis de CCL, calculando índices de máxima verosimilitud y controlando el cumplimiento del supuesto de la independencia local. RESULTADOS: el 61,6 % de los miembros de las familias tuvieron migraña. El 40 % tuvo MSA y el 21,6 % MCA. La intensidad fue de moderada a severa en 96,4 % de los casos. Aproximadamente el 70 % presentaron síntomas de náuseas, vómitos, sonofobia, fotofobia e incremento con el ejercicio. Se derivaron 4 CCL: uno con MSA+MCA, con alta probabilidad de ser mujeres y con crisis de inicio temprano; otro grupo de personas sanas de ambos sexos; un tercero con MSA de aparición a edad intermedia, con crisis moderadas a severas de larga duración y predominante de mujeres; y un cuarto grupo de mujeres con MSA de aparición temprana y crisis de corta duración. CONCLUSIONES: las características clínicas de los pacientes con migraña de estas familias son similares a lo informado en otros estudios. La distribución de los CCL hace pensar en una probable transmisión de una predisposición genética que, en interacción con factores ambientales, determinaría la edad de inicio de las crisis y si esas son de tipo MSA o MSA+MCA.

INTRODUCTION: migraine is a disorder with high prevalence and with probable genetic etiology. OBJECTIVE: to determine the clinical and latent class cluster (LCC) characteristics of Antioquian families with one probands with chronic headache. MATERIALS AND METHODS: 550 individuals (374 females and 176 males) were studied. All participants were asked with one screening question in order to select suspicious of migraine. An interview with the International Headache Society (IHS) criteria and a neurological examination were administered to all probably migraine affected patients. Migraine diagnosis and classification into migraine with aura (MA) and migraine without aura (M0) was done. The IHS were used to develop a LCC analysis, calculating maximum likelihood index and controlling the local independence assumption. RESULTS: 61,6 per cent of the family members were affected with migraine, 40 per cent had M0 and 21,6 per cent had MA. Intensity was estimated between moderate to severe by 96,4 per cent of the cases. Approximately 70 per cent had nausea, vomiting, sonophobia, photophobia and worsening with exercise. 4 LCC were derived: one with M0 + MA, with high probability to be females, and early onset crisis; other group was constituted by healthy people of both genders; the third cluster had M0 of intermediate age onset, with moderate to severe attack, with long duration and predominantly females; finally a 4th cluster of females with M0 of early onset and short duration. CONCLUSIONS: clinical characteristics of migraine patients in these Antioquian families were similar to those informed by others studies. The distribution of LCC suggests a genetic transmission of vulnerability, which interacting with several environmental factors, would determine the age of onset and the types of attacks as M0, or M0+MA.